BOROUGH OF BROMLEY. 1935 ANNUAL REPORT. MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER. BROMLEY, KENT. The Bromley Printing Co., Sherman Road. BOROUGH OF BROMLEY. 1935 ANNUAL REPORT. MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER. BROMLEY, KENT. The Bromley Printing Co., Sherman Road. 2 CONTENTS. page Members of the Health and Maternity and Child Welfare Committees 5 Prefatory Letter 6 Staff 10 Part I.—Statistics and Social Conditions of the Area 12 Summary of Statistics 12 Social Conditions 13 Meteorology 14 Unemployment 14 Occupations 15 Population 15 Part II.—Vital Statistics 16 Births 16 Stillbirths 17 Deaths 18 Infantile Mortality 19 Maternal Mortality 20 Part III.—Maternity and Child Welfare 20 Details of Services 21 Centres and Clinics 22 Ante-Natal Clinic 23 Natal Services 24 Midwives 24 Midwives Acts, Administration of 25 Midwives, Inspection of 26 Maternity Hospital and Maternity Homes 26 Puerperal Fever and Puerperal Pyrexia 27 Post-Natal 27 Home Visiting 27 Welfare Centres 29 Milk in Necessitous Cases 31 Institutional and Convalescent Treatment 31 Minor Ailments Clinic 32 Dental Clinic 32 Ophthalmia Neonatorum 32 Diarrhoea and Enteritis 32 Children and Young Persons Act, 1932 33 Part IV.—Summary of General Provision of Health Services 33 Legislation in Force 33-36 Hospitals 36 Maternity and Nursing Homes 36—37 Institutions, various 38 Ambulance Facilities 38 Laboratory Facilities 38 Clinics and Centres 39 Nursing in the Homes, District Nursing Associations 39 3 CONTENTS—Continued. page Tuberculosis Dispensary 41 Venereal Diseases 42 Part V.—Sanitary Circumstances 42 Rivers and Streams 42 Drainage and Sewerage 42 Cesspool Drainage 43 Water 43 Scavenging 44 Swimming Baths and Pools 44 Rats and Mice Destruction Act, 1919 44 Part VI.—Housing Conditions 45 Overcrowding 46 Inspection of District 48 Unfit Houses 48 Contraventions, Public Health Acts 49 Part VII.—Smoke Pollution 49 Part VIII.—Shops Acts, Contraventions, Etc. 49—51 Part IX.—Petroleum Acts 51 Part X.—Factories and Workshops 52 Part XI.—Premises and Occupations Controlled by Bye-Laws, Regulations, Etc. 52 Part XII.—Inspection and Supervision of Foodstuffs 52 Milk 52 Milk, Bacteriological Examinations 53 Milk, Contraventions 53 Meat 54 Meat, Tables A., B., C., D. and E. 54 Unsound and Unwholesome Food Surrendered 56 Food and Drugs (Adulteration) Act, 1928 56 Part XIII.—Diseases of Animals Acts 57 Tuberculosis Order of 1925 57 Part XIV—Rag Flock Acts, 1911-1928 58 Part XV.—Infectious Diseases Control 58 Scarlet Fever 58 Diphtheria 59 Smallpox and Vaccination 59 Tuberculosis 60 Appendices.—Statistical Tables I. to XV. 64—84 School Medical Service 85 Members of the Education Committee 86 Introduction 87 Summary of Statistics 90 4 CONTENTS—Codtinued. page Hygiene of Schools 90 Medical Inspection 91 Treatment 94 Table IV., Group I. Minor Ailments Clinic 95 Table IV., Group II. Defective Vision Clinic 96 Table IV., Group III. Ear, Nose and Throat Clinic 97 Table IV., Group IV. Orthopaedic Defects 98 Ultra Violet Ray Clinic 99 Table V. Report of School Dental Surgeon 100 Table VI. Uncleanliness and Verminous Conditions 104 Table III. Blind, Deaf, Defective and Epileptic Children 104 Physical Training 104 Provision of Meals 105 Open Air Schools 105 Nursery Schools 105 Occupation Centre 106 Health Education 106 Infectious Diseases in Schools 106 Medical Certificates of Exclusion 107 After Care 108 Report of Bromley Children's Care Committee 108 Appendices:— Table I. Routine Medical Inspections 112 Table II. Return of Defects 113 Nutrition of Children 115 Table III. Return of Exceptional Children 115 Table IV. Group I. Minor Ailments 118 Group II. Defective Vision 119 Group III. Ear, Nose and Throat Defects 120 Group IV. Orthopaedic Defects 121 Table V. Dental Inspection 122 Table VI. Uncleanliness and Verminous Conditions 123 5 MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1935-1936. HEALTH COMMITTEE:— Councillor M. Stafford Smith, m.b.e., b.a. (Chairman). Alderman W. F. Skilton (Vice-Chairman). His Worship the Mayor (Councillor D. P. Law, j.p.). Councillor G. Allen. Councillor E. C. De'Ath. Councillor G. T. Evans. Councillor W. J. Guthrie, j.p. Councillor F. L. Hakris, f.b.o.a., f.s.m.c., f.i.o. Councillor S. G. Humekston. Councillor F. Sutcliffe, f.r.i.b.a. MATERNITY AND CHILD WELFARE COMMITTEE:— Councillor S. G. Humerston (Chairman). Mrs. A. M.. Howe (Vice-Chairman). His Worship the Mayor (Councillor D. P. Law, j.p.). Alderman W. F. Skilton. Councillor G. Allen. Councillor E. C. De'Atii. Councillor G. T. Evans. Councillor W. J. Guthrie, j.p. Councillor F. L. Harris, f.b.o.a., f.s.m.c., f.i.o. Councillor M. Stafford Smith, m.b.e., b.a. Councillor F. Sutcliffe, f.r.i.b.a. Co-opted Members:— Mis. A. M. Howe (Vice-Chairman). Mrs. A. G. Mann, b.a., j.p. Mis. M. Pearce. Miss V. Vincent Mis. E. Yolland. 6 Borough of Bromley. Report of the Medical Officer of Health for the year 1935. To the Mayor, Aldermen and Councillors. Mr. Mayor, Madam and Gentlemen, I beg to submit the Annual Report on the Health of the Borough of Bromley during the year 1935. The general arrangement of the Report is in accordance with that of previous years and follows the requirements laid down in Circular 1492 of the Ministry of Health. The Report is divided into two main sections, the first dealing with the services of the Health Committee and the Maternity and Child Welfare Committee, and the second that of the School Medical Sub-Committee. Whilst separated for the purposes of report they are in practice one co-ordinated service. There is gradually evolving in the public thought a desire for communal health as distinct from individual health. As a consequence, and without our seeking, one notes a greater tendency to use the services provided by the State, not, in my view, because they can be obtained cheaply, but genuinely due to the seeking of the knowledge of health rather than the treatment of illhealth. A gullible section of the public still resorts to an excessive use of patent medicines. There is, too, a tendency to criticise the results of these health services because nursing homes, hospitals and doctors all appear to be increasingly busy. These critics forget that biological decay is a law of Nature, that man must suffer illness with an increasing mean age at death. They forget, too, that the various Death Rates are being reduced, that preventable illnesses are being controlled and minimised, and that the environment is an increasingly healthy one. To take one service alone, the Maternity and Child Welfare; thirty 7 years ago the Infantile Mortality Rate in Bromley showed that of every ten babies born one died before reaching one year of age; in the year 1935 this figure was reduced to as low as one death in every thirty-six babies born. This result has been obtained not by the treatment of the sick, but solely by an increase of knowledge and practice of preventive medicine. The Report indicates the work of the Department during the year 1935, and is to be read from the viewpoint that from one year to another it is not possible to make comparable statistics. The population changes rapidly, especially in the environs of London, no less than 20 per cent. of the population is in a state of flux, so that on this basis alone yearly statistics are not strictly comparable. That the work of the Department increases year by year is indicated by the new Acts, Orders, Circulars and Memoranda that are passed to the Local Authority from the Central Government. In 1935 the following had some influence on the routine work:— Ministry of Health Form H256 received quarterly requiring progress report under the Housing Act, 1930. Ministry of Health Circular 1453 Slum Clearance. Minister's review of local authorities' programmes expressing appreciation of progress made and urging completion of programmes. Report on work of the Central Midwives Board year to 31/3/1934. Ministry of Health List 10(E) of Sanatoria and Residential Institutions approved by the Minister for treatment of persons suffering from tuberculosis. Ministry of Health Circular 1461, enclosing Statutory Rules and Orders of 1935 No. 187, Public Health (Meat) Amendment Regulations, 1935, correcting errors in Articles 9 and 10 of the Public Health (Meat) Regulations, 1924. Statutory Rules and Orders of 1935, No. 162, The Alkali, etc., Works Order, 1935. Ministry of Health Circular 1474, Prevention and Treatment of Venereal Disease—Congenital Syphilis. Ministry of Health Circular 1473 with reference to the Minister's Report on Supervision of Milk Pasteurising Plants. Ministry of Health Circular 1488, Fees to Doctors called in by Midwives, notifying deletion of paragraph 8 of circular 358. Statutory Rules and Orders of 1935, No. 524, The Mental Deficiency Regulations, 1935. 8 Ministry of Health Memo. 188/Med notifying Medical Officers of Health (outside London) of the steps to be taken in suspected food poisoning cases. Ministry of Health Circular 1490 and the Second Report of the Committee on Standardization and Simplification of Requirements of Local Authorities. Ministry of Health Circular 1493 with reference to Housing Act, 1935, enclosing (1) Memorandum on changes in law relating to slum clearance and other amendments in the Housing Acts, and (2) Memorandum with reference to the Housing (Rural Workers) Acts. Ministry of Health, Housing, England (Form or Orders and Notices) Regulations 1935. Ministry of Health Circular 1494, Form H256A requesting information of the full progress made in programme of slum clearance up to 30/9/1935 under Housing Act, 1930. Memo. H256B. Ministry of Health Circular 1497 with reference to the precautions to be observed when Hydrogen Cyanide is employed for fumigations. Poisons and Pharmacy Act 1933 (Date of Commencement of Orders 1935). Ministry of Health Circular 1499, enclosing Memo. 189/Med with reference to Pneumonia. Ministry of Health Circular 1492 as to the Contents and Arrangement of the reports of Medical Officers of Health. Housing Act, 1935, Circulars and Memoranda: Statutory Rules anil Orders of 1935 No. 1110; Circular No. 1505; Memoranda A. B. C. D. and E.; Circulars 1500a and 1507, and Provisional Regulations under the Housing Acts. Ministry of Health Circular 1503 as to Swimming Baths and Pools. Ministry of Health Circular 1504 enclosing forms for Annual Returns with respect to Maternity and Child Welfare, Tuberculosis and Venereal Disease for 1935. Ministry of Health Circular 1505 enclosing Sanitary Officers (Outside London) Regulations, 1935. Diseases of Animals: Foot and Mouth Disease (Infected Areas) Order of 1935, Nos. 16, 17, 18 and 19. Pennine Range (Movement of Sheep) Order, 1935, No. 3. Sheep Dipping Regulations. The staff has increased during the year hy an additional full-time Health Visitor, and a Junior Clerk. I regret to record the death of Dr. A. M. Hickley who had for some years carried out so efficiently the work of the Eye Clinic, 9 The vital statistics for 1935 show an increasing: population, a slight fall in the Death Eate to 9.4, a rise in the Birth Kate to 13.5, and, I am happy to record, a fall in the Maternal Mortality Hate. The Infantile Mortality Rate is the lowest ever recorded in Bromley—a figure of 27.7 per 1,000 babies is far below the expectations of past years. The substance of the Report describes these rates in more detail. I would desire to express my appreciation to the members of the various Committees for the assistance they give to the work, to Mr. Lawley and to the staff of the Department for their individual keenness and efficiency, and to my fellow colleagues for the co-operation they so willingly give at all times. I am, Mr. Mayor, Madam and Gentlemen, Your Obedient Servant, K. E. TAPPER, Medical Officer of Health. 10 PUBLIC HEALTH STAFF, 1935. 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. Orthopaedic Specialist 2 1 H. J. Seddon, f.r.c.s. Ear, Nose and Throat 2 1 Charles C. Beney, m.a., Specialist m.b., ch.b., (Camb.), m.r.c.s. Eye Specialist 2 1 A. M. Hickley, m.r.c.s., l.r.c.p. (Deceased 26/11/35). 2 1 eric lyle, m.a., m.d., b.ch., d.o.m.s.) (Appointed 1/12/35). Anaesthetist 2 1 F. G. France, m.b., b.s.Lond., m.r.c.s., l.r.c.p. Consulting Gynæcologist 2 1 J. Bright Banister, m.a., m.d., f.r.c.p., f.r.c.s. School Dental Surgeon 2 T. S. Latham, l.d.s., r.c.s. Chief Sanitary Inspector 5 4 3 2 G. R. Woods, m.s.i.a., a.r.san.i. Sanitary Inspectors 5 4 3 2 T. C. Towersey, m.s.i.a. 5 4 3 2 C. J. Clark. 4 3 2 H. Handscomb, m.s.i.a. Health Visitors and 8 7 6 2 Miss L. A. Briggs, s.r.n. School Nurses 8 7 6 2 Miss E. Connor, s.r.n. 8 7 6 2 Miss E. B. Crowe, s.r.n. 8 7 6 2 Miss J. E. B. Dunn, s.r.n. (Appointed 2/12/35). 8 7 6 2 Miss D. Prime, s.r.n. 8 7 8 2 Miss E. Rhodes, s.r.n. (Appointed 14/1/35). ii 8 7 6 2 Miss P. M. Trickett (Resigned 12/1/35). 7 6 2 1 Mrs. F. A. Pulleyn (Resigned 1/11/35). 7 6 2 1 Miss J. Dickson (Resigned 9/2/35). Orthopaedic Nurse 21 Miss M. Dodge, c.s.m.m.g. Veterinary Surgeon under the Diseases of Animals Acts 1 P. J. Turner, m.r.c.v.s. Inspector under the Diseases of Animals Acts, and Petroleum G. R. Woods, m.s.i.a., Acts a.r.san.i. General Office Staff: Chief Clerk 2 H. E. Lawley. Junior Clerks 2 Miss B. C. Tucker. 2 Miss L. P. Thorpe. 2 W. S. Dench. 2 D. L. Corder. 2 E. H. Andrews (Appointed 2/12/35). Temporary Clerk G. C. Dickinson (Ap- (Housing Survey) pointed 4/12/35). Dental Assistant Nurse 2 Miss A. M. Penman. Outdoor Staff: Drain Tester and Disinfector J. W. Seager. Market Superintendent 1 F. J. Ephgrave. 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. 6. Three years Hospital Trained. 7. State Certified Midwife. 8. Royal Sanitary Institute Health Visitors' Certificate (under Memo. 101/MCW). 12 1.