BOROUGH OF BECKENHAM REPORT ON THE HEALTH OF THE DISTRICT DURING 1948 BY T. PHILIPS COLE, M.B., D.P.H. Medical Officer of Health BOROUGH OF BECKENHAM REPORT ON THE HEALTH OF THE DISTRICT DURING 1948 BY T. PHILIPS COLE, M.B., D.P.H. Medical Officer of Health REPORT OF THE MEDICAL OFFICER OF HEALTH FOR 1948 TABLE OF CONTENTS. PAGE 1. Members of Public Health Committee 3 2. Staff of the Department 3 3. Introduction 5 4. Vital Statistics 7 5. Infantile Mortality, 1948 11 6. Natural and Social Conditions 11 7. Sanitary Circumstances of the Area 12 8. General Provision of Health Services in the Area 12 9. Local Clinic Services 14 10. Maternity and Child Welfare: (a) Ante-Natal Scheme 15 (b) Welfare Centres and Home Visiting 18 (c) Unmarried Mothers 19 (d) Adoption Act 19 (e) Special Treatments 21 (f) Boarded-out Children 21 (g) Obstetric Consultant's Service 21 (h) Dental Clinic 22 (i) Day Nurseries 23 11. Maternity Hospital 23 12. Notes on the local administration of the transferred services (a) Maternity and Child Welfare 26 (b) Maternity Hospital 29 (c) Diphtheria Immunisation 31 (d) Civil Ambulance Service 32 13. Infectious Disease: (a) Comments on Major Infectious Diseases 33 (b) Table of Cases 34 (c) Poliomyelitis 36 (d) Tuberculosis—Incidence and Deaths 39 14. Sanitary Inspection of the District—Report by Mr. G. Webber, Chief Sanitary Inspector: (a) Nuisances found and remedied 42 (b) Complaints 42 (c) Abatement of Nuisances 43 (d) Food Sampling 43 (e) Milk Sampling 44 (f) School Sanitation 47 (g) Food Wrapping 48 (h) Rats and Mice (Destruction) Act 48 MEMBERS OF PUBLIC HEALTH COMMITTEE, from November, 1948. Chairman: Councillor C. P. Christie. Deputy Chairman: Councillor C. B. Curtis, M.B.E. Alderman C. Guy Brook. Alderman Dr. R. P. S. Edden, O.B.E. Councillor R. C. Cheeseman. Councillor Miss M. E. Gundrey, B.A. Councillor E. F. Hall. Councillor A. F. Hooper, O.B.E. Councillor F. R. Took. Councillor A. W. Waller. Ex-Officio: The Mayor and Deputy Mayor. 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. 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. Woodard, Cert. R.San.I. and S.I.E.J.B., Cert. Food Inspector. Clerical Staff : Senior Assistant J. Dungay. Assistants K. Wood (resigned 9/10/48). Mrs. E. Best. Mrs. D. Foster. Miss J. Fenn. Miss C. Mawbey (appointed 16/8/48). 3 The following were on the Staff of the Public Health Dept., up to the 5th July, 1948, when they were transferred to the Staffs of the Kent County Council or Regional Hospital Board : Assistant Medical Officer Mrs. H. M. H. Mack, M.B., Ch.B. Health Visitors Miss M. G. Kendall, S.R.N., R.F.N., S.C.M., H.V's Cert. Mrs. C. French, S.R.N., T.B., S.C.M., H.V's Cert. Miss I. Gatherer, S.R.N., S.C.M., H.V's Cert. Mrs. D. K. Anderson, S.R.N, S.C.M., H.V's Cert. Miss G. M. Williams, S.R.N., S.C.M., H.V's Cert, (appointed 19/1/48). Maternity Hospital: Resident Medical Officer Dr. L. White (resigned 22/2/48). Dr. W. F. Sunderland (appointed 7/3/48). 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 Mr. S. W. Collett, Cert. R.San.I, Cert. Food Inspector. Assistants M. Graham-Williams. Miss E. Hocking. Miss J. Roberts. 4 INTRODUCTION. WHEN the National Health Service Act came into operation on July 5th, 1948, many services, which had been administered since their very inception by this Authority, passed into the hands of the Kent County Council or the Regional Hospital Board. Consequently, the details of the work carried out and recorded in this report under the headings of Maternity and Child Welfare, Maternity Hospital, Day Nurseries, Home and Domestic Helps, Diphtheria Immunisation and Civil Ambulance are concerned only with the first half of the year. Though the administration of these services is now in other hands, the actual day-to-day work is carried out by the same persons as before : mothers attending Welfare Centres see the same doctors, their homes are visited by the same Health Visitors and the staffs of the Maternity Hospital, Day Nurseries and Civil Ambulance Service are unchanged : the Home and Domestic Help Service is organised locally by an officer of the Kent County Council working in the Public Health Department in the Town Hall. As one would expect, local residents who made use of these services and were in need of advice, continued to seek it in the Public Health Department as they had always done before; and there is no doubt that they will continue to do so for some time to come—the habits of years are not likely to be altered in a few months. Although the Kent County Council has established an office in Beckenham for giving advice about the transferred services, the staff of that office are new to the work, and it will inevitably be some time before they can acquire the intimate knowledge of the subject which the members of my staff have acquired through the years. For our part, we are perfectly willing and anxious to be of service in any way. It is true that, since the responsibility for these services no longer rests with this Authority, we could with propriety refer those seeking advice to the officers of the new Authority; but in many instances this would have resulted in some delay and inconvenience to our people, and to refuse our help would have been opposed to the traditions of service which has always been maintained by the department. In every change involving the transfer of services of such a personal nature there must always be a period of transition; and if this period is to be traversed easily and smoothly and without causing undue inconvenience to the public, the old authority must be willing to cooperate with and, where possible, assist the new. Under these circumstances I am sure that this Authority will not grudge any time expended in the interests of the people of Beckenham, and that the County Authority will not regard these efforts as a tresspass on their affairs. The actual transfer was effected quite smoothly and without any break in the continuity of the services. In the body of this report I give some account of the record of this Authority as a Welfare Authority, and I think that those who study it will be satisfied that the record is an honourable one. 5 I cannot leave this part of my introduction without reference to one who played a very large part in the administration of the services of the Department. Mr. S. W. Collett, who was transferred on July 5th to the staff of the Kent County Council worked in the Department for twenty-eight years. The Assistant Medical Officers were engaged almost entirely on purely clinical duties, and so Mr. Collett was in fact, the real administrative assistant. He was always most zealous in maintaining the efficiency of the services for which we were reponsible, and much concerned for the reputation of the Department. The idea of service which animated all members of the staff was due in no small measure to his personal example. His outlook was essentially a human one; he listened patiently and with sympathy to all who came in need of help or advice ; and he endeavoured by all the means in his power to obtain for them the relief and assistance of which they were in need. His loyalty and faithfulness are things which I will always remember. So far as Infectious Diseases was concerned, it is worth noting that only one case of Diphtheria was notified. The Autumn brought a few cases of Poliomyelitis, from which we had suffered so badly in 1947 the occurrence of a limited outbreak of a disease a short time after it has appeared in epidemic form is a phenomenon which I have observed frequently. A great deal of work was done in the repair of house property. This work goes on week in week out throughout the year, as a reference to the periodical reports of the Chief Sanitary Inspector will show. It does not perhaps attract much attention, but it occupies a very large proportion of the time of the Sanitary Inspectors, and, in these days of acute shortage of houses, is a most valuable contribution to the housing problem : without this constant attention many houses would soon be fit for nothing but demolition. Members will be aware from the reports of the Housing Committee that the waiting list for houses is still a long one. My department is chiefly concerned with people whose situation is causing them a very real distress. It will no doubt be many years before every family in the town has adequate accommodation, but the present situation is merely a very acute exacerbation of a state of affairs which has, to my knowledge, existed in Beckenham for over twenty years. In the meantime the most serious aspect of the matter—and the one of which the Public Health Department has most intimate knowledge—is the threat to family life. Except in the most extreme cases, overcrowding is not so much a danger to physical health as an affliction of the spirit. It is perhaps hardest for the young married couples: frequently they are deterred from having the children whom they so earnestly desire; and if courageously they determine to ignore the circumstances in which they are living and starts family, the arrival of the little ones adds further complications to what is already a somewhat desperate situation. New reasons for friction arise, trivial upsets become serious quarrels, dispositions are gradually changed by the strain and in only too many instances, the continued existence of the family as a family is threatened. I laid considerable 6 stress on this side of the problem in a report I submitted to the Council in January, 1946, and what I have seen and heard since then has satisfied me that what I wrote was in no way exaggerated. The work in connection with rat repression was continued energetically throughout the year. The important word in this connection is "repression": no one who pauses to think for a moment will consider that complete extermination is either possible or likely, no matter how many agents are employed or how much public money is expended. In point of fact the rat is not a danger to the Public Health, though in areas where the food of the people is stored in considerable bulk, his depredations may be formidable. From time to time, men who work in sewers suffer from a severe form of jaundice as the result of rat bites, and in the remote event of the introduction of Oriental Plague into the country the ship-rat—which does not appear to exist in Beckenham—may become a vector of the disease. As a result of regular attention the rat population of the sewers in Beckenham has been reduced to extremely small proportions : but since, as the Chief Sanitary Inspector has repeatedly pointed out, the rat infestation in Beckenham is a surface one and not to any extent connected with the sewers, the clearing of the sewers will have little effect on the general distribution. The transfer of services naturally entailed the transfer of staff. In addition to this, other members of