Borough of Bromley ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For 1933. K. E. TAPPER O.B.E., M.B., Ch.B., D.P.H. BROMLEY, KENT: The Bromley Printing Co., Sherman Road. Borough of Bromley. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For 1933. K. E. TAPPER O.B.E., M.B., Ch.B., D.H.H. BROMLEY, KENT: The Bromley Printing Co., Sherman Road. CONTENTS. page Members of the Health and Maternity and Child Welfare Committees 5 Prefatory Letter 6 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 15 Deaths 15 Infantile Mortality 16 Maternal Mortality 17 Part III.—Maternity and Child Welfare 19 Details of Services 19 Centres and Clinics 20 Ante-Natal Clinic 21 Natal Services 22 Midwives 23 Midwives Acts, Administration of 23 Midwives, Inspection of 25 Maternity Hospital and Maternity Homes 26 Puerperal Fever and Puerperal Pyrexia 27 Post-Natal 27 Home Visiting 27 Welfare Centres 28 Milk in Necessitous Cases 29 Minor Ailment Treatments 30 Ophthalmia Neonatorum 30 Diarrhoea and Enteritis 30 Children and Young Persons Act, 1932 31 Part IV.—Summary of General Provision of Health Services 32 Legislation in Force Hospitals Maternity and Nursing Homes 32 Institutions, various 33 Ambulance Facilities 33 Laboratory Facilities 35 Clinics and Centres 35 Nursing in the Homes: District Nursing Association 35 Tuberculosis Dispensary Venereal Diseases CONENTS—Continued. page Part V.—Sanitary Circumstances 38 Rivers and Streams 38 Drainage and Sewerage 38 Water 39 Scavenging 39 Rats and Mice Destruction Act, 1919 40 Nuisances 41 House to House Inspection 42 Contraventions—Drainage 42 Part VI.—Housing Conditions 43 Housing Acts, 1925-1930 43 Overcrowding 44 Prevalent Defects in Housing 44 Statutory Notices 45 Houses Let in Lodgings 45 Paut VII.—Smoke Pollution 45 Part VIII.—Shops Acts, Contraventions &c 46 Part IX.—Petroleum Acts 46 Part X.—Factories and Workshops 47 Part XI.—Premises and Occupations Controlled by Bye-Laws, Regulations, &c 47 Contravention—Registry Office 48 Part XII.—Inspection and Supervision of Foodstuffs 48 Milk 48 Milk, Bacteriological Examinations 49 Milk, Contraventions 50 Meat 50 Meat, Tables A., B., C., D. and E. 51 Meat, Contraventions 53 Other Food Condemned 53 Unsound Food Surrendered 53 Food and Drugs (Adulteration) Act, 1928 54 Part XIII,—Diseases of Animals Acts 55 Tuberculosis Order, 1925 55 Part XIV.—Rag Flock Acts, 1911-1928 55 Part XV.—Infectious Diseases Control 56 Scarlet Fever 56 Diphtheria 57 Diphtheria Immunisation 58 Vaccination 59 Tuberculosis 59 After-Care Committee for Tuberculosis 61 Appendices.—Statistical Tables I. to XV 64—82 CONTENTS—Continued. page School Medical Service. Members of the Education Committee 84 Introduction and Summary of Statistics 85 Hygiene of Schools 87 Medical Inspections 88 Treatment 88 Disease of Ear, Nose and Throat Clinic 88 Eye Clinic 89 Orthopaedic Clinic 90 Orthopaedic Statistics 92 Sunlight Clinic 93 Dental Clinic 93 Infectious Diseases 97 Medical Exclusion Certificates 97 Open Air Education 98 Provision of Meals 99 Physical Training 99 Blind, Defective and Epileptic Children 99 Conclusion 100 Report of the Bromley Children's Care Committee 100 Report of the Bromley Children's After-Cake Committee for Mental Defectives 103 Appendices:— Medical Inspection Returns, Tables I. to IV 108—119 Dental Clinic, Details of Treatment 120 Head Inspections 121 MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1933-34. HEALTH COMMITTEE:— Alderman W. F. Skilton (Chairman). Councillor W. A. Greenley, c.m.g., d.s.o. ( Vice-Chairman). His Worship the Mayor (Councillor W. D. Gibbs, j.p.). Councillor G. Allen. Councillor F. S. Darby. Councillor S. L. Gibbs. Councillor W. J. Guthrie, j.p. Councillor P. Jones. Councillor A. McIntosh, d.c.m. Councillor M. Stafford Smith, m.b.e., b.a. MATERNITY AND CHILD WELFARE COMMITTEE:- Councillor M. Stafford Smith, m.b.e., b.a. (Chairman). Councillor G. Allen (Vice-Chairman). His Worship the Mayor (Councillor W. D. Gibbs, j.p.). Alderman W. F. Skilton. Councillor F. S. Darby. Councillor S. L. Gibbs. Councillor W. A. Greenley, c.m.g., d.s.o. Councillor W. J. Guthrie, j.p. Councillor P. Jones. Councillor A. McIntosh, d.c.m. Co-opted Members:— Mrs. A. M. Howe. Mrs. A. G. Mann, b.a., j.p. Mrs. M. Pearce. Miss Y. Vincent. Mrs. E. Toll and. Borough of Bromley. Report of the Medical Officer of Health for the Year 1933. Jo the Mayor, Aldermen and Councillors. Mr. Mayor, Madam and Gentlemen, I beg to submit the Annual Report on the Health of Bromley during the year 1933. The Report follows the usual lines as set out in Circular 134G of the Minister of Health, but I regret owing to the work entailed in 1934 in the undertaking of an extended Borough, that the Report is late in issue. The outstanding feature for the year has been an unusually rapid progress in building estates within and surrounding the Borough, with the consequent changing in number and character of the people. This influx and change must leave an effect upon the disease incidence of the population when taken as an isolated unit. Owing to the economic stringency exercised during the year the Health Department has confined its activities to the services already provided, although approval was given to an additional ante-natal clinic at the Maternity Hospital, and an additional welfare session at Bromley Common Centre. Several Acts of Parliament affecting the Public Health services came into operation during 1933, the principle ones being the Rent Restriction Act, 1933, Slaughter of Animals Act, 1933, and the Children and Young Persons Act, 1932, in which is incorporated Infant Life Protection. The vital statistics for the year showed a falling Death Rate and a falling Birth Rate. The Infantile Mortality Rate is again below the average rate during the past quinquennial period 1920-1930. These rates, 7 • which are more fully discussed in the body of the report, are of some importance as they indicate to some extent social conditions of the people and although they are frequently misunderstood or misquoted they are not to he taken as the success or failure of Public Health Services. The improvement in the social conditions of the people in this country is due to many factors, one of which is the Public Health Service. The fact that modern citizenship demands an efficient and comprehensive Public Health Service must be at least an indication that the services are of prime importance to the welfare of the people. I cannot in this report point to anything that will show the results of a year's activities and a year's expenditure; for the improvement in health is not a matter to be measured from year to year. I can show the great saving in infant life in all classes of the population; I can show the improvement in the general environment and in social habits, and above all the physical wellbeing of the young child of to-day brought about by our many services exercising prevention of disease as their cardinal principle. I would express to the Committees my appreciation of their interest and help, and to the staff for their loyal and untiring support. I am, Mr. Mayor, Madam and Gentlemen, Your Obedient Servant, K. E. TAPPER, Medical Officer of Health, 8 PUBLIC HEALTH STAFF, 1933. Medical Officer of Health and School Medical 2 K. E. Tapper, o.b.e.. Officer m.b., ch.b., d.p.h. Assistant Medical Officer of Health and School 2 Miss G. H. Stinson, Medical Officer m.r.c.s., l.r.c.p. Orthopedic Specialist ... 2 1 H. J. Seddon, f.r.c.s. Ear, Nose and Throat 2 1 Charles C. Beney, m.a., Specialist m.b., ch.b., (Camb.), m.r.c.s. Consulting Gynaecologist 1 J. Bright Banister, m.a., m.d., f.r.c.p., f.r.c.s. School Dental Surgeon ... 2 T. S. Latham, i,.n.s., r.c.s. Senior Sanitary Inspector 5 4 3 2 G. R. Woods, m.s.i.a., a.r.san.i. Additional Sanitary 54:i2 T. C. Towersey, m.s.i.a. Inspectors ... ... 5 4:12 C. J. Clark. Health Visitors and 8 7 8 2 Miss L. A. Briggs, s.r.n. School Nurses ... 8 7 8 2 Miss E. Connor, s.r.n. (Appointed 14/8/33). 8 7 6 2 Miss E. B. Crowe, s.r.n. 8782 Miss D. Prime, s.r.n. (Appointed 17/4/33). 8 7 0 2 Miss P. M. Trickett, s.r.n. 8 7 8 2 Miss J. Roseveare, s.r.n. (Resigned 12/8/33). 72 Miss V. Morgan (Resigned 16/4/33). Orthopaedic Nurse 21 Miss M. Dodge (Appointed 22/5/33). 21 Miss D. Gardner, c.s.m.m.g., m.e. (Resigned 19/5/33). 9 PUBLIC HEALTH STAFF.—continued. Veterinary Surgeon under the Diseases of Animals Acts 1 P. J. Turner, m.h.c.v.s. Inspector under the Diseases of Animals Acts, Shops Acts, and GL R. Woods, m.s.i.a., Petroleum Acts ... a.r.san .1. General Office Staff: Senior Clerk 2 H. E. Lawley. Junior Clerks 32 H. Handscomb. 2 Miss B. C. Tucker. 2 Miss L. P. Thorpe (Appointed 23/10/33). 4 Mi ss M. L. Byford (Resigned 20/10/33). Dental Assistant Nurse 2 Miss A. M. Penman. Outdoor Staff: Drain Tester and Disin- J. W. Seager. fector Market Toll Collector 1 H. Deane. 1. Denotes part-time. 2. Exchequer Grants (including Board of Education). 3. Certificate of the Royal Sanitary Institute and Sanitary Inspectors Joint tion Board. 4. Royal Sanitary Institute Certificate for Meat and Other Foods. 5. Royal Sanitary Institute, Smoke Certificate. Three years Hospital Trained. 7. Certificate of Central Midwives' Bard. 8. Royal Sanitary Institute new Health Visitors' Certificate (under Memo. IoI/MCW). 10 I.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA, 1933. Statistics. Area (in acres) 4,697 Population— Census (1921) 35,052 Census (1931) 45,374 Mid-year (1933) (Registrar General's estimate) 48,270 Number of inhabited bouses (Census 1931) 10,764 (December, 1933) 12,170 Rateable value (31.3.1934) £518,103 The sum represented by a penny rate (1.4.1934) £2,352 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. Birth Rate per 1,000 of the estimated resident population: 12.3. Legitimate 564 297 267 Illegitimate 34 19 15 598 316 282 Stillbirths Rate per 1,000 total (live and still) births : .27.6. Legitimate 14 8 6 Illegitimate 3 2 1 17 10 7 Deaths 489 244 245 Death Rate per 1,000 of the estimated resident population: 10.1. 11 Rate per 1,000 total (live and still) births: Deaths from puerperal causes: Number of deaths. still) births: From sepsis 2 3.2 From other causes 2 3.2 Total 4 6.5 Death rate of infants under 1 year of age:— All infants per 1,000 live births 41.8 Legitimate infants per 1,000 legitimate live births 42.5 Illegitimate infants per 1,000 illegitimate live births 29.4 Deaths from measles (all ages) Deaths from whooping cough (all ages) 1 Deaths from diarrhoea (under 2 years of age) 3 Social Conditions. In a small history of Bromley issued in 1858 appears this comment on Bromley: "A prosperous and wellbuilt town, the buildings continually increasing in a situation pleasant and healthy," and so it is at the present time. 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, 1933: Total rainfall 16.77 inches Mean maximum temperature 58.15 degrees Mean minimum daily temperature 43.23 degrees Highest maximum temperature recorded 90 degrees on 27th July and 6th August. Lowest minimum temperature recorded 19 degrees on 23rd January. 12 Lowest grass minimum temperature 17 degrees 011 28th Jan. and 10th and 16th December. Occupations and Unemployment. 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 recorded unemployment figures for the Borough at the end of the year 1933 show a decrease of 110 compared with the figures for the same period 1932. In the absence of knowledge of the number of employable persons in the area, it is somewhat difficult to gauge the degree of unemployment. Taking population as the basis of calculation it is interesting to note that there is a decrease for 1933 compared with 1932. The manager of the Employment Exchange has kindly supplied the following particulars:— 1. Recorded unemployment at the end of December, 1933: Men (18 years and over) 884 Women (18 years and over) 118 2. The highest figures reached in 1933: (a) Men 1276 on 23/1/33. (b) Women 243 on 20/5/33. Population. The Registrar General's mid-year figure, 48,270, gives a continued and even increase over the previous year. The rather unusually rapid progress in building has I believe made this figure an under estimate. On the basis of the census figure of the number of persons per occupied house (4.2) and the number of dwellings on the rate books at 31st December, 1933 (12,170), give the population at the end of the year as 51,114. The population figure is of some importance in the calculation of the various rates of vital statistics, and these 13 are based per 1,000 population as estimated by the Registrar General at the mid-year, 1933. Further, population figure taken alone is not of the same importance as a knowledge of the age groups in that population, and I am therefore recording the figures in the age groups as recorded by the Census taken in 1931: Total Population. Age Groups. Males. Females. 0— 4 1,544 1,524 5— 9 1,752 1,774 10—14 1,628 1,575 15—19 1,600 1,955 20—24 1,670 2,187 25—29 1,671 2,219 30—34 1,493 2,081 35—39 1,488 1,973 40—44 1,456 1,959 45—49 1,358 1,772 50—54 1,264 1,605 55—59 1,064 1,366 60—64 786 1,116 65—69 567 807 70—74 389 625 75—79 239 430 80—84 97 219 85—89 25 70 90—94 7 15 95 and over 1 3 II.—VITAL STATISTICS. Births. Birth Rate 12.3. The Registrar General has furnished the following information:— Total. Legitimate.. Illegitimate. Live Male 316 297 19 Births. Female 282 267 15 598 564 34 14 It is to be noted that the high number of 34 illegitimate births for 1932 remains the same for 1933— nearly 6 per cent, of total live births born out of wedlock. The infant death rate (29 per 1,000) of these illegitimate births, however, is halved for 1933 compared with 1932 when the rate was 58,8 per 1,000. Bromley's annual birth rates are shown in comparison with, England and Wales during the past twelve years: Year. Birth Rates. Bromley. England and Wales. 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 1933 12.3 14.4 It is hardly possible within the limited scope of an annual report to go deeply into the causes of the general decline in the birth rate. Many factors would have to be considered, as, lessening of fertility in the race, indiscriminate use of contraceptives, late marriages, increased celibacy and divorce. Nevertheless the remarkable decline in the birth rate of the country cannot fail to engage attention when one compares the average birth rate per 1,000 living of 35.4 between 1871-1880 and 14.4 for 1933. Such a diminution in the rate without corresponding diminution in proportion in the death rate has had the effect of raising the average age of population, and it would, therefore, seem only a matter of time when increase of population must cease. Further it can be argued that child-bearing ages will lessen as the average age increases and consequently lower the birth rate even more. A low birth rate is generally associated with essentially residential areas such as Bromley, and 15 therefore undue concern need not he expressed at the low rate of 12.3 for 1933. The total number of births notified annually in this area is not a diminishing1 factor, but the rapid influx of population to new estates tends to lower the rate and thus comparison of local birtli rates are misleading. Nevertheless the decline in the birth rate is a problem, but one which is national rather than local. Stillbirths. Seventeen stillbirths were registered in 1933 whereas 14 were notified under the Notification of Births Act, 1907. The latter figure is subject to correction for inward and outwards transfers, and therefore the former figure is the accepted one for statistical record. Since compulsory registration of stillbirths in 1927 it will be seen from the following table that there has been little sign of downward tendency in the stillbirth rate, although there is a reduction for 1933:— 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 1933 17 27.6 Deaths. Four hundred and eighty-nine deaths were registered during the year, being 15 less than the previous year. The crude Death Rate for 1933 is 10.1 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:— 16 Year. Bromley Crude Death Rates. England and Wales Death Rates. 1923 10.5 11.6 1924 11.1 12.2 1925 10.3 12.2 1926 10.04 11.6 1927 10.8 12.3 1928 10.8 11.7 1929 11.7 13.4 1930 9.8 11.4 1931 10.9 12.3 1932 10.7 12.0 1933 10.1 12.3 As I have pointed out in previous reports, important factors which must be taken into consideration when comparing- death rates are age grouping and sex distribution of the population, and these have not been taken into consideration in the above table. Causes of deaths are tabulated in detail in the Appendix III., from which the following main causes have been extracted for 1933 and shown in comparison with 1932:— 1932 1933 1932 1933 1932 1933 No. of deaths Rate per cent, of total deaths. Rate per 1,000 of population. Respiratory disease 45 44 8.9 8.9 0.9 0.9 Heart disease 146 156 28.9 31.9 3.1 3.2 Cancer 78 70 15.4. 14.3 1.6 1.4 Tuberculosis 36 37 7.1 7.5 0.7 0.7 Premature births 12 13 2.3 2.6 0.2 0.2 Infectious disease 8 2 1.5 0.4 0.1 0.04 Influenza 16 16 3.1 3.3 0.3 0.3 In the following table the rates for Bromley are shown in comparison with those for England and Wales:— Infantile Mortality. Twenty-five deaths of infants under one year of age were registered giving a Mortality Rate of 41.8 per 1,000 live births. 