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA, 1935. Statistics. Area (in acres) 6,519 Population— Census, 1921 35,052 Census, 1931 45,374 Mid-year 1935 (Registrar General's estimate) 56,200 Number of Inhabited Houses— Census, 1931 10,764 End December, 1935 (Kate Books) 15,311 Rateable Value (31/3/1936) £650,975 The sum represented by a Penny Pate (Estimated for year ending 31/3/1937) £2,620 Vital Statistics. The following extracts from the vital statistics of the year relate to the net births and deaths after correction for inward and outward transfers, as furnished by the Registrar General:— Live Births. Total. Male. Female Legitimate 721 374 347 Birth Rate per 1,000 of the estimated resident population: 13.5. Illegitimate 37 17 20 758 391 367 Stillbirths. Legitimate 15 9 6 Rate per 1,000 total (live and still) births: 19.4. Illegitimate - - - 15 9 6 Deaths 548 274 274 Death Rate per 1,000 of the estimated resident population: 9.4 — adjusted according to comparability factor .97. 13 Deaths from Puerperal Causes Rate per 1,000 total (live and still) births: No. of Deaths. From sepsis Nil Nil From other causes 1 1.29 Death Bate of Infants under 1 year of age:— All infants per 1,000 live births 27.7 Legitimate infants per 1,000 legitimate live births 24.9 Illegitimate infants per 1,000 illegitimate live births 81, Deaths from measles (all ages) Nil Deaths from whooping cough (all ages) Nil Deaths from Diarrhoea (under 2 years of age) 1. Social Conditions. Progress in the erection of small house property showed no sign of diminution, and in the open space of South borough and in the Hollydale area, fresh fields of building activity developed during the year. Building developments in the large area of Hayes showed steady progress. By the inclusion of Hall's Farm Land and Hollydale during 1935, a further 17 acres of open space for public use has been added to the Town's amenities. The following table gives details of land available for public recreation within the Borough at the end of 1935:— Commons and Open Spaces : Acres. Roods. Poles Acres, Roods. Poles. Keston Common 55 1 24 Hayes Common (including Pickhurst Green) 213 1 32 Hall's Farm Land 11 2 8 Hill Crest, Burnt Ash Lane 1 0 1 Hollydale 6 1 0 Husseywell Crescent 2 1 30 The Knoll 4 1 39 Turpington 1 3 10 296 1 24 14  Acres. Roods. Poles. Acres. Roods. Poles. Public Recreation Grounds: King's Meadow 9 1 0 Martin's Hill 11 0 5 Oakley Road 2 0 0 Queen's Mead 10 3 15 Whitehall 17 1 6 Norman Park (reserved) 56 0 0 106 1 26 Public Gardens and Grounds: Church House Ground 10 3 10 Library Gardens 1 2 0 Queen's Garden 2 1 4 Widmore House 2 0 15 0 14 417 3 24 Meteorology. The following particulars have been extracted from the records kept at the Climatological Station at Church House Grounds for the year ended 31st December, 1935:— Total rainfall 27.08 inches Mean maximum daily tempera- 57.9 degrees ture Mean minimum daily tempera- 44.3 degrees ture Highest maximum temperature 80 degrees on 7th recorded August Lowest minimum temperature 19 degrees on 24th recorded December Lowest grass minimum tern- 10 degrees on 23rd perature and 24th December Unemployment. The Manager of the Employment Exchange has kindly supplied the following particulars:— 1. Recorded unemployment at the end of December, 1935. (a) Men 547 (b) Women 158 Total 705 15 2. Highest figure reached in 1935. (a) Men 876 14/1/1935 (b) Women 192 14/1/1935 It is usual for the peak figure to be reached about January. A very fair estimate would be that 90 per cent. of the unemployed are Bromley residents. The employment position during the year was good. The figures steadily fell from January and remained at about the 500 mark from March to December, only varying a little over or under that figure. It should be borne in mind that this does not mean that 500 men have been regularly unemployed during the year, but that with the exception of about 50, the remainder have been in and out of work and that the actual men unemployed changes from week to week. The position, therefore, is really better than is represented by the figure. Occupations. On page 15 of my Annual Report for 1934 will be found full details of occupations within the Borough according to the Census returns of 1931. Population. The Registrar General gives the mid-year 1935 figure of population for Bromley 56,200, a figure which very closely approximates to the figure obtained through the Housing Survey carried out in January, 1936, when a figure of 50,334 was obtained. A report on this Housing Survey is submitted later in this Report. It shows also the average size of family is below the average of the 1931 Census, 3.61 compared with 3.70, and that with the development of housing schemes in close proximity to hondon one finds that the population is still in a state of change. Approximately 20 per cent. of houses change their tenants each year. As most vital statistics are based on the population figure the importance of a reasonably correct figure is obvious; at the same time it must be realised that we are dealing with a comparatively small number of persons, which, from year to year, change in age and sex groups. With this fact in view an adjustment figure of .97 is given in order to correct the crude figure of mortality 16 rates and render the statistics more readily comparable with other areas. II.—VITAL STATISTICS. Births. Seven hundred and eighty-one live births were notified during 1935 as occurring within the Borough of Bromley. One hundred and fifty-nine of these were transferable to other local authorities, while 136 babies of Bromley residents were born outside the area. These figures give us 758 registrable births, and a Birth Bate for 1935 of 13.5 per 1,000 population. The return shows the following details:— Live Births: Total. Legitimate. Illegitimate. Male 391 374 17 Female 367 347 20 Totals 758 721 37 Still Births: Male 9 9 — Female 6 6 — Totals 15 15 — These figures shew the highest number of births ever recorded in Bromley, an excess of males over females, a reduction in still births and a reduction in the number of babies born out of wedlock. Year. Birth Rates. Bromley. England and Wales. 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 1934 13.3 14.8 1935 13.5 14.7 17 Stillbirths. The rate per 1,000 births is 19.4, a reduction of four per 1,000 compared with the previous year. If the figure is to be still further reduced the expectant mother must have a better understanding of the importance of antenatal hygiene; for from the enquiries made into the 15 stillbirths which occurred in Bromley, if complete care and supervision had been exercised many of these would have been live births. Twelve occurred in the first pregnancy, while three occurred later than the third pregnancy. Five of the stillbirths occurred as a result of malpresentation at birth, being apparently normal up to the time of actual confinement. The following table indicates the scheduled cause of stillbirths in 1935:— Complication at labour and asphyxia 5 Renal disease 2 Placental inefficiency 1 Malformation 2 Cord abnormality 1 Toxaemia 1 Unknown 3 For the five years ending 1935, 99 stillbirths have been recorded—rate equal to 29 per 1,000. This rate does not show reduction. It is apparent that if the cause of stillbirth is to be pathologically investigated, and action taken to prevent the occurrence of stillbirth, each death should be verified by skilled post mortem examination. It is only by knowing the cause that steps can be taken to prevent this waste of life and the consequent distress to the parents. The following table gives the statistics of stillbirths occurring in the area since the inception of compulsory registration of stillbirths in 1927:— 18 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 1934 17 23.6 1935 15 19.4 Deaths. The Death Rate, corrected by the comparability factor, was 9.4, which is 0.1 lower than the previous year and the lowest death rate recorded in Bromley. The following table shows the crude death rates for Bromley in comparison with the death rates for England and Wales since 1925:— Year. Bromley Crude Death Rates. England and Wales Death Rates. 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 1934 9.8 11.8 1935 9.7 11.7 Appendix III. gives a tabulation of the causes of death from which the following have been extracted for the purpose of comparison:— 1934 1935 1934 1935 1934 1935 No. of deaths. Rate per cent, of total deaths. Rate per 1,000 of population. Respiratory disease 43 34 8.2 6.2 0.8 0.6 Heart disease 151 182 28.9 33.2 2.8 3.2 Cancer 73 86 14.0 15.7 1.3 1.5 Tuberculosis 19 27 3.6 4.9 0.3 0.5 Premature births 17 12 3.2 2.2 0.3 0.2 Infectious disease 9 6 1.7 1.1 0.1 0.1 Influenza 7 11 1.3 2.0 0.1 0.2 19 Infantile Mortality. Twenty-one babies died before reaching the end of the first year of life. This figure gives a remarkably low Infantile Mortality Rate of 27.7 per 1,000 babies, which is the lowest rate ever recorded in Bromley. I would refer those interested in the causation of infant deaths to Appendices IV., V. and VI., wherein I have tabulated the ages and causes of baby deaths. It will there be seen that as many as 11 of these babies died within four weeks of birth, nine of whom died in the first few days. This is indicative of the causation being during birth or immediately before birth, so that if one is to reduce the mortality, one must continue to stress better midwifery, better care of the newly born and the extension of the practice of ante-natal hygiene. Those deaths of babies which occur after the fourth week are mainly due to respiratory disease, and the prevention here lies with the protection of the child against contracting the parental or adult infection. One unfortunately meets with the negligent parent who persistently refuses the advice of the health visitor. A case in point is that of a baby who died in 1935 at four months after birth. The health visitor reported at one month: "A difficult mother who refuses advice. Inclined to listen to neighbours' advice. Feeds irregularly and wrongly." At two months, " Does not wish for visits." At three months, " Admitted to hospital for malnutrition." At four months, " Died in hospital." For comparison purposes the following table is of interest, showing rates per 1,000 births:— Year. Bromley. England and Wales. 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 1934 43 59 1935 27 57 20 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 1931-1935 6 9 4 There is a pleasingly low return for the year 1935, but again we must take a period of years to get a true aspect of this distressing cause of death, which is to-day attracting so much public attention. We realise that the maternity services in this country are disjointed. We have a state service, a voluntary service and a private service, with a certain amount of interrelationship, but each with its own function, its own views, and its own procedure in the prevention of maternal morbidity and mortality. It can be said that these have failed separately, and we must ask what prospect there is of a unified maternity service bringing the desired reduction in the maternal death rate. The establishment of a state midwifery service as indicated in the Midwives Bill which is at the present time before Parliament is obviously a step in the right direction, so that midwives will function much in the same way as health visitors do to-day. There is a growing feeling of insecurity in pregnancy, the fear that things will go wrong, a fear of pregnancy, and the consequent increase of birth control, of abortions and miscarriages, It must be accepted that this fear is a real factor in the cause of maternal mortality, for psychology teaches us that fear can produce the thing that is feared. Gradually maternity practice is departing from the home; more and more cases are being admitted to hospital and nursing home, and the normal pregnancy and confinement is being treated as a pathological condition. We must get back to normality on this question. III.—MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare services consist of the following:— 21 1. Six full-time Health Visitors are employed half- time on School Medical duties and the other half is devoted to Maternity and Child Welfare duties. They attend the centres and carry out the teaching of mothercraft in the homes. 2. Eight welfare sessions are held weekly, with a doctor in attendance at six of these each week. 3. Ante-Natal clinics are held four times per month. 4. Maternity Hospital provision for necessitous cases —reservation of four beds. 5. Consultant Gynaecologist, whose services are available for general obstetric work. 6. Consultant Pathologist, whose services became available during the year 1936. 7. Hospital treatment, isolation, and Consultant Gynæcologist for Puerperal Fever and Pyrexia cases. 8. Dental treatment for expectant mothers, nursing mothers, and children under five years of age. 9. Free milk for necessitous cases. 10. Home visiting of boarded-out children under the Children and Young Persons Acts, 1908-1932. 11. Consultant Surgeon and Orthopedic treatment for the crippled child. 12. Minor ailment treatment. 13. Ear, Nose and Throat Consultant and Surgeon. Operative treatment at the School Clinic. 14. Opthalmologist for defective vision cases. 15. Provision of hospital treatment for cases of Ophthalmia Neonatorum, and for acute cases oi complicated measles. 16. Supervision of midwives under the Midwives Acts. 17. Registration and inspection of maternity homes under the Nursing Homes Registration Act. 1927. 