AC-4412(1) BROMLEY Rent BRO 27 Borough of Bromley. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For 1931. K. E. TAPPER, O.B.E., M.B., Ch.B., D.P.H. BROMLEY, KENT: Strong & Sons, Ltd., 39, East Street. 44 Borough of Bromley. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For 1931. K. E. TAPPER, O.B.E , M.B., Ch.B., D.P.H. BROMLEY, KENT: Strong & Sons, Ltd., 39, East Street. CONTENTS. PAGE Members of the Health and Maternity and Child Welfare Committees 4 Prefatory Letter 5 Staff 8 Part I.—Statistics and Social Conditions of the Area 9 Summary of Statistics 9 Social Conditions, and Town Planning Scheme 11 Meteorology 12 Occupations and Unemployment 12 Population 13 Part II.—Vital Statistics 14 Births 14 Stillbirths 14 Deaths 15 Infantile Mortality 16 Maternal Mortality 17 Part III.—Maternity and Child Welfare 17 Details of Services 17 Centres and Clinics 18 Ante-Natal Clinic 19 Natal Services 21 Attendance at Birth 22 Midwives 24 Midwives Acts, Administration 24 Maternity Hospital and Maternity Homes 26 Puerperal Fever and Puerperal Pyrexia 27 Post-Natal 28 Home Visiting 28 Welfare Centres 28 Minor Ailment Treatments 29 Ophthalmia Neonatorum 30 Diarrhoea and Enteritis 30 Children Act, 1908, Part I 30 Pari- IV.—Summary of General Provision of Health Services 31 Legislation in Force 31 Hospitals 32 Maternity and Nursing Homes 32 Institutions, Various 34 Ambulance Facilities 34 Laboratory Facilities 34 Clinics and Centres 34 Nursing in the Homes : District Nursing Association 35 Tuberculosis Dispensary 36 Venereal Diseases 36 Part V.—Sanitary Circumstances 37 Rivers and Streams 37 Drainage and Sewerage 37 Water 37 Scavenging 37 Rats and Mice Destruction Act, 1919 38 Nuisances 38 House-to-House Inspection 38 CONTENTS—Continued. PAGE. Past VI.—Housing Conditions 40 Prevalent Defects 42 Houses Let in Lodgings 42 Part VII.—Smoke Pollution 42 Part VIII.—Shops Acts 42 Part IX.—Petroleum Acts 43 Part X.—Factories and Workshops 43 Part XI.— Premises and Occupations controlled by Bye-Laws, Regulations, &c. 44 Part XII.—Inspection and Supervision of Foodstuffs 44 Milk 45 Meat 47 Other Unsound Food 50 Food and Drugs (Adulteration) Act, 1928 50 Part XIII.—Diseases of Animals Acts 51 Part XIV.—Rag Flock Acts, 1911-1928 52 Part XV.—Infectious Diseases Control 52 Scarlet Fever 52 Diphtheria 53 Diphtheria Immunisation 54 Other Notifiable Infectious Diseases 55 Vaccination 55 Tuberculosis 55 Propaganda 57 Appendices—Statistical Tables I. to XV. 61—78 School Medical Service. Members of the Education Committee 80 Summary of the Year's Work 81 Introduction 81 Hygiene of Schools 83 Co-ordination of Health Services 84 Medical Inspection 85 Main Defects Discovered at Medical Inspection 86 Malnutrition 86 Cleanliness 87 Skin Disease 87 Eye Clinic 87 Diseases of the Ear, Nose and Throat Clinic 88 Ear, Nose and Throat Specialist's Report 89 Minor Ailment Clinic 89 Orthopædic Clinic 90 Orthopædic Statistics 91 Orthopædic Specialist's Report 92 Sunlight Treatment Clinic 92 Dental Clinic 94 School Dental Surgeon's Report 94 Defective Children 97 Conclusion 98 Report of the Bromley Children's Care Committee 99 Report of the Bromley After-Care Committee— Mental Welfare 101 Appendices.— Medical Inspection Returns, Tables I. to IV. 104 Dental Clinic, Details of Treatment 115 Head Inspections 116 MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1931-32. HEALTH COMMITTEE: — Councillor E. J. Heilbron (Chairman). Alderman W. F. Skilton (Vice-Chairman). His Worship the Mayor (Alderman B. A. Glanvill, j.p.). Councillor G. Allen. Councillor W. A. Greenley, c.m.g., d.s.o. Councillor C. H. Gunton. Councillor A. McIntosh. Councillor M. Stafford Smith, m.b.e., b.a. Councillor F. Wood. MATERNITY AND CHILD WELFARE COMMITTEE Councillor F. Wood (Chairman). Councillor M. Stafford Smith, m.b.e., b.a. (Vice-Chairman). His Worship the Mayor (Alderman B. A. Glanvill, j.p.). Alderman W. F. Skilton. Councillor E. J. Heilbron. Councillor T. H. Jayes. Councillor A. McIntosh. Councillor G. Reed. Co-opted Members:— Mrs. A. M. Howe. Mrs. A. G. Mann, b.a., j.p. Mrs. M. Pearce. Miss Y. Vincent. Mrs. E. Yolland. Borough of Bromley. Report of the Medical Officer of Health for the Year 1931. To the Mayor, Aldermen and Councillors. Me. Mayor, Madam and Gentlemen, I beg to submit the Annual Report of the Health of the Borough of Bromley, and of the work of the School Medical Service, during the year 1931. The Report follows the lines of previous reports and is in accordance with the requirements of the Ministry of Health (Circular 1206). This year shows no outstanding feature as far as the health services in Bromley are concerned. There has been no extensions of the provisions, unless such extension be due to the increased use of existing services bought about by the population increase during the past few years. There is a growing demand for public health services, not because the various clinics offer facilities for specialised treatment, but because the public is alive to the fact that advice is more valuable than actual treatment. One sees this so-called health conscience Becoming stronger year by year, an indication that the Practice of living a physiological life is not a matter beyond the capabilities of the human race. It is for this reason that one regrets the tendency to treat the individual at the expense of the community at large; the passing of the Poor Law treatment services into the sphere of local health authorities under the Local Government Act of 1929, is diverting our energies into the sphere of treatment instead of concentrating upon the factors that make for physiological health. 6 The services in Bromley endeavour to practice this policy, and if not carried out in all our services it is most certainly so in the Maternity and Child Welfare and in the services of the Sanitary Inspectors. In certain directions the School Medical Service departs from the principle, especially in the operations for tonsils and adenoids, but this is discussed more fully in the body of the report. Perhaps our outstanding defect is the lack of physical training in our schools, which is not a matter to be shelved indefinitely and to me is of far greater importance than many of the services carried out by the Local Authority. There is a growing demand for maternity beds in hospitals and nursing homes; our local provision is by no means adequate to meet this demand. The advantages to the mother are obvious as they are obvious to all who would have at heart the welfare of the future State. No less than 17 mothers in Bromley in 1931 had their confinements in the one room where they were living as lodgers. Infectious diseases remained at a normal level, except for Scarlet Fever, which reached the apex of its expected incidence curve. We should now have a low incidence of Scarlet Fever for the next five years, unless an influx of population should interfere with the immunity rate of the inhabitants. Summarising the Vital Statistics for 1931, there is an actual fall in the Birth Rate in accordance with the fall in the Birth Rate for England and Wales. The Infant Death Rate shows an unexpected increase, owing to the number of inward transfer deaths exceeding the estimate. A slight increase in the Death Rate over 1930 is brought about by an increase in the deaths from respiratory diseases. The large housing estates developed within the Borough will have an influence on all our vital statistics; unemployment among males and the increased employment of young females will in due course affect these statistics, and must be factors to be taken into consideration when comparisons are made. 7 As far as possible the Report for 1931 has been curtailed and only the necessary tables of statistics inserted; a close study of these will indicate more clearly than words the actual work of the Department during Again would I express my personal appreciation of the help I have received from the Committees during the past year, and of the keenness and efficiency of each individual member of the staff under my control. I am, Mr. Mayor, Madam and Gentlemen, Your obedient Servant, K. E. TAPPER, Medical Officer of Health. 8 PUBLIC HEALTH STAFF, 1931. Medical Officer of Health and School Medical 2 K. E. Tapper, O.B.E., M.B., Officer ch.B., D.P.H. Assistant Medical Officer 2 Miss G. H. Stinson, of Health and School m.r c.s., l.r.c.p. Medical Officer (Appointed 13/5/193l). 2 Miss Marjorie Reekie, M.B., ch B , D.P.H (Resigned 9/5/1931). Orthopaedic Specialist 2 1 H. J. Seddon, f r.c.s. Ear, Nose and Throat 2 1 Charles C. Beney, m.a., Specialist m.b., ch.B., (Camb.), m.r.c.s. School Dental Surgeon 2 T. S. Latham, l.d.s., r.c.s. Senior Sanitary Inspector 5 4 3 2 G. R. Woods, M.S.I.A., a. r. san. i. Additional Sanitary 5 4 3 2 T. C. Towersey. m.s.I.a. Inspectors . 4 3 2 C. J. Clark, m.s.i.a.. (Appointed 3/3/1931). Health Visitors and 7 6 2 Miss L. A. Briggs, s.r.n. School Nurses 8 7 6 2 Miss E. B. Crowe, s.r.n. 7 6 2 Miss S. M. Davies, s.r.n. 8 7 6 2 Miss J. Roseveare, s.r.n. (Appointed 1/7 31). 8 7 6 2 Miss W. Luxmoore. s.b.n. (Resigned 13/7/31). Dental Nurse and Health 7 2 Miss V. Morgan Visitor Orthopaedic Nurse 2 1 Miss D. Gardner, c.s.m.m.g., m.e. 9 PUBLIC HEALTH STAFF—continued. Veterinary Surgeon under the Diseases of Animals Acts 1 P. J. Turner, m.r.c.v.s. Inspector under the Diseases of Animals Acts 1 Alfred H. Sly, General Office Staff: Senior Clerk 2 H. E. Lawley. Junior Clerks 2 Miss M. L. Byford. 2 Miss M. H. Davis. 2 H. Handscomb Outdoor Staff: Drain Tester and DisinJ. W. Seager (Appointed fector 28/12/31.) Market Toll Collector * H. Deane * Retired from post of Drain Tester and Disinfector 13.1.1932, and retains post of Market Toll Collector for one year. 1. Denotes part-time officers. 4. Royal Sanitary Institute Certificate 2. Exchequer Grants (including for Meat and Other Foods. Board of Education). 5. Royal Sanitary Inst., Smoke Cert. 3. Certificate of the Royal Sanitary 6. Three years Hospital Trained. Institute and Sanitary Inspec7. Cert. of Central Midwives' Board. tors Joint Examination Board. 8. Royal Sanitary Inst. new Health Visitors' Certificate (under Memo. 101/MCW). 1.- STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Statistics. Area (in acres) 4,697 Population— Census (1921) 35,052 Census (1931) 45,348 Mid-year 1931 (Registrar General's estimate) 45,430 Number of inhabited houses (Census 1921) 7,400 (December 1931) 11,306 Rateable value £475,216 The sum represented by a penny rate £1,962 10 Vital Statistics. The following extracts from the vital statistics relate to the nett births and deaths after correction for inward and outward transfers: — Live Births Total. Male. Female Legitimate 591 303 288 Birth Rate per per 1,000 of the resident population: 13.5. Illegitimate 26 9 17 617 312 305 Stillbirths Legitimate 25 15 10 Rate per l,000 total (live and stillbirths) births: 40.4. Illegitimate 1 — 1 26 15 11 Deaths 497 221 276 Death Rate per 1,000 of tit estimated resident population 10.9. Deaths from diseases and accidents of pregnancy and childbirth: From sepsis 1 From other causes 3 Death rate of infants under 1 year of age:— All infants per 1,000 live births 47 Legitimate infants per 1,000 legitimate live births 45 Illegitimate infants per 1,000 illegitimate live births 77 Deaths from measles (all ages) 1 Deaths from whooping cough (all ages) — Deaths from diarrhoea (under 2 years of age) 7 It will be noted from the foregoing, and also else where in the report, that disparities exist between figures issued by the Registrar General and statistics collected locally, e.g.:— 11  Registrar General. Local Statistics Live births 617 642 Stillbirths 26 19 Infant deaths 29 27 Maternal mortality 4 5 These discrepancies arise through various reasons. For example, the Registrar General's statistical period may not exactly coincide with the calendar year covered for local statistics, and the allocation of the number of births and stillbirths made by the Registrar General is extracted from the returns of local registrars after deducting those occurring within the area but with residences elsewhere, and adding those occurring elsewhere but ordinarily resident within the area. The same applies to all statistics issued by the Registrar General and makes any preliminary statistical statement issued during the year incorrect. To this there is an obvious remedy; there should be closer co-operation between the local sanitary authority and the authority responsible for the registration of births, deaths, marriages, vaccination, etc. The Local Government Act, 1929, made an effort in this direction of unified administration, but has failed in operation in those large areas of local government such as is Bromley. Social Conditions. There is little to add to my previous report on the social circumstances of the area. Development of the town as a pleasant residential district goes on apace year by year, and the year 1931 has seen no cessation in this respect. It is to be noted that the few remaining sections of residential property in the main thoroughfares of the town are giving way to new business premises. Bromley is so readily accessible to the small towns and villages in the adjacent rural area that its potentialities as a lucrative shopping centre continues to attract the shop builder. The future development of the Borough is almost entirely confined to residential and shop premises under the Town Planning scheme which has been prepared, the density of buildings in the undeveloped area beinar limited as follow:— 12 1526.22 acres not exceeding 4 dwelling-houses per acre. 81.60 „ „ „ 6 „ „ „ „ 1114.7O „ „ „ 8 „ „ „ „ 24.13 „ „ „ „ 10 „ „ „ „ 422.35 „ „ „ 12 „ „ „ „ A great improvement to the business amenities of the town was effected during 1931 with the installation of overhead electric lighting throughout the main thoroughfares. Meteorology. Bromley was not exempt from the generally inclement weather which persisted throughout the country during 1931; lack of sunshine may have contributed in no small measure to the abnormal minor sickness prevalent during the year. The following particulars have been extracted from the records kept at the Climatological Station at Church House Gardens for the year ended 31st December, 1931: Total rainfall 25.05 inches Mean maximum daily temperature 55.52 degrees Mean minimum daily temperature 42.80 degrees Highest maximum temperature recorded 83 degrees on 14th June Lowest minimum temperature recorded 23 degrees on 9th Mar. and 27th Oct. Lowest grass minimum temperature 17 degrees on 10th Mar. Occupations and Unemployment. Until the Registrar General's tabulation of the results of the Census taken in 1931 is published, I am unable to give accurate details of the principal occupations of the Borough. When the figures are publised I do not anticipate any material change in the Table 13 as published in my report of 1930 (page 8), except that the figures will be increased in proportion as the population has increased. The economic stress, almost without precedent in this country, naturally affected our unemployment returns. Bromley has not experienced the acute distress of the industrial areas, but nevertheless the local figures of unemployment are far in excess of those recorded in the past few years. I am indebted to the Manager of the Employment Exchange for the following information:— (1) Recorded unemployment at the Exchange at the end of December, 1931:— Adult Males 921 Adult Females 208 (2) The highest figure reached in 1931 on 7th December:— Males 1074 Females 232 Population. The Census of 1931 shows the population to be 45,348 (20,107 males and 25,241 females), which is an increase of 29.4 per cent. over the population of the previous Census in 1921. This population confers on Bromley the distinction of being the second largest town in the County. The Registrar General's estimate for the mid-year 1931, two months after the taking of the Census, gives the population as 45,430. That remarkable expansion and development has taken place will be appreciated when it is realised that a century ago Bromley as a small market town boasted a population of 4,002. The following Census returns indicates its development:— Year of Census. Popnlation 1891 21,685 1901 27,354 1911 33,649 1921 35,052 1931 45,348 14 II—VITAL STATISTICS. Births. The number of live births registered during 1931 was 617. This figure is calculated by the Registrar General from the births registered with the local registrars after making adjustments for inward and outward transfers and is the basis on which the rates and other statistical data is calculated. Six hundred and seventeen live births produces a Birth Rate of 13.5 per 1,000 of the resident population, and is 0.8 lower than the rate for 1930, and the lowest rate ever recorded in Bromley. The following tabulation gives a comparison of Bromley's annual birth rates with those of England and Wales during the past eleven years:— 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 14.3 16.3 1931 13.5 15.8 (Note.—The Bromley Birth Rate for 1930 has been corrected to the mid-year population for that year). Stillbirths. Nineteen stillbirths were notified in 1931; the Registrar General's figure for the year 1931 is 26 stillbirths. This latter figure would include cases born outside the area which were ordinarily resident in Bromley. During the past five years the number of stillbirths occurring is shown in the following table:— 15 Year. Stillbirths. Rate per 1,000 births. 1927 16 25.2 1928 10 15.3 1929 23 36.8 1930 17 27.0 1931 26 40.4 It is difficult to determine whether the registration of stillbirths has brought about an increased efficiency in notification. The indiscriminate and undue publicity given to birth control is giving rise to interference with pregnancy, a matter to which I drew attention in my previous report. With a downward tendency in the birth rate and an upward tendency in the stillbirth rate there is real reason for concern. Deaths. Four hundred and ninety-seven deaths were registered during the year, of which 221 were males and 276 females. This figure gives a Death Kate of 10.9, an increase of 1.1 over the date for 1930. The 1931 Death Rate for England and Wales is 12.3. The following tabulation gives the crude death rates for Bromley compared with the death rates for England and Wales during the past ten years:— Year. Bromley. Crude Death Rate, England and Wales. Death Rate. 