17 Year. Bromley. England and Wales. 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 1933 41 64 It is remarkable to note that for the last eight years the infantile mortality rate is being held down below 50 in Bromley; the very low figure of 33 being actually touched in 1926 and 1932. There would appear to be no reason why these statistics should not be accepted with reliability and that public health work and teaching in Bromley should not receive a large measure of credit for these encouraging results. As I have previously reported the average infantile mortality rate during 1926-1930 was 44; for 1921-1925 it was 62, and the pre-war rate for 1910-1914 was 68. 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 Triennial period: 1931-1933 4 6 5* (*Rate per 1,000 live and still births—G. 5). During 1933 four mothers died in, or in consequence of, childbirth; two of these were due to sepsis and two from other causes, viz., a case of uraemia and a case of death under anaesthetic for surgical removal of placenta. All cases were admitted to hospital before death. 18 It is a deplorable fact that in every 1,000 live and still births six mothers should die as a consequence of a physiological function. To counter this the Local Authority has made every possible provision; an Obstetrical Specialist is engaged for emergency; special hospital accommodation is provided for the septic case, but more important than all we provide every facility to safeguard the mother against the emergency arising. Adequate ante-natal supervision and care must be the prime principle in the prevention of maternal deaths, but it is deplorable that this is not yet by any means fully appreciated by the pregnant woman; the principle of next importance is to provide for the confinement under the best possible environment and one able to cope with all emergencies. I am not for one moment suggesting that every confinement should take place in hospital or maternity home, as I believe certain dangers exist in the hospitalisation of a normal physiological function. Nevertheless, far too many cases are left to the haphazard ante-natal and post-natal care of the so-called maternity nurse who need not possess any training or knowledge provided slip does not actually carry out the delivery of the child without the presence of a doctor. The midwives of the Bromley District Nursing Association play a large part in the services of prevention of disease—a fact not fully realised by the public. This voluntary association deserves every possible finanrial support so that they may continue to provide skilled midwives for pregnant women. Although we can never fully conquer maternal mortality we can prevent the deaths of some 50 per cent, of the present mortality. In my view every mother should have the attention of a skilled doctor throughout the period of pregnancy; the normal confinement being left in the hands of the certified midwife. The position to-day in this respect is rather the reverse—the majority of mothers are left without skilled supervision before and after confinement; the doctor attending only at the actual labour. 19 III.—MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare services consist of the following:— 1. Five full-time and one part-time Health Visitors, who are employed half-time on school medical duties. They attend the centres and carry out the teaching of mothercraf't in the homes. 2. Seven welfare centre sessions are held weekly, with a doctor in attendance. In addition a fortnightly welfare session is held at Hayes. 3. Ante-natal Clinics are held three times per month. 4. Maternity Hospital provision for necessitous cases—reservation of four beds. 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 mothers, nursing mothers, 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. 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. Ophthalmologist for defective vision. 14. Provision of hospital treatment for cases of Ophthalmia Neonatorum, and for acute complicated cases of Measles. (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 1934-1935). 20 Child Welfare Centres. Bromley Common— St. Luke's Institute, Raglan Road Tuesdays, 2.30 p.m. Fridays, 2.30 p.m. Burnt Ash— Burut Ash Branch Library, Burnt Ash Lane Tuesdays, 2.30 p.m. Wednesdays, 2.30 p.m. Hayes and Keston— Village Hall, Hayes Tuesdays (fortnightly) at 2.30 p.m. Plat stow— School Clinic, Station Boad Wednesdays, 2.30 p.m. Short lands— Congregational Hall, Martins Road Thursday, 2.30 p.m. Widmore— Wesleyan New Hall, Tylney Boad 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. Denial Ciinic. Held at the School Clinic, Station Boad, 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. 21 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. Ultra Violet Ray Clinic. Held at the School Clinic, Station Road, twice weekly: Tuesdays at 2.30 p.m., and Fridays at 2.30 p.m. Diphtheria Immunisation. Held at the School Clinic on Mondays 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 1928 116 184 184 23 1929 118 212 212 24 1930 125 235 233 24 1931 101 184 180 24 1932 123 199 196 24 1933 133 200 200 31 The Ante-Natal Clinic is held on the first and third Thursday of each month at the School Clinic, Station Road, and at the Maternity Hospital on the fourth Thursday of each month. The average number of attendances at the School Clinic, Station Road, may appear smaller than in previous years, but this is because the cases which are sent 22 on to the Maternity Hospital as necessitous cases are seen at the Ante-Natal Clinic there instead of at the Station Road Clinic. The help and advice given is apparently greatly appreciated by the expectant mothers who attend, as is shown by the fact that the same mothers attend for antenatal supervision in subsequent confinements. There is still a large percentage of expectant mothers who do not have ante-natal care at all, and only seek the services of a midwife or doctor at a very late date in pregnancy; even sometimes only when labour is imminent. These cases are difficult and will not be bothered with examination and advice. If they could be persuaded to have proper ante-natal care, I am sure the number of stillbirths and infant deaths in the district would be considerably lessened. It would in many respects be of great value if ante-natal care was in some measure compulsory, for after all it is not only for the safeguarding of the mother, hut also for that of the babes—our future generation. The young expectant mothers of the present day appear to me to be healthier and do not ail in pregnancy as much as mothers did in the past. Probably this is due in part to the healthier life girls now lead with their sport and fresh air, and perhaps in part also to ante-natal supervision and advice. Natal Services. Six hundred and sixty-five births were known to have occurred in Bromley during 1933. Of these 14 were stillbirths. In addition 18 births were found not to have been notified, and warnings for non-notification were given in these cases. The 665 births were notified as follows:— Notified by midwives 446 Notified by doctors and parents 201 "Un-notified" 18 665 23 Under Maternal Mortality I have reported on the need for skilled attention throughout pregnancy, but no less than 91 cases during 1933 were attended by an unskilled person under the direction of a doctor. The balance of 574 were attended by wholly qualified persons; the midwives attended confinements alone in 310 cases, i.e., 40 per cent, of all births. 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 21. (b) Number (i) employed by the Council (ii) directly subsidised by the Council iii) employed by Voluntary Associations 8 (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 310 (ii) as maternity nurses 264 (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 61 Administration of the Midwives Acts, 1902-1926. No. of midwives practising in Bromley at the end of 1932 19 No. of midwives giving notice of intention to practise during 1933 25 No. of midwives removed from the local register having left the district 4 No. of midwives practising in the area at the end of 1933 21 24 Notifications Received. Notices calling in Medical Aid 61 Mothers 51 Infants 10 Notices of Artificial Feeding — ,, ,, Stillbirths 2 „ ,, Deaths 1 ,, ,, Laying out a Dead Body — ,, ,, Source of Infection 7 Summary of Reasons for Sending for Medical Help. Ruptured perineum 19 Delayed labour 6 Breast condition 3 Varicose veins and leg swellings 1 Placenta, partially adherent 1 Abnormal presentation 1 Haemorrhage 5 Ante-natal examination 1 Rise of temperature (puerperal pyrexia) 7 Prolapse, Cord 2 Stillbirth 2 Other causes 3 Infants—Feeble, prematurity, etc. 6 Malformations 2 Cyanosis 0 hJ Total 61 Payment of Doctors called by Midwives, Section 14, Midwives Acts, 1918. No. of applications for fees 52 No. of cases where payment of fee lapsed on account of failure to claim within the prescribed period of two months 7 No. of cases where patient paid the doctor's fee direct 2 Total amount of claims paid £51 10s. 6d. No. of necessitous cases in which repayment of claim was waived, or partial repayment of claim accepted by the Committee 10 25 Inspection of Midwives. Inspections by the Inspector of Midwives. Dr. G. H. Stinson, Assistant Medical Officer of Health, who is the Inspector of Midwives under the Midwives Acts, reports for 1933 as follows:— In carrying out the inspections of midwives one cannot help feeling that one or two midwives tend to look upon the Inspector as a detective rather than as a friend. This makes the inspection sometimes an unpleasant duty instead of a pleasant one. I would like to remind the midwives that these inspections are meant to be a help and safeguard to themselves. It is an opportunity to see that the rules of the Central Midwives Board are correctly and satisfactorily kept, and that in the event of unforeseen occurrences the midwife is in the happy position of having recorded all details of the case thereby showing her knowledge of the importance of detail and leaving no room for criticism. In the near future I hope it may be compulsory that all midwives shall be fully trained nurses besides holding the Certificate of the Central Midwives Board. I think sometimes the non-general trained midwife tends to undertake too much; she does not always seek advice as soon as she might do, and this is where I think the fully trained nurse shows more foresight. The latter I think seeks advice on cases more often than the former, or perhaps it is that she is more able to differentiate earlier between cases needing medical advice and those which do not. It is well to remember that the more one knows the more one realises how comparatively little one knows. We have very good midwives in Bromley. Their's is good work well done. The ante-natal notes in one or two cases might be a little more detailed and accurate, and the post-natal and discharge notes should give more details. Negative notes or no notes at all, may mean to the midwife herself that everything is all right, but who shall not say that a midwife has forgotten one or two things. It is better to state in black and white all particulars to show that all details have been noted. 26 I think the midwives should make more use of the ante-natal clinics, and they certainly might often send along cases which are environmentally necessitous. They are so anxious to keep their cases that I think it possible they sometimes overlook the fact that it would be better and safer sometimes for the mother to be confined in hospital. I should like to appeal to all midwives to take a broad and generous view of things and co-operate more with the Health Department of Bromley, and when their own ten days' duty with each mother and child is completed I ask them in the best interests of all to introduce the mother and babe to the health visitor at the nearest welfare centre that we of the Health Department may be given an opportunity to carry on the good work already begun by the midwife and so help the mother in her endeavours to rear healthy bonny children and therefore help to a healthier Bromley in the future. Post-Certificate Course. A very instructive Course was held at Maidstone during October, 1933. Thirteen midwives applied to attend, but owing to reasons of professional duties, eight midwives only actually attended 16 sessions during the Course. The Local Supervising Authority financially assisted in the travelling expenses of those who attended. Maternity Hospital and Maternity Homes. The Maternity Hospital admitted 150 Bromley patients and 83 from other districts, making a total of 233. Under the Council's scheme 20 cases were referred to the Maternity Hospital and financially assisted. In addition 20 cases were referred through the Ante-Natal Clinic to other hospitals, and four cases entered maternity institutions through the instrumentality of the Health Department. Thus the Public Health Services were instrumental in arranging hospital treatment in 44 cases of confinement, which would otherwise have taken place in undesirable environmental conditions, or which were cases likely to be complicated by some medical or physical conditions. This must remain the true function of the 27 Maternity Hospital to accept only those cases who cannot with safety be confined at home because of medical reasons or environmental reasons. To encourage hospitalisation of the normal cases is to encourage sentiment at the expense of sound Public Health. There are seven institutions classified as Maternity Hospital and Homes within the Borough, which are registered by us under the Nursing Homes Registration Act, 1927, and, including the Maternity Hospital, make provision for 35 maternity beds, to which 289 maternity cases were admitted during 1933. Details of maternity and nursing homes registered by the Local Authority under the Nursing Homes Registration Act appear later in this Report under the Part IV. dealing with Summary of General Provision of Health Services in the Area. Puerperal Fever and Puerperal Pyrexia. Queen Charlotte's Maternity Hospital, Isolation Block, Ravenscourt Square, Hammersmith, accept cases coming under the above-mentioned heading by arrangement with the Local Authority. Patients are conveyed to the Hospital by the London Ambulance Service of the London County Council. Eight cases of puerperal pyrexia were notified; four were removed to hospital, three were nursed in their own homes and one in a nursing home, these latter four cases all being pyrexia of a minor character. In all cases of doubt, or where the cause of the pyrexia is not of a minor character, the consultant services of Mr. Bright Banister are called upon. Four of the above cases were of sepsis and were removed to hospital. Two of these patients died. Post-Natal. Home Visiting. Since the close of the year 1933 the staff of five whole-time health visitors has been supplemented by the addition of one part-time health visitor who devotes three 28 days per week to health visiting in the added areas. All the full-time health visitors give half of their time to the School Medical Service, and one health visitor continues to attend the Tuberculosis Dispensary on each Wednesday afternoon session. Table XII., in the appendix, gives details of the work of home visiting during 1933. The total number of visits made by the health visitors during 1933 amounted to 6.110 compared with 6.118 for 1932. The policy of not including " ineffectual " visits in the total number of visits has been repeated this year. These visits for 1933 numbered in all 1,171 and were made up of visits where no answer was received, the family was discovered to have moved or visits were not appreciated. They have little, if any, value from a public health point of view and consequently should not he tabulated as a contribution to health visiting work and the teaching of mothercraft. I pointed out in my annual report for 1932 that material improvement in the number of visits could not be looked for in 1933 because growing population, additional welfare centre and that constant housing developments creating additional areas to be traversed would exert a retarding influence on satisfics of home visitation. This view has been borne out by the figures which show a negligible decrease of eight between the total visits for 1932 and 1933. With the additional welfare centre in 1933 there has been an all round increase in the attendances and work at the welfare centres, and if the total number of visits at the end of 1934 remain at the same level the health visiting staff will have accomplished all that can be reasonably expected of them especially as development of the area shows no signs of cessation. Welfare Centres. The Corporation provides six welfare centres in the Borough, at which seven sessions are now held weekly, and one fortnightly. During the year under review, however, seven sessions were held weekly, and the 29 following extracts of