BRO 24 E Borough of Bromley. Annual Report OF THE MEDICAL OFFICER OF HEALTH for 1925. K. E. TAPPER, O.B.E., M.B., Ch.B., D.P.H , MEDICAL OFFICER OF HEALTH CROYDON: Printed by the "Croydon Times" Ltd., 108, High Street, Borough of Bromley. Annual Report OF THE MEDICAL OFFICER OF HEALTH for 1925. K. E. TAPPER, O.B.E., M.B , Ch.B., D.P.H, MEDICAL OFFICER OF HEALTH. CROYDON: Printed by the "Croydon Times" Ltd., 108, High Street, MEMBERS OF THE HEALTH COMMITTEE, 1925. His Worshp, The Mayor - Councillor B. A. Glanvill, J.P. Chairman - - Councillor F. W. Isard. Vice-Chairman - Councillor H. Forbes White. Members. Alderman G. Haywood. Councillor R. G. Colquhoun. Alderman Bertram Pearce. Councillor B. H. Bonniface. Councillor G. Allen. Councillor M. Stafford Smith, M.B.E. MEMBERS OF THE MATERNITY AND CHILD WELFARE COMMITTEE, 1925-1926. His Worship, The Mayor. Chairman - - Councillor G. Allen. Vice-Chairman - Councillor M. Stafford Smith, M.B.E. Members. Alderman Bertram Pearce. Councillor W. D. Gibbs. Councillor B. H. Bonniface. Councillor C. H. Gunton. Councillor R. G. Colquhoun Councillor F. W. Isard. Co-opted Members. Mrs. F. Gillftt. Mrs. A. G. Mann, B.A., J.P. Dr. D. R. McArthur. Mrs. E. Satterthwaite. Mrs. E. Yolland. Borough of Bromley. REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1925. To the Right Worshipful The Mayor, Aldermen and Councillors. Mr. Mayor, Madam, and Gentlemen, I have the honour of submitting to you my First Annual Report as Medical Officer of Health of your Borough. The delay in publication of this Report, which covers the year 1925, is regrettable, but has of necessity been delayed through stress of work, the visit of the Foreign Medical Officer of Health to the Borough, and finally the recent Health Week Exhibition. The fact that the Department came under re-organisation in July, 1925, must make this Report of 1925 (which is at the Ministry's request a 5 years' Survey Report) somewhat difficult to compile, so that I trust its shortcomings will be forgiven. The 1925 Vital Statistics continue to keep to the satisfactory level of previous years. The Death Rate remains lower than that for London, and no less than one-third of the deaths occurred in persons over 75 years of age. Bromley continues to have a remarkably low infectious disease rate— only sporadic cases of scarlet fever and diphtheria being reported. But death rates and infectious disease rates are not the Alpha and Omega of Public Health. The economics 4 of Public Health are, I believe, not yet publicly realised, or if realised are not acted up to; to allow a preventable illness to incapacitate a worker in whatever office of work, is the shortest way to national bankruptcy, but even to-day we tend to be apathetic towards prevention of disease. A happy omen is that many traders in foodstuffs are leading public opinion by making hygiene in production one of the essentials of their trades—not only this, but many large business firms have shown that it pays to promote schemes for the health of their employees. What pays in trade pays in local government. Acts of Parliament will not make a healthy people unless the exercise of those Acts is desired by the people, and it is this principle in the Government of England which must govern our policy in Public Health—we must continue propaganda on the fundamentals of Health. We have a long way to go to a health enlightened people, we cannot expect results in a year, but we can be justifiably optimistic, knowing that the great successes of the past years will be small compared with the future. Several new Statutes and Regulations affecting the Department came into force and were enacted during the year 1925. The Milk and Dairies (Consolidation) Act, 1915 (September, 1925) Public Health (Prevention of Tuberculosis) Regulations, 1925, The Public Health Act, 1925, The Housing Act, 1925, The Tuberculosis Orders, 1925 (Nos. 1 and 2), and the Public Health (Meat) Regulation, 1924 (April 1st, 1925). I would like to take this opportunity of extending to the Health Committee my appreciation of their consideration and help during the first year of my office, and of personally acknowledging the very able and willing assistance I have received from each member of the Health Department. I am, Mr. Mayor, Lady and Gentlemen, Your obedient Servant, K. E. TAPPER, Medical Officer of Health. 5 STAFF OF THE HEALTH DEPARTMENT Medical Officer of Health, and School Medical Officer 2K. E. Tapper, O.B.E., M.B., D.P.H. Deputy Medical Officer of Health 21 H. W. Henshaw, M.R.C.S., L.R.C.P. (Lond.), D.P.H. Medical Officer — AnteNatal Clinic 2 1 Margaret G. Best, M.R.C.S. (Eng.), L.R.C.P. (Lond.). Senior Sanitary Inspector Sanitary Inspector 5 4 2 Thomas Butler, A.R.S.I. 5 4 2 Gilbert R.Woods, M.S.I.A. (appointed 9/6/1926). Arthur C. Webster (resigned 8/5/1926). Chief Health Visitor 6 4 5 2 Miss F. G. K. Brennand, C.M.B. Assistant Health Visitor 2Miss V. Morgan, C.M.B. School Nurses 3 2Miss L. A. Briggs, C.M.B. 2Miss W. Irving, C.M.B. Veterinary Inspector under JP. J. Turner, M.R.C.V.S. Diseases of Animals Act Inspector under Diseases Alfred Henry Sly. of Animals Act Disinfector, etc. H. Deane. Chief Clerk Henry E. Lawley. Assistant Clerk Miss D. E. Cooper. 1 Denotes Part-time Officers. 2 Exchequer Grants. 3 Hospital Trained. 4 R.S.I. Certificate. 5 Meat Certificate. 6 Trained Masseuse. 6 STATISTICS, 1925. Acreage 4,696 Population, 1921 34,810 1925 35,440 Inhabited Houses, 1921 7,400 Private Families, 1921 8,400 Rateable Value £291,421 Product of a Penny Rate £1,184 Births— Male, 281; Female, 239. Total, 520. Birth Rate, 14.6. Deaths— Male, 185; Female, 232. Total, 417. Death Rate, 11.7. Infant Deaths— Male, 20; Female, 10. Total, 30. Infantile Mortality Rate, 57.6. (Illegitimate, 2). 1.—SOCIAL CIRCUMSTANCES. HISTORY.—The Public Health Administration of Bromley dates from the formation of a Local Board of Health in 1867. It is to be noted that even in those days government was for reasons of health. In 1894 Bromley had so advanced as to become an Urban District, and in 1903 it received its Charter of Incorporation, being then administered by a Mayor, six Aldermen, and eighteen Councillors. In 1918 the Parliamentary Borough of Bromley was formed, comprising the Borough of Bromley and the Urban Districts of Beckenham and Penge. 7 GENERAL.—Bromley, which is one of the Dormitory Towns within ten miles of London City, covers an area of 4,696 acres. It is 200 feet above sea level, mainly on gravel soil, and abounds in delightfully situated and permanent open spaces and playing fields—all important factors in making Bromley an attractive and healthy town. Its rateable value is £291,421, and the penny rate equals £1,184. POPULATION.—The Registrar-General returns a figure for the middle of 1925 of 35,440. This figure is only 210 above the figure for 1924, but exceeds the census figure for 1921 by 630. Consideration of local circumstances leads one to believe the Registrar-General's figure for 1925 is under-estimated, but as in past years the tendency has been to over-estimate the population between intercensal periods, the acceptance of the Registrar-General's figure is undoubtedly the only figure to consider in the calculation of the vital statistics. On this point the lowest death rates recorded in Bromley were during the period 1906 to 1910 (viz., 9.8), a period during which the population figure was considerablyover-estimated—hence the low death rate which is always calculated per 1,000 of the population. With the Downham Estate in being, the population figure for the coming year will increase by approximately 4,000. This large influx of population from London will be a serious factor in our future vital statistics, and our future health policy. One interesting fact in the consideration of population since the census of 1901 is that persons below 35 years of age have decreased in numbers, and persons over 35 have markedly increased—no small factor in comparison of death rates during the past twenty-five years. This is partly explained by the falling birth rate during these years, the greater tendency of London residents to retire to Bromley, and also by the fact that people to-day live longer by at least 8 ten years. A chart showing the changes in these age groups exists in the Department, and it is intended to have such charts printed in future reports. OCCUPATIONS.—The following table of principal employments of persons over 12 years of age will give a clear indication of occupations at the time of the 1921 census: Males. Females. Total persons occupied 10,194 6,071 Commercial and Finance 1,728 588 Railway and Transport 1,344 73 *Agriculture, Gardeners, etc. 949 22 Clerical 859 823 Metal Workers, etc. 751 7 Professional 531 547 Public Administration, etc. 494 124 Builders, etc. 463 1 Painters and Decorators 432 2 Wood and Furniture 448 28 †Personal Service 390 3,302 Retired, or not generally employed 1,742 10,502 *701 of these are gardeners, †Of these, 2,732 are domestic servants. UNEMPLOYMENT.—This h.as now fallen to pre-war level—Males 312, and Females 50. POOR LAW RELIEF.—The Guardians distributed £10,552 in outdoor relief during the year under review. II.—VITAL STATISTICS. BIRTHS.—520 Births were registered in 1925, giving a Birth Rate of 14.6 per 1,000 population. There were 34 illegitimate births. The excess of births over deaths was only 103. The Birth Rate is falling to the 9 level of the Death Rate. The falling Birth Rate is surely the answer to the advocates of birth control. It is certainly a factor which must give rise to serious thought to those who have the Nation's health at heart. The effect of the continued fall is to raise the average age of the population, and this tends to increase the Death Rate; in effect, too, as the average age of the female population tends to increase there is ultimately a reduction in the proportion of women of reproductive age. There is also a fall in the Marriage Rate per 1,000 females under 45 years of age. In 1911 census this rate was 212 per 1,000 females of this age; in 1921 census this rate had fallen to 204—in other words there are to-day fewer married females of child-bearing age—there is probably also a lessened fecundity of the population. There is another factor in the causation of low Birth Rate which, to say the least of it, is distressing—landlords who refuse to sub-let to families with young babies, tends to encourage the use of abortifacients by the already distressed mother. In the prevention of this fall in the Birth Rate the powers of the Health Authority are indeed limited. We can encourage early marriages and strive to protect the health and life of every baby born; babies still die of preventable causes—there are stillbirths because of lack of ante-natal treatment—but matters are vastly better than they were twenty years ago, and we can but continue to believe that the next twenty years will bring as great, if not greater, return for our efforts. DEATHS.