Ac 442(1) BROMLEY BRO 23 Borough of Bromley THE Annual Report ON THE H EALTH AND SANITARY CONDITION OF THE BOROUGH For the Year 1923. BY W. STEWART STALKER, M.D., CH.B., D.P.H., MEDICAL OFFICER OF HEALTH. CROYDON: PRINTED BY THE " CROYDON TIMBS" LTD., 108, HIGH STRHKT. Borough of Bromley. THE Annual Report ON THE H EALTH AND SANITARY CONDITION OF THE BOROUGH For the Year 1923. BY W. STEWART STALKER, M.D., CH.B., D.P.H., MEDICAL OFFICER OF HEALTH. CROYDON: PRINTliD BY THE "CROYPON TJMBS" L.TD., 108, HIGH STREET, Borough of Bromley. REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1923. Jo the tMayor, Jlldermen and Councillors, and Oo-opfed Members of the Maternity and Child Welfare Committee. of the Borough of Bromley. Mr. Mayor, Ladies and Gentlemen, I have the honour to present the Report of the year 1923 on the Health and Sanitary Condition of Bromley. The report is compiled in conformity with Circular 451 of December 15th, 1923, of the Ministry of Health, with the addition of some commentary relevant to special features of the town's health and of work carried out in pursuit of its preservation. Vital Statistics supplied by the Registrar-General were received in March, 1924. Until these weire received, the report could no't be completed. 4 Appended to the report is a table of certain rates which I have compiled since my appointment as Medical Officer of Health. The table is instructive, supplying as it does a good deal of information concerning the district's vital statistics during the last 30 years. During the year Dr. Ruth E. Proctor, Assistant Medical Officer of Health and Assistant School Medical Officer, resigned, and Dr. Anna M. K. O'Halloran replaced her. Dr. O'Halloran's duties are principally concerned with School Medical Inspection, and the Council's scheme of pre-natal hygiene. She also, however, participates in the general work of the Medical Officer of Health's Department, and deputises in that officer's absence. It is with pleasure that I record the very helpful and efficient services which Mr. Butler and oither members of the staff of the Health Department have put at my disposal during the year under review. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, W. STEWART STALKER. Municipal Offices, Bromley, Kent. May, 1924. 5 1.-GENERAL STATISTICS. Area in acres 4,696 Population (Registrar General, 1923) 34,970 Number of inhabited houses 7,984 Rateable value £287,702 Product of a penny rate £1,097 The Registrar-General's estimate of population is for the middle of 1923. R shows an increase of 200 over the previous year. The natural increase was 211, and the Registrar-General's estimate allows nothing for any increase of immigration over the number of persons who left the district—an unknown quantity. With an increase of over 100 new houses, one would expect a greater increase in the population. An approximate estimate of population awaits the taking of a census under conditions less deceptive than those which characterised the taking of the last census. 2.—EXTRACTS FROM VITAL STATISTICS OF THE YEAR, 1923. Births— Total. Male. Female. Legitimate ... 549 271 to CO Illegitimate 29 19 IO Birth Rate (R.G.)— -16.5. Deaths 367 170 197 Death Rate (R.G.) —10.5. Number of women dying in consequence of child-birth; from sepsis, 1. Deaths of infants under one year of age per 1,000 births : Legitimate, 31; illegitimate, 4; total, 35 (Rate 60). Deaths from Measles (all ages) ... ... ... 3 Whooping Cough ... ... ... 3 ,, Diarrhoea, &c. (under two years) 5 6 Births. According to the Registrar-General, -there were 578 births registered during the calendar year. The number is corrected for inward and outward transfers. The birth-rate of 16.5 was the same as that of the previous year, which was the lowest recorded rate, with the exception of those of three years influenced by the war. If reference be made to the table of rates in the Appendix to this report, the gradual approximation of the birth rate to that of the death rate and the consequent diminution of rates of natural increase will be appreciated. The process of diminution is not peculiar to Bromley. It is a feature of the vital statistics of the country generally. However, its progress in Bromley is more marked than in most other communities. This may be gathered by comparing the birth and death rates of Bromley with those of London and the Provinces. Birth and Death Rates of 1923— Births. Deaths. England and Wales ... 19.7 11.6 105 Great Towns 20.4 11.6 157 Smaller Towns (including Bromley) .9.8 IO.fi London 20.2 11.2 BROMLEY 16.5 10.5 7 DEATHS REGISTERED DURING THE YEAR 192.J. CAUSE'S OF DEATH. Nett Deaths at the Subjoined Ages, of " Residents," whether occurring within or without the Dintricl. All ages Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under Ii5 years. 65 and upwards. 1 2 3 4 5 6 7 8 9 10 1 Enteric Fever ... ... ... ... ... ... ... ... ... 2 Small-pox ... ... ... ... ... ... ... ... ... 3 Measles 3 1 ... 1 1 ... ... ... ... 4 Scarlet Fever ... ... ... ... ... ... ... ... ... 5 Whooping Cough 3 2 ... 1 ... ... ... ... ... 6 Diphtheria and Croup 2 ... ... 1 1 ... ... ... ... 7 Influenza 4 ... ... ... ... ... 1 1 2 8 Erysipelas ... ... ... ... ... ... ... ... ... 9 Phthisis (Pulmonary Tuberculosis) 23 ... ... ... ... 6 11 3 3 10 Tuberculous Meningitis 1 1 ... ... ... ... ... ... ... 11 Other Tuberculous Diseases 4 1 1 1 ... I ... ... ... 12 Cancer, malignant disease 48 ... ... ... ... 1 6 10 31 13 Kheumatic Fever ... ... ... ... ... ... ... ... ... 