22 Child Welfare Centres. Bromley Gammon— South Clinic, Princes Plain Burnt Ash— Burnt Ash Branch Library, Burnt Ash Lane Hayes and Keston— Village Hall, Hayes Mason's Hill— St. Mark's Hall, Mason's Hill Plaistow— North Clinic, Station Road Wid-more— Wesleyan New Hall, Tylney Road Ante-Natal Clinics. Held at the North Clinic, Station Road, on the first and third Thursdays in every month at 2.30 p.m., at South Clinic, Princes Plain, Bromley Common, on the second Thursday of each month at 2.30 p.m., and on the fourth Thursday in each month at 2.30 p.m. at the Maternity Hospital, Widmore Road. Dental Clinics. Held at the North Clinic, Station Road, daily for children, and for expectant mothers and nursing mothers at 9.30 a.m. on Saturdays. Orthopaedic Clinic. For children under five years of age with crippling defects, as well as for school children. Held at the North Clinic, Station Road. Mondays at 9.30 a.m. Tuesdays at 9.30 a.m. Tuesdays, 2.30 p.m. Fridays, 2.30 p.m. Tuesdays, 2.30 p.m. Wednesdays, 2.30 p.m. Tuesdays, 2.30 p.m. Thursdays, 2.30 p.m. Wednesdays, 2.30 p.m. Fridays, 2.30 p.m. 23 Thursdays at 2.0 p.m. Fridays at 12 noon. A Consultant Surgeon attends on the first Monday (afternoon) and third Tuesday (morning) in each month. Ultra Violet Ray Clinic. Held at the North Clinic, Station Road, twice weekly: Tuesdays at 2.30 p.m., and Fridays at 2.30 p.m. Diphtheria Immunisation. Held at the North Clinic, Mondays at 2.30 p.m. Ante-Natal Clinic. Comparative Table 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 1934 142 263 251 32 1935 162 253 253 31 An Ante-Natal Clinic is now held weekly, Dr. G. H. Stinson being in attendance. Demonstrations are also Riven at these Clinics in babycraft and instruction in the proper preparation for confinement. One regrets that more use is not made of these facilities by the midwife in independent practice. It is my view that ante-natal supervision requires the advice and direction of a skilled practitioner, and should not be left to the midwife. Where the ante-natal period indicates normality the 24 confinement should be left to the midwife, but in the case of abnormality the case should be referred to the doctor who must have the required specialised experience. In these directions lie safe maternity. Natal Services. Seven hundred and ninety-eight births (live and still) were known to have occurred in Bromley during 1935, as follows:— Notified by midwives 340 Notified by doctors and parents 439 " Un-notified " 19 Total 798 Of this number the midwives of the two district nursing associations attended 272 confinements. It is of interest to note that of all confinements in Bromley, 4G3 were confined in nursing homes and hospitals, while 335 were confined in their own homes. Remarks on this matter have already been made under the heading Maternal Mortality of this Report. Midwives. I. (a) The number of midwives practising in the area served by the Local Authority for maternity and child welfare at the end of 1935 was 19 (b) Number (i) employed by the Council (ii) directly subsided by the Council (iii) Employed by Voluntary Associations 12 (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 340 (ii) as maternity nurses 312 25 (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 86 Administration of the Midwives Acts, 1902-1926. No. of midwives practising in Bromley at the end of the year, 1934 22 No. of midwives giving notice of intention to practice during the year, 1935 28 No. of midwives removed from the local register, having left the district 9 No. of midwives practising in the area at the end of the year, 1935 19 Notifications Received. Notices summoning medical aid 86 (a) Mothers 67 (b) Infants 19 Notices of Artificial Feeding 2 ,, ,, Stillbirths 3 ,, ,, Deaths 2 ,, ,, Laying out a Dead Body 2 ,, ,, Source of Infection 5 Summary of Reasons for Sending for Medical Help. Ruptured perineum 32 Delayed labour 8 Breast condition 1 Varicose veins and leg swellings 6 Inertia 1 Placenta, adherent 1 Abnormal presentation 6 Haemorrhage 3 Ante-natal examination 3 Rise of temperature (puerperal pyrexia) 2 Other causes 4 Infants—Feeble, premature, etc. 10 Malformations 2 Cyanosis 3 Eye discharge 4 86 26 Payment of Doctors called by Midwives, Section 14 Midwives Act, 1918. No. of applications for fees 60 No. of cases where payment of fee lapsed on account of failure to claim within the prescribed period of two months 8 No. of cases where patient was known to have paid the doctor's fee direct 18 Total amount of claims paid £69 No. of necessitous cases in which repayment of claim was waived, or partial repayment of claim was accepted by the Committee 8 Inspection of Midwives. Dr. G. H. Stinson, Assistant Medical Officer of Health reports:— " All midwives practising in Bromley in 1935 came under routine inspection at their homes and while in attendance on a case. Almost without exception the rules of the Central Midwives Board were being carefully adhered to, and, where minor breaches of the rules were observed the midwives complied with instructions. It is this happy co-operation that makes for good midwifery; the midwives being more appreciative of the helpful advice given at these inspections. If criticism can be offered, it is that there is a tendency for some midwives to delay calling in medical advice until absolute necessity arises. This practice is liable to lead to danger, and midwives now realise that early medical advice is an essential principle of their practice." Post-Certificate Course. Facilities were again made available for midwives to attend this Course at Maidstone, and 15 midwives availed themselves of the opportunity of attending. Maternity Hospital and Maternity Homes. The Maternity Hospital admitted 389 patients during the year 1935. Under the Council's assisted maternity hospital scheme 20 cases were referred to the Maternity Hospital. In 27 addition 53 cases were referred through the Ante-Natal Clinic for hospital treatment. These 73 cases were referred by the Department either because of the existence of undesirable environmental conditions, or the cases were likely to be complicated by medical or physical condition. There are six institutions classified as maternity hospitals and homes within the Borough and are registered by the Local Authority under the Nursing Homes Registration Act, 1927. These institutions make provision for 33 maternity beds to which 463 cases were admitted during 1935. Details of maternity and nursing homes registered by the Local Authority appear later in this Report under Part IV. which deals with Summary of General Provision of Health Services in the Area. Puerperal Fever and Puerperal Pyrexia. The Local Authority has arranged with the Queen Charlotte's Maternity Hospital, Isolation Block, Ravenscourt Square, Hammersmith, to accept cases coming under the above mentioned heading. The London Ambulance Service of the London County Council is used for the conveyance of patients to the hospital. The consultant services of Mr. Bright Banister are available in all cases of doubt and where the cause of pyrexia is not of a minor character. His services were called upon for two cases during the year 1935. Post-Natal. Home Visiting. At the end of 1935 the Nursing Staff comprised six full-time health visitors, who are also school nurses, dividing their time equally between the maternity and child welfare and school medical services.. The purpose of home visiting is to bring to the home expert knowledge of mother-craft and baby-craft, in which our health visitors are specially trained. It is sometimes forgotten that the health visitor is not only a fully general trained hospital nurse, but also possesses the special certificates required by the State for the practice of 28 midwifery and health visiting as well as the State Registration for general nursing. To obtain these qualifications the nurse must give some five arduous years of training to full time study. There are not many professions that require this length of training. The value of home visiting to the baby and mother after the midwife has completed the confinement cannot be over-estimated. The young mother, who would otherwise be left to the unguarded advice of well meaning but misguided neighbours, welcomes her visits and follows her expert advice, and the result is to-day that the knowledge of baby-craft has advanced probably more rapidly than any other branch of medicine; the mother herself is more skilful and more well-informed and the young baby given not only a greater chance of life but a hope of health and happiness. Our " Sarah Gamps " have gone, our infantile mortality rate has fallen from 120 to 27 in a short period of 35 years, and life is happier because the dreadful fear of baby death has been so greatly reduced. Appendix XII. sets out in detail the statistics of home visitation in the six areas apportioned between the health visitors. The aggregate total of home visits amounted to 9,683. This figure includes 1,431 " ineffectual " visits, so classified as they do not in all respects make a substantial contribution to child welfare and mother-craft, e.g., visits where the family is found to have removed, where no answer is received, or where visits meet with no appreciation. There were 798 births (live and still) known to have occurred in Bromley during the year 1935. Some 159 of these babies were transferred out of Bromley after the completion of confinement and therefore did not come under our own maternity and child welfare scheme. Taking the number of primary visits to the newly born, together with enquiries into stillbirths, it will be found that visitation to no less than 80 per cent. of all births was accomplished during the year. The health visitors made 630 effective primary visits to the newly born, and it is satisfactory to note that the welfare centres record no less than 489 new enrolments of 29 babies under one year which figure represents 64 per cent. of all notified births. Further to these visits each expectant mother who attended the Ante-Natal Clinic, received a following-up visit; there were 205 visits in all to 162 individual mothers. Out of the total of 9,683 visits 6,384 (66 per cent.) were devoted to ante-natal, post-natal and welfare generally, of the mother, or to the child under five years of age. It is pleasing to note that notwithstanding the many duties to be performed by the health visitors at the school clinics and welfare centres, there has been no lessening in the number of visits paid. The results of home visitation are reflected in the satisfactory statistical returns from the welfare centres, which show increased activity from year to year. Visitation in a good residential area where the standards of social life and education are high, demands from the visitors not only tact, but also the ability to disseminate convincingly the specialised knowledge at their command. That these qualities are not lacking in the staff personnel is clearly indicated by the growing popularity of the welfare service. Welfare Centres. The Corporation provides six welfare centres in the Borough at which eight sessions are held weekly. It became necessary during the year to take into consideration certain administration changes which would accrue when the School Clinic at Princes Plain opened in the early months of 1936. At the time of writing these changes have been put into effect. The venue of the Bromley Common Centre has been changed from St. Luke's Institute, Raglan Road, to South Clinic, Princes Plain, and it was found expedient to change the meeting place of the Shortlands Centre from the Congregational Hall, Martin's Road, to St. Mark's Hall, Mason's Hill. The removal of the Shortlands Centre has had the effect of narrowing down the gap left by the removal of the Centre from Raglan Road to Princes Plain, without seriously inconveniencing the Shortlands area. 30 The following extracts of figures relate to work at the Centres during the year 1935:— (a) The total number of attendances at all centres during 1935 19,315 (i) By children under 1 year of age 8,682 (ii) By children between the ages of 1 and 5 10,633 (b) The total number of children who attended at the centres for the first time during 1935 740 (i) Children under 1 year of age 489 (ii) Children between the ages of 1 and 5 251 (c) Total number of children who were in attendance at the centres at the end of 1935 2,081 (i) Children under 1 year of age 379 (ii) Children between the ages of 1 and 5 1,702 Appendix XIII. gives statistical details of the work done at the Centres. Beyond a slight falling off in figures at the Shortlands Centre, due in part to only 49 sessions in 1935 against 51 in 1934, there has been a general increase in work. The number of babies attending all centres at the close of the year 1935 amounted to the very high figure of 2,081, an average of 347 per centre. No less than 19,315 attendances were made by the infants, an average of 48 per session. This is an increased average of six per session over the year 1934. The individual centres give the following averages per session for 1935, and figures for 1934 are shown in comparison:— 1935. 1934. Bromley Common 57 50 Burnt Ash 36 32 Hayes and Keston 60 37 Plaistow 60 50 Shortlands 32 38 Widmore 47 42 31 A doctor was in attendance at 251 sessions, at which a total of 3,028 medical examinations were made—an average of 12 per session. Again 1 must record with appreciation the excellent work performed by the Voluntary Workers at the Centres. Not only do they bring a pleasing social influence into the work of the centres, but also render valuable assistance in the clerical duties, e.g., the weighing of babies, the recording of attendances and results of weighing, and the booking of drugs, etc., sold. In connection with this work it is noteworthy that no less than 16,536 weighings were recorded during 1935—an average of 41 per session. Milk in Necessitous Cases. The number of applicants granted assisted milk supply during 1935 w as 52. A total of 4,521 pints of milk being distributed at a cost of approximately £54. The following table gives an analysis of the size of families who received free milk during 1935:— No. of Children in Family. 