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 9.8 11.4 1931 10.9 12.3 Note. The crude death rate for 1930 has been corrected to the mid-year population for that year.) Age grouping and sex distribution of the population are important factors which must be taken into consideration when comparing death rates. A higher death rate 16 prevails in the population of the higher age groups than in a population of the middle or younger age groups, unless a severe form of epidemic disease has caused exceptional mortality during the year. Bromley was happily free of epidemic disease in such a form as to cause undue mortality, but there was an increase of 68 deaths during 1931 over the figure for 1930, which is accounted for in the increase of deaths from the following causes: heart disease, pneumonia, bronchitis, and cerebral haemorrhage. The causes of deaths are shown in detail in the Appendix III., from which the following main causes have been extracted, and the figures for 1930 are given for comparison:— No. of deaths. Rate per cent of total deaths. Rate per 1,000 of population. 1930 1931 1930 1931 1930 1931 Respiratory Disease 31 42 7.2 8.4 0.7 0.9 Heart Disease 104 122 24.2 24.5 2.3 2.6 Cancer 69 71 16.08 14.3 1.5 1.5 Tuberculosis 41 34 9.5 6.8 0.9 0.7 Premature Births 16 13 3.7 2.6 0.3 0.2 Infectious Diseases 5 9 1.1 1.8 0.1 0.1 Influenza 3 8 0.7 1.6 0.06 0.1 Having regard to the fact that the vital statistics and rates in the Annual Report for 1930 were based on the mid-year population figure of 41,840 for 1929, I have corrected the rates per 1,000 population for 1930 in the above table on a population estimated at 43.830 for mid-year 1930. A study of the foregoing table shows that the ratio of deaths is favourable considering the increased population. Infantile Mortality. Twenty-nine deaths of infants under one year of age were registered, giving a Mortality Rate of 47 per 1,000 births. The rates for Bromley and England and Wales during the past ten years are shown in comparison in the following table:— 17 Year. Bromley. England and Wales 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 1931 47 66 Maternal Mortality. 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 1931 1 3 6 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 mothercraft 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. Orthopædic treatment and Consulting Surgeon for the crippled child. 18 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 Gynæcologist for Puerperal Fever and Puerperal Pyrexia cases. Child Welfare Centres. Widmore— Wesleyan New Hall, Tylney Road Tuesdays, 2.30 p.m. Burnt Ash— Burnt Ash Branch Library, Tuesdays and Burnt Ash Lane Wednesdays, 2.30 p.m. Plaistow— School Clinic, Station Road Wednesdays, 2.30 p.m. Shortlands— Congregational Hall, Martins Road Thursdays, 2.30 p.m. Bromley Common— St. Luke's Institute, Raglan Road Fridays, 2.30 p.m. Ante-Natal Clinics. Held at the Clinic, Station Road, on the first and third Thursdays in every month at 2.30 p.m. Orthopædic Clinic. For children with crippling defects under five years of age, as well as school children. Held at the School Clinic, Station Road. 19 Mondays at 9.30 a.m. Tuesdays at 9.30 a.m. Massage Thursdays at 2.0 p.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, Station Road, 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. Dental Clinic. Held at the School Clinic daily for children, and expectant and nursing mothers attend on Saturdays at 9.30 a.m. Diphtheria Immunisation Clinic. Held at the School Clinic on Mondays at 2.30 p.m. 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 19.30 235 233 24 1931 184 180 24 20 It will be noted that the increasing use made of the Ante-natal Clinic up to 1930 received a setback in 1931. Changes in staff personnel is the explanation of this falling off, which is a common experience in work of this nature. The total number of expectant mothers who attended at the clinics during the year was 101, and the average number of expectant mothers per session at all clinics was 8. Of the confinements taking place in the Borough, approximately 16 per cent, had attended the Ante-natal Clinic, the remainder coming under ante-natal supervision of midwives, doctors and maternity nurses. The work of the clinic is supplemented by home visitation, carried out by the health visitors, midwives and nursing staff of the District Nursing Association. During 1931 visits to ante-natal mothers were as follows: — Health Visitors 139 District Nurses 1089 Whilst there was a falling off in the number of ante-natal visits by health visitors in 1931, there was a corresponding increase in visits by the district nurses. The development of the district and its services has had the inevitable effect of depleting the visiting time at the disposal of the health visiting staff. That home visitation to expectant mothers, a work of such importance, should suffer, has been a matter for considerable concern, the solution for which appears to lie only in additional staff. Although the recorded visits is low, there is some compensation in the fact that expectant mothers receive attention from an " unrecorded " aspect, as many of them are regular attendants at the welfare centres and surveillance is then exercised. This type of supervision is in the nature of a " makeshift ' has not the value of the direct home visit, when the visitor can give that undivided attention to the individual in the confines of the home which is so desirable to this branch of the work. The existence of a clinic is now more widely in Bromley and the surrounding districts, and patients have been sent to us from Biggin Hill, Cudham, Orpin ton, Farnborough, Keston and Hayes. 21 Ante-natal examination is being sought more and more by mothers in Bromley and they appreciate the advice and help given them. Twelve cases with abnormal conditions have been referred to London Hospitals for further investigation and treatment, and arrangements are made so that the mother is placed under the best conditions possible for a safe confinement; the results are gratifying. Good ante-natal care is one of the greatest factors that is going to lower the maternal and neo-natal mortality rates. There is a need for more ante-natal clinics, for at the time of writing this report the number of patients attending is far too many for the time at the disposal of the clinic. I am convinced that ante-natal examination can only be effectively performed by the skilled gynaecologist; the present practice whereby the midwife does the antenatal supervision and the doctor the confinement should he reversed, and provided the mother is skilfully and periodically examined by the doctor in the ante-natal period, the actual confinements should be left solely to the midwife in all cases which show themselves as physiologically normal. Natal Services. Six hundred and sixty-one births were known to have occurred in the Borough during 1931, of which 637 were notified in accordance with the provisions of the Notification of Births Act, 1907, and of these 19 were stillbirths. In addition, 24 births were discovered which had not been duly notified, and investigations into noncompliance with the Act proved that in most cases the doctors and maternity nurses attending had left the duty of notifying to the other, with the ultimate result that the duty was not carried out. Warnings were given in these and in other cases of forgetfulness to notify. The 661 births were notified as follows: — Notified by midwives 275 Notified by doctors and parents 362 " Un-notified " 24 661 22 Forty-one per cent, of births in Bromley in 193 were attended by midwives practising in their professional capacity. Attendance at Birth. During 1931 a special point was made into the enquiry of attendance at birth in those cases which are visited by the health visitors. As 74 per cent, of al births occurring in Bromley are visited by the healtl visitors the results of the enquiry are based on 486 births Cases were divided into primipara and multipara, ant the facts obtained were elicited from the mother ant were confirmed in most cases through the midwives records. Attendance. Primipara Of the 486 cases investigated 212 were primipara. 70 per cent, were attended by doctor and midwife. 24 ,, ,, ,, ,, midwife alone. 6 ,, .. ,, ,, doctor and handywoman Multipara. 35 per cent, were attended by doctor and midwife. 57 ,, ,, ,, ,, midwife alone. 8 ,, ,, ,, .. doctor and handy woman Environmental. 50 per cent, of primipara and 24 per cent, of multipara were born in hospitals or maternity homes. 17 babies were born in one-room families, 11 these being the first baby in the family. 214 babies were born at the Maternity Hospital, 51 of these being extra district families. 35 Bromley babies were born at the Farnborough Institution. These statistics bring out several facts of interest, but as they apply to a small number of births their value is limited. However, Bromley being a residential area, similar figures would probably apply to areas ot the same residential character. 23 The employment of handywomen, that is persons untrained in midwifery, in 7 per cent, of all cases is to be regretted, especially so when there are so many experienced midwives who find it difficult to obtain adequate engagements. Many of these cases after the actual delivery by the doctor are left to the care of the unskilled person, who is not regulated by any inspection or rules such as are laid down for midwives. It seems an extraordinary state of affairs that anyone can set themselves up as a maternity nurse and yet have no training either in asepsis, or in the care of midwifery cases. Two cases came to my notice during 1931 where the actual delivery of the baby was performed by a so-called maternity nurse, the doctor arriving late on the scene. A remedy lies largely in the hands of the general practitioner in not agreeing to attend any case unless a skilled midwife has he-en engaged. The real remedy lies in statutory prohibition of the term " maternity nurse " without having had hospital experience in the care of maternity cases. One other interesting fact in the statistics is shown in the difference in the percentage of midwives at the birth between the primipara and the multipara. It is a mistake to consider the primipara the more difficult labour than the multipara. In cases where the ante-natal supervision of the primipara has been adequate it is frequently the very reverse. It is thus difficult to explain why 24 per cent, of primipara who engage a midwife alone should increase to 57 per cent, in the multipara, and the doctor and midwife figure fall from '0 per cent, to 35 per cent. It may be finance; having discovered that the cost of both midwife and doctor is more than the parents can afford, they do not wish to repeat the experience, or it may be, having obtained a faith in the midwife at the first confinement, the mother is prepared to place the whole trust in the midlife on the next occasion. It is probably due to the greater anxiety of the young mother as would be indicated by the hospital confinement figures—50 per cent, in tlie primipara falling to 24 per cent, in the multipara. One disturbing fact brought out of these investigations is that no less than 17 mothers were confined in °ne-room premises, 11 being primipara. None of these 24 cases attended the Ante-natal Clinic, otherwise provision would have been made by the Department for their confinements in hospital. If bad enrivonmental conditions exist, such as one-room family, the Council have made provision to supply maternity hospital accommodation within the financial means of the parents, and yet in spite of this provision the person engaged for the confinement, whether a doctor or midwife, did not take steps to acquaint the mother of the provision made by the Local Authority. In other cases the parents themselves have been neglectful, being perfectly satisfied to run the risk of a confinement in a living room without even the rudiments of the requirements to cope with any emergency that might arise. While such conditions exist in practice we must continue to run the risk of a higher maternal mortality figure. 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 17. Of this number, three are employed by the District Nursing Association, and the remainder are in the employ of the Maternity Hospital, nursing homes or in private practice. None are employed or subsidised by the Council. The number of case attended by midwives during the year 1931: — (1) As midwives 253 (2) As maternity nurses 305 Administration of the Midwives Acts, 1902-1926. No. of midwives practising in Bromlev at the end of 1930 21 No. of midwives giving notice of intention to practice during 1931 No. of midwives removed from the local register having left the district 11 No. of midwives practising in the area at the end of 1931 17 Notifications Received. Notices calling in Medical Aid—Mother Infants 15 44 25 Notices of Artificial Feeding 2 ,, Stillbirths 3 ,, ,, Deaths 4 ,, ,, Laying out a Dead Body 2 ,, ,, Source of Infection 2 Summary of Reasons of Sending for Medical Help. Ruptured perineum 9 Delayed labour 6 Breast conditions 2 Inertia 1 Varicose veins and leg swellings 3 Ante-partum haemorrhage 2 Prolapse of cord—vertex presentation 1 Placenta Praevia 1 Abnormal presentation 1 Collapse after delivery 1 Ante-natal examination 1 Infants—Feeble, prematurity, etc. 8 Malformations 3 Eve discharge 2 Death 1 Melaena 1 Rash 1 44 Payment of Doctors called by Midwives, Section 14, Midwives Act, 1918. No. of applications for payment of fees 39 No. of cases where payment of fee lapsed, on account of failure to claim within the prescribed period of two months 4 No. of cases where patient paid the doctor's fee direct 1 Total amount of claims paid £44 7s. Od. No. of necessitous cases in which repayment of claim was waived, or partial repayment of claim accepted by the Committee 5 Inspection of Midwives. Inspections by the Inspector of Midwives 86 26 The Inspector of Midwives pays as a routine quarterly visits of inspection to all midwives practicing in the area. It is noteworthy that although the skilled midwife is subject to inspection and supervision, the self-styled maternity nurse, who has received no training whatsoever, escapes supervision, and provided she does not act as a midwife in the confinement need keep no records of her work. We hear a great deal about maternal mortality, and the steps that are required to combat this mortality, but we ignore this person who may be the cause of much harm, not only to the patient's physical welfare, but also not infrequently carries influence with the patients in preventing a true knowledge in the care of maternity and infant welfare. Dr. G. H. Stinson, Assistant Medical Officer of Health, who is Inspector of Midwives for the Local Supervising Authority, reports as follows: — The general personal appearance and home conditions of midwives is satisfactory, and in only one case did inspection appear to be resented. Maternity bags and instruments were found to be sufficient and well kept. In one case the equipment lacked completeness, e.g., saline infusion apparatus was not kept in the bag. The standard of keeping registers in some cases is most excellent, but in other cases they were found not so complete. The ante-natal notes of some of the midwives' cases are poor, and apparently not all visits are entered. One midwife appeared to know very little about ante-natal work, a post-graduate course was advised, and this she appeared anxious and willing to carry out. Examinations by the midwife of doctors' cases are not usually done, and the ante-natal notes are not kept in these cases, except in one or two instances. Post-Certificate Course. During October, 1931, an excellent course was heid at Maidstone, and five midwives were financially assisted to attend. Maternity Hospital and Maternity Homes. There were 14 cases financially assisted under the Council's scheme for admission of cases to the Maternity Hospital. In addition, 25 cases were recommended from 27 the Ante-natal Clinic to the Maternity Hospital and were admitted without financial assistance from the Council. The total number of women admitted to the Hospital during the year was 214, and of this number 163 were from the Borough area. There are within the Borough ten institutions maintained by private and voluntary effort coming within the classification of Maternity Hospital and Homes, and registered under the Nursing Homes Registration Act, 1927. Including the Maternity Hospital, these institutions provide 26 maternity beds, to which 277 maternity cases were admitted during 1931. Details of maternity and nursing homes registered by the Local Authority under the Nursing Homes Registration Act, 1927, appears later in this report under the section dealing with the Summary of General Provision of Health Services in the Area. The whole question of adequate maternity hospital accommodation for the Borough must continue to exercise the attention of the Local Authority. This matter I have discussed in previous reports. Puerperal Fever and Puerperal Pyrexia. During the year the arrangements with the Sevenoaks Isolation Hospital for treatment, isolation, etc., came under review with a view to adopting a more economical scheme. The arrangements with Sevenoaks were terminated in December, and the Council has entered into an arrangement with Queen Charlotte's Maternity Hospital, London, for the reception and treatment of cases of Puerperal Fever and Puerperal Pyrexia at their Isolation Block, Ravenscourt Square, Hammersmith. Cases will be conveyed to the Hospital by the London Ambulance Service of the London County Council. One case of Puerperal Fever, and one case of Puerperal Pyrexia were notified during 1931 under the Public uealth (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926. The former case was admitted to the Sevenoaks Isolation Hospital for treatment. 