14 Meningitis 1 1 ... ... ... ... ... ... ... 15 Organic Heart Disease 63 ... 1 ... 1 2 1 17 41 16 Bronchitis 23 l 1 ... ... ... 1 2 18 17 Pneumonia (all foims) 21 3 1 1 ... 1 1 9 5 18 Other diseases of the respiratory organs ... ... ... ... ... ... ... ... ... 19 Diarrhoea and Enteritis 2 1 1 ... ... ... ... ... ... 20 Appendicitis and Typhlitis 3 ... ... ... ... ... 1 2 ... 21 Cirrhosis of the liver 4 ... ... ... ... ... ... 3 1 21a Alcoholism ... ... ... ... ... ... ... ... ... 22 Nephritis and Pl ight's Disease 13 ... ... ... 1 ... 2 2 8 23 Puerperal Fever 1 ... ... ... ... ... 1 ... ... 24 Other accidents and diseases of Pregnancy and Parturition ... ... ... ... ... ... ... ... ... 2« Congenital Debility and Malformation, including Prematuie Birth l6 16 ... ... ... ... ... ... ... 26 Violent Deaths, excluding Suicides 7 ... 1 ... ... 2 2 1 1 27 Suicide 1 ... ... ... ... ... ... 1 ... 28 Other defined diseases 123 7 2 2 5 2 7 26 72 29 Diseases ill-defined or unknown 1 1 ... ... ... ... ... ... ... Totals ... 367 3.5 8 7 9 15 34 77 1S2 8 Deaths. There was a substantial decrease in the death rate of 1923 in comparison with thait of 1922. In the latter year the rate was 11.8; last year it was 10.5. The decrease of mortality applies to the country in general. In Bromley, during the last 30 years, the mean death rate was 10.9, so that, although last year's rate was better than that of its predecessor, there is no evidence that the rate is a dominating quantity, as during the 30 years' period under review several years have provided a lower death rate than that of 1923. With regard to the causes of death, reference to the table of causes will establish the fact that three causes of death predominate, i.e., cancer, cardiac disease and respiratory disease. The rates ot these attections tor the previous ten years show the extent of incidence. Cancer. Heart Disease. Respiratory Disease. 1923 1.4 1.8 1.2 1922 1.6 1.4 2.5 1921 1.3 1.2 2.1 1920 1.2 1.2 2.1 1919 1.2 1.7 2.1 1918 1.7 1.3 2.4 1917 1.3 1.5 2.9 1916 1.1 1.6 2.5 1915 1.4 1.2 2.6 1914 1.3 1.2 2.09 Now the significance of these figures is that the affections which appear in the above table account for nearly one-half of the deaths which occurred. It will be seen that there is a reduction this vear in the death rate from Cancer and Respiratory Disease, and an increase in the mortality from Heart Pisease. 9 INFANTILE MORTALITY. 1923.—Nett Deaths from Stated Causes at Various Ages under 1 year of age. CAUSES OF DEATH. Under 1 wtek. 1 ami under 2 weeks- 2 and under 3 weeks 3 and under 4 weeks. Total under 4 weeks. 4 weekst and under 3 month*. 3 months and under . 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under l year Small-pox ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... 1 ... 1 Scarlet Fever ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... 1 1 ... ... 2 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... 1 ... Tuberculous Meningitis ... ... ... ... ... ... ... ... ... 1 Abdominal Tuberculosis ... .... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... 1 ... 1 1 Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... 1 Convulsions 1 ... ... ... 1 1 l ... ... 3 Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... 1 ... 1 1 Pneumonia (all forms) 1 ... ... ... 1 ... 1 ... ... 3 Diarrhœa ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... ... 1 ... 1 Gastritis ... ... ... ... ... 1 ... ... ... 1 Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... ... ... Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis ... ... ... ... ... ... ... ... ... ... Congenital Malformations 2 ... ... ... 2 ... ... ... ... 2 Premature Birth 4 ... ... 1 5 ... ... ... ... 5 Atrophy, Debilis v and Marasmus 4 ... ... ... 5 ... 1 2 1 9 Other Causes 1 ... 1 ... 2 1 ... 1 ... 4 Totals 13 1 1 1 10 4 6 5 4 35 10 Infant Deaths. The infant deaths of 1923 numbered 35, and the death rate per thousand infants born was 60. This figure is more favourable than is that of the previous year, and ranks as one of the lowest in the past 30 years. I give the figures for the last 10 years for purpose of comparison 1923 60 1922 74 1921 60 1920 66 1919 71 1918 86 1917 79 1916 84 I9I5 51 1914 616l It will be observed in study of these figures how very considerable aire the fluctuations of infanit mortality. These fluctuations are in the main dependent upon two factors, the incidence of pre-natal conditions as a cause of death and the incidence of respiratory morbidity. In former years diarrhoea was very much in evidence as a cause of death. Of recent years, no doubt in response to improved mothercraft as a result of the welfare movement, the diarrhoea factor has been inoperative, even in a season phenomenally favourable ito its development, as was the summer of 1921. 11 Comparative infant mortality figures of 1923 are fls under :— Deaths under one year per 1,000 births. England and Wales 69 105 Great Towns 72 157 Smaller Towns 69 London 60 BROMLEY 60 12 3.—NOTIFIABLE DISEASES DURING THE YEAR 1923. Disease. At all ages. Under 1. 1 1 and under 2, 2 and under 3. 3 and under 4. 4 and under 5. 5 and under 10. 10 and under 15. 15 and under 20. 20 and under 35, 36 and under 45. 45 and under 65. 05 and over- Cases admitted to Hospital Total cases notified in each Ward Plaistow Martin's Hill. Town | Sundridge Bickley. Bromley Common. Scarlet Fever 61 ... ... 1 3 4 24 13 5 7 3 ... 1 51 12 4 8 3 10 24 Diphtheria 21 1 1 ... 1 1 4 8 ... 4 1 ... ... 