the staff have obtained appointments under the new Authorities set up under the National Health Service Act. In consequence there have been considerable periods when the work has had to be done by a depleted staff. The fact that the work has been kept up to date and carried out so efficiently is a tribute to the loyalty, energy and devotion of the staff, and I am glad to take this opportunity of expressing my appreciation of their whole-hearted support. I should like to thank the members of the Council and of the Public Health Committee for the consideration which they have shown to me personally during the last year. To have, after twenty-one years, services in which one took a deep personal interest removed from ones immediate control and supervision is an unhappy and rather unsettling experience, and I am grateful for much sympathy and understanding. T. PHILIPS COLE, Medical Officer of Health. SUMMARY OF VITAL STATISTICS, 1948. Area of District in acres 5,935 Civilian Population as estimated by Registrar-General at 30th June, 1948 75,050 Civilian Population per acre 12.6 Rateable Value at 1/10/48 848,156 Births Registered: male female Legitimate 554 497 Illegitimate 14 8 Total 1,073 7 Birth Rate per 1,000 of Civilian Population 14.297 Deaths Registered: MALE FEMALE 318 377 Total 695 Death Rate per 1,000 population 9.26 Infant Mortality Rate per 1,000 births 13.979 15 Deaths of Infants under 1 year of age: MALE FEMALE Legitimate 10 2 Illegitimate 1 2 Total 15 Deaths from Enteritis under 2 years of age—1 Death. Rate per 1,000 births 0.932 Still Births— Rate per 1,000 population 0.32 Rate per 1,000 births 21.87 MALE FEMALE Legitimate 14 8 Illegitimate 2 Total 24 Death Rate from Cancer (128 deaths) 1.706 Death Rate from Pulmonary Tuberculosis (26 deaths) 0.346 Table A. Birth rates, Civilian death rates, and Infant Mortality in the year 1948. Provisional figures based on Weekly and Quarterly Returns. England and Wales 126 C.Bs. and Great Towns including London 148 smaller Towns Resident Pop. 25,000-50,000 at 1931 Census London Adm. County Beckenham Rates per 1,000 Civilian Population : Births— Live 17.9 (a) 20.0 19.2 20.1 14.28 Still 0.42 (a) 0.52 0.43 0.39 0.32 Deaths 10.8 (a) 11.6 10.7 11.6 9.26 Rates per 1,000 Live Births. Deaths under 1 year of age 34(b) 39 32 31 13.98 Deaths from Diarrhoea and Enteritis under 2 years of age 3.3 4.5 2.1 2.4 0.93 (a) Rates per 1,000 total population. (b) Per 1,000 related births. 8 TOTAL DEATHS, 1948 (Registrar-General's Official Returns). All causes—695; Male, 318; Female, 377. causes of death. males females 1. Typhoid and Paratyphoid Fevers - - 2. Cerebro-spinal Fever — - 3. Scarlet Fever — - 4. Whooping Cough — - 5. Diphtheria — — 6. Tuberculosis of Respiratory System 15 11 7. Other forms of Tuberculosis 4 3 8. Syphilitic Diseases 3 2 9. Influenza 1 1 10. Measles — — 11. Acute Poliomyelitis and Polioencephalitis - - 12. Acute Inf. Encephalitis — — 13. Cancer of Buc. Cav. and Oesoph (M); Uterus (F) 4 5 14. Cancer of Stomach and duodenum 11 10 15. Cancer of Breast — 14 16. Cancer of all other sites 37 47 17. Diabetes 3 3 18. Intra-cranial Vascular Lesions 30 54 19. Heart Diseases 103 106 20. Other Diseases of Circ. System 14 22 21. Bronchitis 17 9 22. Pneumonia 9 9 23. Other Respiratory Diseases 7 5 24. Ulcer of Stomach or Duodenum 4 4 25. Diarrhoea, under two years 1 — 26. Appendicitis — — 27. Other Digestive Diseases 4 10 28. Nephritis 9 11 29. Puerperal and Post-abort. Sepsis — 1 30. Other Maternal Causes — — 31. Premature Birth 2 2 32. Congenital Mal: Birth Injuries: Infantile Diseases 5 2 33. Suicide 3 4 34. Road Traffic Accidents 2 - 35. Other Violent Causes 7 7 36. All Other Causes 23 35 Totals 318 377 9 10 VITAL STATISTICS FOR YEARS 1940 to 1948 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 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 1948 75,050 1,051 22 1,073 14.297 22 2 24 12 3 15 13.98 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 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 0.256 136 1.775 1948 695 9.260 1 26 0.346 128 1 .7 06 INFANTILE MORTALITY, 1948. The number of deaths of infants under the age of twelve months was 15 as compared with 37 in 1947. The Infantile Mortality Rate for the year was 13.979 per 1,000 live births. The following table shows the causes of death in 13 cases for which full records exist. Infantile Mortality. 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 Congenital Heart Disease 1 - - - 1 1 - - - 2 B. Ante-natal or Intranatal conditions Prematurity 4 — — — 4 — — — — 4 Atelectasis 1 — — — 1 — — — — 1 Erythroblastosis Foetalis 1 - - - 1 - - - - 1 Cerebral Haemorrhage 1 — — — 1 — — — 1 C. Infections Bronchitis - - - - - - - - 1 1 Broncho-pneumonia — — — — — 1 — — - 1 Gastro-enteritis - - - - - - - 1 — 1 D. Other Causes Asphyxia (accidental) - - - - - - 1 - - 1 8 — — — 8 2 1 1 1 13 Deaths Males 10. Females 3 The infantile mortality rate of 13.97 per 1,000 live births is the lowest rate ever recorded in Beckenham. Particulars have been obtained of thirteen of the fifteen deaths, and study of the table suggests that quite a large proportion of the deaths were from conditions which are at any rate theoretically preventable. Prematurity of birth still accounts for a large number of infant deaths. Although such a low mortality rate is encouraging, it is clear that there is still much that can be done. The death rate among illegitimate infants was very high, 136.36 per 1,000 live births compared with 11.41 per 1,000 among legitimate infants. The death rate among illegitimate infants is usually higher than that among legitimate ones, but the disparity in the rates is seldom anything like as great as this. NATURAL AND SOCIAL CONDITIONS. No change has taken place from the details printed in previous reports. 11 SANITARY CIRCUMSTANCES OF THE AREA. Sewerage and Drainage. No major alterations or amendments require report. GENERAL PROVISION OF HEALTH SERVICES IN THE AREA (a) Provided by Public Authorities. *1. Fever Hospitals. The West Kent Joint Hospital Board provided Fever Hospital accommodation for Beckenham and a number of other districts. *2. Maternity Hospital. The Beckenham Borough Council and the Penge Urban District Council maintained a Joint Hospital at Stone Park Avenue, Beckenham. *3. General Hospital. The County Council provided General Hospitals at Farnborough and at Orpington for acute cases and the chronic sick. The Hospital at Farnborough included a Maternity Block with 50 beds. *4. Tuberculosis. The Kent County Council were 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. (b) Local Clinic Services provided by the Local Authorities. The table on pages 14 and 15 shows the Centres and Clinics in operation up to 5th July, 1948, when the services were transferred to the Kent County Council. (c) Local Services provided by Voluntary Organisations. *1. Beckenham Hospital. This Voluntary Hospital had accommodation for 78 patients. It was the General Hospital for the district for the treatment of acute medical and surgical cases and was supported by voluntary contributions and charges made to patients. The Hospital provided Consultant's Out-Patient Clinics at which patients could receive the advice of a specialist by appointments which were made through the patients' own doctors. 12 *2. The South-Eastern Hospital for Children. This was situated just outside the Borough, but took a great many cases from the northern part of the area. *3. Heartease Hospital, Woodland Way, West Wickham. This was 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. (e) Homes for the Aged. The County Council remains responsible for the care of old people, but it is extremely difficult to obtain accommodation in homes for the aged. 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 1948 there were 6 private homes registered in the Borough and these provided a total of 81 beds. These premises were inspected under the Nursing Homes (Registration) Act, and 11 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 National Health Service Act, 1946. (b) General. For all general Nursing in the Home, the services of the Queens Nurses are available. This service was organised by the Beckenham and Shortlands District Nursing Association and the West Wickham and Hayes District Nursing Association. These Associations employed 5 Nurses. A small fee was payable according to the circumstances of the patient, or families could join as Annual Contributors. The number of visits made annually by these Nurses was about 10,000 and every type of case was undertaken with skill and kindness. 13 (h) Ambulance Facilities. 1. For Infectious Diseases. The West Kent Joint Hospital Board provided motor Ambulances for the removal of Fever cases to Hospital and returned cases to their homes when discharged. 2. For Non-Infectious and Accident Cases. The Beckenham and Penge Councils collaborated in a Joint Service administered by Beckenham, and this came into operation on 1st July, 1945. The vehicles were stationed at the Beckenham and Penge Fire Stations and all calls were received over the N.F.S. telephone system. The following table shows the calls dealt with by the Joint Service up to 5th July, 1948, when the provision of an Ambulance Service became the responsibility of the Kent County Council. Calls operated Accidents Removals to Hospitals Maternity Cases Calls Transferred to adjoining areas Mileage covered Day 1,014 195 679 140 42 10,853 Night 358 47 65 246 Total 1,372 242 744 386 42 10,853 NOTE : *Transferred to the Regional Hospital Board on the 5th July, 1948. *Transferred to the Kent County Council on the 5th July, 1948. LOCAL CLINIC SERVICES. Arrangements in force at 4th July, 1948. Service Days and Times Premises in Use 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.,Tues.,Wed., 10—12 Matron's Clinic Obstetric Consultant Mondays (weekly), 2—4 Maternity Hospital 14 Service Days and Times Premises in Use Child Welfare Monday, 2—4 Clinic Block, Hawes Lane, West Wickham Tuesday, 2—4 (a) Baths Annexe, Beckenham Road (b) Coney Hall Club, West Wickham Wednesday, 2—4 (a) Church Hall, Langley Road, Elmers End (b) Church Hall, Valley Road, Shortlands Thursday, 2—4 (a) Clinic Block, Town Hall (b) Church Hall, Lennard Road (c) Clinic Block, Hawes Lane, West 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 Dental (Infant Welfare Cases) Fridays — By appointment Clinic Block, Town Hall By appointment Clinic Block, Hawes Lane, West Wickham Ophthalmic Tuesdays, 2.30—4.30 Clinic Block, Town Hall Wednesday (once a month) 2.30—4.30 Clinic Block, Hawes Lane, West 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 was 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. 