28 Post-Natal. Home Visiting. The Corporation employs five health visitors, who are engaged half-time in the School Medical Service, and in one cases as Nurse to the Dental Service. One Nurse attends the Wednesday afternoon session at the Tuberculosis Dispensary and carries out home visitation of tuberculosis patients. Table XII. in the Appendix will give details of the work of home visiting during 1931, a work which is fundamental in the building up or maintaining an efficient Maternity and Child Welfare Service. It is thus all the more serious to record a falling off in this return, a falling off which is in no way due to the personnel, but to the automatic increase in the use of the service, and to the demands of the service since we appointed a fourth health visitor for maternity and child welfare in 1928. In all, there has been 313 visiting days lost each year through these increased demands on the health visitors' time, and it follows that if we are to keep to our present standard of efficiency, of which Bromley is justly proud, the appointment of an additional health visitor has become necessary. Welfare Centres. The Corporation provides five welfare centres in the town, at which six sessions are held weekly. The total number of babies on the registers of these centres at 31st December, 1931, was 1,378. The total number of attendances at all centres during the year were: (i) by children under one year of age, 3,890, and (ii) by children between the ages of' one to five years, 8,015. The average attendance of children per session throughout the year was 40. The total number of children who attended at the centres for the first time during the year: (i) children under one year of age, 285, representing 46 per cent, of notified live births, and (ii) children between the ages of one to five years, 150. The work accomplished by these centres is indicated in the statistical table given in the Appendix XIII The staff of voluntary workers attached to these centres are doing work of untold value, they bring with 29 them that necessary voluntary aspect that is so essential to any State undertaking. No word of praise from me can overstate their valuable services. Milk in Necessitous Cases. Assisted milk supply was granted to 127 individual cases, who received a total of 10,338 pints of milk, and 18 lbs. of dried milk, during the period January to December, 1931, at an approximate cost of £129. Minor Ailment Treatment. The facilities of the School Medical Services are available to the pre-school child, it being the policy to treat early in order to prevent gross defects in the school entrant. Tonsils and Adenoids. Twenty-eight cases under five years of age received operative treatment at the Ear, Nose and Throat 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 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. Minor Ailments. Fifty-nine cases received treatment at the School Uinic for ailments such as skin diseases and minor surgical injuries. Orthopaedic. Mr. H. J. Seddon, Orthoptedic Surgeon, has reported on cases dealt with during the year in the School Medical section of this report, and other details and statistics of this Uinic, including maternity and child welfare cases, are there dealt with. 30 Dental Clinic. Fifty-eight children under five years of age were treated at the Dental Clinic; 17 expectant mothers also received treatment. Ophthalmia Neonatorum. Impairment of vision was not recorded in any of the three cases notified during the year, statistical particulars of which are given in Appendix XI. Diarrhoea and Enteritis. Seven deaths of children under two years of age were recorded during the year. This is equivalent to a rate of 11 per 1,000 babies born in the year, and is again an increase over the average rate for Bromley. This increase, from what is largely a preventable disease, was due to an epidemic which occurred during May and June. Very few of these cases were admitted to hospital, although they could only be inadequately nursed at home. There is, unfortunately, the tendency to treat cases of acute illness in babies in the homes, where it is practically impossible to provide skilled attention throughout the day and night. With a limited health visiting staff' it is also not possible to give the individual instruction in the prevention of this serious disease in babies. Children Act, 1908, Part I. This section of the Children Act refers to the care and supervision of boarded-out children, the responsibility resting on the Maternity and Child Welfare Authority. A new enactment is at present in the committee stage in Parliament, and by the time this report is circulated will no doubt have received the King s consent. The new Act should rectify many defects oi the 1908 Act, and it will be possible to follow more clearly the movements of an unwanted boarded-out childAs the law at present exists it is not always possible tn keep touch with the child from one foster-mother to another, but if the present Bill becomes law the fostermother will be required to give notice before reception 31 of a child and not after as is at present the case. The following statistics will give some indication of the work during 1931: — No. of foster-parents on the Register at 31st December, 1931 44 No. of children on the Register at 31st December, 1931 48 No. of supervising visits paid by the health visitors 135 Except in 10 cases, all remedied by warning letter, the requirements of the Children's Act were carried out, but not infrequently has one met with the difficult fosterparent who can see no reason in our limiting the number of boarded-out children to two to any one foster-mother. Prior to this restriction one frequently met with the foster-parent whose main source of income was the payment received for the care of four or five foster-children. 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 V.) 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-Laics: Common Lodging Houses 1897 Nuisances (Bve-law 13 repealed 13/2/1912) 1897 Cleansing of Earth Closets, Privies, Ashpits and Cesspools 1898 32 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 to 1931 Good Rule and Government 1927 and 1931 Registries for Female Domestic Servants 1927 Nursing Homes 1928 Orders: Hairdressers' Early Closing Order (Made under the Shops Acts, 1912) 1922 Midwives Acts, 1902-1926 (Order under Section 62 of the Local Government Act, 1929) 1930 Regulations: Movement of Sheep 1931 Hospitals. (1) Infectious Diseases Hospitals: West Kent Isolation Hospital 118 beds West Kent Smallpox Hospital 39 ,, (2) General Hospital: Bromley (Kent) and District Hospital 47 „ (3) General Hospital: Phillips Memorial (Homeopathic Hospital) 18 (4) Maternity Hospital: The Bromley and Chislehurst Maternity Hospital 12 Maternity and Nursing Homes. There are 10 maternity and nursing homes registered under the Nursing Homes Registration Act, 1927. 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: — Address Total No. Beds Maternity beds Patients received in 1931 Nursing Staff. Type of cases taken. Maternity. ■Surgical Medical Total. Residen Living Out. Qualifications. 77, Avondale Road 6 3 19 16 10 3 3 — 1 Gen. Trained and C. M.B. 2 Asst. Nurses. Mixed 40, Bromley Common 11 5 24 62 15 6 6 - 1 General Trained. 2 Gen. trained and C.M.B. 1 C.M.B. do. "Greta," Blyth Road 9 1 3 65 19 5 3 2 2 Maternity Trained. 2 Gen. Trained and C.M.B. 1 Gen. Trained. do. 24, Elmfield Road 10 2 12 3 3 - 1 Vacancy. 3 Gen. Trained do. 3, Elmstead Lane 8 1 4 65 16 4 4 3 Gen. Trained. do. "Frascati," Masons 1 Untrained. 10 1 6 5 14 6 6 - 1 (Gen. Trained and C.M.B. do. Hill 3 Gen. Trained. 2 Untrained "The Cloisters," Southborough Road 12 - - - 30 2 2 - 2 Fully Trained. Nursing 13, Tweedy Road 4 - — - 6 1 1 — 1 Gen. Trained Fully trained Nurses do. 43, West Street 1 1 7 - 1 1 engaged when necessary. 1 Untrained. Maternity Maternity Hospital, 12 12 214 - 7 7 1 Gen. Trained and C.M.B. do. 118, Widmore Road 4 C.M.B. 2 Untrained. Bromley (Kent) and 47 — — 605 8 8 - 3 Gen. Trained and C.M.B. (Gen. Hospital District Hospital, (unclas sified) 4 Gen. Trained. cases. Cromwell Avenue 1 Gen. trained and masseuse Phillips Memorial 18 — — 146in-patients 5 5 - 2 Gen. Trained. do. Hospital, 345out- (unclas 3 Asst. Nurses. Lowndes Avenue patients sified) 34 Institutional. (1) The Rochester Diocesan Society for Befriending Women and Girls has a Home at 29, Ravensbourne Road, which was opened in October, 1912. Here 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 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 Corporation, is available at any hour for the removal of accident cases to hospitals ,and it may be requisitioned for the removal of sick cases of a non-infectious nature, the fee being remitted in necessitous cases. Laboratory Facilities. The arrangements for testing throat swabs at the West Kent Infectious Disease Hospital continues to work efficiently and with despatch. The facilities at Maidstone provided by 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, and makes provision for the following treatments and services, details of which have been dealt with in 35 both the Maternity and Child Welfare and School Medical sections of this report:— 1. Minor ailment treatments. 2. Tonsil and Adenoid Clinic. 3. Eye 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:— 1. Bromley Common. 2. Burnt Ash. 3. Plaistow. 4. Shortlands. 5. Widmore. Each centre is held weekly, with the exception of Burnt Ash, where two sessions are held weekly. Full particulars of each centre appear under section III., Maternity and Child Welfare, of this report. Nursing in the Homes. The Bromley District Nursing Association, which was formed in 1907, provides professional district nursing in the homes. I am indebted to the Hon. Secretary of the Association for the following details of the valuable work performed by the staff of nurses during 1931:— Summary for the Year 1931. Cases on the Register, January 1st, 1931 25 New cases during the year 443 Visits Paid. General Nursing 4329 Ante-Natal Visits 1089 Maternity and Midwifery 3056 Casual Visits 611 36 Analysis of New Cases. Medical 13C Surgical 108 Maternity (with Doctor) 62 Midwifery 143 Abortions 6 Cases sent in by: Doctors 134 Visitors and Others 14 Found by Nurse 11 Applied 284 Result of Cases Nursed. Convalescent or Relieved 375 Sent to Hospital, Infirmary or Transferred 21 Died 25 Still on Register at 31st December, 1931 22 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 for attendance at the Dispensary from the Health Visiting staff, who also carries out the home visiting of patients. In a later part of this report the work of the Dispensary is briefly reported on by the Tuberculosis Officer, Dr. W. B. Martin. 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. 37 V.—SANITARY CIRCUMSTANCES. Rivers and Streams. Periodical inspections of all streams and watercourses in the district are made by the sanitary inspectors, and during the year one instance of pollution of a minor character was remedied after service of informal notice. 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 22 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 Short lands valley. The supply is sufficient and of high grade purity, and is accepted as a standard of purity for deep well water. Particulars of reservoirs within the district are given in my Annual Report for 1930 (page 35). Scavenging. During the year 1931 one 2-ton electric vehicle was purchased, the refuse for the greater part of the year being collected with the following transport:— 3 one-ton covered low-loading petrol vehicles. 3 two-ton covered low-loading electric vehicles. 1 high-loading horse-drawn vehicle. All refuse during the year was disposed of at the Refuse Destructor by incineration, and necessity for improvement in disposal did not arise during the year. 38 Rats and Mice Destruction Act, 1919. The arrangements made by the Health Department were similar to those adopted in past years, which included free supplies of Red Squill, Red Squill Biscuits, and a gassing machine and operator were available. The usual baiting of the sewers was carried out. The use of Red Squill continues to give satisfactory results. The local chemists evinced greater interest in the Rat Week Campaign, and six firms co-operated by making special displays of poisons, posters, leaflets, and stuffed rat exhibits were shown. The public appear to take but little interest in Eat Week in Bromley, as only 20 applications for free poisons were received by the Health Department during the Campaign. It does not appear that the public generally realise that it is their duty, and not the duty of the Local Authority, to rid premises of rats. The Health Department assists the public by offering facilities and advice on the best methods of destruction. Such general action is taken throughout the year as may be necessary to abate the presence of rats in property under the control of the Local Authority, and that the efforts of the Health Department were not relaxed during the year is evidenced by the fact that the inspectors made 136 visits to premises where rat infestation existed, and 42 notices were served. Nuisances. Appendices VII. and VIII. are submitted by Mr. G. R. Woods, Chief Sanitary Inspector, and indicate in some measure the varied and valuable work carried out by the sanitary inspectors. The noticeable increase in the figures is due to increase in staff, an additional sanitary inspector being appointed in March, 1931. House-to-House Inspection. Four hundred and seventy-nine houses were inspected under the Inspection of District Regulations. This number is a considerable increase on the former year's figureIn addition, 511 houses were also inspected and notices served to abate nuisances and defects. The majority of 39 these houses were inspected under the Housing Act schedule, but cannot lie legitimately included in the Inspection of District Regulations, although they were made fit in accordance with the Housing Act. There is an increase in the number of defects remedied this year. It has been found possible to make re-inspections more often whilst work is in progress. Supervision of the work carried out by owners and builders is a very important branch of the sanitary inspector's work. The following figures show the progress made under the Housing Act, 1930, in relation to Unhealthy Areas and Insanitary Houses, and indicates the total number of dwelling houses made fit since the inception of the Housing Act, 1930, up to the 31st December, 1931: — Since the inception of the Act to 31st December, 1930 15 March Quarter, 1931 81 June Quarter, 1931. 87 September Quarter, 1931 180 December Quarter, 1931 192 Since the inception of the Act to 31st December, 1931 555 VI.—HOUSING CONDITIONS. In the main, housing conditions remain excellent. According to the Census figures for 1931 there are 191 houses or tenements which contain more than two persons per room. Twenty-six houses were visited on complaint of overcrowding, and in 13 cases the overcrowding was abated. »hen overcrowding exists in a one-family house, and re-distribution of sleepers is not possible, extreme hardship would occur if statutory action was taken. In cases of overcrowding found in houses where there are two or more families action is always taken to abate overcrowding. 40 A special survey was made into the condition of various types of working class houses with the following result, which has been extracted by Mr. G. R. Woods, Chief Sanitary Inspector. Five hundred and ninety-one working class houses were visited for the survey purposes, special enquiries being made for overcrowding conditions for houses containing more than one family, and also for the existence of one-room families. The houses selected for visitation were in various districts throughout the Borough. Seventy-five of the houses visited contained two families, four contained three families, and one contained four families. In these 80 houses 15 one-room families were found to exist. It is singular that in none of these cases did there exist overcrowding, basing the overcrowding on the Registrar's General's standard of more than two persons per room exclusive of scullery. Using the same standard, 10 houses out of 591 were found to be overcrowded, each of these houses contained only one family. It will be observed that 1.6 per cent, were overcrowded and 15 per cent, contained two or more families. The following tables show the figures in relation to overcrowding, houses occupied by more than one family, and the weekly rents and rates paid by the occupiers: — Table I. No. of houses inspected. No. containing 2 families. No. containing 3 families. No. containing 4 families No. of one-room families. Xo. of houses overcrowded e.g., more than 2 persons per room. 591 75 4 1 15 10 41 Table II. Type of House. No. of Rooms. No. containing two families. Weekly Rent and Rates One-room family Remarks. alto 10/- 10/to 12/- 12/to 15/. 15/. to 20/- 20/and over 3 rooms 1 1 - - - - - (a) 1 owner and occupier, lb) 3 owner occupiers. 4 rooms 11 — 4 7 - - 3 5 rooms 44 4 13 (a) 10(b) 16 1 10 6 rooms 18 2 7 3 6 - - 7 rooms 1 — - - - 1 — Totals 75 7 24 20 22 2 3 Families 5 rooms 4 — 1 2 1 — 1 4 Families, 5 rooms 1 — — 1 — — 1 Totals 80 7 25 23 23 2 15 Table III. Total number of houses surveyed 591. Houses overcrowded containing only one family, e.g., more than two persons per room (scullery excluded). Type of House. No. of rooms. Houses overcrowded Weekly Rent and Rates. 