AC. 4412 (1) 2nd copy 2 Library BEC 27 BOROUGH OF BECKENHAM REPORT OF THE MEDICAL OFFICER OF HEALTH FOR I960 BY L. R. L. EDWARDS, M.D. (Lond.), D.P.H. Medical Officer of Health BOROUGH OF BECKENHAM REPORT OF THE MEDICAL OFFICER OF HEALTH FOR I960 BY L. R. L. EDWARDS, M.D. (Lond.), D.P.H. Medical Officer of Health " The chief function of the Medical Officer of Health is to safeguard the health of the area for which he acts by such means as are at his disposal . . ." "He should endeavour to acquire an accurate knowledge of the influences, social, environmental and industrial, which may operate prejudicially to health in the area . . (From the Ministry of Health memorandum on the duties of Medical Officers of Health.) MEMBERS OF THE PUBLIC HEALTH COMMITTEE FROM JUNE, I960 Chairman Councillor R. J. Butcher. Deputy Chairman : Alderman Boyd Boyd. Alderman R. S. Jackson. Alderman W. Duncan. Councillor D. R. Knox-Johnston. Councillor A. T. Johnson. Councillor R. G. Foster. Councillor E. R. Smithers. Councillor W. E. Palmer. Councillor A. C. Garrett. Councillor J. Lloyd-Eley. Councillor M. Williams Councillor Mrs. D. E. L. West, M.B.E. Councillor Mrs. O. L. Roberts. Ex-Officio: The Mayor. STAFF OF THE PUBLIC HEALTH DEPARTMENT Medical Officer of Health Chief Public Health Inspector Deputy Chief Public Health Inspector District Public Health Inspectors C.erical Staff : Secretarial Assistant Clerks.. Rodent Operators Disinfector-General Assistant Mortuary Attendant—General Assistant L. R. L. Edwards, M.D. (Lond.), D.P.H. G. A. Webber, Certificate of the Royal Sanitary Institute and the Sanitary Inspectors' Examination Joint Board. Certificated Food Inspector. E. U. Williams, Cert. R.S.I, and S.I.E.J.B. Certificated Food Inspector. W. T. G. Woodard, Cert. R.S.I, and S.I.E.J.B. Certificated Food Inspector. W. F. Forrest, Cert. R.S.I, and S.I.E.J.B. Certificated Food Inspector. Certificated Smoke Inspector. D. W. Foster, Cert. R.S.I, and S.I.E.J.B., Certificated Food Inspector. Certificated Smoke Inspector. Mrs. E. A. Best. Miss Y. Read Mrs. J. Newman Mrs. H. Whipp. W. J. E. Wickenden. E. J. Read. M. Hindson. T. J. Field. 3 CONTENTS page Introductory Letter 5 Section A. Vital Statistics Natural and Environmental Conditions Summary of Vital Statistics 9 Total Deaths 10 Cancer Deaths, 1956 to 1960 11 Notifications and Deaths from Tuberculosis 12 Infantile Mortality 13 Section B. Health and Social Services Hospitals and Clinics 14 County Council Health Services 14 Private and Voluntary Services 15 Local Clinics for Maternity and Child Welfare 16 Report of District Officer 18 Report of Home Help Organiser 18 Report of Chest Physician 19 Tuberculosis Care Committee 20 Old People's Welfare Services 21 Women's Voluntary Service 23 Home Safety Committee 25 National Assistance Act, 1948 (Section 47) 25 Housing—Medical Applications 26 Sections C, D and E. Environmental Services Housing Inspections 27 Nuisances 27 Food and Drugs 28 Unsound Food 29 Ice Cream 30 Rent Act, 1957 30 Factories Act, 1957 30 Disinfection 30 Mortuary 31 Moveable Dwellings 31 Water Supply 31 Drainage 31 Rodent Control 31 Shops Act, 1950 32 National Assistance Act, 1948 (Section 50) 32 Noise Nuisances 32 Smoke Control 33 Housing Survey 37 Section F. Infectious Disceases Control Age and Sex Incidence 41 Monthly Prevalence 42 District Distribution43 Smallpox Vaccination and Whooping Cough Immunisation 44 Poliomyelitis Vaccination 45 Diphtheria Immunisation (1946-60) 45 Special Article : Hard Waters and Health 46 4 INTRODUCTION To the Chairman and Members of the Public Health Committee. I have the honour to present my Report. The health of the Borough during 1960 shows improvement in many respects. The estimated mid year population has increased by 290; the birth rate has increased by over 1 per 1,000 though it is still 3 per 1,000 less than the figure for England and Wales ; live births for the first time since 1949 exceeded 1,000. Deaths are 34 fewer this year and the death rate is less than that of England and Wales. The accident death rate remains the same as last year, though there were 12 fewer deaths. Only one rate has not shown a general improvement. This rate is the illegitimate infant death rate, which is almost double the figure for 1959. This is related to the increase in illegitimate births which is part of a general rise in England and Wales. The number of new cases of pulmonary tuberculosis again fell and this was confirmed by the results now available of a Mass Radiography Survey in 1959 conducted in the central part of the Borough. Out of 3,515 persons examined, 11 new cases of pulmonary tuberculosis and 35 cases with chest abnormalities were discovered. In the 1956 Annual Report it was noted that out of 11,974 persons examined in various parts of the Borough, 25 new cases of pulmonary tuberculosis and 158 cases with chest abnormalities were recorded. Intolerance to drugs is still a barrier to the early treatment of many cases of tuberculosis but this difficulty should not discourage a thorough search for the early case by Mass X-Ray. Vaccination against Poliomyelitis became freely available to all persons up to the age of 40 years and to a further four priority groups, irrespective of age. Since 1958 evening immunisation clinics for adults have been held twice a month at a convenient centre and there has been a satisfactory response. At the end of the report a Table shows the number of poliomyelitis immunisations for all ages carried out by family doctors and at immunisation clinics. There is an increase in the number of immunisations at 18 to 40 years of age. At present a fourth reinforcing immunisation is being carried out for a group at special risk which include school children up to the age of 12. The Ministry of Health has recommended vaccination by general practitioners for all persons over the age of 40. There seems no doubt that the immunisation scheme is having an effect on the incidence of poliomyelitis in the borough. Though the number in non-epidemic years was small it is noteworthy that there have been no cases of paralytic poliomyelitis for two successive years. A section of the report shows a careful control of other infectious diseases including measles, scarlet fever, whooping cough, diphtheria and dysentery and the maintenance of a satisfactory vaccination rate against smallpox. The co-operation of the medical practitioners was a feature of this work. 5 During the year a review of old people's welfare services followed the formation of a new voluntary committee and the voluntary Emergency Call Scheme (Beckenham) to help handicapped persons was inaugurated with the help of the Health Department. The report on the work of the public health inspectors refers in greater detail to the survey of 2,282 houses in No. 1 Smoke Control area, which was completed in November, and to the statutory supervision of industrial smoke under the provision of the Clean Air Act. In addition a survey of 376 older tenanted houses was carried out. The report shows the wide range of duties of the public health inspector in providing clean and safe food, satisfactory housing and prevention of infection or infestation. It includes the number of contraventions remedied under the Shops Act and the nuisances remedied under the Factories Act. The fluoride content of the water supply of the borough has been investigated and figures show that at best it is only one quarter of the optimum. It is a mixture of water from four different sources, of which one is the River Thames. The water is moderately hard and is not plumbosolvent. At the end of this report a short review of the relationship of hard water to health has been included. I wish to express my thanks to the Chairman and Members of the Health Committee for their continued confidence ; to my colleagues in general medical practice and the hospital service for their helpful co-operation ; to Dr. Elliott and members of the County Health Service and lastly to my own staff for the tact, efficiency and friendliness with which they carry out their duties. L. R. L. Edwards, Medical Officer of Health 6 SECTION A NATURAL AND ENVIRONMENTAL CONDITIONS OF BECKENHAM The Borough lies on the outskirts of London and occupies part of the extreme North-west corner of Kent. It has an area of 5,935 acres of which 2,000 acres are open spaces consisting of Parks, Recreation Grounds, Playing Fields and privately owned Sports Grounds. It contains 270 acres of public open spaces of various kinds, and over 300 acres of other open land without full public access. From North to South of the Borough is a chain of open spaces while farmland and woods to the South form a green belt. The Town extends from the Crystal Palace Grounds to the fringe of the Kentish farmlands and its neighbours are Lewisham (Sydenham and Catford) to the North, Bromley and Hayes to the East—Penge and Croydon to the West and Orpington to the South. The contours fall in height from South to North, so that the district of West Wickham on the South side of the borough averages 210 feet above sea level, whereas Beckenham itself averages 150 feet above sea level. Running from South to North are four streams—the Ravensbourne, the Beck, the Chaffinch Brook, and Pool River. These are culverted through the greater part of their course which is through beds of " valley gravelHalf of the area geologically consists of " Blackheath Pebble Beds and the remaining half of " London Clay ". These valleys create a series of undulations. The Ravesbourne in the East forms part of the boundary between Bromley and Beckenham, but otherwise lies outside the borough. The Pool River is a stream formed by the junction of the Boundary Brook with the Beck. It leaves the borough in the Worsley Bridge Area. The Chaffinch Brook is formed from the South Norwood and St. James tributaries in the South of the Borough and joins the Beck in Cator Park. The climate is comparatively mild, and the annual rainfall is low. The total for 1960 was 31.73 inches. The population has grown from 26,330 in 1901 to 74,834 in the '951 Census (Estimated population in June 1960 was 75,510). The figure is likely to increase slightly in the future because of the process of development of some older areas into smaller housing units. Areas of West Wickham and Hayes were added to the former Urban District in 1934 and in 1955 the Registrar General estimated the population of the West Wickham area as 20,600. Beckenham is now a coherent and well-ordered borough with a wide variety of houses most of which are owner occupied and have been built between the wars. Many of the larger older houses have been converted or replaced by self-contained flats. 