19 4 3 1 3 7 3 Erytipelas 15 ... ... 1 ... ... ... 1 ... 1 3 8 1 ... 1 5 3 4 ... 2 Puerperal Fever 2 ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... ... 2 ... ... Encephalitis Lethargica. 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 ... ... Acute Influenzal Pneumonia 5 ... ... ... ... ... 1 3 ... ... ... 1 ... ... 1 1 ... ... 1 2 Acute Primary Pneumonia 49 4 2 3 2 ... 6 1 5 4 11 7 4 ... 11 2 10 10 8 8 Ophthalmia Neonatorum 3 3 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 1 ... ... Acute Polio-myelitis 2 ... ... ... ... 1 ... ... ... ... 1 ... ... ... ... ... ... ... ... 2 Chicken Pox 8 ... ... 1 ... 1 3 1 ... 1 1 ... ... ... ... 2 ... ... 1 5 Totals 167 8 3 6 6 7 38 27 10 19 20 l6 7 70 29 17 24 24 27 46 13 Tuberculosis. The following table shows the new cases and death for 1923:— Age Periods. New oases notified or otherwise revealed. Deaths. Pulmonary. Non- Pulmonary. Pulmonary. Non-Pulmonary M. F . M. F. M. F. M. F. 0 1 1 1 ... ... 1 1 ... 1 ... ... 4 ... ... ... 2 ... 5 4 2 2 2 ... ... ... ... 10 2 1 2 3 ... ... ... ... 15 3 1 ... ... 2 ... 2 ... 20 3 3 ... 1 ... 3 ... ... 25 2 4 1 3 3 3 ... ... 35 8 3 ... 1 4 1 ... ... 45 1 1 ... 1 1 1 ... ... 55 2 ... 1 ... 1 ... ... ... 65 and upwards 1 1 ... ... 2 1 ... ... Totals 27 17 11 11 13 10 5 ... Of the 28 deaths from tuberculosis, it was found that three (two pulmonary and one non-pulmonary) had not been notified. One was that of a child of three years who died suddenly, and upon whom an inquest was held and a verdict of natural causes due to generalised tuberculosis given. The second was an inward transfer of the death of an exsoldier, who may have been notified elsewhere. In the third case there had been omission to notify. In 5 instances cases were notified on Forms C and D, no previous notification of Form A having been received. Of these, 3 were pulmonary and 2 non-pulmonary tuberculosis. 14 The Tuberculosis Register, which is kept in accordance with the Tuberculosis Regulations, 1912, is amended up to date. The entries go back to February, 1913, bu't all those relating to persons known to have died or left the district have been deleted. Index record cards are also kept up to date with particulars of each case. The following figures include pulmonary and nonpulmonary cases :— Number of names of persons deleted from Register on account of death 267 Ditto. Ditto., left the district Remaining on Register— 186 Pulmonary cases 164 Non-pulmonary cases 120 284 Total persons registered since February, 1913, excluding 392 secondary entries concerning persons notified on Forms C and D 737 Of the 284 entries remaining on the Register, a number relate to cases which are quiescent oir recovered, arid these include a number oif persons suffering from surgical tuberculosis who have been cured by operative treatment. Cards relating to these are filed separately, and tfaey are not visited, but there is no authority for removing their names from the register as there is in the case oi persons who have died or left the district. It is the general practice to carry out disinfection aftei all deaths from tuberculosis notified in the weekly death returns, or otherwise brought to the notice of the Pufbl'ic Health Department, as well as after patients have left the district, whether permanently or for sanatorium treatment, 15 The bedding is steam disinfected when permission is given, and the room occupied by the patient is fumigated with formalin eas. Ophthalmia Neonatorum. Cases. Vision unimpaired Vision impaired. Total Blindness. Deaths, Notified. T reated. At Home In Hospital 3 3 ... 3 ... ... ... 4.—CAUSES OF SICKNESS. Scarlet Fever.—There was little Scarlet Fever during the year, the attack rate being only 1.7 persons per thousand of population. The affection was of a mild type, the death rate being nil. The history of Scarlet Fever in Bromley will be found in the large table in the Appendix to this report. It will be observed that in time past the epidemic proportions of Scarlet Fever were never of great gravity, and there is no evidence in the available figures of Bromley—these extend over a period of 34 years, with a hiatus of one year—that Scarlet Fever was of a severe and fatal type. Diphtheria.—There were few cases of diphtheria (21). The incidence rate was 0.6 per 1,000 population, and there were two deaths. Here again the incidence during 30 years has at no time been very serious, but a different sitory i,s to be told with regard to case fatality. 16 Last year the case fatality per cent, of cases was 9.5. In the years immediately prior to the introduction of antitoxin, of every 100 persons attacked in Bromley, 30 to 40 died. 1 think convincing commentary on the efficiency of antitoxin as a remedial measure is written in the figureis, although I am not without belief that there is some relationship between the diminished fatality of scarlet fever and diphtheria, and that the latter diminution may be a natural process and irrespective in some degree of antitoxin administration. A memorandum of the Ministry of Health, dated July, 1922, emphasises the necessity of the early administration of antitoxin, and deprecates the praotice of awaiting bacteriological examination before administration. Puerperal Fever.— The figures are more satisfactory than those of last year. There were 2 cases and 1 dearth. The following table shows cases and deaths in the last ten years:— Cases Deaths. 1923 2 1 1922 6 2 1921 2 1 1920 5 2 1919 4 3 1918 3 2 1917 1 0 1916 3 2 1915 4 1 1914 3 1 17 5.