8—10/- 10-12/- 12-15/- 15-20/- 20/- and over 3 5 5 - - - - 4 4 1 1 2 - - 5 1 — — 1 — — Totals 10 6 1 3 — — 42 Prevalent Defects in Housing. A reference to the Housing defects (Appendix VIII.) submitted by Mr. G. R. Woods and the Inspectors, indicates the predominating defects to be: \inpaved yards, drinking water from cisterns, want of ventilated food stores, worn stone sinks, dampness due to porosity of bricks, absence of, or perished damp-proof courses. With regard to the repair of houses, very little difficulty is experienced with owners of property. There were no police court proceedings to enforce any work to be done. Co-operation between the owners, agents, tenants and inspectors is encouraged with the result that the work necessary is amicably carried out. Housing 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 growing children. No difficulty has been encountered under the Bye-laws affecting Tents, Vans and Sheds. VII— SMOKE POLLUTION. Five routine visits and observations were made, but no nuisances under the Public Health (Smoke Abatement) Act, 1926, were observed. VIII.—SHOPS ACTS. Four hundred and thirty-four visits were made under these Acts, 22 contraventions were reported which related to the failure to display notices with reference to assistants' half-holidays, and the hours of employment of assistants under the age of 18 years. The shop-keepers in question provided the necessary forms forthwith. The district is periodically patrolled during the week-day and Sunday evenings. In the main, shopkeepers comply with the provisions of the Shops Acts, and no legal action was found necessary during the year 1931. 43 IX.—PETROLEUM ACTS. Number of Licences issued 87 (i) For Petroleum Spirit 83 (ii) For Carbide of Calcium 4 Total Quantity of Petroleum Spirit in gallons 168,925 (i) Bulk storage in gallons 149,825 (ii) Two-gallon can storage in gallons 19,100 Carbide of Calcium in lbs. 704 Of the 87 licences issued, 80 were renewals and 7 were new licences. Included in the total of 87 licences are 24 licences for combined bulk and can storage. Two hundred and seven visits to storage places were made during the year. The following figures show the increase in licenced storage which has taken place since 192G : — Petroleum Spirit. (in gallons). Licences issued, (Petrol only). 1926 66,915 77 1927 103,025 69 1928 159,335 82 1929 159,746 92 1930 166,308 81 1931 168,925 83 X.—FACTORIES AND WORKSHOPS. Statistics with regard to inspections and defects in factories, workshops, workplaces and outworkers' premises may be seen in Appendix XIV. The total number factories, workshops, workplaces and outworkers' premises on the register is 372, and the following is a tabulation of the businesses carried on:— Bakehouses 28 Bootmakers Repairers 31 Tailors 29 Laundries 33 Motor and Cycle Engineers 43 Restaurants, Eating-Houses 23 Dressmakers 24 Upholsteries 16 Other Trades 128 Outworkers 17 44 XI.—PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS, REGULATIONS, Etc. Dairies, Cowsheds and Milkshops 63 Confectionery, Ice Cream, etc. 79 Licenced Premises 33 Bakehouses 28 Butchers' Premises 37 Slaughterhouses 10 Hotels, Restaurants 23 Fish Shops 24 Other Food Shops 140 Shops, various 450 Stables 19 Cinemas 2 Petroleum Spirit Stores (Licenced) 87 Factories, Workshops, Workplaces and Outworkers 372 Offensive Trade (Tallow Melting) 1 Registry Offices 9 Nursing Homes 10 The foregoing premises undergo regular visitation by the staff of the Health Department, and no less than 2,984 inspections were made. XII.—INSPECTION AND SUPERVISION OF FOODSTUFFS. There is a noticeable increase in the visits to food shops and stores during the year; this forms one of tie most important duties in the work of the sanitary inspectors. There were instances of unsound meat brought in from outside the district being found in shops. Complete co-operation exists between the butchers and the Department, so that there is very little chance of imsound meat or food reaching the public. New refrigerating plants have been installed by butchers—these plants are automatically controlled. This is a great advance upon the ice bos method, which was devoid of temperature control, which is so essential in preservation of food. 45 One butcher (luring the year replaced an open window front with a closed windowed front and their trade has increased in consequence. It is hoped that a few remaining Arms will follow this example, and also that the discerning public will buy food only from shops that take the necessary precautions to protect foodstuffs from dust, etc. Bread is still delivered by Bromley bakers unwrapped. This method of delivery is unsatisfactory. Manufacturer of Homemade Fish and Meat Paste. It is the practice in some shops to advertise "Homemade" food products. There is no legal obligation on persons to notify the local authority that they are manufacturing or preparing for sale articles of food at home. It was thus acting on casual information that the Chief Sanitary Inspector visited a certain house, whose occupier was making and preparing meat and fish paste. The house was entirely unsatisfactory for the preparation of this food, and some 50 jars containing various fish and meat pastes were found unfit for food. Forty other jars which were sold to a shop in this district were found in a similar condition. Action subsequently taken by the Department caused this person to cease this type of business and the material was destroyed. The bacteriological examination of the paste proved beyond doubt its unsatisfactory nature, although there -was a printed guarantee that the food complied with the requirements of the Sale of Food and Drugs Act. Firms should be wary of the term "Genuine Home Made" articles of food and strict enquiries should be made before dealing in this class of food. Milk. The milk supply may in the main be considered satisfactory. The bottle method of delivery is increasing and loose milk delivery from cans-is fast disappearing. A very large quantity of milk sold is pasteiirised in accordance witK the Milk (Special Designations) Order, 1923. 46 In ray opinion, there is no question of what is the safest milk supply, as raw milk cannot be guaranteed as free of infection in spite of the various and complicated designations given to graded milks; the only safe milk is that pasteurised under licence. Infections such as scarlet fever, typhoid and streptococcal throats have been known to have been spread by even graded milks, and it would appear to me, while these conditions may be rare in public health, they are active possibilities, and should be safeguarded against by efficient pasteurisation. The adverse question, the change, if any, of the food value by pasteurisation, is not one of importance; alteration in vitamin content is easily remedied and is thus of no practical consequence. So much unreasoned propaganda goes on from door to door by the raw milk producers, that it is time the public was fully and authoritively instructed in what is, and what is not, a safe milk. One notes that raw milk is delivered to institutions, such as hospitals, in the area— they should give a lead to the public and not judge milk on its cream line only. The following premises are registered for the sale of milk: — Dairies and milk-stores 63 Dairies licensed for the sale of: "Pasteurised" milk . 10 "Certified" milk 5 "Grade A" milk . 1 "Grade" (Tuberculin Tested) milk 3 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. Bacteriological Examinations. Samples of milk were submitted for examination with the following results, and where bacterial counts did not comply with the standard laid down under Regulations, the matter was taken up with the producers concerned and subsequently remedied:— 47 Samples. Satisfactory. Unsatisfactory. "Grade A Pasteurised" milk 1 "Pasteurised" milk 11 2 "Certified" milk - 2 Ordinary milk 7 1 In the case of the two unsatisfactory samples of Pasteurised milk, the firm producing this closed their plant. Contraventions. Cases of contraventions of the Milk and Dairies Order, 1926, were reported as follows: — (1) Bottling and sealing in the street Warning given. (2) Ditto Ditto. (3) Dirty sediment in bottles of milk and dirty crates of a dairy firm Ditto. (4) Labelling bottles of milk in street as milk produced at farm Ditto. (5) Milk supply of a dairy firm became contaminated with disinfectant Immediate action taken Cowkeeper in an adjoining district had used milking pail which previously had contained disinfectant. 17 samples of milk from various producers were sent to the Public Analyst to confirm the actual source of contamination Meat. lliere are five licenced and five registered slaughter- louses in the Borough. Five thousand one hundred and eighty animals were Known to have been slaughtered, and 5,080 were Cammed hy the sanitary inspectors. Therefore 98 per 48 cent, of carcases were seen, which represents a very high figure, to attain which it was necessary to engage in night and Sunday work. Table A. Total number of animals known to have been slaughtered and carcases inspected. Total. Beasts. Calves. Sheep. Pigs. Animals known to have been killed 5180 211 543 885 3541 Carcases Inspected 5080 210 536 S77 8457 Table B. Total number of slaughterings, carcases inspected, and 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). 5180 5080 187 (3.6 per cent) 274 (5.3 per cent) 461 Table C. Total number of carcases rejected for Tuberculosis and other defined diseases. Disease. Bulls. Cows. Heifers. Bullocks. Calves, Sheep. Pigs. Total. Tuberculosis .. .. 1 2 .. .. 12 15 Other defined diseases •• '• •• .. 2 2 12 16 Total •• .. 1 2 2 2 21 31 49 Table D. 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 15 43 129 187 Other defined diseases 16 7 261 274 Total 31 50 390 461 Table E. Total weights of carcases, parts of carcases and oifal rejected for all diseases. Tons Cwts. Qrs. lbs. Total in lbs. Carcases 2 4 .. .. 4928 Parts of Carcases ... 7 1 17 829 Offal .. 18 1 24½ 2068½ Total 3 9 3 13½ 7825½ The following contraventions of the Meat Regulations were dealt with during 1931:— (1) Meat conveyed in uncovered van Warning given. (2) Name and address not legibly inscribed on meat stall Ditto. (3) Meat conveyed unprotected on vehicle with other commodities Ditto. 50 (4) Failure of slaughterer to notify diseased conditions (pig) Pig killed outside, but found in a Bromley shop. Adjoining district gave warning to person concerned. Other Unsound Food Seized or Surrendered. Article of Food. Quantity. Weight in lbs. Smoked Codlings 6 boxes 84 Sweets 8 tins 56 Sweets 3 bottles 21 Crabs 1 box of 74 60 White Cherries 10 baskets 240 Cod 1 box 112 Marmalade 8 jars 96 Piccalilli 1 bottle 6 Strawberry Jam 2 jars 24 Mincemeat 6 jars 6 Anchovy Paste 1 pot ½ Paste 13 jars 6½ Escallops 1 bag 120 Preserved Tomatoes 1 tin ½ Apricots 7 tins 7 Rabbits 2 10 Meat (from animals not slaughtered in Bromley) . 63 portions 156 Food and Drugs (Adulteration) Act, 1928. The following tabulation gives particulars of the work of the Food and Drugs Inspector in Bromley during 1931: — Number of samples taken 128 Genuine 127 Adulterated 1 Inferior - Prosecutions 1 The adulterated sample was Ground Cinnamon. The vendors were convicted and fined £5 and £5 5s. 0d. costs. 51 Summary. New Milks 65 Flour 4 Margarine 5 Oatmeal 1 Coffee 6 Rice 3 S. R. Flour 1 Shredded Suet1 Mustard 2 Mincemeat 1 Lard 3 Dem. Sugar 3 Tea 3 f)live Oil 1 Cocoa 4 Sterilised Milk 1 Baking Powder 2 Tapioca 1 Butter 7 Prunes 1 Sausages 4 Ground Cinnamon 2 Mixed Pickles ... 1 Apricots 1 Chicken and Ham Paste 1 Brawn 1 Dried Fruit 2 Fruit Salad 1 XIII— DISEASES OF ANIMALS ACTS. I am indebted to Mr. A. H. Sly, Inspector under these Acts, for the following details in respect of the year ended 31st December, 1931: — Licences issued 149 Inspection of animals brought into the Bonragh: (i) Sheep 363 (ii) Pigs 3662 (iii) Beasts 85 Swine Fever: (i) Outbreaks confirmed 1 (ii) Outbreaks suspected—not confirmed 3 A somewhat serious outbreak of Foot and Mouth Disease occurred in the month of June at County Clare, Northern Ireland, spreading to Scotland and England, but the precautionary measures taken by the Ministry of Agriculture and Fisheries had the effect of checking lts progress, and fortunately the County of Kent was infected on this occasion. The usual Dippings of sheep were carried out and no outbreak of disease was reported in the Borough. 52 XIV.—RAG FLOCK ACTS, 1911-1928. Two samples of rag flock were submitted for examination and both samples complied with the standard in accordance with the Rag Flock Acts, 1911-1928. Rag flock is not used to any great extent by the few upholsterers in this district. XV.—INFECTIOUS DISEASES CONTROL. Except for a continuance of the 1930 scarlet fever epidemic into 1931, Bromley was comparatively free of infectious diseases. Appendix IX. gives a summarised return of notifiable diseases during the year, the incidence rate, mortality rate and the number of cases admitted to hospitals. Scarlet Fever. The incidence rate of 4.3 per 1,000 of population shows an increase over 1930. This rate since 1895 shows a definite downward tendency. This infection was mild in type, but curiously enough appeared to be grossly infectious. The percentage of minor complications, such as otorrhcea, rhinorrhœa, being much greater than usual. This resulted in return cases after the discharge from hospital, in spite of the careful medical supervision exercised over these cases before and after discharge. Not infrequently was it found that infection of scarlet fever recurred in the home of the patient sometimes weeks after the discharge ot the patient from hospital, and appeared to be due to the lighting up of a sinus infection by a catarrhal cold. Again, did I experience the mild case untreated and unrecognised by the parent; that these cases are a source of infection is undoubted, but the difficulty 13 added to when acute scarlet fever throats, without the clinical symptoms of rash, occur. In this respect a scarlet fever infection in a family is worth recording. The mother contracted typical scarlet fever, at the same time the father developed a true quinsy without rash but showed hsemolytic streptococcus in the throat swab. 53 A month later a child in the family developed a laryngitis, the nurse who attended this patient developed true scarlet fever, and 14 days later a maid in the house suffered a typical quinsy with a hemolytic streptococcal swab. This association of scarlet fever and "quinsy" is not unusual, but this instance will indicate the difficulty in the tracing of infection and in the control of the epidemic. A further factor which may play a part in the spread of infection is that the present economic stress discourages the calling in of doctors to doubtful cases, and results in the spread of infection to unprotected children. In 25 families more than one case occurred, in 11 after the return of the patient from hospital. The fact that no less than 41 of the patients were adults indicates the severity of the infection, and this follows the usual experience that when the infectivity of the organism is increased adults become affected. Twenty-seven of the cases of children attended Burnt Ash School, this being the school most severely affected. Thirty-seven of the cases were not of school age, while 18 cases attended a private school. One private school was severely infected from a case residing outside the Bromley area. The incidence of infection at Widmore Schools was increased by two mild cases attending in an infectious condition as missed cases, otherwise the schools in Bromley were comparatively free of infection and in no other case was the school the cause of the spread in infection. At the time of writing the epidemic has abated, and it is not expected that another will occur for six years, this, of course, being subject to certain factors such as is brought about by a change in character of the population or by the developing of large housing areas. Diphtheria. The incidence of diphtheria remained stationary at 1.3 per 1,000 population, being lower than was expected. Whether immunisation is holding this disease in check I am not prepared to say, as the Immunising Clinic ha3 not been functioning long enough to give definite results 54 in Bromley. However, experience elsewhere in this country, and in other countries, has definitely shown that immunisation effectively carried out has definitely not only reduced the incidence rate hut the death rate as well. Diphtheria, as is well known, is a serious and frequently fatal disease in children, and yet being one that can be controlled by immunisation, it is surprising that the request for immunisation is not greater than it is, and that the general practitioner should make so little use of the facilities offered at the Clinic. Until the private medical practitioner takes a little more interest in preventive medicine there can be no reasonable hope of this vitally important branch of medicine being otherwise practiced than by full-time medical officers. However, the statistics will show that the Clinic in Bromley is by no means idle, and that the endeavour to immunise children before they enter school life is not entirely a negative one. One would like to have more time available for this important work, as I am convinced that more value will result from it, than will result from the present inefficient scheme in the organisation of vaccination against smallpox. One must not compare the two, the modus operandi is entirely different, and that while reactions to diphtheria immunisation are practically negligible, this is not always so in vaccination against smallpox. Diphtheria Immunisation Clinic, Statistics, 1931. Total number Schick Tested 114. Found to be positive 71 Found to be negative 43 Not primarily Schick Tested 59 Total number who received full course of injections 130 Total number re-tested 130 1st Re-teat. 2nd 3rd Re-test. Re-test. Found to be positive 10 3 Found to be negative 120 7 55 Other Notifiable Infectious Diseases. Excepting the Pneumonias and Tuberculosis, only sporadic cases of other notifiable infectious diseases occurred during 1931: 2 cases of puerperal infection, 14 cases of erysipelas, 1 case of typhoid fever, 1 of cerebro-spinal fever, 1 of malaria, and 3 of ophthalmia neonatorum. Isolated cases of acute infectious disease such as Typhoid Fever and Cerebro-Spinal Fever always create some anxiety, as they may be the forerunner of an epidemic. Especially is this so with Typhoid Fever, which not infreqiiently escapes notification owing to the irregularity of its symptoms and the difficulties of diagnosis. To-day, when camping and hiking are the rage, there is an increased risk of infection being brought back into the towns unless all camping sites can be guaranteed an unpolluted water supply. Vaccination. I am indebted to the Relieving Officers for the following statistics dealing with primary Vaccination Acts. It will be noted that only 214 children under one year of age were vaccinated compared with 617 born in the area. This is equivalent to only 35 per cent, and indicates the failure of the present Vaccination Acts. Voluntary vaccination would, I am sure, give more satisfactory results, provided the authority is placed in the hands of the Maternity and Child Welfare Authority. Total. Under 1 year. Over 1 year. Bromley N 158 118 40 Bromley S 103 96 7 Tuberculosis. The incidence of Tuberculosis shows a slight fall as compared with 1930. Appendix X. shows a tabulation ot notified cases in age groups together with mortality, ihe middle age groups are again the more severely affected. 