AC 144 12 (1) Bromley Borough of Bromley. ANNUAL REPORT MEDICAL OFFICER OF HEALTH SCHOOL MEDICAL OFFICER For 1930. K. E. TAPPER O.B.E. M B., Gh,B, D.P.H. Bromley: Printed by Bromley Printing Co., Sherman Road Borough of Bromley. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For 1930. K. E. TAPPER O.B.E., M.B., Ch.B., D.P.H. BROMLEY: Printed by Bromley Printing Co., Sherman Road. MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1930-1931. HEALTH COMMITTEE:— Alderman E. Ford Duncanson, d.s.c., m.a., j.p. (Chairman). Councillor E. J. Heilbron (Vice-Chairman). Members:— His Worship the Mayor. Councillor H. Forbes White, j.p. Councillor G. Allen. Councillor A. Mcintosh. Councillor G. Reed. Councillor W. F. Skilton. Councillor M. Stafford Smith, m.b.e., b.a. Councillor F. Wood. MATERNITY AND CHILD WELFARE COMMITTEE Councillor M. Stafford Smith, m.b.e., b.a. (Chairman). Councillor E. J. Heilbron (Vice-Chairman). Members:— His Worship the Mayor. Councillor H. Forbes White, j.p. Alderman E. Ford Duncanson, d.s.c., m.a., j.p. Councillor F. B. Humphrey. Counpillor A. Mcintosh. Councillor G. Reed. Councillor W. F. Skilton. Councillor F. Wood. Co-opted Members:— Mrs. A. M. Howe. Mrs. A. G. Mann, b.a., j.p. Miss E. M. Thompson. Miss V. Vincent. Mrs. E. Yolland. Borough of Bromley. Report of the Medical Officer of Health for the Year 1930. To the Mayor, Aldermen and Councillors. Mr. Mayor, Madam and Gentlemen, I have the honour to submit the Annual Report upon the health of the Borough of Bromley for the Year, 1930. From the point of view of Local Government, 1930 will stand out as an important landmark in the changes that have occurred as a consequence of the coming into practice of the Local Government Act, 1929. Bromley has been little affected by this Act, except that one had hoped for a little more concentration of local public health government, whereas the Act conferred upon district councils such small matters as the administration of Part I of the Children Act, 1908, a work which was already being performed in Bromley by arrangement with the previous Poor Law Authority. The effects of the Local Government Act are not yet fully operative. Certainly the transfer of the Poor Law to the Public Health Authority has done away with, in many areas, the anomaly of two local authorities in one area. The effect of the Act on Bromley's Local Government of Public Health has been advantageous in one direction at least, that the power was given us to act as the Local Authority under the Midwives Acts. This was obtained only after a Local Enquiry, and strong opposition from the County Council. It must be obvious that the Maternity and Child Welfare Authority should be the authority for the administration of the Midwives Acts, and yet there are many authorities throughout England who have been unsuccessful in their applications. Local Public Health government is so much dependent upon the personal contact with the individual that government from a distance must be less effective and more costly than government locally. 4 The year under review saw also the introduction of another important Act—the Housing Act, 1930,—one of the provisions of which requires local authorities to submit to the Minister of Health a statement of their programmes to improve the housing conditions of their areas during the next five years—an effort to abolish the slums. As far as Bromley is concerned the housing conditions are excellent. We have no "slums" to compare with those of many of the large industrial areas in England. A short report on the housing conditions of Bromley appears in the text of the Report. To come to more local conditions during 1930—conditions which are more fully dealt with in the report—perhaps the most important one which requires recording is the Small-pox epidemic, which reached Bromley in February of the year. This necessitated the full energies of the staff of the Health Department to be concentrated on the control of the infection, and much of the routine work such as home visiting under the Maternity and Child Welfare service, inspection of district, etc., suffered as a consequence. The daily examination of hundreds of contacts cannot be performed without routine work suffering. In October we began the supervision of midwives, a work which is already showing the importance of this duty being placed upon Maternity and Child Welfare authorities. The year saw the first step in the amalgamation of the district nursing associations in the Borough, so that gradually within the Borough, administration is being unified and localised, with the result that two active public health functions remain outside local supervision, the County schemes for Tuberculosis and vaccination. The fact that a member of the health visiting staff attends the Tuberculosis Dispensary does assist in the co-operation of the work. The medical inspection of secondary schools in the Borough has not yet been transferred to this Local Authority. The School Medical Report appears again under the same cover as the Annual Health Report; the whole service is one in practice as it is one in theory. We cannot, if we are to promote a healthy people, divorce the services. 5 It is the sole object of all local government that the civic worth of the individual be maintained; the pauper, the mentally defective and the inebriate have no civic worth and yet much civic money is spent on them. Unfortunately, these classes are, as a rule, highly fertile, and unless some form of control is placed upon their fertility, money spent will continue to be ineffective. It is true that the life of a nation is built up from below, and it must be a happy indication that the lower social scales are showing marked improvement, not only physically, but socially. The School Medical Report brings this matter clearly before us, for the elementary school child to-day is a vast improvement on the elementary school child of even 30 years ago. The sanitation and care of the homes have improved be yond measure; the sanitation of schools has reached a high level, but some of them still are far from being model exhibits. Personal hygiene which has been consistently taught for years in schools, in the Maternity and Child Welfare, School Medical Services, and in all Public Health services, is bringing about the daily practice of hygiene in all spheres. Agreed that matters are not yet ideal; we still have roller towels in schools, unprotected foodstuffs in our shops and markets, and one still finds the occasionally neglectful housewife, but vast improvements have already occurred in the past 30 years, and if the next 30 years bring a like improvement, the public health officers will no longer be accused of being idealists. I would again wish to acknowledge the excellent help and co-operation I have received from each member of the staff, and especially from Mr. Woods and Mr. Lawley, who have helped so much in preparing this Report. During 1930 we lost two valuable members, Dr. Sands, the Assistant Medical Officer of Health, and Miss E. McAllester, Health Visitor, both of whom left us to be married, after giving long periods of excellent work in the Public Health Service of Bromley. I am, Mr. Mayor, Madam and Gentlemen, Your obedient Servant, K. E. TAPPER. Medical Officer of Health. 6 PUBLIC HEALTH STAFF, 1930. Medical Officer of Health and School Medical Officer Assistant Medical Officer of Health and School Medical Officer Orthopaedic Specialist Throat and Nose Specialist School Dental Surgeon Senior Sanitary Inspector Second Sanitary Inspector Health Visitors and School Nurses Orthopaedic Nurse Veterinary Surgeon under Diseases of Animals Act Inspector under Diseases of Animals Acts 2 K. E. Tapper, o.b.e., m.b., ch.b., d.p.h. 2 Miss Marjorie Reekie, m.b., ch.b., d.p.h. (Appointed 13/11/1930 2 Miss Margaret Sands, m.b., ch.b., d.p.h. (Resigned 10/6/1930). 21J. B. Barnett, f.r.c.s., l.r.c.p. 2 1 Charles C. Beney, ma., m.r.c.s., l.r.c.p. 2 T. S. Latham, l.d.s., r.c.s. 5 4 3 2 G. R. Woods, m.s.i.a., a.r.s.i. 4 3 2 T.C. Towersey, m.s.i.a. 762 Miss L. A. Briggs, s.r.n. 8762 Miss E. B. Crowe, s.r.n. 7 8 2 Miss S. M. Davies. s.r.n. 8 7 6 2 Miss W. Luxmoore, s.r.n. (Appointed 5/8/1930). 72 Miss V. Morgan. 762 Miss E. McAllester, s.r.n. (Resigned 30/6/1930). 21 Miss D. Gardner, c.s.m.m.g., m.e. 1 P. J. Turner, m.r.c.v.s. 1 Alfred H. Sly. Since this Report was compiled the Preliminary Repoit of the Census, 1931, has been published giving the following information:— POPULATION. Males. Females. Total. BROMLEY 20,107 25,241 45,348 This is an increase of 29.4 per cent. over the population of 1921 Census (35,052), an increase in the number of persons of 10,296, and makes Bromley, next to Gillingham. the largest town in Kent. It is to be noted that the Vital Rates and Statistics in this Annual Report are based on the 1929 mid-year population figure, viz., 41,840. 7 HEALTH DEPARTMENT—continued. Senior Clerk 2 H. E. Lawley. Junior Clerks 2 Miss M. L. Byford. 2 Miss M. H. Davis. 2 H. Handscomb (Appointed 20/10/1930). 2 J. G. Cox (Resigned 13/9/1930) Outdoor Staff: Drain Tester, Disinfector, and Market Toll Collector H. Deane. 1 Denotes part-time Officers. 2 Exchequer Grants (including Board of Education Grant). 3 Certificate of Royal Sanitary Institute and Sanitary Inspectors Joint Examination Board. 4 Royal San. Inst.. Certificate for Meat and Other Foods. 5 Royal San. Inst., Smoke Certificate. 6 Three years' hospital trained. 7 C M,B. 8 Royal San. Inst., new Health Visitors' Certificate (Under Memo 101/MCW). STATISTICS, 1930. Area (in acres) 4,697 Population (1921 Census) 35,052 Population (1929 mid-year) 41,840 Inhabited houses (1921 Census) 7,400 Private families 8,400 Rateable value (1st April, 1931) £462,660 Estimated product of a penny rate (1st April. 1931) £1.885 Live Births— Total. Male. Female. Legitimate 607 299 308 Illegitimate 22 9 13 Birth Rate 15.03 Still-Births— 17 8 9 Rate per 1,000 total Births—27 Deaths— 429 200 229 Death Rate 10.2 8 No. of women dying in, or in consequence of, child birth— from sepsis 1 from other causes 1 Death Rate of infants under one year of age per 1,000 births— Legitimate—41. Illegitimate—45. Total—41. Deaths from measles (all ages) 3. Deaths from whooping cough (all ages) 1. Deaths from diarrhoea (under 2 years of age) 4. I .—SOCIAL CIRCUMSTANCES. Bromley is situated on gravel soil at an altitude of 200 feet above sea level. The town is ten miles from the City of London on the main road to the sea coast. During the town's rapid development within the past decade it has still retained its characteristics as a first class residential centre. There is no staple industry, but the town holds the important position of being the shopping centre for the large surrounding residential area. The records of the Climatological Station at Church House include the following information for 1930:— Total rainfall 27.13 inches. Mean maximum daily temperature 57.1 degrees. Mean minimum daily temperature 43.7 degrees. The highest maximum recorded was 90 degrees on the 28th and 29th August, and the lowest minimum recorded was 22 on 17th November. The lowest grass minimum was 17 on 17th November. Occupations. The principal occupations in the Borough, based on the Census Return of 1921, are as follows:— General Science 3,692 Commercial and Insurance 2,316 Clerks, Draughtsmen 1,682 Transport and Communication 1,417 Professional 1,078 Textile Goods and Dyes 605 Agricultural 699 9 Unemployment. I am indebted to the Manager of the Employment Exchange for the following information:— (1) Recorded unemployment at the Exchange on 31st December, 1930: Adult Males 602 „ Females 192 Total 794 (2) The highest normal figure reached in 1930: Males 635 Females 192 The figures are much heavier than those in 1929, and are of course accounted for by the general trade depression throughout the world. Population. The Census of 1921 gave the population as 35,052. The Registrar General estimated the population two years ago (mid-year) as 41,840. The Census figures for 1931 are not yet available, but taking the number of occupied houses in December, 1930, and allowing a low average number in the family at 4, we get the population figure as 43,412. This is of course a purely estimated figure and is not used in the calculation of the vital rates, which have been calculated on the figure given for mid-year 1929. The rates are thus higher than the true rates to be calculated on the Census figure. Being within the Greater London area, Bromley population is in a state of flux. The extension of building estates in areas of a rural character naturally affects not only the population but the type of inhabitant of the area. Bromley is not so largely affected as are neighbouring authorities, but during the last ten years the changes are obvious. What the future ten years will bring forward is unknown, but a Town Planning Scheme which includes four houses to the acre must make Bromley always a highly 10 desirable residential area. This must be the prime factor when considering the building of houses by the Corporation, that the type of house built must be in accordance with the character of the district. Poor Law Relief. The Public Assistance Committee distributed in outdoor relief in Bromley during the financial year 1930:— In money £4,188 0 0 In kind £ 358 3 9 £4,546 3 9 II.—VITAL STATISTICS. Births. The number of births registered during 1930 were 629, producing a rate of 15.03, which is a slight increase over the rate for 1929. The rate for the whole of England and Wales for 1930 is 16.3, and for London 15.7. The following table shows Bromley's annual birth rates for the past ten years in comparison with the rates for England and Wales:— Birth Rates. Year. Bromley. England and Wales. 1921 17.9 22.4 1922 16.5 20.6 1923 16.5 19.7 1924 15.1 18.8 1925 14.6 18.3 1926 14.8 17.8 1927 14.9 16.7 1928 15.9 16.7 1929 14.8 16.3 1930 15.03 16.3 Still-Births. Seventeen still-births were registered in 1930, of which eight were males and nine females. This is a reduction of six compared with 1929. 11 During the past five years the number of still-births occurring in Bromley is shown in the following figures:— Year. Still-Births. Bate per 1,000 Births. 1926 10 18.6 1927 16 25.2 1928 10 15.3 1929 23 36.8 1930 17 27.0 It is to be noted that the Births and Deaths Registration Act, 1926, which came into operation in July, 1927, requires the registration of still-births with the Registrar of Births and Deaths. Interference with pregnancy is becoming more and more common, and is in my view partly due to the undue publicity given to Birth Control. Birth Control is a medical matter not to be left in the hands of indiscriminating persons. The public extend the interpretation of Birth Control to one of interference with pregnancy, and we therefore get an undue proportion of still-births, neo-natal deaths, and even maternal morbidity. Deaths. Four hundred and twenty-nine deaths were registered during the year of which 200 were males and 229 females. This figure is 61 less than the total deaths for 1929. The Death Rate for 1930 is 10.2 as compared with 11.4 for England and Wales. The crude Death Rates for Bromley during the past decade are compared with the rates for England and Wales during the same period in the following tabulation:— Year. Bromley. Crude Death Rate. England and Wales. Death Rate. 1921 11.08 12.1 1922 11.8 12.9 1923 10.5 11.6 1924 11.1 12.2 1925 10.3 12.2 1926 10.04 11.6 1927 10.8 12.3 1928 10.8 11.7 1929 11.7 13.4 1930 10.2 11.4 12 In the comparison of Death Rates it is important to realise that the age grouping and sex distribution of the population must be taken into consideration, for it naturally follows that a population of the higher age groups must have a higher Death Rate than a population of the middle or younger age groups, unless of course epidemic disease in severe form has occurred during the year. 1930 was comparatively free of any such disease. The causes of deaths are shown in Appendix III from which the main causes have been extracted as follows:— No. of deaths. Rate per cent. of total deaths. Rate per 1,000 population. Respiratory Disease 31 7.2 0.7 Heart Disease 104 24.2 2.4 Cancer 69 16.08 1.6 Tuberculosis 41 9.5 0.9 Premature Births and Congenital Debility 16 3.7 0.3 Infectious Diseases 5 1.1 0.1 Influenza 3 0.7 0.07 On comparison with the figures of previous year (1929) the fact emerges that increases have occurred in Cancer, Tuberculosis and Premature Births, and reductions have occurred in the remaining main causes, particularly Respiratory Diseases and Influenza. The main causes of deaths recorded during the past five years are:— 1926 1927 1928 1929 1930 Total. Percentage of all deaths. Respiratory Disease 58 74 48 72 31 293 13.6 Heart Disease 76 60 85 109 104 434 20.2 Cancer 38 57 68 65 69 297 13.8 Tuberculosis 27 30 35 28 41 161 7.5 Prematurity, etc. 8 14 19 8 16 65 3.03 Infectious Diseases 4 2 12 10 5 33 1.07 Influenza 4 17 6 14 3 44 2.05 The high return of Heart Disease includes the majority of deaths from old age, and is not to be taken as a primary cause of death. Influenza plays an important part in the 13 deaths from Respiratory Diseases, and where Influenza deaths are few there is a fall from Respiratory Disease. Cancer during the past five years has remained at a stationary rate in Bromley. Infantile Mortality. During the year 26 deaths of infants under one year of age were registered. This figure is three less than the previous year, and gives a Mortality Rate of 41 per 1,000 births. It is satisfactory to record that the lowering of the rate is still maintained, and the rate for 1930 ranks next to the lowest recorded rate for Bromley of 33.5 in 1926. The following table gives comparison rates for Bromley and England and Wales during the past ten years:— Year. Bromley. England and Wales. 1921 60 83 1922 74 77 1923 60 69 1924 58 75 1925 57 75 1926 33 70 1927 50 69 1928 49 65 1929 46 74 1930 41 60 The average Infantile. Mortality Rate for the past fire years is 44 per 1,000 births, as compared with 62 per 1,000 of the previous five years, and 77 of the fire years ending 1920. Appendix IV gives detailed statistics of the causes of Infantile Mortality during 1930, and by reference thereto it will be seen that 11 babies died before completing the first week of life, and a further four babies died before the end of the first month. Two of these latter cases resulted because of maternal inefficiency; one of the remedial social conditions that play important parts in the deaths of the tender infants. The employment of unqualified persons as maternity nurses tends not only to faculty teaching of the young mother, hut does not give an ailing baby the attention it requires. 14 Statistics prove that the deaths of "welfare" babies are less than the deaths of "non-welfare" babies. This may be because the negligent mother who "does not hold with welfares" also "does not hold with the principles of sound mothercraft. The fall in the Infantile Mortality Rate in Bromley during recent years is a remarkable one. It has fallen from an average rate of 120 in 1896-1900 to 44 for the years 1926-1930. Some of the credit for this must be granted to the Public Health Service in Bromley. And yet everything is not all as it should be. A close study of the statistics shows that there has not been a corresponding improvement in the death rate of the new born under one week of age, and during the past jive years there has been an annual increase in the rate of baby deaths during the period 1-4 weeks, which appears to be due to deaths from Respiratory Disease. There is a further interesting fact in the figures for Bromley; the deaths from Respiratory Disease corresponds not with the Respiratory Disease Rate in adults, but with the Influenza Rate in adults. It would therefore follow that the cause of death in infants is primarily Influenza and not primarily Respiratory Disease. Of the baby deaths during the past five years, 19261930, 21 per cent. were due to Respiratory Diseases, 19 per cent. to Premature Births, 17 per cent. to Debility at birth, 11 per cent. to Gastritis and Enteritis and only 3 per cent. to Infectious Diseases. 28 per cent. were due to other causes. From these figures it would appear that no less than 36 per cent. of deaths of babies are due to some ante-natal or natal condition in the mother. This shows that there is an actual rise in the proportion of deaths at the age " under one week. The following table gives the age at deaths duringfive yearly periods recorded in proportion of baby deaths during the same period. 1910-1914. 1921-1925. 