7 The Borough has a total of approximately 700 shops which are largely sited along the four main roads in the Borough in two main shopping centres. The water supply of the Borough is a mixture of well water from West Wickham, Orpington and Shortlands pumping stations with River Thames derived filtered water. These wells are in chalk strata and the Shortlands well is 250 feet deep. The natural fluoride of these sources varies and estimated in milligrammes per litre is 0.05—0.15 in the West Wickham well, less than 0.05 to 0.25 in the Orpington well, 0.05—0.25 in the Shortlands well and 0.2—0.25 in River Thames derived water. Three Public Swimming Baths (modernised in 1938) of 100 ft., 80 ft., and 70 ft. lengths are supplied from a borehole 300 ft. into chalk strata. The method of treatment is by rapid pressure, filtration and chlorination with a change over period of one in four hours' duration. As a check on the efficiency of chlorination plant, every two weeks, and more frequently at times of excessive load, a 100 c.c. sample of water from the exit end of the Baths is taken in the middle part of the day and tested for B. Coli in the Laboratory of the Establishment. Three or four times a year, full bacteriological examination at a Public Health Laboratory is carried out. Results even at times of heaviest bathing loads have been very satisfactory. Beckenham possesses quite a large number of Industrial and Commercial Firms, but most of the Industries fall in the category of "Light Industry," and the majority come under the general heading of Engineering. The Industries are almost confined to two main zones of the Borough on the Northern and Southern edges, and in all, employ 7,000 persons, the greatest number being in the engineering firms. Twenty-four establishments employ 50 or more employees. The main industries are concerned with the production of drugs, serums, vaccines, chemical apparatus, electric tools and electric motors, electronic equipment, compressed air equipment, including spray guns for paint or cellulose, bronze nameplates, vitreous enamelled, perspex and plastic signs and letters, bronze founding, metal founding, sheet metal work, general engineering and grading of scrap metals, office accessories, motor accessories, glues and adhesives, cellulose lacquers, leather products, protective food packaging, dyers and cleaners and almond millers. Smaller firms are concerned with printing, film bag manufacture, landscape gardening and rustic work. 8 SUMMARY OF VITAL STATISTICS, 1960 Area of District in acres 5,935 Estimated mid-year population 75,510 Population Density—persons per acre 12.72 Rateable Value at 1st April, 1961 £1,502,987 Number of Inhabited Dwellings 24,088 Product of a Penny Rate (Estimated 1961/62) £6,125 Male Female Live Births 555 501 Total 1,056 Live Birth rate per 1,000 population 13.98 Illegitimate Live Births per cent of total live births (29) 3.03 Male Female Still-births 48 Total 12 Still-births rate per 1,000 live and still-births 11.23 Total live and still-births 1,068 Infant Deaths (deaths under 1 year) 12 Total infant deaths per 1,000 total live births 11.36 Legitimate infant deaths per 1,000 legitimate live births 9.77 Illegitimate infant deaths per 1,000 illegitimate live births 62.50 Neonatal Mortality Rate (deaths under 4 weeks per 1,000 total live births) 9.47 Early Neonatal Mortality Rate (deaths under 1 week per 1,000 total live births) 6.63 Perinatal Mortality Rate (Stillbirths and deaths under 1 week combined per 1,000 total live and stillbirths) 17.79 Maternal Mortality (including abortion) 0 Maternal mortality rate per 1,000 live and still-births 0.00 Death Rate per 1,000 population from Cancer (182 deaths) 2.41 Death Rate per 1,000 population from Pulmonary Tuberculosis (1 death) 0.01 Death Rate per 1,000 population from Non-Pulmonary Tuberculosis (1 death) 0.01 Death Rate per 1,000 population from Accidents (21 deaths) 0.28 Birth Rate (including Stillbirths) per 1,000 population: Crude 14.14 Corrected (x 1.06) 14.99 Male Female All Deaths Registered 387 465 Total 852 Death Rate per 1,000 population: Crude 11.28 Corrected (x 0.94) 10.60 Natural Increase: Births exceeded deaths by 204. 9 TOTAL DEATHS, 1960 (Registrar-General's Official Returns). All causes—852. Male, 387 ; Female, 465. causes of death males females 1. Tuberculosis, respiratory 1 — 2. Tuberculosis, other 1 — 3. Syphilitic disease 1 1 4. Diphtheria — — 5. Whooping Cough — — 6. Meningococcal infections — — 7. Acute poliomyelitis — — 8. Measles — — 9. Other infective and parasitic diseases 1 2 10. Malignant neoplasm, stomach 12 12 11. Malignant neoplasm, lung, bronchus 33 15 12. Malignant neoplasm, breast — 19 13. Malignant neoplasm, uterus — 8 14. Other malignant and lymphatic neoplasms 40 43 15. Leukaemia, aleukaemia 4 2 16. Diabetes 1 2 17. Vascular lesions of nervous system 44 69 18. Coronary disease, angina 106 69 19. Hypertension with heart disease 5 9 20. Other heart disease 33 88 21. Other circulatory disease 12 27 22. Influenza — — 23. Pneumonia 16 24 24. Bronchitis 22 11 25. Other diseases of respiratory system 5 1 26. Ulcer of stomach and duodenum 8 3 27. Gastritis, enteritis and diarrhoea 2 3 28. Nephritis and nephrosis 1 2 29. Hyperplasia of prostate — — 30. Pregnancy, childbirth, abortion — 2 31. Congenital malformations 2 2 32. Other defined and ill-defined diseases 25 37 33. Motor vehicle accidents 6 2 34. All other accidents 2 11 35. Suicide 4 1 36. Homicide and operations of war — — Totals 387 465 10 CANCER DEATHS 1956 1957 1958 1959 1960 Cancer of Lung 30 29 47 49 48 Males 169 Females 34 Total 203 Cancer of Breast 23 26 13 15 19 96 Cancer of Uterus 6 8 6 10 8 38 Cancer of Stomach 17 23 21 14 24 Males 56 Females 43 Total 99 Other Malignant Neoplasms 76 83 90 98 83 Males 219 Females 211 Total 430 Total Deaths from Cancer 152 169 177 186 182 Males 444 Females 422 Total 866 For comparison, deaths from Respiratory Tuberculosis are shown :— 1956 1957 1958 1959 1960 2 3 1 2 1 Males 6 Females 3 Total 9 11 IO TUBERCULOSIS—Table of Notifications and Deaths, 1960, from Local Records. Sex Total LGES Wards* 0 to 5 6 to 10 11 to 15 16 to 20 21 to 25 26 to 35 36 to 45 46 to 55 56 to 65 66 and ovei Age unknown l.Pk. and K.H. m.h. c.c. c.h. E.P. Shortlands W.W. (Nth.) W.W. (Sth.) M. F. notifications New Cases only Pulmonary 14 11 25 1 — — 2 1 5 5 5 4 2 — 2 1 4 2 5 6 2 3 Son-Pulmonary — — — — — — — — — — — — — — — — — — — — — — Totals 14 11 25 1 — — 2 1 5 5 5 4 2 — 2 1 4 2 5 6 2 3 Deaths Pulmonary 5 1 6 1 1 4 1 2 1 1 1 Son-Pulmonary — — — — — — — — — — — — — — — — — — — — — — Totals 5 1 6 — — — — — — 1 1 4 — — 1 2 — 1 1 1 K.H —Lawrie Park and Kent House. M.H.—Manor House. C.C.—Copers Cope. C.H.—Clock House —Eden Park. W.W. (North)—West Wickham North. W.W. (South)—West Wickham (South). INFANTILE MORTALITY, 1960 The number of deaths of infants under the age of twelve months was 10, as compared with 14 in 1959. The Registrar-General returns 12 infant deaths, and the Infant Mortality Rate for the year was 12 per 1,000 live births. The following Table shows the cause of death in 14 cases for which full records exist. Table of Infantile Mortality Under one day Over one day Total under one week age in wef.ks Total under one month age in months Total under one year 1-2 2-3 3-4 1-3 4-6 7-9 10-12 M. F A. Congenital Malformations : Heart — — — — 1 — 1 — — — — 1 — Lungs — — — — — — — — — — — — — Nervous System — — — — — — — — — — — — — Others — — — — — — — — — — — — — B. Other Prenatal and Natal conditions: Immaturity 3 — — — — — 3 — — — — 2 1 Atelectasis Birth Injuries — — 1 1 — — 1 Erythroblastosis (Rhesus) 1 — — — — — 1 — — — — — 1 C. Post-Natal Causes : Pneumonia — — — — 1 — — 1 — — — 1 1 Gastro Enteritis — — — — — — — — 1 — 1 — Other Infections — — — — — — — — — — — — — Neglect — — — — — — — — — — — — — Operation and Immaturity — — — — 1 — 1 — — — — — 1 D. Accidental and Violence — — — — — — — — — — — — — Totals 4 — 1 — 3 — 8 1 — 1 — 6 4 SECTION B. HEALTH AND SOCIAL SERVICES In this section are included hospitals and clinics serving the Borough but not all of which are situated within the Borough. Many of these services, including the provision and supervision of old persons homes within the Borough, are directly administered by the County, and the District Officer and District Organiser of the Home Help Service have contributed information for which I am grateful. 1 am indebted to Mr. Forster and to Mrs. Fisher for their accounts of the work of the T.B. Care Committee and the Women's Voluntary Service. 1. Hospitals and Clinics The Babies' Hospital—Sydenham Hill, S.E.26. Beckenham Hospital—Croydon Road, Beckenham. Beckenham Maternity Hospital—Stone Park Avenue, Beckenham. Bethlem Royal Hospital, Monks Orchard Road, Beckenham. Bromley Chest Clinic—Tiger Lane, Mason's Hill, Bromley. Bromley Hospital—Cromwell Avenue, Bromley, Kent. Brook General Hospital—Shooters Hill, S.E.I8. Cane Hill Hospital—Coulsdon, Surrey. Children's Hospital—Sydenham, S.E.26. Children's Heart Hospital—West Wickham, Kent. Farnborough Hospital—Farnborough, Kent. Joyce Green Hospital—Dartford, Kent. Lennard Isolation Hospital—Bromley Common, Bromley. Leybourne Grange Colony—West Mailing, Kent. Netherne Hospital—Coulsdon, Surrey. Orpington Hospital—Sevenoaks, Orpington, Kent. Penge Chest Clinic—1, Westbury Road, Penge, S.E.20. Sundridge Hospital, Sundridge, Nr. Sevenoaks, Kent. Widmore Road and Mason's Hill Maternity Units, Bromley, Kent. 2 Other Services (Kent County Council). Home Helps. Beckenham District Office, 12, Beckenham Road, Beckenham. Home Nurses. Beckenham District Office, 12, Beckenham Road, Beckenham. Midwives. Beckenham : 12, Beckenham Road, Beckenham. West Wickham : 4, Grosvenor Road and 105a, Station Road. 14 Ambulances. Through Hospital or Beckenham District Office Old People's Homes "Craigie Vane", 3, Durham Rd., Shortin Borough. lands. (Private). 24, Cromwell Road, Beckenham. (Private),. Durham House, 50, Durham Avenue. Shortlands (K.C.C.). 13, Gwydor Road, Beckenham (Private) Rest Haven, 99, Venner Road, Sydenham, S.E.26 (Private). Rutland Lodge, 6, Mays Hill Road, Short- lands (Private). Thornton House, 75, Bromley Road Beckenham (Voluntary). Mental Welfare. District Offices, 12, Beckenham Road, Beckenham. General Welfare. District Offices, 12, Beckenham Road, Beckenham. Clinics for Maternity and Child Welfare. The District Officer and his staff are available to assist in the event of any difficulty arising in the arranging of any of the aforesaid County Health Services. 