56 The Tuberculosis register shows at the end of the year:— Pulmonary: Males 113 Females 85 Non-Pulmonary: Males 56 Females 74 Total 328 These figures show that no less than 7.2 per 1,000 of the population suffers from Tuberculosis. One hundred and thirty-seven of these cases have received institutional treatment, and happily a good proportion of the cases may be regarded as non-infectious. The need for statutory action did not arise either under the Public Health (Prevention of Disease) Regulations, 1925, or under section 62 of the Public Health Act, 1925. The Tuberculosis Officer, Dr. W. P. Martin, has kindly furnished the following details of work done at the Tuberculosis Dispensary during 19-31: — ew lases who have attended the dispensary fok the First Time for Examination during 1931. Adults. Children. Male. Female. Male. Female. Pulmonary 25 18 1 - N on-pulmonary 2 1 3 4 Negative 12 17 14 13 Totals 39 36 18 17 Twenty-five contacts were examined during the year, and of these four were found to be positive; these are not included in the above figures. Total number of attendances at the Dispensary during the year 739 57 Number of cases attending the Dispensary who received a course of sanatorium treatment during the year 53 Total number of visits paid by Health Visitors to T.B. patients in their homes . 427 After-Care Committee for Tubercular Patients. This Committee works in conjunction with the Health Department, and was inaugurated in 1928, the Secretary being a member of the clerical staff of the Department. Eight cases were referred for assistance during the year as follows: (1) Domestic assistance required, but all help was refused. (2) Two cases referred for light work to be obtained for them. (3) Assistance was given towards fares for husband to visit his wife in sanatorium. (4) One case was referred for extra nourishment, which was subsequently assisted by the Guardians. (5) Assistance towards nursing a patient who was eventually admitted to Farnborough Hospital. (6) Help was given towards obtaining the necessary outfit for a boy to go to sanatorium. (7) General assistance was given towards providing extra nourishment and food. Propaganda. Public Health is taught daily at the Clinics and Centres, individual instruction, as well as mass instruction, by means of talks and demonstrations given by the ^aff, but there is no propaganda in the form of pamphlets, bulletins or journals. A useful extension of propaganda carried out by Miss E. B. Crowe, Health Visitor, was the Mothercraft 58 Examination held in November. Some forty-six mothers from all centres entered this examination, and the papers submitted showed an exceedingly high standard. A Mothercraft Examination was also given to the Senior Girls at Burnt Ash Schools, twelve girls submitting papers. Here again the standard was a high one, the children taking a great interest in the subject. Lectures to Girl Guides by Health Visitors, and to Boy Scouts by Mr. T. S. Latham, School Dental Surgeon, for the purpose of badges: Child Nurse and Home Nursing for Girl Guides, and Health Badge and Public Health Man's Badge for the Scouts. APPENDIX. 60 LIST OF APPENDICES. I. Summary of Statistics, 1931. II. Comparison of Statistics, 1931. III. Causes of Deaths, 1931. IV. Causes of Infant Deaths, 1931—Age Groups. V. Analysis of Infant Deaths, 1927—1931. VI. Analysis of Infant Deaths and Maternal Deaths, 1910—1914, 1921—1925, 1926—1930, and 1931. VII. Summary of Work of Sanitary Inspectors, 1931. VIII. Summary of Nuisances Abated, 1931. IX. Return of Notifiable Infectious Diseases, 1931, in Wards, giving attack rates and deaths rates, etc. X. Return in Age Groups of new cases of Tuberculosis notified, and of deaths occurring in 1931. XI. Return of Ophthalmia Neonatorum, 1931. XII. Summary of Health Visitors' Work, 1931. XIII. Summary of Attendances at Welfare Centres, 1931. XIV. Factories, Workshops and Workplaces, Inspections, 1931. XV. Housing Statistics, 1931. 61 APPENDIX I. SUMMARY OF STATISTICS, 1931. Population (mid-year 1931) 45,430 Birth Rate 13.5 Death Rate 10.9 Infantile Mortality Rate 47 Number of Births (live) 617 Number of Stillbirths 26 Number of Deaths 497 Number of Infant Deaths (under 1 year) 29 Death Rate of Respiratory Diseases 1.4 ,, ,, ,, Tuberculosis 0.7 ,, ,, ,, Cancer 1.5 ,, ,, ,, Zymotic Diseases 0.2 Notification of Scarlet Fever 198 ,, ,, Diphtheria 62 ,, ,, Pneumonia 48 ,, ,, Tuberculosis 65 Number of Deaths from Measles 1 „ ,, ,, ,, Scarlet Fever 2 „ ,, ,, ,, Diarrhoea (under 2 years) 7 „ ,, ,, ,, Child Birth 4 Number of visits by Sanitary Inspectors 10,369 „ ,, ,, ,, Health Visitors 5,784 „ ,, Babies on the Registers at the Centres, end December, 1931 1,378 APPENDIX II. BIRTH RATE, DEATH RATE AND ANALYSIS OF MORTALITY during the Year 1931 (Provisional Figures). (The mortality rates for England and Wales refer to the whole population but for London and the towns to civilians only). Rate per 1,000 Annual Death Rate per 1,000 Population. Rate per 1,000 Live Births Total Population. All Causes Enteric Fever Smallpox Measles Scarlet Fever Whooping Cough Diphtheria Influenza Violence Diarrhoea and Enteritis (under Two years). Total Deaths under One year. Live Births Still Births England and Wales 15.8 0.67 12.3 0.01 0.00 0.08 0.01 0.06 0.07 0.36 0.54 6.0 66 107 County Boroughs and Great Towns, including London 16.0 0.67 12.3 0.00 0.00 0.10 0.01 0.07 0.08 0.33 0.48 8.4 71 159 Smaller Towns (1921 adjusted Populations, 20,000-50,000) 15.6 0.73 11.3 0.00 0.00 0.07 0.01 0.05 0.05 0.36 0.43 4.0 62 London 15.0 0.50 12.4 0.01 0.00 0.03 0.02 0.07 0.06 0.26 0.57 9.7 65 BROMLEY 13.5 0.57 10.9 0.04 0.00 0.02 0.04 0.00 0.08 0.17 0 39 11.3 47 Puerperal Sepsis. Others. Total. per 1000 Live Births 1.66 2.45 4.11 The maternal mortality rates for England and Wales are as follows: ,, ,, Total Births 1.59 2.35 3.95 63 APPENDIX III. Causes of Death, 1931. Causes. Male. Female Totl. 1. Typhoid and Paratyphoid Fevers 1 1 2 2. Measles — 1 1 3. Scarlet Fever 2 — 2 4. Whooping Cough — — — 5. Diphtheria 1 3 4 6. Influenza 5 3 8 7. Encephalitis Lethargica — — — 8. Cerebro-Spinal Fever — — — 9. Tuberculosis of respiratory system 19 12 31 10. Other Tuberculosis Diseases 1 2 3 11. Syphilis — 1 1 12. General paralysis of the insane, Tabes Dorsalis 13. Cancer, malignant disease 27 44 71 14. Diabetes 4 3 7 15. Cerebral Haemorrhage, etc. 9 19 28 16. Heart Disease 56 66 122 17. Aneurysm 1 — 1 18. Other Circulatory Diseases 6 8 14 19. Bronchitis 9 12 21 20. Pneumonia (all forms) 16 22 38 21. Other Respiratory Diseases 1 3 4 22. Peptic Ulcer 6 3 9 23. Diarrhœa, etc. (under 2 years) 4 3 7 24. Appendicitis 2 2 4 25. Cirrhosis of Liver 1 — 1 26. Other Diseases of Liver, etc. 1 1 2 27. Other Digestive Diseases 3 8 11 28. Acute and Chronic Nephritis 4 6 10 29. Puerperal Sepsis — 1 1 30. Other Puerperal Causes — 3 3 31. Congenital Debility, Premature Birth. Malformations, etc. 6 7 13 32. Senility 4 12 16 33. Suicide 4 3 7 34. Other violence 6 5 11 35. Other defined diseases 22 22 44 36. Causes ill-defined or unknown — — — Totals 221 276 497 APPENDIX IV. Infant Mortality, 1931. CAUSES OF DEATH. Under 1 Week. 1 and under 2 Weeks. 2 and under 3 Weeks. 3 and under 4 Weeks. Total under 4 Weeks. 1 month and under 3 Months 3 months and under <5 Months 6 Months and under 9 Months 9 Months and under 12 Months. Total Deaths under 1 year. Measles .. .. .. .. .. .. .. .. 1 1 Whooping Cough .. .. .. .. .. .. .. .. .. .. Tuberculosis .. .. .. .. .. .. .. .. .. .. Convulsions 1 .. .. .. 1 .. .. .. .. 1 Bronchitis .. .. .. .. .. .. .. .. .. 1 Pneumonia 1 .. .. .. 1 2 .. .. .. 4 Diarrhœa .. .. .. .. .. .. .. .. .. .. Enteritis .. .. .. .. 2 2 .. .. .. 4 Gastritis .. .. .. .. .. .. .. .. .. .. Suffocation .. .. .. .. .. .. .. .. .. .. Injury at Birth 1 .. .. .. 1 .. .. .. .. 1 Atelectasis 2 .. .. .. 2 .. .. .. .. 2 Malformation .. .. .. .. .. 1 .. .. .. 2 Premature Birth 2 1 .. .. 3 .. .. .. .. 3 Marasmus, etc. .. 1 .. .. 1 1 .. 1 .. 3 Other Causes .. .. .. .. .. .. .. 1 .. 1 Syphilis .. .. .. .. .. .. .. .. .. .. Congenital Heart Disease 3 .. .. .. 3 1 .. •• .. 4 Totals 10 2 1 1 14 7 .. 3 3 . 27 Note : The Registrar General gives 29 deaths for 1931. 65 APPENDIX V. Analysis of Causes of Infant Deaths, 1927-1931. 1927 1928 1929 1930 1931 No, of Births 574 652 623 629 617 Total Infant Mortality Bate 50 49 46 41 47 Premature Birth 5 6 3 7 3 24 Respiratory Diseases 6 8 11 3 5 33 Marasmus and General Debility 3 6 3 4 3 19 Infectious Disease 2 1 1 1 5 Gastro Enteritis 5 3 2 3 4 17 Convulsions 1 1 2 1 5 Other Causes 7 7 9 7 10 40 Total 29 32 29 26 27 143 This table shows that Premature Births and Congenital Debility 30% of the total infant deaths during the past five years, and should be taken as an indication of the great need for ante-natal supervision. 66 APPENDIX VI. Summary of Infant Mortality Statistics. Three five-year periods are taken—five years pre-war, five years to 1925, five years to 1930, and 1931. Years. Total Births. Infant Mortality Kate. 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—1914 3186 68 220 61 41 118 3 6 1921 624 60 38 10 9 19 1 1 1922 576 74 43 19 7 17 2 2 1323 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 1931 617 47 29 10 4 13 1 3 In these figures the following facts are shown:— 1. Reductions in Infantile Mortality Rates. The fall occurs chiefly in the period over four weeks of age. 2. Increase in the deaths of infants under one 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. 67 APPENDIX VII. Summary of Work of Sanitary Inspectors, 1931. Housing— Inspections. ReInspec tions. Under Inspection of District Regulations 479 805 On Complaint (ordinary) 511 1907 Re Overcrowding 26 13 ,, Dirty Conditions 26 16 ,, Water Supply 24 — ,, Infectious Diseases 396 6 Disinfection Purposes 152 17 Disinfestation Purposes 25 38 Housing Survey 591 — Trade Premises— Factories 17 8 Workshops 36 9 Outworkers' Premises 3 — Under tlie Shops' Acts 434 3 ,, ,, Petroleum Acts 164 43 Registry Offices 15 3 Rag flock sampling 2 — Food Preparing Places— Dairies and Cowsheds 130 15 Bakehouses:— Factory 58 23 Workshop 20 3 Slaughterhouses 671 — Hotels, Restaurants, etc 15 2 Confectionery, Ice Cream, etc. 41 1 Greengrocery Shops 114 4 Butchers' Shops 721 3 Fish Shops 64 — Fried Fish Shops 30 — Retail Market 65 — Grocery Shops 104 4 Food Hawkers 21 — Under Meat Regulations 42 — Milk Sampling 54 — Milk examined on the highway 146 — Milk and Dairies Order, 1926— contravention 1 - 68 Miscellaneous— Tents, Vans and Sheds 6 — Streams 8 1 Nuisances from keeping of animals 8 1 Piggeries 12 — Smoke 5 — Drain Tests— (a) Smoke 23 (b) Water 11 (c) Colour 7 (d) Chemical 3 44 — TJrinals 45 — Accumulations 72 28 Rats and Mice Destruction Act 89 47 Interviews, Owners, Agents, etc. 1309 — Specials Visits 465 5 Smallpox contact visits (contacts seen 56) 60 Rag and Bone Dealers 8 — Poison and Pharmacy Act 1 — Cesspools 1 - Stables 24 2 Obstruction of light by trees 4 3 Totals 7359 3010 APPENDIX VIII. Nuisances Abated, 1931. HOUSING: Drainage— Inspection chambers provided 15 Drains relaid or repaired 68 Drains unstopped 78 W.C.'s renewed or repaired 62 W.C. pans cleansed 60 W.C. accommodation provided 1 W.C. box seats removed 215 W.C. ventilation improved 1 Soil pipes, vent pipes, renewed or repaired 22 Sinks renewed 126 Sink or bath waste pipes renewed or repaired 160 Cesspools emptied 2 Surface water drainage provided 9 Drainage system ventilated 1 69 dampness— Roof, rain water pipes, puttering1 renewed, etc. 612 Damp courses:— Vertical 75 Horizontal 50 Solution 125 Repaired or renewed 14 Brickwork repaired or renewed 45 External walls rendered 36 Dry area constructed 1 Pointing repaired or renewed 156 General— Rooms cleansed 1103 Floors renewed or repaired 137 Windows ,, ,, ,, 555 Doors „ ,, „ 94 Stoves ,, ,, ,, 180 Plastering ,, ,, „ 464 Handrails ,, „ ,, (or provided) 75 Yard paving,, „ ,, ,, ,, 173 Coppers 94 New dustbins provided 210 Overcrowding abated 14 Disinfestations 33 Ventilated food stores provided 7 Food stores ventilated 6 Defective chimneys repaired 19 ,, brickwork repaired 23 Ventilation of rooms improved 2 Defective gas flues reconstructed for coal fires 37 Dirty conditions improved 10 Water Supply— Drinking water service supplied direct from main 53 Fittings renewed or repaired 29 Flushing cisterns renewed or repaired 69 Drinking water cisterns provided with covers 31 Drinking water cisterns cleansed 2 Miscellaneous Items 133 70 TRADE PREMISES: Factories and Workshops— Want of cleanliness 5 Want of ventilation — Overcrowding — Want of drainage to floors — Other nuisances 6 Sanitary accommodation— Insufficient — Unsuitable or defective 3 Not separate for sexes 2 Shops Acts—contraventions 22 Outworkers' premises 6 FOOD PREPARING PLACES: Yards, floors repaired, etc., cleansing, limewashing, light, and ventilation improved; refuse bins provided, sanitary conditions improved, etc. Dairies and cowsheds 9 Slaughterhouses 7 Greengrocery shops 11 Hotels, restaurants, etc. 3 Bakehouses 49 Grocers' shops 18 Butchers' shops 31 Fish shops 5 o Confectionery shops 3 Fried fish shops 1 Food store, unsatisfactory and abolished l MISCELLANEOUS: Stream nuisances 1 Urinals cleansed 3 Animal nuisances 5 Accumulations removed 44 Manure receptacles provided 35 Manure removed 7 Stables cleansed 2 Rat nuisances 43 Other nuisances 12 Total 5824 71 NOTICES ISSUED: Preliminary— (i) Housing 922 (ii) Others 214 Total 1136 Statutory— (i) Housing *2 (ii) Others — Total 2 * In respect of 3 premises. 72 APPENDIX IX. Return of Notifiable Infectious Diseases, 1931. 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 198 100 98 71 16 23 21 42 25 179 4.3 2 0.04 Diphtheria . 62 31 31 18 2 16 8 10 8 61 1.3 4 0.08 Pneumonia 48 20 28 13 2 10 5 8 10 12 1.07 38 0.8 Puerperal Fever 1 — 1 — — — — — 1 1 0.02 1 0.02 Puerperal Pyrexia 1 — 1 — — 1 — — — — 0.02 — — Erysipelas 14 6 8 4 2 2 2 1 3 3 0.3 — — Typhoid Fever 1 — 1 — — — 1 — — — 0.02 2* 0.04 Cerebrospinal Fever 1 1 — — — — — 1 — — 0.02 1 0.02 Malaria 1 — 1 1 — — — — — — 0.02 — — Ophthalmia Neonatorum 3 1 2 — — 1 — — 2 3 0.06 — — Tuberoulosis—Lungs 51 28 23 14 6 9 4 3 15 — 1.1 31 0.6 Tuberculosis—other forms 14 9 5 3 3 3 — 1 4 0.3 3 0.06 Totals 395 196 199 124 31 65 41 66 68 259 8.6 82 1 .8 73 APPENDIX X. Tuberculosis. New Cases and Mortality during the Year, 1931. Age periods. New cases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. Under 1 .. .. .. .. .. .. .. .. 1— 5 .. .. .. 2 .. .. .. .. 5-10 .. .. 3 .. .. .. .. .. 10—15 2 1 1 2 .. .. .. 1 15-20 1 4 1 1 .. .. .. 1 20—25 2 5 2 .. 4 2 .. .. 25-35 10 5 1 .. 5 3 35-45 7 5 1 .. 3 4 .. .. 45-55 2 1 .. .. 3 1 .. .. 55-65 2 1 .. .. 2 2 .. .. 65 and over 2 1 .. .. 2 .. .. .. Totals 28 23 9 5 19 12 1 2 APPENDIX XI. Ophthalmia Neonatorum, 1931. Cases. Vi sion. unimpaired Vision impaired. Total Blindness Notified. Treated. Deaths. At Home. In Hospital. 3 .. 3 3 .. .. .. 74 APPENDIX XII. Summary of Health Visitors' Work, 1931. Areas Total Under one year Revisits Expectant Mothers School Children Baby Deaths StillBirths Tuberculosis Speoial Visits Boarded- out Children Primary Revisits year Area No. 1 1701 76 178 669 54 193 6 5 88 432 30 Area No. 2 1183 122 262 400 43 254 4 7 42 49 6 Area No, 3 1635 135 334 566 24 345 I 6 65 159 48 Area No. 4 1265 170 166 516 18 221 4 6 54 110 51 Totals. 5784 503 940 2151 139 1013 15 24 249 750 135* Also included in routine visits under the various headings Tuberculosis Dispensary Work. Patients on the Dispensary Roll at end of December, 1931 121 Health. Visitor's Attendances 51 Total Number of Special Visits to Patients 178 75 APPENDIX XIII. Welfare Centres, Attendances, 1931. Centre. No. of Babies on Rolls at the end of Year 1931. Total Attendances. No. of Sessions held. Medical Consultations. Total No. of Weighings. Total Examined. No. of Sessions held. Babies. Mothers. LASTOW 316 2642 2582 50 340 34 2020 WIDM0RE 192 1577 1419 49 270 27 1183 HORTLANDS 171 1571 1599 52 239 27 893 URNT ASH . 342 2953 2216 97 388 45 1681 BROMLEY COMMON 357 3162 2453 50 344 34 2533 Totals 1378 11,905 10,269 298 1,587 167 8,810 Ante-Natal Clinics. Total Attendances. Medical Consultations. Sessions held. 184 180 24 Dental Clinic. Discharged Treatment. Children. Mothers. 58 17 76 APPENDIX XIV. Factories, Workshops and Workplaces, 1931. I.