1926-1930. Total baby deaths 220 177 134 Proportion of deaths. Under 1 week 28% 36 % 38% 1 to 4 weeks 19% 14 % 10% 4 weeks to 1 year 53% 50% 52% 15 During the year the Report of the Departmental Committee on Maternal Mortality was published. This Report brings before public authorities the main causes of Maternal Mortality. It showed that 48 per cent. of deaths of mothers was due to preventable causes: (1) 17 per cent. lack of ante-natal care, (2) 17 per cent. errors of judgment by doctors and midwives, (3) 5 per cent. lack of facilities for medical care, and (4) 9 per cent. negligence of patient or friends. Statistics are apt to err, and are often misleading, but if we accept the above statistics as true facts it must bring before us the great need for effort in this field of preventive medicine. There has been much criticism of the effectiveness of ante-natal care, but much of this criticism is biassed. Child Welfare underwent the same criticism in its early days because results were not immediate. To-day criticism of Maternity and Child Welfare is silent because results have far exceeded the most sanguine of hopes. Maternal Mortality in Bromley is at the rate of four per 1,000 births; a rate that must be combatted by all the machinery available. If the Death Rate of mothers is so high, what must he the illness rate as a result of ill-managed pregnancy? Every mother is entitled to expert skill and attention throughout pregnancy, and yet we lack adequate maternity hospital accommodation, and we allow unqualified persons to he in attendance at birth. It is my view that maternity hospitals should be part and parcel of the Maternity and Child Welfare service, and that hospital accommodation should always be available for the medically necessitous case, whether ante-natal, natal or post-natal. There is a Maternal Mortality. MATERNAL DEATHS. Years. Sepsis. Accidents of pregnancy, etc. Rate per 1,000. births. 1911-1915 4 5 2 1916-1920 9 9 6 1921-1925 6 7 4 1926-1930 4 6 3 23 27 4 16 growing demand for confinements to take place in maternity homes rather than under the inadequate facilities usually available at the patient's house. This being so, maternity home accommodation for the necessitous patient in Bromley has become inadequate. An important factor in our services in the prevention of Maternal Mortality has been the transfer in 1930 of supervision of midwives to the Maternity and Child Welfare Committee. This unifies control and cannot but lead to more effective results, and prevent much overlapping that previously occurred. III.—MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare Services consist of the following:— 1. Five Health Visitors who are employed half-time on School Medical duties. They attend the centres and carry out the teaching of mother craft in the homes. 2. Six welfare centres are held weekly, with a doctor in attendance. 3. Ante-Natal Clinics are held twice monthly. 4. Maternity Hospital provision for necessitous cases. 5. Home visiting of boarded-out children under the Children Act, 1908—Part I. 6. Free milk for necessitous cases. 7. Orthopaedic treatment and Consulting Surgeon for the crippled child. 8. Minor ailment treatment. Ear, nose and throat Consultant and Surgeon. 9. Dental treatment for the expectant mother, or nursing mother, and children under five years of age. 10. Provision of hospital treatment for cases of Ophthalmia Neonatorum, and for acute complicated cases of Measles under five years of age. 11. Hospital treatment, isolation, and Consulting Gynaecologist for Puerperal Fever and Puerperal Pyrexia cases. 17 Child Welfare Centres. Widmore— Wesleyan New Hall, Tylney Road. Tuesdays, 2.30 p.m. Burnt Ash— Burnt Ash Branch Library, Burnt Ash Lane. Wednesdays, do. Plaistow— School Clinic, Station Road. Wednesdays, do. Shortlands— Congregational Hall, Martins Road. Thursdays, do. Bromley Common— St. Luke's Institute, Raglan Road Friday, do. Ante-Natal Clinics. Held at the Clinic, Station Road, on first and third Thursdays in every month, at 2.30 p.m. Orthopaedic Clinic. For children with crippling defects under five years of age, as well as school children. Held at the School Clinic, Station Road. Mondays at 9.30 a.m. Tuesdays at 9.30 a.m. Massage Thursdays at 9.30 a.m. Fridays at 12 noon. A Consulting Surgeon attends on the first Monday (afternoon), and third Tuesday (morning) in each month. Artificial Sunlight Clinic. Held at the School Clinic twice weekly: Tuesdays at 2.30 p.m. and Fridays at 2.30 p.m. Speech Clinic. Held at the School Clinic on Mondays at 9.30 a.m. 18 Dental Clinic. Held at the School Clinic daily for children, and expectant mothers and nursing: mothers attend on Saturdays at 9.30 a.m. Diphtheria Immunisation Clinic. Held at the School Clinic 011 Mondays at 2.30 p.m. Voluntary Work. It would be convenient at this point in the Report to pay a tribute of commendation to the valuable services the voluntary workers continue to render at all the Centres and Clinics. Without their assistance the social aspect of the work would press heavily on the permanent professional staff, and it is only with the help of the voluntary workers that the work of the Centres can be carried out in its entirety. No less than sixty-two ladies engage in this work either at the Welfare Centres or the School Clinic. Ante-Natal Clinic. COMPARATIVE TABLES OF ATTENDANCES AT ANTE-NATAL CLINIC. Year. Attendances. Medical. Consultations. Sessions. held. 1922 32 26 4 1923 73 73 11 1924 51 51 12 1925 89 78 11 1926 90 90 14 1927 164 164 23 1928 184 184 23 1929 212 212 24 1930 235 233 24 This growth of Ante-Natal practice is indicative of the needs of the day. The women who attend include those who come independently without having made arrangements for midwife, doctor or hospital. Others are referred by midwives and health visitors, and are kept under observation until adequate arrangements have been made for their confinements, or the defective physical and environmental conditions have been remedied. 19 Patients are examined and reported upon to the doctor or midwife engaged. The Clinic also serves as a school for expectant mothers, where expert advice on mothercraft can be given freely. Guidance is given on the hygienic outfit for the coming child, and the young mother is taught the fundamentals of baity care. I am confident that the work of instruction at Ante-Natal Clinics is invaluable, and that without such provision Ante-Natal care would not be safeguarded. The foregoing statistical table shows that an increasing use is being made of the Clinics. One hundred and nineteen individual mothers attended of whom 35 were referred to Maternity Hospitals on physical grounds, or because the home environment did not permit of the possibility of safe confinement. Fifteen of these cases were financially assisted to the Maternity Hospital. Nineteen per cent, of expectant mothers in Bromley attend the Ante-Natal Clinic, and the remainder are under the Ante-Natal supervision of the mid-wife, doctor or maternity nurse. In addition to the Clinic, home visitation of the expectant mother is carried out by the health visitors, midwives and by the district nursing associations. In 1930 the health visitors paid 321 home visits to expectant mothers, while the nursing associations through their own midwives paid 970 visits. Natal Services. Attendance at Birth. Six hundred and thirty-one live births and 16 stillbirths were notified under the Notification of Births Act, 1907. In addition there were 21 "unnotified" births discovered through the Registrars' returns. The births occurring in the Borough were notified as follows:— Notified by midwives 255 Notified by doctors and parents 392 " Un-notified " 21 668 20 In another part of this Report it will be noted that 17 still-births are given as registered, whereas 16 were notified. This apparent discrepancy may be accounted for in that the Registrar General's review does not cover exactly the same period covered for local statistics. After adjusting the total of 668 births in relation to inward and outward transfers, and not including still-births, the nett total of births for the area in 1930 has been calculated by the Registrar General at 629. Forty per cent, of births in Bromley are attended by midwives acting as midwives. The employment of the self styled "maternity nurse" untrained in general nursing or midwifery, is to be strongly discouraged, as not only do they tend to exceed their duty, but it is known that once they have made themselves popular with the public they discourage the services of the skilled person at birth. This state of Natal service requires to be definitely controlled by law—registration and supervision is the least that should be required. The nursing staff of the Bromley and District Nursing Association paid 2,962 maternity and midwifery visits, undertook 137 midwifery cases and 59 cases with doctors. Midwives. The number of midwives practising in the area served by the Council for Maternity and Child Welfare at the end of the year was 21. Of this number seven were in the service of nursing associations, and 14 in maternity homes and private practice. None are employed, or subsidised by the Council. The number of cases attended by midwives during the year was (1) as midwives 255, and (2) as maternity nurses 301. The attendance at births of midwives only is to be encouraged. It is only proper that a physiological process, such as a normal confinement, requires no interference, and should be left while it remains normal in the hands of the skilled midwife. Only the abnormal case need be referred to tbe doctor. The payment made to midwives is in my view too low for the skilled attention given, and the 21 question of the establishment of the service, much in the same way as the establishment of health visitors, appears to be the direction a proper national midwifery service should take. Administration of the Midwives Acts, 1902-1926. A local inquiry was held in Bromley by the Ministry of Health following on our application for the duties under the above-mentioned Acts to be transferred under Section 62 of the Local Government Act, 1929. The transfer was opposed by the Kent County Council, but our application was upheld by the Ministry of Health, and the Council became the Local Supervising Authority as from the 1st October, 1930. This Report covers only three months of the operation of this Act by Bromley: No. of midwives practising in Bromley, August, 1930 18 No. of midwives giving notice of intention to practice during the period October/December, 1930 4 No. of midwives removed from local register having left the district 1 Notifications Received. Notices of calling medical aid—mothers 8 ,, ,, liability to be a source of infection 2 Inspection of Midwifes. Inspections by Inspector of Midwives 31 Summary of Reasons of Sending for Medical Help. Delayed labour 2 Abnormal labour 1 Ruptured perineum 3 Severe haemorrhoids 1 Ante-partum haemorrhage 1 22 During the period October/December it was necessary temporarily to suspend from practice one midwife because of liability to spread infection. It was not necessary to pay compensation for this suspension. One finds that being the Authority for the supervision of midwives that the work can be closely co-operated with the Child Welfare Service—a co-operation long overdue. It is of course too short a period to show the result of this co-operation, but the knowledge received of abnormal Natal conditions is of immense value in the after care of the mother and child. Payment of Doctors called by Midwives, Section 14, Midwives Act, 1918. Out of the eight occasions when midwives called in the assistance of doctors, Seven applications for payment of fees were received. One fee lapsed because of failure to submit a claim within the prescribed period of two months. On receipt of a claim the fee is paid by the Corporation, and recovered by them from the patient. Where circumstances warrant it, the repayment of the claim is waived, or partial repayment of the fee is accepted. During October/December, eight claims were dealt with, the full amounts being recovered from the patients. Post-Certificate Education. The importance of midwives being cognisant of every new development in their professional work is obvious, but unforhinately, owing to the poor financial return for the work performed, many of them are unable to provide for post-certificate training. Every facility must therefore be given by the Local Supervising Authority, either to provide the education or to assist midwives in attending lectures elsewhere. During October, 19-30, six midwives were personally assisted to attend the excellent course of lectures held at Maidstone. Maternity Hospital and Maternity Homes. The Maternity Hospital at the present time provides for 12 beds, and necessitous cases requiring hospital care are accepted from us by this hospital under existing arrangements. It is proposed to extend this hospital on the present limited site by a further three beds; an extension greatly 23 and most urgently needed. However, in my opinion, the question of extension must be considered with a wider field of view in mind as to the future needs of the Borough. The demand for Maternity Hospital beds is a yearly increasing need, so that whatever additions are made on the present limited site in Widmore Road, will become inadequate to meet the demands of the near future. It follows that before expending large sums of voluntarily subscribed money this aspect of the question should be closely investigated. A new site sufficient for the building- of modern maternity wards to meet the present and future demands of a greater Bromley, and a rapidly increasing population in the surrounding County, appears to me to be the only economical method of development. The number of cases admitted by us to the Maternity Hospital, and who received financial aid was 15. In addition 35 cases were referred to the Hospital without financial aid. One case was referred to a London Hospital. There are within the Borough ten institutions, provided by volutary effort and private persons, coming within the category of Maternity Homes and Hospitals, and registered under the Nursing Homes Registration Act, 1927. Including the Maternity Hospital, these institutions provide 24 maternity beds, to which 2G6 maternity cases were admitted during 1930. One Maternity Home, which was in existence prior to the Nursing Homes Registration Act, has resident unqualified staff. The Act made no provision for the refusal of registration of such Maternity Homes. Puerperal Fever and Puerperal Pyrexia. The arrangements with the Sevenoaks Isolation Hospital for treatment, isolation, etc., of these cases, are still in force, and during the year we had occasion to admit one case. Lhe number of cases notified under the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 192G. were as follows:— Notified. Removed to Sevenoaks Hospital. Other Institutional treatment. Home Nursed. Puerperal Fever 1 1 — — Puerperal Pyrexia 11 — 8 3 24 Post-Natal. Home Visiting. Five Health Visitors are employed by the Corporation, who are engaged half-time in the School Medical Service, and in one case as Nurse to the Dental Service. One nurse attends once weekly at the Tuberculosis Dispensary, and carries out the home visiting of tuberculosis patients, thus linking up a County health service with the services of the Borough. About 84 per cent. of babies born in Bromley are visited by the Health Visitors, and it is upon this home instruction by a skilled person that the success or failure of the Maternity and Child Welfare Service depends. With the natural extension of the School Medical Services there has been an inroad into the time available for maternity and child welfare visiting, and the time has arrived when the appointment of additional health visiting staff must be considered. During 1930, 8,156 home visits were paid by the Health Visitors, and Table XII in the Appendix gives an analysis of this sphere of our work. It must be remembered that these visits are not nursing visits, but visits of instruction and advice in mothercraft. Welfare Centres. Five Centres holding six sessions per week are provided by the Council. At the 31st December, 1930, there was a total roll attendance of 1,393 individual babies at the Centres, and the total number of attendances at all Centres by infants under one year of age was 4,300, and by infants between the age of one and five years of age, 7,759. There has been no change in the organisation of these Centres, and the voluntary workers continue to give invaluable help. A total of 7,896 weighings was attained during the year 1930, making an excess of nearly 600 over the previous year. Only 15 per cent, mothers failed to have their babies or toddlers weighed during the year, compared with 17 per cent, failures in the previous year. 25 It is a matter of routine that all new comers to the Welfare Centres are medically examined, and the following routine as far as possible is adhered to:— (1) Babies under one year of age are examined at least once a month. (2) Babies 1-2 years of age, every three months. (3) Babies 2-5 years of age at least twice per year. In addition to the routine examinations, occasions are numerous where babies are examined through loss of weight, where defective physical conditions exist, or upon whom the mothers seek advice. There were 1,789 medical examinations during the year, a number which is lower than the desired standard because of lack of medical staff time occasioned by the smallpox epidemic during the year. Milk in Necessitous Cases. During the year 106 cases received free milk, and 8,091 pints of milk and 41 lbs. of dried milk were supplied free during January/December, 1930, at a cost of approximated £101. Minor Ailment Treatment. Minor ailment treatment of the under school age child is now available through the School Medical Service. Tonsils and Adenoids. Twenty-one cases under five years of age received operative treatment at the Tonsil and Adenoid Clinic under the approved minor ailment treatment scheme. These cases are detained at the School Clinic after operations for 24 hours, and subsequently are visited in their homes daily by the Health Visitors for a period of seven days. This treatment is in the right direction of prevention of disease. Diseased Tonsils require removal at as early an age as possible. The extension of the School Medical Service into the pre-school child is sound in principle. 26 Eyes. Two cases attended the Eye Clinic for treatment and correction of squint. The tendency of parents to leave squints untreated, or treated by the unskilled advice of the neighbour, is rather remarkable in its prevalence. Minor Ailments. Eighty cases received treatment at the School Clinic for ailments such as skin diseases and minor surgical injuries. Orthopaedic. Mr. H. J. Seddon, who has succeeded the late Mr. Barnett as Orthopaedic Specialist, deals very fully in his report on the cases dealt with during the year, which appears in the School Medical Report. Total attendances Consultations. 670 Treatments. 2,261 M aternity and Child Welfare Cases. School Cases. Total. Requiring treatme nt 21 . 108 ... 129 Requiring observa tion 19 34 ... 53 40 142 182 Dental Treatment. Where Dental Sepsis exists in the pre-school child, treatment becomes urgent. Fifty-five children were treated through the School Dental Service during the year. Ophthalmia Neonatorum. Impairment of vision was not recorded in any of the four cases notified during the year, statistical particulars of which are given in Appendix XI. 27 Diarrhoea and Enteritis. Four deaths for 1930 were recorded. The following tabulation shews the figures for the past five years:— Years. Deaths. 1926 3 1927 4 1928 2 1929 3 1930 4 Calculated on the basis of babies born in the year there has been, during the past five years, an increase of Diarrhoea and Enteritis Death Rate. Taking the five yearly periods since 1911 the rate was 16 per 1,000 babies; the rate fell to 3.8 per 1,000 in 1916/1920; 3 per thousand in 1921/1925, and has again risen to 5 per 1,000 during 1926/1930. As I have reported in previous years, this is a disease largely under control, but the need for transfers of all acute cases to hospital for active treatment is most desirable, it being more difficult to maintain home treatment. Children Act, 1908, Part I. There are 54 boarded-out children on the register, and 41 registered foster-mothers. One hundred and fiftyone visits to the homes of these children were made by the Health Visitors, who are the Infant Protection Visitors for the purposes of the Act. This is a most important part of our work, and one not always easy. Difficulty of keeping in close touch with the movements of the foster child has been experienced during the year. Sometimes cases are transferred from the area, and the destination address is either incorrectly notified to the department, or it is unknown; notice of reception is frequently not received by the authority of the district to which the child has been moved, and by the time the correct address has been found the child has been removed still further afield. There is need of new legal provision in the supervision of such children. Before reception can be made, the new foster-mother should receive permission to become a foster-mother, and no child should be removed without a removal certificate. 28 IV.