—There were 417 deaths of Bromley citizens during the year; 185 of these were males. 32 per cent. of all deaths are over 75 years of age, 65 per cent. over 55 years of age, and 7 per cent. under 1 year of age. 10 The return for 1925 gives a Death Rate equal to 11.7 per 1,000 population—.5 per 1,000 less than the rate for England and Wales, and .6 higher than the Bromley rate for 1924. If we standardise this Death Rate by taking into consideration age and sex distribution as compared to the population of England and Wales we get a much truer indication of the healthiness of the Borough during 1925 as compared with other towns. This standardisation reduces the Death Rate for 1925 to 10.3. It is noteworthy that the Death Rate for the five years ended 1925 equals the Death Rate for the five years ending 1900. This is explained chiefly by the fact that the average age of population has increased during these years, and if this fact is corrected by standardising the death rates, there has really been a reduction during the period from 11.08 to 9.8. To indicate the change that occurs in death rates, the following table of comparison at the various census years will be of interest : Percentages of Total Deaths. 1901. 1911. 1921. Under 14 years of age 37 23 14 Between 14 and 45 years 22 15 16 Over 45 years of age 41 62 70 The chief causes of deaths in the past five years have been: Respiratory Disease 17.8% of total deaths. Heart Disease 14.5% ,, ,, ,, Cancer 13.2% ,, ,, ,, Tuberculosis 7% ,, ,, ,, Premature Births, Malformations, etc. 4.1% ,, ,, ,, (or 45% of the total infant deaths during past 5 years). 11 A certain percentage of these deaths are preventable if the beginning's of disease are attacked, and the individual prepared to act upon the doctrines of health rather than to wait for treatment of the established disease. CANCER.—This disease at present is exercising the minds of the press, the public, and the medical profession. In Bromley, in this respect, we have the self-same problems as the rest of England, except that our rate is a fraction lower. In Bromley, 16 males and 29 females died of cancer in 1925, equivalent to a rate of 1.2 per 1,000 of our population. For the five years ending 1920 the rate was 1.3 per 1,000 population, and for the last five years 1.4. There are many factors to be considered in this increase, not the least important being the proportional increase in the older age groups of the population, the period of life when cancer is more liable to arise. The fact that cancer is more prevalent among females, and the fact that since 1901 the female population has increased at the expense of the male population at the rate of 1 per 1,000 population, must also play its part in this increasing rate. Before we can undertake any steps to combat this, one of our "Kings of Death," the public must be prepared to undergo periodically and regularly routine and skilled medical examination for the early discovery of signs and symptoms of cancer, and be prepared on positive evidence to undergo early surgical treatment. Our chances to abate the disease in these circumstances are great, they will be greater still when research has established the underlying cause of cancer. 12 RESPIRATORY DISEASES.—No less than 104 persons, or 25 per cent. of total deaths, died of diseases of the respiratory system during 1925: Tuberculosis of the lung 21 Pneumonia 22 Bronchitis 436 Whooping Cough 2 Other Lung Diseases 13 These give a rate of 2.9 per 1,000 population. Excluding Tuberculosis and Whooping Cough, Bronchitis and Pneumonia cause more deaths than Cancer. Surely these call for public attention to the fundamentals of preventive medicine. It is too early yet to see the results of the School Medical Service and its repeated attention to the hygiene of the nose, mouth, and the throat, but I am convinced the results will be shown in the adult population by a. reduction in the Death Rate from Respiratory Disease. Our Death Rate from Pulmonary Tuberculosis remains stationary, .6 per 1,000 population, a rate considerably lower than that of England and Wales. III.—GENERAL PROVISION OF HEALTH SERVICES. (1) RESIDENTIAL INSTITUTIONS.— Address. No. of Beds. Type of Cases treated. How Supportedp Cottage Hospital, Cromwell Avenue 42 General. Voluntary. Phillips Memorial, Lowndes Avenue 18 ,, ,, Bromley & Beckenham Joint Isolation Hospital 115 (including cots). Notifiable Infectious Diseases except Puerperal Fever, &c. Rates. Bromley & BeckenhamJoint Isolation Hospital 35 (including cots). Smallpox. ,, Bromley & Chislehurst Maternity Hospital 14 Maternity. Voluntary, Ministry of Health Grant and subsidised by Local Authority for cases recommend by Medical Officer of Health. 13 Summary of Year's Work, 1925. Cottage Hospital— 1. No. of Patients in Hospital, Jan., 1925 20 2. ,, ,, ,, admitted, 1925 450 3. ,, ,, ,, in Hospital, Dec., 1925 25 Phillips Memorial— 1. No. of Patients in Hospital, Jan., 1925 8 2. ,, ,, ,, admitted, 1925 98 3. ,, ,, ,, in Hospital, Dec., 1925 4 Out-patients, 295. Seen at home, 43. Maternity Hospital— 1. No. of Patients in Hospital, Jan., 1925— 9 mothers, 7 babies. 2. ,, ,, ,, admitted, 1925— 152 mothers. 3. ,, ,, in Hospital, Dec., 1925— 10 mothers, 9 babies. The easy access to London Hospitals precludes the necessity for extensive institutional facilities for Bromley, but there is need for extension in certain directions, one of which is an observation ward for ailing babies. (2) AMBULANCE FACILITIES.—The Local Authority provides an effective ambulance service for accident cases and for removal of cases to and from hospitals. The Infectious Disease Ambulance is provided by the Bromley and Beckenham Joint Hospital Board. (3) CLINICS.— MATERNITY AND CHILD WELFARE SERVICE. Welfare Centres. Address. Days Open. Plaistow St. Mary's Church Hall, Farwig Lane. Tuesdays, 2.30 p.m. Widmore Weslevan Church Hall, Tylney Road. Wednesdays, 2.30 p.m. Shortlands Mission Room, Bromley Gardens. Thursdays, 2.30 p.m. Bromley Common St. Luke's Institute, Bromley Common. Fridays, 2.30 p.m. A further centre is to be opened at Downham Estate. 14 ANTE-NATAL CENTRE—12, Park Road. 1st Friday in the month at 2.30 p.m. (An additional Ante-Natal Centre is to be opened in Bromley Common). SCHOOL MEDICAL SERVICE. Clinics. Address. Days Held. Inspection and Treatment 12, Park Road (converted dwelling). Mondays, Wednesdays, Thursdays & Fridays, 9.30 a.m. Raglan Road (school premises). Tuesdays, 9.30 a.m. Eye 12, Park Road. 1st Monday in month, at 2 p.m. Tonsils and Adenoids Cottage Hospital. Every 2nd Tuesday, at 9 a.m. (An Orthopaedic Clinic is being opened in September, 1926). A new centra] clinic premises are to be erected in Station Road. TUBERCULOSIS. Dispensary, 2, Park Road. Wednesdays at 1 p.m. (converted dwelling-). This is provided by the Kent County Council. (4) NURSING HOMES.— Address. No. of Beds. No. of Staff. Qualifications of Staff. Type of cases taken. "Greta," Blyth Road. 6 4 4 Gen. Trained. 1 C.M.B. Mainly surgical. Maternity occasional. 40, Brmley Common. 4 3 2 C.M.B. Maternity. 1 untrained. 24, Elmfield Road. 6 4 3 Gen. trained. Medical & Mater nitv occasional. 3, Elmstead Lane. 9 2 2 trained. Medical and Surgical. 6, Exmouth Road. Information refused. 57, Freelands Road. 1 1 1 untrained. Old chronic. 64, Freelands Road. 3 2 1 trained. Medical. 1 untrained. 17, Holwood Road. 3 3 3 trained. ,, 65, Southboro' Road. 35 8 ,, 43, West Street. 2 1 Maternity trained. Maternity. 15 (5) NURSING ASSOCIATIONS.— There are three organisations providing professional nursing for the sick poor in the home—The Bromley District Nursing Association, Bromley Common Holy Trinity Nursing Association, and St. Luke's District Nursing Association. Bromley District Nursing Association.—This excellent Association employs three fully trained nurses who undertake maternity as well as general cases. Fees are payable for midwifery and maternity nursing according to the patient's means, with a minimum fee of 25/- for midwifery and 15/- fee for maternity nursing. Necessitous cases are provided for without charge. 1925 saw an increase in this very necessary work, as is shown by the following tabulation extracted from the Annual Report: Summary for the Year. Cases on the Register, January 1st, 1925 18 New Cases during the Year 317 Visits Paid. General Nursing 2,843 Ante-Natal Visits 303 Maternity and Midwifery 2,012 Casual Visits 656 Analysis of New Cases. Medical 106 Surgical 78 Maternity (with Doctor) 63 Midwifery 63 Abortions 7 Cases sent in by— Doctors 118 Clergy 2 District Visitors and others 13 Found by Nurse 2 Applied 182 16 Result of Cases Nursed. Convalescent or Relieved 270 Sent to Hospital, Infirmary, or Transferred 26 Died 20 Still on Register, December 31st, 1925 19 Patients' Payments. Fees for Maternity Cases £72 19 0 Fees for Midwifery Cases 70 13 6 Donations for General Nursing 38 9 6 From Approved Societies Nursing Scheme 1 19 7 St. Luke's Nursing Association.—This Association employs one fully trained nurse with C.M.B., although she does not act in the capacity of a midwife. The work of the Association is confined to St. Luke's Parish, and patients pay according to their means. The year's work was as follows: General cases nursed 223 Maternity cases nursed 19 General nursing visits 3,249 No ante-natal visits were made. Bromley Common Holy Trinity Nursing Association.— This Association employs one fully trained nurse with C.M.B. and this nurs acts as a midwife. Payment is based on a subscription basis. The charge for midwifery is 30/- (25/- to subscribers), and for maternity nursing 25/- (20/- to subscribers). A tabulation of the year's work is as follows: General cases nursed 52 Maternity cases nursed 13 Midwifery cases 11 Abortions 2 General visits 784 Maternity visits 288 Midwifery 150 Ante-natal 61 17 The Local Authority does not pay a subsidy to any midwife or nursing associations. The nursing of special infectious cases, such as measles, whooping cough, and ophthalmia, is undertaken by these district nurses. This co-ordination with voluntary effort is distinctly favourable. (6) Midwives.—There are 4 district midwives in private practice; two of these have recently come to the Downham Estate. (7) Maternity Hospital.