—SUMMARY (FOR REFERENCE) OF THE NURSING ARRANGEMENTS, HOSPITALS AND OTHER INSTITUTIONS AVAILABLE FOR THE DISTRICT. Professional Nursing in the Home. (a) General.—The Bromley District Nursing Association employs a staff of 3 nurses who undertake general and maternity nursing. One of the nurses engages in general work; two of the nurses undertake midwifery and maternity nursing, and one of them, being trained in general nursing, undertakes a limited amount of general nursing work. Charges.—The charges made for general work are in accordance with ability to pay, and are entirely remitted in the cases of necessitous persons. Midwifery fees range from 25/- to 35/-, and maternity nursing fees from 15/- to 25/-. The work accomplished during 1923 was as follows Midwifery cases 63 Maternity cases nursed49 General cases 154 In connection with the above, the following visits were paid:— General 3,028 Ante-Natal 242 Midwifery and Maternity 2,124 In St. Luke's and Holy Trinity parishes, separate nursing arrangements exist. In (each of these parishes there is a nurse, and the work undertaken is set out in the following statement:— 18 St. Luke's Parish.—1 nurse, C.M.B. and general training. The nurse does not practice as a midwife. Maternity cases nursed 23 General cases nursed 244 Total visits paid 3136 Payment is according to means. Maternity cases nursed from 15/-. These arrangements are confined to St. Luke's Parish, and the Bromley Nursing Association nurses do no general work in this parish. Holy Trinity Parish.—-1 nurse, C.M.B. and general training. Midwifery and maternity cases nursed 29 General cases raursed 31 There is a definite system of charges. Midwifery, 30/- (25/- for subscribers). Maternity, 25/- (20/- for subscribers). (b) Infectious Disease Nursing.—The Bromley District Nursing Association nurses undertake nursing of measles, ophthalmia and whooping cough Cases. No arrangements exist between the Local Authority and any of the voluntary associations with regard to midwifery or infectious disease nursing. It has been possible to secure the services of the District Association Nursing Staff for such attendance in cases of ophthalmia, etc., as was deemed necessary. Midwives.—The number of midwives practising in the district and registered with the County Medical Officer of Health is eight. Three of these are members of Staff of the Local Maternity Hospital. As already staited, no subsidy is paid to midwives by the Local Health Authority. 19 Clinics and Treatment Centres.-—There are four Maternity and Child Welfare Centres in the district, three of which are general maternity and child welfare centres, and one specially conducted for expectant mothers. The former meet weekly and the latter meets monthly. They are all conducted under the auspices of the Borough Council, and have associated with them a number of voluntary workers. This voluntary effort is largely responsible for the success of these centres. The number of children on the registers of the General Centres is set out in the following statement:— CHILDREN REGISTERED AT EACH CENTRE, 1923 Ages. Pladstow. Widinore. Bromley Common. Total. Under 1 54 31 55 140 i and under 2 63 34 53 150 2 and under 3 37 27 52 116 3 and under 4 48 30 33 111 4 and under 5 27 12 13 52 5 and over 8 3 4 15 Totals 237 137 210 584 Infant and Maternity Welfare Centres. Attendances■ t Mothers. Infants. Medical Consultations. Clinics held. Total. . Av'ge. Total. Av'ge. To.tal Av'ge. l'laistow 2347 46 .. . 2544 50 ... 452 8 .. . 51 Widmore 1801 35 . 2003 39 ... 338 6 .. . 51 Bromley Common 1676 34 ... 2138 43 ... 415 8 .. . 50 Ante-Natal Clinic 73 6 ... 73 6 .. . 11 20 1 have drawn attention in detail in another report (the report of the School Medical Officer) to the considerable number of children who do not come under medical supervision until they are of school age. Taking- 2,000 as the number of children under school age who exist ait any given time in the district, it is found that, after making allowance for those who attend the clinics, for those who are outside the scope of maternity and child welfare, and for those who enrol at school at the ages of three and four, a large number of children, probably about one-half of the children under school age, do not attend the centres, and are therefore without medical inspection until they commence attending the public Elementary Schools. That this is unsatisfactory goes without saying. It is probably not less satisfactory than it is in other districts. It's most unsatisfactory feature is the fact that often the children who most require medical examination are not afforded it by their being withheld from the centres. I have suggested in the Report on School Medical Inspection that an effort to improve the clinic attendance could best be made by supplementation of the Health Visitors' work by voluntary effort. It is convenient at this part of the report to record the work done in Health Visiting and other visitation of kindred nature by the two Health Visitors in 1923. Visits Paid— Works-hops 3 Tuberculosis 106 Measles »53 Chicken Pox •9 Special circumstances 468 Infant Welfare :— 21 (a) Primary 465 (b) Re-visits under 1 year 8'3 (c) Re-visits over 1 year 3065 (d) Expectant Mothers 67 (e) Stillbirths 14 (f) Deaths 31 Total 5204 With regard to treatment of children under school age, I wish to put on record the help afforded in this respect by voluntary agencies. I would particularly instance the great kindness of Dr. Alice King, of