3. Private and Voluntary Services. Private Nursing Homes. (1) "Inglewood," 25, Durham Avenue, Bromley, Kent. (2) "Lynton House," 14, Bromley Grove, Shortlands, Kent. (3) "Petersfield Lodge," 69, Crystal Palace Park Road, S.E.26 (4) "Sloane," 131, Albemarle Road, Beckenham, Kent. (5) "Waverley," 51, Albemarle Road, Beckenham, Kent. Registration and supervision is delegated to the Borough Council. Children's Homes. (1) Dr. Barnardo's Home, 16, Park Road, Beckenham. (2) Maude Nathan Home, 72, Crystal Palace Park Road, S.E.26. (3) St. Hilda's Home, Crescent Road, Beckenham. (4) Salvation Army Children's Home, 42, Crystal Palace Park Road, S.E.26. Medical Loan Depot of B.R.C.S. 45, Beckenham Road, Beckenham. Women's Voluntary Services. 12, Bromley Road, Beckenham. 103, High Street, West Wickham, Kent. 15 LOCAL CLINICS FOR MATERNITY AND CHILD WELFARE Service Days and Times Premises in Use 2nd and 4th Fridays, in each month, 10a.m.-12 noon (by appointment). 1st, 3rd and 5th Mondays in Ante Natal each month, 10 a.m.-12 noon (by appointment). Mondays 10 a.m.-12 noon and 2 p.m.-4 p.m. (by appointment). Wednesdays and Thursdays 10 a.m.-12 noon (by appointment). Bookings—Tuesdays and Wednesdays, 2-3 p.m. Clinic Block, Town Hall, Beckenham. Clinic Block, Hawes Lane. West Wickham. Maternity Hospital, Stone Park Avenue, Beckenham. Maternity Hospital, Stone Park Avenue, Beckenham. Maternity Hospital, Stone Park Avenue, Beckenham. Child Welfare Mondays, 2—4 p.m. Tuesdays, 2—4 p.m. Wednesdays, 2—4 p.m. Thursdays, 2—4 p.m. Fridays, 2—4 p.m. Clinic Block, Hawes Lane, West Wickham (a) Baths Annexe, Beckenham Road (b) Assembly Hall, Gates Green Road, West Wickham (a) Church Hall, Langley Road. Elmers End (b) Church Hall, Valley Road, Shortlands (a) Church Hall, Lennard Road, Penge (b) Clinic Block, Town Hall, Beckenham (а) Church Hall, Langley Road, Elmers End (б) Clinic Block, Hawes Lane, Wesi Wickham 2nd and 4th Fridays in each Clinic Block, Town Hall, month 10 a.m.-12 noon (by Beckenham. appointment). Post Natal 1st, 3rd and 5th Monday Clinic Block, Hawes Down, mornings (by appointment). West Wickham. Every Friday 10 a.m.— Maternity Hospital, Stone Park 12 noon. Avenue, Beckenham. Vaccination and Immunisation Clinics Vaccination and poliomyelitis immunisations (by appointment); Diphtheria and whooping cough immunisations without appointment. Held during Infant Welfare Sessions at above Clinics (Langley Road—Friday afternoons only). Dental (Infant Welfare Cases) By appointment. By appointment. Clinic Block, Town Hall, Beckenham. Clinic Block, Hawes lane. West Wickham. 16 LOCAL CLINICS FOR MATERNITY AND CHILD WELFARE Service Days and Times Premises in Use Speech Mondays to Fridays inclusive (by appointment) Clinic Block, Town Hall, Beckenham. Orthopaedic Wednesday mornings (twice per month) (by appointment) Surgeon in attendance Clinic Block, Town Hall Beckenham Treatment. The Physiotherapist attends by appointment as follows :— Monday afternoons Thursday afternoons Clinic Block, Town Hall, Beckenham Mothercraft Classes and Relaxation Exercises Friday mornings, 10.30 a.m. Clinic Block, Town Hall, Beckenham Thursday afternoons, 2 p.m. Clinic Block, Hawes Lane West Wickham Midwives Ante-Natal Monday afternoons, 2 p.m. Clinic Block, Town Hall, Beckenham Thursday afternoons, 2 p.m. Clinic Block, Hawes Lane, West Wickham 17 REPORT OF THE DISTRICT OFFICER The following report has been submitted by Mr. C. J. Moore, District Officer, for which I express my thanks. "During the year 1960 there were two developments in the work of the County Health and Welfare Services which I think are of special interest. Firstly, the County Council's Chiropody Service came into operation on the 1st September, 1960. At present there are 6 Chiropodists in the district who are actively taking part in the County scheme, and during the last four months of 1960, 221 different patients were treated under the scheme in this district. At the moment, the scheme applies only to men over 65 years, women over 60 years, expectant mothers and those suffering from substantial physical handicap. So far the service has been able to cope adequately with the demands upon it and new cases can be treated at the latest within 10 days of application. The future of the Chiropody service provided by the voluntary agencies such as the British Red Cross and Women's Voluntary Service is still a matter for discussion between those bodies concerned and the Kent County Council. It is to be hoped that it will be possible for these organisations to carry on with the valuable work they have done in the past. Perhaps a more publicised event was the coming into force on the 1st November of the Mental Health Act, 1959. On that date the Lunacy and Mental Deficiency Acts ceased to have effect and were replaced by a single Statute. Over the span of 70 years the role of the Local Authority has been reversed. The main duty of the Local Authority under the Lunacy Act, 1890, was to provide 'Asylums for the Accommodation of Pauper Lunatics; Under the 1959 Act, although it is true the Local Authority's Mental Welfare Officers are empowered to act in connection with compulsory admission to hospital where there is no relative able or willing to do so, the principal duty laid on the Local Authority by this Act is to provide Care and After Care Services for patients in the community and thus prevent or reduce the need for hospital care which otherwise might prove necessary." REPORT OF HOME HELP ORGANISER My thanks are due to Miss Hocking for the report on this service for the Beckenham and Penge area. " During the year I960 demands for this service continued to increase steadily. Approximately 350 cases per week received assistance and over 500 new cases were serviced during the year. Sixteen families, of whom 6 were in the Penge area, received assistance under the Family Help Service. One family received assistance under the Child Help Service and there were no applications for the Night Attendant or Evening Service." 18 WORK OF THE CHEST CLINICS I have pleasure in submitting the following report and Table on the work of the Chest Clinics during the year under review, forwarded to me by Dr. D. G. Madigan, Chest Physician, to whom I express my thanks:— "Comparison with the figures for previous years will show that the numbers of new cases of tuberculosis are still slightly decreasing, and as a result the numbers of new contacts examined are correspondingly lower. Again, no active case of pulmonary tuberculosis was discovered among the contacts examined. The total number of patients referred for investigation, however, is increasing, and of these, many are found to be suffering from other chest conditions, and as bronchial carcinoma, bronchiectasis, or chronic bronchitis, and are admitted to hospital for treatment. The increase in the number of children examined is occasioned by the fact that positive tuberculin skin test reactors, found in the course of the Schools B.C.G. vaccination programme, are referred to the Chest Clinics for investigation. It is important to be mindful of the fact that positive Mantoux reactors have been infected with the germ of tuberculosis, and may in the future develop pulmonary tuberculosis. In the field of treatment of tuberculosis by chemotherapy, one must again emphasize the importance of the full co-operation of the patient in regularly taking the drugs prescribed over long periods, in order to minimize the risk of the emergence of resistant organisms. A preliminary period of hospital treatment, whereby the patient can be made to understand fully the reasons why it is essential not to miss taking the drugs in the correct dosage, and where any initial difficulties, such as drug intolerance, can be dealt with, is a sine qua non. Without this full, and understanding, co-operation the great advances made in recent years in the control of the disease might well be of a transient nature." New Cases attending the Chest Clinics for the first time during 1960 Adults Children under 15 years Male Female Male Female Pulmonary Tuberculosis 19 10 — — Non-Pulmonary Tuberculosis — 1 — — Non-Tuberculous 103 85 54 39 Non-Tuberculous Tuberculous New Contacts Examined 162 Nil B.C.G. Vaccination of contacts : 80. Number of Tuberculous Patients admitted to Hospital or Sanatorium during 1960: 22. 19 BECKENHAM DISTRICT TUBERCULOSIS CARE COMMITTEE The following report on the work of the local Tuberculosis Care Committee has been submitted by the Hon. Secretary, Mr. M. F. Forster, to whom I express my thanks. "The work of the Committee carried on in its usual manner in 1960, but with a marked difference. It appears that less families require help, but the expenditure needed for help has increased. The Committee met on eleven occasions, presided over by the Chairman, with the Hon. Secretary and Hon. Treasurer in attendance, to discuss Case Work. The help given consisted mainly of issuing vouchers tor meat; providing fares for families to visit patients in Hospitals or Sanatoria; providing clothing and shoes ; sending families away on holiday and paying their fares ; and settling debts. In one case, assistance was given to keep an Insurance Policy going, and in another, helping with a Correspondence Course. Also, paying for Radio Licences, settling Electricity and Coal Bills, and giving emergency help in very needy cases. During the year under review, 21 families were assisted, with a total of 75 grants." 