—The Bromley and Chislehurst Maternity Hospital is under a voluntary management, receiving a block grant from the Ministry of Health. It is subsidised by the Bromley Council for cases admitted under the recommendation of the Medical Officer of Health. The co-ordination between the Maternity Hospital and the Maternity and Child Welfare Service is a close and happy one. The Hospital is doing work of great value, is highly efficient in its clinical work, and possesses a high reputation among its patients. There are 14 beds, and a summary of the year's work extracted from the Annual Report gives a clear indication of its popularit: No. of cases in Hospital, Jan. 1st, 1925 9 ,, ,, ,, admitted in 1925 152 ,, ,, ,, in Hospital, Dec. 31st, 1925 10 ,, ,, ,, for whom the Local Authority paid grant 18 During the year a mild impetigenous infection entered the hospital affecting some 80 per cent. of babies. This could not be traced to personal contact from staff, nor were any of the steps of disinfection successful in abolishing the disease. It was thus recommended that the hospital be temporarily closed to allow of thorough sterilisation of 18 material and disinfection of wards. The rash has reappeared: in a few cases after re-opening, and further investigation is taking place. IV.—SANITARY CIRCUMSTANCES. Legislation in Force. Adoptive Acts— Infectious Disease Prevention Act 1890 Public Health Acts Amendment Act (1890) 1890 „ (1907) 1907 Public Health Act, 1925, Parts II., III., IV. & V. 1925 Dye-Laws— Houses Let in Lodgings 1898 Common Lodging Houses 1897 Prevention of Nuisances 1897 Cleansing of Earth Closets, Privies and Cesspools 1898 New Street and Buildings (Revised) 1898 Cleansing and Removal of Refuse 1912 Tents, Vans and Sheds 1923 Slaughterhouses (Revised) 1924 Good Rule and Government 1910 Prevention of Nuisances arising from filth or rubbish 1912 Regulations— Dairies, Cowsheds and Milkshops 1904 Swine Fever - Water Supply— Bromley is supplied with water by the Metropolitan Water Board's deep chalk well supply at Shortlands. The supply is sufficient and of high grade purity—it is in fact taken as a standard of purity of deep well water. 19 The average analysis of this unfiltered and untreated water is as follows: Bacteriological— 97.9% samples Bac. Coli absent in 100 c.c. 1.6% ,, ,, ,, present in 100 c.c. .4% ,, ,, ,, ,, in 10 c.c. Chemical— Ammonial Nitrogen .0001 Albuminoid Nitrogen .0014 Oxidised Nitrogen .51 Chlorides 1.73 Oxygen absorbed in 3 hours .01 Permanent Hardness 8.2 Total Hardness 28.8 Rivers and Streams. On seven occasions minor pollutions of streams were reported. None of these were of a serious nature—arising mainly from blockage of flow. These were all remedied without difficulty. A pond in Crown Lane was cleared of refuse, but the nuisance from midges and mosquitoes continues and is a matter which is receiving the attention of the Committee. Drainage and Sewerage. No extensive drainage or sewerage alterations have been undertaken during the past 5 years, excepting that applicable to new housing estates. Main drainage system of Bromley joins that of the undertaking of the West Kent Main Sewerage Board. Bromley has 4 representatives on this Board, whose new purification works are at Long Reach, Dartford. The effluent is finally discharged into the River Thames. 20 The household drainage throughout the town is modern and only in unsewered districts do cesspools exist. There are 6 cesspools and 4 earth closets. Certain trade premises possessed earth closets, but these have happily now been abolished by the Health Department during the year. Scavenging. House refuse is collected by horse traction once weekly by Council workmen. Moveable ashbins with proper coverings exist throughout the Borough and the average collection amounts to 190 tons per week. Non-combustible trade refuse is not collected. The more frequent removal of house refuse is desirable during the summer months, and I would like to see easier facilities for the removal of garden refuse and offensive trade refuse such as fish offal. Without this, refuse will be tipped by irresponsible persons on vacant pieces of land and thus left for the Health Department to discover and abate the nuisance which generally arises. A Horsfall destructor exists at Waldo Road Depot and has recently had extensive repairs carried out. In my opinion extension of destructor plant is necessary. Sanitary Inspection of Districts. Mr. Butler, the Senior Sanitary Inspector, who has now been in your service for 32 years, has compiled the two Tables VII. & VIII. which appear in the appendix. A perusal of them will indicate the very efficient work carried out by the two inspectors, often in the face of great difficulties. The success in the abatement of 2,809 nuisances is an indication, not only of the respect traders and others have for Mr. Butler, but is 21 also an indication of the tact and skill with which the inspectors carry out their work. No less than 5,056 sanitary visits were paid during the year. As Mr. Butler reports, the tables, which shew the numbers of premises inspected, notices served, and results of such inspections and notices, do not indicate any lessening of activities compared with previous years; at the same time it will be noticed that there has been a great increase in visits to and supervision of food preparing places. Complaints. There has been some falling off in complaints of alleged nuisances; this is partly explained by the efficiency of the House-to-House Inspections during the past few years. During 1925, 205 complaints were received, all of which received the immediate attention of the inspectors, and where nuisances were found, the necessary steps were taken to have them abated. The Council found it necessary in one case — a case where there was nuisance from cesspool drainage— to take legal proceedings for failure to obey an Order of the Magistrates. Penalty of £6 1s. 0d. and 4s. costs was imposed. Notices Served. The following tabulation gives a summary of legal action taken by the Department: Preliminary Notices 453 Statutory Notices 138 No Court proceedings were taken in connection with the above notices. '22 Increase of Rent (Restrictions) Act. One formal application was made under the above Act, and the necessary repairs were carried out by the owner, rendering the issue of a certificate to the tenant unnecessary. Smoke Abatement. Bromley is practically free from smoke nuisance, and in only one case was it necessary to take steps for the abatement of this nuisance. This was readily carried out by the owners. Ten cases were fined by the Magistrates for chimney fires. When cooking by gas becomes universal, the pollution of the atmosphere by the domestic chimney will be largely abated. Petroleum Acts. Petrol. 2-gallon can Storage. Bulk Storage. Carbide of Calcium. No. of licences issued, 59 9 8 *[Bulk Sterage is also included on 10 licenses for can stores.] Of the above, 16 were new or additional licenses, the balance, 60, being renewals. Extensive alterations were necessary in many cases before plans were approved for bulk storage in underground cylinders. Prosecutions were instituted in four cases for keeping petrol without licenses, and in each case a fine of 40s. was imposed. 23 Shops Acts. Regular inspections were made by the Inspectors under the Shops (Early Closing) Act, and the Shops Act, 1912. Both these Acts are very well observed in the Borough, and no prosecutions were necessary during the year. Factory and Workshops Acts. The total number on the Register is 258, and the following is a tabulation of the business: Bakehouses 23 Bootmakers 22 Tailors 17 Laundries 33 Motor and Cycle Engineers 28 Restaurant and Eating Houses 16 Dressmakers 18 Other Trades 101 Premises Controlled by Bye=laws or Regulations. The following is a tabulation of premises which came under regular or periodic visitation from the Health Department: Dairies, Cowsheds and Milkshops 45 Ice Cream Premises 50 Bakehouses 23 Butchers' Premises 42 Slaughterhouses 11 Hotels and Restaurants 16 Fish Shops 36 Other Food Shops 40 Cinemas 2* Factories and Workshops 258 Offensive Trade (Tallow melting) 1 Common Lodging House 1 (*0ne is in course of reconstruction.) 21 V.—HOUSING. A statistical table appears in the appendix (XIV.). At the Census, 1921, there were 7,400 dwellings and 8,400 separate occupiers. The average number of rooms per person was 1.32, and the number of families per dwelling was 1.14. Sinoe the 1921 Census, during which time the population has increased by 470 persons, 647 houses have been erected and 10 demolished. On this basis we should soon overtake our overcrowding in Bromley, but there is another side of the problem. An investigation into the housing condition of the babies under 1 year visited during the years 1922, 1923 and 1925, showed that whereas in 1922, 5 percent, of these families were living in one room, by 1925 the percentage had increased to 10 per cent. Again, in 1901, 2 per cent. of the population lived in one-room dwellings, in 1921 the percentage increased to 4 per cent. Much has been done and much is being done to combat this evil of the one-room family. Probably noother country in the world has done so much as England to combat this evil. Bromley is playing its part in this, and will, I trust, continue to fight for one of the fundamentals of a healthy population—a sanitary house for each family. Since the Council undertook a Housing Scheme, 186 houses have been erected and occupied; these houses are all that could be desired as modern working-class dwellings, but the taking in of sub-tenants is defeating the object of the scheme. Private enterprise during 1925 completed 136 houses, and a distinct word of commendation is due to Bromley Tenants Ltd. for their housing scheme in Southlands Road. 25 Overcrowding. Cases of overcrowding still exist, and there are many pitiable cases brought to my notice. The desire for better home conditions is an indication of the general social improvement of the race—what was good enough for the lower strata of the population 20 years ago is far below the standard desired to-day. Twenty years hence we shall be horrified that we allowed such overcrowding in houses as is known to exist in certain houses in Bromley. There are cases where marriage is delayed because of Lack of the possibility of a home. Early marriage is desirable where we desire healthy children and a good Birth Rate. There are cases, too, where wilful restriction of births is exercised, and there are other defects in Public Health resulting from shortage of houses. We hear of the careless tenant, but the landlord who refuses to let because of young children in the family is due for all possible censure. Overcrowding as a nuisance is a difficult matter to remedy under existing shortage; the Department is fully alive to the urgency of the question and constant observation is kept on the careless family. Urgent cases are referred to the Housing Committee for consideration of council houses. I think it would be a useful step if all successful applicants for council houses were immediately notified to the Health Department so that when the premises are vacated steps may be taken to avoid a repetition of sub-letting and overcrowding. Landlords appreciate this, for it is the overcrowded property that so rapidly deteriorates—and what else can be expected when the one lavatory has to meet the requirements of several families, where cooking is done at the open fireplace—where food is kept in the living-room, and washing is attempted at the scullery sink. House=to=House Inspection. House-to-house inspection is maintained under the Inspection of District Regulations. 