South London Hospital, in seeing many children sent for expert diagnosis and treatment. To Guy's Hospital and Great Ormonde Street Children's Hospital, not a few cases have been sent, with neverfailing benefit. A limited amount of elementary treatment has been undertaken at the centres and at the Municipal Offices. This has consisted of simple medications, massage and dressing. But the great difficulty with which any centre has to contend is its tendency to develop into an out-patient department, to which come mothers who are either too poor to afford private medical provisions, or who wish to avoid incurring expenditure, which may, of necessity, be considerable. The diverting of those cases to the appropriate sources of treatment is by no means simple, having regard to the particular circumstances and necessities of each case. The family doctor's aid is naturally the proper channel into which to steer them, but too often it is obvious at the very outset that by no stretch of imagination can adequate treatment be paid for, or repeated journeys to a London Hospital, and it is this consideration and the consideration that 22 the scope of treatment for school children at the instance of the Education Authority is limited, that persuades one of the necessity for an Out-Patient Department at the local Cottage Hospital. The clinic for expectant moifihers met on 11 occasions last year. There were enrolled a total of 45 individuals, and 73 attendances were made—an average of 6.6. There are 3 School Clinics in Bromley—one at Park Road, one at Raglan Road School, and the Dental Clinic at Wharton Road School. The only other clinic in the town is the County Tuberculosis Dispensary at Park Road. Hospitals provided or subsidised by the Local Authority or County Council:— (1) Tuberculosis.—The sanatorium provision is described in the Annual Reports of the County Medical Officer of Health. (2) Maternity.—The Bromley and Chislehurst Maternity Hospital is a voluntary organisation, which receives a block grant direct from the Ministry of Health, and is subsidised by the Bromley Borough Council to the extent that the cost of maintenance of cases recommended for admission by the Medical Officer of Health is defrayed out of the rates. (3) Children.—No children's hospital is provided or subsidised by the Local Authority. (4) Fever.—The Bromley and Beckenham Joint Isolation Hospital, at Skym Corner, in the Borough of Bromley, provides for the isolation of Scarlet Fever, Diphtheria and Typhoid Fever, and for severe cases of Measles. 23 (5) A Small Pox Hospital is also provided by the Joint Isolation Hospital Board. Tbiis Hospital is situated near the Fever Hospital, but is beyond the Borough Boundary. The other hospitals in the district are the Bromley Cottage Hospital at Mason's Hill, which has 42 beds, and the Phillips Memorial Ho-sipi'tal at Queen's Gardens, Which has 18 beds. Neither of these institutions receives any subsidy out of rates. Institutional provision for unmarried mothers, illegitimate infants, and homeless children.—The Rochester Diocesan Association for Befriending Women and Girls has a home at 29, Ravensbourne Road, where unmarried mothers are received and arrangements are made for their confinement, either in Maternity Homes, or in the Infirmary. Subsequent to confinement, the mothers and their babies are received in the Home and kept there until employment is found for the mother. If the employment is not of such a nature as to allow the mother to care for her child, fostermothers are found by the Association. The Home has no subsidy from public funds. Ambulance Facilities. (a) For Infectious Cases.—The Joint Hospital Board has motor ambulances stationed at the Hospital for removal of infectious cases. (b) For Non-Infectious and Accident Cases.—A motor ambulance—the property of the Council—is available free of charge at any hour for the removal of accidents to hospital, and on payment of a fee it may be requisitioned for the removal of cases of sickness of a non-infectious nature, the fee in necessitous cases being remitted. 24 6.—LABORATORY WORK. The following bacteriological examinations were made on behalf of private practitioners and public bodies :— Clinical Research Association. Kent County Council Laboratory. Throat and Nose. Throat and Nose. Sputum. Blood. ] Private Practitioners 15 111 89 2 1 Public Authorities ... 88 25 ... ... Totals 15 197 114 2 1 Diphtheria Antitoxin.—Three 8,000 unit doses were supplied during the year to private practitioners, one at cost price, and two free of cost. 7.—SANITARY ADMINISTRATION. («) Number and Nature of Inspections Recorded during the year by the two Sanitary Inspectors Houses Inspected— On Complaint 419 Re Infectious Disease cases notified 188 Under the Housing (Inspection of District) Regulations, 1910 503 1110 Visits for disinfections only 139 Other Inspections on Complaint 47 Elementary School Inspections 66 Stream Inspections 37 25 Trade Premises— Dairies, Cowsheds & Milk .Store 99 Slaughterhouses 62 Factories & Workshops, including Bakehouses 205 Under Shops Acts 165 Under Petroleum Acts 158 689 2,088 Total Inspections and Re-visits recorded to above 5,245 (b) Number of Notices served to remedy defects— Preliminary Notices, re houses 508 ,, ,, ,, otiher premises 63 Section 94, P.H. Act, 1875 120 ,, 36 ,, ,, ,, 2 ,, 41 ,, ,, ,, 24 ,, 46 ,, ,, ,, 4 ,, 49 P.H.A.A. Act, 1907 10 731 Total notices, letters, reports, etc., written, approximate!)' 