figures relate to the work carried out during these sessions:— (a) The total number of attendances at all centres during 1933 14,595 (i) By children under 1 year of age 3,869 (ii) By children between the ages of 1 and 5 10,726 (b) The total number of children who attended at the centres for the first time during 1933 575 (i) Children under 1 year of age 367 (ii) Children between the ages of 1 and 5 208 (c) Total number of children who were in attendance at the centres at the end of 1933 1,473 (i) Children under 1 year 266 (ii) Children between the ages of 1 and 5 1,207 The work accomplished by these centres is set out in detail in the statistical table given in Appendix XIII. One cannot overpraise the work given by the Voluntary Workers at these centres; they bring into the State Ser vice that essential voluntary spirit that makes for success. Milk in Necessitous Cases. One hundred and seven individual cases were granted assisted milk supply. A total of 7,4G3 pints of milk, and in addition a small quantity of dried milk being distributed, at an approximate cost of £101. The following is an analysis of the families who received milk free during 1933:— No. of children in family 1 2 3 4 5 6 and over No. of applicants 36 21 15 12 13 10 Percentage of total applicants 34 20 14 11 12 9 30 Minor Ailment Treatment. The pre-school child has the benefit of the facilities of the School Medical Service, and thus the policy of early treatment tends to minimise gross defects in the school entrant. Tonsils and Adenoids. Seventeen 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. .1/ i nor AiIments. Thirty-five cases received treatment at the School Clinic for ailments such as skin disease and minor surgical injuries. Orthopaedic. Mr. H. J. Seddon, Orthopaedic 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. Dental Clinic. Ninety children under 5 years of age, and 35 expectant or nursing mothers, received treatment at the Dental Clinic. Ophthalmia Neonatorum. During 1933 no cases were notified under the Public Health (Ophthalmia Neonatorum) Regulations, 1926. Hospital treatment, under the Local Authority's scheme, is available for acute cases. Diarrhoea and Enteritis. Three deaths of children under two years of age were recorded during 1933. Fortunately this serious disease in infants was not prevalent in the Borough during the year. In 1932 the mortality rate per 1,000 babies horn 31 in Bromley was 1.6; for 1933 the rate is 5 compared with 7.1 for the whole of England and Wales. This increase in the death rate generally coincides with a dry and hot summer, but it is not likely owing to the greater knowledge of mothercraft possessed by mothers to-day that this cause of death in young infants will again become a prominent cause of death as in years gone by. Children and Young Persons Act, 1932. The above-mentioned Act came into operation on 1st January, 1933, and the administration of Part V. of the Act which deals with Infant Life Protection devolves on the Maternity and Child Welfare Authority. The Act has rendered proper supervision of the child boarded-out with a foster mother much more effective and beneficial to the child. The policy of one foster child per foster parent has been consistently pursued by this Local Authority when granting sanction under the provisions of the Act; exceptions only being granted in the case of blood relationship between children. This policy is regarded as a hardship by the foster-mother who moves into the area with several foster-children in her care. If the policy were more widely adopted it would undoubtedly tend in my view to give the foster-child the benefit of home life so essential in moulding the character. Settled home life for these children is often nullified through the child being boarded out for short intervals, passing from one foster-mother to another. This is a difficulty which I have discussed in my previous report and would appear to be remediable by rendering frequent removal less easy of accomplishment. Many of these cases of frequent removal, on investigation, either prove to be mere caprice on part of the parent or foster-mother, and in other cases financial difficulties between the parties are found to exist. The possibility of instituting a minimum charge graduated according to age with grants in necessity for the maintenance of boarded-out children might prove worthy of further investigation. The noarding-out of children into impecunious homes needs careful watching in the interests of the children. 32 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 at the end of the year 1933 40 (b) No. of children on the register 51 (c) No. of Infant Life Protection Visitors (These duties are carried out by the health visitors) 5 Several instances of failure to give the required notice of reception or removal were dealt with informally, as such cases proved on enquiry not to be flagrant contraventions. Cancellation of sanction to keep one boarded-out child in one case was imposed owing to the foster-mother permitting increase in the number of child inhabitants in her home and failure to obtain adequate medical treatment for the child under her care. Careful investigation into the home circumstances and character of prospective foster-mothers is producing goodwill and co-operation between the administering authority and the foster-parents, and thus the Act works smoothly and the supply of suitable foster-mothers is maintained. 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 V.) 1925 The Notification of Births Act . 1907 Th e Local Government and Other Officers' Superannuation Act, 1922 1927 Bye-Laws: Common Lodging Houses 1897 Nuisances (Bye-law 13 repealed 13/2/1912) 1897 33 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 Pule 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 1933 Hospitals. (1) Infectious Diseases Hospitals: West Kent Isolation Hospital 118 beds West Kent Smallpox Hospital 39 ,, (2) General Hospitals: Bromley (Kent) and District Hospital 50 ,, Phillips Memorial (Homeopathic) Hospital 18 ,, (3) Maternity Hospital: The Bromley and Chislehurst Maternity Hospital 19 ,, (In addition there are 2 labour wards and 1 isolation ward;. Maternity and Nursing Homes. There are ten maternity and nursing homes registered under the Nursing Homes Registration Act, 1927. The following are particulars of maternity and nursing homes registered by the Local Authority, and for the convenience of tabulation I have included details of the larger hospitals which are exempt from registration under the provisions of the Act:— 34 Address. Total No of Beds. Maternity Beds Patients received in 1933 Nursing Staff. Type of case taken. Maternity. Surgical Medical Total. Resident Qualifications. 77, Avondale Road 6 4 (No returns received). 4 3 1 1 Gen. Trainedand C.M.B. 1 Gen, Trained. 2 Asst. Nurses. Mixed 40, Bromley Common 10 5 26 50 18 3 3 — 1 Gen.TrainedandC.M.B. 1 Gen. Trained. 1 Maternity Trained. do. "Greta," Blytli Road 9 2 6 81 36 7 4 3 1 Gen. Trained and C.M.B. 6 Gen. Trained. do. 24, Elmfield Road 10 2 8 — 12 4 4 — 1 Gen. Trained and C.M.B. 1 Gen. Trained. 2 Asst. Nurses. do. 3, Elmstead Lane 8 1 2 41 16 4 4 — 3 Gen. Trained. l Asst. Nurse. do. "Frascati," Masons Hill 10 2 14 8 16 8 8 — 1 Gen. Trained and C.M.B. 4 Gen. Trained. 1 C.M.B. 2 Asst. Nurses. do. "The Cloisters," Sontliborough Road 6 — — — 14 3 3 — 3 Gen. Trained. Nursing 16, Sundridge Avenue 4 — — — 5 1 1 — 1 Male Mental Nurse. (Home under supervision of Resident Medical practitioner). do. 13, Tweedy Road 5 — — — 2 1 1 — 1 Gen. Trained. Fully trained Nurses engaged when necessary. do. Maternity Hospital, 118, Widmore Road 19 19 233 — — 7 7 — 2 Gen.Trainedand C.M.B. 2 C.M.B. 3 Asst. Nurses. Maternity Bromley (Kent) and District Hospital, Cromwell Avenue 50 — — 556 115 20 20 — 2 Gen.Trained and C.M.B. 5 Gen. Trained. 1 Gen. Trained and masseuse. General Hospital cases Phillips Memorial HospitaJ, — — — 94 83 6 6 — 12 Probationers. 2 Gen. Trained. 1 Gen. Trained and CM.B. 3l Asst. Nurse. do. 35 Institutional. (1) Tlie Rochester Diocesan Society for Befriending Women and (jirls 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 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, etc.), water, milk and foodstuffs are those provided by the Kent County Council at Maidstone. 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 36 and Child Welfare and School Medical sections of this report: 1. Minor ailment treatments. 2. Tonsil and Adenoid Clinic. 3. Eye Clinic. 4. Orthopaedic Clinic. 5. Ultra Violet Ray 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. 6. Hayes and Keston. Each centre is held weekly, with the exceptions of Bromley Common and Burnt Ash where two sessions are held each week, and at Hayes and Keston Centre a session is held once a fortnight. Full particulars of each centre appear under Part III., Maternity and Child Welfare, of this Report. The additional welfare centre session at Bromley Common came into operation as from 1st April, 1933, and has done much to lessen the congestion at this centre. When the auxiliary School Clinic is established at Bromley Common it is hoped that the long standing problem of a clinic within easy access for the ever increasing population of the southernmost portion of the Borough will be solved. The extension of the weighing room at the School Clinic, Station Road, remains to be dealt with in order to overcome the difficulties and overcrowding, which at the present time seriously impede the work of the Plaistow Welfare Centre. 37 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 1933:— Summary for the Year 1933. Cases on the Regiser, January, 1933 15 New cases during the year 536 Visits Paid. General Nursing 5223 Ante-Natal Visits 1481 Maternity and Midwifery 3546 Casual Visits 1083 Analysis of New Cases. Medical 185 Surgical 121 Maternity (with Doctor) 66 Midwifery 162 Abortions 2 Cases sent in by : Doctors 254 Visitors and Others 9 Found by Nurse 16 Applied 257 Result of Cases Nursed. Convalescent 467 Sent to Hospital, Infirmary or transferred 42 Died 16 Still on Register 26 Nursing Staff. (i) General Nurses 2 (ii) Midwives 3 38 Tuberculosis Dispensary. The Tuberculosis Dispensary is provided and maintained by the Kent County Council. The Tuberculosis Officer in charge of District No. 7, which includes Dispensaries at Bromley and Penge, is Dr. B. G. A. Edelston. The districts covered by these two dispensaries are Bromley, Beckenham, Penge, Anerley, parts of Sydenham and Upper Norwood, Orpington, 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 17 inspections were made, and in four instances nuisances from pollution were remedied after service of informal notices. The pollutions were not of a serious character. Drainage and Sewerage. The main drainage of Bromley links up with the undertaking of the West Kent Sewerage Board, whose 39 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 bouses have been erected during 1933 with cesspool drainage. As this Report is concerned with the year 1933, the subject of drainage and sewerage of the added areas will come under review at the appropriate time. 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. From perusal of a History of Bromley published in 1858 it is perhaps interesting to quote what is therein written about the Town's water supply at that time: " Springs flow in copious streams from the hillsides during good part of the year, one in particular, about half-a-mile south-west of the Church under the opposite hill, deserves especial notice, from its apparently unabated supply through the unusually dry summer of 1857; no town at the same altitude can boast of a more plentiful supply of good water." Probably this spring is the main source of the supply to the Board's deep chalk well in Shortlands Valley, and it is satisfactory to know, in these times of threatened shortage, that one of the town's main water supplies has apparently yielded an unabated flow for so many years. Scavenging. There is no important extension or improvement during 1933 to report of the methods of scavenging or refuse disposal within the Borough. 40 Rats and Mice Destruction Act, 1919. The following is a brief statement of the action taken by tbe Local Authority during National Rat Week in November, 1933:— The sewers were baited and special attention was paid to properties owned or occupied by the Corporation which were likely to give rise to rat infestation. A special circular letter was addressed to business premises in the areas which were peculiarly liable to infestation by rats by reason of the nature of the businesses carried on, and a copy of the Ministry of Agriculture and Fisheries' advisory leaflet supplied. The circular letter set forth the objects of Rat Week and the facilities offered by the Local Authority to aid occupiers in the extermination of rats. The co-operation of chemists was enlisted and certain firms made special window displays. The Health Department furnished them with posters, handbills and loaned stuffed rats for window display. The local press co-operated by publishing a special memorandum supplied to them by the Health Department. The memorandum called for concerted action between the Local Authority and the inhabitants and set forth the facilities offered by the Local Authority to aid in rat destruction. Attention was drawn to the statutory obligation of occupiers of land or buildings to take steps to disinfest their property and hints were given with regard to preventive and remedial measures which should be exercised in dealing with rat infestation. Posters were displayed in the Borough and handbills were provided by the Health Department for distribution by welfare centres, clinics, chemists, and by the Bromley Chamber of Commerce. Red Squill rat poison was on free issue on application to the Health Department. The gassing machine was available at cost of labour, and pamphlets issued by the Ministry of Agriculture and Fisheries were distributed to applicants. 41 A small exhibition of stuffed rats and specimen baits, arranged by the Sanitary Inspector, was on view in the Department and attracted considerable attention. As a result of the propaganda of Rat Week, 1933, in Bromley, much greater interest was taken by the general public in comparison with the results of previous years, although, having regard to the additional publicity given in 1933, the response was not as good as was anticipated. The chemists who co-operated were generally satisfied with the results attained and reported that sales were quite good and that there was a noticeable increase in interest in Rat Week. The following particulars relate to applications made to the Health Department for baits, etc.:— Total No. of applicants 88 (a) From trade premises 19 (b) From private residences 69 No. of bottles of red squill given free 103 No. of tins of red squill biscuits given free 12 No. of applications for use of gassing machine 4 (In two instances the gassing machine could not be used with effect on the premises concerned). It is noteworthy that only 16 applications for free poisons during Rat Week were received in the previous year, 1932. During 1933 the sanitary inspectors made 239 inspections with reference to rat infestations, and nuisances in this respect were reported abated in 52 instances after service of informal 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. 42 House-to-House Inspection. Two hundred and sixty-three houses were inspected under the inspection of District Regulations. In addition, 678 houses were also inspected, in the majority of which the inspections and defects found were scheduled in accordance with the Housing Acts. It was necessary to make 2975 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 indicate the total number of dwelling-houses made fit since the inception of the Housing Act, 1930, up to December, 1933:— 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 March Quarter, 1933 112 June Quarter, 1933 66 September Quarter, 1933 84 December Quarter, 1933 146 Since the inception of the Act to 31st December, 1933 1370 CONTRAVENTIONS. DRAINAGE. Public Health Act, 1925, Section 39. Offence. Action taken. Failure to give 24 hours written notice to the Local Authority of intention to re-construct drain (one house concerned) Warning given. 43 Failure to give 24 hours written notice to the Local Authority of intention to re-construct drain such drain having been covered over without notice (two houses concerned) Warning given. VI.