—Inspections. Premises. Number of Inspections, Written Notices. Occupiers Prosecuted. Factories 106 10 .. Workshops 68 15 .. Workplaces (other than outworkers' premises) 4 2 12 .. Totals 216 37 .. 11.—Defects. Particulars. Number of Defects. Found Remedied. Referred to H.M. Inspector. Nuisances under Public Health Act8§ Want of cleanliness 36 36 .. Want of ventilation .. .. .. Overcrowding .. .. .. Want of drainage to floors 1 1 .. Other nuisances 26 28‡ .. Sanitaryaccommo dation insufficient 2 1 .. unsuitable or defective 19 17 .. , not separate for sexes 2 2 .. Total 86 85 .. § Including those specified in sections 2, 3 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Act. ‡Includes 6 defects outstanding at end of 1930 and remedied in 1931. || Includes 10 defects outstanding at end of 1930 and remedied in 1931. Outwork in Unwholesome Premises, Section 108. . Nature of Work. Instances. Notice! Served. Prosecutions. Wearing apparel, making, etc. 1 1 .. 77 APPENDIX XV. Housing Statistics for the Year 1931. Number of new houses erected during the year:— Total 234 (i) By the Local Authority 28 (ii) By other Local Authorities — (iii) By other bodies or persons 206 Total number of inhabited houses at 31st December, 1931 11306 1. Inspection of Dwelling-houses during the Year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 910 (b) Number of inspections made for the purpose 2741 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations,, 1925 479 (b) Number of inspection made for the purpose 805 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 721 2- Remedy of Defects during the year without Service of formal Notices:— Xumber of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 752 78 3. Action under Statutory Powers during the Year:— A. Proceedings under sections 17, 18 and 23 of the Housing Act, 1930: (1) Number of dwelling-houses in respect of which notices were served requiring repairs - (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners - (b) By Local Authority in default of owners - B. Proceedings under Public Health Acts: (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied *3 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners - (b) By Local Authority in default of owners * Notices not complied with at the end of the year, 1931. C. Proceedings under sections 19 and 21 of the Housing Act, 1930 *Nil. D. Proceedings under section 20 of the Housing Act, 1930 Nil. E. Proceedings under section 3 of the Housing Act, 1925 Nil. F. Proceedings under section 11, 14 and 15 of the Housing Act, 1925 Nil. * Two houses in the Bromley Common area demolished as a result of informal action. BOROUGH OF BROMLEY. ANNUAL REPORT FOR 1931 OF THE SCHOOL MEDICAL OFFICER. 80 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1931-32. Alderman F. W. isard (Chairman of the Education Committee). Councillor E. J. Bettson. D. Copping, Esq. A. Cowdry, Esq. Mrs. M. D. Fry. Councillor W. D. Gibbs. Rev. Hugh Glaisyer, m.a. Councillor Colonel W. A. Greenley, c.m.g., d.s.o. G. J. Gully, Esq., j.p. Rev. J. T. Gurney. Councillor Colonel E. J. Heilbron. Councillor T. H. Jayes. Mrs. A. G. Mann, b.a., j.p. (Chairman, School Medical Sub-Committee). Councillor A. McIntosh. Mrs. E. J. Munn. Councillor G. L. Pyrke. Rev. Prebendary B. F. Relton, m.a. Alderman W. F. Skilton. Councillor M. Stafford Smith, m.b.e., b.a. Councillor J. Waters. G. Weeks, Esq. Rev. O. G. Whitfield, m.a. Councillor F. Wood. SUMMARY OF THE YEAR'S WORK, 1931. No. of Children on the Rolls of Elementary Schools 5,114 Average Attendance, 1931 4,508 No. of Inspections by School Medical Officers 6,772 „ ,, Routine 1,416 „ ,, Special and Clinic Inspections, etc. 5,356 „ ,, School Dental Surgeon 4,743 (i) Found to require treatment 2,837 (ii) Actually treated 2,386 „ ,, by School Nurses 12,969 (i) Individual children found unclean 478 ,, ,, by Orthopaedic Surgeon 215 No. of Children operated on for Tonsils and Adenoids 177 81 Introduction. Except for change in the personnel, caused by the retirement of Dr. M. Reekie, on marriage, and the appointment of Dr. G. H. Stinson, Assistant Medical Officer of Health and School Medical Officer, and the holding of Tonsil and Adenoid Clinics weekly instead of fortnightly, the organisation of the services continued throughout the year without change. It thus follows that the report of 1931 must be almost a repetition of the report of 1930, except for alterations in statistics. It is here opportune to submit a general summary of the* figures referring later in the report to the statistics applicable to each service provided by the Education Authority. This summary will in itself give an outline of the extent of the work of the School Medical Service during the year, it being always remembered that the School Medical Service forms only a part of the Health Services of the Borough. Nevertheless it is a part that is year by year increasing not only because of the increase of population, but also because the public is making greater use of these services. It has been stated that this increased use has resulted because parents find the School Medical Service a cheap means of obtaining 82 advice and treatment, and that during times of economic stress the public services are always more in demand, but I am convinced that although this factor may be a reason, it is not the main reason. The School Medical Service is in demand because it is an effective service, and one that has proved its value to the parents and to the nation as a whole. There will always be the antisocialist, and I am not in any way referring to tie political side of the question, but public opinion is to-day more and more democratic in action, and the care of the physical welfare of the child has become a national responsibility whatever the political creed of our rulers. However, there is to me this danger that we are extending the health services into the sphere of treatment at the expense of prevention. The 1929 Act encourages this by the placing of the Poor Law medical treatment under the Health authorities of the counties and county boroughs. It will be agreed that, when a local health authority undertakes the treatment of an individual at the expense of the community, there is a danger that the demand for the maintenance of physiological health will be lost in the popular cry for the treatment of the disease established. Reverting to the summaried figures for 1931, the total number of individual children coming under medical examination was 3,241, of whom 1,416 were examined at school and 1,825 at the Clinic. This called for no less than 6,772 medical examinations in the year, a figure which alone must indicate the extent of medical supervision of the elementary school child in Bromley. The special services such as Eye Clinic, Tonsil and Adenoid Clinic, Orthopsedic Clinic and Dental Clinic are, not included in the above figures, except where they have been previously examined before being passed into the special clinic. Two hundred and two individual children attended the Eye Clinic, 215 the Orthopaedic Clinic, 329 the Tonsil and Adenoid Clinic, and 2,386 the Dental Clinic. These figures are reported on in detail later in the report, but given in broad outline they must give an impression of the work performed by your staff. A problem at present before us is the rapid increase of population of the Borough, and of housing which is 83 extending to the outskirts of the Borough, so that the central facilities of the School Clinic are not easily available to the defective child. If we are to have the full effect of your services, then extension of premises has become increasingly necessary in the southern end of the Borough. This matter was reported on in my annual report for 1930, but the economic conditions interfered with progress. Economic conditions, too, postponed further consideration of playing fields and the organisation of physical training. As time passes it becomes more and more difficult for facilities to be made available for what is, in my firm opinion, a fundamental in the maintenance of physiological health of the school child. This short introduction to the report would not be complete without a word of appreciation to the great voluntary services rendered by Miss E. Carter and the voluntary workers of the Care Committee. Their work indicates the very cordial co-operation that exists in Bromley between the voluntary workers and the Local Authority. All members of the staff have contributed to the success of the work during the year, and to the members of the School Medical Sub-Committee I would take this opportunity of expressing my grateful thanks for their encouragement. Hygiene of Schools. There is little further to report upon the hygiene of the school premises, beyond what has already been reported on in previous years. The following list of repairs, alterations and decorations were carried out in 1931: — Raglan Road Schools.—Improvements to heating systems. Central School.—Screening of girls' and boys' playgrounds to avoid interference during physical exercises and games. Addison Road School.—Provision of "Decolite" flooring throughout. Burnt Ash Schools and School Clinic.—Laying out of grounds. 84 All Schools.—Supplied with hygienic toilet paper containers. The cloak room accommodation and the provision of adequate wash basins is sadly lacking in some of the older schools established in Bromley prior to 1865. The teaching of the young child the principles of hygiene continues in the schools, but it is pure hypocracy to do so when the actual premises in which this teaching is carried out does not comply with the principles. For example, the continued use of roller towels and common drinking vesesls. A little more practice and a little less theory would make a happier condition of affairs. Co-ordination. The Health Services of Bromley act as a unit, and there is also complete co-ordination with those services such as Tuberculosis, Sale of Food and Drugs, which are not under our direct control. The Secondary School Medical Service is still carried out by the County Council, although necessitous cases are treated through the special services of the School Clinic. The School Medical Services are available to the Maternity and Child Welfare cases. There are no nursery schools in Bromley and the accommodation for children under five years of age is being taken up in order to provide for the increased school population. This state of affairs is an increasingly difficult problem. It tends to widen the gap between the Maternity and Child Welfare Service and the School Medical Service, a gap which could be filled by the establishment of nursery classes, or of a nursery school. Taking into consideration the financial as well as the public health aspect of the question, it is a very debatable matter whether such schools or classes are an economical asset. The aggregation of young children at an age when they are very susceptible to infectious disease is a somewhat dangerous procedure. Admittedly such children are present at Sunday Schools and at places of amusement, and so are exposed to mass infection without having the benefit of a medical service, but this should be no reason why we should add to the trouble 85 by the establishment of a nursery school in a residential town such as Bromley. The extension of the provision would certainly fill the gap between the services of Maternity and Child Welfare and School Medical, but there are more economical methods, such as the adequate health visiting of these children in their homes. I leave out of consideration the doubtful question as to whether there are any intellectual advantages to be derived from school instruction of these young children. Medical Inspection. Medical inspections are made according to statute, each child being examined three times in its school life: at the age of entrance, at seven years of age, and again at twelve years of age. Cases with departures from the normal are referred for treatment and kept under observation. Further medical examination of the child is made at the special inspection at the School Clinic, where cases are referred by head teachers, school attendance officers, general practitioners, or referred from medical inspections at the schools. As previously stated, no less than 6,772 medical examinations of 3,241 individual children were made during the year. Of the 1,416 children examined at school routine medical inspection, 20.6 per cent. required treatment. Table IIb. in the Appendix indicates the number in the age groups examined, and Table IIa. the defects discovered. It is of some importance to note that leavers are examined in the January term, intermediates in the March term, and entrants in Autumn term. Seasonal illness plays a part in the defects thus discovered, and in considering the percentage of defects discovered this factor must be taken into account. One still sees at school the child who has been returned too early after an acute illness, such as influenza, and a subsequent loss of nervous vitality is a not infrequent result. The keeping of a high school attendance figure has become almost a fetish and must in many cases run counter to the physical well-being of the child. Admittedly, many cases are better at school than at home, but that is not so with the intelligent 86 pathic child of the younger age groups. The matter is, however, not easily remedied, especially as the grant in aid is dependent fundamentally on the attendance figure. I am again pleased to record the fact that parents attend medical inspections at school in 89 per cent. of children examined, and it is of special interest, now that the Maternity and Child Welfare service is so closely associated with the School Medical service, to examine children who have been seen by the medical inspector at the welfare centres. That this co-operation between public health services should cease at 14 years of age and not continue into the secondary schools is obviously regrettable. Main Defects discovered at Medical Inspection. A reference to the Appendix Table II. will show the result of medical inspection of the children at school, routine inspection, and of children attending the clinic special inspections. The defects are sub-divided into those requiring treatment and those requiring observation. Malnutrition. No standard of physical fitness has been laid down, nor would it be possible to do so. It is thus left to the medical examiner to fix the normal, and to record the departure from the normal. Thus does one get varied results in various areas. In Bromley, unless there is some family constitutional element, all cases of malnutrition are referred to the School Clinic for observation, and where the case is necessitous referred to the Care Committee for convalescence, or for free milk in school. Four per cent. of children examined showed this condition of low physique, 40 of these children were sent to convalescent homes, and 116 were provided with free milk and other nourishment. The net cost to the Children's Care Committee was £46. This cost is an exceedingly small one mainly because of the convalescent home letters granted by the Queen's Reign Commemoration Fund. Many of these children do not respond to treatment, but if we can but stop progression of the defect, we have achieved much. 87 Cleanliness. There can be no question of doubt of the advance in cleanliness of the children attending elementary schools both in regard to clothing and body. Of 12,969 examinations only 478 showed evidence of verminous conditions, i.e., 3.6 per cent. This is mainly due to the higher standard of hygienic practice in the homes of the people, and partly due to the routine vermin inspections carried out by the school nurses. The chronic offender we shall always have with us, and in spite of exclusion and prosecution there has been little improvement in their condition. Five prosecutions were instituted under the school attendance bye-laws, but the fines levied have been nominal and without effect. Until uncleanliness is taken as neglect and cruelty, prosecution will have little effect upon the mother who welcomes exclusion of her child from school, even although that exclusion is due to the verminous condition of her child. Skin Disease. Except for urticarial rashes, skin diseases, which at one time were so common, have practically disappeared from the routine medical inspections. This is not so at the Minor Ailment Treatment Clinic, for here skin diseases occupy the main proportion of the school nurses' time. Nevertheless, the early treatment of these cases at the Clinic prevents the spread of infection into schools, and explains the absence of skin disease at the routine medical inspections. Ringworm appeared in only three cases during the year, and its comparative absence thus effected a saving in school attendance. Scabies occurred in 15 cases, whilst there were 126 cases of impetigo. Ringworm continues to be treated by X-Ray by arrangement with Guy's Hospital, whilst routine treatment is continued for impetigo and for scabies. Artificial sunlight has certainly assisted the chronic impetigo cases. Eye Clinic. Seven per cent. of children examined at the routine medical inspection showed defective vision untreated and undiscovered until the routine inspection. A further 88 4 per cent. attended the medical inspection clinic complaining of defective vision. Thus approximately 6 per cent. of all children examined show defective vision. The correction of this defect is one of the most important branches of the School Medical Service, and a reference to Table IV., Group II., will indicate the work of the Vision Clinic. A Clinic is held once a week, but this is not adequate to deal with the cases. Two hundred and two individual children actually attended this Clinic during the year, but as each child requires at least two attendances before being fitted with glasses, one session per week has become inadequate. At the end of the year there were 67 cases awaiting refraction. Co-operation