—SUMMARY OF GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. Legislation in Force. Adoptive Acts— The Infectious Disease (Prevention) Act 1890 The Public Health Acts Amendment Act, (Parts II, III and Y) 1890 Public Health Acts (Amendment) Act, (Parts II, III, IV, V and VI, and Sections 81, 84, 85, 86 and 95) 1907 Public Health Act (Parts II, III, IV, and V) 1925 The Notification of Births Act 1907 The Local Government and other Officers' Superannuation Act, 1922 1927 Bye-Laws— Common Lodging Houses 1897 Nuisances (Bye-Law 13 repealed 13/2/1912) 1897 Cleansing of Earth Closets, Privies, Ashpits and Cesspools 1898 Houses Let in Lodgings (Bye-Law repealing Bye-Laws of 1890) 1898 Prevention of Nuisances arising from filth or rubbish 1912 Tents, Vans and Sheds 1923 Slaughterhouses 1924 New Streets and Buildings, 1926, 1927 and 1928 Good Rule and Government 1927 Registries for Female Domestic Servants 1927 Nursing Homes 1928 29 Orders— Hairdressers' Early Closing Order (Made under the Shops Acts, 1912) 1922 Midwives Acts, 1902-192G (Order under Section 62 of the Local Government Act, 1929) 1930 Hospitals. (1) Infectious Diseases Hospitals— West Kent Isolation Hospital 118 beds. West Kent Smallpox Hospital 39,, (2) General Hospital— Bromley (Kent) and District Hospital 49 „ (3) General Hospital— Phillips Memorial (Homeopathic Hospital) 18 „ (4) Maternity Hospital— The Bromley and Chislehurst Maternity Hospital 12„ Maternity and Nursing Homes. Under the Nursing Homes Registration Act, 1927. there are 10 Maternity and Nursing Homes on the register. Two applications for registration were received during 1930, and certificates of registration were granted. One was for "mixed" cases, and the other for "nursing" cases. The following are particulars of Maternity and Nursing Homes registered by the Local Authority, and for convenience of tabulation I have included details of the larger hospitals which are exempt from registration under the provisions of the Act:— 30 Address. Total No. of Beds. Maternity Beds Patients received in 1930. Total. Nursing Staff. Type nf case taken Maternity. Surgical Mledical Resident Living Out. Qualifications. 77, Avondale Road 5 2 12 13 4 3 1 2 2 Gen. Trained Mixed 1 Gen. Trained, Fever, and C.M.B. 40, Bromley Common 10 3 23 57 11 6 6 1 Gen.TrainedandC.M.B. do. 1 Gen. Trained 2 C.M.B. 2 Maternity Trained "Greta," Blytli Road 9 1 2 76 24 4 3 1 2 Gen.TrainedandC.M.B. do. 2 Gen. Trained 24, Elmfield Road 9 2 9 2 20 5 5 — 2 Gen. Trained Nursing 3 Asst. Nurses 3, Elmstead Lane 9 1 5 66 19 5 5 — 4 Gen. Trained Mixed 1 Asst. Nurse (Midwife engaged as required) Mixed "Frascati," Masons 12 1 1 5 12 8 4 4 1 C.M.B. Hill 7 Nurses " The Cloisters," 40 — 38 6» 6 — 2 Gen. Trained Nursing Southborongh Road * in cludin g two Princi pals 2 Asst. Nurses Nursing 13, Tweedy Road 4 — — — 7 3 3 — 3 Gen. Trained 43, West Street 2 2 11 — — 1 1 — 1 Untrained Maternity Maternity Hospital, 12 12 203 — — 7 7 — 3 Gen.TrainedandC.M.B. do. 118, Widmore Road 1 C.M.B. and 3 Asst. Nurses Bromley (Kent) and 49 454 72 7 7 — 3 Gen. Trained and C.M.B General District Hospital, 4 Gen. Trained Hospital Cromwell Avenue cases Phillips Memorial 18 — — 86 43 5 5 — 2 Gen.Trained and C.M.B. do. Hospital, (1 temporary) Lowndes Avenue 3 Asst. Nurses 31 Institutional. (1) The Rochester Diocesan Society for Befriending Women and Girls has a home at 29, Ravensbourne Road, where unmarried expectant mothers are received and arrangements made for their confinements in Maternity Homes, or in the Farnborough Hospital (Public Assistance Institution). Subsequent to confinement, the mothers and babies are received into 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, foster-mothers are found by the Society. The Home has no subsidy from public funds. (2) The Blind Hostel, Southlands Road, is a Hostel maintained by the London Association for the Blind, and receives no subsidy out of the rates. Ambulance Facilities. (1) For Infectious Disease cases: The West Kent Joint Hospital Board has motor ambulances stationed at the Hospital, Skym Corner, Bromley Common, for the removal of infectious disease cases. (2) For Non-Infectious and Accident cases. A motor ambulance, the property of the Council, is available at any hour for the removal of accident cases to hospitals, and it may be a requisitioned for the removal of cases of sickness of a non-infectious nature, the fee being remitted in necessitous cases. Laboratory Facilities. The arrangement for the testing of throat swabs at the West Kent Infectious Disease Hospital continues to work efficiently and with despatch. The facilities at Maidstone provided through the Kent County Council are used for the testing of all other material other than urgent Diphtheria swabs. Clinics and Centres. The School Clinic, Station Road, was opened in 1928. The situation of the Clinic in the Northern portion of the 32 Borough is presenting geographical difficulties in affording adequate service for the large estates which have been established in the Southern end of the Borough, and the consideration of the question of the establishment of Clinic facilities for the convenience of the burgesses in the Southern end of the town may not long be deferred. The School Clinic makes provision for the following treatments and services, details of which have been dealt with both in the Maternity and Child Welfare and School Medical Sections of this Report:— 1. Minor ailment treatments. 2. Tonsil and Adenoid Clinic. 3. Vision Clinic. 4. Orthopaedic Clinic. 5. Artificial Sunlight Clinic. 6. Dental Clinic. 7. Diphtheria Immunisation Clinic. 8. Ante-Natal Clinic. 9. Child Welfare Centre (Plaistow area). Welfare Centres are provided for the areas of Bromley Common, Burnt Ash, Plaistow, Shortlands and Widmore, and each Centre is held weekly, with the exception of Burnt Ash, where two sessions are held weekly. The development of the Housing Estates in the Bromley Common area has had the effect of leaving the old established Welfare Centre at Raglan Road too far from the centre of this large area. The Welfare Centre in its present position already serves a fairly densely populated district, and to move it to a more central site for the convenience of the new estates would adversely affect the old portion of Bromley Common area. The solution of the question depends largely on the establishment of Clinic and Centre facilities for the Southernmost portion of the Borough. Nursing in the Homes. There were three organisations providing professional district nursing in the homes: the Bromley District Nursing Association, St. Luke's District Nursing Association, and Bromley Common Holy Trinity Nursing Association. 33 During the year the work of the Holy Trinity Nursing Association was taken over by the Bromley District Nursing Association. I am indebted to the Hon. Secretary of the Bromley District Nursing Association for the following particulars of the valuable work done by the Association's staff of nurses during 1930:— Summary for the Year 1930. Cases on the Register, 1st January, 1930 20 New cases during the year. 509 Visits Paid. General Nursing 4976 Ante-Natal Visits 970 Maternity and Midwifery 2962 Casual Visits 555 Analysis of New Cases. Medical 148 Surgical 162 Maternity (with Doctor) 59 Midwifery 137 Abortions 6 Cases sent in by: Doctors 181 Visitors 16 Found by Nurses. 6 Applied 310 Result of Cases Nursed. Convalescent or Refused 411 Sent to Hospitals, etc 31 Died 22 Still on Register, December 31st, 1930 25 Tuberculosis Dispensary. The Tuberculosis Dispensary is provided and maintained by the Kent County Council. Sessions are held weekly, on Wednesdays, at 2, Park Road, Bromley, commencing at 1.30 p.m. The Corporation provides a nurse 34 for attendance at the Dispensary from the Health Visiting staff, who also carries out the home visiting of patients. A brief report of the work of the Dispensary appears in a later part of this Report. Venereal Diseases Treatment Centres. Provision for this treatment is under the administration of the Kent County Council. There is no centre in the Borough. The close proximity to London, where there are ample facilities available at the various London Hospitals, provides an adequate and convenient service for such cases. IV.—SANITARY CIRCUMSTANCES. Rivers and Streams. The streams and watercourses in the district came under periodical inspection during the year by the sanitary inspectors. Two instances of pollution were dealt with by the Department, but were of such a trivial nature as not to call for statutory action. Drainage and Sewerage. The main drainage of Bromley joins that of the undertaking of the West Kent Main Sewerage Board, whose purification works are at Dartford. Sewerage is there precipitated by gravitation before being discharged into the River Thames. The Town's surface water drainage is separate from the system for foul drainage. There are 21 cesspools in the unsewered portion of the Borough, otherwise there is water carriage. Water. A piped supply is general throughout the Borough, and comes from the Metropolitan Water Board's deep chalk well at Shortlands valley. The supply is sufficient and 35 of high grade purity, and is accepted as a standard of purity for deep well water. The latest average analysis available for this unfiltered and untreated water is as follows:— Bacteriogical. During the period 1905-1929, 291 samples have been taken:— 97.2 per cent, samples B. Coli absent in 100 c.c. 2.1 ,, ,, ,, ,, ,, present in 100 c.c. 0.7 ,, ,, ,, ,, ,, present in 10 c.c. Chemical Averages for 1929. Ammoniacal Nitrogen 0.0006 Albuminoid Nitrogen ... 0.0024 Oxidised Nitrogen ... 0.57 Chlorides 2.57 Oxygen absorbed in 3 hours 0.011 Total hardness ... 30.8 Permanent hardness ... 8.2 At Bickley there is a circular covered reservoir standing 307 feet above sea level, of a depth of 10 feet, holding 1½ million gallons, and also a duplicate rectangular covered reservoir, 10 feet deep, holding 1½ million gallons. In the Downham district of Bromley there is a large covered reservoir holding 5 million gallons, of a depth of 16 feet, and standing 250.5 feet above sea level. The supply for these reservoirs is from the Shortlands valley. Scavenging. There was no extension, or improvement of the methods of scavenging, or refuse disposal, put into operation during the year 1930, except that a further electric vehicle was purchased during the year. The refuse is now collected by means of three petrol vehicles, two electric vehicles and three horses and vans. Provision is being made for more frequent cleansing of the streets. 36 Rats and Mice (Destruction) Act, 1919. During National Rat Week the Health Department issued free supplies of Red Squill (Liquid Extract), Red Squill Biscuits, and a gassing machine and operator were available. The results from the use of Red Squill still appear to give satisfaction. The sewers were baited as in previous years. Four local chemists co-operated by making special displays of poisons, posters and leaflets, which attracted considerable attention, and they are prepared to repeat these displays on future occasions, especially as they led to increased sales of poisons. The response in Bromley to the Rat Destruction Campaign showed some slight improvement compared with the 1929 effort, as 34 applications were made to the Health Department for free poisons, whereas only 13 applications were received in the previous year. This response, however, still falls short of the required effort to deal, in any degree of usefulness, with the known prevalence of rats, which are vermin responsible not only for considerable damage to property, but are a menace to public health. Nuisances. Appendices VII and VIII, which are submitted by Mr. G. R. Woods, Chief Sanitary Inspector, indicate in some measure the very varied and valuable work performed by the inspectors. The extra work entailed by the smallpox outbreak early in the year considerably interrupted the work of the sanitary inspectors. One instance of a contravention of Section 73 of the Public Health Act, 1925, was reported. This Section prohibits the sale or distribution from any vehicle used for the collection of rags, bones or similar articles, of any food or any balloon or other toy. In five cases it was necessary to serve statutory notices to abate nuisances; these were remedied, and it was therefore not necessary to take any further proceedings. 37 House-to-House Inspection. Eighty houses were inspected under the Inspection of District Regulations. The number is less than that of last year owing to the interruption of routine work caused by the smallpox outbreak in the district. In addition, 525 houses were inspected, and notices served to abate nuisances and defects. The majority of these houses were inspected under) the Housing Act Schedule, but they cannot be legitimately included in the Inspection of District Regulations' figures, although they were made fit in accordance with the Housing Acts. V. HOUSING CONDITIONS. The housing conditions are, generally speaking, excellent. This is to be expected in a residential area such as Bromley. One awaits with interest the results obtained by the Census taken in April, 1931, and pending these figures our survey of the housing conditions in Bromley must be subject to error. Without a special survey one is unable to state facts of overcrowding as they exist today; the population in the neighbourhood of London is in a state of flux, and what is to-day "one house—one family" becomes tomorrow sub-let premises. Thus without the Census figures being available one is unable to record with any degree of accuracy the extent of the housing shortage, or the extent of overcrowding, in Bromley. To be inaccurate in a question of such vital importance to the practice of Public Health would be to court disaster in our actions for prevention. Further, while Uromley remains a residential area, and not industrial, the "temporarily resident" class will remain small, but although small in numbers, one finds that they are loudest in complaint. They generally pay excessive rents for inadequate accommodation . Apart from the large residential houses in the Borough, the prevalent type of house in Bromley is the sixroomed house, consisting of three bedrooms, living room, kitchen and scullery, which were built 20-30 years ago. There are some 200 older type houses built 30-40 years ago, consisting of two bedrooms, one living room, kitchen 38 and scullery of which the general soundness of construction is in question, and when housing conditions become easier throughout the country a few of these will probably be demolished because of the site value exceeding the present value of the houses. There is an increasing number of houses so re-constructed as to accommodate two families. They are provided with a common entrance, but most have separate services such as W.C., sink, water supply, and comprise two bedrooms, living room, kitchen and scullery. If one refers back to tlie 1921 Census it will be found that there were :— 1—3 rooms 348 separate dwellings. 4—5 „ 3684 „ „ 6—8 „ 2522 „ „ 9 and over 1103 „ „ These figures make a total of 7,657 dwellings. Since that time there have been erected 2,697 houses, according to the plans submitted to the Local Authority. The extension of the Downham Estate into Bromley has added 780 bouses, of which 64 are flats. 39 NUMBER OF HOUSES AND TYPES OF HOUSES BUI LT BY THE LOCAL AUTHORITY. ASSISTED SCHEME UNDER 1919 ACT. Type "B" large (with hall). Type "B" small (without hall). Non-Parlour Type "A." Flats. Total Parlour Type 72 3 bedrooms 72 3 bedrooms — — 144 1 parlour 1 parlour 1 kitchen 1 Kitchen l scullery 1 scullery Non-Parlour Type — — 42 |3 bedrooms — 42 1 living room 1 scullery TURPINGTON SCHEME UNDER 1923 ACT. 186 Parlour Type 7 14 — 88 2 bedrooms 21 Non-Parlour Type — — 47 47 1 living room Flats — — — 88 1 scullerv 156 SOUTHBOROUGH SCHEME. 91 built under 1923 Act. 63 non-subsidy houses built under Sec. 57, 1925 Act. Non-Parlour Type (all) — — 154 — 154 Grand Total 496 All the foregoing houses are fitted with bathrooms and separate W.C. accommodation. There is a waiting list approximately 200 applicants, but not all are residents of Bromley. 40 Prevalent Defects in Housing. A reference to the sanitary defects (Appendix VIII), submitted by Mr. G. R. Woods and the Inspectors, will indicate that the predominating defects are : unpaved yards, drinking water from cisterns, want of ventilated food stores, worn stone sinks, no permanent ventilation to bedrooms which are without fireplace or flue, and dampness due to porosity of bricks, perished damp course or defective roofing. Many of the complaints of overcrowding received are due to personal animosity between tenant and sub-tenant, but not infrequently the overcrowding is a primary cause of this difficulty; often due to lack of separate offices or of cooking facilities. To expect two families to live in harmony where the house is built for one family only, and to expect even an intelligent mother to rear a healthy family with the use of one gas ring, or one fire-place, without scullery sinks, is demanding too much of human endurance. The effects of such conditions are too well known for reiteration, but they must be taken into consideration when we come to teach a young mother the correct principles of rearing a healthy child. With regard to the discovered defects of fitness of houses, the inspectors are not experiencing difficulties in having the defects remedied. There have been no Court proceedings; the co-operation between owners, tenants and inspectors is an effective one, and is the only reasonable method of procedure under the present national circumstances. During the next five years it is estimated that some 1,750 bouses will be made fit in all respects, which will continue the present rate of correction of defects discovered. There is no property in Bromley, in my opinion, that requires scheduling as an improvement area during the next five years. Practically all houses have adequate internal water supply as supplied by the Metropolitan Water Board, all houses have sinks, but 25 houses are known to have a common water supply in the yard. In 30 known cases there are two houses to one water closet, and 14 outlying houses have pail closets, there being no sewer available. 41 Houses Let in Lodgings. There are no Bye-Laws for Houses Let in Lodgings, and in fact one would find difficulty in working such Bye-Laws when faced with the present national •conditions. The letting of houses to more than- one family where domestic provisions exist for one family only, must lead to trouble, and to a bad environment for developing children. No difficulty has been encountered under the Bye-Laws affecting Tents, Vans and Sheds. VI. SMOKE POLLUTION. Eleven routine visits and observations were made, and one nuisance under the Public Health (Smoke Abatement) Act, 1926, was observed. This was remedied by the Engineer of the steam raising plant after interview with the Inspector. Bromley is fortunate in being particularly free from smoke polluted atmosphere from manufacturing processes. The chief pollution arises from the use of raw coal for heating in domestic fires, and any improvement of this type of pollution can only be accomplished when it is more economic to burn smokeless fuels, and the encouragement of a greater use of electricity and gas in the homes of the people. VII. SHOPS ACTS. Three hundred and eight visits were made under these Acts, and 39 contraventions were reported. These related to the failure to display notices with reference to assistants' half-holidays, and the hours of employment of assistants under 18 years of age. The shop-keepers in question were notified, and they provided the necessary forms forthwith, thereby obviating the necessity for further action. The district was periodically patrolled during the week-day and Sunday evenings, and only one contravention was reported; this was the sale of bananas after 8 p.m., and a warning was sent in this case. Shop-keepers generally comply with the provisions of the Shops Acts relating to the statutory hours of closing. 42. VIII. PETROLEUM ACTS. Number of Licences issued 85 (a) For Petroleum Spirit 81 (b) For Carbide of Calcium 4 Total quantity of Petroleum Spirit in Gallons 166,308 (a) Bulk Storage in Gallons 146,825 (b) Two-Gallon Can Storage in Gallons 19,483 Carbide of Calcium in lbs 704 Of the 85 licences issued, 81 were renewals, and four new licences. Included in tbe total of 85 licences are 24 licences for combined bulk and can storage. One hundred and forty-six visits to storage places were made during the year. The following figures show the increase in licensed storage which has taken place during the past five years:— 1926. 1927. 1928. 1929. 1930. Petroleum Spirit in Gallons 66,915 103,025 150,335 159,746 166,308 Licences issued (petrol only) 77 69 82 92 81 There is a further increase of 6,562 gallons in the gross total of licensed storage for 1930 over that of 1929. The number of licences issued during 1930 shows a small decrease, and this is accounted for where licensees hold two or more licences during the previous year consequent on their extending their bulk storage, and at the close of the licencing year the licences are renewed under one licence. Tbe Petroleum Spirit (Motor Vehicles, etc.) Regulations, which came into force in December, 1929, made it obligatory under certain conditions for keepers of petroleum spirit to notify the Local Authority. It is quite evident that this responsibility has not yet been realised as only one notification has been received by this Department. 