15 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 was carried out by the routine attention of the medical practitioner or midwife who had been engaged for the confinement In cases where a midwife only had been engaged it was necessary that the expectant mother should be examined at least twice during pregnancy by a medical practitioner. It was for this purpose that Antenatal Clinics were established. The Ante-natal Clinics were conducted by a panel of medical practitioners practising in the borough. Expectant mothers were invited to select from the names on the panel the practitioner whom they wished 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 were then made by the Public Health Department. Ante-natal examinations of those mothers who had arranged to have their confinements in Institutions outside the Borough were carried out by the Assistant Medical Officer of Health. All attendances at the Ante-natal Clinics were by appointment, by which means periods of waiting were reduced. Ante-natal Clinics for those mothers attending the Beckenham and Penge Joint Maternity Hospital were held at the Maternity Hospital: for all other mothers they were held at the Borough Clinics at the Town Hall and in Hawes Lane, West Wickham. Ante-Natal Assistant Medical Panel Officer Sessions held 17 21 Number of expectant mothers attending 65 69 Number of attendances made 138 224 (b) Inspection of home conditions; advice as to general hygiene, securing extra nourishment, provision of extra clothing, etc. The Health Visitors payed visits to the homes of expectant mothers and assisted in all these matters—except in the cases of those mothers who had engaged the services of a medical practitioner. 2. Arrangements for the Confinement. (a) Institutions. (b) Mothers' own homes. 16 (a) Institutions. The Institutions within the Borough were:— The Beckenham & Penge Joint Maternity Hospital. Two private Nursing Homes, registered under the Public Health Act, 1936. The Beckenham Hospital which took 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. 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. Home Helps. The Council was empowered to engage suitable women to assist in the housekeeping and domestic work of homes where the mother was confined in her own home; in certain cases the Council paid all or part of the fees for this attendance. A total of 169 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 48 maternity cases and 75 cases of illness for from 15-47 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 were made for the examination of mothers after their confinements. These examinations were carried out by the Assistant Medical Officer. During the period under review, 20 of these examinations were carried out. In addition, all mothers who engaged midwives for their confinements were invited to attend the Obstetric Consultant's Clinic for final examination and the correction of any abnormality caused by pregnancy and childbirth. 17 (b) Nursing Mothers and Infants. Supervision was carried out at the Infant Welfare Centres and by visits to the homes made by the Health Visitors. There were seven Infant Welfare Centres in the Borough and during the period 9 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 up to 5th July is summarised in the following table. INFANT WELFARE CENTRE ATTENDANCES, 1948. Town Hall Alexandra Elmers End Wickham Coney Hall Baths Shortlands Total Total 1947 Total Attendances 2,516 3,126 3,238 2,882 1,319 2,353 1,334 16,768 33,328 New Cases 99 121 105 112 39 102 57 635 1,333 Sessions Held 27 27 51 51 26 26 24 232 460 Aver. per Session 93 116 63 57 51 90 56 75 72 Doctors' Sessions 27 25 26 24 26 24 24 176 354 Cases seen by Doctors 318 518 496 197 168 383 253 2,333 5,229 Aver, per Session by Doctors 12 21 19 8 6 16 11 13 14 The following figures show the attendances of children in agegroups. Year of Birth. Attendances Made. 1943 283 1944 576 1945 786 1946 2,763 1947 9,723 1948 2,637 16,768 Five Health Visitors were engaged in Home Visiting and at the Infant Welfare Centres during the period. Particulars of the visits made are shown in the following table. 18 HEALTH VISITORS' HOME VISITS. New Cases Routine Visits to Childr'n under 1 Routine Visits Aged 1-5 Special Visits for Illness Expectant Mothers No. Reply Total Visits Miss Kendall 220 501 436 61 9 121 1,348 Miss Williams 119 452 441 49 5 180 1,246 Miss Gatherer 124 508 490 105 11 168 1,406 Mrs. French 121 574 374 53 7 156 1,285 Mrs. Anderson 125 206 198 60 2 87 678 Total 709 2,241 1,939 328 34 712 5,963 Comparison, 1947 1,466 2,670 2,602 609 41 1,216 8,604 Unmarried Mothers. The Rochester Diocesan Moral Welfare Council and the Catholic Rescue Society continued to bring cases of unmarried mothers to the notice of the Department. Arrangements were made for these cases to enter special Hostels maintained by Moral Welfare Societies. Adoption Act, 1939. The Health Department received notification under this Act for the proposed adoption of children. The Registered Adoption Societies asked the Department for a report on the home before placing any child and this was a very useful procedure. Any person who acted as a third party in arranging an adoption was required to give notice to the Health Department but in many cases arrangements were made direct between the parent and the adopter. Information was received from four registered Adoption Societies and 14 other bodies during the period relating to 18 children and all the homes were visited regularly. Adoption orders were made by the Courts in 18 cases. Close liaison was 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 was kept at the Centres and sold to the mothers at cost price. During the period, foods to the value of approximately £1,400 were sold. 19 The scheme organised 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 Infant Welfare Centres. The "take-up" of these issues varies very much in different districts, but the periodical statistics furnished by the Ministry of Food show quite conclusively that Beckenham is among those areas with the highest percentage. The figures for the period ending November, 1948, show that the issues were:— Cod Liver Oil 619 bottles representing 61.65% of the possible issues. Vitamin Tablets 141 packets representing 64.68% of the possible issues. Orange Juice 2,397 bottles representing 71.92% of the possible issues. 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. 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 gave most valuable assistance at the Beckenham Welfare Centres. At all Centres there was a band of volunteers who attended regularly and undertook a great deal of work which made it possible for the nurses to concentrate on giving advice and instruction to mothers. Some of the workers had been helping for periods of 10—20 years. Volunteers who were assisting when the service was transferred to the Kent County Council are listed 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. Davieson Mrs. Foster Mrs. Fry Mrs. Groves Mrs. MacWilliam Mrs. Morgan 20 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. Butler Mrs. Saunders Mrs. Greig Mrs. Lebban Mrs. Parham Coney Hall Mrs. Alexander Mrs. Sellows Mrs. Clarke Special Treatment. Arrangements were 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 1948, Infants 42 284 209 179 13 Boarded-Out Children. At the commencement of the year there were 8 registered foster mothers having charge of 12 children. At the end of June, 1948, there were 12 names on the register with 10 children and 2 temporary vacancies. The Health Visitors and the Assistant Medical Officer were Infant Life Protection Visitors and all homes were visited regularly. 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. Ten premises were exempted and two were not. Obstetric Consultant's Service. The consultants clinics were held at the Maternity Hospital: 22 sessions were held; 40 ante-natal cases and 194 post-natal cases were examined. The total number of attendances at the Clinics was 318 compared with 743 in 1947. Mr. D. M. Lindsay, F.R.C.O.G., was asked to see 14 Beckenham cases during the period. The following summary indicates the reasons for the consultations:— 21 (a) Ante-Natal Conditions. Ante-Partum haemorrhage (Placenta Praevia) 1 (b) During Labour. Generally Contracted Pelvis 1 Malpresentations 3 (Extended Breech, 2; Brow presentation, 1). Placenta Praevia 2 Fibroid in Lower Uterine segment 1 Other conditions 4 (c) Post-Natal Conditions. Perineal Repair 1 Retained Placenta 1 Caesarean section was performed on 6 occasions; the conditions necessitating the operation were:— Generally contracted pelvis 1 Placenta Praevia 1 Fibroid in Lower Uterine segment 1 Disproportion 1 Combined with operation for sterilisation 2 MATERNITY AND CHILD WELFARE DENTAL REPORT, up to 5th July, 1948. Sessions were held each Friday afternoon and at such other times as circumstances demanded, the total number of sessions being 34. The attendances were 271. SUMMARY OF TREATMENT. Adults Infants Attendances 133 138 Number treated 62 88 Extractions 104 42 Fillings 29 66 Dressings 42 53 Silver Nitrate — 37 Scalings 14 — Nitrous Oxide 27 15 Ethyl Chloride — 4 Local Injections 8 2 Impressions, etc. 23 — Dentures 9 — 22 DAY NURSERIES. Both Nurseries have been booked to capacity, and there have been waiting lists for admission, particularly for children under 2 years of age. 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 children under the care of trained teachers during the usual school hours. Outside these hours the children were looked after by the Nursery Staff. SpringFIeld—45 Places Beckenham Rd.—40 Places Month under 2 over 2 Total Days Open under 2 over 2 Total Days Open Remarks Jan 248 890 1,138 27 163 602 765 26 Feb 136 758 894 24 151 544 695 20 Mar 161 795 956 24 191 583 774 22 Easter April 131 649 780 26 215 664 879 22 May 34 566 600 24 175 638 813 20 Whitsun June 78 704 782 26 184 684 868 23 Total 788 4,362 5,150 151 1,079 3,715 4,794 133 BECKENHAM AND PENGE JOINT MATERNITY HOSPITAL. This Hospital was provided by the Borough of Beckenham and the Jrban District of Penge, and was administered by a Joint Committee of members of the two authorities. Admissions. The number of admissions up to 30th June, 1948, was 460. 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 10 days. This shortening of the lying-in period placed a considerable strain on the nursing staff, since every patient required 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 were held on three mornings every week. These clinics were conducted by the Resident Medical Officer and the Matron. During the period 467 cases attended for examination and these cases made 2,276 attendances. 