20 BECKENHAM OLD PEOPLE'S WELFARE SERVICES It is estimated that there are approximately 2,400 men over 65 years and 5,800 women over 60 years in the Borough ; the number in need is not known. During the year the former Old People's Welfare Committee voluntarily resigned after expressing its full support for the formation of an enlarged co-ordinating Committee more fully representative of the many voluntary organisations in the Borough. These include two Chambers of Commerce, Councils of Churches, Citizens' Advice Bureau, Emergency Call Scheme, ten Townswomen's Guilds, three Women's Co-op Guilds, four Toc H branches, Rotary, Round Table, Inner Wheel, Soroptomist and Veterans Club, Women's Citizens Association and Women's Institute, four British Legion branches and the W.V.S. In all there are fifty local associations connected to the new Committee and more than half are actively helping old people. Already the Executive Committee have investigated over a wide field by the issue to organisations of questionnaires on the need, or otherwise, to expand services or provide new services. Pamphlets describing available services have been prepared for distribution early in 1961, and it is hoped to develop through the above organisations, and through home visiting, increased services for those who live alone or are housebound. Such services could include shopping, mending, reading aloud and transport to Church, Club or entertainment. Keeping in contact is a most important part of visiting, but often semi-professional advice is needed. The essential home visiting service is a combination of voluntary and whole-time visiting and there should be a scheme for help in emergency. Up to a point both these needs can be met in the same scheme, and in March the voluntary Emergency Call Scheme (Beckenham) made a start on those lines. The scheme is designed to help not only elderly persons but also handicapped persons living alone. The reverse of the emergency plaque issued has details, including those of next of kin, phone number of nearest relative and of doctor. A central file card and police file card are completed with similar details. In time it is hoped to develop the second part of this scheme by recruiting volunteers for home visiting through the various organisations represented on the enlarged old people's welfare Committee. A record card will indicate that a visit has been carried out and arrangements will be made by the Co-ordinating Committee to meet, as far as possible, any needs found by the voluntary visitor. The Committee hope to expand existing services by providing an additional Meals on Wheels " van and if a suitable property can be found additional accommodation for old people. Statutory services are provided by the County Welfare Authority. These include selective and emergency visits to old persons at which details of relatives, need for admission to old people's home, membership of club, provision of service, income and accident prevention are 21 recorded; a comprehensive domestic help service which includes a Night Attendant and Evening service, home nursing for the elderly sick and, either directly or through the British Red Cross Society and St. John Ambulance Brigade, nursing requisites (including bedding) to persons ill at home. Special beds, nursing aids and equipment are also provided. The County Authority also supervises private old persons' homes, including Thornton House, or itself provides residential accommodation, as at Durham House, and makes a grant for welfare services provided for old people's housing accommodation, as at Newlands Park. Recently it has introduced a chiropody service for old people, physically handicapped and expectant mothers, and through the North West Kent Council of Social Service contributes to the home meals, the old people's advisory service and boarding accommodation in private homes. The Borough Council also provides housing accommodation in the form of bungalows and flats and bed-sitter flatlets on various estates in the borough and contributes towards the " Meals on Wheels" Service organised by the W.V.S. and the Chiropody service organised by the British Red Cross Society, which at present treats over 200 elderly persons. The Central Baths provide special facilities at a reduced charge and special concessions are afforded at two launderettes. The report on the Women's Voluntary services gives full particulars on clubs, outings and holidays. Though this is a hospital service, it is convenient to mention here the occupational and rehabilitation work of Lennard Hospital for ambulant elderly persons either nursed at home or in hospital. This department will later be developed into a day hospital for the elderly sick with the aid of a grant from the King Edward's Hospital fund for London which among other activities sponsors such investigations into the care of the elderly sick in their own homes. 22 WOMEN'S VOLUNTARY SERVICE I am very grateful to Mrs. J. M. Fisher, Centre Organizer of the W.V.S. who has kindly submitted the following interesting report— Darby and Joan Clubs Three Darby and Joan Clubs in Beckenham and two Over 60's Clubs in West Wickham are still running in the Borough. Of the Beckenham Clubs, two are held on Tuesday and one on Thursday from 1.45 to 4.15 p.m. Membership of the three Clubs in Beckenham is about 500, and all the members are over 60 years of age. The membership fee is 1d., and a charge of 3d. is made for tea. Whist Drives, Darts Matches and Raffles are held each week, and at least two of the Clubs have talented choirs which entertain not only their own members, but other organisations as well. A free library is available to members and there are also plenty of magazines for reading. Spring and Autumn outings are arranged for the Club members and in the winter visits are made to pantomimes and ice shows. Members also have holidays at reduced rates—out of season—at the seaside. A savings group is run for members who wish to save weekly towards holidays, outings, etc. The Clubs are subsidised by voluntary subscriptions. The two Over 60's Clubs are run in West Wickham with an average membership of 130/150. Meals on Wheels Meals are served twice a week, Tuesdays and Fridays. The service is run principally for the benefit of invalids and elderly people who live alone and cannot cook for themselves. The meals are cooked in the Centre by members of the W.V.S. Appeals for meals usually come from Hospital Almoners, Doctors, and through the Darby and Joan Clubs. An allowance towards the cost of transport is made through the local and County authorities. Cost of the meals is subsidised by voluntary funds, and those in need are only required to pay a very small sum for the service. About 80 meals are served each week. West Wickham Luncheon Club Meals for this Luncheon Club are cooked by W.V.S. and only a nominal charge is made. An average of 35 meals are served weekly in addition to an average of 16 Meals on Wheels three times a week. Old People's Welfare Visits are made to elderly people who live alone, and assistance is given with regard to clothing which is supplied free on the authority of the National Assistance Board, District Nurses, etc. 23 Hospital Work Work in connection with Beckenham Hospital has been much appreciated and consists of help with the Library, flowers and magazines. We also run a trolley shop at Durham House and this is much appreciated by the old people living there. Maternity Work Many baby garments have been knitted and we now have a Guild of Service which will supply help personally to the Matron. This Guild consists of W.V.S. and non-W.V.S. from Beckenham and Penge. Baby Clinics Helpers are supplied at three of the baby clinics in the Borough and assist in the selling of Welfare Foods, weighing and clerical work. Clothing Depot We hold a good stock of second-hand clothing which is available for the old and sick people in the Borough who come to us with a note from the National Assistance Board, Doctor or Health Visitor. We are also able to help younger people with clothes and mothers with baby clothes. The Children's Clothing Exchange is still being run eve|7 Wednesday, and we understand it is the most flourishing one in Metropolitan Kent. Welfare Foods The Centre dispenses National Dried Milk, Orange Juice, Cod Liver Oil and Vitamin tablets. Periodicals for the Forces We send 30 parcels of books and magazines each month to our Forces in the Middle and Far East. We get a small grant from the County Office towards postage and the remainder has to be found by the Centre, usually from any money we obtain from the sale of salvage. Services Club One of our members attends the Victory Club each Friday, where she works in the library. Canning Members from the West Wickham Centre canned a large quantity of fruit for the Maternity Hospital during the summer. In addition to the aforementioned activities the W.V.S. is closely connected with the Tuberculosis After Care Committee, Area Pension Officer, British Legion, the Disabled Persons' Committee and Children's Homes. Children's Holidays We have been able to arrange holidays tor a number of children who are recommended to us by the T.B. After Care Committee and Health Visitors. Last summer twelve children benefited from a holiday at the seaside or in the country. 24 BECKENHAM HOME SAFETY COMMITTEE This voluntary Committee has been in existence for some years and its members represent those local organisations best able to advise on measures of accident prevention in the home. It is not a Committee of the Authority but receives an annual grant from the Accident Prevention Committee. Other funds are extremely small and consist of voluntary donations. Funds are used to purchase posters, leaflets and other publicity material from the Royal Society for the Prevention of Accidents. Since 1955 it has published a handbook containing information on emergency services, first aid, the safe use of electricity in the home, the safe use of household appliances and general safety measures in the home. It organises competition essays on home safety among local school children and arranges the distribution of leaflets and posters to schools, shops, libraries and to organisations concerned with the welfare of the elderly. The Committee meets every two months and is composed of representatives of the following :— Accident Prevention Committee. Beckenham Hospital. Conservative Association : Women's Advisory Council. Federation of Townswomen's Guilds : North-West Kent. Health Department : Beckenham Borough Council. Health Department : Kent County Council. Junior Accident Prevention Council. Kent Fire Brigade. London Electricity Board. Labour Party : Women's Section. Local Press. Pharmaceutical Society : West Kent Branch. Ratepayers' and Residents' Associations. Soroptomists. South Eastern Gas Board. Women's Citizens' Association. Women's Co-operative Guild. Women's Gas Federation. NATIONAL ASSISTANCE ACT, 1948—SECTION 47 Under Section 47 of the above Act, as amended by the National Assistance (Amendment) Act, 1951, persons suffering from grave chronic disease, or who are aged, infirm or physically handicapped, and who are living in insanitary conditions and unable to devote to themselves, and not receiving from other persons, proper care and attention, may be compulsorily removed. No cases were reported for action during the past year. 25 HOUSING—MEDICAL APPLICATIONS From January 2nd to December 22nd, 1960, 45 applications with medical certificates were received. There were five reapplications. For two of these additional points were recommended. Maximum points were recommended in 17 cases, of which 16 required ground floor accommodation. The medical causes are classified in the following groups. Nervous Disorder Functional (Anxiety State, Emotional strain) 13 Organic 4 Illness of Children 10 Disease of bones or joints (Arthrogryposis multiplex congenita) 1 Disease of Pancreas (Fibrocystic) (Steatorrhoea) 1 Bronchitis or Asthma Disease of Kidneys 1 Hydrocephalus and Spina bifida 1 Operation for Imperforate anus 1 General Debility and colds 1 Tuberculosis 1 Cardiovascular Angina 2 Hypertension 3 Myocardial failure 1 Arthritis 7 *Miscellaneous 2 *Pernicious Anaemia, Gastrectomy. During the past four years about half the medical certificates have been on account of nervous state of the parents and illness of children, as shown below:— Year 1955 1956 1957 1958 1959 1960 No. of applications 59 68 65 70 46 45 Nervous illness of parent 3 11 13 22 12 17 Illness of children 15 15 22 9 11 10 26 REPORT ON THE WORK OF THE PUBLIC HEALTH INSPECTORS FOR THE YEAR 1960 I am very grateful for the following Report and Tables from Mr. G. A. Webber, Chief Public Health Inspector, which sets out the work of the Inspectors during the year. SECTIONS C, D, E. Statistical information relating to the work of the Inspectors is appended:— Housing—Inspection of Dwelling Houses during the Year. Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1,072 Number of inspections made for the purpose 2,081 Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 22 Number of inspections made for the purpose 182 Number of dwelling-houses (exclusive of those referred to under the following sub-head) found not to be in all respects reasonably fit for human habitation 89 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 in respect of which informal notices were served 89 Number of dwelling-houses in which defects were remedied after service of informal notices 64 Number of dwelling-houses in respect of which formal notices were served requiring defects to be remedied 42 Number of dwelling-houses in which defects were remedied after service of formal notices: (a) by owners 42 (b) by Local Authority in default of owners 0 Number of complaints received 1,308 Number of initial visits 6,659 Number of re-visits 1,599 Nuisances Remedied Structural Defects of properties—External 77 Internal 142 Insanitary conditions other than vermin 9 Verminous conditions 15 Smoke Nuisances 14 Choked drains 314 Other drainage defects 115 Defective sanitary appliances 14 Insufficient or unsuitable water supply 8 Absence of dustbin accommodation 6 Offensive accumulations 12 27 Foods and Drug Sampling Two hundred and twenty-four samples of food and drugs were submitted to the Public Analyst. Details are appended :— article formal informal Almonds (Ground) 8 1 Baked Beans — 1 Batter Mix — 1 Blackcurrant Drink — 1 Blackcurrant Glucose Drink — 1 Blackcurrant Juice Syrup — 1 Blackcurrant Vitamin " C " Drink — 1 Bronchial Elixir — 1 Butter — 2 Butter (Peanut) — 1 Butter Drops — 1 Butter Mintoes — 1 Butterscotch — 1 Cheese Spread — 3 Cheese Spread with Tomato — 1 Chocolate Drink — 1 Chopped Pork with Beef and Ham — 1 Christmas Pudding — 2 Coffee — 3 Coffee Spread — 1 Corn Oil — 1 Corned Pork Roll — 1 Cough Syrup — 1 Crab (Dressed) — 1 Cream — 7 Custard Powder — 1 Dairy Cream Devonshire Splits — 1 Desiccated Coconut — 1 Egg Rusks — 1 Flour (Ground) — 1 Flour (Self Raising) — 1 Gin — 3 Golden Butter Caramels — 1 Honey — 1 Ice Cream — 12 Jam (Blackcurrant) — 3 Jam (Raspberry) — 1 Jam (Strawberry) — 8 Jelly — 5 Lemon Curd — 2 Lemon Juice — 1 Lemon Pie Filling — 1 Lemon Squash — 3 Lime Juice Cordial — I Luncheon Meat — 3 Marmalade — 1 Margarine — 2 Marzipan — 2 Metholated Balsam — 1 Milk (Evaporated) — 1 Milk (Pasteurised) 48 6 Milk (T.T.) 4 — Milk (Sterilised) 14 — Milk Chocolate Rum Truffle — i Milk Shake Syrup — 1 Minced Meat Loaf 1 Nut Oil 1 28 ARTICLE FORMAL INFORMAL Orange Crush — 3 Orange Drink — 1 Orange Squash 1 6 Pepper (Ground) — 1 Pineapple Squash — 1 Rice Pudding — 5 Salmon Potted with Butter — Sauce( Fruit) — 1 Sausages (Pork) 7 1 Soup (Mushroom) — 1 Soup (Turkey) — 1 Spaghetti in Tomato Sauce with Cheese — 2 Strawberries in Heavy Syrup — 1 Sugar (Demerara) — 1 Sugar Pieces — 1 Tea — 1 Teabreak Rusks — 1 Vinegar — 4 Vitaminised Iron Tonic Tablets — 1 Whisky — 3 No instances of adulteration were found. Food privately purchased, and alleged by the purchaser to be unsound Instances ot alleged unsound or contaminated food sold to the public which came to our notice were investigated, and reported to the Public Health Committee. Details are appended :— ALLEGED COMPLAINT ACTION TAKEN February, 1960 Dirty milk bottle. Dairyman fined £20 and £52 10s. costs. Decision reversed on appeal, and costs awarded against Council. Glass in bread. After full investigation the circumstances did not warrant further action. Animal hair in biscuit. Warning letter to manufacturers. April, 1960. Pin in loaf of bread. Baker fined £10. May, 1960. Mould in meat pie. Manufacturer fined £20. June, 1960. Wasp in tinned plums. Warning letter to manufacturers. Bread contaminated by mouse excreta. Not confirmed by chemical analysis. No action. July, 1960 Dirt on biscuits. Not confirmed by chemical analysis. No action. Foreign matter in milk bottle. Consisted of calcium carbonate. No action. Mould in meat pie. Manufacturer fined £10 and £10 10s. costs. August, 1960 Dirty milk bottle. Dairyman fined £10 and £2 10s. costs. String in cake. Baker fined £10 and £5 5s. costs. September, 1960 Dirty milk bottle. Dairyman given absolute discharge on payment of £31 10s. costs. Dirty milk bottle. (School milk.) Warning letter to dairyman. November, 1960 Dirty milk bottle. Dairyman fined £5 and £2 15s. 6d. costs. December, 1960 Foreign matter in meat pasty. Manufacturer fined £15 15s. and £8 costs. 29 Ice Cream Twenty samples of Ice Cream were submitted to chemical analysis during 1960, and all were found to comply with the statutory standard for this product. Thirty-three samples weresubmitted to bacteriological examination, as a result of which the samples are graded into four degrees of bacterial cleanliness. The results were as follows:— Grade 1 Grade 2 Grade 3 Grade 4 28 5 — — Only samples falling into Grades 3 and 4 are regarded as unsatisfactory, indicating some bacterial contamination either in the manufacture or the retail serving of the product. Rent Act, 1957 The details of the administration of this Act were referred to fully in the 1957 Annual Report. Seven applications were received for Certificates of Disrepair during the year 1960, bringing the total number of applications to 141 since the Act came into operation in June, 1957. Factories Act, 1957 One hundred and twenty-three visits of inspection were made to factories in the area, and the following nuisances were remedied following the service of Intimation Notices :— Want of Cleanliness 1 Insufficient sanitary accommodation 1 Unsuitable or defective sanitary conveniences 8 Disinfection The Council undertakes, free of charge, the disinfection of rooms, articles of clothing and bedding after cases of Tuberculosis and occasionally other Infectious Diseases. Requests for the steam disinfection of bedding, etc., other than for notifiable illness, are met but a charge is made for the service. During 1960, 71 applications were received and accounts rendered for £61 14s. During the year, 142 Library books were collected from homes and hospitals where infectious disease had occurred, disinfected and returned to the Library of origin. 30 Mortuary The administration of the Beckenham Mortuary is the responsibility of the Public Health Department, the Mortuary Attendant being a member of the Medical Officer's staff. During 1960, 151 bodies were brought to the Mortuary where post-mortem examinations were conducted by a Home Office Pathologist. Twenty-seven Inquests were held in the Town Hall. Movable Dwellings Thirteen families occupied movable dwellings under licence from the Council during 1960. Twelve inspections of the sites of the caravans were made, and in no instance was a Public Health nuisance discovered. Water Supply The water supply of the area has been satisfactory in quality and quantity, the Metropolitan Water Board supplying all properties in the area by main. Bacteriological examination has been regular, 36 samples being taken during the year. All proved to be satisfactory. Drainage As will be seen from the Table of nuisances remedied, 340 instances of choked drains were discovered during the year. A great many of these chokages related to public sewers, i.e. drains receiving wastes of two or more houses. The Council accepts as a legal responsibility, the clearance of public sewers, and the work is undertaken without any charge being made to the owners or occupiers of the properties. Of the 340 cases discovered, however, 230 related to private drainage, and in these cases a charge is made for the work undertaken. Accounts were rendered for £168 0s. Od. for this work. The Smoke Testing of the house drains of 3 properties was undertaken, and Accounts were rendered for £6 6s. Infestation by Rats and Mice Five hundred and eighty-five complaints were received in 1960 of which 68 related to business premises. A charge is made for the service provided in respect of business premises, whereas private residential property is served free of charge. During the year, accounts for £98 15s. 9d. were rendered in respect of business premises. Baiting of certain sections of the main sewers known to be rat infested, has been maintained during the year. 31 Shops Act, .1950 The duties of the Public Health Inspectors under this Act differ very widely in character. The health and welfare provisions embrace sanitation, heating, ventilation, rest facilities, etc., but the Inspectors are also the Council's authorised Officers for enforcing the statute so far as it relates to hours of opening and closing, the weekly halfholiday and early closing day, Sunday trading, the type of goods which are prohibited from sale at certain times, the employment of young persons, and the keeping of records. During 1960 301 visits were made to shops in the Borough, and 12 contraventions remedied. National Assistance Act, 1948 Burial and Cremation of Dead Section 50 of this Act places responsibility on a local authority for the burial of persons who have died, or been found dead, in their area where it appears that no suitable arrangements for disposal have been made. During 1960, it was necessary to take action under this Section on two occasions only. Noise Nuisances Complaints of nuisance from noise, particularly that arising from industry sited in a residential area, are not infrequent. The Council had certain powers to obtain abatement under the Beckenham Urban District Council Act, 1935, but they were by no means positive. It was necessary to prove the noise to be either excessive, unreasonable or unnecessary, and injurious or dangerous to health, and capable of being prevented or mitigated having regard to all the circumstances of the case. Where the noise arose in the course of any trade, business or occupation, it was a good defence to show that the best practicable means for preventing noise, having regard to the cost, had been adopted. It was by no means easy, upon receiving a complaint, to institute statutory action under this Act. The advent of the Noise Abatement Act, I960, clarified the position considerably. This enactment provides that any noise or vibration which is a nuisance is a statutory nuisance for the purposes of Part III of the Public Health Act, 1936. The Act did not come into operation until the 27th November, 1960, and it is perhaps too early firmly to assess its value. Nevertheless it obviously provides greater simplification of procedure than existed under previous legislation available to the Council. 