43 IX. FACTORIES AND WORKSHOPS. Statistics with regard to inspections and defects in factories and workshops may be seen in Appendix XIV. The total number of factories, workshops and workplaces on the register is 368, and the following is a tabulation of the businesses:— Bakehouses 27 Bootmakers, repairers 30 Tailors 24 Laundries 31 Motor and Cycle Engineers 37 Restaurants, Eating Houses 22 Dressmakers 30 Upholsteries 17 Other Trades 122 Outworkers 28 X. PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS, REGULATIONS, Etc. Dairies, Cowsheds and Milkshops 60 Confectionery, Ice Cream, etc. 79 Licenced Premises 33 Bakehouses 27 Butchers' Premises 37 Slaughterhouses 10 Hotels, Restaurants 22 Fish Shops 20 Other Food Shops 130 Shops, various 433 Stables 19 Cinemas 2 Petroleum Spirit Stores 85 44 Factories, Workshops and Workplaces 368 Offensive Trade (tallow melting) 1 Registry Offices 10 Nursing Homes 10 The foregoing premises undergo regular visitation by the Health Department stall', and no less than 1,880 inspections were made. XI. INSPECTION AND SUPERVISION OF FOODSTUFFS. There can be no more important work in Public Health than the provision and the supervision of a sound food supply of a people. More and more is the public alive to this question, and because the demand for a clean food supply is active, the retailer finds that it pays not only to protect his food stuffs from contamination, but to provide that it is beyond all question of good quality. Taking only one kind of food, milk; during the past five years milk distribution in Bromley has been revolutionised. Loose milk has practically disappeared, and to-day 90 per cent. of milk is distributed bottled from registered premises. The increase in the use of "Pasteurised" milk must safeguard us against milk infection; the public still tends to judge milk on its cream line and not upon its cleanliness and wholesomeness. Minor offences against hygiene of food still occur; the transport of food is by no means what the hvgienist would desire. Fruit, vegetables, etc., are still hawked about the town in open carts; fish is still transported in dirty boxes; old newspapers are still used for wrapping up fish sold, and there are a few sweetstuff shops and stallholders in the market who handle their produce and blow into the bags. Bread is distributed universally unwrapped and unprotected from human contamination. The supervision of foodstuffs is one of the most important branches of the work of the Health Department's staff, and were it not for the keen supervision which is exercised in Bromley, the itinerant hawker would be the 45 source of some anxiety to the Department. In some directions we are handicapped in the work by the insufficiency of the Public Health Acts to support us, nevertheless the teaching of the public of what is a safe foodstuff is creating a demand for the right article. The manufacturer too is doing much to meet this demand by the production of "packet foods," thus protecting the food against multiple handling. For example, the old type of ice cream vendor is gradually and surely being replaced by the carton ice cream, and foodstuffs, such as butter, cheese, biscuits, etc., are now almost universally packed and sold in cartons. Food and Drugs (Adulteration) Act, 1928. The following tabulation gives particulars of the work of Pood and Drugs Inspectors in Bromley during 1930:— No. of samples taken 126 Genuine 125 Inferior 1 Adulterated Nil. Prosecutions Nil. SUMMARY. New Milk 63 Sausages 2 Sterilised Milk 2 Olive Oil 2 Butter 6 Chicken & Ham Paste 1 S.R. Flour 2 Preserved Cream 1 Pepper 3 Raisins 1 Cocoa 4 Honey 1 Margarine 4 Mustard 1 Coffee 5 Cornflour 1 Tea 2 Baking Powder 1 Bern. Sugar 3 Camphorated Oil 1 Lard 2 Cod Liver Oil 1 Rice 4 Boracic Acid Ointment 1 Currants 1 Friars Balsam 1 Gin 2 Zinc Ointment 1 Whiskey 2 Tapioca 1 Preserved Peas 1 Dried Eggs (foreign) 1 Suet 1 Ground Rice 1 46 Milk. The following premises are registered for the sale of milk:— Dairies and milk-stores 60 Dairies licensed for the sale of:— " Pasteurised " Milk 10 " Certified " Milk 5 " Grade A " Milk 1 " Grade A " (T.T.) Milk 2 Three supplementary licences have been granted for the sale of graded milks, viz., "Pasteurised," "Certified," and "Grade A" (T.T.), within the Borough from premises outside the district. Samples of milk were submitted for bacteriological examinations with the following results:— Samples. Satisfactory. Sediment Contamination. "Pasteurised" Milk 3 — "Grade A" (T.T.) Milk 1 — Ordinary Milk — 2 Cases of contraventions of the Milk and Dairies Order, 1926, were reported as follows:— (1) Bottling and sealing in the street—Warning given. (2) Two cases of dirt sediment in milk—Warnings were given. Meat. There are five licensed and five registered slaughterhouses in the Borough. Five thousand eight hundred and thirty-seven animals were known to have been slaughtered in 1930, 5.02 per cent. showed presence of Tubercular infection and 9.8 per cent. other forms of disease. The number of animals slaughtered is less than in 1929, principally on account of two occupiers of slaughterhouses temporarily suspending killing. The following is a tabulation of diseased meat found in carcases inspected in the various slaughterhouses by the inspectors, and is submitted by Mr. G. R. Woods:— 47 No. of animals known to have been killed. No. of carcases inspected. Carcases, parts and offal destroyed as unsound. No. Weight in lbs. 94 beasts 93 Carcases and Offal: Cow—Generalised Tuberculosis 1 800 „ „ „ 1 772 Parts of Carcases: Diaphragm—Abscess 1 3 Offal: Livers— Cirrhosis 3 54 Cirrhosis (portions) 3 11 Distoma Hepaticum and cirrhosis 2 40 Distoma Hepaticum and cirrhosis (portion) 1 8 Cavernous Angioma 2 33 Abscesses 5 86 Carcinoma 1 20 Spleen— Congestion 1 3 Abscess 1 2 Lungs— Pleurisy 1 10 Decomposition 4 48 Localised Tuberculosis 3 36 Lungs and Heart— Localised Tuberculosis 3 48 Traumatic pericarditis 1 30 Heart—Myocarditis 1 5 Kidney—Abscess 1 4 Mesenteric Fats— Localised Tuberculosis 3 50 369 calves 343 Carcases and Offal: Dropsy and emaciation 1 160 Acute nephritis 1 50 Pyaemia 1 150 Offal: Plucks— Abscess 1 8 Melanosis 1 5 Livers— Abscessed 3 6 Decomposed 1 1 Lungs—Pneumonia 1 1 48 No. of animals known to have been killed. No. of carcases inspected. Carcases, parts and offal destroyed as unsound. No. Weight in lbs. 758 sheep 742 Carcases and Offal: Dropsy and fever 1 66 „ „ „ 1 64 „ „ „ 1 58 „ „ „ 1 88 Offal: Plucks— Distoma Hepalicum and Strongyli Rufescens 23 92 Decomposed 12 28 Livers— Distoma Hepaticum 14 29 Cirrhosis 1 2 Strongyli Rufescens 38 69 Abscess 1 2 Coccidiosis 6 10 Lungs—Strongyli Rufescens 2 2 Omentum— Cysticercus Tenuicollis 1 1 4616 pigs 4174 Carcases and Offal: Generalised Tuberculosis 1 400 „ „ „ 1 270 „ „ „ 1 272 „ „ „ 1 112 „ „ „ 1 432 „ „ „ 1 110 „ „ „ 1 290 „ „ „ 1 72 „ „ „ 1 156 „ „ „ 1 80 „ „ „ 1 72 „ „ „ 1 100 „ „ „ 1 96 „ „ „ 1 146 „ „ „ 1 360 Dropsy 1 70 „ 1 70 „ 1 100 „ 1 64 „ 1 86 „ 1 40 „ 1 100 Nephritis and dropsy 1 40 „ „ „ 1 50 „ „ „ 1 30 49 No. of animals known to have been killed. No. of carcases inspected. Carcases, parts and offal destroyed as unsound. No. Weight in lbs. Carcases and Offal (continued) Nephritis and dropsy 1 20 „ „ „ 1 20 „ „ „ 1 20 Uraemia 1 70 Bacterial necrosis and pneumonia 1 80 Septic pneumonia 1 80 „ „ 1 90 Icterus 1 94 „ 1 96 Emaciation and dropsy 1 80 Parts of Carcases: Heads— Abscess 2 14 Localised tuberculosis 43 526 Loin of pork— Localised tuberculosis 1 4 Forequarters— Pleurisy 3 190 Belly of pork— Inflammation 1 16 Leg- Fracture and bruise 1 14 Offal-. Plucks— Cirrhosis and pneumonia 42 243 Cirrhosis and congestion 48 229 Cirrhosis and pleurisy 7 33 Localised tuberculosis 49 333 Pleurisy and hepatitis 3 15 Hepatitis and congestion 10 40 Fatty degeneration and congestion 5 23 Pericarditis and hepatitis 8 39 Decomposed 2 8 Livers— Cirrhosis 190 719 Fatty degeneration 16 58 Localised tuberculosis 5 16 Hepatitis 4 9 Necrosis 45 175 Bacterial necrosis 7 29 Liver— Cysticercus tenuicollis 6 21 Echinococcis veterinorum 1 4 50 No. of animals known to have been killed. No. of carcases inspected. Carcases, parts and offal destroyed as unsound. No. Weight in lbs. Offal (continued) Lungs— Pleurisy 8 24 Pneumonia 23 44 Congestion 3 8 Mesenteric Fats— Localised tuberculosis 142 147 Enteritis 3 3 Cysticercus tenuicollis 1 1 Heart—Pericarditis 2 2 Lungs and heart— Pericarditis 8 46 Pleurisy 2 6 Pneumonia 2 6 Kidneys—Nephritis 3 1½ Spleen— Localised tuberculosis 3 3 Skin—Inflammation 2 28 5,837 5,352 887 10,300½ 51 Table A. (Total number of slaughterings, carcases inspected, and found affected with various diseases). Total No. known to have been slaughtered. Total No. of animals inspected. Carcases affected with Tuberculosis. Carcases affected with other diseases. Total No. of carcases affected (all diseases). 5,837 5,352 269 525 749 Table B. (Total number of carcases rejected for Tuberculosis and other defined diseases). Disease. Bulls. Cows. Heifers. Bullocks. Calves. Sheep. Pigs Total. Tuberculosis — 2 — — — — 15 17 Other defined diseases - - - - - - 20 20 Total - 2 - — — — 35 37 Table C. (Total number of all carcases, parts of carcases and offal rejected for all diseases). Disease. Carcases. Parts of Carcases. Offals of Carcases. Total number affected. Tuberculosis 17 44 208 269 Other defined diseases 24 8 493 525 Total 41 52 701 794 52 Table D. (Total weights of carcases, parts of carcases and offal rejected for all diseases). Tons. Cwts. Qrs. lbs. Total in lbs. Carcases 2 17 3 8 6,476 Parts of carcases — 6 3 11 767 Offal 1 1 1 5½ 3,057½ Total 4 11 3 24½ 10,300½ Other Unsound Food Seized or Surrendered. Article of Food. Quantity. Weight in lbs. Irish Turkeys 2 19½ Tomatoes 35 boxes 420 Beans 2 „ 40 Dates 1 „ 69 Pears 1 tub 72 Smoked Fillets 2 boxes 28 Haddocks 12 „ 120 Herrings 1 „ 42 Cod Fish 168 Bream 42 Lemons 5½ „ 716 Asparagus 15 bundles 7½ Dates 15 boxes 15 Contraventions. Contraventions of Section 116 Public Health Act, 1875, and Section 28, Public Health Act Amendment Act, 1890, as to unsound food, were reported as follows:— (1) Unsound Bacon sold: Legal proceedings were not instituted, but official warning was given. 53 (2) Unsound Lemons seized Legal proceedings were in- in the Retail Market: stituted against three defendants, with the result that one defendant was fined 40s. and costs, and the case against the other defendants was dismissed on payment of costs. XII. DISEASES OF ANIMALS ACTS. I am indebted to Mr. A. H. Sly, Inspector under these Acts, for the following details:— Licences issued 21 Inspection of animals brought into the Borough:— (a) Sheep 155 (b) Pigs 3,915 (c) Beasts 4 Swine Fever Nil. No suspected outbreak of swine fever was reported. Two milch cows with calf at foot in each case were licensed into the Borough under the Animals (Landing from Ireland, etc.), Order, 1923. The Borough experienced a year of health in regard to animal diseases; to this end it would seem that the steps taken under the Orders of the Ministry of Agriculture and Fisheries as a preventative, including twice the dipping of sheep within 14 days during the sheep dipping period laid down by the Ministry, assisted considerably in giving the Borough a clean bill of health during the period under review. XIII. RAG FLOCK ACTS, 1911-1928. No samples have been taken, but inspections have been made of upholstery workshops. Only clean wool flock is used in the few upholstery workshops in this district. 54 XIV. INFECTIOUS DISEASES CONTROL. The outstanding feature of the year 1930 was the occurrence in Bromley of Smallpox in epidemic form. For two years we escaped infection, although London had been for some time suffering from a rather extensive epidemic. Appendix IX gives the number of cases of all notifiable diseases together with their Mortality Rate, Incidence Rate and the number of cases removed to hospital. It will be seen that compared with the previous year there has been an increase in Scarlet Fever notification, but a slight fall in the Diphtheria Rate. It would appear from the charting of these two diseases in Bromley over the past forty years that the Diphtheria wave closely follows the Scarlet Fever wave; the apex of the curves being reached every five years. If the curves follow their usual courses 1930 would appear to be the apex year, although factors such as emigration and immigration affect the attack rate, for not only does the attack rate depend upon the virulence of the infecting organism, but also upon the proportion of susceptible people present in the community. Sporadic cases of Typhoid and Cerebro-Spinal infections appeared during the year, and although Psittacosis caused some anxiety in England, no case occurred in Bromley. Glandular Fever appeared in the district, but did not reach epidemic form. Whooping cough and measles were low in incidence, but as neither of these diseases is notifiable, one has no definite statistical evidence to submit. Influenza was practically negligible, and although there was an increase in Pneumonia notification, the deaths from the disease were fewer. Scarlet Fever. Although Scarlet Fever in 1930 declined throughout England and Wales as a whole, Bromley showed an increased incidence. The type of infection was mild, causing only one death, but the prevalence of minor complications was marked. As a rule a decline in incidence throughout the country means an increase in virulence of type, and this might explain Bromley conditions 55 in 1930. It was not unusual to be called to cases of acute nephritis, which gave a history of mild Fever, with sore throat, but no history of rash or peeling. I believe, too, it was the experience of cases in hospital that the mild case not infrequently gave rise to increased complications such as enlarged glands, discharging ears, etc. Further in 1930 many cases were retained in hospital because of nasal and aural discharge of an infectious nature. There can be no doubt that although this type was mild in regard to severity of symptoms, the infectivity was increased. This may be the explanation, that, because of the mildness of symptoms of onset, cases were untreated and not isolated, but allowed to mix with the susceptible, and so increased the spread of the infection. Nevertheless 1930 was the expected year of the apex of the five yearly incidence curve of Scarlet Fever in Bromley, brought about mainly by the increase in virulence of the infecting germ, and by an increase in the number of the susceptibles. The average number of Scarlet Fever Cases in Bromley over the past forty years since 1890, is 62 per year. During 1930, 163 were notified, giving an Incidence Rate of four per 1,000 population compared with 1.9 of the previous year. Home isolation is not the general practice—125 of the 163 cases being removed to the Isolation Hospital, i.e., 76 per cent. This has been the adopted practice for many years, and generally speaking appears to be the wiser practice, provided hospital accommodation for acute Measles and Whooping Cough is not prevented by the occupation of beds with uncomplicated Scarlet Fever. Diphtheria. There was a fall in incidence of Diphtheria in 1930, 54 cases being notified as against 72 in the previous year. The attack rate for 1930 is 1.3 per 1,000 population compared with 1.7 for 1929. There were no deaths in 1930, whereas there were three deaths in 1929. Since 1890 Diphtheria follows an incidence curve with six year intervals, with one intermission in 1923, when a rise in incidence did not eventuate. Since 1890 there does not appear to be any lessening of the Diphtheria Rate in 56 Bromley, but there is certainly a lessening in tlie Mortality Rate. Whether this is due to a lessening in the virulence of the Diphtheria germ, or to the more adequate treatment that is made available, is an open question. Occasionally one does meet with the acute fulminating Diphtheria case, so common prior to Antitoxin days, which rather indicates that the decline in the Mortality Rate is due to the increased effectiveness of early treatment. There are three preventable factors playing a part in the Mortality Rate; the first is the delay of the parent in calling medical aid early in sore throats; the second is the delay caused by awaiting the results of swabbing before giving a diagnosis, and the third is the delay in the administration of Antitoxin caused by the failure of diagnosis. Antitoxin is on free issue by the Department, swabs are tested locally, and every facility is given in order that these delays may not occur. It should be the universal practice to give Antitoxin where doubt exists, and not to depend upon the hospital admission for this treatment. Diphtheria Immunisation. An Immunising Clinic has now been in operation for two years, and is held weekly at the School Clinic, Station Road. It is our aim to immunise all susceptible children before admission to school, for the age incidence proves that it is in the school age period that the cases are chiefly prevalent. The response of the parents to this Clinic is good, but does not yet reach the desired aim. One finds that the desire for immunisation increases with the prevalence of Diphtheria in the district, but it must not be forgotten that it takes some three months to successfully immunise a child, so that at the time of epidemics, it is of little use to commence immunisation. One hundred and fifty children attended the Clinic during 1930, and of these 112 completed their treatment. Children under five years of age are not previously Schick tested, but the immunisation is commenced at their first attendance. Toxoid Antitoxin mixture is used—three injections being given at weekly intervals, and the final Schick test is given at the end of three months. The 57 subjoined table gives the statistical return of this Clinic. It is regretted that during the Smallpox epidemic in the first half of the year no time was available for the holding of this Clinic, so that the attendances suffered, and I fear that a certain number of cases eventually failed to continue their treatment. I am satisfied that in this field of preventive medicine much remains to be done, but it is a happy indication when the public are themselves initiating inquiries into the benefits of Diphtheria immunisation. The Medical Staff is so much occupied that it is a great pity that more time is not available for this sphere of useful work. Diphtheria I minimisation. Total No. Schick Tested: 108 Found to be positive: 79 „ „ „ negative: 29 Total No. who received full course of injections: 121 Total No. who were re-tested: 112 1st Re-test. 2nd Re-test. 3rd Re-test. Found to be positive: 13 3 — Found to be negative: 99 10 3 Smallpox. From February to April, 1930, 57 cases of Smallpox occurred in Bromley, 52 being admitted to the Smallpox Isolation Hospital, the other five having already parsed through their infectious period when discovered. This is the first epidemic of Smallpox in Bromley since 1901/1902 when there were 35 cases and five deaths (a case mortality of 15 per cent.). Two sporadic cases occurred in Bromley in 1929, but these were isolated cases who contracted their infection outside Bromley, and whose infections were able to be controlled by being brought early to the notice of the Department. It was never expected that Bromley, being so closely in touch with London, would escape the somewhat extensive infection of London during the past two years. 58 The history of the .1930 Bromley epidemic shows some points of interest. It was of a mild type which had extensively spread by the time it was discovered, and yet able to be controlled to the 57 cases after a period of three months strenuous effort. After the forty-third case had occurred, a freslh source of infection from outside the district was added to our difficulties, so that really there were two epidemics in the one epidemic recorded. A summarised history of this epidemic follows: On February 23rd a doubtful case was brought to my notice; a school child who had attended, before the onset of illness, Raglan Road Girls' School. This case occurred on a Sunday, when the schools were closed, and had not been either out of Bromley or come in contact with visitors from outside Bromley. It therefore appeared to be a Bromley infection. The following: morning a caravan child had been sent by a general practitioner to the School Clinic, as she had an undiagnosed well developed rash. This case, pending diagnosis, was fortunately immediately isolated at the Clinic by the nurse in attendance until removed direct from there to the Isolation Hospital. This rather pointed to a caravan infection, and the encampment was immediately visited. All members of the caravans were examined, but no case could be found, neither did any person show evidence of having recently had Smallpox The Raglan Road School was in the meantime being examined, and here was found another case in attendance at school in the same class as that of the first case, and another child with Smallpox scars and a history of four days absence from school early in February. This child had not only attended school in an infectious state, but also Sunday School, Gymnastic Class and Band of Hope Meetings. Although fortunate in the discovery of this source of infection, it was obvious that the infection had by this time been widely spread. All absentees from school were visited, and the school placed under daily medical examination. While visiting absentees a message was received from a medical practitioner that he had been called to see another school child from the same class suffering from Smallpox. The same afternoon a message was received from another practitioner that he had treated for Chickenpox, during the past three weeks, a family in Aylesbury Road. This 59 family showed four cases of Smallpox, two in an advanced stage of rash, one severe, and one with mild early stage of rash. This family was able to inform me of another family in Devonshire Place with a similar rash, which on visit was found to have three cases of well developed Smallpox. No further cases were discovered that day, but we were fortunate in discovering a source of infection and being able to isolate 13 cases of Smallpox in the first day of the search, but it was obvious that the infection must have been widely spread, and it was only after some three months that we were able to clear the Borough of the infection. Type of Infection. The type of infection in all cases was "mild Smallpox," one case being mildly toxic, six cases had a severe degree of discrete rash and one being confluent. There were no deaths and no complications. As is usual with this type of Smallpox, a case with a few " "spots" frequently gave rise to cases with severe discrete rash. The initial symptoms of onset were in most cases sufficiently severe to put the patient to bed, but in some cases the initial symptoms were no more severe than a passing "cold." The severity of onset of symptoms was no indication of the severity of the rash to come. In all but one case the rash was typical, but one met with the usual difficulties of diagnosis in this type of Smallpox. Infeetivity. For some reason certain cases spread the infection wherever they go, whereas other cases equally severe, in the same stage of rash and with similar chances of spreading infection, result in no secondary case. Thus case 5 of the epidemic was known to have heen the direct cause of 11 other cases, yet other cases similarly affected did not spread their infection. Two cases known to have been in attendance at school throughout their infectious period gave rise to 15 cases in that school. One case attended another school in an active stage of infection, and yet only two other cases arose from it. Another case of a school child attending another school. 