26 The following list of streets and houses, with defects discovered, indicates thework during the past year: Street. No. Inspected. No. with Defects. Bromley Crescent 28 26 Canon Road 57 40 Gravel Pits 12 10 Havelock Road 75 58 Howard Road 43 21 Johnson Road 35 24 Liddon Road 55 35 Newbury Road 91 39 Simpsons Road 30 20 Vale Cottages 16 10 Total 442 283 The Staff were able by the good will of the owners to get the whole of the necessary repairs carried out—a fact of importance in considering the housing question in Bromley. By a reference to the statistical table in appendix the nature of the housing defects will be seen. Over 4,000 houses are on the schedule for inspection, the complete list being inspected every 10 years. In addition houses came under inspection on complaint, infectious disease, and at other specified occasions, and the general willingness of owners to have defects remedied is a happy indication of the success of the inspectors' work. VI.—INSPECTION AND SUPERVISION OF FOOD. Milk.—During the past five years milk has occupied a prominent place in many new orders and regulations. The grading of milks, the registration of dairies and dairymen, and the control of tuberculous milk are all very necessary 27 advances, and the enforcement of the orders and regulations is a very necessary part of the department's work. The greater proportion of milk consumed in Bromley is produced outside the area and must travel considerable distances before distribution to the householder. Premises registered for the sale of milk: Milk shops 45 ,, ,, selling pasteurised milk 3 ,, ,, selling certified milk 3 ,, ,, selling grade A milk 3 ,, ,, selling grade A milk (tuberculin tested) 3 The Department was successful in obtaining during 1925 a Grade A milk production at one farm; and have, I believe, created an increased public demand for cleaner milk. There is no doubt that milk continues to be distributed in a haphazard and non-hygienic manner. There is now one firm who have undertaken a wholly bottled and graded milk distribution. There are several farms in the Borough which do not reach a satisfactory standard. Graded milks are known as "Certified," "Grade A," "Grade A (Tuberculin Tested)" and "Pasteurised," and no milk can be sold under these grades unless authorised to do so by the local authority. No licence can be granted unless a certain standard of cleanliness is attained by the producer. It is to be remembered by the public that milk sold in bottles is not necessarily graded milk, and that the only milks licensed are those in the aforesaid grades. "Nursery Milk," "High Grade Milk," etc., are not graded milks. There is much to be done by the Department in this field of preventive medicine, but it is highly necessary that the public should help us, by demanding a milk guaranteed by law to be clean. 28 "Certified Milk," sold in bottles sealed by a cap with the words "Certified Milk" imprinted thereon, with the date of milking, must be bottled on the farms and produced from cows free from tuberculosis. The milk must not at any time before delivery to the consumer contain (1) more than 30,000 bacteria per cubic centimetre; (2) any Coliform bacilli in one-tenth cubic centimetre. This milk is generally sold at 1/1 per quart. "Grade A" milk is milk produced from a herd examined once every three months by an approved veterinary surgeon. It is sold in bottles sealed with a cap giving date of milking and imprinted with "Grade A Milk." It must not contain (a) more than 200,000 bacteria per cubic centimetre; (b) any Coliform bacilli in one-hundredth cubic centimetre. This generally is sold at 7d. per quart. "Grade A (T.T.) Milk" is the same as Grade A milk, only the herd is tested periodically with Tuberculin. This is generally sold at 7d. per quart. "Pasteurised Milk." This is milk which has passed through pasteurisation at a temperature not less than 145 deg. Fahrenheit and not more than 150 deg. F. for at least half an hour. It is immediately cooled to 55 deg. F., and is sold in bottles with a label "Pasteurised Milk." The milk must not contain more than 100,000 bacteria per cubic centimetre at any time before delivery. "Pasteurised Milk" sells at the price of ordinary non-guaranteed milk. Samples are periodically taken by the Department to see that the Graded Milks are maintaining their standard. During 1925 the Graded Milks were all well within the standard set by the milk orders. A sample of ordinary milk taken for comparison contained 2,364,000 organisms^and Bacillus Coli per l c.c. 29 The distribution of milk by cans, or by bottles filled in the street, is to be condemned; to give one instance, a roundsman filled non-sterilised bottles from a can, and while so doing, held the discs between his teeth. One can thus imagine the possibilities of serious infection being spread in this manner, for milk is an excellent medium for the growth and cultivation of bacteria. That roundsman might have been a Diphtheria carrier, a Typhoid carrier, or have been suffering from grave contagious disease. Cleanliness of handling of milk is essential, and that the bigger firms are now in Bromley undertaking a hygienic delivery is a happy indication of progress. Meat. The inspection of meat is carried out by the Sanitary Inspectors, both of whom possess the meat certificate. The inspection includes shops where meat is sold, of which there are 42 in the Borough, and at the slaughterhouses, of which 6 are licensed and 5 registered by the Local Authority. There have been no additions or deductions from this number of slaughterhouses since 1920. The fact that much of the meat slaughtered in the Borough passes afterwards through Smithfield Market provides for double inspection, and vice versa, much of the meat sold in Bromley passes first through the Smithfield inspection. One can justifiably report that the quality of meat sold in Bromley reaches a high and safe standard. This being so, it is to be regretted that greater protection in the shops by closed windows and by the prevention of fly contamination is not more fully enforced by the trader. There are many excellently conducted shops, but there are others which are not doing all that is desirable in this direction. It is an old established fact that the fly can carry disease, and because meat is cooked after sale should not excuse laxity in 30 ing fly contamination. One can generally indicate the unhygienic shop by the number of blow flies in the shop during the summer months. The public are alive to this fact and will and should patronise only those shops that make protection of meat one of their principles of sale. The inspection of all carcases at the time of slaughter, so necessary if the inspection is to be thorough and competent, cannot be carried out with the present staff, nor with the present scattered places and multiple times of slaughtering. And again, not only are some of the places of slaughtering lacking in facilities for hygiene, but need constant supervision by the officers of the Health Department, if the standard of cleanliness is to be maintained. Centralisation of slaughtering is very necessary, and would, I am sure, be welcomed by the majority of the trade. This is no new policy, but nevertheless a very desirable one from all aspects; it would not be so necessary were every private slaughterhouse built on suitably situated premises and on modern hygienic lines. The cleanliness in the handling of meat, the protection of meat in transit, and the protection in the homes, are further important reforms. These are matters partially covered by the Meat Regulations, but there are people still prepared to receive from the dirty hands of the deliverer the joint unwrapped in paper from a none too clean basket. Public Health (Meat) Regulations, 1924. These Regulations came into force on 1st April, 1925, and are a distinct advance on previous legislature. These Regulations do not fully cover all our aims in the protection of meat and foodstuffs. It was not anticipated, in a district of this character, with the previous experience of the Staff and knowledge of the traders, that much in the way of diseased food would be encountered, or that there would be but little inclination on 31 the part of traders to evade the Regulations. This expectation has been fairly well confirmed, by the way the traders have co-operated with the Staff by sending in necessary notices as to times of killing animals for food, as well as in other ways calculated to assist rather than make more difficult the work of the Council's Officers. The practice of the Inspectors in all important instances of diseased meat is to detain the same for the opinion of the Medical Officer of Health, so that the amount or percentage of bad meat tabulated herewith is a fairly accurate idea as to the moderate amount of bad meat to be found in this area. Most of the animals killed here are sent to the Smithfield Market, this applying more particularly to pigs and hogs, but little has been heard of any carcase failing to pass inspection there. The experience of working the Regulations discloses the need of definite power for the inspector to detain any suspected carcase for 12 hours for a second opinion, also to prevent the entrails being buried or otherwise being done away with until the inspector has had an opportunity of inspecting them. Hence the need for inspection at time of slaughter. A weakness is also disclosed in our Slaughterhouse Regulations as to the lighting in slaughterhouses when killing is in progress, and also as to the capacity of the buildings •compared with the increased extent to which the premises are now used which may formerly only have been required for a few animals on rare occasions. Up to the present no legal proceedings have been taken under these Regulations, and any bad meat destroyed has been willingly surrendered by the tradesmen concerned. The following Table is instructive in that the Inspectors were able, in spite of the scattered premises, and the varying hours of slaughter, to inspect 53 per cent. of carcases known to have been slaughtered since April 1st, 1925. 32 But it is to be again noted, not necessarily inspected at the time of slaughter: 313 Inspections were made to Slaughterhouses. 137 on regular days. 127 re Notices on other days. 38 Casual visits, and 11 for unsound meat. No. of carcases known to have been killed. No. inspected. Carcases and parts destroyed. 1,763 pigs. 962 Livers—Necrosis 11 Cirrhosis 20 Abscess 1 Tuberculosis 1 Fatty degeneration 1 Fatty infiltration 1 Cysts 1 Pyaemic abscess 1 Kidneys—Cysts 2 Hearts—Pericarditis 4 Abscess 1 Lungs—Congested 2 Pneumonia 2 Multiple abscess 2 Tuberculosis 2 Omentums—C. Tenuicollis 5 Heads—Tuberculosis 3 Udders—Inflammation 2 Breast—Abscess 1 Mesentery—Tuberculosis 1 171 sheep. 