32 The council was able by informal action to obtain the reasonable abatement of noise nuisances arising from :— (a) glass blowing in a scientific instrument factory. (b) the operation of a power hammer in an engineering factory. (c) the operation of metal presses in a factory making loose leaf bindings. CLEAN AIR ACT, 1956 BECKENHAM SMOKE CONTROL ORDER, 1960 Throughout 1960 the Department conducted the detailed survey of the first selected Smoke Control Area. The object of the survey was to record the conversions and adaptations of fireplaces necessary to permit the burning of smokeless fuels in the domestic premises in the area, and to estimate the cost thereof. This work entailed visits (and, in many cases, revisits) to 2,282 properties. Where access to a property could not be obtained during the normal working day, evening visits were paid. The results of the survey were reported to the Council in November 1960, in the following form :— 33 34 BOROUGH OF BECKENHAM PROPOSED SMOKE CONTROL ORDER—No. 1 DETAILED SURVEY SUMMARY (DOMESTIC PROPERTIES) Road Number of Dwellings New Appliances Required Adaptations Required Provision of Gas Points, Pokers, Extensions Approx. Total Cost Municipal Private Points Pokers Extensions Municipal Private Joint Total £ £ £ Abbots Way — 98 92 42 103 56 5 699 699 Altyre Close — 5 6 — 2 1 1 38 38 Altyre Way — 83 67 40 69 44 16 545 545 Ambleside Avenue — 43 32 29 42 22 2 251 251 Ashtree Close — 19 16 6 18 12 116 116 Aviemore Close 16 16 10 10 31 31 Aviemore Way 5 114 121 47 119 78 1 13 868 881 Aylesford Avenue 2 161 171 91 155 89 3 4 1,232 1,236 Barwood Avenue 16 — 16 16 16 16 115 115 Beckenham Road, W.W — 57 47 16 53 32 38 — 578 578 Braemar Gardens — 62 50 22 48 31 4 - 354 354 Cavendish Way 6 22 21 18 24 15 4 32 134 166 Cavendish Court — 4 1 2 2 3 - - 11 11 Chamberlain Cres 68 — 4 64 47 51 3 167 167 Eden Way — 241 215 92 226 130 25 - 1.605 1,605 Elmdene Close 10 — — 10 9 9 - 24 24 Fairford Close — 6 7 2 8 5 2 - 58 58 CSrccnvicw Avenue 1 12 18 2 20 10 6 - 144 144 32 22 23 38 21 6 3 1 92 195 35 High Street. W. W. - 48 29 12 32 31 16 - 314 314 Sherwood Court, - 26 11 7 9 9 - - 78 78 High Street, W. W. - 8 8 3 8 7 3 - 72 72 Hillerest View . . - 32 26 18 22 16 2 - 188 188 Holly Crescent - 14 12 8 15 10 - - 89 89 Kent Road - 44 44 21 54 32 25 - 451 451 Crabbs Croft 12 - - 11 11 11 11 54 — 54 Links Way 12 55 55 34 46 35 12 18 395 413 Lloyds Way - 83 79 38 76 51 6 — 589 589 Lodge Gardens - 8 5 2 11 7 1 - 43 43 Manor Park Close - 12 10 10 21 12 — — 86 86 Manor Park Road 18 60 73 50 95 59 41 230 438 668 Monks Orchard Rd - 104 53 31 55 37 23 - 433 433 North Road - 17 14 8 22 11 19 - 277 277 Orchard Way 48 9 48 31 32 - 85 10 95 Pine Avenue 6 66 63 32 48 34 15 33 462 495 Ravenswood Avenue - 64 57 25 34 26 3 - 379 379 Ravenswood Cres - 30 30 13 27 18 6 - 218 218 South Eden Park Rd. - 60 38 29 27 20 9 — 305 305 Stanhope Grove - 12 13 8 15 9 - - 103 103 Station Road w.w. - 32 19 16 21 13 5 - 153 153 Surrey Road - 17 16 6 21 12 11 - 135 135 Sussex Road - 11 11 8 15 10 12 — 120 120 Upper Elmers End Road 6 277 252 76 246 178 58 - 1,861 1,861 Wilmar Gardens - 23 28 7 24 14 — — 198 198 Total 226 2,071 1,846 1,059 1,995 1,329 400 809 14,222 15,031 Approximate Total Cost of Works £15,031 *1. Contribution by Council = £4,509 *2. Contribution by Owners and/or Occupiers = £4,509 3. Contribution by Exchequer= £6,013 *1. This amount will be increased by £243, should the Council accept full responsibility for Municipal Properties. *2. This amount will be correspondingly reduced. On the 19th December, 1960, the Council RESOLVED (i) that in exercise of the powers conferred by Section 11 of the Clean Air Act, 1956, the Council do make an Order, to come into operation on 1st November, 1961, entitled the Beckenham Smoke Control Order 1960, declaring the following area to be a smoke controlled area, viz :— The part of the Borough contained in the Manor House, Eden Park and West Wickham North Wards and bounded on the north, north-east and east by Abbots Way, Lloyds Way, Upper Elmers End Road, Links Way, South Eden Park Road, Beckenham Road and Station Road, West Wickham; on the west and south-west by the Borough boundary with Croydon ; and on the south by High Street, West Wickham. (ii) That provision be made in the Order for exemption from the operation of Section 11 of the Act of :— (a) the houses numbered 112/122 (even) and 146/164 (even) Upper Elmers End Road which are likely soon to be demolished ; (b) all dwellings in the area without a gas supply so as to give legal authority for the use of wood and paper for lighting fires ; and (c) the factory premises known as J. & R. Killick's Joinery Works, Kent Road, West Wickham, where wood waste is burned. (iii) That the Common Seal of the Corporation be affixed to the Order and to a map showing the area covered by the Order. (iv) That the Town Clerk be authorised to seek the confirmation of the Minister of Housing and Local Government to the Order, and to arrange for the publication and giving of the required notices stating the general effect of the Order and that within a period of six weeks from the date of the last publication of the notice in the press any person who will be affected may object to the confirmation of the Order by giving written notice to the Min;ster. 36 INSPECTION OF HOUSES FOR PURPOSES OF PART I AND II OF HOUSING ACT, 1937 The Public Health Committee was informed in July, 1960 that regular house to house inspection under the Housing Acts, which was carried on more or less continuously during the period 1946 to 1958, had been discontinued owing to the pressure of other work. During the period mentioned several hundred houses were brought by the owners to a proper state of repair and habitability so far as the law required. It is nevertheless the statutory duty of a local authority regularly to inspect the houses within its district to ascertain whether any are unfit for human habitation. The Officers to whom these duties (inter alia) are assigned come to know their districts intimately, and can identify the black spots, and as easily determine those areas where their services are unlikely to be required in this particular connection. It will be obvious that, in any district, parts of the area may be disregarded completely, leaving attention to be paid to the black spots, and the potential black spots of the foreseeable future. In common with all districts, Beckenham has its black spots, but the emphasis here is on the potential rather than the existing, largely because of the work completed during 1946 to 1958. In an endeavour to find out whether there is a need for a resumption of regular house inspection, a sport check was undertaken. 376 houses were visited, and answers were obtained to the following questions :— 1. Do public health nuisances exist which require urgent attention. 2. Is the house unfit for human habitation within the meaning of the Housing Act, 1957. 3. Has the rent been increased as a result of the 1957 Rent Act. 4. If so, has the tenant obtained a Certificate of Disrepair. Where a house visited was found to be owner-occupied, no inspection was made. The survey shows that 121 or 32.1 % of the 376 houses visited are owner-occupied. This figure is noteworthy, and surely indicative that the stability and repair of these older houses in the Borough is satisfactory, particularly as many will be mortgaged to Building Societies, or the local authority, and thus have been subject to strict survey within the last two or three years. It is also of interest as an index to the changing pattern of living standards, for a few years ago the percentage of owner-occupied houses in these roads was negligible. This information left us with 255 houses which were inspected in relation to the four questions above. 37 29 or 11.4% were considered to be in a condition prejudicial to health or a nuisance, and to call for action under the Public Health Act, 1936. 4 or 1.5% were considered to be unfit for human habitation within the meaning of the Housing Act, 1957. It was found that in 168 instances the owners had increased rents under the provisions of the Rent Act, 1957, but in only 13 of these cases had the tenants applied for Certificates of Disrepair. Undoubtedly in some of the remainder the owner had complied with the tenant's request for repair works, and thus obviated the necessity for the tenant to apply for a Certificate. Of the 33 houses found to require attention, 3 had not had rent increases, and of the 30 where increase had been applied only 4 of the tenants had sought the repair of the property by the exercise of their right to serve Form G on the owners. The remaining 26 had accepted the increase, failing to exercise their rights under the Act, to secure the repair of the property. The reason for this may be apathy, perhaps ignorance of the law, but the opinion has been formed that many tenants regard the Rent Act with apprehension, and are frightened of being evicted. The information obtained from this quick survey confirms an opinion that the problem, though not to be completely ignored, does not warrant interruption of the present routine of work, which is concentrated very largely now on the duties imposed on the Council by the Clean Air Act, 1956. The premises found in this survey to need attention were dealt with, and further spot checks will be undertaken at regular intervals. 