1 2 3 4 5 6 and over No. of Applicants 14 14 8 5 5 6 Percentage of total Applicants 27 27 15 10 10 11 Institutional and Convalescent Treatment. We are still dependent upon the good offices of voluntary associations in cases where mothers, and ailing children under five years of age, need convalescent treatment. Although we are never denied this assistance there are many cases of mothers and babies coming under our notice who would materially benefit by convalescent treatment, but we perforce confine ourselves to seeking assistance in only the most urgent cases in the financial interests of the voluntary bodies. 32 The Department referred 16 children under five years of age to institutions for sick and ailing children during 1935, and in one case a mother and baby were admitted to a convalescent home. Minor Ailments Clinic. The policy of early treatment of the pre-school child is carried out, and thus with the benefits of the facilities of the School Medical Service, we are able to minimise gross physical defectiveness in the school entrant. Treatment in 107 cases was carried out at the School Clinic as follows:— Minor ailments 59 Tonsil and Adenoid operations 18 Eye defects 21 Orthopaedic 9 Dental Clinic. The number of cases treated during 1935 were:— Expectant. mothers or nursing mothers 42 Children under five year of age 51 Ophthalmia Neonatorum. There were three cases notified under the Public Health (Ophthalmia Neonatorum) Regulations, 1926. Each case received hospital treatment. In two cases vision has been impaired and the patients are still under treatment. Diarrhoea and Enteritis. It. is satisfactory to note that only one death is recorded within Bromley in 1935. The mortality rate per 1,000 live births is given in the following comparative table Mortality per 1,000 live births. England and Wales as a whole 5.7 121 County Boroughs and Great Towns including London 7.9 140 Smaller Towns 3.8 London 11.2 BROMLEY 1.30 33 Children and Young Persons Act, 1932. 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 1935 35 (b) No of children on the register at the end of 1935 39 Failure to give notice of reception in three instances within the prescribed number of days were dealt with informally as in each case the contraventions were not flagrant breaches of the regulations. One boarded-out child died in 1935 from diphtheria. 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 The Public Health Acts (Amendment) Act (Parts II., III., IV., V. and VI., and Sections 81, 84, 85, 86 and 95) 1907 The Public Health Act (Parts II., III., IV. and V.) 1925 The Notification of Births Act 1907 The Local Government and Other Officers Superannuation Act, 1922 1927 Bye-Laws: (a) Made by the Town Council:— 1. With respect to the Regulation of Advertisements (Advertisements Regulation Act, 1907) 1910 2. With respect to the lighting of Road Obstructions 1922 34 3. With respect to Good Rule and Government of the Borough 1927-1935 4. With respect to Registries for Female Domestic Servants 1927 5. For Public Libraries 1926 G. With respect to Public Pleasure Grounds 1906 7. With respect to Common Lodging Houses 1/5/1935 8. With respect to Nursing Homes 1928 9. For imposing on the Occupier of any premises duties in connection with the removal of house refuse so as to facilitate the work of collection 1/5/1935 10. With respect to the cleansing of earth closets, privies, ashpits or cesspools 1/5/1935 11. With respect to Slaughterhouses 1/5/1935 12. With respect to Nuisances arising from snow, filth, dust, ashes and rubbish, and for the prevention of the keeping of animals on any premises so as to be injurious to health 1/7/1935 13. With respect to Nuisances in connection with the removal of offensive or noxious matters 1/5/1935 14. With respect to New Streets and Buildings, and the drainage of existing Buildings 1926-1934 15. With respect to lodging and accommodation for persons engaged in hop and vegetable picking (Part only of the Borough) 1931 16. Providing for Means of Escape from Fire in certain Factories and Workshops 1/7/1935 17. With respect to School Attendance 1900 18. With respect to the Prevention of Disturbances in School Buildings, etc. 1912 35 19. With respect to the Employment of Children 1/3/1935 20. As to Commons (Under Metropolitan Common Scheme Confirmation Act, 1909) (b) Made by the Kent County Council, but in force in part of the Borough for a period of three years from 1st April, 1934, unless previously repealed or altered by bye-laws made by the Town Council (Kent Review Order, 1934):— With respect to the Regulation of Advertisements (Advertisement Regulation Acts, 1907 and 1925) 1912-1927 Orders: 1891: Cap. LXII. 54 and 55. Vict. Supply of Electricity in the urban sanitary district of Bromley. 1934: Kent Review Order, 1934. (Under Local Government Act, 1929: sec. 46). 1922: Hairdressers' Early Closing Order (Made under the Shops Act, 1912). 1930: Midwives Acts 1902-1926 (Order under Section 62 of the Local Government Act, 1929). Regulations: 1. As to Sewer Connections. 2. As to the Movement of Sheep 1933 3. Kent (Music and Dancing) Licensing Regulations, 1928. No. 1 (Made by the Kent County Council under the Home Counties (Music and Dancing) Licensing Act, 1926). 4. As to Cemeteries. 36 txical Act: 1909: Cap. CXXV1. 9. Edw. 7. (To confirm a Scheme under the Metropolitan Commons Acts, 1866 to 1898, with respect to Keston Common and Leaves Green). Hospitals. (1) Infectious Diseases Hospitals: West Kent Isolation Hospital- Recognised accommodation 115 beds. Actual number in use 160 beds. 27 cots. West Kent Smallpox Hospital— Recognised accommodation 39 beds. Actual number in use 39 beds. 9 cots. (2) General Hospitals: Bromley (Kent) and District Hospital 50 beds. Phillips Memorial (Homeopathic) Hospital 20 beds. (3) Maternity Hospital: The Bromley and Chislehurst Maternity Hospital 19 beds. (In addition there are 2 labour wards and 1 isolation ward). Maternity and Nursing Homes. The following table gives particulars of maternity and nursing homes registered by the Local Authority, anil for convenience of tabulation I have included details of the larger hospitals which are exempt from registration under the provisions of the Act:— Address. ??? ??? ??? ??? ??? Total. Resident Living out. Qualifications. ??? 77, Avondale Road 6 3 17 23 17 4 1 3 1 Gen. Trained and S.C.M. Mixed 3 Gen. Trained. 40, Bromley Common 10 5 25 44 22 5 5 - 2 Gen. Trained and S.C.M. Mixed 2 Gen. Trained. 1 S.C.M. "Greta," Blyth Road 10 — — 106 27 7 4 3 3 Gen. Trained and S.C.M. Nursing 3 Gen. Trained. 1 Assistant. 24, Elmfield Road 10 2 6 — 9 4 4 — 2 Gen. Trained Mixed 2 Assistants. 3. Elmstead Lane 8 1 2 34 12 4 4 - 4 Gen. Trained. Mixed 29, King's Avenue 2 Registered in 1936 4 4 - 1 Gen. Trained. Nursing 2 Masseuse. 1 post vacant. "Frascati," Masons Hill 23 3 24 31 53 12 12 4 4 Gen. Trained and S.C.M. Mixed 2 Gen. Trained. 1 S.C.M. 5 Asst. Nurses. 126, Princes Plain 2 — — 3 1 1 — 1 Gen. Trained. Nursing 16, Sundridge Avenue 4 - - - 8 2 2 - 1 Gen. Trained. Nursing 1 Male Nurse trained R.N. (Home under supervision of Resident Medical practitioner). 13, Tweedy Road 4 — — 2 1 1 — 1 Gen. Trained. Nursing Maternity Hospital, 118, Widmore Road 19 19 389 - - 11 11 - 5 Gen.Trainedand S.C.M. Maternity 1 S.C.M. 5 Asst. Nurses. Bromley (Kent) and District Hospital, Cromwell Avenue 50 - - 575 223 22 22 - 2 Gen. Trained and S C M. General Hospital cases 5 Gen. Trained. 2 Masseuse. 1 vacancy. Phillips Memorial Hospital, Lownds Avenue 20 — — 98 104 7 7 — 12 Untrained. 3 Gen.TrainedandS.C.M. General Hospital cases. 2 Gen. Trained. 1 Asst. Nurse. 1 Probationer. 37 38 Institutional. (1) The Rochester Diocesan Society for Befriending Women and Girls has a home at 29, Ravensbourne Road, which was opened in October, 1912. Here unmarried expectant mothers are received and arrangements made for their confinements in maternity homes or in the Farnborough Hospital (Public Assistance Institution). Subsequent to confinement the mothers and babies are received into the Home and kept there until employment is found for the mother. If the employment is not of such a nature as to allow the mother to care for her child, foster-mothers are found by the Society. The Home has no subsidy from public funds. (2) The Blind Hostel, Southlands Road, is a Hostel maintained by the London Association for the Blind, and receives no subsidy out of the rates. (3) Hostel for Women at 10, Crescent Road, is for women and girls, and was opened in September, 1933, by the Bromley National Council of Women. The Hostel has no subsidy from public funds. Ambulance Facilities. (1) For Infectious Disease Cases: Provided by the West Kent Joint Hospital Board at their Hospital at Lennard Road, Bromley Common. (2) For Non-Infectious and Accident Cases : The Corporation provides two ambulances, stationed at the Fire Brigade Station, which are available at all hours for the removal of sick cases of non-infectious nature and accident cases. The fee may be remitted in necessitous cases. Laboratory Facilities. The West Kent Isolation Hospital undertakes the testing of throat swabs, and the arrangements continue to work satisfactorily, and the facilities provided by the Kent County Council are used for the examination or analysis of clinical material (sputum, etc.), water, milk and foodstuffs. 39 Clinics. There are now two School Clinics, viz., North Clinic, Station Road, opened in 1928, and South Clinic, Princes Plain, opened in February, 1936. The extension of the North Clinic building was completed in August, 1935, and the increased accommodation thus afforded has remedied the inconvenience of overcrowding which had for some time hampered the work of the clinic. The building of the new clinic at Princes Plain was commenced in 1935, and in February, 1936, the services began to function there. The benefit of a clinic more easily accessible to the rapidly growing area at the southern end of the Borough is becoming more apparent week by week judging from the increased attendances. At the present time the staff personnel is only adequate to maintain at the South Clinic the following services provided by the Local Authority:— 1. Special Medical Inspections (daily). 2. Minor Ailment Treatment Clinic (daily). 3. Dental Clinic (two sessions weekly). 4. Ante-natal Clinic (once a month). 5. Welfare Centre (two sessions weekly) transferred from Raglan Road. Items 1 to 4 are extensions of existing services undertaken by the present staff. The North Clinic at Station Road continues to provide the following clinics:— 1. Special Medical Inspection Clinic (daily). 2. Minor Ailment Treatments Clinic (daily). 3. Eye Clinic (six sessions per month). 4. Orthopaedic Clinic (two sessions per month). 5. Massage and Remedial Exercises Clinic (four sessions a week). 6. Ultra Violet Ray Clinic (two sessions a week). 7. Dental Clinic (daily). 8. Diphtheria Immunisation Clinic (once a week). 9. Ante-natal Clinic (twice a month). Nursing in the Homes. (1) The Bromley District Nursing Association, which was formed in 1907, provides two general trained nurses 40 for professional district nursing in the homes of those who are unable to provide their own nursing facilities. There are three State certified midwives on the staff of the Association who undertake midwifery and maternity work. The fee for midwifery and maternity cases is £2 2s. 0d, except in necessitous cases. The general nursing takes the form of visits, and not of residential nursing. No fee is charged for general nursing. Cases of notifiable infectious disease are not undertaken, with the exception of complicated cases of measles. Summary for the year 1935. Cases on the Register, January, 1935 23 New cases during the year 502 Visits Paid. General nursing 4738 Ante-natal visits 1545 Maternity and midwifery 3555 Casual visits 926 Analysis of New Cases. Medical 142 Surgical 142 Maternity (with Doctor) 67 Midwifery 148 Abortions 3 Cases sent in by: Doctors 235 Visitors and others 3 Applied 204 Result of Cases Nursed. Convalescent 420 Sent to Hospital, Infirmary or transferred Died Still on register 24 Nursing Staff. (i) General Nurses 2 (ii) Midwives 3 41 (2) The Hayes and West Wickham Nursing Association provides similar facilities for the areas of Hayes and Keston. Their sphere of activity also covers West Wickham, which is within the area of a neighbouring Local Authority. Membership of the Association entitles parents, and children under 16 years of age, in a family, to free nursing on payment of 5/- per annum, and members of the same family over 16 years of age may join on payment of a further 2/6 a year. Non-members may have the nurse's services, if her time permits, at a charge from 1/- per visit. Members' fees for maternity work are:— Midwifery £2 0 0 Maternity nursing £1 10 0 Non-members' fees are:— Midwifery £2 10 0 Maternity nursing £2 2 0 The Association employs one general trained nurse for general work and one State certified midwife for midwifery and maternity nursing. Details of nursing visits for the year 1935-1936 are as follows:— Cases Nursed. General 230 Midwifery 16 Monthly 21 267 Visits Paid. Nursing 2578 Ante-natal 618 Casual 196 3392 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. 42 B. G. A. Edelston. The districts covered by these two dispensaries are, Bromley, Beckenham, Penge, Anerley, and parts of Sydenham and Upper Norwood, Chislehurst and Sidcup Urban districts and Orpington Urban district. The Tuberculosis Officer's head office is at the Bromley Dispensary, which is held at 2, Park Road, Bromley, on Wednesdays at 1.30—3.30 p.m., and on Fridays at 5—6 p.m. The Corporation supplies a nurse from the Health Visiting staff for the Wednesday dispensary who also carries out home visiting of patients. The work of the Dispensary is briefly reported on by the Tuberculosis Officer under Part XY. of this Peport. Venereal Diseases Treatment Centres. The Kent County Council provide treatment at various centres in the County. There is no centre in the Borough. The close proximity of London, where ample facilities are available at the various London Hospitals, provides an adequate and convenient service for such cases. V.