74 Liver—Flukes 2 164 calves. 82 38 cattle. 25 Cows— Carcase & Organs 1 Lungs 4 Mesentery 1 Skirt 1 Bullocks— Livers—Flukes 1 2,136 1,143 74 33 Other Foods. Food inspection has been a prominent feature of the Staff's work during 1925, the following premises other than the foregoing coming under routine inspection:— Bakehouses 23 Restaurants and Eating-Houses 16 Ice Cream Premises 50 Fish Shops 36 Shops, Confectioners, etc. 30 Grocers, etc. 60 Sanitation of these premises have in many instances been improved as a result of these visits, and there is a marked improvement in the general desire of the traders to safeguard their foodstuffs from contamination. This desire for hygiene and protection of food stuffs is an indication of the great advance in Public Health ideals in trade. One notes the lack of protection in shop windows of food stuffs such as fish, green vegetables, dates, sweets, cakes, pastries, etc., mostly foods that are not subject to cooking and so more liable to dangerous contamination. It is necessary, in my opinion, that all food premises should come under registration by the local authority, and that such registration be refused should reasonable standards of cleanliness and protection from contamination be not maintained. The fact that we have escaped cases of food poisoning, is more a matter of good fortune than of good government of the past. Sale of Food and Drugs Act. The following is a tabulation of samples taken by the Foods and Drugs Inspector, in Bromley, during 1925:— No. of samples 113 Genuine 113 Adulterated Nil. 34 Summary. Nos. Nos. Nos. 56 New Milk. 2 Lard. 1 Ground Ginger. 9 Butter. 1 Tapioca. 1 Cream. 5 Coffee. 1 Baking Powder 1 G. Cinnamon. 5 Margarine. 2 Jam. 1 Olive Oil. 5 Cocoa. 5 Dem, Sugar. 1 S.R. Flour. 4 Custard 2 Condensed 1 S. Whisky. Powder. Milk. 1 Gin. 4 Pepper. 3 Rice. 1 Oatmeal. 1 Mustard. VII.—PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASE. A tabulated return of infectious disease during the past year is given in the appendix (IX.) and the year has again shown that Bromley is remarkably free from disease in epidemic form. It is not possible, nor is it desirable, to compare our town with another, because no two towns have identical population of the same age and sex grouping, or identical environmental conditions, but the fact does remain that Bromley's history of scarlet fever and diphtheria (the two most common notifiable infectious diseases in England) is not one of any great gravity. I trust Bromley will continue its history, but it would be foolhardy to acquiesce the present circumstances. Scarlet Fever. Only 32 cases of scarlet fever were notified during the year, all of which were admitted to hospital. This gives an incidence rate of .9 compared with 2.3 for England and Wales. 35 I am personally of the opinion that admission to hospital played no part in the prevention of the spread of infection. Since 1920, 524 cases of scarlet fever have been notified (being more prevalent in 1921 and 1922 than in the latter three years), and 4 deaths therefrom. The type of case during 1925 has continued mild in nature, and except in two cases were free from complications. In two instances "return" cases arose in two families; in one family all four children but one became infected, and were admitted to hospital. . The "Dick" test is not carried out in Bromley, and a practical policy does not appear to be necessary at present. Diphtheria. Eighteen casey were notified during the year, with no deaths, giving an incidence rate of .4 per 1,000 population, compared with 1.23 the incidence rate for England and Wales. Since 1920, 237 cases have been notified and 7 deaths. Antitoxin is now on free issue to practitioners, and I have made it a practice chat no case is admitted to hospital without 8,000 units of antitoxin having first been administered. It is essential if we are to prevent deaths in diphtheria that antitoxin in sufficient doses be administered at the earliest possible moment. The practice of waiting for swab results before the adminstration of antitoxin has been distinctly discouraged; cases should be inoculated pending the result of the swab. The modern success that has attended the Schick Routine, whereby susceptibles are inoculated with a 36 antitoxin, has not been adopted in Bromley. Although our incidence rate is so low, I believe all residential schools should carry out this routine, and I trust that the Department will shortly have an opportunity of carrying out this very desirable preventive step. Influenza and Primary Pneumonia. Notification of these notifiable infections has been given by the general practitioners in every case attended by them. In all there were 36 cases notified, an incidence rate of 1 per 1,000 population. This is the lowest rate for any of the past five years, and indicates a comparative freedom of acute respiratory infection. For the five years ending 1925, 305 notifications of pneumonia have been received, of whom 125 died. This gives an incidence rate of 1.9 per 1,000 population, and a case mortality of 41 per cent. Puerperal Fever. One case of puerperal fever was notified and died shortly after admission to the infirmary. Present arrangements of isolation and treatment of these cases is through the Isolation Hospital, Sevenoaks. Cerebro-Spinal Fever. Three cases were notified during 1925, bringing the total of the past five years to 7. One case was notified after death, and the other two died shortly after admission to the Isolation Hospital. All three were sporadic cases, no secondary cases arising, and in no case was the diagnosis verified by cerebro-spinal fluid examination. 37 Tuberculosis. On December 31st, 1925, there were 94 cases of male and 70 cases of female tuberculosis of the lungs, and 38 males and 55 female cases of tuberculosis in other forms. This gives a total of 257 cases of tuberculosis in the Borough, and this, after deletion from the register of cases cured, died, and left the district. Thus 7.2 per 1,000 of the population are at present suffering from tuberculosis. Happily not all these cases are in an infectious state. Of these 257 cases, 85, or 33 per cent. have passed through a course of sanatorium treatment. I have no figures of tuberculosis of past years to compare with these, but I believe I would be correct in saying that improvement is taking place in Bromley, as over the rest of England and Wales. In comparing the past five years' notifications we get the following figures:— Deaths. Lung. Other. Lung. Other. 1921 37 8 20 6 1922 37 23 21 7 1923 44 22 23 5 1924 44 18 22 3 1925 38 17 21 4 Totals 200 88 107 25 On these figures, and making no allowance for migration of patients or for cures, or for correction of diagnosis, there is an increase in the five years of 93 lung cases and 63 other forms. 38 The incidence rate per 1,000 over these five years is 1.6, so the 1925 rate of 1.5 shows a slight reduction. In 1914, the first complete year after the coming into force of the Public Health (Tuberculosis) Regulations, 1912, there were 68 cases of tuberculosis notified, an incidence rate of 2 per 1,000 population, but this high rate is no doubt partially due to the notification of old existing cases. I am indebted to Dr. Martin, of the Tuberculosis Dispensary, 2, Park Road, for the following return of the very valuable work of the Dispensary during the past year:— New Cases who attended the Dispensary for the first time for Examination during the Year. Adults. Children. Male. Female. Male. Female. Pulmonary 16 21 1 4 Non-Pulmonary 3 — 3 6 Negative 10 7 4 5 Ninety-three contacts were examined during the year, and of these 32 were found to be positive. These are not included in the above Table. Total number of Attendances of Patients to the Dispensary during the year 1,475 Number of cases who attended the Dispensary and who received Institutional Treatment (including Sanatorium treatment) during the year 50 A nurse from the District Nursing Association attends the Dispensary with the Tuberculosis Officer, but the routine home visiting is done by one of the Health Department's 39 Health Visitors. Close co-operation is here needed, and it would be of advantage to the Department, and, I believe, to the work generally, if the Health Visiting Staff attended the Dispensary. It would, I am sure, bring about a closer coordination between treatment and prevention. There is, too, the need of a Committee in Bromley to deal with the aftercare of the tuberculous patient. The Health Department's main duty in tuberculosis is prevention, rather than treatment, and whatever we are doing to improve the environment of the people must have its results in the control of this infection. The crux of the whole problem lies with the infant. It has been repeatedly proved that tuberculosis in the adult arises in the main from a childhood infection. It then follows that if we are to prevent tuberculosis we must remove the infant from the proximity of infected persons, and especially from the infected mother. In Bromley 53 babies under visitation have tubercular parentage; 15 of these babies were under 1 year of age on December 31st, 1925. The necessity of ante-natal warning to the pregnant and tubercular mother is just one instance of the desirability of close co-operation between Tuberculosis Dispensary and the Maternity and Child Welfare Service. Provision of open-air hospitals for the infant so removed from infection, the necessity of controlling and preventing the tubercular infection of milk and other foodstuffs, combined with environmental improvement, will all help to complete our preventive steps, and help to prevent each year the spread of the infection. Two additional statutes came into force during 1925 dealing with the tubercular patient, viz.:— Section 62, Public Health Acts, 1925, gives power to a local authority to remove by order of a Court of Summary Jurisdiction an infectious pulmonary tubercular patient to suitable hospital or institution. There are certain necessary 40 safeguards, but I have not found it necessary during 1925 to act in any case. Public Health (Prevention of Tuberculosis) Regulations, 1925. These are important regulations, and Section 4 reads as follows:— "No person who is aware that he is suffering from tuberculosis of the respiratory tract shall enter upon any employment or occupation in connection with a dairy which would involve the milking of cows, the treatment of milk, or the handling of vessels used for containing milk." At present no notified case is engaged in the milk trade. Non=notifiable Infectious Diseases. These are in the main measles, whooping cough, and chicken-pox. There are many other infectious states of no less importance and often of serious import in physical deterioration