38 SECTION F INFECTIOUS DISEASES CONTROL Tables at the end of this report show that 8,238 persons were immunised against Poliomyelitis, 1,793 persons were immunised against Diphtheria, 980 persons were immunised against Whooping Cough and 810 persons were vaccinated against Smallpox. One case of non-paralytic poliomyelitis was notified. This was a boy of five years who was notified on the completion of investigations in hospital. He had not been inoculated against poliomyelitis but made an uneventful recovery. There were 785 fewer cases of measles and two fewer cases of scarlet fever. The rise and fall of epidemic prevalence of measles contrasts with the constantly elevated figure each year for scarlet fever. Both measles and scarlet fever were milder this year. No cases of measles were admitted to hospital compared with three cases in 1959. Three cases of scarlet fever were admitted to hospital compared with seven cases last year. As the infectivity of measles or whooping cough is greatly reduced once the rash has manifested itself, or the whoop has developed, whereas the infectivity of scarlet fever continues after the rash has appeared, it is customary for no visit by inspectors to be made to measles or whooping cough households, whereas visits are made to scarlet fever households and households containing other notified infectious diseases. Further investigations in cases of scarlet fever showed that in 5 out of 63 families 2 children had scarlet fever. Family contacts of scarlet fever cases were found in seven instances to be handling fresh food in catering establishments and were advised temporarily to discontinue this. Two family contacts were school teachers and the appropriate authorities were notified. Defects in sanitary conditions were found in three properties and these were remedied. Library books were collected and disinfected from fifteen households and returned to the library. It was found that the notifications of scarlet fever were reasonably prompt and effective. The intervals between the onsets of rash and the dates that notifications were received by the Medical Officer of Health were as follows : one day or less 15; two days 14; three days 14; four days 9; five days 5; six days 5; nine days 1; ten days 1; 16 days 1; one, date not known but after return home from hospital. In 1960 there was again a high incidence of Sonne Dysentery. School children aged 5-15 years provided the greatest number of cases: 28 out of 61 cases notified. The largest number (21) of cases occurred in March. Inspectors visited 46 families to complete enquiry cards and to obtain specimens for pathological examination. The notifications of dysentery came from a fairly circumscribed area of the Borough. As was the case last year, two wards, the Lawrie Park 39 and Kent House and the Clockhouse Wards, were mainly effected but Manor House Ward showed the greatest increase. Six cases were notified after admission to hospital. The remaining cases were notified by doctors from 14 practices. Thirteen cases were notified by one practitioner, four cases by another practitioner and three cases each by three other practitioners. A single case was notified by ten practitioners. Seven cases were notified but pathological examination failed to reveal sonne dysentery organisms. Six cases of food poisoning were notified by medical practitioners in the Borough and were investigated. All were single incidents and Salmonella Typhimurium was isolated from two cases. A symptomless excreter of salmonella typhimurium on the nursing staff of a London Hospital was kept under surveillance until bacteriological clearance was obtained. Other investigations included that of a member of a crew of a ship arriving at the port of London from Port Said and on which an outbreak of gastroenteritis due to dysentery and salmonella had occurred during the voyage. Investigations were also carried out at the request of a neighbouring authority of contacts of a food poisoning outbreak in one of their canteens. Arrangements have continued for the examination of faeces for bact. coli. serotypes of admissions to St. Hilda's Nursery. Forty-eight specimens were examined and all were reported by the laboratory to be negative. 40 41 INFECTIOUS DISEASE (1) disease 0-4 years 5—15 years 15 years and over Age Unknown admitted to Hospital total total M. F. M. F. M. F. M. F. M. F. M. F. Measles 35 43 31 39 — 1 1 — — — 67 83 150 Scarlet Fever 14 8 28 16 — 2 — — 3 — 42 26 68 Whooping Cough 8 12 6 8 1 4 — — 1 — 15 24 39 Dysentery 7 7 18 10 9 10 — — 5 — 34 27 61 Puerperal Pyrexia — — — — — 9 — — — 8 — 9 9 Pneumonia — 2 1 — 1 9 1 — 3 — 3 11 14 Erysipelas — — — — 1 1 — — — — 1 1 2 Poliomyelitis—Paralytic — — — — — — — — — — — — — Non-Paralytic — — 1 — — — — — 1 — 1 — 1 Food Poisoning — — 1 1 — — — — 1 I 1 2 Meningococcal Infection — 1 — — — — — — — 1 — 1 1 42 INFECTIOUS DISEASE (2) The following Table gives the number of cases notified during the year. disease jan. feb. mar. apr. may june july aug. sept. oct. nov. dec. total Measles 2 12 15 4 13 71 23 7 — — 1 2 150 Scarlet Fever 10 7 12 12 7 4 2 3 1 4 6 — 68 Whooping Cough — — 16 6 2 6 4 2 2 1 39 Dysentery 1 1 21 11 7 1 7 4 4 2 1 1 61 Puerperal Pyrexia 6 — — 1 — 2 — — — — — — 9 Pneumonia .. 2 5 2 — ] — — — — 1 — 3 14 Erysipelas — — — 1 — — — — — 1 — — 2 Poliomyelitis Paralytic — — — — — — — — — — — — — Non-Paralytic — — — — — — 1 — — — — — 1 Food Poisoning 1 — — — — — — 1 — — — 2 Meningococcal Infection — — — 1 — — — — — — — — 1 Totals 22 25 66 36 30 84 37 16 8 8 8 7 347 INFECTIOUS DISEASE (3) disease wards* L. Pk. and K.H. C.C. C.H. M.H. E.P. Short lands W.W. (North) W.W. (South) Measles 19 4 5 1 5 19 18 79 Scarlet Fever 9 1 7 15 5 3 5 23 Whooping Cough 10 2 2 6 2 2 6 9 Dysentery 23 1 11 15 4 3 4 — Puerperal Pyrexia 1 — — — 8 — — — Pneumonia 4 1 1 3 3 — 1 1 Erysipelas — — — — — — — 2 Poliomyelitis—Paralytic — — — — — — — — Non-Paralytic 1 — — — — — — — Food Poisoning — — 1 — — — 1 — Meningococcal Infection — — 1 — — — — — Totals 67 9 28 40 27 27 35 114 *L. Pk. and K..H.—Lawrie Park and Kent House. M.H.—Manor House. C.C.—Copers Cope. C.H.—Clock House. E.P.—Eden Park. W.W. (North)—West Wickham North. W.W. (South)—West Wickham South. IMMUNISATION AND VACCINATION I have set out below the Diphtheria Immunisation, Whooping Cough Immunisation and Smallpox Vaccination figures for I960 based on record cards received. Year of Birth Diphtheria Vaccination Smallpox Vaccination Whooping-Cough Immunisation Primary Reinforcing Primary Revaccination Primary 1960 451 4 377 — 446 1959 509 2 324 — 400 1958 73 31 29 — 64 1957 22 11 10 — 19 1956 14 65 7 — 16 1955 12 341 3 — 17 1954 9 92 3 — 1 1953 8 46 2 — 5 1952 5 16 3 — 4 1951 2 25 1 1 1 1950 5 22 4 — 2 1949 4 9 1 2 2 1948 2 6 3 2 1 1947 2 2 — 2 — 1946 — 1 — 1 — Before 1946 2 — 15 20 2 Total 1,120 673 782 28 980 44 45 POLIOMYELITIS VACCINATION, 1960 The following Table gives the number of persons resident in the Borough (A) who have received second injections and (B) who have received third injections, given during the year ended 31st December, 1960 :— Year of Birth 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 19331942 Before 1933 * Others Total (A) 175 563 74 24 16 12 15 24 11 7 6 8 7 5 4 7 11 11 401 2,041 147 3,569 (B) 10 376 409 121 75 71 77 56 39 47 38 49 49 52 57 37 46 70 1,764 908 309 4,669 * Priority groups irrespective of age. IMMUNISATION AGAINST DIPHTHERIA, 1960 The following is a return of the number of children in the Borough under the age of 15 years on 31st December, 1960, who had completed a course of immunisation at any time before that date (i.e., at any time since 1st January, 1946). Year of Birth 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 Total Last complete course of injections (whether primary or booster) 1956-1960 371 658 403 127 254 564 522 495 509 759 703 705 712 696 455 7,933 1955 or earlier 43 35 33 117 357 35 8 22 313 52 - - - - - 1,015 HARD WATERS AND HEALTH By L. R. L. EDWARDS, M.D., London, D.P.H., Liverpool Medical Officer of Health, Borough of Beckenham The purpose of this article is to consider the evidence relating to health in areas where the drinking water is of a hard nature, and especially concerning stone in the urinary tract. This is a matter of some importance to areas such as the Borough of Beckenham whose drinking water supply is moderately hard and is obtained by admixture of water from the River Thames with waters from wells in chalk strata. The total hardness as calcium carbonate from the River Thames averages 282 mg./l. and in the wells of Orpington, Shortlands and West Wickham averages 272, 280 and 260 mg./l. respectively. There are no comparative studies to indicate whether calculus of the kidney and ureter is more common in this area than in other parts of the country where the incidence is generally a low one. A research study of the College of General Practitioners and the General Register Office covering the clinical records of over 100 medical practitioners at random throughout the country over the period May, 1955, to April, 1956, gave an incidence of 0.4 per 1,000 for males and 0.2 per 1,000 for females. The population at risk was 180,000 males and 202,769 females. In practically all cases the hardness of a water depends upon the presence of certain salts, calcium and magnesium, bicarbonates and sulphates. Temporary hardness is due to bicarbonates and permanent hardness to sulphates. Effects on general health Excessively hard waters have been alleged to cause kidney disease, calculus, gout, rheumatism, constipation, biliousness, goitre and arteriosclerosis. Amongst veterinarians there is a popular idea that hard water has a bad effect on animals in some general indefinite way. It is thought that the coats of horses and cattle is made rougher and the animals do not " do as well " if forced continually to drink hard water. This belief is particularly prevalent among poultry raisers. Many sanitarians think that hard water has no effect on human health either good or bad. Thresh (1913) remarked that hard water had no bad effects on health. He based his conclusions on a comparison of the death-rate from typhoid fever and similar diseases in hard water regions and in soft water regions. Sherman (1919) states that "since inorganic forms of calcium are utilised in nutrition, the lime of drinking water may be added to that of the food in calculating the amount consumed, and to this extent the nutritive supply may be greater than the dietary studies show, but unless a very hard water is used for drinking it is unlikely that the lime from this source will cover more than a small part of the calcium requirement." 