—SANITARY CIRCUMSTANCES. Rivers and Streams. No cudverting of watercourses was carried out except the normal piping in of small streams by estate developers as their building operations took place. Four nuisances from pollution of a minor character were investigated during the year, and after service of informal notices the unsatisfactory conditions were remedied. Drainage and Sewerage. The main drainage of Bromley links up with the undertaking of the West Kent Main Sewerage Board, whose purification works are at Dartford. New Sludge Digestion Works were inaugurated by the Board at their Sewage Purification Works, Dartford, on 6th July, 1935, which is capable of dealing with a population of 340,000. The process is reported to have proved successful in every way. Soil sewers were extended in Longdon Wood, Forest Ridge and Forest Drive, 43 Cesspool Drainage. Five new premises were erected with cesspool drainage. Four of these premises, however, drain to one cesspool, which at the time of writing are being connected up to the soil sewer now being laid. Progress of Conversion f rom Cesspools to Main Drainar/e. After the survey of the added areas of Hayes and Keston it was found at 1st April, 1934, that 361 premises were not on main drainage, as follows:— Total. Sewers available. Sewers not available. Premises with privy pans 103 89 14 ,, ,, cesspools 254 82 172 „ ,, purification plants 4 4 — 361 175 186 With the laying of new sewers in these areas during the past two years, the availability, or otherwise, of sewers indicated in the above table of figures has necessarily undergone a change, as will be seen from the following tabulation of progress made in conversions (luring the past two years:— Premises Re-drained and Connected to the Server. 1934. 1935. Total. Cesspools abolished 24 114 138 Earth closets 3 — 3 Privy pans 28 35 63 55 149 204 Water. A piped supply is general throughout the area, and comes mainly from the Metropolitan Water Board's deep chalk wells at Shortlands valley. The supply is sufficient, very hard, but of high grade purity. Particulars of reservoirs within the district are given on page 35 of my Annual Report for 1930. 44 The following particulars have been extracted from the Metropolitan Water Board's Report for 1934, which shows the results of bacteriological and chemical examinations of deep well waters, being the averages for twelve months ended 31st December, 1934:— Shortlands Wells. Bacteriological Examinations:— No of samples 13. Average No. of microbes per c.c. 0.08 B. Coli test 100 per cent absent in 100 c.c. Chemical Examination—Averages 12 months ended 31st December, 1934 :— No. 1. Shortlands. No. 2. No. 3. No. of samples 1 2 0 Ammoniacal Nitrogen 0.0004 0.0000 0.0000 Albuminoid Nitrogen 0.0030 0.0020 0.0022 Oxidised Nitrogen 0.53 0.38 0.51 Chlorides 1.96 1.77 1.82 Oxygen absorbed in 3 hrs. 0.011 0.008 0.010 Total hardness 27.5 23.7 27.0 Permanent hardness 5.3 6.3 6.9 Scavenging. The public cleansing services have been functioning normally throughout the year. There is no extension of improvement in refuse collection and disposal to record. Swimming Baths and Pools. The filtration and chlorination installation at the Corporation's Swimming Bath at Southlands Road continues to work satisfactorily. Rats and Mice Destruction Act, 1919. The general public evinced some increased interest in "Rat Week" of 1935 as is shown by the statistics below of the comparative statement of distribution of poisons. An exhibition of stuffed rats and poison products was again organised by the Chief Sanitary Inspector and proved a useful medium for instruction in the best methods of rat destruction. Large and small posters issued by the 45 Ministry of Agriculture and Fisheries were displayed throughout the area, official leaflets and pamphlets were distributed and special notices on rat destruction were inserted in the local press. 1935. 1934. Total No. of applicants for poison during Rat Week 120 78 (a) From Trade premises 38 16 (b) From private premises 82 62 No. of bottles of red squill given free 219 123 No. of tins of red squill biscuits given free 27 28 During 1935 the Department's Officers were active in following-up cases of infestation and investigating potential sources of infestation. The following figures indicate to some extent their activities:— Total No. of inspections during 1935 289 „ ,, ,, infestations discovered 107 ,, ,, ,, ,, abated 63 VI.—HOUSING CONDITIONS. The housing conditions of Bromley keep to the high standard of a good residential area. At the same time one must note the gradual change in character, due mainly to the change in economic conditions and to the efflux of working-class population from London to the area known as Greater London. Some of the larger estates are beingdivided up, and the larger residences converted into flats. This change does not apply only to Bromley, and we can still say that Bromley retains its character of what has been described as a dormitory town of London. It is of some interest in this respect of change of character to note the statistical comparison of the population per acre as compiled for each ward from the census returns for 1921 and 1931:— 1921. 1931. Area as a whole 7.5 9.7 Bickley 5.4 6.1 Bromley Common 4.7 6.1 Sundridge 4.9 5.5 Town 15.5 21.4 Plaistow 15.0 24.7 Mason's Hill 16.8 16,7 Keston and Hayes 0.7 1.2 46 A further interesting comparison is shown by tiie following figures which explain themselves and which include extracted figures from the housing survey made in January, 1936. 1921 Census. 1931 Census. 1936 Housing Survey. Families living in one room 293 304 471 Families per dwelling 1.14 1.11 1.08 Average size of family 4.04 3.70 3.61 Average persons per room 0.76 0.72 0.65 Average rooms per house 6.08 5.70 5.5 In recent years Parliament has given much attention to the housing question, and the passing of the Housing Act, 1935, placed upon local authorities increased responsibilities and consequent increased activity in this fundamental service for the welfare of the people. This Act improved the provision relating to the abatement and prevention of overcrowding, for the re-conditioning of working-class houses and generally consolidated the enactments relating to housing questions. The result in Bromley, even in these early years of the Acts, has been an improvement in the living conditions of the people, although one still notes the lack of provision of baths in many of the houses erected before the establishment of modern bye-laws.. Overcrowding. Under Section I. of the Housing Act, 1935, it became the duty of this Local Authority to make an inspection of the district, and to submit before the 1st June, 1936, a report on the state of over-crowding and at a later date, to submit proposals for the abatement of overcrowding.. The standard of overcrowding laid down in the Act is as follows:— Rooms. Persons. 1 2 2 j 3 3 5 4 7½ 5 or more 10 with an additional 2 in respect of each room in excess of 5. OVERCROWDING SURVEY—PRELIMINARY REPORT. Number of families containing the number of persons in the first column occupying dwellings with the permitted number shown at the head of this column. No. of “ersons ” in family. 1 1½ 2 2½ 3 3½ 4 4½ 5 5½ 6 6½ 7 7½ 8 8½ 9 9½ 10 10½ 11 11½ 12 13 14½ 16 17½ 19 20-30 30 -40 40-50 50-60 Over 60 Families. Overcrowded. Un- crovvded. Total. 1 345 230 189 148 132 47 24 7 2 1 1 2 1127 1127 14 6 5 5 3 4 24 24 2 97 407 688 895 1C50 573 201 80 26 9 4 3 4 1 97 4541 4638 24 11 105 249 314 497 163 31 5 3 2 1 11 1370 1381 3 10 49 376 760 1348 647 279 132 64 32 7 9 5 59 3659 3718 3½ 1 18 95 176 287 111 52 16 7 2 1 19 747 766 4 1 11 139 361 830 414 227 121 68 52 28 11 12 1 12 2264 2276 44 1 50 93 177 69 46 21 20 3 2 1 1 51 433 484 47 or on the basis of floor space Rooms. Persons 110 sq. ft. or more 2 90—110 sq. ft. 1½ 70- 90 „ „ 1 50- 70 „ „ ½ Less than 50 sq. ft. 0 On either of these bases the standard is by no means a high one, and it is a little disappointing that the living room should be considered as available for sleeping accommodation. Although this survey was carried out in January, 1936, which does not rightly come under the Report for 1935, it might be of some interest to give the state of overcrowding as disclosed by this survey. The preliminary survey was limited to a house-tohouse enquiry to obtain number of rooms, number and age of occupants and number of families in each house. The survey was completed during the month of January so that the figures obtained are accurate; a lengthy survey would have resulted in an inaccurate return owing to the fact that 20 per cent, of the inhabitants change their residence every year. The survey was not limited to houses of the working-classes as the definition of a working-class house remains obscure. Fifteen thousand five hundred and ninety-five houses were visited, in 12 instances information being refused and not obtained at the end of the survey. The figures are of interest:— 1022 had 2 families per house 134 „ 3 „ „ „ 25 „ 4 „ „ „ 1 „ 5 „ „ „ 844 took in lodgers. Form C was completed and forwarded to the Ministry. For reference I have inserted this form with footnote for explanation. The form which is compiled of families and not necessarily structurally separate houses includes L.C.C. Estate and houses erected by the Town Council, which make up 8.4 per cent, of all houses. It is to be 48 noted that the overcrowding is based on Table I. of the Act of 1935 which allows for a reduction factor of one-fifth, a factor which in Bromley is proving too great a reduction with the result that the overcrowding figure of 459 families will be greatly reduced on actual measurement of the houses. In the current year these "overcrowded" houses are being individually investigated. Overcrowding exists chiefly in the sub-tenant families and brings forward again the necessity of bye-laws dealing with houses let-inlodgings. It is these families who live not only in overcrowded conditions, but without the amenities that make for a happy home. There are no less than 1,371 families in Bromley living as sub-tenants. Inspection of District. Nine hundred and sixty-six dwelling-houses were inspected during 1935 and these involved 5,517 visits for inspections. Of these 960 houses 721 were found not to be in all respects reasonably fit for human habitation, and at the end of the year 712 had been rendered fit after service of informal notices. Six houses were made fit after formal notices under the Public Health Acts, and statutory notices under the Housing Act, 1930, were served in 33 instances. This housing inspection of the district is a duty placed upon the Local Authority by statute and forms one of the main duties of the Sanitary Inspectors. By reference to appendices VII., VIII. and XV., the extent of this work will be seen, and I would here like to record the very efficient manner in which these duties are carried out by Mr. G. R. Woods, Chief Sanitary Inspector, and the District Sanitary Inspectors. Unfit Houses. Since the inception of the Housing Act, 1930, 62 houses have been scheduled as unfit for habitation (four of which number have been rendered fit in Gravel Pits) and condemned as not repairable at reasonable cost. Ten of these houses had been demolished at the end of 1935, and a further 23 had been closed to human habitation. This good progress has only been possible by goodwill of 49 owners and tenants who have been so ready to meet us in our aim to make every house a fit one. Contraventions. Public Health Acts. No serious contravention which called for statutory proceedings came under the notice of the Department. VII.—SMOKE POLLUTION. Eight inspections were made in connection with nuisances arising from the emission of smoke; five were through complaints received and three in the course of routine inspection. In six instances a nuisance existed, and, as a result of informal action taken, abatement was secured in each case. The Sanitary Inspectors, three of whom hold the special certificate of the Royal Sanitary Institute for Smoke Inspection, find that there is a general desire on the part of firms having steam generating equipment, to remedy as much as possible the causing of nuisances from emission of smoke, and to carry out the expert advice given for improvement in stoking methods. VIII.—SHOPS ACTS, 1912-1934. The Shops Act, 1934, came into operation on the 30th December, 1934. The Sanitary Inspectors were reappointed as inspectors for the purposes of the Act, and also one Health Visitor is authorised to act as an inspector under the direction of the Medical Officer of Health where special circumstances warrant it. We have in Bromley some 800-900 premises of retail business to which this Act applies. Happily the Act has received the support generally of shop-keepers, otherwise the multiple provisions of the Shops Acts would entail a superabundance of detailed work which could only be encompassed by a special staff. Fundamentally the Act of 1934 aims at control of hours of employment and the safeguarding of the young growing adolescent against undue fatigue through working long hours. Inasmuch as the Act controls the hours of 50 employment, it becomes a natural sequence to the Children and Young' Persons Act, 1933. Fatigue is known to be responsible for much chronic disease, and is, therefore, to be controlled in the young person as well as in the child. The inspectors made 396 inspections during 1935, and it will be noted from the following tabulation that the bulk of contraventions was absence of certain prescribed forms under the Act. Informal action secured compliance with the requirements in all cases. Particulars of Contraventions found under the Shops Acts. Unsatisfactory conditions relating to— Ventilation 1 Temperature 22 Sanitary conveniences 16 Absence of statutory forms— Assistants Half-Holiday forms 43 Form E (Record of hours of employment of young persons) 3 Closing declaration 24 Form F (Daily hours to be worked by young persons) 35 Form Gr (To be used only in connection with form F) 37 Statutory Closing Notice (if partially exempt) 5 Form H (Abstract of provisions of the Shops Act relating to hours of employment of young persons—for retail shops) 39 Form .T (The like in connection with wholesale and warehouses) 1 Form K (Notice with regard to the provision of seats for female workers) 49 Other unsatisfactory conditions found— Meals rest interval not satisfactory 1 Unsuitable and insufficient means for meals Washing facilities not satisfactory 11 Refuse accommodation not satisfactory 5 51 Other Contraventions. Nature of Offence. Type of Shop. Action taken. Assistants working after Wireless Warning given, closing hour on statutory Appliances, half-holiday. Hours of employment of Provisions. Do. young persons exceeded. IX.