23 An additional clinic was held each week by the Resident Medical Officer for the collection of blood samples, so that the Hospital Staff knew in advance all the essential facts for each individual patient in cast blood transfusion was subsequently needed at any time during Labour or in the puerperium. Gas-Air Analgesia. All members of the Nursing Staff were 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, were 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 period 12 pupils completed training and 8 passed the examination for Part I. Consulting Staff. Mr. Douglas Lindsay, M.D., F.R.C.O.G., in his capacity of Obstetric Consultant attended at the request of the Resident Medical Officer and of General Practitioners to give advice and treatment in all cases presenting special difficulties. He was also always ready to discuss any case with the Resident Medical Officer on the occasion 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 was very much appreciated. Dr. N. M. Jacoby was the Consulting Paediatrician to the Hospital Dr. Jacoby paid regular weekly visits to the Hospital and advised generally on the care of all infants, with particular reference to premature infants. His services were also available at any time for any emergency. STATISTICS for Period 1st January—30th June, 1948 Relating to the Beckenham and Penge Joint Maternity Hospital 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 24 3. Number of Maternity cases ad- Beckenham 337 460 mitted Penge 123 3a. Number treated in Ante-Natal beds 26 3b. Average duration of Ante-Natal Stay 2 days 4. Average duration of stay 10 days 5. Number of cases delivered by (a) Midwives 317 (b) Doctors 105 6. Number of cases in which medical 31 up to 31/3/48, when the assistance was sought by a practise of issuing medical midwife in emergency aids ceased. 7. Number admitted after delivery 6 (included in 3) 8. Number of cases of Pemphigus Neonatorum Nil 9. Number of cases notified as: (a) Puerperal Fever Nil (b) Puerperal Pyrexia 5 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) 52 (b) Number of Infants wholly breast fed on leaving the Hospital 365 11. (a) Number of cases notified as Ophthalmia Neonatorum Nil (b) Result of treatment in each case— 12. Number of Maternal Deaths Nil 13. Number of Still Births 11 14. Number of Infant Deaths 5 25 NOTES ON THE LOCAL ADMINISTRATION OF THE TRANSFERRED SERVICES. 1. Maternity and Child Welfare Service. Although some work for the care of Mothers and Babies had been done by voluntary committees in various parts of the Country for some years, the Act of Parliament which laid the foundation of the Maternity and Child Welfare Services was not passed until 1907. In that year an adoptive Act, called the Notification of Births Act was placed on the Statute Book, and this Act gave powers to those Local Authorities who adopted it to make provision for the care of mothers and young children. The Urban District Council of that time adopted the Act in April, 1908 : but they anticipated the formal adoption of the Act by appointing a Lady Health Visitor in the middle of 1907. Dr. George Carpenter, a distinguished children's physician, was then carrying out, on a part-time basis, the duties of Medical Officer of Health. He prepared a leaflet giving comprehensive instruction on the feeding, care and general management of babies, and this leaflet was handed to mothers by the Health Visitor who visited the homes. Dr. Carpenter, was however, a realist : he incorporated this leaflet in bis Annual Report for 1907, but added :— " after an experience of twenty years at two of the leading Children's Hospitals in London, I am no firm believer in medical literature for the poor." His experience had apparently made him somewhat pessimistic, for in the same report he said :— " it cannot be expected that the unmarried Health Visitor will be received with open arms by the young British matron. The young woman who has been presented with a baby feels that its presentation to her carries with it a profundity of knowledge as to its feeding and treatment, and no amount of literature or health visiting will alter that feeling." Still, Dr. Carpenter was quite willing to try : he felt that it was necessary to go further than— " thrusting pamphlets into their often unwilling hands." He recommended that personal instruction in the ordinary management of infants be given to (a) School Girls, and (b) young mothers, and he regarded the School Girls as the most fruitful soil. In this, Dr. Carpenter was well in advance of his times, because, although the instruction of the young mother has been developed to a high degree, the instruction of the School Girls in the care of infants by qualified and experienced persons has not so far found its way into the regular School curriculum. 26 Dr. Carpenter's pessimism was not justified really by results because by 1913 the calls on the time of the Health Visitor was so numerous that it was considered advisable to establish an Infant Welfare Centre, which was held once a week and at which the Health Visitor could watch the progress of infants and give all necessary advice. In 1908 the Health Visitor made 599 home visits : this relatively small number did justify in some measure, Dr. Carpenter's pessimism ; but when one considers that the Health Visitor also acted as the School Nurse in the elementary schools it represented a reasonable start. The service developed rapidly and by 1914 the number of home visits was 2,500, and there was a regular weekly Infant Welfare Centre with a Medical Officer in attendance. At the end of the first war, the Maternity and Child Welfare Act, 1918, gave further powers to Local Authorities. Under this Act, and subsequent orders and memoranda, the Urban District Council— (a) Approved a comprehensive scheme for the care of expectant and nursing mothers and young children drawn up by my predecessor Dr. J. M. Clements. This scheme included the provision of milk and the supply of Infant Foods at the Welfare Centre. (b) In conjunction with the Urban District of Penge, acquired premises in Croydon Road, Beckenham, for use as a Maternity Home. During the ensuing years, the service was expanded to meet the needs of a growing district, but all subsequent developments were either the implementation of new powers conferred on Local Authorities, or extensions of the scheme put forward by Dr. Clements, whose original scheme remains the basis of the service as it exists to-day. Additional Health Visitors were appointed and more Infant Welfare Centres opened as the years went by. All of the specialist services of the School Medical Service were made available to children under the age of five, including the development of a special dental service for mothers and young children. An ante-natal scheme was established and conducted by the general medical practitioners of the district, under which expectant mothers were examined by the doctor of their choice— the same doctor being subsequently called at the confinement if medical help were required : this scheme provided an excellent service for many years, and I personally very much regretted its termination. Other services were established during the recent war to meet special needs. Two Day Nurseries were opened in the Borough and an attempt —only partially successful— was made to provide Home and Domestic helps for domiciliary maternity cases, and for those who through illhealth or other infirmity were in need of assistance in the ordinary work of their homes. The relative failure of the Home Help Scheme was due 27 to the demands which the war effort was making on the woman-power of the country, and to the fact that the remuneration authorised could not compete with the wages paid in the war industries and in private employment. The Day Nurseries served a very useful purpose: both were recognised as training institutions for Nursery Nurses and Assistants; and the best tribute which can be paid to the constant care and supervision exercised by the Matrons of the Nurseries, and the Assistant Medical Officers of Health is the fact that, during the six years of their existence, only one extensive outbreak of infectious disease occurred this being an outbreak of a mild type of Dysentery. On July 5th, 1948, the Corporation was employing five Health Visitors ; there were ten Infant Welfare Centre sessions held every week and two Ante-natal clinics. The average number of home visits annually was about 10,000, and in 1947 the attendances at the Infant Welfare Centres totalled 33,328. Glancing back over the old records, it is noticeable that when there was only one Health Visitor, she managed to make over 3,000 home visits a year ; this was largely because there was then only one Infant Welfare Centre held each week, and all the rest of her time was devoted to home visits. The increase of Welfare Centres was necessary as the district, developed, but I have never regarded the large number of attendances, at these as a criterion of the efficiency of the service. The Health Visitors most valuable work is done in the homes, and it is regrettable when the pressure of attendances at clinics encroaches on time could be better employed : nevertheless it is necessary to maintain the efficient working of Infant Welfare Centres by increasing the number of sessions when the attendances at any particular Centre tend to become excessive and unwieldy. The remedy is to increase the number of Visitors, but in recent years the demand for these officers has greatly exceeded the supply. Growth of services does not necessarily imply increase in efficiency. It is not very easy to assess precisely the results of a personal health service. Those who work in the service among the mothers and babies know from their own experience and observation how great an improvement has taken place over the years in the health, care and management of infants and young children; but these are subjective impressions cannot really be conveyed in a comprehensible way to other persons The only statistical information readily available relates to mortality rates, and to the Infantile Mortality Rate and the Maternal Mortality Rate in particular. I think that the following tables do provide some evidence of improvement in the welfare of Infants and Mothers since the Maternity and Child Welfare Service came into operation over 40 years ago.It is fair to assume that decline in mortality has been accompanied by reflects a decline in morbidity. 28 Infantile Mortality Rates in Beckenham. 1892— 1948. 1892—1901 114.3 per 1,000 live births Prior to the introduction of the Service. 1902—1907 99.0 „ „ „ „ 1908—1913 75.6 „ „ „ „ 1914—1919 63.5 „ „ „ „ Includes the years 1918 and 1919 when many babies died in the pandemic of Influenza. 1920—1924 53.19 „ „ „ „ 1925—1929 48.03 „ „ „ „ 1930—1934 35.51 „ „ „ „ 1935—1939 33.04 ,, ,, ,, ,, 1940—1944 30.04„ „ „ „ 1945—June, 1948 27.16„ „ „ „ Maternal Mortality Rates in Beckenham. 1920—1948. 