46 Other sanitarians consider that hard water is better than soft or distilled water for drinking purposes. Rector (1916) remarks "the weight of evidence is in favour of the use of a natural hard water containing a moderate amount of mineral." Opitz draws from a large amount of statistical data the following conclusions: "Communities with a very hard water are better as regards frequency of dental trouble in registrants for military service, among disability claimants and in school children. Also there was a better body weight and degree of robustness among registrants for military service. The vitality of the newborn was better. There were fewer signs of nervous excitability in infants, school children and those insured for disability. There was a slight advantage as regards size of infants and school children and with reference to mortality from tuberculosis." Thresh, Beale and Suckling (1949) conclude that the evidence that excessively hard waters cause kidney disease, dyspepsia, etc., is most unreliable and state that " a French Commission arrived at the conclusion that a moderately hard water was the best, and that persons residing in districts supplied with such water had a better physique than those living in districts where soft water was used." A Vienna Commission expressed the same opinion. Other evidence is derived from animal experiments. Thus Myers (1925) experimented on white mice, white rats, rabbits, dogs, calves, pigeons and chickens as to the relationship between hard water and growth. These experiments show similar equivocal results to the human studies already quoted. White mice and white rats show no striking difference in growth and appearances between the groups fed on grain and meal but with a natural hard water in one instance and distilled water in the other group. Young rabbits, calves and a few dogs grow faster and are heavier when natural hard water instead of distilled water is the supplement to the diet. Similar results are obtained with chicks and when salts are added to distilled water to simulate natural hard water growth in both groups is equal. These experiments show that in no instance do animals on distilled water develop better than on hard water and the reverse is true in several conditions. In fact most investigations show that hard waters are a valuable source of calcium when the diet is otherwise low in this mineral. Effect on incidence of stone in the urinary tract Experiments on animals give no evidence that hard water is by itself a factor in urinary concretion formation. John T. Myers (1925), quotes an early study by Studewsky, in which various foreign bodies are introduced into the urinary bladders of dogs where they remain for periods of one to three months. The objects include polished glass beads, pellets of gutta percha, hollow jug shaped glass objects, rolls of lead wire, balls of gum and irregular pieces of tin plate. 47 The animals are divided into four groups. The first group is kept under as nearly normal conditions as possible using ordinary food and a rather soft water. A small amount of lactic acid is added to the food and water of the second group and of oxalic acid to that of the third group. The fourth group is kept under normal conditions, except that they are given water containing one part per thousand of chalk. In almost every instance there is some deposition of salts on the foreign bodies especially if the surfaces are rough. The salts consist largely of calcium and magnesium phosphates. Three dogs are given chalk water and powdered bone is added to their food for three and a half months. No foreign bodies are introduced into their urinary bladders and at necropsy all three dogs are normal. Human studies indicate that hard water is important under certain circumstances. Urinary concretions are more common in regions with a limestone soil. In this country certain " stone areas" used to exist in the Eastern Counties, Westmorland, parts of Derbyshire and North Wales, but these no longer remain, in Switzerland the water is hard but urinary lithiasis is relatively rare. In Holland the water is soft but there is plenty of lithiasis. Clearly there are factors other than the hardness of the water. It is probable that the astonishing "stone wave"of Central Europe which apparently started about 1924 and was still continuing in 1938 was most likely an expression of a widespread change in the conditions of life, and that dietary deficiency was a highly probable cause. It is believed that the almost complete disappearance of vesical calculus among the children of the poor today is again due to improved nutrition. The part played by water supply in the occurrence of urinary calculus under bad dietetic conditions was illustrated in South Staffordshire where the disease diminished considerably when a softer water than was formerly used was obtained by sinking wells to a deeper level. It is considered that it is in the presence of vitamin deficiency especially in the amount of vitamin A that excess of lime in the water is a factor in the formation of stone in the urinary tract. Such dietary deficiency today could only occur under exceptional circumstances and the formation of urinary stone now depends on numerous other aetiological factors. These have been fully investigated by WinsburyWhite (1954) who points out that the old conception that the presence of stone depends largely on the ingestion of the chemical substances of which the stone is composed has now faded into significance. He points out that today the two commonest components of urinary calculi are calcium oxalate and uric acid. Exclusion of calcium and oxalate from the diet has no appreciable effect on the formation of urinary stones. Uric acid stones are found quite commonly amongst people whose diet never includes any protein. It is of special interest 48 that Winsbury-White found an increased incidence of upper urinary tract lithiasis at older ages among the 866 cases investigated and an incidence of two cases of urinary stone in males to one case in females, and that both renal and ureteric stones are more common on the right than the left side. He refers to McCarrison's work in India on rats to whose diets deficient amongst other things in vitamin A, calcium was added, and states: "McCarrion's experiments have made it clear that it is in the presence of vitamin deficiency that excess of lime in the water is a factor." The full extent of the pathological processes which take place in the body as a result of lack of vitamin A and which lead ultimately to urinary lithiasis have yet to be defined. One consequence is that degenerative changes in epithelial structure involve the urinary tract to a marked degree. There seems no doubt that desquamated epithelium often forms the nucleus of the stone but whether infection always precedes stone-formation is a point yet to be settled. Experiments of Bliss, Livermore and Prather (1933) appear to substantiate the generally accepted conclusions that deficiency of vitamin A alone can induce the formation of urinary calculi in the rat. These experiments throw light on the incidence of vesical calculus in Great Britain in former days ; it was in fact in the counties where the best pasture land was found that stone was not prevalent ; for in these districts milk and butter both rich in vitamin A and absorbable calcium were commonly available. In some parts of the East children develop vesical calculus while still at the breast. In the dry belts of the world such as Northern Africa, Arabia, Persia, Mesopotamia and Northern Italy stone abounds. Because vegetation is scarce, meat, milk and butter are scanty but the animals which do exist depend on green fodder for vitamin A. Moreover, the dry food on which they so largely live is rich in calcium and phosphates. It is not surprising that lithiasis is common even amongst the animals themselves. In 1828 William England quoted by Thomas commented on the following facts :— (1) The rarity of stone in Ireland where the people lived on vegetables, potatoes and milk. (2) The scarcity of stone in Scotland where the diet consisted of oatmeal, milk, cheese, vegetables and fish. (3) Its prevalence in Norfolk where the diet consisted of bread, water, tea and very little milk—the last because pasture land was poor. Switzerland and Normandy are two places where the inhabitants have access to plenty of milk and its by-products and where lithiasis is rare. 49 It is believed that persisting food faults may act in the same way as low grade chronic infections by causing damage to the tubular epithelium of the kidneys. Metabolic, endocrine, osseous and perhaps other derangements can cause an imbalance of chemical substances in the blood and urine which will assist the formation of stone. Urinary stasis, hypervitaminosis and foreign bodies play their part. It is clear that we do not know all the contributory factors, or the intimacy and delicacy of their combinations. Summary The consumption of a hard water is described by some authors as the cause of various diseases such as gastric complaints including biliousness, constipation ; also rheumatism, gout, arteriosclerosis, goitre and stone in the kidney. I find clear evidence only in respect to stone in the kidney and then only in certain circumstances. There is no literature to describe any varying incidence of these diseases in different parts of this country according to the hardness of the water supply. It would be of interest to know if in fact such differences do exist. References Bliss, A. R., Livermore, G. R., Prather, E. O. (1933) : J. Urol. {Baltimore), 30, 639. Logan, W. P. D., General Register Office (1960): Studies on Medical and Population Subjects, No. 11. McCarrison, R. (1927) : Brit. Med. J., i, 717. (1931): Brit. Med. J., i, 1009. Myers, John T. (1925): J. Infect. Dis., John McCormick Institute, Vol. 36, 566, 37, 13. Opitz, K. (1920) : Deutsch. Med. Wchmschr., 46, 1391. Rector, F. L. (1916) : NYMed. J., 104, 1142. Sherman, H. C. (1918) : Chemistry of Food and Nutrition, 2nd Edit., 267, NY, Macmillan. Thresh, J. C. (1913) : Lancet, i, 1057. Thresh, Beale and Suckling (Ed. E. Windle Taylor): Examination of Waters and Water Supplies, 6th Edit. (1949), 34. Thomas, J. M. R. (1949) ; Brit. J. Urol, 21, 20. Winsbury-White, H. P. (1954) : Stone in the Urinary Tract, 2nd Edit., 153, 156,London, Butterworth. 50