—PETROLEUM ACTS. Number of Licences issued 108 (i) For Petroleum Spirit 106 (ii) For Carbide of Calcium 2 Total quantity of Petroleum Spirit in gallons 189,504 (i) Bulk storage, in gallons ... 176,925 (ii) Two-gallon can storage, in gallons 12,579 Carbide of calcium, in lbs 444 Of the 108 licences issued, 96 were renewals and 12 were new or additional licences. Included in the total of 108 licences are 15 combined licences for bulk and can storage. Two hundred and sixty-two inspections of storage places were made during 1935. The following figures show the increase in licenced storage since 1926 :— Year Petroleum Spirit. Licences issued. (in gallons). (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 1934 174,554 96 1935 189,504 106 52 X.—FACTORIES AND WORKSHOPS. Appendix XIV. gives details of statistics with repaid to inspections and defects in factories, workshops and workplaces. There are 484 of these premises on the register. XI.—PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS, REGULATIONS, ETC. Visits of inspection to the number of 4,976 were made to the following premises and occupations controlled by Bye-laws, Regulations, etc., Bakehouses, Butchers' premises, Cinemas, Confectionery, Ice Cream, etc., Dairies, Cowsheds and Milk shops, Factories, Workshops, Workplaces and Outworkers' premises; Fish shops, Food Hawkers, Food shops, Hotels, Restaurants, Licensed premises (public houses), Nursing Homes, Offensive Trade (tallow melting), Petroleum Spirit stores (licenced), Piggeries, Bag and Bone Dealers, Registry Offices, Shops (various), Slaughterhouses, Stables, Tents, Vans and Sheds. XII.—INSPECTION AND SUPERVISION OF FOODSTUFFS. The Sanitary Inspectors have devoted a large proportion of their time to this important branch of the health services, and during the year paid 2,8.30 visits to various types of food preparing premises. Milk. Fortunately the main supply of milk distributed within the area is pasteurised. During the year registered premises concerned with the retail of milk underwent; complete inspection, and revision of the register resulted in some 25 names being deleted, the proprietors having ceased to carry on milk business. The current register is made up as follows:— Dairies and Milk Stores:— (i) Premises within the Borough 73 (ii) Premises outside the Borough 25 53 Dairies licenced for sale of Graded Milk:— " Pasteurised " milk 14 " Certified " milk 8 " Grade A Pasteurised " milk 1 " Grade A (Tuberculin Tested) milk 9 Two milk producers hold licences from the Ministry of Health for " Certified " and " Grade A " (Tuberculin Tested) milk in respect of farms within the area. Milk. Bacteriological Examinations. There were 119 samples of milk submitted to bacteriological examination, and the results are shown in the following table, which includes the samples taken at the request of the Ministry of Health from licenced producers of "Certified" and "Grade A (Tuberculin Tested) " milk. Samples. Totals. Satisfactory. Unsatisfactory. " Certified " 29 29 — " Grade A (T.T.) " 29 27 2 " Pasteurised " 13 13 — Ordinary milk 48 19 29 119 88 31 Eighteen samples of milk were submitted to test for the presence of tubercle bacilli and in one case the result was positive. Action was taken under the Tuberculosis Order of 1925 and the infected animal was destroyed. In the 31 instances of unsatisfactory results in the above table, it was found that the presence of bacillus coli was the prevailing fault, and in every case improvement was brought about with the producers concerned. Milk. Contraventions. The Milk and Dairies Order 192(1 was contravened during 1935 in the following instances:— Oftence. Action taken. Filling and sealing two half-pint Warning given. bottles in roadway. Dirt contaminated milk and Do. Utensils, and not registered. 54 Meat. There are five registered slaughter-houses and three licenced slaughter-houses which undergo regular visitation by the inspectors. During 1935 the number of animals known to have been slaughtered within the Borough was 3,012, and of this number 2,988 of the carcases were viewed by the inspectors. Thus 98.8 per cent, of carcases were examined before reaching the purchasing public. In addition to the above inspections 87 carcases coming into the district from other areas were inspected. This work is mostly done at the request of local butchers. It is pleasing to record that cordial co-operation exists between the local butchers and the Department, and has proved on many occasions to be exceedingly helpful to all concerned. The Local Authority granted 22 licences to slaughtermen during 1935, under the provisions of the Slaughter of Animals Act, 1933. 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 3012 301 Ill 1460 1140 Carcases Inspected 2988 300 110 1458 1120 55 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). 3012 2988 127 (4.3 per cent) 138 (4.6 per cent) 265 Table C. Total number of carcases rejected for Tuberculosis and other defined diseases. Disease. Bulls. Cows. Heifers. Bullocks Calves. Sheep. Pigs. Total. Tuberculosis — 3 3 — I — 8 15 Other defined diseases - - - - - - 4 4 Total -- 3 3 — 1 — 12 19 Table D. Total number of all carcases, parts of carcases and offal rejected for all diseases. Disease. Carcases. Parts of Carcases. Offals of Carcases. Total number affected. Tuberculosis 15 51 61 127 Other defined diseases 4 1 133 138 Total 19 52 194 265 56 Table E. Total weights of carcases, parts of carcases and offal rejected for all diseases. Tons. Cwts. Qrs. Ibs Total in lbs. Carcases 2 13 1 12 5976 Parts of carcases — 11 3 9½ 1325½ Offal — 11 3 4 1320½ Total 3 16 3 26 8622 Meat. Contraventions. No serious contraventions of the Meat Regulations were encountered during the year, 1935. Unsound and Unwholesome Food Surrendered. Article of Food. Weight. Meat 94 lbs. Poultry 69 „ Fish 75 „ Tinned Goods. Quantity. 980 lbs. Vegetables 22 tins Fruit 1001 „ Fish 81 „ Milk, Cream 80 „ Meat 51 „ Miscellaneous 11 „ Food and Drugs (Adulteration) Act, 1928. The following tabulation gives particulars of the work of the Food and Drugs Inspector (Mr. E. RGranger) in Bromley during 1935:— 57  No. of Samples. No. of Samples. New milk 55 Dried fruit 2 Ammoniated tine. Quinine 1 Flour 1 Gin 2 Boracic Acid Ointment 1 Ground rice 1 .Tams and Marmalade 2 Brandy 1 Lard 3 Butter 2 Margarine 5 Camphorated Oil 1 Oatmeal 2 Castor Oil 1 Olive oil l Cheese 1 Rice 1 Cocoa 4 Rum 1 Cod Liver Oil 1 Sugar 2 Coffee 2 Tea 1 Condensed milk 1 Tincture of Iodine 1 Custard Powder 1 Whisk 2 Cream confectionery 2 Pepper 1 Total No. of samples taken during 1935 102 No. not genuine, or reported on unfavourably Nil XIII—DISEASES OF ANIMALS ACTS. No. of movement licences received of animals moved into the Borough 82 Animals inspected— (i) Pigs 715 (ii) Sheep, lambs 122 No. of licences issued by the Local Authority 1 Animals inspected—Pigs 8 No. of inspections made in connection with the above details 70 No. of interviews in connection therewith 91 Tuberculosis Order of 1925. A sample of mixed milk, taken in the course of routine visits, on examination proved to be tubercular infected. The animals on the farm concerned were inspected by the Veterinary Officer and one cow was discovered to be suffering from tuberculosis. Action was at once taken under the above Order and the cow was slaughtered. Post mortem examination disclosed an advanced condition of tuberculosis in the animal. 58 These facts are noteworthy in order to demonstrate the importance of pasteurisation of milk which ensures distribution of milk free of tubercular infection. XIV.—RAG FLOCK ACTS, 1911-1928. Three raj? flock samples were submitted for analysis, two of which conformed to standard, but one contained a somewhat excessive proportion of chlorine. Flock is deemed to conform to the standard laid down in the regulations when it does not exceed 30 parts chlorine per 100,000 parts of flock. In the case of the defective sample the remaining quantity of stock was destroyed by the firm concerned, and a subsequent sample proved quite satisfactory. XV.—INFECTIOUS DISEASES CONTROL. Appendix IX. gives the incidence of all notifiable infectious diseases in wards, the cases removed to hospital, the attack rate per 1,000 population, the deaths and the death rates. Appendix IXa. gives the age groups. Scarlet Fever. One hundred and sixty-seven cases were notified during the year, 135 of them were removed to hospital, while the balance of 32 were isolated at home. The practice of removal to hospital of mild uncomplicated cases of scarlet fever is not one to be encouraged, and yet 80.8 per cent, of cases are still admitted to hospital. 116 families had one case in the family. 16 „ „ 2 cases „ „ „ 3 2 „ „ „ „ „ „ 2 „ „ 4 „ „ „ „ 1 „ „ 5 „ „ „ „ Return cases, that is to say cases occurring in the same family within twenty-eight days after discharge of first case from hospital amounted to 10 cases. The swabbing of cases is confusing owing to the fact that the causative organism is so widely spread, even 59 among normal patients. During the year 143 swabs were taken from convalescent patients and from contacts for the presence of hemolytic streptococci as follows:— (i) 44 of which proved positive. (ii) 99 of which proved negative. Diphtheria. Forty-four cases were notified during the year, giving an attack rate of 0.7 per 1,()00 of the ]M)pulation. All of the cases were admitted to hospital. There were 4 deaths, giving a death rate of 0.07 compared with 0.03 of the previous year. This rise in the death rate was due to two factors, the virulence of the infection and delay in calling medical aid early in the disease. The delay in the administration of anti-toxin is primarily caused by the parent overlooking the seriousness of the complaint, medical aid being sought only when the child is “ in extremis.” There is, on the other hand, a tendency to keep the child at home pending the result of a throat swab examination. This practice is liable to be dangerous causing a delay in the correct form of treatment and a danger in spreading the infection. The chief safeguard against this serious infectious disease lies in the immunisation of susceptible children. A weekly Immunising Clinic was held throughout the year at which 90G attendances were made. Patients attend this clinic purely of their own volition, and this gives an indication of the extent of the public response to a service which undoubtedly offers a protection against a disease that last year caused deaths in 9 per cent, of those attacked. Smallpox. No cases were reported during the year 1935. The Vaccination Officers have kindjy furnished the following figures of vaccinations during 1935:— Births registered, in 1934. Successfully vaccinated Unsuccessfully vaccinated Declarations of conscientious object ions 378 Died unvaccinated 18 60 Births registered in 1935. Successfully vaccinated 320 Declarations of conscientious objections 289 Tuberculosis. Appendices IX. and X. give incidence and particulars of cases of tuberculosis in Bromley in 1935. The current register contains a total of 385 names of patients notified as suffering from this infection. This figure gives a rate of 6.8 per 1,000 of the population which, although somewhat lower than the rate for the previous year (7.01 per 1,000), shows a rather high percentage of incidence. Fortunately many of the cases may be classified as in a non-infectious state. An analysis of the total ot 385 cases on the register gives the following details of sex and type of disease:— Total of both types. Pulmonary Tuberculosis. Non-Pulmonary Tuberculosis. Male 195 135 60 Female 190 119 71 385 254 131 Sixty-seven new cases were notified or otherwise revealed to me during the year 1935, of which 52 were pulmonary and 15 non-pulmonary cases, whilst 27 cases died—25 pulmonary and 2 non-pulmonary. I have submitted the following table to indicate the state of tuberculosis in Bromley since 1926—a fall in incidence will be noted. New cases Incidence per 1,000 population. Death Bate. Year. Pulm. Non-Pulm. Pulm. Non-Pulm. 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 1934 1.4 0.2 0.2 0.1 1935 0.9 0.3 0.4 0.03 61 The Health Visitor paid -375 visits to tubercular patients during 1935, giving; advice on care of the patient and on the principles that make for fitness in the contacts. No occasion arose during the year to take action under the provisions of the Public Health (Prevention of Tuberculosis) Regulations, 1925, which relates to persons suffering from pulmonary tuberculosis employed in the milk trade, or under Section 62 of the Public Health Act, 1925, which relates to the compulsory removal to a hospital of persons suffering from tuberculosis. Dr. Edelston, Tuberculosis Officer, has kindly furnished me with the following statistics of the work of the Dispensary during 1935:— NEW CASES which have attended the DISPENSARY for the first time for EXAMINATION during the year 1U35. Adults. Children. Male. Female. Male. Female. Pulmonary 26 13 - - N on-Pulmonary 2 1 - 1 Negative 4 7 4 8 Totals 32 21 4 9 No. of contacts examined during 1935 4 No. found to be positive (not included in above table) 1 Total No. of attendances at the Dispensary 1464 No. of patients receiving residential treatment 87 APPENDIX. 