60 untreated, and not isolated until discovered three weeks after onset of rash, gave rise to only four cases, and these were all in her own family. No other child in the same school became infected. Another case (45a), infected while visiting a case with Smallpox at Enfield during the infectious period of rash, regularly attended throughout a period of one month a Mothers' Mission, and infected only two other cases, both being of her own household. It was also shown that cases directly infected from case 5 were themselves more infectious than cases infected from a different source. It was not discovered where case 5 contracted her infection. The mfectivity depends upon the virulence of the infecting germ, and upon the susceptibility of the person exposed to infection. There may be a third factor, an environmental factor which either enhances the infectivity or lowers the resistance of the exposed person. It may be in this Bromley epidemic that we were dealing with more than two sources of infection, each with different powers of infectivity. AGE GROUPS AFFECTED. Age periods. Female. Male. 0— 1 3 — 1— 5 9 6 6—10 14 5 11—15 4 4 16—20 1 4 21—25 1 1 26—30 1 1 31—35 3 — 36—40 1 — 41—45 2 — 46—50 — — 51—55 — 1 56—60 1 — 61—65 — 2 66—70 — — 33 24 61 It will here be noticed that the age group 6/10 females is the largest group, mainly due to the infection in the Raglan Road Girls' School. Inevbation Period. In the early days of the epidemic all known contacts, whether close or indirect, were seen daily for sixteen days after contact, but it was soon discovered that cases arose after the sixteenth day; thereafter contacts were observed for twenty-one days. In one case the onset of symptoms arose twenty-two days after the case in the family had been removed to hospital. There are several factors affecting this incubation period. One must be the susceptibility or the resistance of the individual infected, and other factors are the amount and virulence of the infecting organism. It was also shown that in a vaccinated person the period of incubation appears to be prolonged, and unless vaccination is carried out within 48 hours of exposure to infection it appears to have no effect upon the onset of Smallpox, nor did it modify the period of rash. Vaccination. In reporting on Smallpox and the action taken against its spread, one regrets that the control of vaccination is not placed with the sanitary authority. I am unable to give particulars of the number of persons vaccinated during this period, nor am I able to report on the severity or otherwise of the effects of vaccination. However in the following-up of close contacts amounting to many hundreds, during the period of three months, practically 100 per cent. were vaccinated or became vaccinated after contact. I would here like to record my appreciation of the help given me in this respect by Dr. J. H. Yolland, the Vaccinating Officer of the Bromley Common area of the Borough. Of the 57 cases infected 44 were unvaccinated, nine Mere vaccinated in infancy (ages 05, 00, 53, 45, 41, 34, 27, 23, 5,), while four were vaccinated in the incubation period. The case aged five, who had been vaccinated in infancy, showed one doubtful scar of vaccination, and developed a true case of Smallpox of mild degree. 62 There can be no question of the value of recent vaccination as a prevention against Smallpox. Especially is this marked in the contacts, for example:—taking three families of 21 persons exposed repeatedly to Smallpox infection, four of them had been vaccinated and 17 unvaccinated: all the 17 contracted Smallpox, whilst the four previously vaccinated escaped. In a Smallpox epidemic of this nature, within a residential area such as Bromley, one meets with many difficulties. On one side, because of there being no deaths, one is liable to be accused of making too much fuss of a mild disease, and on the other side, one was not doing enough; schools should be closed, vaccinations made compulsory, and all contacts isolated. There is some truth on both sides. The disease was Smallpox, and as such had to be eradicated; that it bred true to type is, I believe, now accepted. A mild type does not give rise to a toxic type, nevertheless in an epidemic of mild type Smallpox, severe cases do arise. To close schools would handicap control and make the supervision of contacts almost impossible; to make vaccination compulsory would, in my view, undermine the present active public opinion that the only prevention against Smallpox is recent and successful vaccination. There is no need to isolate contacts if they are kept under daily observation, and have been successfully and recently vaccinated. Apart from all this the public responded well to our directions, and were of great assistance to the officers of the Department. Without it our efforts would have been practically useless. I am indebted to the Relieving Officers for the following figures giving primary vaccinations during the year. Ti is to be noted that primary vaccinations increased over 1929 as a consequence of the Smallpox epidemic, but that only 351 babies under one year out of a total of 629 born in 1930 were vaccinated, must indicate the ineffectiveness of the present routine administration. Primary vaccinations. Sub-Districts. Under 1 year. 1 year & upwards. Total. Bromley North 211 337 548 Bromley South 140 293 433 351 630 981 63 Tuberculosis. This is the only notifiable infectious disease that does not wholly come under the direct control of the local Medical Officer of Health. From a Public Health aspect the wisdom of this dual control is doubtful. In Bromley we endeavour with some success to overcome this duplication; primarily by the co-operation of the Tuberculosis Officer, Dr. W. B. Martin, who attends the Bromley Dispensary every week, and secondly by having one of our Health Visitors to act us Dispensary Nurse and Tuberculosis Visitor. All notified cases are first visited by the Sanitary Inspector, who makes the initial enquiry with regard to housing conditions, source of infection, disinfection, etc., and the case is then visited regularly by the Tuberculosis Nurse. We thus endeavour to carry out the advice given in Circular 1107 issued in 1930. Nevertheless one feels the lack of success in dealing with this infectious disease. One person in every 125 of the population in Bromley is on the register of Tubercular patients, and knowing this one must realise that every possible effort is needed to combat such an insidious infection. One can now definitely say that in Bromley, with increased consumption of pasteurised milk, that the milk infection has practically been eliminated. Meat inspection shows that 5 per cent. of meat condemned was due to Tubercular infection, and as now more than 91 per cent. of all meat is inspected at slaughter, one can again eliminate this source of infection. We are thus in Bromley left with the personal factor as the main source of infection. There is no doubt that Tuberculosis is a "family" disease. The close contact of the family, especially of the young baby of Tuberculosis parents, must indicate the main line of attack, if one would lessen the incidence of disease among our people. The following up of all contacts, and the skilled and regular examination of all contacts should be the main function of the Tuberculosis Dispensary and its staff. Every infected and infectious person should undergo a course of sanatorium treatment in order to learn the practical methods of the safe mode of life to be adopted by a tubercular patient, and be taught that close contact 64 with young children is one of the main reasons of the spread of the infection. Only 44 per cent. of our cases in Bromley have received institutional treatment. Forty-one persons died in the year from Tuberculosis, being the third highest cause of death during the year, and equivalent to a rate of 9 per 1,000 population. Appendix X gives the ages at death, and these follow the Mortality Bate of England and Wales, in that the middle age groups have the highest Death Bate. It is not to be forgotten that whenever a widespread epidemic illness occurs, such as influenza, a subsequent rise occurs not only in the incidence, but also in the deaths from Tuberculosis. Appendix X gives particulars of new cases notified or otherwise revealed during 1930, with age groups and records of mortality. At the end of December, 1930, there were 330 cases on the register, as follows:— Pulmonary— Male 113 Female 86 N on-Pulmonary— Male 52 Female 79 330 These figures show that 7.8 per 1,000 of Bromley's population are suffering from this disease. Happily a large proportion of these cases may be regarded as noninfectious. One hundred and forty-eight of the cases on the register have received institutional treatment. There was no call for statutory action under either the Public Health (Prevention of Disease) Begulations, 1925, or the Public Health Act, 1925, Section 62, with regard to the compulsory removal of patients. In one case the patient's occupation was that of a milk roundsman, but as he had not been pursuing his calling for some time prior to notification, the need for taking action under the first mentioned Begulations did not arise. 65 The Tuberculosis Officer, Dr. W. B. Martin, has kindly furnished the following details of work done at the Tuberculosis Dispensary during 1930:— NEW CASES WHO HAVE ATTENDED THE DISPENSARY FOR THE FIRST TIME FOR EXAMINATION DURING 1930. Adults. Children. M F. M. F. Pulmonary 25 14 — — Non-Pulmonary 4 4 5 2 Negative 14 18 13 15 Totals 43 36 18 17 Twenty-six contacts were examined during the year, and of these, seven were found to be positive; these are not included above. Total number of attendances at the Dispensary during the year 805 Number of cases attending the Dispensary who received a course of Sanitorium treatment during the year 56 After-Care Committee for Tubercular Patients. This Committee, which was inaugurated in 1928, works in conjunction with the Health Department, the Secretary being a member of the Clerical Staff of the Health Department. In 1930 some cases were referred to the Committee for assistance, mainly with an endeavour to obtain suitable employment, or to obtain domestic help while the patient is admitted to hospital. Both are matters of almost insurmountable difficulty, especially during the present days of excessive unemployment. In two of the cases the Committee were instrumental in having the patient admitted to hospital; in one case financial assistance was given in order to pay rent, and in another case the children were hoarded out under supervision while the mother was in sanatorium. APPENDIX. 68 List of Appendices. I. Summary of Statistics, 1930. II. Comparison of Statistics, 1930. III. Causes of Deaths, 1930. IV. Causes of Infant Deaths, 1930—Age Groups. V. Analysis of Infant Deaths, 1926—1930. VI. Analysis of Age of Infant Deaths and Maternal Deaths, 1910—1914, 1921—1925, and 1926--1930. VII. Summary of Sanitary Inspectors' Visits, 1930. VIII. Summary of Nuisances Abated, 1930. IX. Return of Notifiable Infectious Diseases, 1930,—in Wards, giving Attack Rate, Death Rate, etc. X. Return in Age Groups of New Cases of Tuberculosis notified, and of Deaths occurring in 1930. XI. Return of Ophthalmia Neonatorum, 1930. XII. Summary of Health Visiting, 1930. XIII. Summary of Attendances at Welfare Centres, 1930. XIV. Factories, Workshops and Workplaces, Inspections, 1930. XV. Housing Statistics, 1930. 69 APPENDIX I. SUMMARY OF STATISTICS, 1930. Population (mid-year, 1929) 41,840 Birth Rate 15.03 Death Rate 10.2 Infantile Mortality Rate 41 Number of Births 629 Number of Deaths 429 Number of Infant Deaths 26 Death Rate of Respiratory Diseases 0.7 ,, ,, ,, Tuberculosis 0.9 „ „ „ Cancer 1.6 ,, ,, ,, Zymotic Diseases 0.2 Notification of Scarlet Fever 163 „ ,, Smallpox 52 ,, ,, Diphtheria 54 ,, ,, Pneumonia 40 ,, ,, Tuberculosis 66 Number of Deaths from Measles 3 ,, ,, ,, ,, Scarlet Fever 1 ,, ,, „ ,, Diarrhoea (under 2 years) 4 ,, ,, „ Child Birth 2 Number of Visits by Sanitary Inspectors 8,703 ,, ,, ,, ,, Health Visitors 8,156 „ ,, Babies on the Registers at the Centres, end December, 1930 1,393 70 APPENDIX II. BIRTH RATE, DEATH RATE, AND ANALYSIS OF MORTALITY during the Year, 1930. (Provisional figures. The rates for England and Wales have been calculated on a population estimated to the middle of 1930, but those lor the towns have been calculated on populations estimated to the middle of 1929. The mortality rates refer to the whole population as regards England and wales, but only to civilians as regards London and the groups of towns. Rate per 1,000 Total Population Annual Death Rate per 1,000 Population Rate per 1,000 Live Births. Live Births Still Births All causes. Enteric Fever. Small-Pox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under Two Years). Total Deaths under One Year. England and Wales 16.3 0.69 11.4 0.01 000 0.10 0.02 0.05 0 09 0.12 0.53 6.0 60 107 County Boroughs and Great Towns, including London 16.6 0.71 11.5 0.01 0.00 0.15 0.02 0.05 0.10 0.11 0.50 8.3 64 159 Smaller Towns (1921 adjusted Populations 20,000-50,000) 16.2 0.69 10.5 0.00 0.00 0.08 0.01 0.05 0 07 0.13 0.43 4.4 55 London 15.7 0.56 11.4 0.01 0.00 0.23 0.02 0 03 0.10 0.08 0.55 9.9 59 BROMLEY 15.03 0.40 10.2 0.00 0.00 0.07 0.02 0.02 0.00 0.07 0.62 6.3 41 71 APPENDIX III. Causes of Death, 1930. Causes. Male. Female. Total Enteric Fever — — — Smallpox — — — Measles 2 1 3 Scarlet Fever 1 — 1 Whooping Cough — 1 1 Diphtheria — — — Influenza 2 1 3 Encephalitis Lethargica — — — Meningococcal Meningitis — — — Tuberculosis of the respiratory system 22 12 34 Other Tuberculosis diseases 2 5 7 Cancer, malignant disease 31 38 69 Rheumatic Fever — 1 1 Diabetes 3 3 6 Cerebral Haemorrhage, etc. 7 4 11 Heart Disease 47 57 104 Arterio-sclerosis 9 5 14 Bronchitis 3 2 5 Pneumonia (all forms) 13 9 22 Other respiratory diseases 2 2 4 Ulcer of stomach or duodenum 1 2 3 Diarrhoea, etc. (under two years) 1 3 4 Appendicitis and Typhlitis 4 5 9 Cirrhosis of liver — — — Acute and chronic Nephritis 4 7 11 Puerperal Sepsis — 1 1 Other accidents and diseases of pregnancy and parturition - 1 1 Congenital debility and malformation, premature birth 5 11 16 Suicide 4 3 7 Other deaths from violence 11 8 19 Other defined diseases 26 47 73 Causes ill-defined or unknown — — — Total 200 229 429 72 APPENDIX IV. Infantile Mortality, 1930. CAUSES OF DEATHS. 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 ... ... ... ... ... ... ... ... ... ... Tuberculosis ... ... ... ... ... ... ... ... ... ... Convulsions ... 2 ... ... 2 ... ... ... ... 2 Bronchitis ... ... ... ... ... ... ... ... ... ... Pneumonia ... ... ... ... ... 1 1 1 ... 3 Diarrhæa ... ... ... ... ... ... ... 1 ... 1 Enteritis ... ... ... ... ... ... 2 ... ... 2 Gastritis ... ... ... ... ... ... ... ... ... ... Suffocation ... ... 1 ... 1 1 ... ... ... 2 Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis ... ... ... ... ... ... ... ... ... ... Malformation 2 ... ... ... 2 1 ... ... ... 3 Premature Birth 6 1 ... ... 7 ... ... ... ... 7 Marasmus, etc. 2 ... ... ... 2 1 1 ... ... 4 Other Causes ... ... ... ... ... ... ... 1 ... 1 Syphilis ... ... ... ... ... ... ... ... ... ... Congenital Heart Disease 1 ... ... ... 1 ... ... ... ... 1 Totals 11 3 1 ... 15 4 4 3 ... 26 73 APPENDIX V. Analysis of Causes of Infant Deaths, 1926-1930. 1926 1927 1928 1929 1930 No. of Births 536 574 652 623 629 Total Infantile Mortality Rate 33 50 49 46 41 Premature Birth 4 5 6 3 7 25 Respiratory Disease 1 6 8 11 3 29 Marasmus and General Debility 7 3 6 3 4 23 Infectious Disease — 2 1 1 — 4 Gastro Enteritis 2 5 3 2 3 15 Convulsions — 1 1 — 2 4 Other Causes 4 7 7 9 7 34 Totals 18 29 32 29 26 134 This table shows that Premature Births and Congenital Debility caused 36 per cent. of the total infant deaths during the past five years, and should be taken as an indication of the great need for AnteNatal supervision. 74 APPENDIX VI. Summary of Infant Mortality Statistics. Three five year period figures are taken—five years pre-war, five years to 1925 and five years to 1930. Years. Total Births. Infant Mortality Rate. Total Infant Deaths. Age at Death. Maternal Deaths. Deaths under 1 week. Deaths 1 week to 4 weeks. Deaths 4 weeks to 1 year. Sepsis. Other. 1910 647 60 39 9 8 22 — 2 1911 649 74 49 15 7 27 2 3 1912 660 60 41 13 9 19 — — 1913 613 84 52 10 8 34 — — 1914 617 61 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 — 1924 535 58 31 11 4 16 1 2 1925 520 58 30 11 3 16 1 2 1921—1925 2832 62 177 64 26 87 6 7 1926 536 33 18 11 - 7 1 — 1927 574 50 29 12 2 15 — 1 1928 652 49 32 11 4 17 1 3 1929 623 46 29 6 4 19 1 1 1930 629 41 26 11 4 11 1 1 1926—1930 3014 44 134 51 14 69 4 6 In these figures the following facts are shown :— 1.—Reductions in Infantile Mortality Rates. The fall occurs chiefly in the period over 4 weeks of age. 2.—Increase in the deaths of infants under X week of age. Rate 1910-1914, 28 per cent. Rate 1926-1930, 38 per cent. 3.—Increase in Maternal Deaths. Rate 1910-1914, 2.7 per 1.000 births. Rate 1926-1930, 3.3 per 1,000 births. 75 APPENDIX VII. Summary of Work of Sanitary Inspectors, 1930. Inspections ReInspec tions. Housing— Under Inspection of District Regulations 80 210 On Complaint (ordinary) 821 1511 Re Overcrowding 14 7 ,, Dirty Conditions 5 13 „ Water Supply 2 1 ,, Infectious Diseases 505 2 Disinfection Purposes 105 - Disinfestation Purposes 29 35 Trade Premises— Factories 15 35 Workshops 23 16 Outworkers' Premises 3 — Under the Shops' Acts 306 2 Under the Petroleum Acts 136 10 Registry Offices 5 - Food Preparing Places— Dairies and Cowsheds 67 12 Bakehouses 49 9 Slaughterhouses 575 — Hotels, Restaurants, etc. 3 4 Confectionery, Ice Cream, etc. 26 — Greengrocery Shops 65 — Butchers' Shops 333 — Fish Shops 27 — Fried Fish Shops 5 — Retail Market 58 — Grocery Shops 32 — Food Hawkers 24 — Under Meat Regulations 51 — Milk Sampling 6 — 76 Miscellaneous— Streams 3 4 Nuisances from keeping of Animals 2 1 Piggeries 5 — Smoke 11 — Drain Tests— (a) Smoke 14 (b) Water 4 (c) Colour — (d) Chemical 2 20 — Urinals 21 13 Accumulations 26 16 Rats and Mice Destruction Act 102 35 Interviews, Owners, Agents, etc. 691 — Stables 8 2 Special Visits 382 — Smallpox Epidemic—visits to contacts (No. of contacts seen at all visits, 4,715) 2121 - Rag and Hone Dealers 3 — Totals 6766 1938 APPENDIX VIII. Nuisances Abated, 1930. HOUSING: Drainage— Drains relaid or repaired 65 Drains unstopped 54 W.C.'s renewed or repaired 204 W.C. pans cleansed 12 Soil pipes, vent pipes, renewed or repaired 7 Sinks renewed 76 Sink waste pipes renewed or repaired 51 Bath waste pipes renewed or repaired 4 Dampness— Roofs, rain water pipes guttering renewed, etc 285 Damp courses provided 75 77 Damp courses renewed 20 Brickwork renewed or repaired 37 Pointing renewed or repaired 179 General— Rooms cleansed 601 Floors renewed or repaired 107 Windows ,, ,, ,, 369 Doors ,, ,, ,, 38 Stoves ,, ,, ,, 81 Plastering „ „ „ 245 Hand-rails renewed, repaired, or provided 72 Yard paving „ „ „ 92 Coppers „ „ „ 74 New dustbins provided 293 Overcrowding abated 10 Disinfestations 10 Dirty conditions improved 12 Ventilated food stores provided 26 Staircases repaired 2 Water Supply— Drinking water service supplied direct from main 54 Fittings renewed or repaired 15 Miscellaneous items 147 TRADE PREMISES: Factories and Workshops— Want of cleanliness 18 Want of ventilation 4 Overcrowding 3 Want of drainage to floors 1 Other nuisances 29 Sanitary accommodation— Insufficient — Unsuitable or defective 11 Not separate for sexes 4 Shops Acts—contraventions 39 FOOD PREPARING PLACES :78 Yards, floors repaired, etc., cleansing, limewashing-, light and ventilation improved, refuse bins provided, sanitary conditions improved, etc. Dairies and Cowsheds 7 Slaughterhouses 1 Greengrocery Shops 12 Hotels, Restaurants, etc. 2 Bakehouses 8 Grocers' Shops 10 Butchers' Shops 18 Fish Shops 2 MISCELLANEOUS: Animal nuisances 8 Urinals cleansed 5 Smoke nuisances 1 Accumulations removed 33 Manure removed 1 Stables cleansed 1 Rat nuisances 35 Total 3,570 NOTICES ISSUED: Preliminary— (a) Housing 754 (b) Others 182 Total 936 Statutory— (a) Housing 5 (b) Others - Total 5 79 APPENDIX IX. Return of Notiffiable Infection Diseases, 1930. Disease. Total M. F. WARDS. Cases removed to Hospital. Attack Rate per 1,000 population. No. of Deaths. Death Rate. Plaistow Martin's Hill. Town. Sundridge. Bickley. Bromley Common. Scarlet Fever 163 69 94 58 17 29 16 18 25 125 3.8 1 0.02 Diphtheria 54 23 31 21 2 11 8 8 4 54 1.2 — — Primary Pneumonia 31 21 10 9 2 5 2 7 6 3 0.7 22 0.5 Influenzal Pneumonia 9 6 3 3 2 1 — 1 2 — 0.2 Puerperal Fever 1 — 1 — — — — 1 — 1 0.02 1 0.02 Puerperal Pyrexia 11 — 11 — — 3 4 1 3 8 0.2 — — Erysipelas 11 9 2 4 — 1 — 3 3 — 0.2 — — Para-typhoid B 4 1 3 1 — 1 1 — 1 1 0.08 — — Small-pox 52 22 30 5 2 18 — 7 20 52 1.2 — — Encephalitis Lethargica 1 — 1 — — — 1 — — — 0.02 — — Ophthalmia Neonatorum 4 1 3 2 — 1 1 — — 4 0.08 — — *Chicken pox 82 61 21 8 3 16 3 45 7 — 1.9 — — Tuberculosis—Lungs 49 28 21 21 5 4 3 4 12 — 1.1 34 0.8 Tuberculosis—Other Forms 17 7 10 4 1 3 1 4 4 — 0.4 7 0.1 Totals 489 248 241 136 34 93 40 99 87 248 116 65 1.5 *Chicken pox was notifiable for a period of 6 months from 14th March, 1930. 80 APPENDIX X.—Tuberculosis. New Cases and Mortality during the year 1930. Age Periods. New cases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. 0 ... ... ... ... ... ... ... ... 1— 5 ... ... ... ... ... ... ... 1 5—10 ... ... 4 ... ... ... 1 1 10—15 1 1 1 3 ... ... ... ... 15—20 1 1 1 ... 1 ... ... ... 20—25 2 4 1 4 2 2 1 1 25—35 6 5 ... 1 6 2 ... ... 35—45 6 5 ... ... 4 7 ... 1 45—55 8 3 ... 1 5 ... ... ... 55—65 3 2 ... 1 3 1 ... 1 65 and over 1 ... ... ... 1 ... ... ... Totals 28 21 7 10 22 12 2 5 APPENDIX XI. Ophthalmia Neonatorum, 1930. Cases. Vision unimpaired. Vision impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 4 ... 4 4 ... ... ... 81 APPENDIX XII.—Summary of Health Visitors' Work, 1930. Areas. Total. Under one year. Revisits over one year. Expectant Mothers. School Children. Baby Deaths. Stillbirths. Tuberculosis Special Visits. SmallPox. Boarded out Children. Primary Revisits Area No. 1 2452 98 199 820 52 142 4 2 88 293 754 40 Area No. 2 1676 122 379 402 89 261 2 5 50 104 262 5 Area No. 3 2025 172 203 277 102 250 3 3 94 297 624 34 Area No. 4 2003 166 172 541 78 191 1 5 61 115 673 72 Totals 8156 558 953 2040 321 844 10 15 293 809 2313 151* *Also included in routine visits under the various headings. TUBERCULOSIS DISPENSARY WORK. Patients on the Dispensary Roll at end of December, 1930 131 Health Visitor's attendances 52 Total No. of home visits to Patients 196 82 APPENDIX XIII.—Welfare Centres.—Attendances, 1930. CENTRE. No. of Babies on the Rolls at the end of the Year, 1930. Total Attendances. No. of Sessions held. Medical Consultations. Total No of Weighings. Babies. Mothers. Total Examined. No. of Sessions held. PLAISTOW 299 2549 2489 50 397 31 1938 WIDMORE 203 1675 1397 50 257 26 1134 SHORTLANDS 158 1544 1487 49 259 26 946 BURNT ASH 435 3708 2538 93 521 42 1974 BROMLEY COMMON 298 2583 1992 49 355 33 1904 Totals 1393 12059 9903 291 1789 158 7896 Ante-Natal Clinics. Total Attendances. Medical Consultations. Sessions held. 235 233 24 Dental Clinic. Discharged treatment. Children. Mothers. 39 11 83 APPENDIX XIV. Factories, Workshops and Workplaces. I.—Inspections. Premises. Number of Inspections Written Notices. Occupiers prosecuted. Factories 101 12 ... Workshops 47 11 ... Workplaces 21 8 ... Total 169 31 ... II.—Defects. Particulars. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts*— Want of Cleanliness 23 23 ... Want of ventilation 4 4 ... Overcrowding 3 3 ... Want of drainage to floors 1 1 ... Other nuisances 35 29 ... Sanitary accommodation. insufficient — — ... unsuitable or defective 21 11 ... not separate for sexes 4 4 ... Total 91 75 ... *Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Act. 84 APPENDIX XV. Housing Statistics for the year, 1930. Number of New Houses erected during' the Year:— (a) Total 440 (I) By the Local Authority (under Sec. 57, 1925 Act) 63 (II) By other Local Authorities 1 (III) By other bodies or persons 376 1. Inspection of Dwelling-houses during the Year:— (1) Total number of dwelling-houses inspected for housing defects (under the Public Health or Housing Acts) 605 Number of inspections made 1791 (2) Number of dwelling-houses (included under sub-bead (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 80 Number of inspections made 290 (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) Number of dwelling-houses (exclusive of those referred to under the previous subhead) found not to be in all respects reasonably fit for human habitation 502 2. Remedy of Defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 530 3. Action under Statutory Powers during the Year:- A. Proceedings under Section 3 of the Housing Act, 1925: (1) Number of dwelling-houses in respect of which notices were served, requiring repairs - 85 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners — (b) By the Local Authority in default of owners — (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close — B. Proceedings under Public Health Acts: (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 5 (2) Number of dwelling-houses in which defects were remedied after service of formal notices: (a) By owners 5 (b) By Local Authority in default of owners — C. Proceedings under Section 11, 14, and 15 of the Housing Act, 1925 (1) Number of representations made with a view to the making of Closing Orders — (2) N\imber of dwelling-houses in respect of which Closing Orders were made — (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit . — (4) Number of dwelling-houses in respect of which Demolition Orders were made — (5) Number of dwelling-houses demolished in pursuance of Demolition Orders — 4 Number of houses owned by the Local Authority 490 Built under Section 57 of the Housing Act, 1925 (included in the above total) 63 BOROUGH OF BROMLEY. ANNUAL REPORT FOR 1930 OF THE SCHOOL MEDICAL OFFICER. 88 Members of the Education Committee of the Borough of Bromley. Alderman F. W. Isard, (Chairman of Education Committee). D. Copping, Esq. A. Cowdry, Esq. Alderman E. Ford Duncanson, d.s.c., m.a., j.p. Mrs. M. D. Fry. Councillor W. 13. Gibds. Rev. H. Glaisyer, m.a. G. J. Gully, Esq. Councillor C. H. Gunton. Alderman G. IIaywood. Councillor E. J. Heilbron. Councillor D. P. Law. Mrs. A. G. Mann, b.a. (Chairman, School Medical Sub-Committee) Mrs. E. J. Munn. Councillor G. L. Pyrke. Rev. Prebendary B. F. Helton. Councillor W. F. Skilton. Councillor M. Stafford Smith, m.b.e., b.a. Councillor J. Waters. G. Weeks, Esq. Rev. 0. G. Whitfield, m.a. Councillor F. Wood. Rev. J. T. Gurney. 89 SUMMARY OF YEAR'S WORK. No. of Children on the Roll of Elementary Schools 4,833 Average Attendance, 1930 4,321 No. of Examinations by School Medical Officers 7,806 ,, ,, Routine 1,372 ,, „ Special and Clinic Inspections, etc. 6,434 No. Examined by the School Dental Surgeon 5,771 No. found to require treatment 3,068 No. treated by the School Dental Surgeon 2,352 No. of Examinations by School Nurses 12,402 No. of individual Children found unclean 482 No. of Children Examined by the Orthopaedic Surgeon 182 No. of Children Operated on for Tonsils and Adenoids 120 Introduction. In spite of Medical Staff changes, the work of the School Medical Service has continued to exercise its functions to the fullest capacity. Nevertheless frequent changes in personnel are not good for the smooth working of a service which is so largely dependent upon its personal factor. The more one is associated with the School Medical Service, so much the more is one impressed with the importance of the service in the sphere of national welfare. There is no other service that could replace it with equal effectiveness. The aim of the service is not only to remedy the 23 per cent. of defective children discovered at routine medical inspection at school, but to make for freedom from illness, so that the child may receive continuously the education provided by the Local Authority. Absence from school through preventable illness must lead to costly and ineffective education. If we fail to act so as to prevent perpetuation of defects discovered, we encourage racial deterioration; it is not a question of "spoon-feeding" a social class, but one that underlies the very foundation of the evolution of our people towards true national fitness— 90 financial and physical. The only extravagance in the School Medical Service is inefficiency. It is the uninitiated who are loudest in their criticism of the service; they ignore the fact that beyond all wealth is mental and physical fitness of the individual. The great changes that have occurred in the physical welfare of the school child since the Education Act, 1907, are obvious. No longer do we see gross crippling; wilful malnutrition has disappeared, and the brightness and cleanliness must be the first thing that would strike a visitor from a previous generation. In the years 1910/1914, the yearly average showed 23 per cent. of the children anaemic, 16 per cent. rickets, 15 per cent. defective vision, 27 per cent. enlarged tonsils and adenoids, and 5 per cent. ringworm of the scalp. In 1911, 71 per cent. of children examined showed evidence of vermin. Compare these figures with the present day school children, who show a total of 23 per cent. as suffering from early stages of defects—defective vision has fallen to 7 per cent.; anaemia has disappeared; defects of nose and throat have fallen to 12 per cent.; ringworm of the scalp is a rarity, and only 3.4 per cent. of children show evidence of vermin. It is in the investigation of these discovered defects that the field of prevention widens. They can in many cases be traced back to the infant stage, to the parents, or to the environmental conditions of the home or school, and so it is that we must have the closest possible coordination of all Public Health Services; the bad feeding of the infant may not make its effects obvious until the child reaches school age, or ideal school hygiene may be counteracted by the bad home conditions. I would repeat that there is still much to be done before we can realise even our most modest of aims, viz., a healthy child in a healthy environment. Children to-day live at a greater nervous tension than did their parents before them, and this, with the cheaper means of indoor amusements, not always of a desirable mental or moral stimulus, must have a detrimental effect on the health of the child of to-day. In spite of these detrimental factors in present day school life, there is 91 little effort made to counteract the effect of the loss of the hours of rest and sleep incurred. Evolution works in many unknown ways, but unless we make some counter by the proper organisation of school games and physical training, and have a right sense towards its importance in life, we shall but encourage a moral and physical deterioration. Another matter that will require attention by the School Medical Service is the shifting of the school population to the housing estates at the extremes of the Borough. If our work is to be fully effective, it is just as important to bring the Medical Service to the people in that neighbourhood, as it is to provide school accommodation in the neighbourhood. Clinic facilities have become necessary in the Bromley Common area. I have already given some figures indicating the vast improvements that have resulted since the School Medical Service became an active force in Bromley. It is not unfair to give main credit for this improvement to the service that has been engaged in the prevention of these defects. Nevertheless we are dealing with small numbers and an ever changing population, so that for true statistics one must be referred to the Annual Reports of the Chief Medical Officer of the Board of Education, who records the state of improvement over the whole of the country. As this is a Report upon the state of the health of the school child in Bromley for the year 1930, the occasion seems a suitable one for enumerating the changes in the service since I became your School Medical Officer in 1925. I was allowed the opportunity in that year of re-organising the Public Health Service, so that the School Medical Service, Public Health and Maternity and Child Welfare Ser vices became one unit, and not as prior to 1925, separate units working independently. This unification of services has in my view been the main factor in the effectiveness of the service; the pre-school child is a potential school child, and the factors making for public ill-health interact irrespective of the age of the individual. In 1925 I was assisted by five part-time Medical Officers, two Health Visitors, one Dental Nurse, one School Nurse and two clerks. The following year, 1926, an Orthopaedic scheme was commenced— an entirely new service, which to-day 92 is doing so much for the child with early deformities, and doing so much to eliminate the cripple from our schools. This brought into the staff a Masseuse, and a part time Orthopaedic Specialist, and in the same year an additional junior clerk was appointed. The increasing use made of the Public Health Services in 1927, and the development of the Borough by the building of the Downham Estate, for economic reasons part-time medical assistance was replaced by the appointment of a full-time Assistant Medical Officer of Health, and an additional Health Visitor. The following year saw the completion of the new School Clinic, which allowed us to continue the operations for tonsils and adenoids under hospital conditions, and the appointment of a part-time Ear, Nose and Throat Specialist. In 1929 the part-time Dentist was replaced by a full-time Dentist, with the result that the Dental Service is now able to cope with the demand for a complete Dental Service. In this year also an Ultra Violet Lamp was given to the Clinic, a Diphtheria Immunising Clinic was developed, and is now dealing with some 200 children per year. Beyond provision of treatment for necessitous secondary school children, there has been no extension of the School Medical Service since 1929. 1930 saw the consolidation of our existing services and improvement in details. Beyond praise is the help given to the staff by Miss Carter and the voluntary workers of the Bromley Children's Care Committee. Without this help at our Clinics, not only would the work be less effective, but the cost of the services would be increased. A word too is due to the teachers and parents who gave us at all times such happy co-operation. Hygiene of Schools. The modern aspect of school hygiene is something greater than the washing of floors, and the general cleanliness of class-rooms and lavatories. The principles of school structure have been modernised, so that the few hours spent in school will be spent under conditions ideal to health. It is for this reason that the principles of 93 open-air schools, which primarily were built for the debilitated child, are now being incorporated into the ordinary elementary school. We have some old schools in Bromley built prior to the passing of the Public Health Act, 1875; the Bromley Common Church of England Schools and the Bromley Parish Schools were built prior to the issue of the " Rules to be observed in Planning and Putting Up of Schools " in 1865. The Bickley and Widmore Schools in 1867, and the Plaistow St. Mary's Schools in 1870, were built prior to the adoption of the central hall type of school. These schools cannot, without unreasonable expenditure, be expected to reach the modern standard of hygiene. In time these schools will be replaced according to the needs of the Borough. However, progress is being made, and the following summary of improvements carried out since 1925 will give some indication of the improvements in hygiene in school premises:— (1) A new school for 1,000 pupils built at Downham on the Derbyshire Open Air type of school. (2) Gas lighting has been modernised in Wharton Uoad, Aylesbury Road, Valley, Addison Road and Central Schools. (3) Electric lighting at Raglan Road Schools. Lavatories. Modern lavatories provided at Bickley and Widmore Schools. Removal of Galleries. At Wharton Road, Raglan Road and Central Schools. Flooring. Raglan Road Schools. Lighting and Ventilation. Upper lights at Wharton Road and Central Schools. Heating. Low pressure heating at Raglan Road Schools (partial). Drinking Water. Aylesbury Road Schools. Provision for Heating Mid-day Meals. Bromley Common and Central Schools. Re-decoration. All schools are re-decorated according to schedule and needs. 94 There is a wider field than structural hygiene—the practice of hygiene by the pupils in the schools. In every way is this to be taught and practised, but the presence of roller towels, drinking vessels for common use, and inadequate washing accommodation, makes the practice of hygiene difficult and the teaching of hygiene sometimes useless. Co-ordination of School Medical Service with the Health Services. The co-ordination is not only complete in theory, but is complete in practice. The pre-school child being a potential school child is now receiving routine medical examination through the Centres, and the treatment of defects discovered is being carried out through the Clinics of the School Medical Service. The diseases of Ear, Nose, Throat, Eye, Dental and physical deformities discovered at the Welfare Centres, or through home visits of Health Visitors, receive treatment at the Special Clinics. There is an ever increasing appreciation of the practice that early discovery of defect will lead to the prevention of disease and ill-health. Head teachers, voluntary workers, and attendance officers all give the greatest help in the work of these services, and every opportunity is thus given the child, whether it be a school child or preschool child, to develop along the lines of true fitness. Uecause an unfit child cannot partake of the educational facilities provided by the Local Authority, it becomes an expense upon that Local Education Authority. It therefore behoves all of us to make these medical services efficient and wide in extent of service. The fact that shortage of school accommodation is now precluding the attendance of the under five years old child, raises the question of the provision of nursery schools or nursing classes. Medical Inspection. Routine medical inspection of the child at school is carried out as previously, viz., at age of entry to school, at seven years of age, and at 12 years of age. We have been unable to extend to a further age group between seven and 12 years of age. 95 Only three parents refused routine medical inspection of their children, and the attendance of parents at inspections reached 90 per cent. In addition to the routine inspection at school, medical examination of the child is carried out at the daily medical inspection Clinic, where during the year no less than 1,528 individual children attended for 5,013 examinations. These children are referred by head teachers, attendance officers, health visitors and ethers, and as the services have now a staff of consultants in Orthopaedics, Ear, Nose, Throat and Eye defects, these Clinics are likely to further increase in scope. Of the 1,372 children examined at routine medical inspections at school, 23.6 per cent. showed evidence of defects, mainly in an early stage of development, but grave defects undiscovered but for routine inspection were not uncommon. Particulars of these defects will be seen in Table Ila, in the Appendix of this Report. Of the children examined at school, the most common defects were those of the Respiratory Tract; 9 per cent. showed enlarged Tonsils and Adenoids, while 5 per cent. showed defective Vision. The discovery of defects, and the treatment and remedying of defects discovered is not the be all and end all of our services, it is more important to discover and remedy, if one is able, the cause of the departure from the normal; a task of far greater difficulty, and one that is apt to be overshadowed by the desire for treatment. Main Defects discovered at Medical Inspections. The particular statistics of the defects discovered at medical inspections can be seen by reference to Table IIa in the Appendix. Here are tabulated the defects under the headings of those which require treatment, and those which require observation. It might broadly be taken that where treatment is indicated the defect is gross, and where observation only is required, the defect is of a mild degree. One thousand five hundred and twenty-eight individual children attended Medical Inspection Clinic held each 96 morning at the School Clinic in Station Road, making a total attendance of 5,013 in the year, or 3.3 attendances per child. This does not include attendance for actual treatment, there being a further 8,544 attendances made at the minor ailments treatment Clinic. A child thus makes on an average 8.8 attendances at the Clinic each year. Further the 1,528 children attending the medical inspection have been found to suffer from 4,097 defects, or 2.6 defects per child. The inter-relationship of these defects in the same child is usually a close one; a child with Spinal Curvature may be caused by poor musculature because of mal-nutrition. Again a child may attend early in the year with Tonsillitis, and later in the year with Rheumatism, the result of the Tonsillitis. From these figures quoted above one can realize the important part the School Clinic plays in social services in Bromley, and how much it is doing to remedy those minor defects which would remain untreated and unobserved were it not for these public health services. When one finds 23 per cent. of children in school with untreated and uncorrected defects, it is a sufficient answer to those who would say that private services could replace existing public service. Were it not for routine medical inspections, these defects would remain undiscovered until the child became sufficiently ill to call for domiciliary treatment. In summarising the reports covering 1925-1930, I have submitted figures indicating the state of the child at school, and the state of the child at Medical Inspection Clinic. These figures are of interest, but it must not be overlooked that during these years the population of Bromley has not only increased in numbers, but has changed by the influx of housing at Downham and Palace Estates. Routine Medical Special Inspections. Inspections. Total individual children examined, 1925-1930 7,273 6,246 Percentage of children examined showing defects:— Eyes 6 per cent. 9 per cent. Tonsils and Adenoids 12 „ „ 28 „ „ 97 Nutrition 4 „ „ 4 „ „ Glands 2 „ „ 3 „ „ Lungs 2 „ „ 13 „ „ Nervous Disease 1 „ „ 3 „ „ Deformities 3 „ „ 2 „ „ Skin 2 „ „ 19 „ „ Ears 1 „ 5 „ „ Other defects 67 „ „ 14 „ „ From these figures it will be seen that 6 per cent. of children examined at routine school inspection are discovered to be suffering from defective Vision, 12 per cent. have diseases of the Nose and Throat, 4 per cent. are classified among the mal-nourished, while 3 per cent. have minor degrees of deformities, such as Spinal Curvature, Rickets, Flat Feet, etc. When we turn to the Medical Clinic figures we find that 28 per cent. of the children attend because of Nose and Throat conditions, 13 per cent. for diseases of the Lungs, while 19 per cent. have diseases of the skin. Scheme for Treatment, etc., of Defects Discovered. Having discovered a defect in a child it becomes first necessary to see that the defect receives adequate treatment, and next to discover, where possible, the cause of the defect, in order that steps of prevention may be taken. This is a difficult task, and one not always successful. Much is done by other public services outside the School Medical Service, and is not reported on here. The talks to the mothers, the home visiting of the child by the school nurse, and the voluntary workers of the Care Committee, all play their part in the scheme. The fact that 34 children were sent for couyalesence to convalescent homes, that 865 children receive each day at school half a pint of milk, contributes towards the prevention of malnutrition. The teaching of cleanliness, proper dietary, regular habits, and adequate exercise and sleep are important factors in the prevention of disease. But here and there we meet our failures; we still have the parents who do not want advice, who declare that what was good enough for their parents is good enough for the present day child, and we still have "the neighbour" who though unable to manage her own household is so ready to advise on other people's children. 98 Malnutrition. The classification of malnutrition is not an easy one, and it is still more difficult to discover the cause. It is usual in these cases to find together with malnutrition, defects such as enlarged glands, septic teeth, tonsils and adenoids, rheumatism or defective dietary. When these have been duly corrected, the child usually makes progress. For other cases convalescent home treatment is provided by the Care Committee, or a course of Artificial Sunlight Treatment, carried out through the School Clinic. Milk or extra nourishment in school, or at home, is provided free if necessary, or environmental improvement carried out in the home by the action of the sanitary inspector. It is in this class of case that much remains to be done. One child in 25 examined shows nutrition below the average, sometimes temporary in character following upon infectious disease or prolonged illness, sometimes an inherited diathesis, sometimes as a sequela from preventable illnesses in babyhood, sometimes tubercular, and not infrequently as a result of dietetic errors. To treat malnutrition one must treat the underlying cause, and this brings into action all the Special Clinics provided through the School Medical Service. It is useless to expect improvement in health merely because we provide tonsil and adenoids clinics, sunlight clinics, and convalescent home treatment, if we neglect the physiological principles of a correct living. The after care of children who have suffered from common epidemic diseases such as Measles and Whooping Cough, is frequently neglected, and the desire to return them early to school interferes with the complete recovery. Especially is this true where the family is large, and the house as small as the family income. It is in these cases that convalescent home treatment is so desirable if we are to prevent chronic debility. Eight hundred and sixty five children are receiving milk in school each day in the winter term, but one regrets that a nil return must be recorded against Raglan Road Boys' School and the Central School. 99 Tonsils and Adenoids Clinic. This is now, in 1931, held weekly; in 1930 it was held fortnightly. An Ear, Nose and Throat Specialist attends for consultations and operations. The details of the scheme have been submitted in previous Reports. Five cases are operated on at the School Clinic on each Wednesday morning at 8 a.m. These cases are retained at the Clinic for twenty-four hours, and then returned home by a suitable conveyance. The school nurse visits the case at home for the next seven days. Cases are selected as follows: 12 per cent. of all children examined at school are found to have diseased Tonsils and Adenoids, 24 per cent. of entrants, 9 per cent. intermediates and 5 per cent. leavers. All cases are referred to the School Clinic where they are kept under observation pending their reference to the Specialist (Mr. C. Beney), who himself decides as to operation or further observation. The cases for operation are selected in parties of five, and prepared at the Clinic on the day prior to operation. Twenty-eight per cent. of children who attend the Medical Clinic suffering from disease of the nose and throat, are likewise dealt with, but it is to be remembered that not all are suffering from enlarged tonsils and adenoids; many of them are acute tonsillitis, not infrequently the precursor of chronic rheumatism. One hundred and fifty-eight cases in 1930 were referred to the Clinic for operative treatment, 120 of these had the operation carried out at the Clinic, while the remaining 38 were operated on privately by their own doctor or at hospitals. One hundred and forty-two other cases were treated otherwise than by operation. Six hundred and three operations have been performed through the School Medical Service during the period 1925-1930; 126 have been referred to hospitals and private practitioners, and 710 received other forms of treatment. It will thus be seen that only 50 per cent. of enlarged tonsils and adenoids are treated by operation. 100 Defective Vision. Treatment for minor diseases of the eye are carried out at the routine Treatment Clinic for minor ailments. Cases discovered at school inspection, or at special inspection at the School Clinic, and who have 6/9 vision or less, are referred to the special Eye Clinic held weekly. The Assistant School Medical Officer attends to the children tested under atropine. Those requiring glasses are sent to a local optician, who through the agency of the Care Committee provides glasses at reduced prices. Six per cent. of children examined at Bromley schools, and 9 per cent. of children attending the School Clinic, are found to have defective vision, and if the routine medical inspection did nothing else hut this, it would be well worth the expenditure at present incurred. A child with undiscovered defective vision cannot fully acquire the education provided. I am finding that one Eye Clinic a week is not enough to cope with the work demanded of it. Not only have we to test the new cases discovered, but the re-testing of children of previous years must be carried out periodically. Thus, in 1930, 438 attended the Eye Clinic, 414 of these requiring refraction, 13 cases only were treated privately, and 144 cases were referred for provision of glasses, all of which were provided. In one case it was necessary to take action through the National Society for the Prevention of Cruelty to Children, who were successful in their Court action, the parent being fined £5 for neglect. By the co-operation of the teachers, children who fail to wear their glasses in school are reported, and the necessary action taken. Three cases of high myopia were sent to special schools for physically defective children, and are making progress in their education. The wisdom of this is debatable; it adequate attention can be given to the high myopic in an ordinary elementary school, their scholastic progress is said to be better than if they are referred to a special school. Two blind and two partially blind children are in residential schools. 101 Orthopaedic Clinic and Sunlight Treatment. Statistics. Mr. H. J. Seddon's interesting Report on the work of the Clinic and cases treated in hospital during the year 1930. is as follows:— Consultations. Treatments. Total attendances 670 2,261 M. & C. W. School. Total. Requiring treatment 21 108 129 Requiring observation 19 34 53 40 142 182 "During the last year eight patients have been under treatment at the Country Branch of the Royal National Orthopaedic Hospital, Stanmore Middlesex. C.W., a boy of 8, who had had a little pain and muscle spasm in the dorsal spine, thought to be early Tuberculosis; after repeated X-ray and clinical examination no evidence of this could be found, and he was discharged on 10.1.30. R.K., boy of 7, admitted on 9.1.30, with Tuberculosis of the left ankle. The local condition was serious as there was a persistently draining sinus and an equino-varus deformity. By June, 1930, the sinus was healed, and on 26.11.30, an operation was performed to stabilise the foot. His progress was most satisfactory, and he was discharged on 15.4.31. F.G., a boy of 8, was admitted on 4.2.30, with a deformity of the lower dorsal spine, due to Tuberculosis. He was nursed in recumbency for 15 months, and on 8.5.31 a bone graft operation was performed at the level of the disease. His post-operative progress has been satisfactory, and in a short time it will be possible to discharge him with a spinal support. D.W., a girl of 13, with left Hemiplegia and Athetosis, admitted on 30.3.30. Two operations were performed, a left tibial neurectomy and elongation of the Tendo-Achilles on 12.4.30, and a tendon transplantation on 102 the left forearm on 17.5.80. Control of the left, upper and lower extremities was markedly improved, and it was possible to discharge her on 3.9.30. T.S., a boy of 14, admitted on 28.3.30, on account of numerous bony swellings. He was a well marked case of Diaphyseal Aclasia. Operations were performed on 11.4.30 and 1.5.30, for the removal of the bony masses that were interfering with joint function. He was discharged on 15.8.30. F.B., age 6 years, was admitted on 7.G.30 for repairs to his splint. He had a flexion contracture of the left knee, which was corrected by the application of extension, and the wearing of a caliper splint. He was discharged on 8.7.30. G.B., a girl of 15, was admitted on 1.7.30 on account of backache and round shoulders. She had a rigid Kyphosis with some X-ray evidence of Epiphysitis of the Spine. She was fitted with a spinal support, and in a short time her mobility had improved rapidly under gymnastic treatment. She was discharged on 20.11.30. S.C., age 7 years, was admitted on 10.7.30 with a contracture of the left little finger, the result of a burn. Two plastic operations were performed, and he was discharged on 14.10.30 with a slightly stiff, but perfectly straight finger. Sunlight Treatment. The total number of cases treated was 115, which is an increase of 25 over the previous year. Thirteen of these cases were irregular in attendance, and therefore did not benefit to the fullest extent by the treatment. The types of cases submitted for treatment were as follows:— General Debility 54 Impetigo 11 Chilblains 5 Pre-Choreic and Nervous Children 6 Rickets 5 Septic Spots 4 103 Mastoid 4 Bronchitis 3 Discharging Glands 2 Curvatures of Spine 2 Asthma 2 Alopecia 2 Acne 1 Cervical Adenitis 1 DEBILITY. The courses of treatment varied from two to six months. Thirty-nine cases showed a steady gain in weight, improvement in appetite and muscular tone, etc. Ten showed definite improvement in general condition. IMPETIGO. Nine out of eleven cases were cured, and in most cases six to eight exposures were necessary. CHILBLAINS. Five cases were treated; three attended regularly, and the treatment was completely successful—the children remaining free from Chilblains during the whole winter. PRE-CHOREIC AND NERVOUS CHILDREN. Five cases showed improvement, but in one case the treatment was without effect, and was discontinued. "SEPTIC SPOTS." This condition has not been treated before. Two cases were cured, and two cases improved under treatment. BRONCHITIS. All cases improved. MASTOID. This condition had not been treated before. In each case treated there was an improvement in the general condition, but the local condition did not yield to the treatment. DISCHARGING GLANDS. One case was cured, and the other case the treatment was ineffective and was discontinued. CURVATURES OF SPINE. The general condition of the two cases treated improved and gained in weight ALOPECIA. These were new cases, though the lamp is not suitable for local treatment. Good results were obtained, one case being cured. 104 Dental Defects. I would especially direct attention to Mr. Latham's exceedingly interesting report. The complete year's working of a whole-time dentist is already giving demonstrable benefit to the health of the school child. As the public now so fully appreciate, dental sepsis frequently is the underlying cause of much ill-health. If this is true in the adult, how much more is it so in the growing child. It is very pleasing to note how readily the parents bring their children for treatment, and the habit that is being created in the children to visit the dentist periodically. Where gross sepsis was once common at the routine medical inspection, it is to-day a rare occurrence. SCHOOL DENTAL SERVICE. Report of the School Dental Surgeon for 1930. Inspection. During 1930 each elementary school in the Borough was visited, and 5,505 children from 3 to 16 years of age received the benefit of dental examination. In 1929, the total number of scholars examined in the schools was 4,228, and of these 63 per cent. were in obvious need of attention. In 1930, an additional 1,277 children were inspected, but only 52 per cent. were referred for treatment. From these percentages it would appear that the dental condition of elementary school children in Bromley is improving. Propaganda. The object of public health work is prevention rather than treatment, and to this end we have carried out propaganda work on every suitable occasion. The parents are always invited to attend at school dental inspections, and often as many as fifty parents and friends have been present. Lectures and demonstrations are given, questions are invited, and any suggestions for the improvement of the Dental Service are carefully considered. This year the parents have been allowed to be present in the surgery 105 while the treatment was being carried out, and they can see for themselves how the work is performed; they can see that their child is treated with care and consideration, and that the Clinic is conducted in a businesslike manner. Home Visits. The Dental Nurse has made 160 visits to certain parents during the year. A proportion of the children who are referred for treatment do not attend, and the object of these visits is to ascertain why they have absented themselves. The nurse often finds the parents in distressed circumstances, they cannot afford the necessary one shilling. In these cases the Children's Care Committee is always willing to assist, and the necessary treatment is carried out. Sometimes it is found that the mother has no spare time to bring the child to the Clinic owing to the nature of her work. In these cases a neighbour or friend is readily found, and the children eventually attend. Such cases we can deal with. Unfortunately, we are not always successful, and the cause is apathy—the parents are not interested in their children. No reason is offered for their absence, they promise to keep their appointment, and then fail again. During the coming year we hope to find some method to secure the attendance of these children who suffer through the apathy of their parents. Other Services. During the year certain children were received from the Girls' County School, and the necessary work undertaken. These girls are usually of a keen type, and make good and appreciative patients. A number of very young children are treated at the Dental Clinic under the Maternity and Child Welfare scheme, with the result that they enter their respective schools later on in good dental condition. On Saturday mornings a Clinic is held for nursing and expectant mothers under the Maternity and Child Welfare scheme. Advice is given and operative work undertaken, but no provision is made for artificial dentures. 100 Treatment. The principles of treatment were described in the Report of 1929. Prophylactic Treatment. During the dental inspections at the schools it was often found that many children, although they were free from dental caries, presented mouths in a dirty and illkept condition. Cases of this nature are referred for prophylactic treatment, that is, scaling, polishing and thorough mechanical cleansing. The treatment is not unpleasant, and the results are often surprising both to the child and the parents; the appreciation that clean, polished teeth improve the appearance, is often the first step in their dental education, and leads to a real desire for dental health. Constant reading and the study of other dental schemes, not only in England, but also in America and our Colonies, often suggests new methods; where these are within our power, and are of proved value, they are introduced. Lord Riddell in his address before the Central Coiincil for Health Education described our teeth as a " national disgrace," and having regard to the fact that 52 per cent. of our school population are suffering from very obvious dental disease, constant work and constant education in this matter must be our slogan in this department. Our aim is that the scholars shall leave school with a desire for dental health. They must be taught that correct treatment will eradicate disease, and that with proper methods there is nothing to fear. Lastly I must express my appreciation of the assistance given me by the committee and the staff. I would especially thank the voluntary workers who attend the Clinic each day and render such very practical service, for without their help it would be impossible to deal with so great a number of patients. (Signed) T. S. LATHAM, L.D.S. (Eng.). The extent of each type of treatment, and the various statistics, will be found in the Appendix. 107 Further Statistics—Dental Clinic. Deductions from Annual Report:— Averages. Each patient pays 1.7 visits to Clinic. Each patient receives 1.6 extractions. „ 0.5 local injections. „ 0.4 gas administrations. „ 1.0 metal fillings. ,, 0.4 dressings, scalings, and odd work. Each session has 10.7 patients. Total work per session 17.1 extractions. ,, 5.3 novocain anaesthesia. „ 4.3 gas anaesthesia. „ 10.7 fillings. ,, 4.3 dressings. At each school inspection 196 children are examined. Defective Children. The particulars of the 448 children classified as defective appear in Table III. It will there be noted that the majority of these children come under the classification of "delicate children," who because of their medical condition are necessarily kept under constant supervision. This Table III also shows those children who attend residential schools and special day schools. As far as one can judge, this classification is a complete one of the defective children in Bromley, but with the general flux of population, there may be isolated cases that have escaped our notice, or are attending private day schools in the Borough. Bromley possesses at Shortlands a special day school for educable. mentally defective children, but is dependent upon other Education Authorities for children otherwise specially classified. The average annual cost to the Education Authority for the maintenance of defective children in special institutions, or day schools, is £770. This sum covers the cost of: two blind children; four deaf children; and three epileptic children, in residential schools. Eight children attend special day schools in London provided by the L.C.C. for the physically defective, and partially blind and deaf. During 1930 two heart cases were in a special 108 residential home at West Wickham, and have since been discharged. One case mentally defective and partially blind has now left the special residential school at Reigate. Special School for Mentally Defectives. The roll for 1930 included 11 Bromley children and 11 children from the Kent County Council. This school is at present provided for by the allocation of class-rooms at the Valley Council Schools, where the children are taught a curriculum approved for the mentally defective. The children are not high grade mental defectives, but rather of the low grade classification. This fact must be taken into account when comparing the very excellent results that are being obtained by the teachers. The children come from all parts of the Borough, and are collected daily by a guide, and conveyed to and from school by a motor conveyance. The annual transport costs of these children is £240. The total cost of the school is £864 0s. 0d., an average cost pel' head of £39. During the year the Committee had under consideration the Hadow Report, and the recommendations of this Report as it affected the retarded child. The Sub-Committee approached the Beckenham Education Authority as to the possibility of a joint school for the purpose of fuller provision than exists at the present time. The matter will again come under consideration when the re-organisation of schools in the Borough becomes necessary. The After-Care Committee, whose Annual Report appears at the end of this Report, exercises supervision over the children after they have left the special school, and also any of those cases residing in Bromley and classified as ineducable. No other local provision is made for the latter child, and the question of the establishment of an occupation centre would be a distinct advance, and fulfil a need. The mongol and other low grade ineducable children are left to the attention of private schools, or no school at all. 109 Physical Training. Early in 1930 the facilities for physical training became a matter for investigation, as it is agreed that the present syllabus carried out in the schools is somewhat haphazard and inadequate. At the present time the matter of the provision of playing fields is in the hands of a special committee appointed for the purpose, while the scheme for the provision of halls suitable for physical training rooms includes hulls at the Bromley Common Girls' and Juniors, Raglan Road Seniors', Aylesbury Road and Valley Schools. We are sadly laching in playing field provision, and it has been decided that even if all the recreation grounds were made available for school use, the provision would be inadequate, and the turf would not stand the strain put upon it. As time goes on it becomes increasingly difficult to obtain land for playing fields. Included in the limited physical training scheme at present carried out in our schools is the instruction in swimming. Three hundred and ten children per week in 1930 attended the Open-air Swimming Bath, and 31 certificates were granted by the Education Committee. These certificates are awarded to each swimmer who can complete 50 yards. One class of twenty minutes duration each week is given to each child in standard iv, and scholars in standard v and upwards, who have already learned to swim, attend also. The class is limited to twenty pupils. The instruction is not optional, but medical certificates are given by the School Medical Officer when it is considered that swimming would be detrimental to the child's health. 110 REPORT OF THE BROMLEY CHILDREN'S CARE COMMITTEE FOR 1930. Executive Committee. Chairman and Hon. Treasurer: Mrs. A. G. Mann, B.A., J.P. Hon. Secretary: Miss E. Carter, 1, Hoinefield Road. Local Hon. Secretaries. Wharton and Plaistow: Miss E. Carter. Valley: M iss Poole Smith. Aylesbury and Masons Hill: Mrs. Taylor. Bromley Parish : Miss Bush. Bickley and Widmore: Miss G. Moore. Bromley Common: Mrs. Foster. Raglan and Addison: Mrs. Freeman. Burnt Ash: Mrs. Yalden. Bertram Pearce, Esq. George Weeks, Esq. Alderman F. W. Isard. John Williams, Esq. E. C. De'Ath, Esq. Miss D. Beddome. Dr. K. E. Tapper. Dr. G. H. Stinson. The extension of the School Medical Services has called for increased service from the members of the Committee. The School Clinic which is open daily, has an average of 15 sessions per week. This necessitates two of our members attending each morning, and there are two or more doing duty on most afternoons, while some give the whole 111 day to the work. The work has been found not only interesting, but we feel that our services are useful and appreciated. Figures cannot express this service, but a brief summary of the cases receiving financial assistance uirougli the Care Committee will indicate the variety and extent of the work performed. Tonsil and Adenoid operations 7 Vision 22 Dental 118 Hospital fares 5 Boots 83 Clothes 2 Milk and extra nourishment 133 Convalescent home treatment 34 The total number of cases receiving our aid has been 404, at a cost of £117 13s. 8½d. The following-up of these cases, and the home visitation by the voluntary workers, gives us an opportunity to realise the difficulties that the necessitous parent encounters, and opens to us a great field of work for the Children's Care Committee. The Committee has again to thank Colonel E. Satterthwaite, Hon. Secretary of the Queen's Reign Commemoration Fund, for his kind help in allotting to us so many convalescent letters, and Mrs. Parfect, of Rogate, also deserves a word of gratitude for the way in which she has looked after the children we have put under her care during convalesence, even to the mending of their clothes, which in many cases had been a great help to the parents. AVe would here also like to add our thanks to the Bromley Benevolent Society for their yearly help to our funds, for our work would be much curtailed were it not for their financial aid. We are once again only too pleased to thank Alderman A. T. Harris for his generosity in providing all spectacles at a reduced charge and in many cases free. 112 Statement of Accounts, 1930. Receipts. Expenditure. £ s. d. £ s. d. From Bromley Benevolent Association 80 0 0 Deficit last year 3 0 1 Milk 29 6 1 ,, Charity Festivities 20 0 0 Boots 30 14 5 Royal Sea Bathing Hospital 12 12 0 ,, Sale of cod liver oil and chemical food 5 12 4 Convalescent Homes 15 3 0 Insulin 3 18 0 Repaid Convalescent Homes 8 12 0 Cod liver oil and chemical food 12 9 8 ,, Royal Sea Bathing Hospital 7 0 0 Fares 2 2 8½ Dental Clinic 6 0 6 „ Milk 12 6 Medical Clinic 1 5 0 ,, Fares 1 6 1½ Cod liver oil and malt 8 4 „ Dental Clinic 12 0 Clothes 2 16 3 ,, Tonsil and Adenoid Clinic 10 0 Taxis 8 6 Glasses 9 3 Clinic Box 13 8 Balance carried forward 4 15 10 County School Old Girls' Association 11 0 £125 9 7½ £125 9 7½ (Signed) E. CARTER, Hon. Secretary. 113 BROMLEY AFTER-CARE COMMITTEE. (Affiliated to the Central Association for Mental Welfare). Chairman: Mrs. A. G. Maun, B.A., J.P. Hon. Secretary: Miss E. A. Wise, Farningham, Kent. Committee: Miss Bush, 4, Holligrave Road. Mrs. Drew, 23, The College. Mrs. Foster, "Belair," Bromley Common. Sister Morgan, 29, Ravensbourne Road. Mrs. Palmer, 39, Canadian Avenue, Catford. Mrs. Petley, 15, Murray Avenue. Miss M. Stafford Smith, M.B.E., B.A., 32, Madeira Avenue. Mrs. Slater, 3, Longfield. K. E. Tapper, Esq., O.B.E., M.B., D.P.H., Municipal Buildings. Miss E. Thompson, 5, Homefield Road. Miss Weeks, "Netherton," Cambridge Road. Mrs. Westwood, 53, Highland Road. Report for the Year 1930. The Committee record that during the past year, unless the fact be excepted, that no less than ten of our defectives have been married, there have been no untoward incidents. Twelve cases are placed under our care by the County Council for statutory supervision. The families of two infectives have left the neighbourhood. 114 Visits to four have been dropped, these four having given, for some time past, satisfactory service to their employers, and their home circumstances appearing also to be satisfactory. Supposing all goes well with them we shall probably either cease visits to, or visit them at much rarer intervals, twelve more defectives. These sixteen persons are all ex-pupils of the special school. Visits have been paid to 74 persons. This number is less than the number given in our report for 1929. The explanation for the decrease is not unhappily to be found in a corresponding decrease in the incidence of mental deficiency, but in the tendency on the part of the authorities to certify low-grade defectives only. In accordance with this change of policy, high grade defectives remain in the ordinary elementary school, a special school being provided (or in the case of some areas and occupation centre beingassisted), for such low grade defectives as are educable It is this latter class who in future, when they leave school will be placed under supervision, the former case, it will be supposed, needing no such care. Presumably, the County Council will continue to recommend to our friendly or statutory supervision such mentally defective children as are ineducable, but whom it is desirable to leave in their own homes. A few particulars about those remaining on our list may be of interest, the most cogent reason for the continuance of visits being stated in each case. Imbeciles (five are mongolian imbeciles between the ages of six and fourteen) 8 Epileptics 3 Idiot 1 Cretin 1 In service, so far doing well, but have recently left school 3 Deplorable homes 12 Poor health, unfitted for continuous work 4 Suffering from disabling physical defect 2 115 Doing fairly well, but parents are uneasy about them 2 No family connections 1 Unstable, and often in and out of work 3 Past history, or home circumstances give cause for uneasiness 18 Thirteen of these are married. We regret losing the help of Mrs. Garner, Mrs. Towse, and Mrs. Ward-Perkins, who can no longer find time to serve on the Committee. We welcome Mrs. Slater and Mrs. Petley, who already have had much experience of after-care work. Statement of Accounts. Receipts. Expenditure. £ s. d. £ s. d. Balance from 1929 2 7 11 Hire of room 1 2 6 Grant 6 10 0 Mental Welfare 3 6 Cheques 8 Printing and stationary 2 6 1 Postage 17 3 Travelling expenses 1 6 11 Cash in hand 3 1 0 £8 17 11 £8 17 11 APPENDIX. 118 *Not including 8,554 minor treatments at Clinic. TABLE 1. RETURN OF MEDICAL INSPECTIONS A.—ROUTINE MEDICAL INSPECTIONS. Number of Code Group Inspections:— Entrants 561 Intermediates 469 Leavers 342 Total 1,372 B.—OTHER INSPECTIONS. Number of Special Inspections 2,276 Number of Re-Inspections 2,737 Total *5,013 119 TABLE IIa.—Return of Defects found by Medical Inspection in the year 31st December, 1930. Defect or Disease Routine Inspections Special Inspections No. of Defects No. of Defects Requiring Treatment Requiring observation Requiring Treatment Requiring observation (1) (2) (3) (4) (5) Malnutrition 27 25 55 63 Skin Ringworm Head — — 4 — Body — — 1 — Scabies 1 — 19 33 Impetigo 5 — 34 23 Other Diseases (non- tubercular) 8 3 247 182 . Eye Blepharitis 3 - 19 16 Conjunctivitis - — 24 37 Keratitis — — — — Corneal Ulcer — — 1 4 Corneal Opacities — — 1 — Defective Vision (excluding squint) 86 4 58 11 Squint 3 — 9 — Other conditions 3 1 42 61 Ear Defective hearing 4 1 12 7 Otitis Media 5 1 27 28 Other Ear Conditions 2 — 73 88 Nose and Throat Enlarged Tonsils 44 110 105 69 Adenoids 4 4 18 2 Tonsils and Adenoids 29 6 47 234 Other conditions 10 5 337 299 Enlarged Cervical Glands (non-tubercular) 10 31 70 37 Defective Speech 1 1 1 — Heart and Circulation Organic - 8 - - Functional 3 28 14 31 Anaemia 2 3 4 1 Carried forward 250 231 1222 1226 120 TABLE 11a.—Continued. Defect or Disease Routine Inspections Special Instructions No. of Defects No. of defects Requiring Treatment Requiring observation Requiring Treatment Requiring onaservation (1) (2) (3) (4) (5) Lungs Brought forward 250 231 1222 1226 Bronchitis 3 11 57 62 Other Diseases (non-tubercular) 8 6 194 213 Tuberculosis. Pulmonary Definite — — — 4 Suspected — 3 1 — Non-Pulmonary Spine — — — — Glands — 3 3 5 Hip — — — — Other bones and joints — — 1 — skin — — — — Other forms — — — — Nervous System Epilepsy — 1 6 5 Chorea — 1 9 17 Other conditions 6 13 26 20 Deformities Rickets — — — — Spinal Curvature 13 1 6 1 Other forms 48 7 33 21 Other Defects and Diseases 268 16 603 362 Totals 596 293 2161 1936 121 TABLE IIb.—Number of Individual Children found at Routine Medical Inspection to Require Treatment (excluding Uncleanliness and Dental Diseases) Group Number of Children Percentage of Children found to require Treatment Inspected Found to require Treatment (1) (2) (3) (4)  Code Groups— Entrants 561 134 23.8 Intermediates 469 122 26.0 Leavers 342 68 19.8 Total (Code Group) 1372 324 23.6 122 TABLE III.—Numerical Return of all Exceptional Children in the Area.—1930. Boys. Girls. Total  BLIND (including partially Blind). (i) Suitable for training in a School or Class for the totally Blind). Attending Certified Schools or Classes for the Blind 1 1 2 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... (ii) Suitable for training in a School or Class for the partially Blind. Attending Certified Schools or Classes for the Blind 2 1 3 Attending Public Elementary Schools 1 1 2 At other Institutions ... ... ... At no School or Institution ... ... ... DEAF (including Deaf and Dumb and partially Deaf). (i) Suitable for training in a School or Class for the totally Deaf or Deaf and Dumb. Attending Certified Schools or Classes for the Deaf ... ... ... Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 1 ... 1 (ii) Suitable for training in a School or Class for the partially Deaf. Attending Certified Schools for the Deaf 3 2 5 Attending Public Elementary Schools 2 2 4 At other Institutions ... ... ... At no School or Institution ... ... ... MENTALLY DEFECTIVE. Feeble Minded (cases not notified to the Local Control Authority). Attending Certified Schools for Mentally Defective Children 13 14 21 Attending Public Elementary Schools ... ... ... At other Institutions 1 ... 1 At no School or Institution 3 2 5 Notified to the Local Control Authority during the year. Feeble minded (See Form 307M) Imbeciles Idiots EPILEPSY. Suffering from severe epilepsy Attending Certified Special Schools for Epileptics 1 1 2 In Institutions other than Certified Special Schools ... ... ... Attending Public Elementary Schools ... ... ... At no School or Institution ... ... ... Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 3 2 5 At no School or Institution 1 ... ... 123 TABLE III.—Continued. Boys. Girls. Total Infectious pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Non-Infectious but active pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At Certified Residential Open-Air Schools ... ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools 20 17 37 At other Institutions ... ... ... At no School or Institution ... ... ... cally defective. Delicate children (e.g., pre or latent tuberculosis, malnutrition,debility, anaemia, &c.). At Certified Residential Open-Air Schools 1 ... 1 At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools 123 95 218 At other Institutions 1 ... 1 At no School or Institution ... ... ... Active non-pulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 1 ... 1 At Public Elementary Schools 6 6 12 At other Institutions 2 ... 2 At no Institution or School ... ... ... Crippled children (other than those with active tuberculosis disease), e.g., children suffering from paralysis etc., and those with severe heart disease At Certified Hospital Schools ... 1 1 At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... 1 1 At Public Elementary Schools 62 53 115 At other Institutions ... ... ... At no School or Institution 1 ... 1 124 TABLE IV.—Return of Defects Treated during the year ended 31st December, 1930. GROUP 1.—Minor Ailments (excluding Uncleanliness, for which see Group V.). Defect or Disease. Number of Defects treated or under Treatment during the year. Under the Authority's Scheme. Otherwise Total. Ringworm—Scalp 3 1 4 —Body 1 — 1 Scabies 21 — 21 Impetigo 177 1 178 Other Skin Diseases 161 5 166 Minor Eye Defects 72 5 77 Minor Ear Defects 142 3 145 Miscellaneous 373 12 385 Totals 950 27 977 125 TABLE IV.—Return of Defects treated during the year ended 31st December, 1930. GROUP II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group 1.). Defect or Disease. Number of Defects dealt with. Under the Authority's Scheme. Submitted to Refraction by Private Practitioner or at Hospital. Otherwise. Total. Error of Refraction (including Squint) 414* 7 1 422 Other Defects or Diseases of the Eye 24 — 5 29 Totals 438 7 6 451 Total number of children for whom spectacles were prescribed:— Under the Authority's Scheme 144 Otherwise 7 Total number of children who obtained or received spectacles:— Under the Authority's Scheme 144 Otherwise 7 *This figure 414 included 276 re-inspections; 138 refractions. 126 TABLE IV.—Return of Defects treated during the year ended 31st December, 1930. GROUP III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS Received operative Treatment. Received other forms of treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital apart from Authority's Scheme. Total. 120 38 158 142 300 GROUP IV.—Dental Defects. (1) Number of children who were— (a) Inspected by the Dentist:— Aged: 3 30 „ 4 135 „ 5 501 „ 6 633 „ 7 696 „ 8 773 „ 9 684 „ 10 639 , 11 389 „ 12 358 „ 13 424 „ 14 218 „ 15 70 „ 16 26 Total 5,576 Specials 195 Grand Total 5,771 127 (b) Found to require treatment 3,068 (c) Actually treated 2,352 (d) Re-treated during the year as the result of periodical examination 581 (2) Half-days devoted to—Inspection 28 Treatment 390 418 (3) Attendances made by children for treatment 4,186 (4) Fillings—Permanent teeth 1,512 Temporary teeth 753 2,265 (5) Extractions—Permanent teeth 434 Temporary teeth 3,451 3,885 (6) Administrations of general anaesthetics for extractions 921* (7) Other operations—Permanent teeth 526 Temporary teeth 588 1,114 *In addition there were 1,374 local anaesthetics. GROUP V.—Uncleanliness and Verminous Conditions. 1. Average number of visits per school made during the year by the School Nurses 3 2. Total number of examinations of children in the schools by the School Nurses 12,402 3. Number of children found unclean 482 4. Number of children cleansed under arrangements made by the Local Education Authority Nil. 5. Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 Nil. (b) Under the School Attendance Bye-laws 6 128 DENTAL CLINIC AND DETAILS OF TREATMENT GIVEN, 1930. Total No. of half-days given to Inspections. Total No. of half-days given to treatment Total No. of appointments. S.M.O. and Emergency Cases. Total No. of Permanent teeth. Total No. of Temporary teeth. Total No. of Fillings. Anaesthetics. Other Operations, Scalings, Dressing, Regulations.  Made. Kept. Extracted. Filled. Extracted. Filled. Gas. Local. 28 390 8169 4186 195 434 1512 3451 753 2265 921 1374 1114 Total number of visits to patents made by the Dental Nurse 160. 129  School. Dept. FIRST INSPECTIONS. FINAL INSPECTIONS. ALL INSPECTIONS. ch Number Inspected Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous Slightly Verminous Highly Verminou ADDISON ROAD G.& I. 188 183 5 - 172 172 - - 360 355 5 - 5 - AYLESBURY B. 187 186 1 — 230 229 1 — 615 612 3 — 2 — BICKLEY AND J. 123 123 — - 131 130 1 — 384 382 2 — 2 — WIDMORE I. 102 102 — - 119 116 2 1 348 344 3 1 2 1 BROMLEY COM. J. 210 197 12 1 228 200 25 3 667 606 55 6 21 4 BURNT ASH B. 293 284 7 2 326 305 19 2 910 870 33 7 26 8 G. 183 165 13 5 270 221 44 5 676 588 78 10 60 6 j 336 297 37 2 374 316 53 5 1168 1042 114 12 81 12 MASONS HILL G. & I 248 248 — — 274 272 2 — 792 787 3 2 5 2 GENTRAL B. 76 76 — - 96 95 1 — 253 250 3 — 2 — G. 66 66 — — 80 78 2 — 206 204 2 — 2 — PARISH B. 211 203 3 5 246 238 8 — 700 675 16 9 10 6 G. 202 191 8 3 244 225 17 2 655 610 37 8 27 4 I. 92 89 2 1 107 101 3 3 333 319 8 6 7 5 PLAISTOW j. 71 65 4 2 70 61 6 3 215 191 19 5 9 5 RAGLAN ROAD B. 368 363 4 1 359 352 6 1 1022 1001 16 5 13 4 G. 210 193 16 1 241 210 28 3 645 586 51 8 46 5 j. 241 229 10 2 261 251 8 2 747 712 29 6 25 5 I. 225 216 8 1 207 197 10 — 671 642 29 — 21 3 VALLEY G. 102 91 8 3 102 95 4 3 305 284 15 6 7 2 I. 116 111 4 1 125 121 2 2 376 358 12 6 9 5 Special 23 22 1 — 21 19 2 — 64 57 6 1 5 4 WHARTON ROAD j. 100 92 4 4 88 82 6 — 290 268 14 8 10 4 Totals 3973 3792 147 34 4371 4086 250 35 12402 11743 553 106 397 85