—HOUSING CONDITIONS. There was a special drive during 1933 throughout the country to abolish slums, but I am happy to report that Bromley possesses no slums, the housing conditions have always maintained a high standard of repair and every tendency to overcrowd or to create an unhealthy environment being rapidly dealt with. The Local Authority has in fact built 524 houses for the working classes, which is equivalent to 4.3% of the total number of inhabited houses. When one considers that Bromley is purely a residential town and not industrial, this in my opinion should be adequate to meet the needs. Private enterprise has nowtaken the field and is building houses at a much lower rental than existed a few years ago, thus providing for the owner-occupier an environment which must lead to public health, provided such houses are built on lines of sound construction and will not call lor early structural repairs at such a cost as will effect a lower standard of living of the occupier. This, in my view, is a possible danger and one that can only be controlled by strict compliance with the Building Bye-laws. It is specially noticeable on new housing estates, council houses included, that no sooner are they occupied than all sorts of sheds are haphazardly erected in the back yards, not only detracting from the orderliness of the housing lay-out but giving a general appearance oi neglect and a harbourage for rats and other vermin. Housing Acts, 1925-1930. No less than 1045 houses were inspected by the sanitary inspectors, 952 of which were not in all respects reasonably lit for habitation ; 714 of these were remedied by informal action. 44 We were successful in closing 11 houses under Part II. of the 1930 Act. Four of these have since been demolished; the others are now uninhabited and are shortly to be demolished. A further four houses were so altered and improved as to fit them for habitation for two persons per house only. In all these instances the owners met us with goodwill and joint action between us led to the closing of the 11 houses without resort to complicated legal action. The displaced tenants were either re-housed on the Council's Housing Estate, or were successful in obtaining their own alternative accommodation. There remains in Bromley no house that can be classified as unfit for habitation at the present time ; certain houses at low rental are necessary to all towns, but provided they possess the amenities of modern living conditions, I see no reason why they should be demolished because they have been in existence over 100 years. An equally important work, with the demolition of unfit houses, is the maintenance in good repair of the existing houses, a work which is indicated by Appendix XV. and Appendix VIII. and is actively pressed by this Local Authority. Overcrowding. Seven bouses were visited on complaint of overcrowding, and in six cases conditions were remedied. When over-crowding 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 bouses occupied by two or more families. Prevalent Defects in Housing. Appendix VIII. indicates the prevalent defects found in bouses, 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 guttering and pipes. 45 It was not found necessary to take summary proceedings to enforce the abatement of nuisances. The cooperative action between owners, agents, tenants and the sanitary inspectors continues to get the necessary work carried out effectively in an amicable manner. Statutory Notices. Thirty-five notices were served under the Public Health Acts. One owner who had not completed the work satisfactorily at the expiration of the notices served, was sent a warning letter, which resulted in the work being executed without the necessity of taking proceedings in Court. Houses Let in Lodgings. When the larger type of residential house becomes empty it is often re-let to a number of families, usually by the occupier, and frequently it is found that no alterations are made to provide conveniences, such as, food storage, suitable cooking convenience, supply of water and clothes washing accommodation. The occupants soon realise the lack of these conveniences and seek better accommodation in the new housing estates. VII.—SMOKE POLLUTION. Twenty-seven routine visits and observations were made, and the inspectors were successful in getting three smoke nuisances abated as a result of informal action. In these three 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, three of whom hold the special certificate for smoke inspection of the Royal Sanitary Institute, is readily sought. 46 VIII.—SHOPS ACTS. Five hundred and fifty-nine visits were made under these Acts. Fifty-one 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. Contraventions. Nature of Offence. Type of Shop. Action taken. Assistant employed Wireless and Warning. on statutory half- Electrical dav closing. Appliances. IX.—PETROLEUM ACTS. Number of Licences issued 102 (i) For Petroleum Spirit 98 (ii) For Carbide of Calcium 4 Total quantity of Petroleum Spirit in gallons 170,789 (i) Bulk storage in gallons 156,745 (ii) Two-gallon can storage in gallons 14,044 Carbide of Calcium in lbs. ... 668 Of the 102 licences issued, 85 were renewals and 17 were new or additional licences. Included in the total of 102 licences are 23 licences for combined bulk and can storage. Two hundred and seven visits to storage places were made during 1933. The following figures show the increase in licenced storage which has taken place since 1926:— 47 year. Petroleum Spirit, (in gallons). Licences issue (Petrol only) 1926 66,915 77 1927 103,025 69 1928 159,335 82 1929 159,746 92 1930 166,308 81 1931 168,925 83 1932 176,090 93 1933 170,789 98 X.—FACTORIES AND WORKSHOPS. Statistical details with regard to inspections and defects found in factories, workshops and workplaces may be seen in Appendix XIV. The total number of factories, workshops, workplaces, and outworkers' premises on the registers is 445, and the following is a tabulation of the businesses carried on:— Bakehouses 31 Bootmakers 40 Dressmakers 27 Laundries 41 Motor and Cycle Engineers 59 Outworkers 18 Restaurants, Eating Houses, etc. 38 Tailors 34 Upholsterers 17 Sundry trades 140 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 in connection with this work 4,896 visits were made:— Bakehouses. Butchers' premises. Cinemas. Confectionery, Ice Cream, etc. Dairies, Cowsheds and Milkshops. Factories, Workshops, Workplaces, and Outworkers' premises, 48 Fish shops. Food Shops, various. Hotels, Restaurants, etc. Licensed premises (public houses). Nursing Homes. Offensive trade (Tallow melting). Petroleum Spirit Stores (licenced). Piggeries. Registry Offices. Shops, various. Slaughterhouses. Stables. Tents, Vans and Sheds. Contraventions. Registry Office. There was one contravention with reference to Rye-laws 7 and 9 regarding advertising without indicating the trade name. A warning was given in this instance which was of a minor character. Contraventions relating to meat, milk and other foods appear later in this report under their respective headings. XII.—INSPECTION AND SUPERVISION OF FOODSTUFFS. The sanitary inspectors continue to devote as much time as practicable to this important branch of the work of the Health Department. 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 ... 17 Dairies licenced for the sale of:— " Pasteurised " milk 9 " Certified " milk 4 " Grade A Pasteurised " milk 1 " Grade A (Tuberculin Tested) " milk 4 49 The Ministry of Health has granted a producer's licence to sell under the designation "Certified" milk to one farm within the Borough. Four supplementary licences have been granted for the sale of graded milks, viz., "Pasteurised," "Certified" and "Grade A (T.T.)" within the Borough from premises outside the district. Bacteriological Examinations. Sixty-two samples of milk were submitted for bacteriological examination and the results shown in the following table which also includes the results of samples taken on ten occasions at the request of the Ministry of Health from the producer holding licence for the production of " Certified " milk:— Samples. Totals, factory, factory. " Pasteurised " milk 10 9 1 " Certified " milk 10 10 Ordinary milk 42 21 21 62 40 22 Seventeen samples of milk were tested for the presence of tubercle bacilli and after inoculation tests the, results were negative. The following examples are given as indicating the nature of the above unsatisfactory samples:— (1) Ordinary milk sample. A very high count of bacteria 6,100,000 per 1 cc. and presence of Bacillus Coli. The centrifugalised deposit of the sample showed a moderate number of leucocytes with a minute trace of carbonaceous debris. In addition one or two large black particles also carbonaceous in character and an occasional fragment of vegetable nature. Tubercle Bacilli not detected. 50 (2) Ordinary milk sample. High count 330,000 per 1 cc. Centrifugalised deposit contained a marked excess of leucocytes, some squames and a trace of detritus. Films from cream and deposit showed a few long chains of streptococci probably of the Bovine Mastitis type hut Tubercle Bacilli not detected. (3) Ordinary milk sample. High count of 460,000 per 1 cc. Centrifugalised deposit contained slight excess of leucocytes, some squames and a trace of vegetable debris. Tubercle Bacilli not found. Contraventions. Cases of contraventions of the Milk and Dairies Order, 1926, were reported as follows:— Offence.. Action taken. (1) Removing discs for closing bottles of pasteurised milk and re-bottling the milk ... Warning given. (2) Carrying on trade of a dairyman without being registered Warning given. (3) Not taking practicable precautions for preventing the milk from being contaminated Warning given and —milk measure being used as dairy farm refused drinking vessel registration. (4) Filling bottles of milk on the highway Warning given. Meat. There are two licenced and six registered slaughterhouses in the Borough. Regular visits are made to these slaughterhouses, 6,219 animals were known to have been 51 slaughtered, and 6,195 were examined by the sanitary inspectors after slaughter. Therefore 99 per cent. 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 599 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 all concerned. Table A. Total number of animals known to have been slaughtered and carcases inspected. Total. Beasts. Calves. Sheep. Pigs. Animals known to have been killed 6219 122 539 1202 4356 Carcases Inspected 6195 122 534 1191 4348 Table B. Total number of slaughterings, carcases inspected, and found affected with various diseases. Total No. known to have been slaughtered. Total No. of animals inspected. Carcases affected with Tuberculosis. Carcases affected with other diseases. Total No. of carcases affected (all diseases). 6,219 6,195 124 (2.0 per cent) 322 (5.1 per cent) 446 52 Table C. Total number of carcases rejected for Tuberculosis and other defined diseases. Disease. | Bulls. Cows. Heifers. Bullocks Calves. Sheep. Pigs. Total Tuberculosis — 1 - - 1 - 8 10 Other defined diseases — — - - 3 — 7 10 Total — 1 - — 4 - 15 20 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 10 38 76 124 Other defined diseases 10 10 302 322 Total 20 48 378 446 Table E. Total weights of carcases, parts of carcases and offal rejected for all diseases. Tons. Cwts. Qrs. lbs. Total in lbs. Carcases — 19 3 4 2,216 Harts of carcases — 6 1 16 716 Offal — 12 2 20 1,420 Total 1 18 3 12 4,352 53 Contraventions. Carcase and Action parts of carcase. Disease. Premises. taken. Carcases of pork Generalised Shop Warning Tuberculosis Portion of sheep's liver Granulomata Ditto Ditto Pig's liver Cirrhosis Ditto Ditto Pig's lungs Pleurisy Ditto Ditto Other Food Condemned. Complaints made to the Department of food purchased which was considered by the buyer as unfit to eat. Type of Food. Condition found. Action taken. 1| lb. Cocoa Maggots — full Owing to a lapse of in cardboard grown larvae of 6 days from the date container. the Brown House of purchase and the Moth. date of complaint and the absence of any evidence that the remaining packets of same consignment contained maggots, no statutory action was taken. 6 lb. 3 oz. Decomposed. Owing to a lapse of boneless 5 days from date of ham. purchase and the date of complaint, no statutory action was taken. This ham was sold by a firm outside the Borough. Unsound and Unwholesome Food Surrendered. Article of Food. Weight. *Meat 1851 lbs. Poultry 13 ,, Fish 224 „ 54 Potatoes 728 „ Sausages 8 ,, Cooked meats 31 ,, Rabbits 12 ,, Tinned Goods. Quantity Vegetables 127 tins Fruit 1588 ,, Fish 139 ,, Milk 285 „ Meat 41 ,, Miscellaneous 55 ,, Approx. 1676 ,, *Leakage of sulphur dioxide from defective refrigerator plant. Food and Drugs (Adulteration) Act, 1928. The following tabulation gives particulars of the work of the Food and Drugs Inspector in Bromley during 1933:— New milk 75 Mustard 2 Sterilised milk 2 Mixed pickles 1 Apricots 1 Tapioca 1 Dem. Sugar 3 Raspberry jam 1 Coffee 6 Gin 1 Baking powder 1 Ammon. Tincture Cocoa 5 Quinine 1 Rice 5 Iodine 1 Margarine 4 Olive oil Custard powder 1 Corned beef 1 Brawn 1 Viota 1 Pepper 4 Fruit salad 2 Lard 5 G. Cinnamon 1 Butter 6 Semolina 1 Sausages 4 Flour 3 S. Whiskey 2 Cornflour 1 S.R. Flour 1 Cakeoma 1 Condensed milk 1 No. of samples 148 Genuine 147 Adulterated 1 Inferior Nil The adulterated sample was new milk. Tbe offender was prosecuted and convicted and fined £3 and £2 2s. Oncosts, 55 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. No. of movement licences received of animals moved into the Borough 178 Animals inspected: (1) Pigs 1,981 (2) Sheep 93 (3) Heifers 2 Xo. of licences issued by the Local Authority 32 Animals inspected: (1) Pigs 98 (2) Sheep, lambs 43 (3) Beasts 6 (4) Calves 12 Sheep Dipping: Certificates issued by the Local Authority 2 No. of sheep dipped 349 No. of inspections made in connection with the above details 196 No serious outbreak of Foot and Mouth Disease occurred during the year so as to affect the County of Kent. Tuberculosis Order, 1925. No action was needed under the above-mentioned Order. XIV.—RAG FLOCK ACTS, 1911-1928. Three rag flock samples were submitted for examination and all the samples complied with the standard in accordance with the above-mentioned Acts. 1 lie upholsterers" few in number, engaged in this business in the Borough, do not use rag flock to any great extent. 56 XV.—INFECTIOUS DISEASES CONTROL. Scarlet Fever. One hundred and fifty-five rases were notified during the year, equivalent to 3.2 per 1,000 population. Six were over the age of 18 years. The crest of the periodic wave of incidence was reached in 1931. The fall in yearly incidence since was continued with a slight rise in 1933, due to prevalence of scarlet fever in the surrounding areas. It is rather noteworthy that 59 per cent, of cases (92 in all) occurred in the Downham area where there is frequent intercommunication with friends in other areas where scarlet fever has been prevalent. This fact is experienced in practically all large and new housing estates. Of the 155 cases notified 85 per cent, were admitted to hospital and only 15 per cent, were home nursed. It is well established knowledge that the sending of patients to hospital does not control the incidence of scarlet fever, and that mild cases of the infection may safely be isolated at home. I have endeavoured to encourage this policy in past years, but in spite of this no less than 85 per cent, were admitted to hospital in 1933. The 155 cases occurred in 113 families; 23 families (65 patients in all) having more than one case per family. In 16 of these families the secondary cases arose within 10 days of the first case being sent to hospital. In seven families the second case arose within 20 days after the return of first patients from isolation (the average period of detention in hospital is 57.5 days) and these may be taken as return cases. The infectivity of a patient is not controllable by practical means and in spite of every possible care being taken before discharge of the patient from isolation, it is found that certain cases are period)caJly infectious to other persons even months after discharge from hospital. This raises the question as to whether hospital detention increases the infectivity of the causal organism, but on this authoritative opinion varies. It is of interest to note that in one of the 22 home nursed cases in 1933 a second 57 case arose within 10 days, and both were then removed to hospital owing to lack of nursing facilities. In another home nursed case a second case arose six months after freedom of isolation of the first case; it is possible a new infection arose in this case. All other home nursed cases had an uninterrupted recovery without secondary cases arising and with an average isolation period of 31 days. On the face of it it would appear that irrespective of the care taken against return cases occurring, whether hospital nursed or home nursed, the infectivity of the patient cannot be satisfactorily controlled. Routine swabbing of children for the presence of Hiemolytic Streptococci (Scarlet Fever strain) has further added to the complication of administration; the child being found to be negative or positive at irregular intervals over long periods. Nevertheless what knowledge we gain should be and is used so that precautionary action may be taken to prevent spread of infection. The mild missed case is the main cause of spread of infection through susceptible children. Schools are frequently blamed and the public demand their closure, but in my experience even if congregation of children in schools was the main cause of spread of infection, closure of the school would not have any appreciable effect on the spread of infection. Even now when contacts are excluded they are found in Sunday schools, cinemas and other places, or playing with the child on the streets after school hours. Parental control is not fully exercised in this direction and until it is so one must expect a certain number of needlessly infected school children. Diphtheria. Twenty-nine cases of diphtheria (0.6 per 1,000 population) were notified against 12 in 1932, and all but one case were admitted to Hospital. There were no deaths. There is still too great a tendency to depend upon bacteriological examination before admission of patients to hospital. In epidemic times this becomes a dangerous practice as it delays the administration of anti-toxin—the only method of cure. 58 The prevention of diphtheria lies in immunising susceptible persons and in creating a general improvement of the environment so as to operate against the spread of infection when it arises. The susceptible person we can discover by the Schick Test even with its occasional error. They can be immunised by the Schick routine with a reliability equal to 95 per cent. It is not claimed for this valuable method in the prevention of a dangerous disease that it is infallible, but we can certainly say that any method that can give 90 per cent, success is worthy of public support. During the past five years the incidence of diphtheria has been a low one. I am satisfied that the amount of immunising carried out in the past five years has not been the cause of this low incidence, but the low incidence has certainly kept the public in a sense of false security and in spite of propaganda the public has not responded to immunisation as they should have done. If one is to prevent diphtheria, immunisation must be on a large scale and must operate many months before any epidemic starts. It takes at least three months to create an immunity in a susceptible person. Diphtheria Immunisation, 1933. The following are the statistics of the Immunising Clinic held every Monday afternoon at the School Clinic:— Total not previously Schick Tested 30 Total Schick Tested 77 Found to be positive 59 Found to be negative 18 Total No. of persons who received full course of injections 107 Total No. of persons who were finally re-tested after following results 101 1st Re-test. 2nd Re-test. 3rd Re-test. 4th Re-test. Positive 5 2 1 Negative 96 3 1 1 It is the practice where Schick positive after the first re-test at three months after immunising to give a 4th injection and to re-test again after three months. 