64 LIST OF APPENDICES. I. Summary of Statistics, 1935. II. Comparison of Statistics, 1935. III. Causes of Deaths, 1935. IV. Causes of Infant Deaths, 1935—Age Groups. V. Analysis of Infant Deaths, 1931—1935. VI. Analysis of Infant Deaths and Maternal Deaths, 1910—1914, 1921—1925, 1926—1930 and 19311935. VII. Summary of Work of Sanitary Inspectors, 1935. VIII. Summary of Nuisances Abated, 1935. IX. Return of Notifiable Infectious Diseases, 1935, in Wards, giving- attack rates, death rates, etc. IXa. Notifiable Infectious Disease—Age Groups, 1935. X. lteturn in Age Groups of new cases of Tuberculosis notified, and of deaths occurring in 1935. XI. Return of Ophthalmia Neonatorum, 1935. XII. Summary of Health Visitors' Work, 1935. XIII. Summary of Attendances at Welfare Centres, 1935. XIV. Factories, Workshops and Workplaces, Inspections, 1935. XV. Housing Statistics, 1935. 65 APPENDIX 1. SUMMARY OF STATISTICS, 1935. Population (mid-year 1935, Registrar General) 56,200 Birth Rate 13.5 Death Rate (crude) 9.7 Infantile Mortality Rate 27.7 Number of Births (live) 758 Number of Stillbirths 15 Number of Deaths 548 Number of Infant Deaths (under 1 year) 21 Death Rate of Respiratory Diseases 0.6 „ „ „ Tuberculosis 0.5 „ „ „ Cancer 1.5 „ „ „ Zymotic Diseases 0.1 Notifications of Scarlet Fever 167 „ „ Diphtheria 44 „ „ Pneumonia 36 „ „Tuberculosis 67 Number of Deaths from Measles — „ „ „ „ Scarlet Fever 1 „ „ „ Diarrhoea (under 2 years) 1 „ „ „ „ Child Birth 1 Number of Visits by Sanitary Inspectors 10,970 „ „ „ „ Health Visitors 9,683 Number of Babies on the Registers at the Wel- fare Centres, end December, 1935 2,081 66 APPENDIX II. Birth Rates, Death Rates, Analysis of Mortality, Maternal Death Rates, and Case Rates for certain Infectious Diseases in the Year 1935 (Provisional figures). Bromley. England and Wales. 121 County Boroughs and Great Towns including London. 140 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census) Londoi Admini irative Count; Births:— Hates prr 1000 Popnlalion. Live 13.5 14.7 14.8 14.8 13.3 Still 0.27 0.62 0.68 0.64 0.52 Deaths:— All causes *9.4 11.7 11.8 11.2 11.4 Typhoid 0.02 0.00 0.00 0.00 0.00 Smallpox — — — — - Measles — 0.03 0.04 0.03 0.00 Scarlet Fever 0.02 0.01 0.01 0.01 0.01 Whooping cough - 0.04 0.04 0.03 0.04 Diphtheria 0.07 0.08 0.09 0 07 0.08 Influenza 0.19 0.18 0.16 0.17 0.11 Violence 0.37 0.52 0.45 0.41 0.51 Notifications:— Smallpox — — — — - Scarlet Fever 2.97 2.96 3.19 2.75 2.64 Diphtheria 0.78 1.60 1.96 1.34 2.25 Enteric Fever 0.09 0.04 0.04 0.06 0.05 Erysipelas 0.18 0.42 0.48 0.37 0.45 Pneumonia 0.64 1.15 1.36 0.98 0.89 Rates per 1000 Live Births. 58 Deaths under 1 year ot age 27 57 62 55 Deaths from Diarrhoea and Enteritis under 2 years of age 1.30 5.7 7.9 3.8 11.2 Maternal Mortality:— Puerperal Sepsis... — 1.68 Not available Others ... 1.30 2.42 Total 1.30 4.10 Maternal Mortality. Rates per 1000 Total Births (i.e. Live and Still Puerperal Sepsis — 1.61 1 Not avail-able Others 1.29 2.32 I Total 1.29 3.93 ) Notifications: Puerperal Fever — 3.60 4.55 2.76 4.32 Puerperal Pyrexia 6.72 9.44 11.14 8.25 1189 *Adjusted. 67 APPENDIX III. Causes of Death, 1935. Male. Female. Total. 1. Typhoid Fever, etc. 1 — 1 2 Measles — — — 3. Scarlet Fever — 1 1 4. Whooping Cough — — — 5. Diphtheria 3 1 4 6. Influenza 6 5 11 7. Encephalitis lethargica — — — 8. Cerebro-spinal fever — — — 9. Respiratory tuberculosis 14 11 25 10. Other tuberculosis 1 1 2 11. Syphilis — — — 12. Gen. paralysis of insane, etc. 1 — 1 13. Cancer 46 40 86 14. Diabetes 1 1 2 15. Cerebral hemorrhage 14 16 30 16.. Heart disease 82 100 182 17. Aneurysm — 1 1 18. Other circulatory 12 11 23 19. Bronchitis 6 7 13 20. Pneumonia 8 11 19 21. Other respiratory 1 1 2 22. Peptic ulcer 10 3 13 23. Diarrlupa, etc. (under 2 years) — 1 1 24. Appendicitis 3 — 3 25. Cirrhosis of liver — — — 26. Other liver diseases 1 1 2 27. Other digestive 10 6 16 28. Nephritis 8 3 11 29. Puerperal sepsis — — — 30. Other puerperal" causes — 1 1 31 Congenital causes, etc. 6 6 12 32 Senility 3 7 10 33 Suicide 3 5 8 34 Other violence 7 6 13 35 Other defined causes 27 27 54 36 Ill-defined causes — 1 1 Totals 274 274 548 89 APPENDIX IV. Infant Mortality, 1935. 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 monthsaiid under 6 months. 6 months and under 9 months. 9 months and under 12 months. Total deaths under 1 year. Measles ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... ... ... Tuberculosis ... ... ... ... ... ... ... ... ... ... Convulsions ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... ... ... Pneumonia ... ... ... ... ... ... ... ... ... 4 Diarrhoea ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... ... ... ... ... Gastritis ... ... ... ... ... ... ... ... ... 1 Suffocation ... ... ... ... ... ... ... ... ... ... Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis 4 ... ... ... 4 ... ... ... ... 4 Malformation 2 ... ... ... 2 ... ... ... ... 3 Piemature Birth 3 ... ... ... 4 ... ... ... ... 4 Marasmus, etc. ... ... ... ... ... ... 2 ... ... 2 Other Causes ... ... ... ... 1 2 ... ... ... 3 Syphilis ... ... ... ... ... ... ... ... ... ... Congenital Heait Disease ... ... ... ... ... ... ... ... ... ... Totals 9 1 ... 1 11 3 5 1 1 21 69 APPENDIX V. Analysis of Causes of Infant Deaths, 1931-1935. 1931 1932 1933 1934 1935 No. of Births 617 605 598 706 758 Infantile Mortality Rate 47 33 41 43 27 Total Malformation 4 6 4 7 7 28 Premature Births 3 4 5 5 4 21 Respiratory Diseases 5 5 6 5 4 25 Marasmus and General Debility 3 1 4 2 2 12 Infectious Disease 1 ... 1 ... ... 2 Gastro Enteritis 4 1 ... 4 1 10 Convulsions 1 ... ... 2 ... 3 Other Causes 6 3 5 6 3 23 Totals 27 20 25 31 21 124 This table shows that Premature Births, Congenital Debility and Malformation caused C>9 per cent, of the total infant deaths during the past five years, and should be taken as an indication of the great need for Ante-Natal supervision. 70 APPENDIX VI. Summary of Infant and Maternal Mortality Statistics. Three 6ve-year period figures are taken—five years pre-war, five years to 1925, five years to 1930, and five years to 1935. 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 1934 706 43 31 14 3 14 2 2 1935 758 27 21 9 2 10 — 1 1931—1935 3284 38 126 54 10 60 6 9 (R.G.'s return 29, Local returns 27). In these figures the following facts are shown:— 1—Reductions in Infantile Mortality Rates. The fall occurs chiefly in the period over 1 week 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. Rate 1931-1935, 43 per cent. 3—Increase in Maternal Deaths, Rate 1910-1914. 2.7 per 1.000 births. Rate 1926-1930, 3.3 per 1.000.births. 71 APPENDIX VII. Summary of Work of the Sanitary Inspectors for the Year 1935. Inspections. Nuisances and Defects found. On Complaint. Routine Inspections. Re- Inspections. Total Inspections. Houses Visited— Under Insp. of District Reg 2'278 3 263 21-25 2391 Housing Act, 1930, Sec. 17 383 — 52 220 -27-2 Sec. 19 — — — 6 6 For Nuisances (No. not confirmed, 50) 1648 458 45 1433 19345 Overcrowding 6 11 1 23 35 Verminous houses 38 43 1 35 79 Dirty conditions 3 1 4 2 7 Water supply — — 5 — 5 Cesspools 6 8 45 329 38-2 Earth closets — — — 1 1 Privy pans — — 6 83 89 Privy bins 1 — 2 394 396 Infectious disease 1 — 231 28 '259 Disinfection purposes — — 95 14 109 Disinfestation purposes 11 — 7 9 16 Tuberculosis visits — — 7 — 7 Miscellaneous — — 4 — 4 Totals 4375 524 768 470-2 5994 Food Preparing Places— Bakehouses—Factories 18 — 28 15 43 Workshops 11 1 28 23 52 Butchers' shops 9 6 952 19 977 Confectionery shops — — 4 1 5 Dairies, Cowsheds, etc — 1 86 5 92 Fish shops — — 231 - 231 Fried fish shops — — 10 — 10 Food hawkers 4 2 155 1 158 Greengrocery, fruiterers 1 1 121 — 122 Grocery shops 36 4 161 7 172 Hotels, Restaurants, etc 10 2 11 9 22 Ice cream premises — — 3 — 3 Meat Regulations (spec, visits) 1 — 3 — 3 Milk Sampling—Bact. ord — 2 52 1 55 „ graded — — 59 — 59 Tuberc — — 5 — 5 Chemical — — 1 - 1 Milk and Dairies Order—Contravention — — 1 - 1 Milk examined on highway — — 54 — 54 Retail market — — 121 121 Slaughterhouses — — 634 7 641 Cooked meat shops 3 — 2 1 3 Totals 93 19 2722 89 2830 72 ]Inspections Nuisances and Defect! found. On Complaint. Routine Inspections. Re- Inspections. Total Inspections. Trade Premises— Factories 9 8 12 10 30 Workshops 8 8 31 17 56 Outworkers' premises — 2 11 — 13 Under Shops Acts 296 15 315 66 396 Under Petroleum Acts 12 — 253 9 262 Registry Offices 8 1 20 — 21 Diseases of Animals Acts— Inspections Interviews (91) - 1 69 - 70 Offensive Trades 3 4 4 9 17 Viscose Works, observations made 3 4 32 — 36 Totals 339 43 747 111 901 M iscellaneous— Accumulations 80 52 23 104 179 Drain tests— Smoke 7 10 31 6 47 Water — 5 85 2 92 Colour — 1 1 1 3 Chemical — 2 — — 2 Mirror — 1 15 — 16 Piggeries — — 9 1 10 Rag and Bone Dealers — — 1 — 1 Rats and Mice Destruction Act 107 86 54 149 289 Schools 3 2 1 6 9 Smoke 6 5 3 — 8 Special visits 2 — 490 — 490 Stables 9 2 16 11 29 Streams 4 4 2 — 6 Tents, vans and sheds — 1 2 — 3 Rag Flock sampling — — 2 2 4 Tuberculosis Order, 1925 — 1 — 4 5 Interviews, owners, agents (Total 2747) Urinals 2 1 50 1 52 Totals 200 173 785 287 1245 GRAND TOTALS 5007 759 5022 5189 10970 73 APPENDIX VIII. Nuisances Abated, 1935. HOUSING: Drainage— lie-drained aud connected to sewer 149 Cesspools abolished 114 Earth closets — Privy pans 35 Drains relaid or repaired 91 Drains unstopped 71 Inspection chambers provided 315 W.C.s additional or separate provided 39 „ buildings reconstructed 20 „ „ repaired 23 „ pans renewed or provided 89 „ pans cleansed 3 „ box seats removed 87 Soil pipes, vent pipes, renewed or repaired 23 Sinks renewed 52 Sink or bath waste pipes renewed or repaired 185 Cesspools emptied 36 Sink waste soakaways abolished 33 Surface water drainage provided 7 Baths provided 14 Dam/mess— Roofs repaired or renewed 180 Rain water pipes, guttering, etc., repaired or renewed 123 1 )amp courses:— Vertical plinths provided 33 Walls rendered 32 Horizontal d.c. provided 29 Solutioning 15 Earth removed from walls 16 Walls repointed 172 Weather boarding repaired or renewed 2 Dry areas constructed 4 Subfloor ventilation provided or improved 11 Brickwork renewed or repaired 53 74 General— Rooms cleansed 397 W.C. walls, etc., cleansed 72 Entrance hall and staircase cleansed 49 Bathroom cleansed 5 Light and ventilation of rooms improved 33 Plastering- repaired or renewed 250 Floors „ „ 60 Window frames, etc., repaired or renewed 186 Sash cords „ „ 101 Putty pointing „ „ 81 Doors „ „ 55 Stoves „ „ 85 Coppers „ „ 40 Handrails „ „ 18 Stairtreads, etc. „ „ 12 Dustbins provided 173 Dirty conditions remedied 7 Overcrowding abated 9 Defective chimneys repaired 52 External woodwork painted 18 Food stores—Provided 72 Ventilated 12 Cleansed 10 Yard paving renewed or provided 68 Houses disinfested 42 Water Supply— Separate and additional supply provided 4 Drinking water service supplied direct from main 24 Fittings renewed, etc 6 Supply re-instated 4 Flushing cisterns repaired or renewed 61 Miscellaneous 210 TRADE PREMISES: Factories and Workshops— Want of cleanliness 4 Want of drainage to floors 2 Other nuisances 4 75 Sanitary accommodation— Insufficient 3 Unsuitable and defective 2 Not separate for sexes — Outworkers premises 1 Petroleum Acts—contraventions 1 Registry office—contraventions 6 Meat regulations—contraventions 1 Milk and Dairies—contraventions 2 Shops Acts—contraventions— Ventilation 1 Temperature 22 Sanitary conveniences 16 Absence of statutory forms 236 Meals rest interval not satisfactory 1 Unsuitable and insufficient means for meals 2 Washing facilities not satisfactory 11 Refuse accommodation not satisfactory 5 Assistants working after closing hour 1 Hours of employment of young persons exceeded 1 FOOD PREPARING PLACES: Defects and nuisances remedied in— Butchers' shops 11 Bakehouses 52 Confectionery shops 1 Dairies, etc. 10 Fish shops 2 Fried fish shops 3 Greengrocery shops 2 Grocery shops 30 Hotels, restaurants, etc. 14 Slaughterhouses 14 MISCELLANEOUS: Accumulations removed 53 Nuisances from keeping animals 1 Manure removed 2 Manure receptacles provided 1 Rats and mice nuisances 63 76 Smoke nuisances 6 Stables cleansed 1 Urinals cleansed 2 Piggeries cleansed 2 Stream pollutions 4 Offensive trades nuisances 1 Total 4738 NOTICES ISSUED: Preliminary— Housing 721 Others 284 Total 1005 Statutory— Housing 6 77 APPENDIX IX. Return of Notifiable Infectious Diseases, 1935. Disease. Total. M. F. WARDS. Cases removed to Hospital. Attack Rate per 1,000 population. No. of Deaths. Death Rate. Plaistow Martin's Hill. Town. Sundridge. Bickley. Bromley Common. Keston & Hayes Scarlet Fever 167 74 93 49 24 25 7 21 37 4 135 2.9 1 0.02 Diphtheria 44 24 20 9 5 10 4 5 11 — 44 0.7 4 0.07 Pneumonia 36 27 9 10 3 6 2 3 11 1 20 0.6 19* 0.3 Puerperal pyrexia 5 — 5 2 — 1 — — 2 — 3 0.09 — — Erysipelas 10 8 2 3 1 2 1 1 — 2 4 0.18 1 0.02 Ophthalmia Neonatorum 3 1 2 — — — — 2 1 — 3 0.05 — — Acute Poliomyelitis 3 1 2 — — — — 1 1 1 2 0.05 — — Typhoid fever 5 3 2 — — 1 2 2 — — 4 0.09 1† 0.02 Tuberculosis—lungs 52 29 23 12 4 7 5 9 12 3 — 0.9 25 0.4 Tuberculosis—other forms 15 7 8 8 — 2 2 1 — 2 — 0.3 2 0.03 Totals 340 174 166 93 37 54 23 45 75 13 215 6.05 53 0.9 •Includes Pneumonia (all forms), whereas notifiable types include only acute primary pneumonia and acute influenzal pneumonia. tThis case was a Bromley resident who was notified outside the area and also died outside the area. 78 APPENDIX IXa. Notifiable Infectious Disease, 1935 Age Groups. Disease Total 0-1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-66 65 & over Scarlet Fever 167 1 2 6 14 14 80 24 6 13 5 2 — Diphtheria 44 — — 1 3 2 22 7 1 7 — 1 – Pneumonia 36 — – — 1 — 4 3 — 9 6 5 8 Puerperal pyrexia 5 — — — — — — — — 4 1 — — Erysipelas 10 — 1 — — — — 2 — 1 2 3 1 Ophthalmia Neonatorum 3 3 — — — — — — — — — — — Acute Poliomyelitis 3 — — — — — — 2 1 — — — — Typhoid fever 5 — — — — — — — 2 1 1 1 — Totals 273 4 3 7 18 16 108 37 9 35 15 12 9 Y9 APPENDIX X. Tuberculosis. New Cases and Mortality during the Year, 1935. Age Periods. New eases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M F. Under 1 .. .. ... ... ... ... ... ... 