of the patient. The common cold, the acute tonsilitis, and the so-called influenza are sources of great loss of employment and efficiency, and how often the patient forgets the infectiousness of his disability and carelessly passes his disease to other non-immune persons. The new slogan—and it is the age of slogans—"cover your mouth when you cough"—is only part of the campaign against the spread of these diseases. The main, sources of our information of the presence of measles and whooping cough are through the Maternity and Child Welfare Service and the School Medical Service, and serious cases are referred to the nursing association for district nursing. An infectious disease nurse is not employed by the Corporation, but at times of epidemics I am sure such an 41 appointment would be of immense value in prevention of serious complications, and in some cases of death. In my opinion it is not wise to allow health visitors to undertake this work. Isolation Hospital. The Bromley and Beckenham Joint Hospital Board are the isolation hospital authority for Bromley, and I append herewith an epitome of their activities. The United District consists of:— The Municipal Borough of Bromley; The Urban Districts of Beckenham, Chislehurst, and Sidcup; The Rural District of Bromley; and was formed for the purpose of the provision, maintenance, and management of a hospital or hospitals for cases of infectious diseases, occurring among the inhabitants of such districts. The Board consists of eleven members, the Chairman of each of the five constituent districts being ex-officio members by right of their office and the remaining six elective members. The United District has an area of 66 square miles, a rateable value of £950,893, and an estimated population of 116,000. The cost per head of population in the Board's District for the year ended March, 1925, for all purposes (including capital repayments) was approximately 2s. 0½d., while the Common Fund charge in each of the constituent districts was equivalent to a rate of approximately 2½d. in the £. 42 Two hundred and fifty-four patients, representing 10,327 patient days, were under hospital treatment from the United District during the same year. The Isolation Hospital which is situated in Bromlev has provision for 115 beds (including cots), a bacteriological laboratory, and in addition a hospital for the treatment of smallpox, with provision for 35 beds (including cots). The permanent nursing and domestic staff of the Isolation Hospital consists of: Matron, 3 Sisters, 22 Assistant Nurses, Cook, 2 Kitchenmaids, 3 Housemaids, 7 Wardmaids, Head Laundress, 3 Laundrymaids, Sewing Maid, Portress, 4 Motor Ambulance Drivers, and Male Attendants. Disinfection and Disinfestation. For disinfection purposes, rooms are sprayed with a solution of formalin, with additional gas produced subsequently in sealed-up rooms by formalin lamps (Formigators). The rooms are left closed up from 8 to 24 hours. The bedding, clothing, etc., are, when necessary, 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 disinfector, but there is no provision made for the cleansing of the person at a cleansing station, nor in my opinion is such provision necessary in Bromley. In the case of tuberculosis, steam disinfection is carried out on notification and when bedrooms are vacated by removal of patients by death or otherwise. Similar routine applies to cancer. When cases of diphtheria, scarlet fever, and a few other infectious diseases are removed to the Infectious Diseases Hospital, the vacated room and its 43 tents are disinfected with formalin in the manner set out above. Cleaning and airing of the room is always advised, and the remedying of any insanitary condition found by the Inspector whilst visiting is taken in hand as a routine matter. The value of disinfectants and of room disinfection is a very debatable matter, and I favour their abolition entirely. Cleanliness, soap and water, fresh air and sunlight will do all and more than our present efforts in this direction. I do not believe it a correct economic policy to pander to a wrong public opinion which is quite contented if the air smells strongly of some pungent chemical. Laboratory Work. The following bacteriological examinations were made during the year:— Positive. Negative. Sputum examination for Tubercle 16 98 Swabs for Diphtheria 14 159 Widal Reaction for Typhoid 3 2 Bacteriological examinations of milk are carried out periodically. Some counts were extraordinarily high, showing needless dirt contamination, while the Graded Milks kept well within the standard set by the Graded Milk Orders. The efficiency of the scheme for bacteriological examinations by the Kent County Council Laboratory proved itself during the year and there is no need at the present time to alter these arrangements. Diphtheria Antitoxin. Diphtheria Antitoxin in 8,000 unit doses is on free supply to the Doctors. No case is admitted to hospital before this antitoxin has been injected. 41 VIII.—MATERNITY AND CHILD WELFARE. In the appendix will be found certain vital statistics which indicate that the Maternity and Child Welfare Service in the Borough has by the lives saved more than returned the money spent upon it. They, too, indicate the need of extension of ante-natal practice if we are to reduce the maternal mortality, and the mortality of the new-born babe, both of which rates are on the upward curve. There are needed also other extensions of the Maternity and Child Welfare Service, the dental treatment for necessitous expectant mothers, and children under 5 years of age, orthopaedic treatment of the crippled child and minor ailment treatment for the necessitous child under 5 years. It is not to be overlooked that while our schemes are incomplete in these directions we are allowing early disease to remain untreated, until the child's entry to school. In my School Report it is shown that 16 per cent. of Bromley children entering school life require treatment. I trust the Committee will take these additions to the Service undr early considration. Ante-natal Service. A medical consultation clinic is held at 12, Park Road, on the first Friday of every month. Since its inauguration in 1922 the attendances have gradually increased, until recently the attendance figure has averaged 12 per session, an indication of the improvement in public desire for pre-natal service which follows propaganda on these matters. There is also an indication of the mother attending earlier in pregnancy so offering greater chance for prevention of disease and the development of a normal pregnancy. 45 The Committee are extending this service to Bromley Common in 1926, and as the attendance at Park Road increases an additional session will be called for. Ante-nataling of mothers who book for the Maternity Hospital is effectively carried out by the staff of the Maternity Hospital. One would like to see this general routine in all midwifery practice. It is worthy of notice that in the 1925 Report of the Nursing Associations doing midwifery, 364 ante-natal visits were made to 74 expectant mothers. This excellent work needs every possible encouragement. Ante=Natal Clinic, 1925. Clinics held 11 New Patients 54 Total Attendances 89 Average per Clinic 8 Referred for treatment 6 Natal Service. All births are notifiable to the Medical Officer of Health and in only a few cases was there neglect to do so. As certain babies are born outside the area they are not reported upon until discovered in the course of home visiting by the health visitors. It is very desirable that the home address of the mother should be given in such notification of birth so that information may be forwarded to the Medical Officer of Health of the district to which the mother will return after confinement. Of the 555 births occurring in the Borough, no less than 364 were notified by general practitioners. This indicates that 65 per cent. were attended at birth by doctors. 46 There are four private nursing homes in the Borough who accept maternity cases; in one of these qualified nursing staff does not exist. The total beds in these homes (and not all are available for maternity cases), number 18. The Maternity Hospital has 14 beds and is reported on elsewhere in the report. Two of the three District Nursing Associations do maternity work, and during 1925 delivered 74 cases. There are four independent district midwives, two of whom have recently come to the Downham Estate. Stillbirths. While stillbirths are notifiable, miscarriages are not. This is certainly a defect in administration of maternity service and an obstacle in the path of preventive practice. Eleven stillbirths were notified during the year, all those occurring on the district being visited by the Health Visitors, for special investigation. Health Visiting. Practically all notified births are visited upon the 10th day of life, and kept under regular visitation until 5 years of age, when the child passes to the School Medical Service. Owing to the residential nature of Bromley certain districts do not call for visiting. Others escape early visitation owing to being born outside the district. These are generally "picked up" in the course of routine visiting in the district. In 1925, 74 per cent. of babies in Bromley were visited. 47 This routine visiting is the main cause of success of the Maternity and Child Welfare Service, and cannot be too thoroughly performed. We aim at four routine visits in the first year and second year of life, and two in every subsequent year until the fifth year, but it has been found that the visiting staff is inadequate to meet the demand, especially as the special baby requires frequent and regular visiting. The staff, at the time of writing, has been increased, and it is hoped will be found adequate when the Downham Estate is fully occupied. It is intended to co-ordinate the home visiting of the school child and the baby so that duplication of home visiting will be avoided, and the present year should see this in operation. Appendix XI. will show the extent of home visiting during each month of 1925. 4,298 home visits were paid during the year by the two health visitors. As a considerable portion of the time is occupied in attendance at the four welfare centres, the two visitors are certainly devoid of adequate time for home visiting. As some 2,000 babies are on the register for regular visiting, and as each case should statistically average at least 3 visits per year, 6,000 visits should be the minimum for each year. Now that Downham Estate is rapidly being completed, our home visiting list will be further extended. Infantile Mortality. Thirty deaths of babies were recorded during the year, two of these being illegitimate babies. This gives an Infantile Mortality Rate of 57.6 per 1,000 babies born, being the second lowest infantile mortality rate for the Borough. Our infantile mortality rate is 10 per 1,000 less than London, and nearly 20 per 1,000 less than the rate for England and Wales during 1925. 