9,341. They were in connection only with Sanitary Administration, and the figures do not include clerical work for the Medical Officer of Health and Health Visitors. (c) The Result of the Service of Such Notices— House drains renewed entirely 9 Drains repaired 45 ,, unstopped 101 Soil-pipes or Ventilators renewed or repaired 26 W.C.'s repaired 168 Cesspools emptied 2 Damp houses remedied by damp courses 97 ,, ,, ,, ,, repairs to roofs, rain water pipes, etc. 235 26 Entire external brick re-pointing 8 Sinks renewed, 13; waste-pipes repaired, 14 27 New dustbins 108 Overcrowding- abated 1 Houses cleansed and whitewashed or re-decorated wholly or in part 242 Number of rooms so treated 902 Rooms lighted by additional window 2 Room floors renewed or repaired 79 Windows ,, ,, ,, 96 Stoves ,, ,, ,, 88 Water cisterns ,, ,, ,, 3 Yard pavings ,, ,, „ 72 Miscellaneous items 275 Dairies, Cowsheds or Milk Stores cleansed and whitewashed 26 Bakehouses cleansed and whitewashed 37 Slaughterhouses cleansed and whitewashed 6 Other workshops ,, ,, ,, 2 Piggeries ,, ,, ,, 1 Manure, etc., removed 6 Sanitary convenience (urinal) provided 1 M.W.B. water substituted for well water 1 Animal nuisances 3 Dwellings vacated (2 under Closing Order and 2 informal action) 4 From the foregoing, it will be seen that over 1,000 dwelling houses came under observation in one way or another, this being about one-eighth of the total houses in the district, and nearly 1,000 other visits were paid to various kinds of premises; the total inspections and re-visits recorded being 5,245. This is somewhat in excess of the previous year, notwithstanding the fact that for two months there was no 27 assistant inspector, but the comparatively few cases of infectious disease combined with less trouble generally in obtaining compliance with notices, allowed more time for Housing Inspection, which is the most important part ol the inspectors' work. Over 4,000 cottages in some 80 streets are on the Working Schedule for housing inspection duties, and on this schedule is indicated when the last inspection was made. From time to time streets of houses are selected for attention, care being taken to choose property which is most likely to require inspection, to give various parts of the district attention, and to note when the street was last inspected. A great many more inspections might be recorded by visiting houses built within the last twenty years, but these are usually omitted, unless complaint has been made or an infectious disease notified. As a result of the above method of selection of houses for routine inspection, the proportion of defects found to the number of houses inspected is consequently high, an inspection card being rarely marked "no defect." This, coupled with the facts that in this district householders seldom complain without cause, and that quite 95 per cent, of defects are remedied, gives support to the view that it is not the number of inspections that matters, but the results obtained. These are shown in Table (c). The staff was able to get the whole of the repairs, etc., carried out without resorting to legal proceedings, though in many cases not until after service of preliminary, statutory and final notices. Only in a few instances did property owners raise any question about the necessity or reasonableness of the works required by notices, and all notices were 28 complied with except one particular lot concerning 15 houses. It was decided action with regard to these houses should be left in abeyance for special reasons. It will be seen that the most common defects found were damp ocr dirty conditions in houses, and when it is realised that the houses mostly dealt with were built from 30 to 60 years ago, often of absorbent bricks, without sufficient damp-courses, the ground floors level with or betow the ground line, it appears almost an endless task to effect remedy. This suggests that bye-laws should be in force to provide a stucco or other damp-proof exterior to houses, a step or two up to the ground floor, and a definite dampoourse to all walls, including sleeper walls and piers carrying floors, so that eaves gutters may leak for a while without saturating the walls and floors. When inspecting the houses the officer has to bear in mind the standard of fitness laid down by the Ministry of Health, and what is a reasonable state of repair, both from the tenants' and landlords' points of view. He has also to consider the defined nuisances and powers under the Public Health Acts. Fortunately, in this district it is usual to obtain such good results under these Acts that it is unnecessary to resort to the more drastic powers that exist. The 503 houses included in the Housing Inspection comprised the following streets or roads in the various wards :— H 'ses. All or part. Street or Road. Ward. 5' 40 18 38 103 Part All Part All ,, Homesdale Road Waldo Road Cowper Road Herbert Road Victoria Road Bickley. ,, Bromley Com'n, No. 1. ,, ,, 29 6 11 14 103 2.2 8 15 14 45 15 .. ,, ,, ,, Part ,, ,, All ,, ,, Hooker's Place Orchard Place Sharp's Cottages Park End Croft Road Palace Road Bromley Gardens Devonshire Sq. Napier Road Prospcct Place Martin's Hill, No. I. ,, ,, ,, Plaistow. Sumlridge. Town. ,, ,, ,, 503 There were comparatively few applications from tenants under the Increase of Rent (Restrictions) Act, with reference to houses which were not in reasonable repair. The reasons for this probably were the dislike of tenants for anything savouring of legal proceedings, and the fact that agents and owners appear to act more promptly now in carrying out repairs than formerly, especially if declared necessary by a sanitary notice. Moreover, the tenants appear to hold the opinion that a complaint to the saniitarv department is the most effective and least troublesome method of getting house repairs carried out. It is difficult to form a close estimate of the cost of repairs carried out, as indicated in Table (c), because such items as "Repairs to stoves" often mean a new kitchen stove or range costing £."6 or more, and frequently a stove -is repaired at much less cost. Similarly with regard to the 902 rooms re-decorated, the cost in some cases would be 20/- or less, in others 40/- or more. Some of the floor repairs would cost per room, and others much less. It may be said, however, that visits to 1,110 houses resulted in necessary remedial work being carried out in 700 of 30 tnem, and that, in consequence, there was an expenditure of several thousands of pounds, whidh provided useful employment as well as improvement of the housing conditions of many of the inhabitants. Disinfection and Disinfestation. For disinfection purposes, rooms are sprayed with a strong solution of formalin, with additional gas produced subsequently in sealed-up rooms with formalin lamps (FormigatOirs). The rooms are left closed from 8 to 24 hours, or longer if not required. The bedding, clothing, etc., when necessary, is steam disinfected in the Council's " Washington Lyon " apparatus. Disinfestation of parasites is dealt with as required on application of residents, or at the direction of the School Medical Officer. In these cases the fumes of burning sulphur are relied upon for rooms; garments and bedding are sterilised in the steam disinfeator. Steam disinfection is carried out after bedrooms are vacated by removal of tubercular patients by death or otherwise, after convalescence of ordinary notifiable infectious disease cases nursed at home—few in number—and after deaths from cancer, on application. Most of the cases of diphtheria, scarlet fever, and a few other infectious diseases, upon notification, are removed to the Infectious Diseases Hospital. The vacated room and its contents are disinfected with formalin in the manner set out above. Cleaning and airing of the room is always advised. The remedving of any insanitary condition found by the inspector whilst visiting is taken in hand as a routine matter. Dairies, Cowsheds and Milk Stores. There are 43 of these premises in use, 14 of them being farms where cows are kept. Twice yearly all are inspected. 31 Other visits are made at irregular intervals. The regulations have been fairly well complied with. The number of cows kept remains at about 300, and much of the milk produced goes out of the district. Much milk comes also into the town by rail, and otherwise, for local consumption. The Milk and Dairies Amendment Aat, 1922, requires local authorities to keep two registers of milk purveyors, one for retailers and one for wholesalers and producers. The old register is preserved for reference if required. During the earlier part of the year the Medical Officer of Health and the Sanitary Inspector visited all the premises to see if any were unfit for milk distribution trade. One; of the premises for retail business was reported as unfit, which resulted in the sale of milk at a general shop being discontinued. One other refusal to register resulted in the person moving to more suitable premises, which were approved. The Milk (Special Designations) Otder, 1922.-—One firm only holds a licence under this Order, permitting the sale of "Certified Milk," produced elsewhere, from three local depots. Inspection of Places Where Food is Prepared. This is provided for by the visits to premises—included in Table (a)—supplemented by various casual visits to food cooking or preparing rooms in butchers' premises, refreshment shops, hotels, etc. Sla light e rhouses. The number is Registered 5 Licensed 6 11 32 One licensed slaug-hterhou.se is only a knacker's premises, and is not much used. l'our of the licensed slaughterhouses are used only for pigs raised on the premises, and are used at irregular intervals, according to season. Most of the remaining slaughterhouses arc used onl} rarely, or irregularly. All the slaughterhouses have public water supply laid on, two have cess pool drainage, and nine drain to sewer. All have been kept in a satisfactory state, and were subject to regular inspections. Food Destroyed. An unusually small amount of food was confiscated, compared with that destroyed in previous years. The only destruction was that of 5 cwts. of bacon. This was dealt with on the complaint Oif a tradesman, who asked for inspection on receiving the food in an unsound state from a London market. Smoke Nuisance. One smoke nuisance was dealt with and eventually abated. This was from a chimney of a saw-mill. There was no improvement for a considerable time after notice was served, and extended observations were made as to the cause of so much dense black smoke. The remedy was indicated, and finally was successfully applied. It consisted of letting the stoker devote his whole time to the furnace, so that a little fuel could be put on a blazing fire every few minutes, instead of it being necessary for him to divide his attention between stoking and running machinery near-by. The change prevented the choking of the fi.re with too much fuel at a time, and continuous stoking kept the fire blazing to consume the black smoke. 33 Legal Proceedings. (a) Slaughtering pigs without licence, fine 40/- and warned. (b) Under Section 306, P.H. Act, 1875, summons re tenant preventing landlord complying with sanitary notice; order made and obeyed. (c) Shops Acts. Four summonses re selling sweets after 8 p.m. on Sunday; fines in three cases of 20/each and one of 5/-. (d) Petroleum Acts. One summons for unlawfully keeping petrol; fined £12. Other Duties. The Sanitary staff has, as usual, given a proportion of their time to the administration of the Factory and Workshops Act and the Shops Acts, as well as to the inspection of various premises where petrol is kept under licence or notice given. The total of these premises is approximately as follows:— Shops 721 Factories and Workshops 248 Petrol Stores 80 1,049 Matters arising out of the inspection of these premises which require any action arc reported to, and dealt with by, the Health Committee at their fortnightly meetings. 34 8.—PUBLIC HEALTH STAFF. Medical Officer of Health . \V. Stewart Stalker, M.I)., Ch.B., D.P.H. Assistant Medical Officer of Health Chief Sanitary Inspector Second Sanitary Inspector Health Visitor Assistant Health Visitor Clerk Anna M. K. O'Halloran, M.B., Ch.B., D.P.H. Thomas Butler.* A. C. Webster, † Miss F. Is. Brennand.‡ Miss V. Morgan.¶ H. E. Lawley. *Holds Certificate of the K.S.I. as Inspector of Nuisances (1894) and as Inspector of Meat and other Foods. Also holds Certificate on Advanced Building Construction (South Kensington). †Holds Certificates of Sanitary Inspectors' Examination Board as Sanitary Inspector, of 11.S.I. as Inspector of Nuisances, and as Inspector of Meat, etc. Also holds Certificates on Building Construction and Practical Sanitary Soience. ‡Guy's Hospital, trained. Certificates: Sanitary Inspector (R.S.I.), C.M.B., and Chartered Society Trained Masseuses. 11C.M.B. Certificate. All the above are whole-time officers. Contributions to salaries are made under the Public Health Acts, or by Exchequer grants in the case of the Medical Officer of Health, Assistant Medical Officer of Health, the Sanitary Inspectors and Health Visitors. 9.—HOUSING. Number of new houses erected durng the year:— (a) Total 115 (b) As part of a municipal housing scheme Nil. 1. Unfit Dwelling Houses. Inspection— (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 1110 30 (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 503 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 4 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 601 2. Remedy of Dcfects without Service of formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action by the Ijocal Authority or their Officers 460 3. Action under Statutory Powers. A.—Proceedings under section 28 of the Housing, Town Planning, &c., Act, 1919. (1) Number of dwelling houses in respect of which notices were served requiring repairs o (2) Number of dwelling houses which were rendered fit:— (a) by owners o (b) by Local Authority in default of owners o (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to clo.sc 0 36 B.—Proceedings under Public Health Acts. (1) Number of dwelling houses in respect of which notices were served requiring defeats to be remedied 141 (2) Number of dwelling houses in which defects were remedied:— (a) bv owners 126 (b) by Local Authority in default of owners Nil. C.—Proceedings under sections 17 and 18 of the Housing, Town Planning, &c., Act, 1909. (1) Number of representations made with a view to the making of Closing Orders 2 (2) Number of dwelling houses in respect of which Closing Orders were made 2 (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 0 (4) Number of dwelling houses in respect of which Demolition Orders were made 0 (5) Number of dwelling houses demolished in pursuance of Demolition Orders 0 37 Bromley Borough Council. Medical Officer of Health's Report 1923. APPENDIX. BROMLEY VITAL AND SICKNESS RATES. 1923—1894. I923. 1922. 1921. 1920. 1919. 1918. 1917. 1916. 1915. 1914. 1913 1912. 1911. 1910. 1909. 1908. 1907. 1906. 1905. 1904. 1903- 1902. 1901. 1900 1899 1898. 1897. 1896. 1895- 1894. Birth Rate 16.5 16-5 17.9 20 8 14.7 13.1 13.9 18.00 18.4 182 17.6 19.6 19.5 I9-5 22.1 22.9 22.8 23.8 23.6 22.8 23.9 23.6 24.5 23.4 25.7 24.1 23.8 24.5 25.8 26.2 Death Rate 10.5 11.7 11 08 9.8 11.7 13.3 12.4 11.5 11.5 10.3 9.5 90 10.1 9.1 10.2 9.6 10.2 10.03 9.3 10.3 107 1O.8 11.3 11.9 128 12.09 10.5 11.9 11.2 13.1' Infant Death Rate 60 74 60 66 71 86 79 84 51 61 84 60 74 60 68 72 70 113 60 131 124 101 92 103 139 155 93 108 105 102 Rate Natural increase 6.0 4.6 6.8 10.9 3.4 1.2 2.7 7.3 6.4 73 8.07 10.6 9.3 10.4 11.8 I3.2 12.6 13.8 14.3 I2.4 13.2 12.8 13.1 11 .4 12.9 12.09 13.2 12.5 14.9 i13.4 Scarlet Fever Incidence 1.7 3.9 4.8 27 2.07 0.9 0.6 0.8 3.2 2.09 1.5 5.4 2.6 2.2 1.4 3.8 5.2 1.9 2.6 1.06 1.3 1.8 2.1 1.8 5.9 4.3 7-6 2.4 1.6 2.2 Diphtheria Incidence 0 6 1.3 1.4 2.9 3.07 1.8 1.1 l.4 3.6 1 .5 1.7 2.03 l.3 0.3 1.1 2.2 1.6 2.9 2.4 0.4 0.3 1.3 1.3 12 1.6 1.2 0.7 0.4 0.4 1-07 Pulmonary Tuberculosis Death Kate 0.6 0.6 0.6 0.4 0.6 0.9 0.8 1.2 0.7 0.8 0.4 0.7 0.6 0.4 0.5 0.5 0.8 0.2 0.6 0.5 0.4 0.7 0.9 0.7 0.7 0.7 0.8 1 .02 0.7 0.7 Pneumonia Bronchitis Death Rate 1.2 1.7 2.1 1.6 1.5 1.5 2.07 2.7 1.9 1.3 1.3 1.4 1.1 1.1 1.4 – – – – – – – – – – – – – – – Marriage Rate 11.5 11.1 12.6 12.1 24.9 9.7 9.3 8.9 11.8 9.7 8.7 9.0 8.9 8.3 7.9 9.1 9.3 8-6 7.2 8.1 8.5 9.8 8.8 9.1 9.6 10.2 8.5 10.1 8.7 7.9 Diarrhoea. 1898, 1899, 1903, 1904, 1906. 19 Deaths from Measles in 1896.