59 Vaccination. I am indebted to the Vaccination Officers for the following figures regarding vaccination during 1933:— Babies born in 1932. No. successfully vaccinated 279 No. unsuccessfully vaccinated 5 No. of Declarations of conscientious objectors 231 No. of Primary Vaccinations of Children under 14 years of age in 1933 293 No. of Statutory objections in 1933 262 Tuberculosis. Appendices IX. and X. give the incidence and particulars of tuberculosis in Bromley. The current Register shows:— Pulmonary tuberculosis: Males 112 Females 93 Non-Pulmonary tuberculosis: Males 52 Females 72 329 A total of 329 cases is equivalent to 6.8 per 1,000 of the population. A high figure of incidence, but happily many of the cases are not active cases, but are kept on the register for purposes of observation and visitation by the health visitors. The fact that Bromley has such a high incidence figure is explained by the fact that the new housing estates have attracted certain number of cases from other areas. Forty-nine pulmonary cases aud 12 non-pulmonary cases were notified to me during the year. There were 31 deaths from pulmonary tuberculosis and six deaths from non-pulmonary. 60 The efficiency of notification in Bromley is well maintained and only four cases died as un-notified cases. The following table indicates the condition of tuberculosis as it lias affected Bromley since 1925:— New cases Incidence per 1,000 population. Death Rate. Year. Pulm. Non-Pulin. Pulm. Non-Pulm. 1925 1.07 0.4 0.5 0.16 1926 1.4 0.4 0.6 0.05 1927 1.3 0.6 0.5 0.2 1928 1.3 0.7 0.7 0.1 1929 1.1 0.3 0.6 0.04 1930 1.1 0.4 0.8 0.1 1931 1.1 0.3 0.6 0.06 1932 1.2 0.3 0.5 0.19 1933 1.01 0.25 0.6 0.12 To tuberculosis patients the health visitors paid 302 special visits, instructing- the patient or parent in the care of a tuberculosis infection and the maintenance of fitness of the contacts. It is in this latter that the real crux of prevention of tuberculosis arises, while good and adequate food (free of tubercular infection), good house conditions and avoidance of physical and mental overstrain all play their part in prevention. There are no occupations in Bromley specially causing susceptibility to tuberculosis infection and I am satisfied that recent unemployment has not affected the resistance of the individual so far as Bromley is concerned. The Tuberculosis Officer reports 011 the work of the Dispensary as follows :— New Cases who have Attended the Dispensary for the First Time for Examination During 1933. Adults. Children. Male. Female. Male. Female. Pulmonary 18 9 1 — Non-Pulmonary — — 1 — Negative 5 8 3 6 Totals 23 17 5 6 61 No. of contacts examined duriug 1933 15 No. found to be positive (These figures are not included in the above table) 1 Total No. of attendances at the Dispensary during 1933 828 No. of patients receiving residential treatment during 1933 79 Tuberculosis After-Care Committee. This Committee has not been very active during 1933 only five cases being referred for their assistance. The cases referred were as follows:— (1) Light work was required in three cases. (2) Assistance needed for provision of clothes aud work in one case. (3) One case required extra milk aud nourishment. appendix. 64 LIST OF APPENDICES. I. Summary of Statistics, 1933. II. Comparison of Statistics, 1933. III. Causes of Deaths, 1933. IV. Causes of Infant Deaths, 1933—Age Groups. V. Analysis of Infant Deaths, 1929—1933. VI. Analysis of Infant Deaths and Maternal Deaths, 1910—1914, 1921—1925, 1926—1930, and 1931— 1933. VII. Summary of Work of Sanitary Inspectors, 1933. VIII. Summary of Nuisances Abated, 1933. IX. Beturn of Notifiable Infectious Diseases, 1933, in Wards, giving attack rates and death rates, etc. X. Beturn in Age Groups of new cases of Tuberculosis notified, and of deaths occurring in 1933. XI. Beturn of Ophthalmia Neonatorum, 1933. XII. Summary of Health Visitors' Work, 1933. XIII. Summary of Attendances at Welfare Centres, 1933. XIV. Factories, Workshops and Workplaces, Inspections, 1933. XV. Housing Statistics, 1933. 65 APPENDIX I. SUMMARY OF STATISTICS, 1933. Population (mid-year 1933) 48,270 Birth Rate 12.3 Death Rate 10.1 Infantile Mortality Rate 41.8 Number of Births (live) 598 Number of Stillbirths 17 Number of Deaths 489 Number of Infant Deaths (under 1 year) 25 Death Kate of Respiratory Diseases 0.9 ,, ,, ,, Tuberculosis 0.7 „ „ „ Cancer 1.4 ,, ,, ,, Zymotic Diseases 0.10 Notification of Scarlet Fever 155 ,, ,, Diphtheria 29 ,, ,, Pneumonia 27 ,, ,, Tuberculosis 61 Number of Deaths from Measles — „ ,, ,, ,, Scarlet Fever — „ ,, ,, ,, Diarrhoea (under 2 years) 3 „ „ ,, ,, Child Birth 4 Number of visits by Sanitary Inspectors 9,850 ,, ,, ,, ,, Health Visitors 6,110 „ ,, Babies on the Registers at the Ceutres, end December, 1933 1,473 APPENDIX II. BIRTH RATE, DEATH RATE, AND ANALYSIS OF MORTALITY during die Year, 1933. Rate per 1,000 Total Population Annual Death Rate per 1,000 Population. Rate per 1,000 Live Births. All causes. Enteric Fever. Small-Pox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under Two Years). Total Deaths under One Year. Live Births Still Births England and Wales 14.4 0.62 12.3 0 01 0.00 0.05 0.02 0 05 0 06 0.57 0.54 7.1 64 118 County Boroughs and Great Towns, including London 14.4 0.67 12.2 0.00 0.00 0 06 0.02 0.06 0.08 0.55 0.49 9.4 67 132 Smaller Towns (Populations, 25,000-50,000 at census 1931) 14.5 0.63 11.0 0.00 0.00 0.04 0.02 0.04 004 0.53 0.44 4.9 56 London 13.2 0.45 12.2 0.00 0.00 0.02 0.02 0 08 0.08 0.51 0.58 11.6 59 BROMLEY 12.3 0.35 10.1 0.00 0.00 0.00 0.00 0.02 0.02 0.33 0.53 5.0 41 66 The maternal mortality rates for England and Wales are as follows : Puerperal Sepsis. Others. Total, per 1000 Live Births 1.79 2.63 4.42 ,, „ Total Births 1.71 2 52 4.23 BROMLEY „ ,, (live and still) 3.2 3.2 6.5 67 APPENDIX III. Causes of Death, 1933. Male. Female. Total. 1. Typhoid and Paratyphoid Fevers — — — 2. Measles — — — 3. Scarlet Fever — — — 4. Whooping Cough 1 — 1 5. Diphtheria — 1 1 6. Influenza 8 8 16 7. Encephalitis Lethargica — — — 8. Cerebro-Spinal Fever — — — 9. Tuberculosis of respiratory system 20 11 31 10. Other Tuberculosis Diseases 3 3 6 11. Syphilis — 1 1 12. General paralysis of the insane, Tabes Dorsalis - - - 13. Cancer, malignant disease 37 33 70 14. Diabetes 2 3 5 15. Cerebral Haemorrhage, etc. 10 10 20 16. Heart Disease 70 86 156 17. Aneurysm 1 1 2 18. Other Circulatory Diseases 5 8 13 19. Bronchitis 1 3 4 20. Pneumonia (all forms) 16 13 29 21. Other Respiratory Diseases 2 9 11 22 Peptic Ulcer 7 - 7 23. Diarrhoea, etc. (under 2 years) 1 2 3 24. Appendicitis 1 1 2 25. Cirrhosis of Liver 3 1 4 26. Other Diseases of Liver, etc. — 3 3 27. Other Digestive Diseases 2 7 9 28. Acute and Chronic Nephritis 4 4 8 29. Puerperal Sepsis — 2 2 30. Other Puerperal Causes — 2 2 31. Congenital Debility, Premature Birth, Malformations, etc. 9 4 13 32. Senility 5 8 13 33. Suicide 6 2 8 34. Other Violence 13 5 18 35. Other defined diseases 17 14 31 36. Causes ill-defined or unknown — — — Totals 244 245 489 APPENDIX IV. Infant Mortality, 1933. CAUSES OF DEATHS. Under 1 week. 1 and under 2 weeks. 2 and under 3 weeks. 3 and under 4 weeks. Total under 4 weeks. 1 month and under 3 months. 3 months and under 6 months. 6monthsand under 9 months. 9 months and under 12 months. Total deaths under 1 year Measles ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... 1 1 Tuberculosis ... ... ... ... ... ... ... 1 ... 1 Convulsions ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... 1 ... ... 1 Pneumonia 1 ... ... ... 1 ... 1 1 ... 5 Diarrhœa ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... ... ... ... ... Gastritis ... ... ... ... ... ... ... ... ... ... Suffocation ... ... ... ... ... ... ... ... ... ... Injury at Birth 1 ... ... ... 1 ... ... ... ... 1 Atelectasis 2 ... ... ... 2 ... ... ... ... 2 Malformation 1 ... ... ... 1 ... ... 1 ... 2 Piemature Birth 5 ... ... ... 5 ... ... ... ... 5 Marasmus, etc. 2 ... ... ... 2 1 ... ... 1 4 Other Causes ... ... ... ... ... ... 1 ... 2 3 Syphilis ... ... ... ... ... ... ... ... ... ... Congenital Heait Disease ... ... ... ... ... ... ... ... ... ... Totals 12 ... ... ... 12 3 3 3 4 25 68 69 APPENDIX V. Analysis of Causes of Infant Deaths, 1929-1933. 1929 1930 1931 1932 1933 Total No. of Births 623 629 617 605 598 Infantile Mortality Kale 46 41 47 33 41 Premature Birth 3 7 3 4 5 22 Respiratory Diseases 11 3 5 5 6 30 Marasmus and General Debility 3 4 3 1 4 15 Infectious Disease 1 ... 1 ... 1 3 Gastro Enteritis 2 3 4 1 ... 10 Convulsions — 2 1 ... ... 3 Other Causes 9 7 10 9 9 44 Totals 29 26 27 20 25 127 This table shows that Premature Births and Congenital Debility caused 29 per cent, of the total infant deaths during the past five years, and should be taken as an indication of the great need for AnteNatal supervision. APPENDIX VI. Summary of Infant Mortality Statistics. Three five-year period figures are taken—five years pre-war, five years to 1925, five years to 1930, and 1931-1933. Years Total Births Infant Mortality Rate Total Infant Deaths Age at Death. Maternal Deaths. Deaths under 1 week Deaths 1 week to 4 weeks Deaths 4 weeks to 1 year Sepsis Other 1910—1914 3186 68 220 61 41 118 3 6 1921 624 60 38 10 9 19 1 1 1922 575 74 43 19 7 17 2 2 1923 578 60 35 13 3 19 1 — 1924 535 58 31 11 4 16 1 2 1925 520 58 30 11 3 16 1 2 1921—1925 2832 62 177 64 26 87 6 7 1926 536 35 18 11 — 7 1 - 1927 574 50 29 12 2 15 — 1 1928 652 49 32 11 4 17 1 3 1929 623 46 29 6 4 19 1 1 1930 629 41 26 11 4 11 1 1 1926—1930 3014 44 134 51 14 69 4 6 1931 617 47 29* 10 4 13 1 3 1932 605 33 20 9 1 10 1 1 1933 598 41 25 12 - 13 2 2 70 •(R.G.'s return 2Q, 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 4 weeks of age. 2—Increase in the deaths of infants under 1 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 l.OOO births. Rate 1931-1933, 5.5 per 1,000 births (live). 71 APPENDIX VII. Summary of Work of Sanitary Inspectors, 1933. Re- Inspec- Inspections. tions. Housing— Under Inspection of District Regulations 263 1482 On Complaint (ordinary) 469 1534 Re Overcrowding 7 14 „ Dirty Conditions 4 — „ Water Supply 2 — ,, Infectious Diseases 225 5 Disinfection Purposes 78 8 Disinfestation Purposes 11 4 Trade Premises— Factories 16 8 Workshops 40 12 Outworkers' Premises 6 — Under the Shops' Acts 555 4 „ ,, Petroleum Acts 267 62 Registry Offices 9 — Rag flock Acts (sampling) 8 — Offensive Trades 14 9 Diseases of Animals Acts 196 — Poisons and Pharmacy 14 — Food Preparing Places— Dairies and Cowsheds 112 35 Bakehouses:— Factory 70 17 Workshop 10 2 Slaughterhouses 592 — Hotels, Restaurants, etc. 25 — Confectionery, Ice Cream, etc. 34 1 Greengrocery Shops 105 — Butchers' Shops 1656 1 Fish Shops 277 — Fried Fish Shops 19 — 72 Retail Market 74 Grocery Shops 235 3 Food Hawkers 121 Under Meat Regulations 8 Milk Sampling 82 Milk examined on the highway 60 — M iscellaneous— Tents, Vans and Sheds 4 4 Streams 15 2 Nuisances from keeping animals 5 2 Piggeries 17 Smoke 25 2 Drain Tests— (a) Smoke 38 (b) Water 61 (c) Colour — (d) Chemical 4 (e) Mirrored 2 — 105 - Urinals 34 19 Accumulations 74 15 Rats and Mice Destruction Act 151 88 Special Visits 362 13 Smallpox contact visits (contacts seen 8) 8 — Rag and Bone Dealers 3 Food Poisoning 3 Schools 3 1 Stables 19 — Water Sampling 11 Totals 6503 3347 In addition there were 1,943 interviews with owners, agents, etc., many of which were at properties under notice. 73 APPENDIX VIII. Nuisances Abated, 1933. HOUSING: Drainage— Inspection chambers provided 26 Drains relaid or repaired 77 Drains unstopped 68 W.C.'s renewed or repaired 32 W.C. pans cleansed 40 W.C. box seats removed 156 Separate W.C.'s provided 7 New W.C.'s constructed 1 W.C.'s disconnected from food preparing places 3 Soil pipes, vent pipes, renewed or repaired 21 Sinks renewed 75 Sink or bath waste pipes renewed or repaired 205 Dampness— Hoof, rain water pipes, guttering renewed, etc. 411 Damp courses:— Vertical 111 Horizontal 44 Solution 16 Repaired or renewed 7 Brickwork repaired or renewed 38 Dry areas constructed 2 Pointing repaired or renewed 213 Sub-floor ventilation supplied or improved 5 Weatherboard walls renewed or repaired 5 General— Rooms cleansed 845 Floors renewed or repaired 110 Windows ,, ,, ,, 402 Doors „ „ ,, 41 Stoves ,, ,, ,, 123 Plastering „ ,, „ 323 Handrails ,, ,, ,, (or provided) 27 Yard Paving,, ,, ,, ,, ,, 77 Coppers „ „ „ 60 New dustbins provided 136 74 Overcrowding abated 6 Disinfestations 15 Ventilated food stores provided 32 Food stores ventilated 20 Defective chimneys repaired 45 ,, brickwork repaired 40 Eight and Ventilation of rooms improved 18 Dirty conditions improved 10 Houses closed for human habitation 11 Water Supply— Drinking water service supplied direct from main 31 Fittings renewed or repaired 11 Flushing cisterns renewed or repaired 49 Water supply re-instated 3 Miscellaneous Items 232 TRADE PREMISES: Factories and Workshops— Want of cleanliness 7 Want of ventilation 4 Overcrowding 4 Want of drainage to floors 1 Other nuisances 12 Sanitary accommodation— Insufficient 2 Unsuitable or defective 6 Not separate for sexes — Shops Acts—contraventions 51 Petroleum Acts—contraventions Registry offices— ,, 1 FOOD PREPARING PLACES: Yards, floors repaired, etc., cleansing, limewashing, light, and ventilation improved; refuse bins provided, sanitary conditions improved, etc. Dairies and cowsheds Slaughterhouses 1 75 Greengrocery shops 11 Hotels, restaurants, etc 10 Bakehouses 39 Grocers' shops 19 Butchers' shops 18 Ice Cream premises 1 Fried fish shops 7 Fisli shops 1 Retail market 1 MISCELLANEOUS: Stream nuisances 4 Urinals cleansed 8 Animal nuisances 4 Accumulations removed 52 Manure receptacles provided 6 Manure removed 5 Smoke nuisances 3 Rat nuisances 52 Stables—sanitary conditions improved 1 Food poisoning 3 Total 4577 NOTICES ISSUED: Preliminary— (i) Housing 938 (ii) Others 64 Total 1002 Statutory— (i) Housing 35 (ii) Others — Total 35 76 APPENDIX IX. Return of Notifiable Infectious Diseases, 1933. WARDS. Cases removed to Hospital. Attack Rate per 1,000 population. No. of Deaths. Death Rate. NOTIFIABLE INFECTIOUS DISEASE, 1933. Age Groups. Bickley. Bromley Common. Disease Total 0-1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-65 65 St over 12 14 133 3.2 — — Scarlet Fever ... 155 — 3 3 8 15 82 35 3 4 2 — — 2 13 28 06 — — Diphtheria 29 — — 1 2 4 7 6 3 3 ' 2 1 — 3 5 10 0.5 27* 0.5 Pneumonia 27 — — — 1 — 3 2 1 1 7 6 6 2 2 4 0.16 2 0.04 Puerperal Pyrexia 8 — — — — 8 — — — 2 1 1 2 0.22 0.10 — Erysipelas 11 — — — 1 — — — — 1 5 3 ?. 1 0.04 — — Typhoid Fever 5 _ — — — 1 2 2 — — — 7 8 14 — 1.01 31 0.64 Acute Poliomyelitis 2 — — — 2 — — — — — — — — — 2 4 — 0 25 6 0.12 Totals... 237 — 3 4 14 19 92 44 10 18 12 12 9 8 31 56 178 6 08 66 1.36 elude only acute primary pneumonia 3nia. 76 APPENDIX IX. Return of Notifiable Infectious Diseases, 1933. Disease. Total. M F. WAKDS. 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 155 89 66 104 6 12 7 12 14 133 3.2 — — Diphtheria 29 8 21 7 2 5 — 2 13 28 06 — — Pneumonia 27 18 9 8 2 8 1 3 5 10 0.5 27* 0.5 Puerperal Pyrexia 8 — 8 — — 3 1 2 2 4 0.16 2 0.04 Erysipelas 11 3 8 4 1 1 2 2 1 2 0.22 — — Typhoid Fever 5 3 2 2 1 1 — — 1 — 0.10 — — Acute Poliomyelitis 2 2 — — — — — — 2 1 0.04 — — Tuberculosis—Lungs 49 28 21 7 3 10 7 8 14 — 1.01 31 0.64 Tuberculosis—Other Forms 12 5 7 5 — 1 — 2 4 — 0 25 6 0.12 Totals 298 156 142 137 15 41 18 31 56 178 6 08 66 1.36 •Includes Pneumonia (all forms), whereas notifiable types include only acute primary pneumonia and acute influenzal pneumonia. 77 APPENDIX X. Tuberculosis. New Cases and Mortality during the Year, 1933. Age Periods. New cases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. Under 1 ... ... ... 1 ... ... ... 1 1— 5 1 ... 2 ... 1 ... ... ... 5—10 ... ... 1 3 ... ... 1 ... 10—15 ... ... 1 2 ... 1 1 ... 15—20 ... 6 ... ... ... 1 1 ... 20—25 8 3 1 ... 3 2 ... ... 25—35 9 6 ... ... 4 4 ... 1 35—45 5 2 ... ... 3 1 ... ... 45—55 4 1 ... 1 6 1 ... ... 55—65 1 3 ... ... 3 ... 1 65 and over ... ... ... ... ... 1 ... ... Totals 28 21 5 7 20 11 3 3 APPENDIX XI. Ophthalmia Neonatorum, 1933. Cases. Vision unimpaired. Vision impaired. " Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. ... ... ... ... ... ... ... 78 APPENDIX XII. Summary of Health Visitors' Work, 1933. Areas. Total. Under one year. Revisits over one year. Expectant Mothers School Children. Baby Deaths. Stillbirths Tuberculosis Special Visits. M'wives Acts enquiries Boarded out Children. Ineffectual Visits. Primary Revisits Area No. 1 1356 97 152 440 51 346 4 1 50 211 4 31 170 Area No. 2 1223 80 236 524 32 252 1 54 41 3 6 241 Area No. 3 1327 119 257 615 28 145 6 4 75 73 5 51 214 Area No. 4 2204 199 367 1119 49 259 6 3 123 60 19 63 546 Totals 6110 495 1012 2698 160 1002 17 8 302 385 31 151* 1171J * Also included in routine visits under the various headings. t " Ineffectual " visits are those where no answer is received, discovered removed from district, or where visits are resented, and are not included in the total number of visits. TUBERCULOSIS DISPENSARY WORK. Patients on the Dispensary Roll at end of December, 1933 108 Health Visitor's attendances 47 Total No. of special visits to Patients 170 79 APPENDIX XIII. Welfare Centres, Attendances, 1933. CENTRE. No. of Babies on Rolls at the end o( the Year, 1933. Total Attendances.' No. of Sessions held. Medical Consultations. Total No. of Weighings. Babies. Mothers. Total Examined. No. of Sessions held. PLAISTOW 278 2726 2346 50 370 32 2367 WIDMORE 176 1575 1485 47 200 27 1335 SHORTLANDS 221 2148 1936 51 220 31 1419 BURNT ASH 365 3395 2711 93 463 48 2191 BROMLEY COMMON 433 4751 3948 84 505 53 4069 Totals 1473 14595 12426 325 1758 191 11381 Dental Clinic. Discharged treatment. Children. Mothers. 90 35 Ante-Natal Clinics. Total Attendances. Medical Consultations. Sessions held. 200 200 31 80 APPENDIX XIV. Factories, Workshops and Workplaces, 1933. 1.—I nspections. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. Factories 111 19 ... Workshops 87 15 ... Workplaces (other than outworkers' premises) 50 16 ... Total 248 50 ... II.—Defects. Particulars. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Ac/s*— Want of Cleanliness 43 39 ... Want of ventilation 5 5 ... Overcrowding 4 4 ... Want of drainage to floors 1 1 ... Other nuisances 32 28 ... Sanitary accommodation. insufficient 2 2 ... • unsuitable or defective 10 6 ... not separate for sexes 1 1 ... Total 98 86 ... •Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. 81 APPENDIX XV. Housing Statistics for the Year 1933. Number of new houses erected during the year:— Total 485 (i) By the Local Authority — (ii) By other Local Authorities — (iii) By other bodies or persons 485 Total number of' inhabited houses at 31st December, 1933 12170 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) ... 1045 (b) Number of inspections made for the purpose 4020 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 263 (b) Number of inspections made for the purpose 1745 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for humail habitation 11* (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 941 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 716 *Demolished under Housing Act, 1930, without resorting to formal action. 82 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 — (Repairs were effected to four houses without Statutory action..) (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 35 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 35 (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. *See note above (section 1 9ub-section (3). BOROUGH OF BROMLEY ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR 1933 84 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1933-1934. Alderman F. W. Isard (Chairman of the Education Committee). D. Copping, Esq. A. Cowdry, Esq. Councillor F. S. Darby. Councillor E. C. De'Ath. Mrs. M. D. Fry. His Worship the Mayor. (Councillor W. D. Gibbs, j.p.). Rev. Hugh Glaisyer, m.a. C. J. Gully, Esq., j.p. Councillor C. H. Gunton. Rev. J. T. Gurney. Councillor W. J. Guthrie, j.p. Councillor T. H. Jayes. Mrs. A. G. Mann, b.a., j.p. (Chairman of the School Medical Subcommittee). Councillor J. Crosland Mallam, m.a. Councillor A. McIntosh, d.c.m. Mrs. E. J. Munn. Councillor G. L. Pyrke. Rev. Prebendary B. F. Relton, m.a. Councillor M. Stafford Smith, m.b.e., b.a. Alderman W. F. Skilton. G. Weeks, Esq. Rev. 0. G. Whitfield, m.a. 85 Introduction. The School Medical Service forms an integrant part of the educational system, and also a no less important one of the Public Health Services. It is for these reasons that the closest possible co-operation must be maintained in all services and local government directed to this end. Any public health government which tends to separate the administration of the environment from the administration affecting the individual must lead to faulty and expensive government. On these broad principles the Public Health Services in Bromley are administered. The year 1933 called for continued economy in social services, necessary because of national economic circumstances. Unfortunately, for Bromley, this curtailment of expenditure co-incided with a rapidly increasing school population and an increasing demand on the services provided through the Health Department. Since 1926 the elementary School population has increased by 48 per cent, and it has been increasingly difficult, without increase in staff, to meet the requirements of a fully functioning school medical service. One can now say definitely of the school medical services that they have passed the experimental stages. They are not extravagant in ideas, although it will be readily admitted that medical services because of their very nature are apt to be experimental unless a strict watch is kept on fundamentals. I have endeavoured to avoid all experimental services; thus we have no special clinic for the so-called difficult " child; such children, referred to us by head teachers, parents and others, are dealt with through the ordinary medical clinics and treated on the principles of commonsense management without delving into the psycho-analytical spheres, a practice, which in my liumble view, is rather over-stressed in medical practice to-day. Is the establishment of child guidance clinics necessary in order to deal with the "difficult child"? I doubt it. The decentralisation of efforts to promote 86 public health is not to be encouraged; the further we depart from the close contact between the public health services and the parent the greater will be the danger of misdirection of our efforts. I am convinced that the " difficult " child should not be " specialised," but that we should continue to treat the minor physical impairment, to follow-up and correct the environment, and to abolish all harmful stimuli. This has been the policy of the School Medical Service in the past without exercising intense psychological investigation and 011 this basis we get equally good results without increasing the expenditure of the local authority; it is not for us especially during times of economic pressure to undertake any service other than of approved value. Our policy must be to limit the service to essentials, to maintain close touch with the parent and teachers, and to inculcate in the homes and clinics the principles of prevention of ill-health. A statistical summary of the year's work will indicate, in so far ;is statistics are able to do so, the work of the School Medical Service during 1933:— Average school roll 5,519 Number of individual children who attended medical clinics 1,817 Number of individual children medically examined at schools 1,453 Medical examinations made 7,07(5 Treatments at the School Clinic 3,950 ,, ,, ,, Dental Clinic 3,992 ,, ,, ,, Eye Clinic 320 Operations for Tonsils and Adenoids 129 Attendances at the Orthopaedic Clinic 2,687 Treatments at Massage Clinic 2,229 ,, ,, Sunlight Clinic 1,477 Children referred for own doctors' certificates 731 Children receiving milk in schools daily 698 Children referred to the Care Committee 306 87 1 would take this opportunity of expressing to the Committee my personal appreciation of the interest they have taken, and of the help they have given me, in promoting the School Medical Service. I would also like to bring to the notice of the Committee the invaluable help I have obtained from each member of my staff, from head teachers, voluntary workers, and from all the staff employed by the Education Committee. Hygiene of Schools. The following list of improvements have been carried out during 1933. The establishment of the Princes Plain Schools, with its modern equipment, has added greatly to the standard of the schools in Bromley, but we still possess some old church schools with equipment far below the modern conception of school hygiene. Plaistow St. Mart's C.E. School.—Electric light system installed. Raglan Road Council Boys' School.—New range of wash hand basins provided. Bromley Central School.—Vertical jet drinking fountain provided. Valley Council Girls' and Junior Mixed School. Electric light system installed in Girls' School. Prince's Plain Senior Girls' Council School.— Opened 4th September, 1933. Special features: Playing field; Homecraft; Cookery and Laundry rooms; gas, electric and coal cookers; modern equipment throughout; drying racks and storage accommodation for scholars' shoes, and mid-dav meals facilities for scholars. Plaistow Lane E.C. School.—Previously known as St. Joseph's R.C. School. Increased in size, furnished with modern equipment by Managers and taken within the Committee's administration from 24th April, 1933. 88 Medical Inspection. Medical inspections of school children are carried out at the schools and at the School Clinic. Tables I. and II. in the Appendix give details of these inspections. Of the 1,453 children examined at routine medical inspections, 23.7 per cent, showed evidence of defects requiring treatment. Details of the defects are shown in Table II. The 1,817 individual children who attended the medical clinic were found to have 3,802 scheduled defects (see Table Ila.). Treatment. Children found with defects are referred for treatment to the various clinics, hospitals or their own doctors. The education Committee provides treatment clinics for eyes, ear, nose and throat, orthopaedic, sunlight and minor ailments. All cases requiring domiciliary treatment are referred to their own doctor. Treatment in convalescent home, extra nourishment and assistance to the necessitous patient is given by the Bromley Children's Care Committee, w hose annual report is included later in this report. The Care Committee also provide voluntary workers at the various clinics who give invaluable help in the smooth working of the service. Diseases of the Ear, Nose and Throat Clinic. Four per cent, of the children examined at routine medical inspection had complicated enlarged tonsils ant! adenoids, and were referred to the Specialist for direction on treatment. An additional 4 per cent, were kept under special observation. Eighteen per cent, of those children attending medical clinic were referred to the Specialist, and a further 17 per cent, kept under observation. A summary of these figures show that 24 per cent, of all children examined at school, or at the Clinic, had enlarged tonsils and adenoids. Less than one-third of these (29 per cent.) were recommended and received operative treatment either through the Clinic (129 cases), or through their own doctor (52 cases). The balance (71 per cent.) are being kept under periodic inspection. It 89 will thus be seen tliat operative procedure is controlled and not undertaken without due and careful consideration. The Specialist, Mr. Charles Benev, reports as follows: "Once more I have been asked to write a report of "the work of the Ear, Nose and Throat Clinic during the "past year. I am glad to say that the work has "continued without any serious complications arising. "Forty clinics were held. There were 201 consulta"tions with the Medical Officer of Health. One hundred "and twenty-nine operations for tonsils and adenoids "were performed, and 45 cases were referred to their "general practitioners for operation, or taken into my "beds at St. John's Hospital, Lewisham; of these latter "there were five cases of mastoid disease, six cases of "sinus trouble and the remainder dissection of tonsils "where some complication was present. Fifty-six cases "received other forms of treatment. "Once more I have to thank the permanent and lay "staff for their loyal co-operation." Chari-es Beney, m.a., m.b., b.ch., m.r.c.s. In recent years the surgical removal of tonsils has been widely discussed both by the profession and by the lay press. The result of this publicity has been an increased reluctance on the part of parents to give consent to operative procedure, thus adding to the difficulties in the prevention of further ill-health of the child. It is right that public opinion should exercise a controlling influence over any over-enthusiastic surgeon or school medical officer, but it is rather a pity that difficulties should be encouraged where we have in Bromley for years past been strictly conservative in our treatment, and in selecting cases for operation. Eye Clinic. 4.4 per cent, of children examined at school had defective vision to a degree equal or greater than 6/9 in each eye. Of the children attending the Medical Clinic 4.5 per cent, had a like defect. All such children, and also those children with subjective symptoms are referred 90 to the Eye Clinic held once weekly. In addition those children who have had glasses prescribed previously are kept under regular periodic examination. Table IV., Group II., gives detailed statistics of this Clinic. In 1933, of the 357 children who attended, 130 were new cases requiring glasses. It is not the practice to test for visual defect in the young entrant to school other than for squint, which as a rule is discovered and treated under the Maternity and Child Welfare service. It is thus not until seven years of age that the child comes under routine visual test of Snellin's type. The co-operation of the teachers in the discovery of visual defects is invaluable and I have been able to report cases to the Specialist where, if it were not for this co-operation, the child would be left untreated until the next routine inspection at twelve years of age. The use of a plus-1 sphere in testing vision defects has been found useful, but sometimes confusing. In the year under review 18 children under the age of seven years were examined and glasses prescribed through the Eye Clinic. The services go further than the treatment of the defect present; the lighting in the schools; the posture of the child in reading and writing are all taken into consideration, and those children with glasses suitably placed in the class when being taught from the blackboard. Only by so doing shall we be able to control an existing visual defect and obtain full benefit of the work of the Eye Clinic. It is here that we find the co-operation of the teachers so invaluable. Orthopaedic Clinic. This Clinic is held twice monthly, when a Consulting Surgeon attends from the Royal National Orthopaedic Hospital. A Masseuse attends five sessions a week, and is in charge of remedial exercises, massage and sunlight clinic. 91 The report of the Surgeon, Mr. H. J. Seddon, on those cases referred by him to hospital is as follows: "P.I. was admitted on 27/1/1933 with arthritis of the left hip. Since admission X-rays have been taken at regular intervals and there is now 110 doubt that we are dealing with a definitely tuberculous lesion. This means that treatment will have to be continued for at least another year. "T.W. was admitted 011 25/5/1933 with tuberculosis of the right hip. The disease is almost quiescent, but as there is a persistent tendency for the hip to go into a vicious position (and so make walking difficult) an operation will have to be performed to fix the joint in a useful position. We hope to do this shortly. " F.G., who has formerly been under our care with tuberculosis of the spine, was re-admitted on 14/6/1933, with pain in the hip. We could find no definite signs of hip disease, and his symptoms cleared up within a few weeks. As his general condition was unsatisfactory and his home conditions still worse he remained with us until 3/11/1933. At the time of his discharge he was to all intents a thoroughly fit child. "F.H. presented unmistakable signs of a dislocated cartilage in the left knee and was admitted for operation on 6/7/1933. However, all signs of trouble in the knee rapidly subsided shortly after admission and it was finally decided to postpone operation until such time as further symptoms developed. He was discharged on 21/7/1933. M.B. was admitted on 1/9/1933 with Perthe's disease of the left hip. She is making excellent progress and we are reasonably certain that by the end of 1934 the hip will be normal again and that she will walk perfectly. "E.W. was admitted on 11/8/1933 for operative correction of a wry-neck. A subcutaneous operation (i.e., division of the tendon without any external scar being produced) was performed and the immediate result was excellent. She was discharged 011 22/9/1933 and is attending the Clinic for the all important after treatment. 92 "J.B. fractured the head of the right radius late in October, 1933. When seen at the Clinic the elbow joint was so stiff that operative replacement of the fractured head was thought to be necessary. She was admitted on 24/11/1933, but as it was found that a good range of movement could be obtained by physical treatment, operation was not performed. She was discharged with good movement in the elbow on 6/12/1933." H. J. Seddon, f.r.c.s. The lesser defects such as functional scoliosis create one of the main defects in children attending the Orthopfedic Clinic, and the treatment of these cases in the early stages prevent permanent crippling or disability, often far-reaching if left untreated. The response of these cases to massage and remedial exercises is very pleasing. Statistics. Total attendances 2,687 (i) For consultations 458 (ii) For treatments, massage, remedial exercises 2,229 Maternity School and Child Medical Welfare. Service. Total. Requiring observation 25 102 127 Requiring treatment 35 139 174 Totals 60 241 301 New Cases seen at the Clinic diirina 1933. Scoliosis 12 Kyphosis 19 Kvpho-lordosis 7 Fiat Feet 5 Arthritis 1 Congenital Equino Varus 3 Slack Back 14 Flat Chest 4 Torticollis 1 Varus Toes 1 Valgus Feet 11 Spastic Diplegia 1 Genu Valgum 16 Outward Curvature Tibia 9 Pes Piano Valgus 3 Slight paralysis 2 Post Osteomyelitis 1 Sprains 6 Fractures 9 Injuries 14 Contracted Scar 2 Other Conditions 36 93 Sunlight Clinic. The Sunlight Clinic is held on Tuesdays and Fridays at 3 p.m. There were 1477 treatments last year of whom 120 were new cases. The majority of these were general debility which responded readily to treatment. Out of 82 cases of general debility 70 made good progress showing steady increase in weight and improved appetite. Ten did not continue treatment long enough to benefit by it, and two showed improvement -without gaining weight. Acne.—Two cases were treated; one showed a negative result and one slight improvement. Alopecia.—Seven cases were treated with local and general exposures. Five were cured after five months' treatment, but two did not continue long enough to show improvement. Intestinal Catarrh.—One case was treated and showed good results. Nervous Children.—Ten children were treated; nine showed distinct improvement, gaining weight, eating and sleeping better. One did not benefit by the treatment. Enlarged Glands.—Five cases were treated, all showing good progress. Chilblains.—Three cases were treated ; two were cured and one improved during the short attendance at the Clinic. Rickets.—Three cases were treated and in all the cases the condition was greatly improved. Impetigo.—One case was treated which cleared up rapidly. Rheumatic Cases.—Six cases were treated. Five made good progress and the other did not continue treatment. Report of the School Dental Surgeon for 1933. Inspection. The annual dental inspection of scholars attending elementary schools was carried out during the year. In 1932 every school received a dental examination, as is 94 recommended by the Board of Education, and 4,531 children were seen. This year, although a total of 4,685 children have been examined, two schools have been omitted, as had they been inspected there would have been no time left in the year for treatment. Treatment should follow directly after inspection; a long- delay between creates an impression of casualness, and also in a long waiting period the scholars change classes and even schools. This question will have to be considered. Last year 58 per cent, required treatment, this year 54 per cent., an improvement due, 1 think, to the fact that our treatment at the Clinic is trusted and appreciated, and parents send their children along. There is a very interesting comparison this year. It will be remembered that Plaistow Lane K.C. School has not had the benefit of the Committee's Dental Scheme; this year was the first dental inspection in the history of the school, and at my inspection I discovered that very obvious attention was needed in 84.9 per cent, of the scholars; the defects were not just caries (small cavities of decay), but a question of real septic conditions of the mouth, gum boils, abscess and decaying roots. This figure of 84.9 per cent, needing treatment must be compared with the corresponding figure for the remainder of the Committee's schools, where the figure is 54 per cent. From these extreme figures it will be seen that inspection, treatment and education in dental matters can very appreciably reduce the ravages of oral sepsis and dental disease. We cannot prevent the origin of dental disease, at the moment our only effective method of control over it is to treat it as soon as it arises, and hence my regret that a good number of children have been omitted this year. However, seeing that two new schools, Plaistow Lane R.C., and Prince's Plain, have increased the school accommodation, this is unavoidable. 95 Twenty-four visits of inspection were made at the various schools and an average of 195 scholars were examined at each inspection. Treatment. Of those children who were inspected during the year and were referred for treatment, 91 per cent, attended and were treated. This seems a very good percentage of attendance. The 9 per cent, who do not attend are made up to a great extent of the same children every year. On looking at their cards in the office all one can see is a list of dates running back several years, and against each date the words " failed to attend." The Dental Nurse made 989 visits during the year, very many of them to the same people as last year and previous years. We do manage to persuade a few, sometimes it is through the efforts of the Dental Nurse and sometimes through the form master at school. The attendances at the Clinic were 3,992 this year as compared with 3,827 in 1932, that is a little over 10 per session. This allows each child roughly 15 minutes in the chair at each visit. Each child has given on an average 1.7 visits, that is about 25 minutes actual treatment. It must be remembered that although the attendances increase, the time allotted for treatment remains constant, hence the more children, the less treatment per child. Gas was administered on 1,103 occasions, a record number since there has been a full-time dental service. As regards the office side of the Dental Clinic, it may be of interest to note that 7,319 appointments were sent out- in order to secure the 3,992 actual attendances, that is 54.5 per cent, of the appointments made are kept, or on an average each child requires two notices. Other Services. On Saturday mornings we hold a session for Maternity and Child Welfare patients. Ninety infants and 35 mothers attended. The bulk of the work consists of gas extractions, a certain number of fillings and especially scalings. No artificial teeth work is undertaken. 96 Lastly, I must again express my appreciation of the assistance given me by the Committee and the Staff. I must also thank the Teachers at the various schools for their interest in the work and their influence on the children as regards their keeping appointments. Nor must I forget our Voluntary Workers, who give us so much valuable and practical assistance. T. S. Latham, School Dental Surgeon. Dental Inspections, 1933. Total number of inspections 24 Average number of children inspected per session 195 Number requiring treatment 54% School. Department. No. Kxamined. Number referred for treatment. Raglan Road Juniors 281 149 Princes Plain Girls 202 100 ,, „ 267 142 Masons Hill Girls and Infants 185 99 Aylesbury Road Boys 175 112 Addison Road Girls and Infants 205 115 Valley Infants 162 80 " ... ... Girls 162 72 Bickley & Widmore Infants 158 95 ii >> Juniors 119 75 Parish Infants 154 94 Bromley Common Juniors & Infants 209 126 Burnt Ash Boys 217 112 " " „ 188 75 " " Girls 180 98 " " „ 192 89 " " Infants 230 119 " " „ 205 119 Plaistow Lane R.C. Juniors & Infants 86 73 Raglan Road Boys 242 122 " " „ 284 127 Parish Boys 265 148 " Girls 212 140 Plaistow Juniors 105 58 Totals 4685 2539 97 Infectious Disease. Scarlet Fever epidemic was the cause of not unexpected invalidity and loss of school attendance during 1933. This mainly affected the Downliam area which is in close proximity to London, where the epidemic was widespread. Measles and Mumps were prevalent in Bromley Common area affecting mainly the Raglan Road Schools. The following table indicates the various schools affected according to the weekly returns received:— Infectious Disease Returns received from Schools during 1933. Schools. Diphtheria. Scarlet Fever. Measles. Whooping Cough. Mumps. Chicken Pox. Addison Road — 1 1 — 18 2 Bickley & Widniore — 3 69 — 1 — Burnt Ash — 61 26 5 28 3 Bromley Common 4 3 — 1 62 — Masons Hill — 2 — — — — Parish 1 5 1 — 74 — Plaistow — 6 — 1 10 1 Raglan Road 3 8 107 21 178 9 Valley — 4 5 — 4 7 Plaistow Land R. C. — 12 — — — — Princes Plain 2 — — — — Central — 4 — — — — Medical Certificates of Exclusion from School. The following is a tabulation of conditions for which medical certificates were issued by general practitioners excluding children from attendance at school. The 776 certificates issued during the year indicate the type of illness and the prevalence of illness causing loss of school attendance. Taken in conjunction with the School Clinic certification (see Table II.) diseases of the Ear, Nose and Throat are the main causes of loss of education time. 98 Conditions for which Medical Certificates of Exclusion from School were issued by General Practitioners in 1933. Malnutrition, Debility, etc. 28 Skin 21 Eyes 9 Ears 29 Nose and Throat 109 Enlarged Cervical Glands 27 Heart 3 Lungs 2 Nervous Diseases 6 Deformities, Accidents 12 Operations 24 Measles 56 Whooping Cough 16 Mumps 37 Influenza 98 Chicken Pox 15 Rheumatism 25 Miscellaneous 259 Total 776 Open Air Education. No special open air school is provided for the chronically debilitated child. This type of case is dealt with mainly by sending such children on prolonged convalescence (G2 cases in 1933), or by selecting the children to be sent to the Burnt Ash School, which is built on the Derbyshire Open air principles. Children not adaptable to this arrangement are admitted to London Day Special Schools by arrangement with the London County Council. Physically defective children requiring prolonged hospital treatment are admitted to Stanmore Hospital, where education is provided whilst the child receives treatment. Heart cases are admitted to the Heartease Hospital, West Wickham, or to the Edgar Lee Home. At the end of the year 24 children were in residential, or certified day special schools (see Table III.). 99 Provision of Meals. The Local Authority does not exercise the facilities under Section 82/84 of the Education Act, 1921. Milk is, however, provided in schools at cost to the parent, and in necessitous cases at the cost of the Children's Care Committee. Six hundred and ninety-eight children received half-pint ration of pasteurised milk daily. Physical Training. The syllabus on physical training is carried out as a routine. There are no gymnasium halls in the elementary schools, and the playing field accommodation for elementary schools is very limited. Organised games in the playground are effective in some of the schools, but make a poor substitute. The economical difficulties remain an obstacle to this development, especially during the period when new schools are required for the growth of population which must have first claim for expenditure. Blind, Defective and Epileptic Children. Table III. in the appendix gives statistical details of these children. These cases are referred to the School Medical Service by Head Teachers, School Attendance Officers and by medical certificates of the family doctor. Many of the cases are brought to the knowledge of the Department during the Maternity and Child Welfare years and prior to their entry to school. The following-up of these children and the provision of special education to meet their physical disability is not an easy task. Our proximity to London and the co-operative facilities offered by the London County Council aid greatly in providing accommodation at day special schools. We have no day special schools or special classes for physically defective children in Bromley, but Table III. will indicate the number of children in residential schools and day schools for the specially defective children. 100 Conclusion. The year has been a difficult one, and the staff has found it difficult to comply with the requirements of the School Medical Services. We fell short in our routine medical inspections, hut this was countered by the increasing number of children coming up for special examination at the School Clinic. The special clinics were found to occupy too large a proportion of the time of the full time staff, especially in regard to anaesthetics and tonsil and adenoid operations. The appointments of an Anaesthetist and an Ophthalmic Surgeon in 1934 will overcome this difficulty and permit the full-time staff to undertake more fully the essential work of a school medical service, which is the maintenance of health of the elementary school child and the controlling of minor illness. This can only be done by the frequent and regular medical examination of the school child throughout its school years, and by keeping a high standard of hygiene in the school environment. Even these efforts will fail unless there is the closest possible touch with the parents and educational staff, and by realising the fact that the School Medical Service is not a watertight compartment, but that it is just a part of the Health Services of the Borough and of the country as a whole. In these services no small part is played hy the voluntary associations, the Nursing Association, the Children's Care Committee and the work so willingly and efficiently given by the voluntary workers at the clinics and centres. After Care. The Hon. Secretary of the Care Committee reports as follows:— " The main function of the Bromley Children's Care Committee is to provide convalescent home treatment and extra nourishment to those children of necessitous families referred to them through the School Medical Service. Members of the Committee assist at the various clinics held daily adding a valuable voluntary spirit to a municipal service. 101 In presenting this Report for 1933 the Committee think it well to say that they have this year incorporated into their servce the Rest Room Clothing Depot for unemployed, and that therefore they have been able to supply to school children repaired boots instead of buying new ones. This year they have had to supply only 45 new pairs instead of 119 as last year. Through this Depot they have also been able to help 143 women and 278 children with clothes. The Committee has again been fortunate in placing four children in the National Children's Home, when their own homes were broken up. They also succeeded in getting a child into Earlswood Mental Home, and with the help of many kind friends collected 520 votes in three months, so that the child was accepted at her first application. Convalescent cases have been heavy, and this year we have sent 63 children away. This is an increase of 23 on last year's figure. A brief summary will show to some extent the work done bv the Committee. The following cases have been investigated and helped financially:— Tonsils and Adenoid cases 1 Vision cases 13 Fare to hospitals 10 Convalescent homes 63 Permanent homes 4 Milk and extra nourishment 170 Boots 45 Total 306 It will be seen that 306 cases have been helped at the cost of £142 1s. 5d. In November the Honorary Secretary bad to give up the work for a time and Miss Isard kindly took on the work most successfully and efficiently. The Committee owe Miss Isard grateful thanks for thus stepping into the breach. 102 The Committee still supply the School Clinic with voluntary workers, two and sometimes three attending both morning and afternoon, also members attend at the Rest Room Clothing Depot two or three times a week to distribute clothing. The Committee again thank Mr. Harris for his generosity in giving spectacles at reduced prices, and in many cases free; they also thank Mr. Harvey Lowe, Honorary Secretary of the Queen's Reign Commemoration Fund for allotting them so many letters for convalescent cases." Statement of Accounts. Receipts. Expenditure. £ s. d. £ s. d. Balance brought forward 11 10 3 Milk 28 14 10 Boots 20 16 10 Bromley Benevolent Association 80 0 0 Royal Sea Bathing Hospital 42 0 0 Charity Festivities Association 20 0 0 Convalescent homes 34 4 6 Fares 10 3 0½ Raglan Road Parents' Association 1 1 0 Glasses 1 13 0 Chemical food 1 8 6 Congregational Church 4 0 0 Food 1 5 6½ Q.V.J.F. 2 0 0 Clothes 17 11 Sale of chemical food 1 17 0½ Taxis from Clinic 8 3 Returned re Royal Sea Bathing Hospital 6 15 0 Medical Clinic 5 0 Medicine 2 6 Repaid— Book for Earlswood 1 6 Royal Sea Bathing Hospital 11 5 0 Balance carried forward 12 8½ Fares 1 4 1 Convalescent homes 2 4 6 Glasses 7 6 Clinic Box 9 9 £142 14 1½ £l 42 14 1½ Amy G. Mann, Chairman and Hon. Treasurer. E. H. Carter, Honorary Secretary. 103 BROMLEY CHILDREN'S AFTER-CARE COMMITTEE FOR MENTAL DEFECTIVES. Report for the Year 1933. It may be remembered by those interested in the welfare of Mental Defectives that the original purpose with which our Committee was formed was to keep in touch with ex-pupils of the Special School. But from the early days of our Committee the County Council referred to our supervision certain ineducable persons and children, including imbeciles and idiots, whom it was thought possible to leave in their own homes. These last we shall continue to visit and report upon to the local authority. The closing of the Special School, however, will for the time being gradually diminish the number of higher grade defectives such as we supervised before the change. On arriving at school age high-grade defectives are classed as dull and backward, and pass into the ordinary elementary school. But it is precisely these persons, so often of unstable disposition, who present the most serious problem when they are due to leave school, for they begin life at the age of fourteen handicapped from the outset. As they cannot be notified to the County Mental Deficiency Committee until they reach the age of sixteen, during the intervening two years, they are subject to no supervision beyond that which they get in their own homes, where parents sometimes find difficulty in controlling potential or actual wage earners. The Central Association for -Mental Welfare are aiming at legislation whereby this two years gap may be bridged. For the present we still visit forty-two persons who passed through the Special School, twenty-three of whom are employed in various occupations. Visits cease when there is reason to believe that the defectives have acquired some self-reliance. This happens rarely, for it is a mark of mental deficiency that the sufferer is unable to carry on unaided. 104 The Committee have grounds for believing that supervision acts as a deterrent on those too easily led away into evil courses, and on those who give trouble to their employers, and too easily throw up their jobs for no particular reason, or for a fancied grievance. A small minority try to escape away from supervision altogether and leave the neighbourhood. An endeavour is always made to trace them. This is done not only for the sake of the mental defective himself, but in the interest of the community as well. The majority of the parents have shown that they are glad there is a body to whom an appeal can be made in times of difficulty, and who will see to it that their children are not left stranded when they, the parents, are no longer here to protect them. The Board of Control, continuing their investigations into the mental and physical condition of children of defectives, require now a yearly return through the local authority of particulars of those defectives who have married during the preceding year, and of those defectives who have given birth to children during the same period (a) after marriage; (b) while unmarried. Two of our defectives were married in 1933. Three married, and one unmarried, defectives have had children. The total number of married defectives on our 1933 list is seventeen. The number of children born to them twenty-eight. Three defectives, each suffering from distressing physical disabilities in addition to their mental infirmities, were removed during the year to the Farnborough Institution, to await places in Institutions more specially equipped to deal with such cases than an ordinary Poor Law Institution can be. Of these three, one has recently died; one has been removed to Eastney; the third, a case needing a great deal of attention, is still at Farnborough. The unmarried mother mentioned above was in Farnborough Institution for her confinement. For her and her baby, Sister Morgan has secured places in a Church Army Home. 105 Visits to three who have had the same employment for some time have been dropped. Nine have left the neighbourhood, five being notified to the Association who will in future be responsible. Ten new cases have been notified to us, three for statutory supervision. Three are mongolian imbeciles, three are epileptics, one is an imbecile, and three lowgrade defectives. One of the epileptics died soon after his return home from the Lingfield Colony. It was with deep regret that the Committee heard of the death of Mrs. Palmer. In her they have lost a colleague whose judgment of the character of her pupils was sure and kindly. Her school was a place of order and happiness where it seemed to us the impossible was achieved, not by drive, but by hope and courage and knowledge. Occupation Centre. The great event for our defectives during the Year has been the opening of the Occupation Centre by the Kent Voluntary Association for Mental Welfare. This is due to the combined efforts of our Chairman and Miss Nugent, the Association's Secretary. After a prolonged search for suitable premises, and many negotiations which ended in disappointment, the Churchwardens of St. Mark's agreed to let the Parish Hall at a rent which the funds (contributed in part by the County Council, and in part by the Association) could meet. Here in St. Mark's Hall are gathered for five days in the week, from 10 to 3, about thirty children debarred from attendance at the elementary schools. The sight on the opening day of the joy of these children that they were really going to school, and of their mothers that something was to be done for the children, will not easily be forgotten by those who had the privilege of an invitation to attend. Visitors have heard relations of these defectives speak with real gratitude of the training given at the 106 Centre. The work is carried on under the direction of a trained Superintendent, a paid assistant, a paid cook (the last two of whom act also as escorts) and a few voluntary helpers. More helpers are needed who can give of their time even but half-an-hour a week. Statement of Accounts. Receipts. Expenditure. £ s. d. £ 8. d. Cash in hand 3 8 0 Travelling Expenses 3 8 0 Grant 6 10 0 Printing and Stationery 3 8 6 "Mental Welfare" 3 6 Hire of Room 1 2 6 Postage 1 5 0½ Telephone 4 9 Cheques 1 2 6½ Cash in hand 4 £9 18 0 £9 18 0 APPENDIX. 108 TABLE 1.—MEDICAL INSPECTION RETURNS. Year ended 31st December, 1933. A.—ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed Groups:— Entrants 565 Second Age Group 336 Third Age Group 552 Total 1453 Number of other Routine Inspections Nil B.—OTHER INSPECTIONS. Number of Special Inspections 2324 Number of He-Inspections 4743 Total 7067 109 TABLE 11a.—Return of Defects found by Medical Inspection in the year ended 31st December, 1933. 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 32 23 56 24 Skin Ringworm Scalp — — 2 — Body 2 — 20 11 Scabies — — 49 11 Impetigo — — 75 21 Other Diseases (non-tuberculous) 10 — 257 67 Eye Blepharitis 3 1 5 4 Conjunctivitis 1 — 23 10 Keratitis — — 1 — Corneal Opacities — — 3 4 Defective Vision (excluding squint) 62 16 76 31 Squint 3 — 6 — Other conditions 1 — 76 16 Ear Defective hearing 7 5 13 4 Otitis Media 8 — 51 25 Other Ear Diseases 3 — 79 16 Nose and Throat Chronic Tonsillitis only 24 71 124 60 Adenoids only 8 5 38 16 Chronic Tonsillitis and Adenoids 26 25 167 246 Other conditions 13 4 279 120 Enlarged Cervical Glands (non-tuberculous) 7 35 102 46 Defective Speech 2 1 2 — Heart and HeartDisease Cicrculation Organic 1 2 14 3 Functional 5 9 103 40 Anaemia 2 2 14 3 Carried forward 220 199 1635 778 110 TABLE IIa.—Continued. Defect or Disease Routine Inspections Special Inspections No. of Detects No. of Defects Requiring Treatment Requiring observation Requiring Treatment Requiring observation (1) (2) (3) (4) (5) Brought forward 220 199 1635 778 Lungs Bronchitis 4 1 39 9 Other Non-Tnberculous Diseases 19 4 280 143 tuberculosis Pulmonary Definite — — — — Suspected — 1 9 4 Non-Pulmonary Glands — 1 10 4 Bones and joints — — 5 — Skin — — — — Other forms — — — — Nervous System Epilepsy — — — 4 Chorea 2 1 8 3 Other conditions 3 9 36 18 Deformities Rickets — 9 4 1 Spinal Curvature 16 5 6 — Other forms 42 8 49 21 Other Defects and Diseases (excluding uncleanliness and Dental Diseases) 11 11 510 226 Totals 317 249 2591 1211 111 TABLE l1b.—Number of Individual Children found at Routine Medical Inspection to Require Treatment (excluding Uncleanliness and Dental Disease). Group. Number of Children. Percentage of Children found to require Treatment. Inspected. Found to require Treatment. Prescribed GroupsEntrants 565 163 28.8 Second Age Group 336 67 19.9 Third Age Group 552 115 20.8 Total (Prescribed Groups) 1453 345 23.7 Other Routine Inspections — — — TABLE III.—Return of all Exceptional Children in the Area, 1933. CHILDREN SUFFERING FROM MULTIPLE DEFECTS. At No School or Institution. Mentally Defective and Partially Blind 2 Mentally Defective and Epileptic 1 BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At No School or Institution. Total. 2 — — — 2 112 PARTIALLY BLIND CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At Other Institutions. At No School or Institution Total. 1 2 2 _ 2 7 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At Other Institutions. At No School or Institution. Total. 5 — — — 5 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools lor the Partially Deaf. At Public Elementary Schools. At Other Institutions. At No School or Institution Total. — — 3 — — 3 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. At Certified Schools for Mentally Defective Children At Public Elementary Schools. At Other Institutions. At No School or Institution. Total. 2 5 1 4 12 MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN) REGULATIONS, 1928. Total Number of Children notified during the year 1933 by the Local Education Authority to the Local Mental Deficiency Authority (I) Children incapable of receiving benefit or further benefit from instruction in a Special School : Imbeciles 2 boys, 2 girls 4 113 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Ctrtified Special Schools. At Public Elementary Schools. At Other Institutions. At No School or Institution. Total. 1 — — — 1 PHYSICALLY DEFECTIVE CHILDREN. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At No School or Institution Total. A. I.—Children suffering from Pulmonary Tuberculosis — 3 1 — 4 11.—Children suffering from Non-Pulmonary Tuberculosis 3 6 1 — 10 Delicate Children 1 15 1 2 19 C. Crippled Children 2 16 — 1 19 Children with Heart Disease 1 — — 5 6 114 TABLE IV.—Return of Defects Treated during the year ended 31st December, 1933. Treatment Table. Group 1.—Minor Ailments. (Excluding Uncleanliness for which see Group VI.). N umber of Defects treated or under Treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin— Ringworm—Scalp (XRay treatment shown in brackets) 2 (2) — 2 Ringworm—Body 27 3 30 Scabies 54 1 55 Impetigo 88 6 94 Other Skin Diseases 256 7 263 Minor Eye Defects (External and other, but excluding cases falling in Group II) 56 7 63 Minor Ear Defects 77 5 82 Miscellaneous (e.g., Minor injuries, bruises, sores, chilblains, etc.) 181 2 183 Total 741 31 772 115 TABLE IV.—Group II. Defective Vision and Squint (Excluding Minor Eye Defects treated as minor ailments—Group I.). Defect or Disease. No. of Defects dealt with. No. of Children for whom Spectacles were Under the Authority's Scheme. By Private Practitioner or at Hospital apart from the Authority's Scheme Otherwise. Total. Prescribed. Obtained. Under the Authority's Scheme. Otherwise. Under the Authority's Scheme. Otherwise. Errors of Refraction (including squint) 243 31 274 101 29 101 29 Other Defects or Disease of the Eyes (excluding those recorded in Group 1) 77 6 83 — — — Total 320 37 357 101 29 101 29 116 TABLE IV.—Group III. Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative Treatment. Received other forms of Treatment. Total Number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private F'ractitioner or Hospital, apart from the Authority's Scheme. Total. (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) 58 239 2 20 107 — 21 — 26 5 23 20 133 5 (i) Tonsils only, (ii) Adenoids only, (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat. 117 TABLE IV.—Group IV. Orthopaedic and Postural Defects. Under the Authority's Scheme. Otherwise. Total Number Treated. Residential treatment with Education. Residential treatment without Education. Nonresidential treatment at an Orthopaedic Clinic. Residential treatment with Education, Residential treatment without Education. Nonresidential treatment at an Orthopaedic Clinic. Number of Children treated 7 — 102 — — 5 107 118 TABLE IV.—Group V. Dental Defects. (1) No. of Children who were:— (i) Inspected by the Dentist:— Routine Age Groups Aged: 5 364 „ 6 431 „ 7 539 „ 8 577 „ 9 632 „ 10 597 „ 11 512 „ 12 482 „ 13 474 „ 14 77 Total 4685 Specials 849 Grand Total 5534 (ii) Found to require treatment 2539 (iii) Actually treated 2268 (2) Half-days devoted to:— Inspection 24 417 Treatment 393 (3) Attendances made by children for treatment 3992 (4) Fillings:— Permanent teeth 1804 2221 Temporary teeth 417 (5) Extractions:— Permanent teeth 639 3910 Temporary teeth 3271 (6) Administrations of general anesthetics for extractions 1103* 119 (7) Other Operations:— Permanent teeth 462 662 Temporary teeth 200 *In addition there were 1,022 local anaesthetics. TABLE IV.—Group VI. Uncleanliness and Verminous Conditions. (i) Average No. of visits per school made during the year by the School Nurses 3 (ii) Total number of examinations of children in the Schools by the School Nurses 14640 (iii) Number of individual children found unclean 383 (iv) Number of children cleansed under arrangements made by the local Education Authority Nil (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 Nil (b) Under School Attendance Bye-laws 4 120 Dental Treatment and Details of Treatment Given, 1933. 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. Anaesthetics. Other Operations, Scalings, Dressings Regulations. Made. Kept. Extracted. Filled. Extracted. Filled. Gas. Local. 24 393 7319 3827 849 639 1804 3271 417 2221 1103 1022 662 Total Number of Visits to parents made by the Dental Nurse, 989. 121 HEAD INSPECTIONS School. Depts. FIRST INSPECTIONS. FINAL INSPECTIONS. ALL INSPECTIONS. Individual Inspections. Number Inspected Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous Number Inspected Clean Slightly Verminous Highly Verminous Slightly Verminous Highly Verminous ADDISON ROAD G. & I. 148 144 4 — 141 138 3 — 496 486 10 — 9 — AYLESBURY RD B. 189 188 1 — 189 187 2 — 560 557 3 — 3 — BICKLEY AND I. 110 108 2 — 121 117 2 2 354 341 11 2 5 3 WIDMORE I. 123 121 2 — 127 125 1 1 412 404 4 4 — 4 BROMLEY COM I. 189 178 9 2 160 149 8 3 551 514 31 6 20 6 BURNT ASH G. 377 342 31 4 428 418 10 — 1184 1122 57 5 33 5 B. 440 434 — 6 430 429 1 — 1232 1224 8 — 6 — I. 327 314 13 — 438 429 5 4 1195 1156 34 5 25 4 MASONS HILL G. & I. 274 274 — — 309 301 7 1 881 868 12 1 12 1 CENTRAL B. 87 87 — — 115 115 — — 286 286 — — — — G. 90 89 1 — 108 108 — — 281 280 1 — 1 — PARISH B. 241 238 1 2 254 250 2 2 740 727 5 8 3 4 G. 235 228 7 — 220 213 2 5 684 659 17 8 11 6 I. 131 126 2 3 152 147 4 1 418 404 9 5 7 3 PLAISTOW I. 97 88 3 6 91 84 3 4 283 257 12 14 7 10 LANE R.C. I. 85 76 2 7 84 78 3 3 169 154 5 10 2 8 RAGLAN ROAD B. 423 417 6 — 229 220 8 1 1366 1343 20 3 20 3 I. 248 230 15 3 261 244 17 — 780 726 47 7 37 6 I. 282 264 13 5 219 203 9 7 824 777 40 7 29 13 RAGLAN RD. (G.) PRINCES PLAIN G. 260 235 20 5 469 452 13 4 996 933 53 10 34 9 VALLEY G. 170 160 7 3 177 166 11 — 505 475 27 3 15 5 I. 151 143 6 2 137 129 7 1 443 422 17 4 9 5 Total 4677 4484 145 48 4859 4702 118 39 14640 14115 423 102 288 95