48 A table in the Appendix IV. gives the age at death of babies, no less than 50 per cent. occurring during the first month. 26 per cent, of baby deaths were under 1 week of age, a striking fact that shows, if we are to save a needless waste of life, the necessity of intensive ante-natal work. Further our deaths of babies under 1 week of age are increasing; in the 5 years 1911-1915 the rate equalled 28 per cent, and in the 5 years 1921-1925, 35 per cent. Some twenty years ago the rate of baby deaths was double that of to-day. What was thought to be almost an unachievable objective twenty years ago is to-day an established fact. We have proved the truth of our doctrine and have set ourselves the task of again halving our baby death rate. We know of lives ignorantly destroyed, we know the causes that must be abolished, and we know that an infantile mortality rate of 30 is not an unachievable objective. Knowing these things, it would be criminal not to apply our knowledge and financial resources. Child Welfare Centres. There are 4 centres held each week—each centre being within easy reach of a populous district—an additional welfare centre is to be opened for the Downham Estate. Plans of a new health centre are at present being prepared, which when completed will help considerably in the organisation of our services. These centres are under the control of the Local Authority through its officers, and the voluntary helpers give freely of their services. The happy co-operation between voluntary and state services that exists in Bromley is showing its results in the better welfare of the mothers and babies attending—which after all is our united and sole aim. 1925 has seen an increase not only in attendances but also in individual mothers and babies at the centres. This 49 increase has been shown at each centre and has recently been most marked at Shortlands, which was a new centre opened in April, 1925. 61 per cent. of all babies visited attend the centres, and the Table in Appendix XII. will shew statistically the actual attendances made during the year. The attendances for 1925 show an increase over 1924 of 843 babies and 784 mothers. The following tabulation shews the individual children on the register of each of the centres at the year end:— Plaistow. Widmore. Br. Common. Shortlands. Total. Under 1 43 24 53 26 145 1 „ 2 51 34 51 19 155 2 „ 3 40 30 38 21 129 3 ,, 4 30 14 28 16 88 4 ,, 5 17 25 19 10 71 5 & over 12 11 15 5 43 193 138 204 97 631 No treatment is carried out at the centres and no milks are sold. Cod liver oil is on sale at cost price. Dried milks are obtained by coupons issued at the centre for chemists in the town who are co-operating very willingly in this method of distribution. These milks are obtained by the mothers at 2d. over cost price, and the scheme is adding greatly to the efficiency of the centre. Medical Consultation. The re-organisation of the medical attendance of the centres took place in August of 1925, whereby the Medical Officer of Health attends each alternate week at each centre. 50 "Should a baby require a medical opinion during the interim, "it is referred to the neighbouring centre, where the doctor is in attendance, or to the Health Department. In this way every necessary case is seen by the Medical Officer. Actually more babies are seeing the doctor than was the case prior to the re-organisation. Thus, comparing the figures since July, 1925, with corresponding months of 1924, we get 502 consultations in 1925 and 471 in 1924. The rule made is that every new baby is seen by the Medical Officer 4 times in the first year of life and twice yearly after one year of age. I may be allowed to express here that I am finding it, owing to the increasing numbers attending and to increase of other Public Health Services, almost impracticable to keep to this standard, and as the services will be greatly augmented by the Downham Estate, increase of medical staff becomes necessary. Milk in Necessitous Cases. The Committee supply free milk (Grade A) to necessitous cases in attendance at the Welfare Centres. Applications are made on approved forms which are submitted monthly to the Committee for their approval. In 1925 6,614 pints of milk were supplied free at a cost of £76 3s. 6|d. Special Cases. All special cases, other than necessitous, are referred to the general practitioner for treatment; others requiring specialised treatment, such as orthopaedics, are referred to London Hospitals, and one is indebted to these hospitals for the efficiency of their treatment. In the coming year an orthopaedic clinic is to be held in Bromley, So' that the irksomeness and expense of travelling to and from London Hospitals will be avoided. 51 The question of operative treatment for Tonsils and Adenoids, Circumcisions, etc., in the cases that cannot afford the practitioner's fee, is repeatedly difficult to overcome. The Maternity and Child Welfare Committee I hope will, when the new central clinic is completed, undertake such cases through the School Medical Service. The baby requiring hospital observation or treatment is. a difficulty not infrequently met with, and one which could be met by the provision of one or two beds in one of the local Hospitals. During the past year the Phillip Memorial Hospital has successfully undertaken the treatment of two such babies. Boarded Out Children. The inspection of boarded out children under the Children Act, 1908, was transferred to the Council by the Guardians, January 1st, 1925. Ninety-two such children were registered and visited by Miss Brennand during 1925. As a routine they are visited quarterly and reports made thereon. IX.—CONCLUSION. The foregoing pages of the Report and the tables which appear in the Appendix will, I hope, give some idea of the year's activities of the Health Department, which in addition carry out the extensive work of the School Medical Service. They will also show, I believe, the direction of desirable extensions of service. They certainly are beginning to show the results of Public Health activities in past years. It is worth notice that this saving of life and health improvement of the people has resulted from an annual expenditure on the rates of only 4½d. of the 12/- rate. In spite of the fact that as far back as 1867 a local Board of Health was formed because of the acknowledged necessity 52 to safeguard the health of the people—it is only within recent year that Health has come .again to the forefront of public opinion and Local Government. It appears, by recent declaration of Parliament, to be again in the melting-pot. New large Health Authorities are to be formed whereby Poor Law, National Health Insurance, and Public Health will be amalgamated under the one administration. However necessarv this may appear to be, and I believe it is probably agreed that too much overlapping of services does exist, there is a distinct danger of the efficient but sometimes small authority being swamped in an authority which will, in great probability, lose touch with the unit of population. It is on this individuality that the whole success of Public Health has resulted—to destroy it will, I fear, defeat our ends. LIST OF APPENDICES. 1. Summary of Statistics. II. 1925 Comparison Statistics. III. Causes of Deaths, 1925. IV. Causes of Infant Deaths, 1925—Age groups. V. Analysis of Infant Deaths, 1921-1925. VI. Analyses of age of Infant Deaths and Maternal Deaths, 1910-14 and 1921-25. VII. Summary of Sanitary Inspector's Visits. VIII. Summary of Nuisances abated. IX. Return of Notifiable Infectious Diseases, 1925, in wards—giving Attack Rate and Death Rate, etc. X. Return in age groups of new cases of Tuberculosis, notified 1925. Xa. Return of Ophthalmia Neonatorum. XI. Summary of Health Visiting, 1925. XII. Summary of Attendances at Welfare Centres, 1925. XIII. Factories, Workshops and Workplaces Inspections. XIV. Housing Statistics, 1925. 53 APPENDIX I. Summary of Statistics, 1925. Population 35,440 Birth Rate 14.6 Death Rate (standardised) 10.3 Infant Mortality Rate 57.6 Number of Births 520 Number of Deaths 417 Number of Infant Deaths 30 Death Rate of Respiratory Diseases 2.9 ,, ,, ,, Tuberculosis 6 ,, ,, ,, Cancer 1.2 ,, ,, ,, Zymotic Diseases .7 Notification of Scarlet Fever 31 ,, „ Diphtheria 18 ,, ,, Pneumonia 36 ,, ,, Tuberculosis 55 No. of Deaths from Measles Nil. ,, ,, ,, ,, Scarlet Fever Nil. ,, ,, ,, ,, Diarrhœa (under 2) 4 ,, ,, ,, ,, Child Birth and Puerperal Sepsis 3 Number of Inspections by Sanitary Inspectors 5,056 Visits by Health Visitors 4,298 Number of babies in attendance at Centres, January, 1926 505 54 APPENDIX II. — Birth-Rate, Death-Rate, and Analysis of Mortality during the year 1925. Birthrate per 1000 Total Population Annual Death-Rate per 1000 Population. RATE PER 1,000 BIRTHS. All Causes. Enteric Fever. Smnl -pox Measles. Scarlet Fever. Whoopng Cough. Diphtheria. Influenza. Violelce. Diarrhœa and Enteritis (under Two years) Total Deaths under One year. England and Wales 18.3 12.2 0.01 0.00 0.13 0.03 0.15 0.07 0.32 0.47 8.4 75 105 County Boroughs and Great Towns, including London 18.8 12.2 0.01 0.00 0.17 0.03 0.18 0.09 0.30 0.43 10.8 79 0.38 7.6 74 157 Smaller Towns (1921 Adjusted Populations 20,000-50,000) 18.3 11.2 0.01 0.00 0.15 0.02 0.14 0.06 0.31 I.ondon 18.0 11 7 0.01 0.00 0.08 0.02 0.19 0.11 0.23 0.46 l0.6 67 Biomley 14.6 10.3* .00 .00 .00 .00 .06 .03 .28 .33 7.7 58 *Corrected Death Rate. APPENDIX III. Causes ok Deaths, 1925. Cause of Deaths. Male. Female. Totals. Enteric Fever — — — Small-pox — — — Measles — — — Scarlet Fever — — — Whooping' Cough 2 — 2 Diphtheria — — — Influenza 5 11 16 Encephalitis Lethargica — — — Meningococcal Meningitis 1 1 2 Tuberculosis of respiratory system 12 9 21 Other Tuberculosis diseases 2 2 4 Cancer, malignant diseases 16 29 45 Rheumatic Fever — 1 1 Diabetes 1 6 7 Cerebral Hæmorrhage, etc. 12 15 27 Heart disease 24 36 60 Arterio-sclerosis 14 11 25 Bronchitis 16 30 46 Pneumonia (all forms) 12 10 22 Other respiratory diseases — 3 3 Ulcer of stomach or duodenum 2 — 2 Diarrhœa, etc. (under 2 years) 4 — 4 Appendicitis and Typhlitis 2 1 3 Cirrhosis of liver — 2 2 Acute and Chronic Nephritis 3 8 11 Puerperal Sepsis — 1 1 - 2 2 9 8 17 Suicide 2 1 3 Other deaths from violence 5 7 12 Other defined diseases 41 38 79 185 232 417 55 56 APPENDIX IV. Infantile Mortality, 1925. causes of death. Under 1 week. 1 and under 2 weeks. 2 and under 3 weeks 3 and under 4 weeks. Total under 4 weeks. 1 month and under 3 months. 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total Deaths under 1 year Whooping Cough ... ... ... ... ... ... 1 ... 1 2 Tuberculosis ... ... ... ... ... ... ... ... ... ... Convulsions ... 1 ... ... 1 2 ... ... ... 3 Bronchitis ... ... ... ... ... ... ... 1 ... 1 Pneumonia ... ... ... ... ... 