1920-1924 2 .23 per 1,000 births 1925-1929 3.24 ,, ,, ,, 1930—1934 2.53 ,, ,, ,, 1935-1939 1.47 ,, ,, ,, 1940-1944 0.70 ,, ,, ,, 1945-june, 1948 0.85 „ „ ,, Of course, it would not be right to claim the whole of this saving of infants' lives for the special Maternity and Child Welfare Service: many other factors have their part. Other activities of the Public Health Service such as the improvement in housing and other environmental conditions; control of infectious disease, the supervision exercised over the production, storing and distribution of food—particularly milk-have all had their effect. Improvement in the economic conditions of the poorer members of the community and the reduction in the number of children per family have been of importance. But most important of all has been the interest shown by the mothers and their appreciation of the benefits to be received from the regular supervision of their children and the advice given by persons with experience. 2. Beckenham and Penge Joint Maternity Hospital. The original Maternity Home was opened in August, 1920, in a large house in Croydon Road, Beckenham. The establishment of this Home was the joint effort of the Beckenham and Penge Urban District Councils. Throughout the whole period of its existence, the Maternity Hospital was asministered by a Joint Committee with representatives from both Authorities, and the Committee's Officers were the Officers of the Beckenham Authority. When the Home was opened it had accommodation for ten patients, but to meet the increasing demand, the number of beds was soon raised to fourteen. Quite early in its career, the Home was recognised by the Central Midwives Board as a Training Institution for pupil midwives. 29 Although subject to the usual inconveniences which always exist it premises adapted and not specially designed for the work, the Home provided very valuable service for nineteen years. After the first two or three years, it was always filled to capacity, and in the last eight or nine years of its existence, could not accommodate all those who sought admission. Additions and improvements were made as the years went by, including the provision of a separate Isolation unit and a residential hostel for the staff. The overhead costs were low, and the pupils who formed nearly 50 per cent, of the staff paid fees for their training ; consequently the total annual cost was very moderate. During the nineteen years of its existence 5,573 patients were admitted ; the maternal mortality rate over the whole period was 1.79 per 1,000 births ; the rate for the country as a whole during those years was about 4 per 1,000 births. Seventy-nine pupils were trained and passed the qualifying examination of the Central Midwives Board. In 1934 it was evident that much more accommodation was needed to meet the demands of the two districts. Steps were taken to provide a new Hospital and in January, 1940, the Hospital in Stone Park Avenue, Beckenham, was opened. The new Hospital contained 30 lying-in beds, four beds for antenatal cases, and a separate isolation block with four beds. Most members of the Council will be familiar with the new building, and although the costs of maintenance were high, it was a well designed and equipped hospital of which any district could be justly proud. The war brought its vicissitudes, but the work was steadily carried on in spite of lengthy periods of enemy bombing. The difficulties of obtaining sufficient nursing and domestic staff during these years were very great, but a depleted staff worked with great devotion and fidelity. For a few months in 1944, at the request of the Ministry of Health, the Hospital was moved to Wales. After the end of the war, the demands on the accommodation increased enormously, and to help to meet this demand, the period of stay in the hospital was reduced from the normal fourteen days to ten days. In the last complete year during which it remained under the control of the Joint Committee, nearly one thousand patients were admitted. In January, 1944, the Hospital was recognised by the Central Midwives Board as a training institution under Part I of the new Training Regulations, and the problem of securing an adequate nursing staff was made easier. A Resident Medical Officer was appointed in 1946. The Hospital also had the services of a Consulting Obstetrician and a Consulting Paediatrician. 30 From January 1940, to June, 1948, 5,164 patients were admitted to the Hospital, and the Maternal Mortality Rate was 1.55 per 1,000 births. The Hospital always admitted difficult cases and cases of special emergency and several of the mothers who died had not previously been under the supervision of the staff and were admitted in a dying condition. Summing up the work done in both buildings over a period of twenty-eight years, the following figures are obtained Total Admissions 10,737 Maternal Deaths 18 Maternal Mortality Rate Total 1.67 per 1,000 births from Sepsis 0.46 „ „ „ from other causes 1.21 „ „ „ Neo-natal Deaths 162 Neo-natal Death-rate 15.09 „ „ „ Pupils trained 125 Throughout the whole period during which the Hospital was under the control of the two Authorities, all those who were connected with its administration and operation worked as a single united team. Recognition of individual services were recorded at Meetings of the Joint Committee just prior to the date when the Hospital was transferred to the control of the Regional Hospital Board. 3. Diphtheria Immunisation. Although the mortality from Diphtheria had been considerably reduced as a result of the introduction of Antitoxin in the closing decade of the last century, the disease remained prevalent and continued to cause the deaths of many children. In Beckenham, the records show that the disease appeared in waves, a period of high incidence occurring every six or seven years. When I took up my duties in the autumn of 1927 the district was experiencing one of these periods of high incidence, in which, as was usual, the children of school age were the group principally affected. For a number of years a great deal of work had been done in research laboratories in perfecting an antigen, the administration of which by injection conferred a high degree of immunity on the persons treated. In 1927 this form of protection was in active use in many institutions in the country and a few local authorities were offering it to the general public. In 1928 the Urban District Council approved a scheme for inviting parents to have their children protected by this method, and in the autumn of that year regular immunisation clinics were established in the district. With the unhappy effects of the recent outbreak fresh in their minds, a large number of parents consented to the treatment; and, although in subsequent years the receding danger lead to a certain amount of apathy, it was found possible, by the co-operation of the Head Teachers 31 of the Schools with the staff of the Department, to maintain a reasonable level of protection among the children of Beckenham. The percentage of protected individuals was seldom much above fifty, and though this was not an ideal figure, it did seem to be sufficient to prevent the reappearance of those waves of high incidence from which the district had suffered in the past. Although the Ministry of Health had always encouraged this form of protection, it was not until the early years of the late war that the Government started a nation-wide campaign for Diphtheria immunisation ; as a result of this a considerably larger proportion of the children were protected. I gave a full account of the work done in Beckenham in a monograph presented to the Council in 1943. Since that time the incidence of the disease has continued to decline, and in the last four years, the total number of cases notified was ten: only two of these cases occurred in children in the Council's schools, and in the same period there was one death from the disease. I reprint the Table included in the Annual Report for 1945, brought up to June, 1948, when the administration of the Service passed into the hands of the Kent County Council. Five year period. Attack rate per 1,000 population. Death rate per 1,000 population Case Mortality rate. Deaths per 100 cases 1895—1899 1.24 0.19 15.8 1900—1904 1.27 0.17 13.9 1905—1909 1.92 0.14 7.4 1910—1914 2.32 0.15 6.6 1915—1919 0.93 0.03 3.4 1920—1924 0.88 0.07 8.2 1925—1929 1.07 0.09 8.3 1930—1934 0.40 0.008 2.0 1935—1939 0.22 0.014 6.6 1940—1944 0.24 0.017 7.1 1945—June, 1948 0.04 0.004 10.0 The Case Mortality Rate shows that although the incidence is very greatly reduced, the disease is still dangerous. 4. Civil Ambulance Service. This service was administered by the Fire Brigade Committee in the years before the war. The service started in January, 1920, and the first motor ambulance was presented by the British Red Cross Society. In the first complete year, the Ambulance Service were called upon to answer only 87 calls. Since the vehicle was manned by members of the Beckenham Fire Brigade, there was an admirable machinery to receiving and answering calls, and only a small number of staff in addition to those required for Fire Service duties was required; consequently the service was conducted very efficiently and very economically. 32 The calls on the service increased as the years went by and just prior to the late war, between eight and nine hundred calls were dealt with annually. At the beginning of the war there were two motor ambulances, one of which had been purchased in 1930. The Fire Service continued to man the ambulances until the formation of the National Fire Service, when the work was taken over by the Civil Defence Casualty Service. This service was disbanded at the end of the War in Europe in May, 1945, and the responsibility for carrying on the work devolved on the Public Health Committee. This entailed the engagement of a considerable number of men which greatly increased the cost of the service without adding to its efficiency. The Beckenham and Penge authorities joined in a scheme to serve both districts and the service was administered from Beckenham. The National Fire Service co-operated to the extent of providing quarters and messing arrangements for the staff at the Beckenham and Penge Fire Stations, and by allowing all calls to be received at the watch-rooms of the respective stations. The pre-war ambulances in the possession of Beckenham and Penge were showing signs of wear : it was not possible to purchase new vehicles, and so the service was largely worked with old Civil Defence ambulances equipped with special bodies. These vehicles were originally large private cars and could not be expected to stand up to the constant heavy work they were called upon to undertake. The number of calls received annually had risen to over 2,000. Reciprocal arrangements for dealing with calls were made with all neighbouring authorities. I think that it is greatly to the credit of all concerned that in the three years during which this service was in existence, only 7 per cent. of all calls received had to be transferred to neighbouring ambulance services. INFECTIOUS DISEASE. Diphtheria. Two cases were notified during the year. In one case the diagnosis was not confirmed and the notification was subsequently withdrawn. In each of the two previous years, two cases were notified. This almost complete extinction of the disease is highly satisfactory, but, although it sounds paradoxical, it makes the need for immunisation even more necessary than before. As I have pointed out in the past, freedom from the disease depends on the degree of individual and of mass resistance present in the population. In communities, resistance to infectious disease is naturally governed by the gradual acquisition of an active immunity, which is produced by the repeated reception of subclinical doses of the toxins of the diseases : each of these minute doses helps to build up a natural content of antitoxin in the person's tissues, and in time the amount of antitoxin so produced is sufficient to protect against even massive doses of infection. To enable this natural 33 INFECTIOUS DISEASE. The following Table gives the number of cases notified during the year, the number removed to Hospital and the number of Deaths. 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 Whooping Cough 96 37 133 11 59 59 — — 2 2 — — — — Chickenpox 110 10 120 — 16 86 14 3 — 1 — — — — Mumps 80 15 95 — 6 75 8 2 4 — — — — — Poliomyelitis 7 — 7 — — 1 4 1 1 — — — 5 — Polioencephalitis 2 — 2 — — 2 — — — — — — 2 — Scarlet Fever 70 37 107 — 17 71 13 2 3 1 — — 34 — Measles 200 118 318 7 117 168 14 9 2 — 1 — — — Pneumonia 16 7 23 — 4 — 1 — 2 11 5 — 1 18 Cerebro Spinal Meningitis 1 1 2 — — — — 1 1 — — — 2 — T.B. Meningitis 1 — 1 — 1 — — — — — — — 1 — Erysipelas — 3 3 — — — — — — 2 1 — — — Paratyphoid B. 1 — 1 — — — — — 1 — — — 1 — Undulant Fever 1 — 1 — — — — — 1 — — — 1 — Puerperal Pyrexia 13 1 14 — — — — 5 8 — — 1 1 1 (11 were Hospital Confinements) Diphtheria — 1 1 — — 1 — — — — — — 1 — 34 immunity to occur, it is necessary that there should be opportunities for individuals to receive these small doses of infection, and this can only happen if the disease is constantly present in the community. If a community has been free from a disease for many years, the natural immunity of the individuals will practically disappear, and the re-introduction of the disease would result in an extensive and very serious epidemic. So far as the present state of affairs regarding Diphtheria is concerned, it can be argued that the infection has not in point of fact disappeared, but has merely become concealed—that although it is still present amongst us, the high degree of protection present in the community prevents the characteristic reaction between parasite and host, which we recognise as clinical Diphtheria. I think this view is correct because it would be quite unjustifiable to assume that the parasite itself had ceased to exist. The position is, then, that we still have a dangerous disease producing parasite in our midst, but that our protective measures are sufficient to hold it in check, and that if we do not maintain our present high degree of protection, it will inevitably re-assert itself. There is possibly another factor at work. From bacteriological work it appears to be true that the repeated passage of a particular parasite through susceptible hosts, increases its virulence, whilst similar passage through immune hosts attenuates or weakens it. Whether as the result of the maintenance of high degree of protection over a number of years, a marked reduction in the virulence of the parasite will be achieved remains to be seen. It is safe to say that such a desirable state of affairs has not yet arrived, because cases of infections by a parasite with a very high degree of virulence continue to occur in all parts of the country. During 1948 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. Up to 30th June, 1948, 433 new cases completed treatment and 182 old cases had extra doses, compared with 869 and 490 for 1947. Scarlet Fever. The number of cases notified during the year was 107, compared with 54 in 1947. The incidence was proportionately greatest in the West Wickham Ward, but cases occurred in all parts of the Borough. Incidence was fairly evenly spread over the year, the months with the highest incidence being March and June. The disease was mild—as it has been for many years now—and there were no serious complications. 35 Poliomyelitis and Polioencephalitis. Seven cases of Poliomyelitis and two cases of Polioencephalitis were notified. An isolated case of Poliomyelitis was notified in January, and the remaining cases occurred in the autumn : these cases were in the Shortlands, Copers Cope and Langley Park Wards. Detailed investigation failed to show any connection between the cases, except for the fact that three occurred in one household—a somewhat unusual state of affairs In a past annual report (1936) I referred to a condition which I called Epidemic Vomiting. Subsequently, accounts of this illness were reported in the medical journals. It is usually a very mild illness which seldom lasts more than thirty-six hours, and is definitely of an infectious nature; medical aid is not usually sought and so it is only by chance that out becomes aware of its existence. I have noted outbreaks on two occasion! since I first referred to it, and it is curious that on those particular occasions it was followed by the occurrence of a few cases of poliomyelitis. As mentioned above, knowledge of its existence is incomplete, but it seems to be most prevalent in the summer months. It enquiring into the cases of poliomyelitis this year, I found that epidemic nausea and vomiting had been present in one of the areas shortly before poliomyelitis appeared. I do not believe that the infection in epidemic vomiting is a gastro-intestinal one, but suggest that it may be duetoai affection of the central nervous system—possibly of the centres in the brain stem. This is at present just a suggestion, though the sudden explosive character of the vomiting closely resembles the vomiting which is produced by the injection of the drug known as Apomorphine The apparent association is perhaps just coincidental: epidemic vomiting almost certainly occurs quite often, though it is seldom reported ; whilst cases of definite poliomyelitis are comparatively rare Moreover I was not aware of any outbreak of this particular kind of vomiting occurring in the weeks preceding the large incidence of poliomyelitis in 1947. Still, it would be interesting to know whether any association between the two conditions has been observed in other districts. Measles. The number of cases notified was 318 compared with 253 in 19ft The incidence of Measles is still irregular and unpredictable. I append charts showing the annual incidence of measles in the ten years preceding the war, and in the nine years since 1940. The child population was constantly on the move during the war years, and this may have been the cause for the alteration of the regular periodicity of the pre-war years. During the last three years, the population has been more stable, but there is still no sign of the incident reverting to its previous regularity. 36 37 Epidemic Diarrhoea. This disease becomes notifiable annually during the period 15th July to 15th October. No cases were notified. Puerperal Pyrexia. Fourteen cases were notified. Of these, 10 occurred in the Beckenham and Penge Joint Maternity Hospital, 3 in other institutions and 1 in the patient's own home. Other Diseases Notified. Whooping Cough (133 cases) occurred mostly during the firs; half of the year. Chickenpox (120 cases) and Mumps (95 cases) occurred mostly during the first quarter of the year. Scabies. It has not been found necessary to continue the war-time arrange ments for the treatment of scabies. Instructions and material are issue; to any cases referred to the Department. Overseas Contacts. Information was received from Ports and Air Ports of the arrival of 3 persons from areas where Smallpox and or Cholera existed. These cases were visited daily until we were satisfied that no infection existed Bacteriological Work. The number and results of the examinations made at the Public Health Department Laboratory up to 30th June, 1948, was:— Disease Suspected Total 1948 Results Comparative Total for 1947 Positive Negative Diphtheria 19 — 19 95 Tuberculosis 17 — 17 39 Other Diseases 31 — 31 12 Total 67 — 67 146 Tuberculosis. The total of 71 cases compare with 81, 78, 64, 79 and 71 in the preceding five years. In addition to the new cases there were 9 definite cases transferred from other areas, and 2 old cases restored to the register. 6 cases were not notified until after death. At the end of the year, the number of notified cases in the area was:— 38 289 Pulmonary Males, 246 Pulmonary Females, 51 non-Pulmonary Males and 38 non-Pulmonary Females; a total of 624 cases which compares with 578 last year. 42 cases were placed off the register for the following reasons: Died, 22; Cured, 5; Left Area, 14; Withdrawal of notification, 1. New Cases attending the Tuberculosis Dispensaries for the first time during 1948. (information from the tuberculosis officer) Adults Children under 15 years Male Female Male Female Pulmonary 28 24 — — Non-Pulmonary — — — — Negative 129 118 30 55 Contacts Negative Positive Contacts examined 127 2 Number of patients admitted to Sanatoria during the year : 61 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 £1,500 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 tor the removal of a patient to hospital. 39 TUBERCULOSIS—Table of Notifications and Deaths, 1948, from Local Records. Sex Total Ages Wards M. F. 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. Shortlands w.w. Notifications New Cases only Pulmonary 36 26 62 3 1 2 14 9 13 8 7 3 2 7 16 4 3 12 1 5 14 Non-Pulmonary 4 5 9 1 2 - 3 2 - 1 - - - 2 1 2 - 3 - - 1 Totals 40 31 71 4 3 2 17 11 13 9 7 3 2 9 17 6 3 15 1 5 15 Deaths Pulmonary 8 11 19 - - - - 1 6 6 3 2 1 - 1 4 1 3 5 2 3 Non-Pulmonary - 3 3 1 - - - - - 1 - 1 - - - - - 1 1 - 1 Totals 8 14 22 1 - - - 1 6 7 - 3 1 - 1 4 1 4 6 2 4 40 REPORT ON THE SANITARY INSPECTION of the DISTRICT FOR THE YEAR 1948 By G. A. Webber, Chief Sanitary Inspector, Beckenham Borough Council. The many calls on the services of the Sanitary Inspectors were maintained during the year 1948. In the earlier months of the year our support was sought for almost every licence application, but with the raising of the "free" limit from £10 to £100 the position eased. 374 licence applications were supported compared to 500 in 1947. The sense of frustration imposed by our inability speedily to act in the face of so many controls remained. One has the greatest sympathy with owners (and, of course, occupiers) whose desire to restore their properties to a proper and reasonable degree of comfort is hampered by restriction, however necessary that restriction may be ; and one must continue to deplore the actions of those who use every possible artifice to evade their responsibilities. The hands of such persons have considerably been strengthened by the existence of control and restriction in the execution of work to property, and they have not been slow to take full advantage of their opportunities. It is pleasing to record that such persons are few in number, but nevertheless proper to emphasize the costly nature of the administrative work necessitated by their actions ; what time insanitary and unhygienic conditions must perforce continue to exist. The desired result is, however, finally achieved by the systematic closing of all loopholes through which escape is possible. I should like, on the other hand, once again to express appreciation and thanks to the vast majority of persons with whom our work brings us into contact, usually with the object of pointing out that they are required to take certain action in a particular matter. Co-operation is, generally, readily forthcoming and here one should specifically mention the owners of rented properties in the Borough, so many of whom still receive pre-war rentals and are required to maintain increasing standards of comfort at post-war price levels. Although the contrary may have been assumed to be the case, therein lies the reason for the institution of Housing Act procedure to many of our properties which, by dint of age, and enforced neglect during the years of war, coupled with bomb damage, had reached such a pitch of disrepair and insanitation as to warrant the closest attention. A Local Authority has a specific duty in such cases to institute measures of remedy, by the implementation of the Public Health and/or the Housing Acts. There is an important difference between these two Acts. Items of disrepair and sanitary defects may properly be dealt with by each but in the case of the Public Health Act, providing a nuisance is proved, and the person legally in default is before the Court, the Bench have to make an Order requiring abatement, from which there is no appeal. The Housing Act, on the other hand, gives certain rights of appeal. Accordingly it is fairer to an owner of property, where numerous sanitary defects or nuisances exist, to allow him the facilities provided by the law. We do, of course, still serve far more Notices under the Public Health Act than under the Housing Act, the properties dealt with under the latter being those where, because of their advanced dilapidation, there is reasonable need to implement the provisions of the Act both from the Authority's and the Owner's point of view. The decision to institute this general course of action was first taken in 1946 when six properties in West Wickham were renovated from hovels to units of reasonable and sanitary housing accommodation. The work has continued, but is necessarily slow, the administrative work being vastly different in character, and taking much longer. Details are appended giving statistical information, particularly in relation to work arising from complaints :— Number of complaints received and investigated 2,049 Number of initial visits 3,992 Number of revisits 6,583 Number of Intimation Notices served 944 (The figures relating to Notices served do not include those issued to support licence applications—viz 374) Nuisances Found and Remedied. found remedied Structural defects—external 1,728 858 Structural defects—internal 2,760 1,587 Insanitary conditions, other than vermin 68 48 Verminous conditions 13 13 Choked drains 204 204 Other drainage defects 295 265 Defective sanitary appliances 197 163 Insufficient or unsuitable water supply 16 16 Absence of dustbins 46 44 Offensive accumulations 1 1 Totals 5,328 3,199 Housing—Inspection of Dwelling Houses during the Year. Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,636 Number of inspections made for the purpose 8,082 Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 106 Number of inspections made for the purpose 359 Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 0 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 944 Number of dwelling-houses in respect of which informal notices were served 944 Number of dwelling-houses in which defects were remedied after service of informal notices 892 Number of dwelling-houses in respect of which formal notices were served requiring defects to be remedied 162 Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) by owners 171 (b) by Local Authority in default of owners 1 The number of complaints received in 1948 was slightly less than in 1947, as also was the number of visits and revisits paid by the Inspectors. The number of defects found and remedied, however, 42 greatly increased, and this undoubtedly has relation to the concentration given to the poorer class property in the Borough, by the exercise of Housing Act procedure. It will be noted that the verminous conditions discovered remained low, but in two cases the circumstances were particularly bad, and very stringent action was necessary to restore the property concerned to habitable condition. In both cases the inmates of the houses were removed to Hospital, and one person still remains away. This, with the co-operation of property owners, enabled us thoroughly to disinfect, repair and redecorate the premises. It is pitiful to see the conditions which self-neglect can induce, but the much happier circumstances which now prevail in these homes which, when first discovered were littered with the accumulation of years, infested with vermin, and occupied by persons sick in health physically and mentally, makes worth while the unpleasant tasks which fell to our lot in the early stages of the cases. We continue to find many broken and defective drainage systems resulting undoubtedly from war damage, and this will probably be a continuing factor in our work. Properties not possessing main drainage systems. The position remains substantially the same as the details given in the 1947 Annual Report. Five domestic properties have been connected to main drainage during the year, where previously cesspool drainage only was available. Proposals for conversion in respect of four other properties have been put forward but no work thereon had commenced by the end of 1948. Details to the 31st December, 1948, may be summarised as follows :— Number of cesspools in the area 18 Number of domestic properties connected to cesspools 28 Number of sports pavilions connected to cesspools 11 Number of properties having earth closet or chemical closet accommodation 7 (Not including moveable dwellings.) Moveable Dwellings. Six families occupied moveable dwellings under licence from the Council during 1948. Frequesnt inspections were made, but no public health nuisance was discovered. Legal Proceedings. Proceedings were commenced in eleven cases where owners failed to comply with Statutory Notices served by the Authority. Where work was commenced after the laying of the Information but before the date fixed for the hearing the proceedings were withdrawn. In other cases Nuisance Orders were obtained with the imposition of fines and /or costs. In one case the Bench made a Nuisance Order, and fined the Owner £3 0s. Od. with £3 3s. 0d. costs. The owner failed to comply with the Order and the Court imposed a daily penalty of 5 /- for 32 days continuing default plus £3 3s. Od. costs. The Council, exercising its right, then executed the work, and instituted action to recover the costs from the Owner. Beef sausages which proved to be deficient in meat content formed the subject of prosecution, in that the article purchased was not of the nature substance or quality demanded. The defendant's were fined £5 0s. 0d. 43 A quantity of oatmeal deposited for the purpose of sale, was found to be contaminated with mouse excreta. The Sanitary inspector formally seized the oatmeal and secured its condemnation. The firm concerned were subsequently fined £2 0s. 0d., and £2 2s. 0d. costs. Olive oil, found to be adulterated with Arachis Oil resulted in the Vendors being fined £15 0s. 0d., with £5 19s. 5d. costs. Food and Drugs Sampling. During 1948, 243 samples were purchased and submitted to the Public Analyst. Details are appended:— formal samples informal samples Milk 135 17 Beef Sausages 2 — Sponge Mixture — 2 Cake Flour — 2 Apple Juice — 2 Yorkshire Pudding Mixture — 2 Bicarbonate of Soda — 1 Savoree — 1 Worcester Sauce — 1 Coffee and Chicory Essence 1 1 Black Pepper 1 1 Orange Malt Wine 1 — Lemon Squash 1 — Grapefruit Squash 1 — Mustard Sauce — 1 Aspirin — 1 Ice Cream — 41 Horse Radish 1 1 Rennet — 1 Butter 3 — Margarine 3 — Lard 1 — Jam 2 — Sago 1 — Fish Paste 1 — Malt Vinegar 2 — Olive Oil 3 — Ground Cinnamon 1 — Mustard 1 — Coffee Extract 1 — Salad Cream 1 — Raisin Flavoured Wine 1 — Pepper (White) 2 — Cordial 1 — Ground Ginger 1 — 168 75 A sample of Olive Oil found to be adulterated, and Beef Sausages not conforming to legal standard resulted in the institution of legal proceedings, to which reference has already been made. The Sale of Milk Regulations, 1939, made under the Food and Drugs Act, 1938, prescribe the following presumptive standards " Where a sample of milk contains less than 3 per cent of milk fat or less than 8.5 per cent, of milk solids other than fat, it shall be presumed for the purposes of the Food and 44 Drugs Act, 1938, until the contrary is proved, that the milk is not genuine by reason of the abstraction therefrom of milk fat or milk solids other than milk fat or the addition thereto of water." On the 8th April, 1948, a formal sample of milk was taken from a milk roundsman employed by a local producer-retailer. The Public Analyst certified the milk as containing only 2.75 per cent. of milk fat and 8.6 per cent. of solids-not-fat. With those bare facts it had to be presumed that there was an adulteration of the milk, but after discussion with the Analyst it was agreed that, before the question of legal proceedings was considered, a further formal sample should be taken from the roundsman, together with samples of the milk at the time of production. The second formal sample was taken on the 12th April, 1948, and analysis showed:—Fat, 2.7 per cent.; Solids-not-fat, 8.7 per cent. Again there was presumptive evidence of adulteration. On the same day samples were taken from each of two churns, the result of the afternoon milking, and on the following morning, the 13th April, 1948,1 was again present during milking operations and took samples from four churns. The analysis were as follows:— fat solids-not-fat Afternoon Milking Churn 1 4.1% 8.7% Churn 2 3.6% 8.6% Morning Milking Churn 1 3.0% 8.7% Churn 2 3.3% 9.1% Churn 3 3.05% 8.5% Churn 4 2.7% 8.7% It was known that the retailer bottled his milk direct from the churns, and the above results, particularly of the morning milk, proved that the farmer was not, in any way, wilfully adulterating the milk. It will be seen that milk bottled from Churn 4 would give an "illegal" low fat content. Some purchasers, however, were receiving a high fat content milk, e.g. the bottles filled from Churn 1 of the afternoon milking. At this stage of the investigation the farmer had, legally, a complete answer to the case, but he agreed that some of his customers were not receiving a good quality milk, as was their due. There are many reasons to account for the production of low fat content milk. The two reasons apparently obvious in this case were (1) the breed of dairy cow and (2) the considerable length of time between afternoon and morning milking. This farmer's herd is nearly 100 per cent. Friesian, a breed common in the South of England, and known to give milk high in quantity, but low in quality. The farmer milked at about 3 p.m. each afternoon and at about 6 a.m. each morning, so that consecutive intervals were nine hours and fifteen hours. The farmer did not look favourably on the suggestion that he should introduce into his herd Channel Islands cattle, which give a high percentage of milk fat compared with Friesians. He agreed, however, to lesson the period between afternoon and morning milking so far as he was able with the labour available. The reduction in interval commenced at once, but samples taken at milking times on the 20th April, 1948, and the 13th May, 1948, still showed the morning milk to be low in fat content. 45 During the lengthy period of the investigation, many discussions were held with the farmer in order to ensure that the public received milk conforming to the legal standards. Afternoon and morning milk is now bulked. The result of a formal sample of milk taken when bulking was instituted was as follows:—Milk Fat, 3.4% ; Solids-not-Fat, 8.7% —a perfectly genuine sample. Subsequent analyses also proved satisfactory. The Public Analyst informed me that similar trouble had occurred all over the County, so that ours was by no means an isolated case. A sample of loose mustard proved to be inferior in that there was a deficiency of allyl isothiocyanate. The mustard had deteriorated during storage and, following representation to the Vendors, the stock was withdrawn from sale. A sample sold as lard proved to be vegetable cooking fat. At the present time there is no difference in price and the substitution is not a fraud, but even though the two are lumped together in the " fat ration" lard is, of course, the fat of the pig, and the distinction should clearly be maintained. A letter was sent warning the Vendors of their responsibilities in the matter. Numerous samples were taken from the two dairymen in the Borough who pasteurise their bulk milk supplies. These samples were submitted to heat treatment and keeping quality tests, and a series of failures, indicating insufficient heat treatment, made it necessary to conduct a special investigation. Milk Heat Treatment Plants, in common with other mechanised installations, are subject to breakdown ; and repair, necessitating the use of spare parts in short supply, is often delayed. In such cases, however, immediate arrangements are made for pasteurisation to take place elsewhere. In the series of failures mentioned above, no mechanical failure was apparent, and, together with the dairymen, we were much perturbed by the results. The matter was less understandable because the Dairymen had submitted to analysis samples taken at the same time, and the results were satisfactory. After consultation with our own Analyst it was agreed that a series of samples should be taken by this Authority, by a neighbouring Authority, by the Ministry of Agriculture and by the Dairymen concerned. All these samples proved satisfactory, and no indication was obtained as to the reason for the previous conflicting results. Many factors may cause a sample to fail the very delicate "heat treatment" test, and it would be quite wrong to assume that in every case of failure an "unsafe" milk is being vended to the public. Nevertheless we must regard failures as of major importance, calling for immediate action, and in this matter I am happy to record that the Dairymen concerned give every cooperation. There are three producers of specially designated milks in the Borough, one producing Accredited Milk and two Tuberculin Tested. These special designations relate to milk produced from herds receiving frequent veterinary inspection, and are herds which are, as far as is reasonably possible, known to be free from Tuberculosis. The milk is sold raw (that is, it is not subjected to heat treatment) and may be regarded as a " safe " milk. Frequent inspection is made to check the conditions 46 in which the milk is produced, and the product is subjected to specific examination regarding its keeping quality, which provides an indication as to whether or not the conditions of cleanliness necessary have been observed. Unsound Food. Reference has already been made to the one case where it was considered necessary formally to seize unsound food. Many tons of unsound food are surrendered annually by Food Vendors in the area, and its proper disposal is supervised by the Inspectors. A few instances of milk delivered in dirty bottles were again brought to our notice, but in no case was there evidence of wilful neglect, and accordingly no prosecutions were instituted. Other complaints related to bread, cakes, sweets, etc., contaminated by foreign matter. In no case, however, was the contamination harmful or injurious to health, nor was there evidence of wilful neglect. The Welfare Officer of a local factory submitted a sample of meat, which a canteen user alleged was horse flesh, and not beef as stated. From superficial examination the Inspector was satisfied that the meat was, in fact, beef, but because of the vehement nature of the complaint the meat was subjected to chemical analysis. The Analyst reported— " The fat of this meat has the chemical characteristics of beef fat." Specimens of decomposing meat or poultry are quite frequently submitted to us by a purchaser, demanding action against the Vendor. We are rarely able to take action because the time lag between purchase and inspection is often as much as 48 hours or more, and we cannot proceed on the allegation that the commodity was decomposing at the time of purchase. A sample of savoury sausage submitted was alleged to contain rat or mouse hair. Analysis showed it to be cow's hair, which should, of course, have been removed at the time of slaughter. The consumer, expressing appreciation for our assurances in the matter, thanked us for "restoring my wife's stomach to normality !" Noise Nuisances. Occasional complaints are received regarding nuisances caused by mechanised installation in business premises. There is no general power conferred upon local Authorities (outside London) to deal with nuisances arising as a result of noise from industry, but all firms approached were most co-operative and all steps reasonably practicable to overcome the nuisance were taken. School Sanitation. It is necessaary to express concern regarding the maintenance and use of some school sanitary conveniences. Many of our school buildings are so old and the type of sanitary installation so out of date and beyond renovation, that one looks forward eagerly to the installation of the accommodation required in School buildings by the Education Act, 1944. An enormous and ever growing amount of public money is spent annually on health education, and yet scant attention appears to be paid to instilling into the minds of our children the elementary rules of personal 47 hygiene. In fact the facilities now provided tend to discourage whatever instinctive principles a child may have. Persistent endeavour is now being made throughout the country to institute proper facilities in restaurant kitchens and all food premises to enable staffs to maintain personal cleanliness, and to educate the workers to achieve this object. One person's ignorant neglect in this matter may cause numbers of people to suffer illness. This has amply been demonstrated on many occasions in recent times (once in Beckenham) and accordingly all support to the present clean food campaign must be given. It should really not be necessary to lecture and supervise adults in matters of this nature, but attention should be directed to giving such education to the child. Yet how infrequently are the wash basins in schools used, and indeed how fat removed they usually are from other sanitary conveniences in the School. Certainly the planners of the older school buildings paid little attention to the association of hand washing with other toilet necessities. Tie greatest co-operation has, however, been received from all School teachers in Beckenham, and from the Officials of the Education Authority, in an endeavour to teach the child these simple principles, but it must be said that the task is difficult. Food Wrapping. A Local Authority has power to make byelaws as to the handling and wrapping of food in accordance with the provisions of the Food and Drugs Act, 1938, but the Council has not, so far, made such byelaws in Beckenham. Circumstances caused by the shortage of paper and the control of its allocation have tended to allow food stuffs to be inadequately wrapped and many complaints were received from housewives, particularly in relation to the sale of wet fish. The majority of our fishmongers now use an initial wrapping of clean paper, and the Public Health Committee made no recommendation for the making of byelaws. It was decided, therefore, to communicate with all fishmongers in the area seeking full co-operation. The response was satisfactory. Rat Infestation. Routine measures for rat repression have continued throughout the year under review. Whilst we may claim that the intensity of infestation has considerably decreased, the nuisance is still widespread, and there are very few areas of the Borough from which complaints have not been received. This is a disappointing feature to report. There is no doubt that the increased practice of poultry keeping (apparently a very necessary feature of our present day life) plays its part in maintaining the nuisance at a steady level, added to which we have the many small and unofficial refuse dumps which litter our town. Nevertheless we find that by immediate action we have been able to prevent any severe intensity of infestation arising such as has formed the subject of report in previous years. In presenting this report of the work of the Sanitary Inspectors, I am very conscious of the helpful advice given to me throughout the year by the Medical Officer of Health ; whilst to my immediate colleagues I renew my thanks for the loyal co-operation and assistance which they so readily offered. 48