is maintained with the London Eye Hospitals and special cases, such as congenital cataract, ptosis or severe squint are referred for operative treatment. The high myopics, of whom there were five during the year, are referred to schools allocated for this special purpose, and the maintenance of these children charged to the Education Committee. Three children are maintained at residential schools for the blind. Diseases of the Ear, Nose and Throat Clinic. There was an increase in acute otitis media during the year as a consequence of influenzal infection. Most of these cases responded to routine treatment at the School Clinic, but as will be seen from the Specialist's report on the work of the Ear, Nose and Throat Clinic, some of these cases required operative interference. Far too many of these cases arrive at the Clinic too late for preventive surgical treatment, and many of them will suffer from slight impairment of hearing. No use has so far been made of the audiometer which has proved so valuable in the discovery of the partially deaf children attending school. Of the children examined during the year at school medical inspections, 17 per cent. showed enlargement of tonsils and adenoids. This is an increase over the previous years, when the average has been 12 per cent. It has become a popular belief and practice that all 89 enlarged tonsils should he removed by operation, but personally I doubt if such practice is justifiable. The practice in the Bromley School Medical Service is to refer for operation only those cases with enlarged tonsils or adenoids, which suffer from a secondary effect of the enlargement, such as enlarged glands, discharging ears, or a general impairment of the physical condition of the child. Mr. Beney's report, which follows, will indicate the work of the Ear, Nose and Throat Clinic during 1931:— The increase in the number of clinics held during the year under review has been fully justified by the results. Occasional Inspection Clinics have been instituted. This has enabled special treatment to be undertaken for nasal and aural conditions not requiring surgical intervention. Out of the total number of 329 cases referred to me by the School Medical Officer, 198 required operation for the removal of tonsils and adenoids; 177 of these were successfully operated on at the Clinic, 21 cases being referred to their own doctors for operation or admitted to my beds at the Hospital. Of the latter 7 required operation for acute and chronic mastoid disease, and in 4 cases intranasal operations for sinus disease were necessary. The remainder of 131 cases received non-operative treatment. No cases of any serious complications arising after operation have been reported to me. I cannot speak too highly of the efficient and loyal co-operation of the Nursing and Voluntary Staff, without whose care these results could not have been achieved. Charles Beney, m.a., m.b., ch.b. (camb.), m.r.c.s. Minor Ailment Clinic. A Medical Inspection Clinic is held each week-day morning, except Tuesdays, at the School Clinic, Station Road, Dr. G. H. Stinson being in attendance. Cases are referred to this Clinic by head teachers, school attendance officers, school nurses, or from routine medical inspections at schools. Cases occasionally attend direct from the parents without having been referred by head teachers; this can only be avoided by the establishment of an out-patient department at local hospitals. Until 90 the hospitals undertake this work, and the general practitioners place their services in this direction, cases of acute illness will attend the School Clinic. It must be clearly understood that no case requiring domiciliary treatment is treated at the Clinic, all such cases being referred to their own doctor. The parents appreciate this fact, and act ou the principle that early treatment is both economical and effective. It is the experience of those working at the Clinic that abuse of the service offered by the Local Authority does not exist beyond an occasional attempt to use the Clinic as an excuse for non-attendance at school. The 1,825 individual children attending the medical inspection clinic in 1931 suffered from 4,371 defects, an average of over two defects per child. These children made 5,356 attendances. These figures may be compared with the routine examination of the child attending school when the total defects discovered numbered 905, or less than one defect per child examined. Children found to be suffering from minor ailments not requiring domiciliary treatment are passed to the treatment clinic, where they are treated under the skilled care of the school nurses. It is not generally understood by the public that the nurses employed by the Local Authority are not only general hospital trained, but have obtained the highest qualifications in their profession. A reference to Table IV., Group I., will show the number treated by the nurses during 1931. The majority of complaints treated are skin diseases and minor injuries. Chronic otitis media cases amounted to 146, and being peculiarly resistant to treatment occupy a large proportion of the nurses' time. Most cases improve under the acriflavine routine, generally without impairment of hearing, but others, approximately 30 per cent., are recurrent and require the more radical surgical treatment, such as complete mastoid operation. Orthopaedic Clinic. The Orthopaedic Clinic has now been established nearly six years and continues to be used to its full capacity. The type of case is now of a less severe kind, 91 mainly clue to the early treatment of the Maternity and Child Welfare cases, and the supervision kept over the minor deformities. The Clinic is made available to cases attending the Maternity and Child Welfare centres and many children are thus corrected before entry to school. The Clinic provides an Orthopaedic Surgeon who attends twice monthly, a Masseuse who holds five sessions a week, remedial exercises, and a Sunlight Clinic twice weekly. Cases requiring hospital treatment are admitted to the Royal National Orthopaedic Hospital at Stanmore. Statistics. Total attendances: (i) For consultations 589 (ii) For treatments, massage, remedial exercises 2001 Maternity School and Child Medical Welfare. Service. Total. Requiring treatment 21 110 131 Requiring observation 25 59 84 Totals 46 169 215 New Cases seen at the Clinic durina 1931. Outward Curvature Tibia 9 Flat Feet 8 Scoliosis 14 Kypho-scoliosis 3 Kyphosis 23 Lordosis 3 Kypho-lordosis 7 Slack Back 7 Hollow Chest 8 Fractures 8 Congenital Equino Varus 2 Tubercular Knee 1 Congenital Shortening 1 Injuries 10 Lt. Hemiplegia 1 Genu Valgum 11 Atrophy 1 Torticollis 3 Paralysis 4 Exostosis 1 Metatarsal Varus 3 Sprains 7 Tubercular Hip 3 Schlatters Disease 1 Spina Bifida 1 Keloid Scar 1 Other Conditions 11 92 Mr. H. J. Seddon's interesting report on the cases who received treatment at Stanmore during the year 1931 is as follows:— A.A., Boy, Age 9.—Was admitted on 27/1/31 with multiple exostoses. On 13/2/31 an operation was performed for the removal of bony tumours from the upper ends of both humeri. It was necessary to re-admit him 12th September, 1931, for the removal of other tumours involving both tibiae and the right ilium. He was discharged finally on 13/11/31 without any deformity. It is possible there will be further growth of other exostoses in the future, but the ultimate outlook is good. F.R., Boy, Age 11.—Was admitted on 12/3/31 with pain in the abdomen and signs of pleurisy on the right side. It was suspected that an early Tuberculous focus might be present in the lower part of the spine. Repeated X-Ray examination failed to reveal any evidence of bony disease. The pleurisy and abdominal pain subsided and the patient was discharged on 27/7/1931. M.D., Girl, Age 5.—Was admitted on 7/5/31 with spastic paralysis. On 12/6/31 a bilateral obturator neurectomy was performed and a bilateral internal popliteal neurectomy on 10/8/31. There was a most remarkable improvement in the child's gait after operation. She was discharged on 21/11/31 and her subsequent progress has been most satisfactory. P.J., Boy, Age 3.—Was admitted on 24/10/31 with a double fracture of the bones of the right forearm. The fractures had occurred three weeks before admission and had united with much callus formation and some bowing. An open operation was performed on 4/11/31 which gave a good correction of the deformity. Unfortunately a re-fracture occurred on 18/2/32 and it has been necessary to re-admit the child. His present progress is satisfactory. Sunlight Treatment Clinic. This Clinic is held at the School Clinic twice weekly on Tuesday and Friday afternoons. 93 One hundred and thirty-one cases were treated during 1931, which is an increase of 16 over the figure for the preceding year. The types of cases submitted for treatment were as follows:— General Debility.—The Majority of all cases were of general debility which responded readily to treatment. Eighty-one debility cases were treated; of these, 48 gained in weight and their general condition rapidly improved; 15 improved without gaining weight, and 18 patients did not attend regularly enough to benefit by the treatment. Enlarged Glands.—Seven cases were treated; 4 gained weight and the condition improved; 2 showed improvement without gaining weight, and one did not benefit by the treatment. Impetigo.—Ten cases were treated. They were given local and general exposures, and in 7 cases the impetigo cleared rapidly, but iu 3 cases the treatment was discontinued. Septic Antrum.—Of 2 cases treated, one improved under general treatment. Discharging Ears.— Two cases treated and improved in health. In one case the discharge ceased. Alopecia Areata.—Four cases were given local and general exposures. Two were cured after three to five months treatment, but 2 did not attend regularly enough to show any marged improvement. Nervous Children.—Eight children were treated and 6 showed definite improvement, gaining weight, and eating and sleeping better. Two did not benefit by the treatment. Rheumatic Cases.—Five were treated, of whom 4 improved under the treatment. Chilblains.—Six cases received local and general exposures; 3 were cured; 1 very much improved; 2 did not attend long enough to show improvement. 94 Rickets.—Five cases received treatment; 3 were cured; 1 showed great improvement, but in one case the treatment was ineffective and was discontinued. Acne.—One case was treated with a negative result. In all general treatment three minute doses were given at a distance of 36 inches, and doses were increased by two minute intervals to 24 to 30 minutes. Dental Clinic. A full-time Dental Surgeon, Mr. T. S. Latham, is engaged by the Education Committee, and he is assisted by a Dental Nurse. Treatments are carried out daily at the School Clinic, six sessions per month being allocated to Gas Clinics, and one session per week to routine inspection at schools. All children at school are examined by the School Dentist once during the school year. Home visiting by the Dental Nurse is now limited to those who fail to keep the appointments made for treatment. Table IV., Group IV., gives a statistical record of the excellent work of the Dental Department, 4,743 children were dentally inspected, 63.5 per cent. were found to require treatment. Mr. Latham reports as follows:— Inspection. I have the honour to present the Dental Report of the inspection and treatment of the Elementary School children for the year 1931. The annual inspection required by the Board of Education was carried out in each school during the year. The Dental Nurse and I made 24 visits to the schools, and all the children, with the exception of a very small number who were absent, received dental examination. The total number of children who were examined during the year was 4,743. Treatment. In 1931, the number of sessions for treatment at the School Clinic was 404, and 4,030 appointments were 95 kept; this means that at each session approximately 10 children received treatment. As regards the actual treatment, our aim is to relieve pain, clear up gross septic conditions, and to secure a clean functional mouth. Unless one has actually seen for oneself, it is difficult to realise how septic and dirty the condition of the mouth can be. A child who is constantly suffering from toothache and whose whole system is being undermined by oral sepsis cannot enjoy its life as it should, nor can it derive full profit from its school time. Dental Education. Instruction in the principles of oral health is carried out at our School Inspections, and in the Clinic at the chairside. At some schools, after my inspection, I find perhaps as many as fifty parents assembled in the hall. This gives me a valuable opportunity to say something about "The Healthy Mouth," and I am also able to explain our system at the Clinic. Parents are still allowed to be present in the surgery during the treatment of their children. Some valuable time is expended in illustration and explanation of what is being done, but I am quite certain that this time is being very well spent, and is the most powerful form of propaganda—"seeing is believing." Home Visits. We have a number of children—about 500—who consistently fail to attend the Clinic when they receive an appointment. On looking through this list of failures to attend, a rather striking fact is brought to notice, namely, that these failures are children who have never yet attended the Dental Clinic. In this there is some cause for satisfaction in that those who do come are not afraid to come again, the treatment is appreciated. The Nurse made 364 visits to parents during the year. When the 1s. fee has prevented their attendance they are referred to the Bromley Children's Care Committee, who never refuse their help. 96 Sometimes the parents are at work all day, and in such cases the Nurse usually finds some friend or neighbour to accompany the child. Sometimes, unfortunately, the parents are apathetic or careless, and in such cases it is very difficult to do anything. Eventually many of these cases do put in an appearance at the Clinic, suffering from acute abscess; we treat these only on condition that they promise to keep their appointment when they are sent for on some future occasion. Other Services. A number of children, 34, from the County and High Schools have attended the Clinic for treatment. They keep their appointments with great precision and make good and appreciative patients. On Saturday mornings we hold a session for Maternity and Child Welfare cases. During last year, 17 mothers and 58 children received treatment. The dental condition of most of the mothers is very bad, showing appalling neglect, and the only possible treatment is the extraction of all the teeth. We do not make dentures for these mothers at the Clinic, but even without dentures their health is better than with a mouth of septic teeth. As regards the children, one might almost call them babies, much can be done to preserve the milk teeth if they are attended to soon enough, but with very many of these cases it is not until they are having severe pain and swelling from an acute abscess that they attend, and then, of course, conservative treatment is impossible. Lastly, I must express my appreciation of the assistance given me by the Committee and the Staff. I also wish to thank the head teachers for their continued help and interest in the dental work. A great deal of the success of this work is due to their efforts. I would also especially thank the voluntary workers who give up so much of their times, often, I know, at great inconvenience to themselves, to help us in such a practical manner. T. S. Latham, School Dental Surgeon. 97 Defective Children. A new table (Table III.) appears this year in the report, and remodels the return of all exceptional children in Bromley. A close study of this table indicates the variety of defects which constitutes exceptional children, and the provision made for their education. Exceptional children lead to costly education, as one has to provide the type of education suitable to the individual defective. It thus follows that any service which tends to limit the severity of the defect, or to prevent its actual occurrence, must receive the support of the true economist. One hundred and ninety-nine children have been classified as defective within the meaning of this Table; blind, deaf, mentally defective, epileptic, physically defective, tubercular and organic heart disease. Twenty of these children were maintained in special residential schools, 22 attending special school for mentally defectives and 9 at special clay schools. At the time of writing this report the Special Day School for Mental Defectives in Bromley has been closed, and active steps are being taken to promote the establishment of an Occupation Centre for the low grade type of child. This will provide a long needed service in this area, as the ineducable child in the past has been generally unprovided for. Severe heart cases are admitted to the West Wickham Heart Hospital, where they come under the skilled treatment of a staff of heart specialists. London County Council Schools provide, where accommodation is available, for the child requiring special day school education, such as the high myopics, the partially deaf, or the physical defectives. The general medical supervision over these children is by no means easy, as much staff time is occupied in the investigation and disposal of such cases. With a growing area, and an increased school population, the matter becomes yearly more difficult. 98 Conclusion. Without a close study of the statistics in the appendix, one is not able to visualise the detail of the work of the School Medical Service, the interest the work creates and the vast possibilities for research in the physiology of the growing child. One regrets the lack of time more than the lack of money for its adequate development. There is much criticism of the service levied by those who misunderstand the work and see it only from its fringe. We do not pauperise the people by giving more than we receive, and if one must look at the matter from the financial aspect, it is noteworthy to record that £383 was in 1931 received by the Education Committee from parents in payment for services rendered to the children through the School Clinic. This problem of finance is not easily settled by the passing of a few shillings into the coffers of the State, but as I stated in the introduction rather to what extent treatment should be given to the individual at the expense of the community as a whole. But we are faced with this fact, if the School Medical Service does not treat, there is no existing service that can adequately fill its place, and that until the child lives a physiologically healthy life in a health-giving environment, treatment of disease will become necessary. As medical services at present exist the child can be placed under two categories, those so ill that they required domiciliary treatment by the private practitioner, and those who are defective and suffer from minor ailments who come under treatment or supervision of the out-patients departments of hospitals or at school clinics of the local authorities. The bringing of these two categories together is no easy matter; the general practitioner cannot afford to treat except at a fee which the people are themselves unable to pay, nor are local authorities prepared to pay the scale of fees of a part-time medical staff when a full-time staff is far more economical. I cannot end this report without a special reference to the keen work of each and all the members of the staff of the School Medical Service, to the Head Teachers for their co-operation and help, and finally to the ladies of the Care Committee who give so much valuable time and service to the work of the various clinics. 99 REPORT OF THE BROMLEY CHILDREN'S CARE COMMITTEE FOR 1931. Executive Committee. Chairman and Hon. Treasurer: Mrs. A. G. Mann, b.a., j.p. Hon. Secretary: Miss E. Carter, 1, Homefield Road. Local Hon. Secretaries. Wharton and Plaistow Miss E. Carter. Valley Miss Poole-Smith. Aylesbury and Masons Hill Vacant. Bromley Parish Miss Bush. Bickley and Widmore Miss G. Moore. Bromley Common Mrs. Foster. Raglan and Addison Mrs. Freeman. Burnt Ash Vacant. Bertram Pearce, Esq. George Weeks, Esq. Alderman F. W. Isard. Miss D. Beddome. E. C. DeAth, Esq. Dr. G. H. Stinson. Dr. K. E. Tapper. The members of the Bromley Children's Care Committee still work at the School Clinic, which is open daily and has an average of 15 sessions a week. This necessitates four or five of our members attending daily. There has been an increase in convalescent cases, 40 as against 34 last year. A brief summary will show to some extent the Committee's work, financial assistance being provided in the following cases, which have been investigated and approved for assistance:— Tonsils and Adenoids 13 Vision 14 Dental 141 Fares to Hospitals 11 Boots 68 Milk and Other Nourishment 116 Convalescent Homes 40 100 The total number of cases receiving our aid was 403, at a cost of £125 12s. 1d. The following up of the cases and the home visits give an opportunity of realising the difficulties, financial and otherwise, of the parents. The Committee has to thank Colonel Satterthwaite for allotting a larger number of convalescent letters for school children, especially owing to our loss of Mrs. Parfect, who, much to our regret, has been unable to take any children this year. The Committee has also to thank Mr. Harris for his generosity in giving so many spectacles free to necessitous cases. Statement of Accounts, 1931. Receipts. Expenditure. £ s d. £ s. d. Bromley Benevolent Association 60 0 0 Royal Sea Bathing Hospital 25 4 0 Charity Festivities 25 0 0 Milk 26 5 1½ Raglan Road Parents' Association 2 2 0 Boots 27 19 7 Convalescent Homes 18 17 8 Re paid— Dental Clinic 8 15 0 Royal Sea Bathing Hospital 18 0 0 Medical Clinic 3 12 6 Cod Liver Oil and Parrish's Food 8 1 2 Convalescent Homes 4 4 0 Fares 1 5 6 Fares 4 10 1 Dental Clinic 19 0 Glasses 1 8 0 Milk 6 0 Taxis from Clinic 19 0 Sale of Cod Liver Oil and Parrish's Food 5 18 1½ Clinic Box 1 0 6½ Donation (Anon.) 1 0 0 Balance from 1930 4 15 10 1931 Deficit due to Treasurer 1 1 1½ £125 12 1½ £125 12 1½ (Signed) E. Carter, Hon. Secretary. 101 BROMLEY CHILDREN'S AFTER-CARE COMMITTEE. Chairman: Mrs. Mann, b.a., j.p. Hon. Secretary: Miss E. A. Wise, Farningham, Kent. Committee: Miss Bush. Mrs. Petley. Madame Duché. Mrs. Slater. Mrs. Drew. Miss D. Tapper. Mrs. Foster. Miss E. Thompson. Sister Morgan. Miss Weeks. Mrs. Palmer. Mrs. Westwood. Report for the Year 1931. As was stated in our last report, the reduction in the numbers sent to the Special School has resulted in a corresponding reduction on our list. We still visit 61 persons, including ten on behalf of the Kent Mental Deficiency Committee. Five of these ten suffer from obvious disabilities, and there can never be any question of their unfitness to become wage-earners. In addition to these five, are five others under friendly supervision who also are incapable of paid employment. During the past year 21 of our cases have been in steady employment, 20 have been in and out of work, one youth has joined the Army, one has been recommended for guardianship under the scheme recognised by the Board of Control, and is now working on a farm near Dover. One girl has disappeared, and all efforts to trace her have so far failed. One man married, but his wife left him after three months, and returned to her home in the North of England. This man has already one illegitimate child. Another case, a girl, has also given cause for grave anxiety. Undoubtedly these two people should be placed under proper control. We have to record our great regret that the need for economy has brought about the closing of the Special School, where by the individual care bestowed upon them, 102 no less than the prolonging of their school-life, has enabled so large a proportion of the pupils to become, in spite of their handicap, both self-respecting and selfsupporting. The Committee are glad to welcome Madame Duché, who joined us in the early part of the year. We earnestly hope that it will be found possible to open the proposed Occupation Centre, for which there are already more than the required number of prospective entries required by the Board of Control. This would provide such training as they are capable of receiving for those former pupils of the Special School, and for certain other children on our list, who are too defective to profit by teaching in elementary schools. The difficulty is to find suitable accommodation for such a centre. Statement of Accounts. Receipts. Expenditure. £ s. d. £ s. d. Cash in hand 3 1 0 Hire of Room 1 2 6 Grant from Kent Public Assistance Committee 6 10 0 Mental Welfare 3 6 Report of Conference 3 6 Printing and Stationery 1 16 6 Postage 15 5 Cheques 1 0 Travelling 1 0 7 Cash in hand 4 8 0 £9 11 0 £9 11 0 APPENDIX. 104 TABLE I.—MEDICAL INSPECTION RETURNS. Year ended 31st December, 1931. A.—ROUTINE MEDICAL INSPECTIONS. Number of Code Group Inspections: Entrants 607 Intermediates 508 Leavers 301 Total 1416 Number of other routine inspections — B.—OTHER INSPECTIONS. Number of Special Inspections 2020 Number of Re-Inspections 3336 Total 5356 105 TABLE IIa.—Return of Defects found by Medical Inspection in the year ended 31st December, 1931. 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 15 32 59 66 Uncleanliness (See Table IV., Group V.) Skin Ringworm—Scalp .. .. 1 11 Body 1 .. 2 1 Scabies .. .. 15 20 Impetigo 2 .. 18 18 Other Diseases (Non-tuberculous) 7 2 219 216 Eye Blepharitis 3 .. 21 8 Conjunctivitis 1 .. 21 10 Keratitis .. .. .. ... Corneal Opacities .. .. .. .. Defective Vision (excluding squint) 98 11 59 13 Squint 7 .. 10 1 Other Conditions 3 .. 51 19 Ear Defective Hearing 1 3 16 4 Otitis Media .. .. 6 2 Other Ear Diseases 8 .. 99 82 Nose and Throat Enlarged Tonsils only 40 169 279 138 Adenoids only 2 2 12 3 Enlarged Tonsils and Adenoids 16 17 74 295 Other Conditions 11 5 404 292 Enlarged Cervical Glands (Non-Tuberculous) 12 28 82 44 Defective Speech 1 .. 1 2 Teeth—Dental Diseases 206 .. 42 1 Heart and Tion Heart Disease—Organic 2 5 .. 1 Functional .. 34 42 88 Anaemia .. 5 11 9 Carried forward 436 313 1544 1344 106 TABLE II.a—Continued. 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) Brought forward 436 313 1544 1344 Lungs Bronchitis 15 4 53 43 Other Non-Tuberculous Diseases 9 6 231 229 losis Pulmonary—Definite .. .. .. .. Suspected .. 3 .. 5 Non-Pulmonary—Glands .. 1 2 3 Spine .. .. .. .. Hip .. .. 1 .. Other Bones & Joints .. .. .. .. Skin .. .. .. .. Other Forms .. .. .. .. Nervous System Epilepsy .. .. 1 .. Chorea 1 .. 5 8 Other Conditions 1 4 24 18 Deformities Rickets .. .. .. .. Spinal Curvature 15 2 8 .. Other Forms 53 11 61 25 Other Defects and Diseases 16 15 463 303 Totals 546 359 2393 1978 107 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 607 118 19.4 Intermediates 508 116 22.8 Leavers 301 59 19.6 Total (Code Groups) 1416 293 20.6 Other Routine lnspections — — — 108 TABLE III.—Return of all Exceptional Children in the Area, 1931. Boys. Girls. Total Children Suffering from types of Multiple Defect: Partially Blind and Mentally Defective. At no School or Institution 1 .. 1 At Certified School for the Blind or Partially Blind 1 .. 1 Blind (including partially Blind). (i) Suitable for training in School for the totally blind. At Certified Schools for the Blind 1 2 3 At Public Elementary Schools .. . .. At other Institutions .. .. .. At no School or Institution .. .. .. (ii) Suitable for training in a School for the partially blind. At Certified Schools for the Blind or partially Blind 2 3 5 At Public Elementary Schools 1 .. 1 At other Institutions .. .. .. At no School or Institution .. .. .. Deaf. (including Deaf and Dumb and partially Deaf.) (i) Suitable for training in a School for the totally deaf or deaf and dumb At Certified Schools for the Deaf 2 2 4 At Public Elementary Schools .. .. .. At other Institutions .. .. At no School or Institution .. .. .. (ii) Suitable for training in a School for the partially deaf. At Certified Schools for the Deaf or Partially Deaf 1 1 2 At Public Elementary Schools 2 .. 2 At other Institutions .. .. .. At no School or Institution .. .. .. Mentally Defective Feebleminded. At Certified Schools for Mentally Defective Children 9 13 22 At Public Elementary Schools .. .. .. At other Institutions .. .. .. At no School or Institution 4 4 8 Epileptics Suffering from severe Epilepsy. At Certified Schools for Epileptics 1 1 2 At Certified Residential Open-Air Schools .. .. .. At Certified Day Open-Air Schools .. .. .. At Public Elementary Schools .. .. .. At other Institutions .. .. .. At no School or Institution .. .. .. Suffering from Epilepsy which is not severe. At Public Elementary Schools 5 2 7 At no School or Institution .. .. .. 109 TABLE III.—Continued. Boys, Girls. Total. Physically Defective. Active pulmonary tuberculosis (including pleura and intrathoracic glands). 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 .. • • .. At other Institutions 2 . 2 At no School or Institution .. .. .. Quiescent or arrested pulmonary tuberculosis (including pleura and intrathoracic glands). 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 5 2 7 At other Institutions .. .. .. At no School or Institution .. .. .. Tuberculosis of the peripheral glands. 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 14 9 23 At other Institutions .. .. .. At no School or Institution •• •• .. Abdominal 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 4 6 10 At other Institutions .. ... .. At no School or Institution .. .. .. Tuberculosis of bones and joints (not including deformities due to old tuberculosis). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board .. .. .. At Public Elementary Schools 5 1 6 At other Institutions .. .. .. At no School or Institution 1 .. 1 110 TABLE III.—Continued. Boys. Girls. Total. Physically Defective (oontinued). Tuberculosis of other organs skin, etc.). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board .. . .. At Public Elementary Schools .. .. .. At other Institutions .. .. At no School or Institution .. .. .. Delicate children, i.e., all children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an Open-Air School. At Certified Residential Cripple Schools .. .. .. At Certified Day Cripple Schools .. 1 1 At Certified Residential Open-Air Schools .. .. .. At Certified Day Open-Air Schools .. .. .. At Public Elementary Schools 24 15 39 At other Institutions .. .. .. At no School or Institution 1 .. 1 Crippled children (other than those with active tuberculosis disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life. At Certified Hospital Schools .. .. .. At Certified Residential Cripple Schools .. .. .. At Certified Day Cripple Schools .. 1 1 At Certified Residential Open-Air Schools .. .. .. At Certified Day Open-Air Schools .. .. .. At Public Elementary Schools 12 16 28 At other Institutions .. .. .. At no School or Institution .. .. .. Children with heart disease, i.e., children whose defect is su severe as to necessitate the provision of educational facilities other than those of the public elementary school. At Certified Hospital Schools .. .. .. At Certified Residential Cripple Schools 1 .. 1 At Certified Day Cripple Schools .. .. At Certified Residential Open-Air Schools .. .. .. At Certified Day Open-Air Schools .. .. .. At Public Elementary Schools 5 5 10 At other Institutions .. ... ... At no School or Institution .. 1 1 111 TABLE IV.—Return of Defects Treated during the year ended 31st December, 1931. Group 1.—Minor Ailments (excluding Uncleanliness for which see Group V.). Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) Skin— Ringworm—Scalp 1 - 1 Body 3 - 3 Scabies 15 — 15 Impetigo 101 - 101 Other skin disease 120 6 126 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 76 2 78 Minor Ear Defects 146 1 147 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 338 4 342 Total 800 13 813 112 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.) Defect or Disease. Number of Defects dealt with. Under the Authority's Scheme. Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) 360* 41 - 401 Other Defect or Disease of the Eyes (excluding those recorded in Group I). 7 — 4 11 Total 367 41 4 412 * This figure 360 includes 239 re-inspections: 121 Refractions. Total number of children for whom spectacles were prescribed:— (a) Under the Authority's Scheme 126 (b) Otherwise 38 Total number of children who obtained or received spectacles:— (a) Under the Authority's Scheme 126 (b) Otherwise 38 113 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. (1) (2) (3) (4) (5) 177 21 198 131 329 Group IV.—Dental Defects. (1) No. of children who were:— (a) Inspected by the Dentist:— Age Routine Groups Aged: 5 414 „ 6 422 „ 7 483 „ 8 459 „ 9 571 „ 10 563 „ 11 469 „ 12 251 „ 13 233 „ 14 130 Total 3995 Specials 748 Grand Total 4743 (b) Found to require treatment 2837 (c) Actually treated 2386 (2) Half-days devoted to:— Inspection 24 Treatment 404 428 114 (3) Attendances made by children for treatment 4030 (4) Fillings:— Permanent teeth 1630 Temporary teeth 642 2272 (5) Extractions:— Permanent teeth 440 Temporary teeth 3120 3560 (6) Administrations of general anaesthetics for extractions 1067* (7) Other operations:— Permanent teeth 423 Temporary teeth 298 721 * In addition there were 1008 local aæsthetics. Group V.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses 3 (ii) Total number of examinations of children in the Schools by School Nurses 12969 (iii) Number of individual children found unclean 478 (iv) Number of children cleansed under arrangements made by the Local Education Authority Nil (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 Nil (b) Under School Attendance Bye-laws 5 116 Dental Treatment and Details of Treatment Given, 1931. Total No. of half-days given to Inspections. Total No. of half-days given to treatments. Total No. of Appointments. S.M.O. and Emergency cases. Total No. of Permanent Teeth. Total No. of Temporary Teeth. Total No. of Fillings. Anæsthetics. Other Operations. Sealings, Dressings, Regulations. Made Kept. Extracted. Filled. Extracted. Filled, Gas. Local. 24 404 7483 4030 748 440 1630 3120 642 2272 1067 1009 721 Total Number of Visits to parents made by the Dental Nurse, 364. 116 Head Inspections, 1931. School Depts. FIRST INSPECTIONS. FINAL INSPECTIONS. ALL INSPECTIONS. individual children Number 1 Inspected. Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous. Slightly Verminous Highly Verminous ADDISON ROAD G & I 134 125 8 1 176 170 6 310 301 8 1 8 1 AYLESBURY B 205 203 2 .. 231 228 3 .. 651 638 11 2 10 2 BICKLEY and J 117 115 2 .. 112 108 3 1 342 332 9 1 8 1 WIDMORE I 116 104 11 1 130 126 3 1 377 350 22 5 14 4 BROMLEY COM. J 180 173 7 .. 173 161 11 1 546 520 25 1 16 1 BURNT ASH G 290 259 30 1 332 307 17 8 901 812 69 20 44 11 B 312 297 14 1 399 394 5 .. 1023 998 24 1 20 1 J 477 461 15 1 400 385 13 2 1335 1287 44 4 34 1 MASONS HILL G & I 262 257 3 2 288 277 9 2 848 829 15 4 11 3 CENTRAL B 95 95 .. .. 94 94 .. .. 270 270 .. .. .. .. G 83 80 3 .. 91 91 .. .. 243 240 3 .. 3 .. PARISH B 229 224 5 .. 259 250 7 2 716 698 14 4 10 2 G 217 205 9 3 246 226 16 4 697 649 39 9 25 7 I 89 86 3 .. 97 91 4 2 311 297 10 4 6 2 PLAISTOW J 57 47 9 1 73 64 8 1 205 173 28 4 13 2 RAGLAN ROAD G 225 218 7 .. 262 241 20 1 703 658 42 3 34 4 B 330 320 9 1 402 394 8 .. 1053 1026 26 1 22 1 J 245 230 13 2 261 248 12 1 762 717 39 6 32 6 I 115 131 11 3 229 214 12 3 646 595 35 16 25 15 VALLEY G 97 76 10 11 95 86 8 1 292 256 23 13 14 11 I 130 123 5 2 134 122 9 3 414 374 32 8 26 7 SPECIAL SCHOOL WHARTON RD J. 21 18 3 .. 28 24 3 1 71 59 11 1 9 1 89 80 8 1 79 75 3 1 253 232 14 7 7 6 Total 4 145 3927 187 31 4591 4376 180 35 12969 12311 543 155 391 87