1 1 ... ... 2 Diarrhœa ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... 1 ... 1 2 Gastritis ... ... ... ... ... ... ... ... ... ... Suffocation ... ... ... ... ... ... ... ... ... ... Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis 1 ... ... ... 1 ... ... ... ... 1 Malformation 1 ... ... ... 1 ... ... ... ... 1 Premature Birth 6 ... ... ... 6 1 ... ... ... 7 Marasmus, &c. 1 ... ... ... 3 1 1 ... ... 5 Other Causes 2 ... ... ... 2 1 ... ... 1 4 Syphilis ... ... ... ... ... ... 1 ... ... 1 Congenital Heart Disease ... ... ... ... ... 1 ... ... ... 1 Totals 11 1 ... 2 14 7 5 1 3 30 67 APPENDIX V.— Analysis of Causes of Infant Deaths, 1921-1925. 1921 1922 1923 1924 1925 No. of Births 624 575 578 535 520 Total. Infant Mortality Rate 60 74 60 58 58 Premature Birth 2 11 5 6 7 31 Respiratory Diseases 3 6 4 11 3 27 Marasmus & General Debility 10 15 11 5 5 46 Infectious Disease 2 3 6 4 2 17 Gastro Enteritis 6 0 2 ... 2 10 Convulsions 2 1 3 1 3 10 Other Causes 13 8 4 4 8 37 Total 38 44 35 31 30 178 This Table shews that when a high infantile mortality rate occurs a rise also occurs in the deaths of marasmus and debility at birth which inclines one to the opposite fact that when the infantile mortality late falls a general improvement is recorded in the vitality of the new born. This Table also shews that Premature Birth and congenital debility caused 43 p.c. of the total infant deaths during the past 5 years and should be taken as an indication of the great need for antenatal supervision. 58 APPENDIX VI.—SUMMARY OF INFANT MORTALITY STATISTICS. Two five year period figures are taken—five years pre war and five years to 1925. Years, Total. Births I.M.R. Total Infant Deaths. Age at Death. Maternal Deaths. Deaths under I week. Deaths 1 week to 4 weeks. Deaths 4 weeks to 1 year. Sepsis. Other. 1910 647 60 39 9 8 22 - 2 1911 049 74 49 15 7 27 2 3 1912 660 60 41 J3 9 19 0 0 I913 613 84 52 10 8 34 0 0 1914 617 6l 39 14 9 16 1 1 1910—1914 3186 68 220 61 41 118 3 6 1921 624 60 38 10 9 19 1 1 1922 575 74 43 19 7 17 2 2 1923 578 60 35 13 3 19 1 0 1924 535 58 31 11 4 16 1 3 1925 520 58 30 11 3 16 1 2 1921 — 1925 2832 62 177 64 26 87 6 8 On these figures the following facts are shown— 1—Decrease in the number of births. 2—Reduction of Infantile Mortality Rates, The fall occurs chiefly in the period over 4 weeks of age. 3—Increase in the deaths of infants under 1 week of age. Rate 1910-1914, 28 percent, of deaths. Rate 1921-1925, 33 per cent. of deaths. 4—Increase in maternal deaths. Rate 1910-1914, 2.7 per 1,000 births. Rate 1921-1925, 4.9 per 1,000 births. 59 APPENDIX VII. Summary of Visits of Sanitary Inspectors. Housing— Under Inspection of District Regulations 442 No defects found 150 Requiring notices 292 On Complaint 205 Re Infectious Disease 128 For Disinfection purposes 40 Under Rent Restriction Act 1 Trade Premises— Factories and Workshops 51 Under Shops Acts 547 Under Petroleum Acts 147 Food Preparing Places— Slaughterhouses 343 Bakehouses 66 Hotels and Restaurants 2 Ice Cream Premises — Dairies, Cowsheds and Milkshops 119 Others (butchers' premises, etc.) 51 Sundry other premises— Elementary Schools 26 Common Lodging-houses 2 Tents, Vans and Sheds — Miscellaneous Visits— Stream 7 Piggeries 2 Smoke 3 Miscellaneous 744 Other Inspections and Revisits 2,130 Total 5,056 60 APPENDIX VIII. Nuisances Abated. Drainage— House drains relaid or repaired 32 House drains unstopped 58 W.C.'s renewed or repaired 147 Soil-pipes, vent pipes repaired 12 Cesspools emptied 3 Dampness— Roofs, rain water pipes, gutters renewed or repaired 408 Damp course renewed or repaired 21 Brickwork, pointing, etc., renewed or repaired 58 General— Sinks renewed or repaired 17 Sink waste pipes repaired 25 Rooms cleansed 738 Floors renewed or repaired 135 Windows 342 Doors ,, ,, 52 Yard Paving ,, 50 Stoves ,, ,, 152 Coppers ,, ,, 28 New dustbins provided 101 Overcrowding 6 Plasterings 84 Miscellaneous 120 Water Supply— Water cisterns renewed or repaired 9 Water fittings 12 61 Accumulations, etc.— Animals— Nuisance from keeping of 1 ,, ,, ,, Pigs 4 Food-Preparing Places— Dairies, etc., cleansing and limewashing, etc. 25 Bakehouses, ,, ,, 34 Slaughterhouses, ,, ,, 11 Slaughterhouse paving provided 1 Others cleansed 4 Sundries— Workshops cleansed 1 Smoke nuisance 1 Total 2,809 62 APPENDIX IX.—Return of Notifiable Infectious Diseases, 1925, Disease. WORD. Total. Attack rate per 1000. Cases to Hospital No of Deaths. Death Rate. Plaistow Martin's Hill. Town Sundridge Bickley. Promley Common. Scarlet Fever 8 1 4 4 11 4 32 .9 30 ... ... Diphtheria ... 2 1 3 4 7 17 .4 17 ... ... Erysipelas 2 ... 1 1 ... 3 7 .1 ... ... ... Puerperal Fever ... ... ... ... ... 1 1 .02 1 1 .02 Acute Influenzal Pneumonia 1 1 ... 3 ... 2 7 .1 1 22 .6 Acute Primary Pneumonia 4 5 7 3 1 9 29 .8 5 Ophthalmia Neonatorum 2 ... ... 1 ... ... 3 .08 ... ... ... Malaria (contracted abroad) ... 1 ... 1 ... ... 2 .05 ... ... ... Cerebro-spinal Fever ... ... 1 ... 1 1 3 .08 2 Encephalitis Lethargica ... ... ... ... 1 ... 1 .02 ... ... ... Acute Poliomyelitis 1 ... 1 ... ... ... 2 .05 2 t.B. Lungs 4 6 6 5 6 11 38 1.07 ... 21 .5 T. B. Other 3 1 1 3 2 7 17 .4 ... 6 .16 63 APPENDIX X.—Tuberculosis. New Cases and Mortality during 1925. Age Periods. New cases notified or otherwise revealed. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. m. F. M. f. M. f. m. F. 0 ... ... ... ... ... ... ... ... 1 ... ... 2 2 ... ... 1 ... 5 1 ... 2 4 ... ... ... ... 10 ... ... 4 1 ... 1 1 1 15 1 3 ... ... ... ... ... 1 20 4 5 ... 1 ... 4 ... ... 25 4 8 ... ... 4 2 ... ... 35 4 2 ... 1 3 1 ... ... 405 1 4 ... ... 4 1 ... ... 55 1 ... ... ... 1 ... ... ... 65 and upwards ... ... ... ... ... ... ... ... Totals 16 22 8 9 12 9 2 2 APPENDIX Xa.—Ophthalmia Neonatorum, 1925. Cases. Vision unimpaired Vision impaired. Total Blindness. Deaths. Notified. Treated. At Home In Hospital 3 2 1 3 ... ... ... 64 APPENDIX XI.—Summary of Health Visitors' Work, 1925. Month. Primary. Revisits under 1 year. Revisits over 1 year. Expectant Mothers. Special Circumstances Deaths. Stillbirths. Tuberculosis. Measles Total. January 39 48 200 2 40 4 ... 3 2 338 February 23 63 241 7 27 ... ... 8 8 377 March 29 61 216 3 31 2 ... 10 ... 352 April 33 101 245 1 38 1 2 14 ... 435 May 27 140 188 6 31 4 1 3 ... 400 June 29 119 138 1 18 ... 1 9 ... 315 July 49 96 187 4 59 3 ... 8 ... 406 August 34 45 130 ... 17 ... ... ... ... 226 September 33 88 238 1 31 ... 1 5 ... 397 October 41 75 242 4 44 3 ... 4 ... 413 November 29 76 190 9 28 4 ... 4 ... 340 December 43 53 124 6 02 5 2 4 ... 299 Total 409 965 2339 44 426 26 7 72 10 4298 65 APPENDIX XII.—Welfare Centres—Attendances 1925. PLAISTOW. WIDMORE. SHORTLANDS. BROMLEY COMMON. A. N. CLINIC. M. Av B. Av. Cn. Av Cl. M. Av. B. Av. Cn Av. Cl. M. Av B. Av. Cn. Av Cl. M Av. B. Av. Cn. Av. Cl. M. Cn. Cl Jan. 167 56 170 56 25 8 3 140 35 174 43 42 10 4 137 34 161 40 33 8 4 3 3 1 Feb. 154 38 163 41 33 8 4 139 35 '57 39 30 7 4 144 36 174 43 33 8 4 13 10 1 Mar. 163 41 159 40 29 7 4 155 39 170 42 35 9 4 163 41 208 52 31 8 4 7 7 1 Ap. 193 39 206 41 25 5 5 144 29 177 35 38 7 5 99 25 115 29 35 9 4 178 44 214 53 25 6 4 6 4 1 May 153 38 152 38 23 6 4 111 28 128 32 24 6 4 63 21 72 24 19 6 3 164 41 212 53 34 8 4 13 13 1 June 169 42 191 48 30 7 4 125 31 136 34 23 6 4 66 l6 85 21 18 4 4 173 43 210 52 42 10 4 6 6 1 July 181 40 181 45 24 5 4 140 186 41 10 78 100 11 10 206 259 29 10 8 8 1 Aug. 182 40 229 45 35 17 5 117 157 23 71 94 12 181 237 31 — Sept. 180 45 171 43 30 15 4 115 29 141 35 40 13 4 91 23 107 27 26 13 4 164 41 218 54 42 14 4 6 6 1 Oct. 193 48 191 48 29 14 4 115 29 141 35 18 9 4 97 24 117 29 19 9 4 182 45 226 56 31 15 4 4 4 1 Nov. 179 45 172 43 26 13 4 126 31 148 37 18 9 4 105 26 131 33 20 10 4 183 46 232 58 26 13 4 14 8 Dec . 226 38 227 38 18 9 6 155 31 193 38 16 5 5 132 26 162 32 21 7 5 135 34 156 39 20 10 4 9 9 2140 42 2212 43 327 8 51 1582 30 1908 37 348 10 52 802 21 983 26 181 6 38 2010 40 2507 50 378 9 50 89 78 11 Mr—Mothers. Av. — Average. B.—Babies. Cn. — Medical consultations. Cl. - C linics. A. N. Clinic—Ante-Natal Clinic, From August 1st the medical °ssions were held fortnightly, 66 APPENDIX XIII. Factories, Workshops and Workplaces. 1.—Inspection of Factories, Workshops and Workplaces. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. Factories (Including Factory Laundries) 51 5 - Workshops (Including Workshop Laundries) 66 34 — Workplaces (Other than Outworkers' premises) 53 4 — Total 170 43 — II.—Defects found in Factories, Workshops and Workplaces. Particulars. Number of Defects. Number of offences in respect to which Proseutions were instituted. Found. Remedied Referred to H.M Inspector. Nuisances under the Public Health Acts*— Want of cleanliness 17 17 Want of ventilation Overcrowding Want of drainage of floors Other nuisances 8 8 Sanitary accommodation. insufficient 6 6 unsuitable or defective 10 10 not separate for sexes 2 2 Offences under the Factory and Workshop Acts Illegal occupation of underground bakehouse (s.101) Other offences (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order. 1921). 43 43 — — Total Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable tinder the Public Health Acts. 67 APPENDIX XIV. Housing Statistics for the Year 1925. Number of new houses erected during the year— (a) Total 136 (b) With State assistance under the Housing Acts: (i.) By the Local Authority — (ii.) By other bodies or persons — 1. Unfit Dwelling-houses. Inspection—(1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 776 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910, or the Housing Consolidated Regulations, 1925 442 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil. (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 526 2. Remedy of defects without Service of formal Notices— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 403 3. Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925— (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil. 68 (2) Number of dwelling-houses which were rendered fit after service of formal notices— (a) By owners Nil. (b) By Local Authority in default of owners Nil. (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil. B.—Proceedings under Public Health Acts. (1) Number of Dwelling-houses in respect of which notices were served requiring defects to be remedied 123 (2) Number of dwelling-houses in which fects were remedied after service of formal notices:— (a) By owners 123 (b) By Local Authority in default of owners — C.—Proceedings under Sections 11, 14, and 15 of the Housing Act, 1925— (1) Number of representations made with a view to the making of Closing Orders Nil. (2) Number of dwelling-houses in respect of which Closing Orders were made Nil. (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit Nil. (4) Number of dwelling-houses in respect of which Demolition Orders were made Nil. (5) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil.