Borough of Bromley. ANNUAL REPORT OF THE medical officer of health AND school medical officer For 1932. K. E. TAPPER, O.B.E., M.B., Ch.B., D.P.H. BROMLEY, KENT: Strong & Sons, Ltd., East Street. Borough of Bromley. ANNUAL REPORT OF THE medical officer of health AND school medical officer For 1932. K. E. TAPPER, O.B.E., M.B., Ch.B., D.P.H. BROMLEY, KENT: Strong & Sons, Ltd., 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 10 Summary of Statistics 10 Social Conditions 11 Meteorology 11 Occupations and Unemployment 12 Population 12 Part II.—Vital Statistics 13 Births 13 Stillbirths 14 Deaths 15 Infantile Mortality 16 Maternal Mortality 17 Part III.—Maternity and Child Welfare 18 Details of Services 18 Centres and Clinics 19 Ante-Natal Clinic 20 Natal Services 22 Midwives 22 Midwives Acts, Administration of 23 Midwives, Inspection of 24 Maternity Hospital and Maternity Homes 25 Puerperal Fever and Puerperal Pyrexia 26 Post-Natal 27 Home Visiting 27 Welfare Centres 28 Milk in Necessitous Cases 29 Minor Ailment Treatments 29 Ophthalmia Neonatorum 30 Diarrhœa and Enteritis 30 Children Act, 1908, Part I 30 Part 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 35 Nursing in the Homes: District Nursing Association 36 Tuberculosis Dispensary 37 Venereal Diseases 37 Part V.—Sanitary Circumstances 37 Rivers and Streams 37 Drainage and Sewerage 38 Water 38 Scavenging 38 Rats and Mice Destruction Act, 1919 38 Nuisances 39 House to House Inspection 39 CONTENTS—Continued. Page Part VI.—Housing Conditions 40 Overcrowding 40 Prevalent Defects in Housing 40 Houses Let in Lodgings 40 Part VII.—Smoke Pollution 41 Part VIII.—Shops Acts 41 Part IX.—Petroleum Acts 42 Part X.—Factories and Workshops 43 Part XI.—Premises and Occupations Controlled by Bye-Laws, Regulations, &c 43 Part XII.—Inspection and Supervision of Foodstuffs 44 Milk 44 Milk, Bacteriological Examinations 45 Milk, Contraventions 46 Meat 46 Meat, Tables A., B., C., D. and E. 46 Meat, Contraventions 48 Other Food Condemned 49 Unsound Food Surrendered 49 Food and Drugs (Adulteration) Act, 1928 49 Part XIII.—Diseases of Animals Acts 50 Part XIV.—Rag Flock Acts, 1911-1928 51 Part XV.—Infectious Diseases Control 51 Scarlet Fever 51 Diphtheria 52 Diphtheria Immunisation 52 Typhoid Fever 53 Other Notifiable Infectious Diseases 53 Vaccination 54 Tuberculosis 54 After-Care Committee for Tuberculosis 56 Part XVI.—Propaganda 57 Appendices.—Statistical Tables I. to XV 61—78 School Medical Service. Members of the Education Committee 80 Introduction and Summary of Statistics 81 Hygiene of Schools 82 Medical Inspections 82 Routine Medical Inspections 82 Special Medical Inspections 83 Treatment 84 Eye Clinic 84 Disease of Ear. Nose and Throat Clinic 85 Orthopaedic Clinic 86 Orthopaedic Statistics 87 Defective Children 88 Dental Clinic 89 After-Care 92 Report of the Bromley Children's Care Committee 93 Report of the Bromley After-Care Committee— Mental Welfare 96 -Appendices.— Medical Inspection Returns, Tables I. to IV 100 Dental Clinic. Details of Treatment 111 Head Inspections 112 MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1931-32. HEALTH COMMITTEE:— Councillor E. J. Heilbron (Chairman). Resigned 30/5/1933. Alderman W. F. Skilton (Vice-Chairman). His Worship the Mayor (Councillor W. D. Gibbs, J.P.). Councillor G. Allen. Councillor F. S. Darby (vice Councillor E. J. Heilbron, resigned). Councillor S. L. Gibbs. Councillor W. A. Greenley, C.M.G., D.S.O. Councillor C. H. Gunton. Councillor A. McIntosh, D.C.M. Councillor M. Stafford Smith, M.B.E., B.A. MATERNITY AND CHILD WELFARE COMMITTEE:— Alderman W. F. Skilton (Chairman). Councillor M. Stafford Smith, M.B.E., B.A. (Vice-Chairman). His Worship the Mayor (Councillor W. D. Gibbs, j.p.). Councillor E. J. Bettson, f.c.a. Councillor F. S. Darby (vice Councillor E. -T. Heilbron, resigned). Councillor S. L. Gibbs. Councillor Sir Gilbert Grindle. k.c.m.g., c.b. Councillor E. J. Heilbron, resigned. Councillor T. H. Jayes. Councillor A. McIntosh, d.c.m. Co-opted Members: — Mrs. A. M. Howe. Mrs. A. G. Mann, b.a., j.p. Mrs. M. Pearce. M iss Y. Vincent. Mrs. E. Yolland. Borough of Bromley. Report of the Medical Officer of Health for the Year 1932. To the Mayor, Aldermen and Councillors. Mr. Mayor, Madam and Gentlemen, I have the honour to submit the Report on the Public Health of Bromley for the year 1932. Much in the report is a reiteration of services reported upon in previous years, and is drawn up in accordance with the requirements of Circular 1269 issued by the Minister of Health. Although the report that follows deals more in the detail of the Public Health Service, it is a difficult matter to summarise the work of the Department. However, it may give some indication to those who fail to realise the extent of the activities by giving here a mere statement of figures: In the year under review 2,383 individual children passed through medical supervision at the School Clinic; 1,421 babies attended the welfare centres; 1,032 houses were inspected for sanitary defects; and 4,654 animals examined after slaughter. The year was one of strict economy, especially so in local government, and any necessary extension of services to cope with the increasing population of Bromley had to be curtailed. However, some extension took place in the Maternity and Child Welfare service whereby new arrangements were agreed upon by the appointment of a Consultant Gynaecologist, the reservation of the right of admission of necessitous cases to Maternity Hospital, and extension of Ante-Natal Clinic provision. 6 The outstanding event of the year, from the administration point of view, was the local enquiry into the local government areas under the Local Government Act, 1929, and the Provisional Order put forward by the Corporation. The Minister of Health has confirmed the decisions of this local enquiry to increase the area of Bromley by the inclusion of the major portions of Hayes and Keston, and minor portions of Farn borough and West Wickham, and minor adjustments of boundaries between the Borough and Beckenham and Chislehurst. Further alteration in administration in the Department came about by the undertaking of the Diseases of Animals Acts; the Chief Sanitary Inspector being appointed the Inspector under these Acts. A Dental Assistant Nurse was appointed to release a Health Visitor for home visiting work. Otherwise there has been no increase in staff to cope with the rapidly increasing work of the Department. Bromley is approaching the 50,000 population figure, and a gradual change in the type of resident is taking place. This in turn has its effect on the administration of the public services. We are happily not faced with the slum problem, nor are the housing conditions in any way an acute problem, except in those cases where the economic conditions has encouraged the house built for one family to be let in lodgings, and the subsequent lowering of social conditions by the impairment of an environment which attempts to provide for sleeping, cooking and living all in the one room. The Vital Statistics for 1932 show at least one outstanding feature, the Infantile Mortality Bate is the lowest ever recorded in Bromley, being one-third of the pre-war rate. The Death Rate remains stationary, but there is a fall in the Birth Bate. Infectious Diseases showed their expected fall, especially in regard to Scarlet Fever, which reached the apex of its curve in 1931. Measles, Mumps am Chicken-pox were prevalent during the year and caused much absence from school, and a consequent increase in the work in this section of Public Health. 7 The Report again includes the School Medical Service Report, with its statistical appendices. I would take this opportunity of bringing to your attention the invaluable work given by the Voluntary Workers at the centres and clinics, and by the Staff of the Health Department, who throughout a very difficult year have given unsparingly of their services. I am, Mr. Mayor, Madam and Gentlemen, Your obedient Servant, K. E. TAPPER, Medical Officer of Health. 8 PUBLIC HEALTH STAFF, 1932. Medical Officer of Health and School Medical Officer Assistant Medical Officer of Health and School Medical Officer 2 K. E. Tapper, o.b.e., m.r, Ch.b., d.p.h. 3 Miss G. H. Stinson, m.r c.s., l.r.c.p. Orthopaedic Specialist 2 1 H. J. Seddon, F.R.C.S Ear, Nose and Throat Specialist Consulting Gynaecologist 2 1 Charles C. Beney, M.A., M.B.. Ch.B., (Carab.), M.R.C.S. 1 J. Bright Banister, M.A., M.D., F.R.C.P., F.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. Health Visitors and 6 7 6 2 Miss L. A. Briggs, S.R.N. School Nurses... ... 8 7 6 2 Miss E. B. Crowe, S.R.N. 8762 Miss J. Roseveare, S.R N. 8 7 6 2 Miss P. M. Trickett, S.R.N. 7 2 Miss V. Morgan 7 6 2 Miss S. M. Davies, S.R.N. (Resigned 13/7/32). Orthopaedic Nurse 2 1 Miss D. Gardner, C.S.M.M.G., M.E. Veterinary Surgeon under the Diseases of Animals Acts 1 P. J. Turner, M.R.C.V.S. 9 PUBLIC HEALTH STAFF—continued. Inspector under the Diseases of Animals Acts, Shop Acts, and Petroleum Acts G. R. Woods, (Duties under the Diseases of Animals Acts were taken over on 1st April, 1932) General Office Staff: Senior Clerk 2 H. E. Lawley. Junior Clerks 2 Miss M. L. Byford. 3 2 H. Handscomb 2 Miss B. C. Tucker (Appointed 13/9/1932). 2 Miss M. H Davis. (Resigned 11/9/1932.) Dental Assistant Nurse 2 Miss A. M. Penman. Outdoor Staff : Drain Tester and Disin- J. W. Seager fector Market Toll Collector 1 H. Deane Denotes part-time. 2. Exchequer Grants (including Board of Education). Certificate of the Royal Sanitary Institute and Sanitary Inspectors Joint Examination Board. 4. Royal Sanitary Institute Certificate for Meat and Other Foods. 5. Royal Sanitary Inst., Smoke Cert. 6. Three years Hospital Trained. 7. Cert. of Central Midwives' Board. 8. Royal Sanitary Inst. new Health Visitors' Certificate (under Memo. 101/MCW). 10 I.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Statistics. Area (in acres) 4,697 Population— Census (1921) 35,052 Census (1931) 45,34874 Mid-year (1932) (Registrar General's estimate) 46,800 Number of inhabited houses (Census 1921) 7,400 (December, 1932) 11,711 Rateable value £489,637 The sum represented by a penny rate £2,010 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 571 284 287 Birth Rate per 1,000 of the estimated resident poulation: 12.9. Illegitimate 34 17 17 605 301 304 Stillbirths Legitimate 24 18 6 Rate per 1,000 total (live and still) births: 38.1. Illegitimate — — - 24 18 6 Deaths 504 228 276 Death Rate per 1,000 of the estimated resident population : 10.7. Deaths from puerperal causes : Number of deaths Rate per 1,000 total (live and still) births: From sepsis 1 1.5 From other causes 1 1.5 11 Death rate of infants under 1 year of age:— All infants per 1,000 live births 33.05 Legitimate infants per 1,000 legitimate live births 31.5 Illegitimate infants per 1,000 illegitimate live births 58.8 Deaths from measles (all ages) 2 Deaths from whooping cough (all ages) 1 Deaths from diarrhoea (under 2 years of age) 1 Social Conditions. Bromley remains a delightful residential area with a rather rapid increase in the small house property, an indication of a "levelling up" of social conditions during times of continued distress in the country generally. There is an increasing predominance of the three-person family, whether due to economic conditions, or birth control, or a loss of fecundity, cannot be known. The Census shows that the average size of a family in Hromley is 3.70 persons, compared with 4.04 of i921 Census, while the average size of dwelling has fallen from 6.08 rooms to 5.70 rooms; 86 per cent. of families have three children or less. Bromley continues to be the main shopping centre of the surrounding area. Meteorology. The following particulars have been extracted from the records kept at the Climatological Station at Church House Gardens for the year ended 31st December, 1932: Total rainfall 22.40 inches Mean maximum temperature 56.68 degrees Mean minimum daily temperature 43.22 degrees Highest maximum temperature recorded 94 degrees on 19th August. 12 Lowest minimum temperature recorded 21 degrees on 13th March. Lowest grass minimum temperature 17 degrees on 1st Jan. and 2nd and 13th March. Occupations and Unemployment. The Registrar General's tabulation of the results of the Census taken in 1931 with regard to occupations is not yet available. The figures published in my Report of 1930 (page 8) will probably change in proportion as the population has increased. The unemployment figures for the Borough still rank high on comparison with past years, but in comparing total figures one must bear in mind the relationship to increased population, and on this basis of calculation there is a slight percentage decrease for 1932 in comparison with 1931. Acknowledgment is due to the Manager of the Employment Exchange for kindly supplying the following particidars:— (1) Recorded unemployment at the end of December, 1932:— Men, 18 years and over 958 Women, 18 years and over 154 (2) The highest figure reached in 1932 on 23rd J anuary:— Men 1203 Women 275 A higher figure was reached during a frost period and for obvious reasons this figure is not shown. Population. The Registrar General gives the mid-year estimate of population as 46,800, an increase of only 1,452 over the Census of 1931. The rate books at the end of the year 1932 show 11,711 inhabited houses, and if we take 13 the Census figure of 4.2 as being the average number of persons per house the population would work out at 49,186. With a rapidly increasing area of housing in the immediate surroundings of London, it must be a difficult matter to give the true population figure, and estimated figures must be taken with reservation. However, for the purposes of calculation of the vital statistics, the Registrar General's figure of 46,800 must be taken as the correct one. As it is of more importance to know the details of the population, a reference to the Census of 1931, which was published after the issue of my last Annual Report, might be of interest:— There has been a 29 per cent. increase in population since 1921. Females exceed males by over 5,000, and this is so in each age group over 15 years. Males exceed females in the age groups under 15 years. The number of rooms exceed the number of persons —the average working out at 0.72 persons per room. In Bromley Common area the average is higher, working out at 0.84 persons per room. The conditions of over-crowding are indicated by ihe figure, which shows that 191 families are living more than two persons per room, although at the time of the Census there were 198 unfurnished vacant dwellings; 118 houses were each occupied by three or more families, but this was chiefly in the six or more room dwellings, having in all 939 rooms. One other interesting figure appears ir the Census return. The average size of family has fallen from 4.04 in 1921 to 3.70 in 1931, in spite of the fall in the death rate from 11.8 to 10.9. II.—VITAL STATISTICS. Births. The number of live births as furnished by the Registrar General after correction for inward and outward transfers for 1932 is 605. This figure represents a 14 Birth Rate of 12.9 per 1,000 of the resident population, and is 0.6 lower than the rate for 1931, and is also the lowest rate ever recorded in Bromley. Bromley's annual birth rates are shown in comparison with those of England and Wales during the past twelve years in the following tabulation: — 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 1932 12.9 15.3 The high number of 34 illegitimate births is to be noted—nearly 6 per cent. of total births are born out of wedlock. The infant death rate of these is equivalent to 58.8 per 1000, compared with 31.5 per 1,000 of those born legitimate. Stillbirths. Twenty-four stillbirths were registered in 1912. which corresponds exactly with the number notified under the Notification of Births Act, 1907, and gives a rate per 1,000 total (live and still) births of 38.1. This shows a slight improvement on the rate of 40.4 for 1931. During the past six years the number of stillbirthoccurring is shown in the following table:— 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 1932 24 38.1 15 Enquiries are made into all stillbirths notified and occurring in the district, and these help to bring forward in some cases the cause, or neglect, of the principle of prevention. In one case the neglect was wilful, the mother refusing treatment and the stillbirth resulting from toxaemia of neglected albuminuria in the mother. The outstanding factor in nine of the cases was the neglect of the mother to seek ante-natal advice. In one case neither doctor, nor midwife, was engaged, the confinement taking place in emergency. All this means that more than 50 per cent. of stillbirths are preventable. There is, too, the desire todestroy the foetus in utero, or bring forward a miscarriage—a practice which is unhappily encouraged by quack medicine advertisements, which shelter their action by a wilful misinterpretation of birth control. Deaths. Five hundred and four deaths were registered during the year, and is the nett figure furnished by the Registrar General after due allowance has been made for inward and outward transfers. This figure is seven in excess of the figure for 1931 and gives a crude Death Rate of 10.7 per 1,000 of the estimated population. In the following tabulation is shown the crude death rates for Bromley in comparison with the death rates for England and Wales during the past eleven years:— Year. Bromley Crude Death Rates. England and Wales Death Rates. 1922 11.8 12.9 1928 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 1932 10.7 12.0 16 Age grouping and sex distribution of the population are important factors which must be taken into consideration when comparing death rates, but these factors are not taken into consideration in the above table. A higher death rate 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. Causes of deaths are shown in detail in the appendix III., from which the following main causes have been extracted, and the figures for 1931 are given for the purpose of comparison:— 1931 1932 1931 1932 1931 1932 No. of Deaths. Rate per cent, of Total Deaths. Rate per 1,000 of population. Respiratory Disease 42 45 8.4 8.9 0.9 0.9 Heart Disease 122 146 24.5 28.9 2.6 3.1 Cancer 71 78 14.3 15.4 1.5 1.6 Tuberculosis 34 36 6.8 7.1 0.7 0.7 Premature Births 13 12 2.6 2.3 0.2 0.2 Infectious Diseases 9 8 1.8 1.5 0.1 0.1 Influenza 8 16 1.6 3.1 0.1 0.3 Infantile Mortality. Twenty deaths of infants under one year of age were registered, giving a Mortality Rate of 33.03 per 1,000 live births. If statistics are accepted as an indication of the success of Public Health work in Bromley, then 1932 is worthy of record. The infantile mortality rate of 33.05 is the lowest figure ever recorded in Bromley. The average infantile mortality rate during 1926-1930 was 44; for 1921-1925 it was 62, and the pre-war rate for 1910-1930 was 68. We have therefore been successful in halving our baby death rate. In the following table the rates for Bromley are shown for the past eleven years in comparison with those for England and Wales:— 17 Year Bromley England and Wales 1922 74 77 1923 60 69 1924 58 75 1925 57 75 1926 33.5 70 1927 50 69 1928 49 65 1929 46 74 1930 41 60 1931 47 66 1932 33.05 65 Further statistical tables in the Appendix (IV., V. and VI.) will indicate that 10 of the 20 deaths occurred before reaching four weeks of age, and that eight of these 10 occurred in the first week of life, the prevention of which must be in the pre-natal and natal periods. In spite of this fact and every endeavour to increase our activities in this direction, the public is very slow to respond, and in fact there has actually been a falling off in the Ante-natal Clinic attendances as compared with 1928-1929. Maternal Mortality. Quinquennial periods: 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 Biennial period: 1931-1932 2 4 5 To combat maternal Mortality the Local Authority has made arrangements to provide for safeguarding the life of the mother. Cases that are necessitous either on medical grounds, or on environmental grounds, have access to the reservation of beds in the Maternity Hospital, and may be financially assisted thereto. I feel in this matter that the Maternity Hospital should form an essential part of the Maternity and Child Welfare 18 service of the Local Authority, and not as at present a separate entity in the management of a Voluntary Committee. An Obstetrical Specialist is provided in cases of emergency; the fee of a doctor is paid where his attendance is requested by the midwife; three ante-natal clinics are held monthly with a specially skilled doctor in attendance; extra nourishment is provided where necessary; the midwives are highly skilled and capable, and yet the public is slow to respond to these provisions, and the unskilled "handy woman" still permitted to give unsound advice. I reported rather more fully on this matter in my Report of 1931. I can only reiterate what I then wrote. IlI—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. Seven welfare centre sessions are held weekly, with a doctor in attendance. 3. Ante-natal Clinics are held three times per month. 4. Maternity Hospital provision for necessitous cases. 5. Consulting Gynaecologist, whose services are available for general obstetrics work. 6. Hospital treatment, isolation, and Consulting Gynaecologist for Puerperal Fever and Puerperal Pyrexia cases. 7. Dental treatment for expectant mother, nursing mother, and children under five years of age. 8. Free milk for necessitous cases. 9. Home visiting of boarded-out children under Children and Young Persons Acts, 1908-1932. 19 10. Orthopaedic treatment and Consulting Surgeon for the crippled child. 11. Minor ailment treatment. 12. Ear, Nose and Throat Consultant and Surgeon. Operative treatment at the School Clinic. 13. Provision of hospital treatment for cases of Ophthalmia Neonatorum, and for acute complicated cases of Measles under five years of age. (Note: The above particulars of Services have been revised so as to include such extension of services as became operative at the commencement of the financial year 1933-34). Child Welfare Centres. Bromley Common— St. Luke's Institute, Raglan Road Tuesdays, 2.30 p.m. Fridays, 2.30 p.m. Burnt Ash— Burnt Ash Branch Library, Tuesdays, 2.30 p.m. 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. Widmore— Wesleyan New Hall, Tylney Road Tuesdays, 2.30 p.m. Ante-Natal Clinics. Held at the School Clinic, Station Road, on the first and third Thursdays in every month at 2.30 p.m., and at the Maternity Hospital, Widmore Road, on the fourth Thursday in each month at 2.30 p.m. 20 Dental Clinic. Held at the School Clinic, Station Road, daily for children, and for expectant mothers and nursing mothers at 9.30 a.m. on Saturdays. Orthopaedic Clinic. For children under five years of age with crippling defects, as well as school children. Held at the School Clinic, Station Road. Mondays at 9.30 a.m. Tuesdays at 9.30 a.m. 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 011 Mondays at 9.30 a.m. Diphtheria Immunisation. Held at the School Clinic 011 Mondavs at 2.30 p.m. Ante-Natal Clinic. Comparative Tables of Attendances at Ante-Natal Clinic. Year. Individual Attendances. Total Attendances. Medical Consultations. Sessions held. 1922 17 32 26 4 1923 47 73 73 11 1924 47 51 51 12 1925 60 89 78 11 1926 59 90 90 14 1927 109 164 164 23 23 1928 116 184 184 1929 118 212 212 24 1930 125 235 233 24 1931 101 184 180 24 1932 123 199 196 24 21 An endeavour was made during the year to see patients only by appointment, but this failed for the usual reasons that appointments were not always kept and patients attended without appointments. We have now reverted to the previous system whereby the Clinic is open to all cases whether sent direct by the doctor, midwife or by appointment from the various clinics and centres. Ante-natal work would be much more effective if mothers sought advice earlier in pregnancy and preventive work began before the causes of stillbirths and premature births can do damage. This is brought out in the investigation into stillbirths, as very few of these received skilled ante-natal supervision. The following tables give the order of pregnancy and the date the mother first attended at the Clinic. It will be noticed from this that there is still much work to be done in educating the mothers in the necessity of seeking advice early and frequently during the pregnancy. Order of Pregnancies. No. of mothers who attended in the First three months of Pregnancy. No. of mothers who attended in the Second three months of Pregnancy. No. of mothers who attended in the Third three months of Pregnancy. 1st 4 17 8 2nd 10 18 3 3rd 3 11 6 4th 1 12 3 5th 2 4 4 6th 1 5 1 7th 1 1 - 8th - 1 1 9th - 1 1 10th - 2 - 11th - - 1 14th - 1 - Total 22 73 28 The table explains itself—17 per cent. attended early in pregnancy; 23 per cent. late in pregnancy. Of 635 22 births occurring in Bromley only 12-3 expectant mothers attended the Ante-Natal Clinic, approximately 20 per cent. Quite apart from the medical aspect, the instruction and advice given to the mothers on the normal conduct of a pregnancy creates an attitude of mind of vast importance to a healthy confinement and a healthy baby. Expectant mothers are now seeking dental treatment more frequently than in the past, although there is still much prejudice to be overcome in this respect. There is no doubt that the Ante-Natal Clinic is appreciated and is doing work of great value in the prevention of invalidity and a high mortality rate among: mothers who attend. Natal Services. Six hundred and thirty-five births were known to have occurred in Bromley during 1931, of which 610 were notified in accordance with the provisions of Notification of Births Act, 1907, and of these 24 were stillbirths. In addition, 25 births were found not to have been notified, and warnings were given in these cases. The 635 births were notified as follows:— Notified by midwives 304 Notified by doctors and parents 306 "Un-notified " 25 635 Forty-three per cent. of births in the Borough in 1932 were attended by midwives practising in their professional capacity. Sixty-eight cases were attended by doctor and an unskilled attendant after confinement. Midwives. I. (a) The number of midwives practising in the area served by the Council for maternity and child welfare at the end of the year was 19. 23 (b) Number (i) employed by the Council - (ii) directly subsidised by the Council - (iii) employed by Voluntary Associations 7 (c) Number of cases during the year in which the Council paid or contributed to the fee of a midwife — II. (a) Number of cases attended by midwives during the year:— (i) as midwives 276 (ii) as maternity nurses 291 (b) Number of cases during the year in which medical aid was summoned by a midwife under Section 14 (1) of the Midwives Act, 1918 48 Administration of the Midwives Acts, 1902-1926. No. of midwives practising in Bromley at the end of 1931 17 No. of midwives giving notice of intention to practise during 1932 27 No. of midwives removed from the local register having left the district 8 No. of midwives practising in the area at the end of 1932 19 Notifications Received. Notices calling in Medical Aid 48 Mothers 36 Infants 12 Notices of Artificial Feeding 1 ,, ,, Stillbirths 9 ,, ,, Deaths 2 ,, ,, Laying out a Dead Body — ,, ,, Source of Infection 5 24 Summary of Reasons of Sending for Medical Help. Ruptured perineum 10 Delayed labour 6 Breast condition 1 Varicose veins and leg swellings 4 Placenta Præ evia 1 Placenta, partially adherent 2 Abnormal presentation 4 Miscarriage 1 Ante-natal examination 4 Rise of temperature 3 Infants—Feeble, prematurity, etc. 7 Malformations 1 Eye discharge 2 Cyanosis 1 Spina bifida 1 Total 48 Payment of Doctors called by M id wives, Section 14, Midwives Acts, 1918. No. of applications for fees 38 No. of cases where payment of fee lapsed on account of failure to claim within the prescribed period of two months 9 No. of cases where patient paid the doctor's fee direct 1 Total amount of claims paid £50 13s. 6d. 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. Dr. G. H. Stinson, Assistant Medical Officer of Health, who is Inspector of Midwives for the Local Supervising Authority, reports as follows: — Every midwife is inspected each quarter, both her records and actual work. There is definitely an improvement in the record keeping, especially in the ante-natal 25 notes, and in some cases of the post-natal notes kept by the midwives. The method of keeping the temperature chart of each case attached to the case notes is being generally adopted by all midwives, and is very helpful in the inspection of their registers. Most midwifery bags are well equipped, but attention has still to be called to the ill-fitting linings. There is room for much improvement in bag linings. The use of rubber gloves in midwifery is not generally adopted. There are one or two midwives who use them at work. I think it is a pity that it is not more general, as it is very easy to boil a pair of gloves and it is a safeguard not only to the patient, but also to the midwife herself. The question of the married midwife with home and children to look after is still, to my mind, unsatisfactory. To try and do domestic work and manage a family of children, and do midwifery is, to say the least of it, difficult. It is impossible to combine midwifery and housewifery successfully — something or someone is bound to suffer in the end. Perhaps we shall see an improvement in this matter as time goes on. I would like to express appreciation of the assistance given to me by the midwives and their helpful co-operation at all times during inspections. I am satisfied that in Bromley we have a very efficient body of midwives. Post-Certificate Course. Nine midwives were financially assisted to attend the very valuable Post-Certificate Course for Midwives which was held at Maidstone during October, 1932. Maternity Hospital and Maternity Homes. During the period of closure of the Maternity Hospital for alterations, arrangements were made for the admission of necessitous cases under the Council's scheme to the Bromley Common Nursing Home. I would here like to record my appreciation to the Matron of this Home for the kindly care and very skilled attention she gave to the patients we admitted. 26 Twenty-five cases were financially assisted under the scheme, of whom 10 were admitted to the Maternity Hospital and the remainder went to the Nursing Home. In addition, 13 cases were recommended from the AnteNatal Clinic or by the Department to other Maternity Institutions. The total number of women admitted to the Maternity Hospital during the year was 127. The Maternity Hospital should he reserved for those cases other than normal, those that would take place in bad environmental conditions, and those whose confinements are likely to be complicated by some medical or physical condition. There is no doubt an encouragement to hospitalise all maternity cases on the grounds of giving the mother greater comfort and perhaps to ease the economic stress if the confinement took place at home. Hospitalisation must be watched so that it does not become a hindrance, but an aid to public health and a guard against maternal mortality. There are nine institutions classified as Maternity Hospital and Homes within the Borough, which are registered under the Nursing Homes Kegistration Act, 1927; and, including the Maternity Hospital, make provision for 26 maternity beds, to which 226 maternity cases were admitted during 1932. 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 Summary of General Provision of Health Services in the Area. Puerperal Fever and Puerperal Pyrexia. The arrangements for treatment, isolation, etc., of cases coming under the above-mentioned heading are made with Queen Charlotte's Maternity Hospital, London, at their Isolation Block, Bavenscourt Square, Hammersmith. Cases are conveyed to the Hospital by the London Ambulance Service of the London County Council. 27 Two cases of Puerperal Fever and nine cases of Puerperal Pyrexia were notified under the Regulations; four were removed to the Queen Charlotte Maternity Hospital for treatment under the Corporation's scheme; three received treatment in other hospital institutions or nursing homes, and four were nursed at home. Post-Natal. Home Visiting. The Corporation employs five health visitors, who . devote half their time to the School Medical Service. One Health Visitor attends the Tuberculosis Dispensary on each Wednesday afternoon session, and carries out home visitation of tubercular patients. Table XII. in the Appendix gives details of the work of home visiting during 1932. It is satisfactory to note that there has not been a further falling off in the total number of recorded visits for 1932, but actually an increase of 334 over the total for 1931. The appointment of a Dental Assistant Nurse has enabled a Health Visitor, who had been engaged in Dental Clinic duties, to be employed in her proper sphere of duties, viz., maternity and child welfare and school medical services. It was not anticipated that any material improvement in the number of visits would result from this change, because the resignation of a Health Visitor and the illness of another during 1932, naturally disturbed staff activities. Even with the full complement of five Health Visitors engaged in their rightful sphere of action, it is not to be expected that the current year will produce proportionate increase in visiting records, because growing population, an additional welfare session, and the constant housing developments creating additional areas to be traversed, will all exert a retarding influence on statistics of home visitation. The total number of visits by the health visitors during 1932 amounted to 6,118. Not included in this number are 1,015 visits designated as "ineffectual" which are made up of visits where no answer is received, the family is discovered to have moved, or visits are resented. It will be appreciated that time and energy is 28 unavoidably lost in these cases, and having no true value as a contribution to health visiting work are not included in the tabulation of statistics. Welfare Centres. The Corporation provides five welfare centres in the Borough, at which seven sessions are now held weekly. During the year under review, however, six sessions were held weekly, and the following extracts of figures relate to the work carried out during these sessions:— (a) The total number of attendances at all centres during 1932 13,138 (i) By children under 1 year of age 3,991 (ii) By children between the ages of 1 and 5 9,147 (b) The total number of children who attended at the centres for the first time during 1932 576 (i) Children under 1 year of age 358 (ii) Children between the ages of 1 and 5 218 (c) Total number of children who were in attendance at the centres at the end of 1932 1,421 (i) Children under 1 year 289 (ii) Children between the ages of 1 and 5 1,132 The work accomplished by these centres is set out in detail in the statistical table given in Appendix XIII I have already referred in the introduction of this Report to the invaluable work done by the Voluntary Workers at the Centres, and too much cannot be said in praise of this voluntary effort. 29 Milk in Necessitous Cases. Assisted milk supply was granted to 125 individual cases, a total of 11,813 pints of milk being distributed at an approximate cost of ±'146 during the period January—December, 1932. The following is an analysis of the 125 families who received free milk during the year:— Size of Family—excluding parents. No. of children in family 1 2 3 4 5 6 and over No. of applicants 37 24 24 18 12 10 Percentage of total applicants 30 19 19 14 10 8 Minor Ailment Treatment. The facilities of the School Medical services are available for the pre-school child, and this policy of treating early does much to prevent gross defects in the school entrant. Tonsils and Adenoids. Twelve cases under five years of age received operative treatment at the Ear, Nose and Throat Clinic under the approved scheme for Minor Ailment Treatment. These cases are detained at the School Clinic for 24 hours after their operations, and subsequently receive daily visitation from the health visitors for a period of seven days. Minor Ailments. Thirty-five cases received treatment at the School Clinic for ailments such as skin disease and minor surgical injuries. Orthopæ dic. Mr. H. J. Seddon, Orthopæ dic Surgeon, has reported on cases dealt with during the year in the School Medical section of this report, and other details and statistics relating to the work of this Clinic, including maternity and child welfare cases, are there dealt with. 30 Dental Clinic. Seventy-six children under 5 years of age, and 30 expectant or nursing mothers, received treatment at the Dental Clinic. Ophthalmia Neonatorum. Appendix XI. gives statistical details of the 3 cases notified under the Public Health (Ophthalmia Neonatorum) Regulations, 1926. Hospital treatment was provided in one case. This was the first case to receive hospital treatment under the Local Authority's scheme. Impairment of vision in any of the cases fortunately did not result. Diarrhcea and Enteritis. Two deaths of children under two years of age were recorded during 1932. Fortunately this serious disease in infants was not prevalent in the Borough during the year. In 1931 the mortality rate per 1,000 babies born in Bromley was 11; for 1932 the rate is 3 compared with 6.6 for the whole of England and Wales. Children Act, 1908, Part I. The following particulars have been extracted from the records kept with reference to foster-children and foster-parents:— (a) No. of persons receiving children for reward on the register at the end of 1932 39 (b) No. of children on the register:— (i) At the end of the year 1932 42 (ii) Who died during 1932 1 Certain minor contraventions of the provisions of the Act were remedied by preliminary warning letters in 6 instances. The Health Visitors are Infant Protection Visitors for the purposes of the Act, and as a routine matter all boarded-out children are visited once a quarter. In all 168 visits were made in this respect. The above Act has been amended by the Children and Young Persons Act, 1932, which came into force on 1st January, 1933. The administration of the section of 31 the Act dealing with Infant Life Protection devolves on (he Maternity and Child Welfare Authority. It is early days to pass judgment on its effectiveness in the proper supervision of the child boarded-out with foster-parents, but as far as one is able to judge during the past six months' working, it is proving a step in the right direction in protecting the interests of the unwanted fosterchild. The requirement of seven days' notice before reception of a child, seven days' notice before change of residence, and the extension of supervision until a child is nine years of age, are important factors which are proving beneficial. The working of the Act has, however, increased duties both in the administrative and visiting services, it being a service that requires the goodwill and co-operation of the foster-mother if the Act is to work smoothly, and the supply of fostermothers maintained. We still have the difficulty where the child is boarded-out at short intervals passing from one foster-mother to another, thus losing the benefit of family life. Such children would, I believe, benefit more by being in institutions in spite of the effects of institutional life. IV.—SUMMARY OF GENERAL PROVISIONS 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 Y.) 1925 The Notification of Births Act 1907 The Local Government and Other Officers' Superannuation Act, 19221927 Bye-Laws: Common Lodging Houses 1897 Nuisances (Bye-law 13 repealed 13/2/1912) 1897 32 Cleansing of Earth Closets, Privies, Ashpits and Cesspools 1898 Houses Let in Lodgings (Bye-law repealing Bye-laws of 1890) 1898 Prevention of Nuisances arising from Filth or Rubbish 1912 Tents, Vans and Sheds 1923 Slaughterhouses 1924 New Streets and Buildings, 1926 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 Hospitals: Bromley (Kent) and District Hospital 47 ,, Phillips Memorial (Homeopathic) Hospital 20 ,, (3) Maternity Hospital: The Bromley and Chislehurst Maternity Hospital 12 „ Maternity and Nursing Homes. There are nine maternity and nursing homes registered under the Nursing Homes Registration Act, 1927. One maternity home has been deleted from the register, having ceased to exist. 33 The following are particulars of maternity and nursing homes registered by the Local Authority, ana for the convenience of tabulation I have included detail of the larger hospitals which are exempt from registration under the provisions of the Act :— Address Total No- of Beds- ity beds. Patient received In 1982 Total. Residents Nursing staff. Type of cases taken. Maternity Surgical Medical Living out. Qualifications. 77, Avondale Road 6 4 28 14 13 4 3 1 1 Cen. Trained and C. M B 1 General Trained. 2 Asst. Nurses. Mixed 40, Bromley Common 10 4 38 41 9 5 5 - 2 Gen. trained and C.M.B. 1 C.M.B. 2 Maternity Trained. do. "Greta," Blyth Road 9 1 4 73 25 6 2 4 1 Gen. Trained and C.M.B 5 Gen. Trained. do. 24, Elmfield Road 10 2 12 — 12 4 4 - 1 Gen. Trained and C M B 1 Gen. Trained 2 Asst. Nurses. do. 3, Elmstead Lane "Frascati," Masons Hill 8 1 3 38 4 4 4 — 4 Gen. Trained. do. 10 2 14 6 16 8 8 1 Gen. Trained and C.M.B. 4 Gen. Trained. 1C.M.B 2Asst. Nurses do. "The Cloisters," Southborough Road 2 — — — 2 2 2 — 2 General Trained Nursing 13, Tweedy Road 5 - - - 4 1 1 - 1 Gen. Trained Fully trained Nurses engaged when necessary. do. Maternity Hospital, 118, Widmore Road 12 12 127 — — 7 7 - 2 Gen Trained and C.M.B. 2 C.M.B. 3 Asst. Nurses Maternity Bromley (Kent) and District Hospital, Cromwell Avenue 47 - - 624 (unelas sifled) 19 19 - 2 Gen. Trained and C.M.B. 5 Gen. Trained. I Gen. trained and masseuse II Probationers Gen. Hospital cases. Phillips Memorial Hospital, Lowndes Avenue 20 - - 87 86 6 6 - 1 Gen. Trained. 2 Gen. Trained and C.M.B. 3 Asst. Nurses do 34 The inspection of nursing homes in Bromley is carried out once every quarter. There have not been any breaches of the Bye-laws during 1932 and the inspections have shown satisfactory conditions in the nursing homes, and in certain cases resulted in improvements being made in the internal arrangements. A voluntary change of ownership and management overcame the necessity for legal action being initiated in one home. 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 confinement 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 four 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 sick cases of non-infectious nature, the fee being remitted in necessitous cases. Laboratory Facilities. The West Kent Isolation Hospital undertakes the testing of throat swabs and the arrangements continue to work very satisfactorily. The facilities used for the examination or analysis of clinical material (sputum, 35 etc.), water, milk and foodstuffs are those provided by the Kent County Council at Maidstone, but on more than one occasion these facilities have not been equal to those available to us at the London laboratories. Clinics and Centres. The School Clinic, Station Road, was opened in 1928, and makes provision for the following treatments and services, details of which are dealt with in 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. Orthopedic Clinic. 5. Artificial Sunlight Clinic. 6. Dental Clinic. 7. Diphtheria Immunisation Clinic. 8. Ante-Natal Clinic. 9. Child Welfare Centre (Plaistow Area). Welfare Centres are provided for the areas of:— 1. Bromley Common. 2. Burnt Ash 3. Plaistow. 4. Shortlands. 5. Widmore. During the past year each centre was held weekly, with the exception of Burnt Ash where two sessions were held weekly. Full particulars of each centre appear under Section III., Maternity and Child Welfare, of this Report. It is to be noted here that an additional session is now in operation at Bromley Common centre as from 1st April, 1933. This has done much to ease the congestion at this centre, but has not solved the problem of a clinic in easy access to the increasing population in the Southborough district and the southernmost portion of the Borough. Extension of the weighing room at the School Clinic has become desirable to avoid crowding and difficulty of working at this centre, and it is hoped that this matter will be remedied at an early date. 36 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: 1932:— Summary for the Year 1932. Cases on the Register, January, 1932 20 New cases during the year 551 Visits Paid. General Nursing 4969 Ante-Natal Visits 1359 Maternity and Midwifery 3907 Casual Visits 870 Analysis of ,New Cases. Medical 176 Surgical 114 Maternity (with Doctor) 86 Midwifery 170 Abortions 5 Cases sent in by: Doctors 196 Visitors and Others Found by Nurse 12 Applied 339 Result of Cases Nursed. Convalescent 487 Sent to Hospital, Infirmary or transferred 38 Died 25 Still on Register 15 Nursing Staff. (i) General Nurses 2 (ii) Mid wives 3 37 Tuberculosis Dispensary. The Tuberculosis Dispensary is provided and maintained by the Kent County Council. The Tuberculosis Dispensaries have undergone recent re-organisation throughout the county. The Tuberculosis Officer in charge of District No. 7, which includes Dispensaries at Bromley and Penge, is Dr. G. B. A. Edelston. The districts covered by these two dispensaries are Bromley, Beckenham, Penge, Anerley, parts of Sydenham and Upper Norwood, Bromley Rural, Chislehurst and Sidcup. The Dispensary for Bromley is held at 2, Park Road, on Wednesdays, from 1.30 to 3.30 p.m., and on Fridays from 5.0 to 6.0 p.m. The Corporation provides a nurse for attendance at the Dispensary from the Health Visiting Staff for the Wednesday Dispensary, and a nurse from Chislehurst at the present time undertakes the duty for Fridays. The Health Visitor also carries out home visiting of patients. The work of the Tuberculosis Dispensary is briefly reported on by the Tuberculosis Officer, and appears in a later part of this report. Venereal Diseases Treatment Centres. Provision for treatment is under the administration of the Kent County Council. There is no centre in the Borough. The close proximity of London, where there are ample facilities available at the various London Hospitals, provides an adequate and convenient service for such cases. V.—SANITARY CIRCUMSTANCES. Rivers and Streams. The sanitary inspectors carry out periodical inspections of all the watercourses and streams in the Borough. During the year 23 inspections were made, and in two instances nuisances from pollution were remedied after service of informal notices. The pollutions in both cases were not of a serious character. 38 Drainage and Sewerage. The main drainage of Bromley links up with the undertaking of the West Kent Sewerage Board, whose purification works are at Dartford. Sewerage is there precipitated by gravitation before being discharged into the River Thames. The surface water drainage of the Borough is separate from the system for foul drainage. There are 22 cesspools in the unsewered portion of the Borough, otherwise there is water carriage. No houses have been erected during 10.32 with cesspool drainage. Water. A piped supply is general throughout the Borough, and comes mainly from the Metropolitan Water Board's deep chalk well at Shortlands Valley. The supply is sufficient, very hard, but of high grade purity, and is accepted as a standard of purity for deep well water. For particulars of reservoirs within the district reference may be made to page 35 of my Annual Report for 1930. Scavenging. There is no important extension or improvement during 1932 to report of the methods of scavenging or refuse disposal within the Borough. Rats and Mice Destruction Act, 1919. The arrangements made by the Health Department in connection with National Rat Week from 7th to 12th November, 1932, again followed those carried out in previous years. A gassing machine and operator were available, free supplies of Red Squill products were procurable on application to the Health Department, and baiting of sewers was carried out. The co-operation of the local chemists was again sought, and several firms made special displays of poisons, and posters and leaflets were supplied to them. The general public in Bromley appeared to take but little interest in the propaganda of National Rat Week. as only 16 applications for free poisons were received during the campaign. 39 During the course of 106 inspections for rat infestation in 1932 there was abundant evidence that occupiers of rat infested premises, especially dwellinghouses, are ignorant of their responsibility to rid their premises of rats. The abatement of infestation in 43 instances was secured after service of notices. Nuisances. Appendices VII. and VIII. are submitted by Mr. G. R. Woods, Chief Sanitary Inspector, and indicate by statistics the valuable work carried out by the Sanitary Inspectors. House-to-House Inspection. Two hundred and thirty-four houses were inspected under the Inspection of District Regulations. In addition, 778 houses were also inspected, in the majority of which the inspections and defects found were scheduled in accordance with the Housing Acts. It was found necessary to make an increased number of visits to houses during the periods when builders were executing work to remedy defects and nuisances which had been found on inspection. The following figures show 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 December, 1932:— Since the inception of the Act to the 31st December, 1930 15 March Quarter, 1931 81 June Quarter, 1931 87 September Quarter, 1931 180 December Quarter, 1931 192 March Quarter, 1932 114 June Quarter, 1932 59 September Quarter, 1932 121 December Quarter, 1932 113 Since the inception of the Act to 31st December, 1932 962 40 VI.—HOUSING CONDITIONS. There are no slums in Bromley, and no area warranting scheduling for clearance or improvement under Part I. of the Housing Act, 1930. Houses are being dealt with successfully under Part II. of the Act, and before the "5-year period" has elapsed those few unfit individual houses will have been remedied of defects or demolished. It must not be overlooked when considering the Housing question, that Bromley is not a manufacturing town, and if low rental houses of the working class type are erected to excess it "will lose much of its charm as a "dormitory" town of London. To date the Local Authority has erected 524 houses for the working classes—4.5 per cent. of total number of inhabited houses. Overcrowding. Seventeen houses were visited on complaint of overcrowding, and in 8 cases conditions were remedied. When overcrowding exists in a one-family house, and the re-distribution of sleepers is not practicable extreme hardships would occur if statutory action was taken. Legal action is always taken when overcrowding is found in houses occupied by two or more families. Prevalent Defects in Housing. Appendix VIII. indicates the prevalent defects found in houses, viz., unpaved yards, drinking water from cisterns, want of ventilation to food stores, worn stone sinks, insanitary box seats to W.C.s, dampness due to porosity of bricks, absence of, or perished damp-proof courses, and defective roofs, rain water glittering and pipes. It was not found necessary to take summary proceedings to enforce the abatement of nuisances. The co-operative action between owners, agents, tenants and the sanitary inspectors continues to get the necessary work carried out effectively in an amicable manner. Houses Let in Lodgings. With a rapidly increasing population and during times of economic stress this problem becomes an acute 41 one and not always easy of correction. It is becoming a common practice to buy working class houses on the weekly instalment process, payments which during times of ready employment may be easily met, become difficult when unemployment is prevalent. The taking in of lodgers is an avenue of relief, but becomes a public health problem when the family sub-tenant has to live in a room or rooms not provided with the minimum essentials of a home. VII.—SMOKE POLLUTION. Five routine visits and observations were made, and the inspectors were successful in getting four smoke nuisances abated as a result of informal action. In these four instances it was necessary to make suggestions for improvement in stoking which were willingly carried out. There is a general desire on the part of owners of steam raising plants to eliminate as far as possible the emission of smoke, and the advice of the sanitary inspectors, two of whom hold the special certificate for smoke inspection of the Royal Sanitary Institute, is readily sought. VIII—SHOPS ACTS. Six hundred and one visits were made under these Acts. Forty contraventions were reported, which principally related to the failure to display notices with reference to the Assistants' Half-Holiday form and the hours of employment of Assistants under the age of 18 years. In every case the shop-keepers provided the necessary forms forthwith. This district is patrolled periodically during the week-days and Sunday evenings. 42 Contraventions. Nature of Offence. Type of Shop. Action taken Sale after statutory hour of closing Bags, trunks, etc. Warning Ditto Fruiterer and Greengrocer Ditto Ditto Confectionery Ditto Ditto Silk Stall (in Market) Ditto Assistants employed after statutory hour on half-day closing Grocers Ditto IX.—PETROLEUM ACTS. Number of Licences issued 93 (i) For Petroleum Spirit 88 (ii) For Carbide of Calcium 5 Total quantity of Petroleum Spirit in gallons 176,090 (i) Bulk storage in gallons 158,745 (ii) Two-gallon can storage in gallons 17,345 Carbide of Calcium in lbs.704 Of the 93 licences issued, 81 were renewals and 12 were new or additional licences. Included in the total of 93 licences are 24 licences for combined bulk and can storage. Two hundred and seven visits to storage places were made during 1932. The following figures show the increase in licenced storage which has taken place since 1926: — Year. Petroleum Spirit, (in gallons). Licences issued. (Petrol only). 1926 66,915 77 1927 103,025 69 1928 1929 159,335 159,746 82 92 1930 166,308 81 1931 168,925 83 1932 176,090 93 43 X—FACTORIES AND WORKSHOPS. Statistical details with regard to inspections and defects in factories, workshops, workplaces and outworkers' premises may be seen in Appendix XIV. The total number of factories, workshops, workplaces and outworkers' premises on the register is 405, and the following is a tabulation of the businesses carried on:— Bakehouses 31 Bootmakers 36 Tailors 34 Laundries 35 Motor and Cycle Engineers 46 Restaurants, Eating Houses, etc. 25 Dressmakers 26 Upholsteries 16 Other Trades 136 Outworkers 20 XI—PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS, REGULATIONS, Etc. The following types of premises undergo regular visitation by the staff of the Health Department, and no less than 4,330 inspection were made. Dairies, Cowsheds and Milkshops Confectionery, Ice Cream, etc. Licenced Premises (public houses) Bakehouses Butchers' Premises Slaughterhouses Hotels, Restaurants Fish Shops Other Food Shops Shops, various Stables Cinemas Petroleum Spirit Stores (licenced) Factories, Workshops, Workplaces and Outworkers Offensive Trade (Tallow Melting) Piggeries Tents, Vans and Sheds Registry Offices Nursing Homes 44 XII.—INSPECTION AND SUPERVISION OF FOODSTUFFS. The sanitary inspectors continue to allot as much time as practicable to this most important branch of the work of the Health Department. There is evidence that butchers, fruiterers, and grocers, are showing a marked desire to improve their shops and storage places of food. Some butchers' shops and fruiterers' shops still lack closed window fronts, and the unsatisfactory delivery of bread unwrapped is still persisted in. The public is demanding a clean handling of their foodstuffs, and the marked advance during the past few years in this direction is but one direction showing the result of the educational work of sanitary inspectors and health visitors of the Department, and of all those concerned with a high state of communal hygiene. Milk. The following premises are registered for the sale of milk:— Dairies and milk-stores:— (i) Premises within the Borough 80 (ii) Premises outside the Borough 15 Dairies licenced for the sale of: "Pasteurised" milk 9 "Certified " milk 4 "Grad A" milk 1 "Grade A (Tuberculin Tested)" milk 4 The Ministry of Health has granted a producer's licence to sell under the designation "Certified" milk to one farm within the Borough. 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. The progress made in Bromley during the past few years in the distribution of safe milk is rather remarkable. Much of the credit for this must be given to the large firms, United Dairies, Express Dairy and the Co-operative Society. There can be no question in my 45 mind from the public health standpoint that milk pasteurised under licence is the greatest safeguard against the spread of infectious disease, tuberculosis, undulent fevers, scarlet fever, diphtheria, streptococcal sore throats and other milk borne diseases. The food value of the milk is not affected by pasteurisation as carried out under licence. Bacteriological Examinations. Fifty-five samples of milk were submitted for bacteriological examination, and the results shown in the following table, which also includes the results oi samples taken on nine occasions at the request of the Ministry of Health from the producer holding licence for the production of "Certified" milk:— Samples. T'otals. Satisfactory. Unsatis factory "Grade A Pasteurised" milk 3 3 - "Grade A (T.T.)" milk 2 2 - "Pasteurised" milk 11 10 1 "Certified" milk 16 16 -- Ordinary milk 22 10 12 Sterilised milk 1 1 - Totals 55 42 13 Nineteen samples of milk were tested for the presence of tubercle bacilli, and after inoculation tests the results were negative. In three instances the presence of pus was detected. In each case the source of supply was outside the district and the matter was taken up with the producers and medical officers of health of the districts concerned. In the cases where the bacteriological counts did not comply with the required standard, the matter was taken up with the producers concerned and subsequently remedied. Bottles of milk are regularly examined on vehicles prior to the delivery to the consumer, and in several cases it was found necessary to advise dairymen to eliminate dirt sediment. In every case the dairymen co-operated with the Department and improvement has been maintained. 46 Contraventions. Cases of contraventions of the Milk and Dairies Order, 1926, were reported as follows:— Offence. Action taken. (1) Unsealing bottles of milk in the street Warning given. (2) Dirt sediment in bottles of milk Ditto. (3) Bottle of milk containing larvae of a dipterous fly, and dirt contaminated Ditto. Meat and Other Foods. Meat. There are five licenced and five registered slaughterhouses in the Borough. Regular visits are made to these slaughterhouses. Four thousand seven hundred and nine animals were known to have been slaughtered, and 4,654 were examined by the sanitary inspectors after slaughter. Therefore, 98 percent. of carcases were seen; this represents a very high figure, necessitating a very large amount of work being carried out at night and on Sundays. In addition to carcases examined in butchers' shops, the inspectors also examined on the request of local butchers 518 carcases coming from outside the district. There is complete co-operation between the local butchers and the Department, and there have been numerous instances where this co-operation has been helpful to butchers, consumers and to the Public Health staff. Table A. Total number of animals known to have been slaughtered and carcases inspected. Total Beasts. Calves. Sheep. Pija- Animals known to have been killed 4709 180 526 1050 2963 Carcases Inspected 4654 180 526 1042 2906 47 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). 4709 4654 150 (3.2 per cent) 254 (5.4 per cent) 504 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 2 .. 9 14 Other defined diseases .. .. .. ... 1 4 8 13 Total .. .. 1 2 3 4 17 27 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 14 28 108 150 Other defined diseases 13 11 330 354 Total 27 39 438 504 48 Table E. Total weights of carcases, parts of carcases and offal rejected for all diseases. Tons Cwts. Qrs. 1bs. Total in 1bs. Carcases 1 19 .. 15 4383 Parts of Carcases 8 3 20 1000 Offal 1 .. .. 8 2248 Total 3 8 .. 15 7631 In addition, forty-one portions — 270 lbs. — of unsound meat and offal was found in Bromley butchers' shops, delivered from outside the district. Contraventions. The following contraventions were dealt with during 1932 in relation to meat deposited or exposed for sale in shops:— Parts of carcase. Disease. Premises. Action taken. Pig's head, neck end and hand Tuberculosis Shop Seller warned 4 sheep's plucks Parasitic Ditto Ditto Pig's head Tuberculosis Ditto Ditto Neck end of pork Ditto Ditto Ditto Carcase of pork Ditto Ditto Ditto Pig's head Ditto Ditto Ditto Sheep's pluck Parasitic Ditto Ditto Portion of beast's kidney Decomposed Ditto Ditto Brisket of beef, 6 ox kidneys, and 6 chilled legs of beef contaminated Warning given to with dirt, etc., in course of transit meat carriers. Want of cleanliness of van used for carrying meat. Ditto. 49 Other Food Condemned. Type of Food. Premises. Action taken. 10 lbs. pears ... Market stall Seized as unsound and unfit for food. Warning sent. 7 1bs. strawberry jam, 1-311) tin apricot jam, and 1-½lb. tin gooseberries in syrup Baker's shop Ditto. Unsound Food Surrendered. Article of Food. Quantity. Weight. Pears 1 box 40 lbs. Pears 1 box 60 lbs. Prawns 5 boxes 70 lbs. Herrings 2 boxes 200 lbs. Bananas 1 crate Potatoes 1 sack 224 lbs. Bacon 4 pieces 12¼ lbs. Smoked Codling 5 boxes 70 lbs. Wet fillet of fish 4 boxes 56 lbs. Vegetables 251 tins Fruit 754 tins Fish 132 tins Milk 467 tins Miscellaneous tinned or bottled foods 100 Food and Drugs (Adulteration) Act, 1928. The following tabulation gives particulars of the work of the Food and Drugs Inspector in Bromley during 1932: — New Milks 51 Oatmeal 1 Condensed Milk 1 Flour 2 Margarine 4 Dried Fruit 1 Coffee 4 Olive Oil 2 Ground Rice 1 Fruit Salad 1 Cornflour 2 Brawn 1 Butter 3 Gregory Powder 1 Ground Cinnamon 2 Zinc Ointment 1 Cocoa 4 Boracic A. Ointment 1 50 Malt Vinegar 1 S. Whisky 1 Preserved Peas 1 Dem. Sugar 1 Lard 3 Rice 1 S.R. Flour 2 Vita Cream 1 Mustard 1 Pepper 1 Baking Powder 1 Number of samples taken 97 Genuine 96 Adulterated 1 Inferior - The adulterated sample was new milk. This milk was purchased by a Bromley vendor under warranty. Further samples being taken from farmers in Sevenoaks area and on delivery at Bromley. One farmer was cautioned and Bromley vendor exonerated. XIII.—DISEASES OF ANIMALS ACTS. The administration of the above Acts within the Borough came under the Department as from 1st April, 1932, and the Chief Sanitary Inspector was appointed Inspector for the purposes of these Acts. The following statistics cover the period April-December, 1932; figures for the first three months of the year have been asked for but are not available. No. of movement licences received, of animals moved into the Borough ... 142 Animals inspected: (1) Pigs 1476 (2) Sheep 132 No. of Licences issued by the Local Authority 8 Animals inspected: (1) Pigs 15 (2) Sheep 58 (3) Cattle 24 Sheep Dipping: Certificates issued by the Local Authority 6 No. of sheep dipped 419 No. of inspections and interviews made in connection with the above details 228 51 A serious outbreak of Foot and Mouth Disease occurred in December in the country, affecting the County of Kent. The precautionary measures taken by the Ministry of Agriculture and Fisheries had the effect of checking its progress. XIV.—RAG FLOCK ACTS, 1911-1928. Two rag flock samples were submitted for examination and both samples complied with the standard in accordance with the above-mentioned Acts. Rag flock is not extensively used by the few upholsterers engaged in this business in the Borough. XV—INFECTIOUS DISEASES CONTROL. Scarlet Fever. The curve of incidence of this disease in Bromley took the expected fall in 1932, the cases notified being 123 as against 179 for the previous year. In the year 1931 this curve reached its peak, and should, with other factors being equal, continue to fall during the next five years. It is of interest to note that although the number of cases notified is greater than during the pre-war years, owing to increase of population, the actual incidence rate per 1,000 poulation has fallen from 7.4 to 2.2. In the Report of 1931 by the Chief Medical Officer of the Ministry of Health there are at least two references worthy of noting here: "Two striking characteristics of scarlet fever during the past 20 years—its uncontrollable nature in regard to prevalence as revealed by the recurring high wave of incidence, and the downward trend of the fatality rate irrespective of the incidence of the disease." " There was no good reason to prescribe a routine period of detention of more than four weeks and that, whatever may have been the influence of hospital treatment on the prevalence of scarlet fever in former years, the incidence in recent times appears to show no marked reduction as a result of hospital isolation. I have previously, in 1926, expressed my'view that admission of scarlet fever patients to hospital is primarily for treatment, and that it plays little, if any, 52 part in the control or prevention of spread of infection. I have endeavoured to encourage the home isolation of uncomplicated cases of scarlet fever, but no less than 93 per cent. are still admitted to hospital. There would appear to be a gradual increasing period of detention compared with previous years. If it is possible to lessen this actual period of detention in accordance with the recommendation of the Ministry of Health, and also to admit only the selected scarlet fever cases to hospital, there should result a greater hospital accommodation for more acute types of infectious diseases. Diphtheria. There was a further fall in 1932 in the incidence of Diphtheria, 12 cases only being notified, all of which were admitted to hospital. The incidence rate of 0.2 per 1,000 of the population for 1932 is the lowest recorded in Bromley records dating from 1890. If the curve of incidence follows the usual rise and fall, 1934 should see this disease in early epidemic prevalence. In Immunisation we have a successful prevention measure, if the public will respond during 1933. Diphtheria Immunisation, 1932. Total number Schick Tested, 77. Found to be positive 63 Found to be negative 14 77 Total number who received full course of injections 86 Total number re-tested 81 1st. 2nd. 3rd. 4th. Found to be positive 8 3 1 Found to be negative 69 5 6 1 There has been a falling off in cases, partly due to complacence of the public during the non-epidemic years, and partly due to the campaign by the anti vaccinationists against immunisation in any form. This criticism is to be regretted primarily because there is 53 offered no alternative method of prevention against a serious disease which causes deaths in one child in every 10 children infected under the age of 6 years. We have in Diphtheria Immunisation a valuable means of prevention of this disease, and if the public will respond we shall be able to control not only the spread of the disease but prevent the crippling and deaths that follow. Typhoid. Two cases of typhoid and one of para-typhoid were notified during the year. One of the cases of typhoid was a contact with the epidemic in Yorkshire during the year, whilst the other was a sporadic case whose infection it was not possible to trace. Both infections were kept under control without further spread. The paratyphoid case was employed in the area of a neighbouring Authority which had other cases of para-typhoid at the lime when the Bromley case was notified. These sporadic cases occur from time to time, without one being able to account for their infection. There can be no doubt that typhoid is a disease spread mainly by contaminated food supply, and that modern sanitation, controlled water, food and milk supplies, are the main reasons for their not being wide-spread. Other Notifiable Infectious Diseases. Appendix IX. gives details of diseases notified in 1932, together with districts and other statistics. The increase in pneumonia was brought about by the influenza epidemic during the year. No complete statistics are kept of the occurrence of measles and whooping-cough—two diseases which cause much invalidity among the child population. The following table gives the incidence of infectious disease in the schools in Bromley during 1932. This is a large return and accounts for much invalidity and loss of school attendance. Home visitation of all these cases cannot be carried out as the staff available is not sufficient for the purpose, and in consequence much useful public health work is missed. 54 DiphScarlet Whooping Chicken School theria Fever Measles Cough Mumps Pox Addison Road 1 6 49 Bickley and Widmore 6 16 2 - 5 2 Burnt Ash 3 9 86 10 53 17 Bromley Common - 5 12 - 32 29 Masons Hill - — 18 32 2 44 Parish - 1 64 10 7 Plaistow - 7 3 10 - 8 Raglan Road... 1 9 96 32 127 77 Valley - - 1 15 1 26 Totals 11 53 331 109 227 203 Vaccination. I am indebted to the Relieving Officers for the statistics relating to Vaccination Acts. The lowreturn of cases vaccinated indicates the failure of the Vaccination Acts, as they stand at the present time, as an efficient means of creating a population which is immune against small-pox. Of the 605 live births occurring in Bromley during the year only 291 of the infants were vaccinated, but this does not take into consideration the small number of those vaccinated privately and not under the Vaccination Acts. Tuberculosis. The incidence of Tuberculosis within the Borough is practically stable on comparison with 1931. Appendix X. gives in tabular form the number of notified cases in age groups together with particulars of mortality. The Tuberculosis register, which is required to be kept under the Public Health (Tuberculosis) Regulations, 1930, shows at the end of the year 1932 the following analysis of cases:— 55 Pulmonary cases: Male 114 Female 92 Non-Pulmonary: Male 55 Female 75 336 These figures show that in Bromley 7.1 persons per 1,000 of the population are affected with tuberculosis. Out of the 336 cases 130 have received sanatorium or hospital treatment, this works out on the basis of 38.6 per cent. The need of 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 health visitors, during the course of routine visitation, made 320 visits to tuberculosis patients, and the total number of special visits to patients arising out of the health visitor's work at the Dispensary was 206. Where the health visitors discover housing conditions which would be detrimental to the tubercular subject, the sanitary inspectors make an inspection and procure the remedy of any defective conditions. Out of a total of 36 tuberculosis deaths for the year, 9 had not been previously notified. It is not to be deduced from these figures that the efficiency of notification of tuberculosis in the area is lax, for on inquiry it is learned that in many cases conclusive diagnosis was not arrived at until after death and in most cases deaths occur outside the district in hospital institutions, where there have been bona fide reasons for supposing that they have already been notified in the home district. Wilful neglect, or refusal to notify, was absent in all these cases. There is no evidence of excessive incidence of, or mortality from, tuberculosis in any particular occupation in the area. 56 The Tuberculosis Officer, Dr. B. Gordon Edelston, who has recently taken over the duties at the Tuberculosis Dispensary from Dr. W. B. Martin, has kindly furnished me with the following particulars of work done at the Dispensary at 2, Park Road, Bromley, during 1932:— New Cases who have Attended the Dispensary for the First Time for Examination during 1932. Adults Children Mule Female Male Female Pulmonary 15 12 1 Non-pulmonary 2 1 - 1 Negative 6 7 10 6 Totals 23 20 11 7 Fourteen 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 723 Number of patients receiving residential treatment during the year 61 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 stall: of the Department. Nine cases were referred for assistance during the year, as follows :— (1) Three cases required extra milk and nourishment. This was supplied by the Bromley Children's Care Committee. 57 (2) In one case domestic help was required, but the patient died before arrangements could be completed. (•3) In one case introduction was needed to people who would purchase leather goods made by the patient. Help was given. (4) Other accommodation was required for a patient with a large family, but there were no housing vacancies at the time. (5) Light work was required. Work obtained. (6) Accommodation needed for three children while mother was in sanatorium. The Public Assistance Committee made arrangements, but subsequently the father of the family made his own arrangements. (7) Assistance needed for the provision of clothes, etc., before admission to Sanatorium. Help given. XVI.-PROPAGANDA. It might be well said that all public health work carries its own propaganda. Preventative medicine is 90 per cent. instructional and 10 per cent. medical practice. Whether general propaganda is valuable is debatable; a quiet talk to the delinquent individual brings a quicker return to the ways of health, but there will, I fear, always remain the one person in ten who is "anti" to everything and with whom nothing can be done. Little general propaganda is carried out by the Department; talks are given at the centres and at the Clinic; mothercraft classes are held each year open to mothers attending the centres, and recently monthly evening meetings are held for talks, lectures and film demonstrations. This work could not be carried out except for the keeness of the staff who give much of their own free time to this work. 58 Finally this brings me again to express the great appreciation I owe to each member of the staff for their help at all times, and to Mr. Lawley who has been responsible for the compilation of the statistics that appear in this Report. APPENDIX 60 LIST OF APPENDICES. I. Summary of Statistics, 1932. II. Comparison of Statistics, 1932. III. Causes of Deaths, 1932. IV. Causes of Infant Deaths, 1932—Age Groups. V. Analysis of Infant Deaths, 1928—1932. VI. Analysis of Infant Deaths and Maternal Deaths, 1910—1914, 1921—1925, 1926—1930, and 1931— 1932. VII. Summary of Work of Sanitary Inspectors, 1932. VIII. Summary of Nuisances Abated, 1932. IX. Return of Notifiable Infectious Diseases, 1932, in Wards, giving attack rates and death rates, etc. X. Return in Age Groups of new cases of Tuberculosis notified, and of deaths occurring in 1932. XI. Return of Ophthalmia Neonatorum, 1932. XII. Summary of Health Visitors' Work, 1932. XIII. Summary of Attendances at' Welfare Centres, 1932. XIV. Factories, Workshops and Workplaces, Inspections, 1932. XV. Housing Statistics, 1932. 61 APPENDIX I. SUMMARY OF STATISTICS, 1932. Population (mid-year 1932) 46,809 Birth Rate 12.9 Death Rate 10.7 Infantile Mortality Rate 33.05 Number of Births (live) 605 Number of Stillbirths 24 Number of Deaths 504 Number of Infant Deaths (under 1 year) 20 Death Rate of Respiratory Diseases 0.9 „ ,, ,, Tuberculosis 0.7 ,, ,, ,, Cancer 1.6 „ ,, ,, Zymotic Diseases 0.17 Notification of Scarlet Fever 124 ,, ,, Diphtheria 12 „ ,, Pneumonia 75 ,, ,, Tuberculosis 76 Number of Deaths from Measles 2 „ ,, ,, ,, Scarlet Fever 3 ,. ,, ,, Diarrhoea (under 2 years) 1 „ ,, ,, ,, Child Birth 2 Number of visits by Sanitary Inspectors 10,202 ,, ,, ,, ,, Health Visitors 6.118 „ ,, Babies on the Registers at the Centres, end December, 1932 1,421 APPENDIX II. BIRTH RATE, DEATH RATE AND ANALYSIS OF MORTALITY during the Year 1932. e mortality rates for England and Wales refer to the whole population but for London and the towns to civilians only). Rate per 1,000 Total Population. Annual Death Rate per 1,000 Population. Rate per 1,000 Live Births. All Causes Enteric Fever Smallpox Measles Scarlet Fever Whooping Cough Diphtheria Influenza Violence Diarrh(ea and Enteritis (under Two years). Total Deaths under One year. Live Births Still Births England and Wales 15.3 0.66 12.0 0.01 0.00 0.08 0.01 0.07 0.06 0.32 0.53 6.6 65 118 County Boroughs and Great Towns, including London 15.4 0.70 11.8 0.00 0.00 0.11 0.01 0.08 0.07 0.28 0.48 8.9 69 126 Smaller Towns (Populations, 25,000-50,000 at census 1931) 15.4 0.69 10.8 0.00 0.00 0.06 0.01 0.06 0.03 0 31 0.42 4.5 58 London 14.2 0.51 12.3 0.00 0.00 0.19 0.02 0.08 0.07 0.27 0.53 12.6 66 BROMLEY 12.9 0.51 10.7 0.00 0.00 0.04 0 06 0.02 0.00 0.34 0.47 1.6 33 Puerperal Sepsis. Others. Total. The maternal mortality rates for England and Wales are as follows: per 1000 Live Births 1.61 2.63 4.24 Total Births 1 7,4 2.52 4.06 Bromley 1.5 1.5 3.0 63 APPENDIX III. Causes of Death, 1932. Causes Male Female Total 1. Typhoid and Paratyphoid Fevers — — — 2. Measles — 2 2 3. Scarlet Fever — 3 3 4. Whooping Cough 1 — 1 5. Diphtheria - - - 6. Influenza 6 10 16 7. Encephalitis Lethargica 1 - 1 8. Cerebro-Spinal Fever — 1 1 9. Tuberculosis of respiratory system 14 13 27 10. Other Tuberculosis Diseases 7 2 9 11. Syphilis — 1 1 12. General paralysis of the insane, Tabes Dorsalis 1 1 2 13. Cancer, malignant disease 38 40 78 14. Diabetes 3 2 5 15. Cerebral Hemorrhage, etc. 8 13 21 16. Heart Disease 60 86 146 17. Aneurysm 2 1 3 18. Other Circulatory Diseases 6 10 16 19. Bronchitis 5 6 11 20. Pneumonia (all forms) 14 13 27 21. Other Respiratory Diseases 2 5 7 22 Peptic Ulcer 6 1 7 23. Diarrhoea, etc. (under 2 years) — 1 1 24. Appendicitis — 1 1 25. Cirrhosis of Liver 1 — 1 26. Other Diseases of Liver, etc. — 4 4 27. Other Digestive Diseases 3 3 6 28. Acute and Chronic Nephritis 6 7 13 29. Puerperal Sepsis — 1 1 30. Other Puerperal Causes — 1 1 31. Congenital Debility. Premature Birth. Malformations, etc. 7 5 12 32. Senility 2 5 7 33. Suicide 7 2 9 34. Other violence 6 7 13 35. Other defined diseases 22 28 50 36. Causes ill-defined or unknown — 1 1 Totals 228 276 504 APPENDIX IV. Infant Mortality, 1932. 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 under6 Months 6 Months and under 9 Months 9 Months and under 12 Months. Total Deaths under 1 year. Measles .. .. .. .. .. .. .. .. .. .. Whooping Cough .. .. .. .. .. .. .. .. .. .. Tuberculosis .. .. .. .. .. .. .. .. .. .. Convulsions .. .. .. .. .. .. .. .. .. .. Bronchitis .. .. .. .. .. .. 1 .. .. 2 Pneumonia .. .. .. .. .. 1 1 2 .. 3 Diarrhœa .. .. .. .. .. .. .. .. .. .. Enteritis .. .. .. .. .. .. 1 .. .. 1 Gastritis .. .. .. .. .. .. .. .. .. .. Suffocation .. .. .. .. .. .. .. .. .. .. Injury at Birth .. .. .. .. 1 .. .. .. .. .. Atelectasis 1 .. .. 3 1 .. .. .. 1 Malformation 2 .. .. 1 3 1 1 .. .. 5 Premature Birth 3 .. .. .. .. .. .. .. 4 Marasmus, etc. .. .. .. .. .. .. 1 .. .. 1 Other Causes .. .. .. .. .. .. .. .. Syphilis .. 1 .. .. 1 .. .. .. .. 1 Congenital Heart Disease 2 .. .. .. 2 • • .. .. .. 2 Totals 8 1 .. 1 10 3 5 2 .. 20 65 APPENDIX V. Analysis of Causes of Infant Deaths, 1928-1932. 1928 1929 1930 1931 1932 Total No. of Births 652 623 629 617 605 Infant Mortality Kate 49 46 41 47 33 Premature Birth 6 3 7 3 4 23 Respiratory Diseases 8 11 3 5 5 33 Marasmus and General Debility 6 3 4 3 1 17 Infectious Disease 1 1 • • 1 .. 3 Gastro Enteritis 3 2 3 4 l 13 Convulsions 1 2 1 .. 4 Other Causes 7 9 7 10 9 42 Total 32 29 26 27 20 134 This table shows that Premature Births and Congenital Debility caused 29 8% 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 1931-1 Y ears. Total Births. Infant Mortality Rate. Total Infant Deaths. Age at Death. Maternal Deaths. Deaths under 1 week. Deaths 1 week to 4 weeks. Deaths 4 weeks to 1 year. Sepsis Other 1910-1914 3186 68 220 61 41 118 3 6 1921 624 60 38 10 9 19 1 1 1922 575 74 43 19 7 17 2 2 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 i 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 61 14 69 4 e 1931 617 47 29* 10 4 13 1 3 1932 605 33 20 9 1 10 1 l *R.G's return, 29 Local returns, 27). 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. Rate 1931-1932, 4.9 per 1,000 births. 67 APPENDIX VII. Summary of Work of Sanitary Inspectors, 1932. Housing— Inspections ReInspec tions Under Inspection of District Regulations 234 1373 On Complaint (ordinary) 610 2087 Re Overcrowding 17 13 „ Dirty Conditions 25 18 ,, Water Supply — — ,, Infectious Diseases 177 10 Disinfection Purposes 122 16 Disinfestation Purposes 17 36 Housing Survey 67 — Rent (Restrictions) Act 1 4 Provisional Order Enquiries — 5 Trade Premises— Factories 26 6 Workshops 35 21 Outworkers' Premises 14 2 Under the Shops' Acts 601 10 ,, ,, Petroleum Acts 186 21 Registry Offices 15 — Rag flock, sampling 2 — Offensive Trades 5 13 Food Preparing Places— Dairies and Cowsheds 104 6 Bakehouses:— Factory 47 5 Workshop 46 — Slaughterhouses 768 — Hotels, Restaurants, etc. 22 — Confectionery, Ice Cream, etc. 15 — Greengrocery Shops 123 — Butchers' Shops 1440 2 Fish Shops 136 — Fried Fish Shops 37 — 68 Retail Market 79 — Grocery Shops 147 14 Food Hawkers 23 — Under Meat Regulations 9 — Milk Sampling 79 — Milk examined on the highway 98 — Observations of Milk Roundsmen 5 — Miscellaneous— Tents, Vans and Sheds 14 — Streams 21 2 Nuisances from keeping animals 5 7 Piggeries 35 — Smoke 4 1 Drain Tests— (a) Smoke 8 (b) Water 10 (c) Colour 21 (d) Chemical 13 (e) Mirrored 4 — 56 — Urinals 65 2 Accumulations 87 35 Rats and Mice Destruction Act 64 42 Special Visits 438 — Smallpox contact visits (contacts seen 132) 139 — Rag1 and Bone Dealers 7 1 Poison and Pharmacy Act 2 — Diseases of Animals Acts 167 — Stables 13 — Water Sampling 1 — Totals 6450 3752 In addition there were 2,126 interviews with owners, agents, etc., many of which were at properties under notice. 69 APPENDIX VIII. Nuisances Abated, 1932. HOUSING: Drainage— Inspection chambers provided 14 Drains relaid or repaired 50 Drains unstopped 76 W.C.'s renewed or repaired 31 W.C. pans cleansed 68 W.C. box seats removed 204 Soil pipes, vent pipes, renewed or repaired 27 Sinks renewed 87 Sink or bath waste pipes renewed or repaired 210 Surface water drainage provided 14 Dampness— Roof, rain water pipes, guttering renewed, etc. 882 Damp courses:— Vertical 112 Horizontal 64 Solution 21 Repaired or renewed 3 Brickwork repaired or renewed 59 Dry areas constructed 2 Pointing repaired or renewed 451 Stone cills renewed or repaired 83 Sub-floor ventilation supplied or improved 21 General— Rooms cleansed 1001 Floors renewed or repaired 158 Windows ,, ,, „ 653 D°ors ,, „ 131 Stoves ,, „ 147 Plastering ,, ,, „ 514 Handrails ,, ,, ,, (or provided) 27 Yard paving,, ,, „ ,, ,, 94 Coppers ,, ,, „ 61 New dustbins provided 181 70 Overcrowding abated 8 Disinfestations Ventilated food stores provided 2 Food stores ventilated 31 Defective chimneys repaired 168 ,, brickwork repaired 86 Ventilation of rooms improved 5 Dirty conditions improved 13 House under-pinned 1 Water Sup-ply— Drinking water service supplied direct from main 40 Fittings renewed or repaired 15 Flushing cisterns renewed or repaired 48 Miscellaneous Items 259 TRADE PREMISES: Factories and Workshops— Want of cleanliness Want of ventilation -p Overcrowding Want of drainage to floors — Other nuisances 9 Sanitary accommodation— Insufficient — Unsuitable or defective 14 Not separate for sexes Shops Acts—contraventions 40 Petroleum Acts—contraventions 3 FOOD PREPARING PLACES: Yards, floors repaired, etc., cleansing, lime- washing, light, and ventilation improved: refuse bins provided, sanitary conditions improved, etc. Dairies and cowsheds Slaughterhouses 4 71 Greengrocery shops 2 Hotels, restaurants, etc. 9 Bakehouses 19 Grocers' shops 25 Butchers' shops 15 Ice Cream premises 1 Fried fish shops 1 Food store, unsatisfactory and abolished 1 MISCELLANEOUS: Stream nuisances 2 Urinals cleansed 11 Animal nuisances 3 Accumulations removed 48 Manure receptacles provided 1 Manure removed 3 Smoke nuisances 4 Rat nuisances 43 Tents, vans and sheds—sanitary accommodation provided 1 Total 6424 NOTICES ISSUED: Preliminary— (i) Housing 930 (ii) Others 214 Total 1144 Statutory— (i) Housing 18 (ii) Others — Total 18 72 APPENDIX IX. Return of Notifiable Infectious Diseases, 1932. 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 124 46 78 54 7 16 13 16 18 115 2.6 3 0.06 Diphtheria 12 4 8 2 3 — 2 2 3 12 0.2 — — Pneumonia 75 45 30 20 10 14 10 10 11 35 1.6 27 0.57 Puerperal Fever 2 — 2 1 — — — — 1 2 0.04 1 0.02 Puerperal Pyrexia 9 — 9 2 1 1 2 2 1 7 0.19 — — Erysipelas 9 4 5 2 1 3 1 — 2 3 0.19 — — Typhoid Fever 3 1 2 — — 2 1 — — 2 0.06 — — Ophthalmia Neonatorum 3 1 2 — — — 2 — 1 1 0.06 — — Tuberoulosis—Lungs 59 31 28 9 11 8 8 11 12 — 1.2 27 057 Tuberculosis—other forms 17 10 7 8 1 — 3 3 2 — 0.3 9 0.19 Totals 313 142 171 98 34 44 42 44 51 177 6.7 67 1.4 73 APPENDIX X. Tuberculosis. New Cases and Mortality during the Year, 1932. periods. New cases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F M. F. M. F. M. F.[/##] Under 1 .. .. .. .. .. .. .. .. 1— 5 .. 1 2 1 .. 1 2 1 6—10 1 .. 1 3 .. .. 2 .. 10—15 2 .. 1 .. .. .. .. .. 15—20 2 2 2 .. .. .. 1 20-25 5 5 .. 2 2 .. .. .. 25-35 9 12 3 .. 6 6 2 .. 35-45 5 3 .. 1 2 2 1 .. 45—55 4 2 .. .. 2 1 .. .. 55—65 3 2 1 .. 2 .. .. .. 65 and over .. 1 .. .. .. 1 .. .. Totals 31 28 10 7 14 13 7 2 APPENDIX XI. Ophthalmia Neonatorum, 1932. Cases. Vision unimpaired Vision impaired. Total Blindness Deaths. Notified. Treated. At Home. In Hospital. 3 2 1 3 .. .. .. 74 APPENDIX XII. Summary of Health Visitors' Work, 1932 Areas Total Under one year Revisits over 1 year Expectant Mothers School Children Baby Deaths StillBirths Tuberculosis Special Visits M'wives Acts enquiries Boarded- out Children ual Visits Primary Revisits Area No. 1 1568 98 227 681 55 222 1 3 59 216 6 30 237 Area No. 2 1530 106 353 663 42 238 4 8 69 42 5 12 257 Area No. 3 1570 126 375 674 52 166 3 5 103 61 5 42 280 Area No. 4 1450 167 231 665 35 187 5 12 89 43 16 84 241 Totals. 6118 497 1186 2683 184 813 13 28 320 362 32 168* 1015 *Also included in routine visits under the various headings. "Ineffectual" visits are those where no answer is received, discovered removed from district or where visits are resented. Tuberculosis Dispensary Work. Patients on the Dispensary Roll at end of December, 1932 112 Health Visitor's Attendances 51 Total Number of Special Visits to Patients 206 75 APPENDIX XIII. Welfare Centres, Attendances, 1932. Centre. No. of Babies on Rolls at the end of Year 1932. Total Attendances. No. of Sessions held. Medical Consultations. Total No . of Weighings. Babies. Mothers. Total Examined. Sessions held. PLAISTOW 298 2205 1975 49 379 31 1817 WIDMORE 185 1677 1509 48 232 27 1152 8HORTLANDS 228 1920 1832 52 260 31 1402 BURNT ASH 357 3320 2615 90 436 47 2007 BROMLEY COMMON 353 4016 3272 52 374 30 3348 Totals 1421 13,138 11,203 291 1,681 166 9,726 Ante-Natal Clinics. Dental Clinic. Total Attendances. Medical Consultations. Sessions held. Discharged Treatment. 199 196 24 Children. Mothers. 76 30 76 APPENDIX XIV. Factories, Workshops and Workplaces, 1932. 1.—Inspections. Premises. Number of Inspections Written Notices. Occupiers Prosecuted. Factories 107 21 .. Workshops 104 12 .. Workplaces (other than outworkers' premises) 35 11 .. Totals 246 44 .. 11.—Defects. Particulars. Number of Defects. Found Remedied. Referred to H.M. Inspector. Nuisances under Public Health Acts§ Want of cleanliness 28 22 .. Want of ventilation 1 1 .. Overcrowding .. .. .. Want of drainage to floors .. .. Other nuisances 36 29 .. Sanitary accommodation insufficient .. .. .. unsuitable or defective 16 14 .. not separate for sexes 2 2 .. Total 83 68 .. §Including those specified in sections 2, 3 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. 77 APPENDIX XV. Housing Statistics for the Year 1932. * Number of new houses erected during the year:— Total 515 (i) By the Local Authority — (ii) By other Local Authorities — (iii) By other bodies or persons 515 Total number of inhabited houses at 31st December, 1932 11711 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) 1032 (b) Number of inspections made for the purpose 4636 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 234 (b) Number of inspections made for the purpose 1607 (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 952 2. Remedy of Defects during the year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 766 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 18 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 18 (b) By Local Authority in default of owners — 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 sections 11, 14 and 15 of the Housing Act, 1925 Nil. BOROUGH OF BROMLEY ANNUAL REPORT FOR 1932 OF THE SCHOOL MEDICAL OFFICER 80 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1932-1933. Alderman F. W. Isard (Chairman of the Education Committee). D. Copping, Esq. A. Cowdry, Esq. Councillor F. S. Darby. Mrs. M. D. Fry. Councillor S. L. Gibbs. Councillor W. D. Gibbs, j.p. (His Worship the Mayor). Rev. Hugh Glaisyer, m.a. Councillor Colonel W. A. Greenley, c.m.g., d.s.o. Councillor Sir Gilbert Grindle, k.c.m.g., c.b. G. J. Gully, Esq., j.p. Rev. J. T. Gurney. Councillor T. H. Jayes. Mrs. A. G. Mann, b.a., j.p. (Chairman of School Medical Sub-Committee) Councillor A. McIntosh, d.c.m. 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. 81 Introduction. There has been no increase since 1928 in the provisions of the School Medical Service, in spite of the increasing school roll and an ever increasing demand to use the services provided by the Local Authority. There has been difficulty in coping with this demand, and if we are to maintain a high standard of efficiency of the Public Health Services some increase of provision is due. In Bromley the School Medical Service is not a unit separate from the Public Health functions of the Local Authority, and the defects in any branch of the service detracts from the efficiency of the others. The extension of houses in the Bromley Common area has brought a new problem to be faced in the provision of adequate clinic facilities for that area. Bromley is without an out-patient department of a general hospital, so that the School Clinic becomes a clearing house for much minor illness, which is not really the true function of a school medical service. Nevertheless, this outpatient work of the Clinic forms an essential part of the medical services generally of the Borough, and brings forward many instances of the minor illness which is frequently the precursor of a crippling disease. Statistics are perhaps uninteresting, but they are the only means of indicating the extent of the work of the School Medical Service in Bromley: The average School Roll, year ended 31/3/33 = 5195 Average Attendance, year ended 31/3/33 ... = 4663 A summary of the year's work, therefore, follows:— 2348 individual children attended the clinics; 1482 came under routine inspection at school; 6700 medical examinations; 5395 dental examinations; 2387 were treated by the Dentist; 394 were treated for defective vision; 130 were operated on for enlarged tonsils and adenoids; 165 crippled children were examined by the Orthopaedic Surgeon; 1456 artificial sunlight treatments: 2258 treatments by the Masseuse. 82 With what results? Anyone will be convinced who has had experience over a number of years that the children attending school to-day are vastly superior to children of twenty years ago. Not only their cleanliness and general appearance, but in general healthiness and well being. This is the true return of the money spent on the service during the past years, and one is more than ever convinced to-day that any statutory diminution of these services on the grounds of economy will only result in retrogression in the growing child, and subsequent loss of efficiency of the adult. It is not claimed that the whole effect of the improvement results from the School Medical Service alone, but there can be no gainsaying that the School Medical Service has been a great factor in this improvement, and that its effect is not limited to the school child alone. I would ask the Committee to direct special attention to the report of the Care Committee, whose workers are giving invaluable service at the Clinic, and assist greatly towards the ultimate care of the defective child, and also would I direct attention to the work of the staff who have given unstintinglv of their services during a year of difficulty. Hygiene of Schools. The following is a list of improvements and alterations carried out in 1932:— Raglan Road Girls' Schools.—New range ot lavatories provided. Parish C.E. Schools.—Installation of electric light throughout. Plaistow C.E. Schools.—Alteration of' schools to provide shelter for scholars; provision of W.Caccommodation for staff, and hand basins for scholars. Lighting improved in one class-room. Medical Inspections. Routine Medical Inspection. With the increasing school roll, difficulty is being encountered in finding time to meet the requirement ot the Regulations affecting routine medical inspection at 83 the schools. This can, of course, be met by increasing the number of inspections at each session, but it is found where parents are so regular in attendance at these inspections that it is not practicable without loss of efficiency in the examination, to increase the number called up for inspection beyond 20 per session. 1 here has been 35 per cent. increase in the number of medical inspection sessions compared with 1926. Tables I. and II. give details of the routine medical inspections at schools. It will there be seen that of the 1,482 individual children examined at school, 22.8 per cent. shewed evidence of defects requiring treatment; the age group shewing the greatest percentage being the intermediate group with 24.5 per cent. defects. The main defects which cause this percentage were found to be defective vision 4.6 per cent.; enlarged tonsils and adenoids 7 per cent.; malnutrition 1.5 per cent.; deformities 5.2 per cent.; and non-tubercular lung disease 2 per cent. These are still somewhat formidable figures and they would be further increased if one took into consideration those defects not necessarily requiring treatment, but requiring observation. Special Medical Inspection. As all children found with defects are referred to the Clinic, or their own doctor, the statistics included under Table II. will give a clearer picture of the defects among school children in Bromley. During 1932, 2,348 individual children made an attendance at the Medical Clinics. Of these children: — 7.5 per cent. required treatment for skin disease. 6.0 ,, ,, ,, ,, eye 5.0 ,, ,, „ ,, ear 24.0 ,, ,, ,, ,, nose and throat disease (of whom 13 per cent. were enlarged tonsils and adenoids). 15.0 per cent. required treatment for lung disease. The medical inspection is now recognised by the parent as a means of receiving expert advice and direction on the medical condition of their child. They have passed the stage of believing a doctor's service is 84 needed only when the child is ill. The discovering of major defects at school inspection is perhaps a reflection on the parental care of the child, or it may be that parents wait for the routine medical inspection, or use the School Clinic as a hospital out-patient department; but the fact that major defects in the child are discovered at the medical inspection indicates a failure somewhere in our method of prevention. The present economic conditions play a part in this; medical expenses in the household are seldom provided for in the allocation of the weekly wage. Bromley lacks an Out-patient Service, so that the School Clinic is bound to be used as a consultation clinic for the children attending elementary schools. It must not be forgotten that the School Medical Service forms no part in the domiciliary treatment of the sick child. Treatment. It is in the correction of these defects that the various special clinics are established. I am convinced from my own experience that if the special clinics were not provided by the Local Authority, few of these children would receive the necessary treatment in the early stages and that much impairment of the child would result from the delay. In this respect we ourselves are not blameless, for there is delay on part of the Clinic in the correction of the eye defects. The Board of Education was approached on this matter, hut would not allow the provision of staffing additional eye clinics, and suggested a lowering of the standard of reference, which is at present 6/9 in both eyes. Eye Clinic. Table IV., Group II., gives details of the work carried out at the Clinic during the year. If one refers to the medical inspection it will be found that approximately 5 per cent. of the children examined were found to have defective vision. This means that 190 children should come under periodical examination for refraction each year. Unfortunately, in 1932, we were able to refract only 123 cases, so that at the end of the year we are left with a waiting list of some 70 cases. With increasing school population of the Borough, and the 85 general increase in all Public Health work, the coming year will see this matter becoming' more acute, and unless provided for, will leave us with a lower standard of work performed, by neglecting what is one of the main branches of school medical service. Diseases of the Ear, Nose and Throat Clinic. This Clinic is held weekly on Wednesday mornings. Mr. Beney, whose report follows, is the Specialist and Consultant upon all ear, nose and throat conditions coming to our notice, and he also carries out tonsil and adenoid operations at the School Clinic where special facilities are provided. Children undergoing operation are retained over the 24 hours at the Clinic following the operation, and returned by private conveyance to their homes, where the Health Visitor visits daily for one week. It will be seen from the report that it is not every enlarged tonsil case that is operated upon, as it has always been our policy not to operate unless some other impairment in health exists in the child. Thus less than 50 per cent. of cases with enlarged tonsils and adenoids come under operation, and, although 130 operations in one year may appear a large figure, it must not be forgotten that practically 10 per cent. of children examined shew abnormality of the tonsils. Mr. Beney reports as follows: — "During the past year I have operated on 130 "cases for the removal of septic or chronically enlarged "tonsils and adenoids. Forty-three clinics have been "held. Two hundred and sixty-eight children have "been examined in consultation with the Assistant "School Medical Officer. Sixteen cases have been "referred to their own doctors for operation, and seven"teen have been operated on by me at St. John's "Hospital. Of the latter, five cases were for acute or "chronic mastoid disease; four required intranasal "operations for sinus infection, and eight were admitted "for dissection of tonsils, because there was some com"plication present which made hospital treatment "necessary. 86 "Of the cases operated on at the Clinic, there were "again no cases reported to me of any serious compli"cations arising after operation. "Once more I have to thank both the Clinic and "Voluntary Staff for their loyal co-operation, and also "Dr. Stinson for her care in administering the anæs"thetics." Charles Benet, m.a., m.b., B.ch., m.r.c.s. Orthopaedic Clinic. As this Clinic has now been in existence for seven years it seems almost unnecessary to define it, but apparently some indication is necessary of the type of work that this Clinic performs. All children shewing physical deformity are referred to the Consultant, who attends twice a month; he directs surgical treatment in the Orthopædic Hospital, and the remedial exercises, or massage, at the School Clinic by the masseuse, who attends on five sessions each week. A Sunlight Clinic is held twice weekly in conjunction with the Orthopædic Clinic. The work of the Clinic is not limited to school children only. There can be no doubt of the valuable work that this Clinic is doing for the crippled child, and as the report of the Consultant will shew, many children are being returned to a normal physical condition. Mr. H. J. Seddon reports as follows on cases admitted to Hospital: — "P.J. Admitted 24/10/31 with a fracture of the bones of the right fore arm. An open operation was performed to correct the position and the patient was discharged on 19/1/32. Unfortunately, both bones were broken again in February and the child was re-admitted on 18/3/32. The fragments were manipulated correct position under anæsthesia and the patient was discharged on 5/5/32. "P.G. Admitted 10/2/32 with a thickened scar on the neck following a burn. The scar was excised and the patient discharged on 4/4/32. 87 "M.M. Admitted on 10/2/32 with hammer toes. Treated by operation and discharged 4/4/32. "B.B. Admitted 4/4/32 with unusually severe bilateral club foot. Manipulative treatment failed to correct the deformities and open operation has been necessary. The immediate result is most gratifying and there is every indication that it will be permanent. "J.H. Admitted 6/5/32 with stiffness of the knee following arthritis occurring at the close of scarlet fever. The knee could not be straightened completely. Corrective plasters were applied and at the time of discharge (21/7/32) full extension was possible. Subsequent progress has been unusually good. An excellent range of movement has been obtained. "C.C. Admitted 4/7/32 with a fracture of the lower end of the right humerus. Position excellent and discharged for further treatment at the Clinic on 13/7/32." An unusual number of cases (49) have attended the Clinic with spinal defects. Their response to treatment has been most satisfactory, and it has not been necessary to consider the admission of any of them for radical hospital treatment. Statistics. Total attendances 2781 (i) For consultations 523 (ii) For treatments, massage, remedial exercises 2258 Maternity and Child Welfare. School Medical Service. Total. Requiring observation 24 83 107 Requiring treatment 17 106 123 Totals 41 189 230 88 New Cases seen at the Clinic during 1032. Scoliosis 18 Genu Valgum 13 Kyphosis 23 Outward Curvature Tibia 12 Kypho-lordosis 8 Flat Feet 5 Rickets 2 Arthritis 2 Wasting of Leg 2 Congenital Equino Varus 2 Ganglion 1 Slack Back 6 Sprains 6 Flat Chest 3 Fractures 14 Tubercular Glands 1 Injuries 15 Varus Toes 1 Contracted Scar 2 Valgus Feet 9 Other Conditions .20 Defective Children. Table III. in the Appendix gives details of those children classified as specials, and who come under examination and observation during the year. The work entailed in the administration of these children call? not only for considerable time and expense, but also in providing the education suitable to their physical condition. One hundred and seventy children come within the scope of the table, blind, deaf, mentally defective, epileptic, physical defective, tubercular and organic heart disease. An occupation centre for ineducable children was opened in July, 1933. The following is a summary of the children maintained in Residential Special Schools, or in attendance at Special Day Schools during 1932: — Blind (including partially blind) 9 Deaf (including partially deaf) 6 Mentally defective 4 Epileptics 4 Physically defectives (excluding Orthopedic Hospital treatment) 8 89 Report of School Dental Surgeon for Year 1932. Inspection. The annual inspection required by the Board of Education was carried out in each school during the year. The Dental Nurse and I made 28 visits to the schools and all the children, with the exception of a small number who were absent, received dental examination. The total number of school children who were examined during the year was 5,395, an increase of 652 over the previous year; due, of course, to the increase in the school population. At each inspection about 152 children are examined. It was found that 50 per cent. of these children had reasonably sound teeth and healthy mouths, while 50 per cent. required treatment; in some cases extensive —several fillings and several extractions—in other cases perhaps one extraction, or a filling or two was all that was necessary to maintain a good dental condition. This figure—50 per cent. having sound, healthy teeth—is very satisfactory; but I am afraid it is due only to the fact that as a whole the children attend the Clinic for treatment in a very regular manner. On examining children who are just beginning their school life at the age of four or five years I am inclined to think that their teeth are no better, that dental decay is as prevalent as ever. In our present state of knowledge we cannot prevent the origin of dental disease; at the moment our only effective method of control is to treat the disease as soon as possible after it arises, and hence the value of this regular annual inspection. Treatment. During the year 1932 the number of sessions for treatment at the School Clinic was 391. The number of attendances was 3,827, which gives an average attendance per session of just over 9 patients. The total number of children referred for treatment was 2,653, and of this number 2,387 were actually treated, this is about 89 per cent. This would appear to be a satisfactory proportion, especially since it must be remembered that we have increased the cost of our 90 treatment (where gas extractions are necessary besides conservative or other work, an additional 1/- is charged for the gas), and that amongst our school population shillings are not as plentiful as they were in more prosperous times. A statistical record of the work performed will be found in Table IV., Group IV. Dental Education. It will be seen from the paragraph above that a certain number of children who needed attention did not receive it. In some cases the Dental Nurse on her visit to the parent found that the reason for their nonattendance was due to a genuine lack of time and money. In such cases a friend or neighbour can often be found to accompany the child to the Clinic, and if it is a question of the 1/- fee, a certain amount of time may be allowed in which to pay it. Some of the parents—a proportion steadily decreasing—are either so ignorant of the evils of dental disease, or so indifferent to their children's welfare, that they decline the facilities offered. Common sense and common humanity determine that the inevitable consequences of neglect shall he widely made known, hence the visits of the Dental Nurse,the talks given to the parents at the time of the school inspections, and the practical demonstrations at the chair side. Our instruction and education in dental matters is to point out to parents their own obligations, and the clinic affords to most of them a way of meeting these. It will thus be seen we have to overcome sometimes an unfelt sense of duty on the part of the parents, sometimes a perverted sense of duty, and sometimes a spirit of laissez faire. During the year the Dental Nurse made 613 home visits. 91 Other Services. On Saturday mornings we hold a session for Maternity and Child Welfare cases. During 1932, 30 mothers and 76 children under school age attended for treatment. The dental condition of these expectant and nursing mothers is usually very bad indeed. They are referred by the Medical Officer from the Ante-Natal Clinic or the Welfare Centres, and I generally find that this is their first visit to a dentist. On examining the mouth it usually takes me a very short time indeed to realise that the only possible course of treatment is to clean up the mouth as well as possible and then by degrees extract all or nearly all the teeth. As regards the very young children, dental disease seems very prevalent. These cases are, of course, referred to the Dental Clinic by the Medical Officers at the Welfare Centres, so that all I see are definitely in need of treatment, but it does seem appalling when one has to extract, say, four teeth from a child of two in order to relieve pain and swelling. Conclusion. Lastly, I must again express my appreciation of the assistance given me by the Committee and the Staff. I also wish to thank the Head Teachers of the various schools for their help and continued interest in the dental work, for I know how great their influence on the children can be. Last, but not least, I would especially thank the voluntary workers for the time they have given to the Dental Clinic, it would at times be almost impossible to carry on were it not for their help. T. S. Latham, School Dental Surgeon. After Care. The following up of the ailing child and the providing of extra nourishment, convalescence, boots, etc., tor the necessitous patients, is in the very capable hands of Miss E. Carter, the Hon. Secretary of the Bromley Children's Care Committee, whose report for 1932 92 follows. This essential work of the School Medical Service is happily co-ordinated with that service, and I would like to express my great appreciation of all the help given us by the lady helpers at the Clinic, and in providing for the necessitous person at home and at school. It is the following-up of cases that completes the function of the school medical services. We have now had a united service since 1926 and there is no longer any separation of Public Health, Maternity and Child Welfare, School Medical and the Voluntary Services of the Borough. There is almost complete supervision of the young child from babyhood to school leaving age, through the visitation in the homes, through Clinics and Centres, but I do find that the work is becoming increasingly difficult with the increasing area and the increasing population. The time has come when extension of existing services must be permitted by a loosening of the strings which have held the purse so closely during the recent financial distress of the country. 93 REPORT OF THE BROMLEY CHILDREN'S CARE COMMITTEE FOR 1932. Executive Committee. Chairman and Honorary Treasurer: Mrs. A. G. Mann, b.a., j.p. Honorary Secretary: M iss E. H. Carter, 1, Homefield Road. Local Honorary Secretaries. Wharton and Plaistow Miss E. H. Carter. Valley Miss Pooole-Smith. Aylesbury and Masons Hill Vacant. Bromley Parish Miss Bush. Bromley Common Mrs. Foster. Raglan and Addison Mrs. Freeman. Burnt Ash Miss E. H. Carter. Bertram Pearce, Esq. Alderman F. Isard. E. C. De'Ath, Esq. Dr. K. E. Tapper. George Weeks, Esq. Miss I). Beddome. Dr. G. II. Stinson. In presenting this Report for 1932, the Committee think it well to explain that owing to a note sent to the Education Committee in March, 1932, stating that "as the Education Committee had power to give Dental and Tonsil and Adenoid treatment free to necessitatis cases, the Care Committee would no longer pay for these treatments." Therefore, though more work has been done, the numbers may be lower. A brief summary will show to some extent the Committee's work. The following cases have been investigated and helped: — 94 Tonsils and Adenoids 4 Dental 32 Vision 20 Fares to Hospital, etc. 15 Milk and Extra Nourishment 160 Convalescent Homes 40 Permanent Homes 4 Boots 119 Total 394 Three hundred and ninety-tour cases were assisted at a cost of £114 2s. 11d. The Committee was able to help in a sad case where six motherless children were left. They were able to get two little girls into Dr. Barnardo's Homes, and a girl and boy into the National Children's Home at Edgeworth, in Lancashire, whilst the two elder boys went into the Farnborough Institution with the Father. In September, the Committee was asked to take over the Clothing Department of the Best Boom. This was done and several of our members meet three or four times a week to sort and distribute the clothing, and to the end of the year 70 mothers and 149 children were helped in this way. Our members are still busy at the School Clinic, which is open daily and has an average of 15 sessions per week. This necessitates three or four of our members working there every day, and giving between 54 and 58 hours a week to the work. We are still wanting more helpers in this department. The Committee has again to thank Mr. Harris for his great kindness in giving spectacles at very reduced prices, and in many cases free of cost. The Committee cannot close this report without referring to the great loss they have sustained in the 95 death of the late Colonel Satterthwaite; he was so good in allotting them letters for convalescence, and they are glad that Mr. Harvey Lowe has consented to take on the work. E. H. Carter, Hon. Secretary. Statement of Accounts. Receipts. £ s. d. Expenditure. £ s. d. Bromley Benevolent Association 90 0 0 Royal Sea Bathing Hospital 16 16 0 Charity Festivities Association 25 0 0 Milk 31 3 2 Boots 36 9 2½ Sale of Cod Liver Oil and Parrish's Food 4 7 9 Convalescent Homes 4 10 3 Dental Clinic 2 0 0 Repaid— Medical Clinic 1 3 0 Royal Sea Bathing Hospital 2 5 6 Fares 5 16 8½ Cod Liver Oil and Parrish's Food 5 18 10 Convalescent Homes 1 17 6 Fares 10 10 Glasses 1 0 3 Boots 5 0 Fares 11 3 Dental Clinic 3 6 Clothes 6 5 4 Clinic Box 1 3 1 Surgical Belt 15 0 Food 12 9½ £125 13 2 Deficit for last year 1 1 1½ Balance carried fwd. 11 10 3 £125 13 2 96 BROMLEY CHILDREN'S AFTER-CARE COMMITTEE. Chairman: Mrs. A. G. Mann, b.a., j.p. Hon. Secretary: Miss E. A. Wise, Farningham, Kent. Committee: *Miss Bush. Mrs. Petley. Madame Duche. Mrs. Slater. Mrs. Drew. Dr. K. E. Tapper, Mrs. Foster. o.b.e., m.b., d.p.h. Miss Fluck. Miss E. Thompson. Sister Morgan. Miss Weeks. *Mrs. Palmer. Mrs. Westwood. *Resigned in the autumn of 1932. Report for the Year 1932. During the past year 64 cases have been visited and reported upon to the Committee. Fifteen of these being statutory cases have been visited for, and reported upon to the Kent Mental Deficiency Committee. In addition, four other cases for whom our Committee is only temporarily responsible, have been frequently visited and reported upon to the appropriate authority. Forty-four ex-pupils of the Special School are still on our list: — Twelve of these are in regular work and appear to be giving satisfaction. Six are sometimes in work but have unsatisfactory homes, and suffer from the prevailing unemployment. Six are never likely to do much, being too feeble either mentally or physically. Eleven are in domestic work, either as housewives or as domestic servants. Nine are occasionally in work, but are unstable. 97 Of the remaining twenty, one has removed to another neighbourhood and will possibly be recommended to the London Association for Mental "Welfare. Four have been recommended to us by outside authorities; one has been placed under guardianship; fourteen are of very low grade (imbeciles for the most part). Several of the last named will be invited to attend the Occupation Centre to be opened, it is hoped, by the Kent Voluntary Association for Mental Welfare, as soon as negotiations for a suitable hall can be completed. A grant has been promised by the Kent Mental Deficiency Committee towards the necessary expenses. The centre will be under the direction of a trained supervisor. The Secretary of the Association who is carrying through the scheme is making an appeal for help from voluntary workers who would be willing to give even half-an-hour a week to helping an individual child, or to playing for their singing and exercises. It may be recalled that in our previous reports we have stated that where an ex-pupil of the Special School seems to have given satisfaction for some two or three years, it is our practice to drop visits. There are 26 such persons. In the ordinary course, visits to the twelve mentioned in a former paragraph would by degrees cease. But in view of a circular letter with a questionnaire from the Board of Control lately issued to such Committee's as ours, relating to the children of' defectives, we have decided to keep in touch with as many defectives as possible. The Hon. Secretary attended a Conference called together by the Central Association for Mental Welfare. Her report of the Conference was circulated among members of the Committee. It was with very great regret that the Committee heard of the illness of Mrs. Palmer, and of her enforced resignation. They hope that she will soon recover and be able to return to her new appointment. She was always ready to put her specialized knowledge and her experience at the service of the visitors, and they wish to thank her for the help she gave us willingly. From many conversations with the parents, we gather that they acknowledge that it was mainly owing to her that 98 so many young people, instead of going through life feeling bewildered and unsure, have been able to go on steadily and earn a living. We regret also that Miss Bush and Miss Thompson have through pressure of other work been obliged to give up their cases. We welcome Miss Fluck. The following table relates to those defectives who have been supervised since the Committee was reformed in 1921, and are no longer under our supervision. Satisfactory reports, and, in consequence, visits dropped 27 Sent to Institutions or Colonies for defectives 13 Promoted to ordinary elementary schools 1 Died 9 Lost sight of 7 Left the neighbourhood, and recommended to other local associations 2 Removed to Farnborough Institution 2 Under the care of the Salvation Army 1 Placed under guardianship 2 Statement of Accounts. Receipts. Expenditure. £ s. d. Rent of Room 1 2 6 Cash in hand 4 8 0 Grant, K.M.D.C. 3 5 0 Travelling Expenses 18 1 Printing and Stationery 2 3 9 Conference Ticket 10 6 Postage 18 2 Cheques 1 0 "Mental Welfare" 3 6 Cash in hand 1 15 6 £7 13 0 £7 13 0 APPENDIX. 100 TABLE I.—MEDICAL INSPECTION RETURNS. Year ended 31st December, 1932. A.—ROUTINE MEDICAL INSPECTIONS. Number of Code Group Inspections: Entrants 594 Second Age Group 514 Third Age Group 374 Total 1482 Number of other Routine Inspections — B.—OTHER INSPECTIONS. Number of Special Inspections 2636 Number of Re-Inspections 4064 Total 6700 101 TABLE IIa.—Return of Defects found by Medical Inspection in the year ended 31st December, 1932. 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 23 18 37 37 Skin Ringworm—Scalp .. .. .. .. Body .. .. 1 .. Scabies 1 .. 14 19 Impetigo .. .. 10 15 Other Diseases (Non-tuberculous) 6 .. 152 157 Eye Blepharitis 1 .. 11 3 Conjunctivitis 2 .. 12 4 Keratitis .. .. .. 1 Corneal Opacities 1 .. .. .. Defective Vision (excluding squint) 66 3 69 15 Squint .. .. 5 .. Other Conditions .. .. 34 19 Ear Defective Hearing 3 9 23 8 Otitis Media 5 .. 11 28 Other Ear Diseases 3 .. 86 73 Nose and Throat Enlarged Tonsils only 42 88 202 77 Adenoids only 4 5 27 16 Enlarged Tonsils and Adenoids 59 47 78 283 Other Conditions 11 6 258 180 Enlarged Cervical Glands (Non-Tuberculous) 5 17 44 25 Defective Speech 1 1 4 .. Heart and Circulation ( Heart Disease—Organic 4 2 .. .. Functional 3 36 64 69 Anæmia 1 3 6 3 Lungs Bronchitis 5 .. 20 8 Other Non-Tuberculous Diseases 25 7 336 288 Carried forward 271 242 1504 1328 102 TABLE Il.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 271 242 1504 1328 Tubercu- losis Pulmonary—Definite .. .. 1 .. Suspected .. .. 2 1 Non-Pulmonary—Glands 2 1 2 2 Spine .. .. .. .. Hip .. .. .. .. Other Bones & Joints .. .. 1 .. Skin .. .. .. .. Other Forms .. .. .. .. Nervous System Epilepsy .. .. 1 .. Chorea 1 3 15 21 Other Conditions 2 5 18 17 Deformities Rickets .. .. .. .. Spinal Curvature 36 3 7 1 Other Forms 41 2 51 27 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 12 6 367 216 Totals 365 262 1969 1613 103 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 594 133 22.4 Second Age Group 514 126 24.5 Third Age Group 374 79 21.1 Total (Code Groups) 1482 338 22.8 Other Routine Inspections — — — 104 TABLE III.—Return of all Exceptional Children in the Area, 1932 Boys. Girls. Total. Children Suffering from types of Multiple Defect : Mentally Defective and Partially Blind. At no School or Institution 1 1 2 Mentally Defective and Epileptic. At no School or Institution 1 .. 1 Blind (including partially Blind). (i) Suitable for training in a School for the totally blind. At Certified Schools for the Blind 1 1 2 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 2 4 At Public Elementary Schools 2 1 3 At other Institutions .. .. .. At no School or Institution 1 .. 1 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 1 1 2 At Public Elementary Schools 1 3 4 At other Institutions 1 1 2 At no School or Institution 5 5 10 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 .. .. .. 105 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 1 .. 1 At Certified Residential Open-Air Schools .. .. .. At Certified Day Open-Air Schools .. .. .. At Public Elementary Schools .. .. .. At other Institutions 1 .. 1 At no School or Institution 1 1 2 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 17 10 27 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 4 8 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 3 2 5 At other Institutions • • • • • • At no School or Institution 2 • • 2 106 TABLE III.—Continued. Boys. Girls. Total.  Physically Defective (continued). 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 .. .. .. At Certified Residential Open-Air Schools 1 .. l At Certified Day Open-Air Schools .. 1 1 At Public Elementary Schools 14 10 24 At other Institutions .. .. .. At no School or Institution .. .. .. 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 1 .. 1 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 10 12 22 At other Institutions .. .. .. At no School or Institution (*Indicates the number of these children who should be receiving special education). .. .. .. Children with heart disease, i.e children whose defect is so severe as to necessitate the provision of educational facilities other than those of the public elementary school. At Certified Hospital Schools l .. 1 At Certified Residential Cripple Schools .. .. .. At Certified Day Cripple Schools .. .. .. At Certified Residential Open-Air Schools .. .. .. At Certified Day Open-Air Schools .. .. .. At Public Elementary Schools 6 7 13 At other Institutions 1 ... 1 At no School or Institution 2 2 4 107 TABLE IV.-—Return of Defects Treated during the year ended 31st December, 1932. Treatment Table Group I.—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 - - - Body 1 - 1 Scabies 15 - 15 Impetigo 87 - 87 Other skin disease 163 8 171 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 46 10 56 Minor Ear Defects 108 6 114 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 246 13 259 Total 666 37 703 108 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) 312* 51 - 363 Other Defect or Disease of the Eyes (excluding those recorded in Group I). 27 4 - 31 Total 339 55 - 394 * This figure 312 includes 189 re-inspections : 123 Refractions. Total number of children for whom spectacles were prescribed: — (a) Under the Authority's Scheme 107 (b) Otherwise 49 Total number of children who obtained or received spectacles: — (a) Under the Authority's Scheme 102 (b) Otherwise 49 109 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS Received Operativ 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) 130 33 163 78 211 Group IV. —Dental Defects. (1) No. of children who were: — (a) Inspected by the Dentist: — Routine Age Groups Aged: 5 505 ,, 6 514 ,, 7 490 ,, 8 535 ,, 9 511 ,, 10 557 ,, 11 548 ,, 12 471 ,, 13 292 ,, 14 108 Total 4531 Specials 864 Grand Total 5395 (b) Found to require treatment 2653 (c) Actually treated 2387 (2) Half-days devoted to: — Inspection 28 Treatment 391 419 110 (3) Attendances made by children for treatment 3827 (4) Filling: — Permanent teeth 1675 Temporary teeth 569 2244 (5) Extractions: — Permanent teeth 509 Temporary teeth 3107 3616 (6) Administration of general anæsthetics for extractions 962* (7) Other operations: — Permanent teeth 446 Temporary teeth 314 760 * In addition there were 1194 local anaesthetics. Group V.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses (ii) Total number of examinations of children in the Schools by School Nurses 13551 (iii) Number of individual children found unclean 420 (iv) Number of children cleansed under ments made by the Local Education Authority (v) Number of cases in which legal proceedings were taken: — (a) Under the Education Act, 1921 Nil (b) Under School Attendance Bye-laws 111 Dental Treatment and Details of Treatment Given, 1932. 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 dealings, Dressings, Regulations. Male Kept. Extracted. Filled. Extracted. Filled, Gas. Local. 28 391 7279 3327 864 509 1675 3107 569 2244 962 1194 760 Total Number of Visits to parents made by the Dental Nurse, 613. 112 Head Inspections, 1932. School Depts. FIRST INSPECTIONS. FINAL INSPECTIONS. ALL INSPECTIONS. individual children Number Inspected. Clean Slightly Vermino us Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous. Slightly Verminous Highly Verminous ADDISON ROAD.. G & I 155 151 4 .. 160 155 4 1 485 470 14 1 8 1 AYLESBURY B 171 166 5 .. 196 191 2 3 537 523 11 3 10 3 BICKLEY and WIDMORE J 105 105 .. .. 115 110 2 3 338 331 2 5 2 3 I 101 96 3 2 130 118 9 3 365 342 17 6 15 5 BROMLEY COM. J 178 157 16 5 189 172 16 1 549 500 42 7 27 7 BURNT ASH G 328 324 2 2 387 365 17 5 1069 1023 39 7 30 5 B 375 372 2 1 420 415 4 1 1178 1170 6 2 6 2 J 390 378 7 5 352 342 10 .. 1186 1111 36 9 29 5 MASONS HILL G & I 269 259 10 .. 273 262 9 2 776 740 28 2 19 2 CENTRAL B 68 68 .. .. 104 104 .. .. 250 250 .. .. .. .. G 85 85 .. .. 104 104 .. .. 268 267 1 .. 1 .. PARISH B 245 243 1 1 266 256 9 1 749 732 13 4 7 4 G 224 206 16 2 216 233 9 4 709 662 39 8 23 6 I 68 64 1 3 121 115 2 4 298 282 7 9 4 8 PLAISTOW J 56 50 6 .. 87 77 7 3 267 237 21 9 15 8 RAGLAN ROAD G 278 247 30 1 282 255 25 2 838 757 78 3 24 3 B 395 391 4 .. 440 437 3 .. 1220 1209 11 .. 10 .. J 244 222 21 1 280 257 22 1 798 730 61 7 41 7 I 194 182 12 .. 276 256 19 1 715 676 37 2 30 2 VALLEY G 121 111 9 1 167 163 1 3 421 395 17 9 13 8 special school wharton RD i 127 117 7 3 143 130 10 3 425 395 23 7 16 6 30 25 5 .. School Closed 30 25 5 .. 5 .. J 80 75 2 3 School Closed 80 75 2 3 2 3 TOTAL 4287 4094 163 30 4738 5417 180 41 13551 12938 510 103 337 88