1—5 2 ... 1 1 ... ... ... ... 5—15 ... ... 2 5 ... ... ... ... 15—25 6 4 3 ... 3 1 ... ... 25—35 8 13 1 1 3 4 ... 1 35—45 7 3 ... ... 3 2 ... ... 45—55 2 1 ... 1 2 1 ... ... 55-65 4 1 ... ... 3 3 ... ... 65 and over ... 1 ... ... ... ... ... ... Totals 29 23 7 8 14 11 1 1 APPENDIX XI. Ophthalmia Neonatorum, 1935. Cases. Vision unimpaired. Vision impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 3 ... 3 1 2 ... ... 80 APPENDIX XII. Summary of Health Visitors' Work, 1935. 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 1468 77 180 573 38 336 2 4 99 155 4 13 310 Area No. 2 1118 117 232 437 42 197 3 49 31 10 6 227 Area No. 3 1919 133 392 980 29 194 2 3 94 59 33 38 204 Area No. 4 1295 62 229 828 43 63 5 2 39 23 1 14 174 Area No. 5 1252 112 203 551 30 209 1 3 53 82 8 15 257 Area No. 6 1200 129 279 573 23 124 2 4 41 20 5 6 259 Totals 8252 630 1515 3942 205 1123 15 16 375 370 61 92* 1431‡ * Also included in routine visits under the various headings. ‡ "Ineffectual" visits are those where 110 answer is received; discovered removed from district, or where visits are resented, and are not included in the first total column. The aggregate total of visits is, therefore, 9,683. TUBERCULOSIS DISPENSARY WORK, 1935. Patients on the Dispensary Roll at end of December, 1935 142 Health Visitor's attendances at Dispensary 49 Total No. of special visits to Patients 171 APPENDIX XIII. Welfare Centres, Attendances, 1935. CENTRE. No. of Babies on the Rolls at the end of the Year, 1935. Total Attendances. No. of Sessions held. Medical Consultations. Total No. of Weighings. Babies. Mothers. Total Examined. No. of Sessions held. PLAISTOW 411 3015 2537 50 425 32 2613 WIDMORE 248 2364 2211 50 387 33 2230 SHORTLANDS 270 1585 1553 49 279 32 1239 BURNT ASH 425 3510 2916 98 547 42 2758 BROMLEY COMMON 442 5767 4808 101 864 70 4814 HAYES & KESTON 285 3074 2846 51 526 42 2882 Totals 2081 19315 16871 399 3028 251 16536 81 Ante-Natal Clinics. Total Attendances. Medical Consultations. Sessions held. 253 253 31 Dental Clinic. Discharged treatment. Children. Mothers. 51 42 82 APPENDIX XIV. Factories, Workshops and Workplaces, 1935. I.—Inspections. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. Factories 117 21 ... Workshops 134 20 ... Workplaces 59 11 ... Total 310 52 ... II.—Defects. Particulars. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts*— Want of Cleanliness 27 27 ... Want of ventilation 4 1 ... Overcrowding ... ... ... Want of drainage to floors 2 2 ... Other nuisances 53 50 ... Sanitary accommodation. insufficient 3 3 ... unsuitable or defective 4 2 ... not separate for sexes ... ... ... Total 93 85 ... *Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acts. Outwork in Unwholesome Premises, Section 108. Nature of Work. Instances. Notices. served. Prosecutions. Wearing apparel—Making etc. 1 1 ... 83 APPENDIX XV. Housing Statistics for the Year, 1935. Total number of inhabited houses at 31st December, 1935 15311 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) 966 (b) Number of inspections made for the purpose 5517 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 260 (b) Number of inspections made for the purpose 2388 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 23 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subhead) found not to be in all respects reasonably fit for human habitation 721 2. Remedy of Defects during the Year without Servicc of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 712 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 28* *Statutory action was not pursued as further action progressed informally. 84 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 28 (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 6 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners C (b) By local authority in default of owners — (c) Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 5† (2) Number of dwelling-houses demolished in pursuance of Demolition Orders — (d) Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made — (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — † As a result of informal action progress under the Housing Act. 1930, up to 31/12/1935 showed that 10 houses had been demolished and 23 houses closed to habitation. Statutory action was commenced with regard to the 5 houses, but subsequently progressed informally. BOROUGH OF BROMLEY. ANNUAL REPORT OF THE « SCHOOL MEDICAL OFFICER FOR 1935. 86 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1935-1936. Alderman F. W. Isard (Chairman of the Education Committee). *D. Copping, Esq. *A. Cowdry, Esq. Councillor E. C. De'Ath. *Mrs. M. D. Fry. *Rev. H. Glaisyer, m.a. *G. J. Gully, Esq., j.p. Councillor C. H. Gunton, j.p. *Rev. J. T. Gurney. Councillor C. A. Holliday, f.s.a.a. Councillor S. G. Humerston. Councillor T. H. Jayes. *Mrs. A. G. Mann, b.a., j.p. Councillor A. McIntosh, d.c.m. *Mrs. E. J. Munn. *Rev. Prebendary B. F. Relton, m.a. Councillor L. A. Simmons. Alderman W. F. Skilton. Councillor M. Stafford Smith, m.b.e., b.a. Councillor F. G. Hamilton Spratt. Councillor F. Sutcliffe, f.r.i.b.a. *G. Weeks, Esq. (Vice-Chairman). *Rev. O. G. Whitfield, m.a. *Co-opted Members, 87 Introduction. Much careful thought and study has been devoted by the school hygienist in order to put into practice the purpose and design of the School Medical Service as outlined in the Education enactments of recent years. Briefly the plan of work has been to discover any defect in the child, to facilitate its treatment, and to ensure that the child is physically fit to receive full benefit from the education provided, so that on entry into national life it shall be in possession of the best possible physical equipment. It is not to be expected that a yearly report on the School Medical Service is much more than a statistical return of the defects discovered and treated during that year, and a repetition of the summary of the various branches of the School Medical Service. It should not be taken as a report showing physical improvement or retardation of the school child during the year under review. Anyone, however, who may feel inclined to criticise the effects of the service cannot but be impressed with the vastly improved environment of the elementary school, the greater happiness and alertness of the children, and, taken as a whole, greater healthiness and higher standard of nutrition. Whilst much of this is due to better educational facilities and improved home environment, some credit must be given to the effect of a continuous school medical service. I am myself convinced that the stature and nurture of the elementary school child has definitely improved over the past fifteen years, but on the other hand one meets much more frequently the child with a functional neurosis, due to the hurried stress of modern life. In recent years much has been said about the neglect of the child between the ages of two and five years, and that it generally escapes the supervision which the child under one year of age receives at the maternity and child welfare centres. We have, however, in Bromley for some years past provided facilities for such children to receive treatment through the School Medical Service special services. We have also endeavoured to make a routine medical examination of the four year old child before its 88 entry to school, and valuable work in the discovery and subsequent correction of defects is being done, thus working towards a co-ordination of the two services. The fact that the health visitor is also a school nurse materially assists this co-ordination, and we do find that parents are realising the importance of the services provided and are making an increasing use of them. I would not suggest that the co-ordination is complete, for in the care of the 2—5 year old children there is still much work to be done. There are few nowadays who will deny the importance of the years spent at school, or contest the fact that ill effects in later life result from failure to counter during the tender years the deleterious effects of ill-regulated dietary, the lack of properly directed exercise, and, perhaps above all, the neglect of the convalescence of minor illness. Sir George Newman, when Chief Medical Officer of the Hoard of Education, directed attention to the fact that much labour, time and money had been devoted to the treatment of the defective child, but feared that we were not doing all that is practicable for the nutrition, physical education, nurture and health of the normal child. He wrote, "Yet if we are failing to ensure the physical health of the normal child under fourteen years of age, we must not complain or be surprised if such neglect brings with it, in later years, a harvest of preventable impairment or incapacity of body and mind." Nevertheless the children in the State aided schools do enjoy a good measure of well regulated hygienic routine throughout their tender years of school age, a service which goes far to make them fit citizens of the nation. The need remains constant to improve, develop and apply the fruits of scientific research for betterment of the School Medical Service. Whilst all this watchful guard is being exercised over the physical well-being of the school population of the State controlled schools, there is ever present the problem of the private school child who is outside the provisions of the State service and has no comparable substitute. One cannot help being a little disturbed by the fact that a by no means inconsiderable number of children pass their early days in uncongenial surroundings with a complete lack of the facilities conducive to physical 89 fitness as is enjoyed by a great proportion of the child population. In Bromley there are many excellent private schools and boarding schools where it is usual to have a medical officer on the staff, but in many of the small private dwelling-house schools medical supervision of the scholars is not carried out. Little fault can be found with the good type of establishment which is suitably planned, admirably situated, and finely equipped for educational purposes, but up and down the country totally inadequate small private dwelling-houses are functioning as schools. The small dwelling-house school with one or two rooms devoted to the education of a few children cannot be regarded as a suitably planned building possessing sufficient surrounding air space and playground space to meet modern educational essentials. Some parents are apathetic as to their responsibility in the correct selection of schools for their children, and in many cases the choice is made on purely sentimental grounds, and the small private dwelling-house school is selected for the delicate child. Such a child at once finds itself in a school environment unsatisfactory for its physical condition; restricted space, faulty lighting and ventilation, all go to militate against an already impaired physical condition. It is an interesting commentary on this subject to recall the striking statistical facts disclosed after the first dental inspection was held at the Plaistow Lane R.C. School in 1933, after the school ceased to be a private one and came under the purview of the Local Education Authority. No less than 85 per cent. of the children were found by the School Dental Surgeon to require treatment, not merely for minor defective conditions, but for severe dental defects, whereas in the elementary schools under the Local Authority where dental examination and treatment had functioned for many years, the dental inspection showed only 54 per cent. of children requiring treatment for dental defects. There appears to be a field for action against conditions under which certain types of scholastic institutions function, and particularly must we focus our attention on the anomaly that one section of the school population entirely escapes something which is established as of vital necessity for the other. 90 Taking our own area, which happily contains many excellent private boarding and day schools mostly set in surroundings above reproach, it is interesting to note that there are upwards of thirty private schools accommodating 1,500 children, varying in individual accommodation from 4 to 170 scholars each. Summary of Statistics, 1935. School Roll 5,705 Number of individual children who attended medical clinics 1,718 Number of individual children medically examined at schools 1,767 Number of medical examinations at the Clinic 5,386 Number of treatments at the Clinic 5,912 Number of treatments at the Dental Clinic 3,808 Number of treatments at the Eye Clinic 398 Number of operations for Tonsils and Adenoids 156 Total number of attendances at the Orthopaedic Clinic 3,648 (i) For Consultations 673 (ii) For Treatments, massage, etc. 2,975 Total number of attendances at the Ultra Violet Ray Clinic 1,511 Number of children referred to the Care Committee 99 Hygiene of Schools. I am indebted to Mr. G. P. L. Syms, Chief Education Officer, for the following list of improvements which have been carried out in the elementary schools during the year under review:— Princes Plain.—New Department to accommodate 400 mixed juniors and infants opened in September. Mid-day meal arrangements provided. Contract entered into for erection of new School Clinic. 91 Raglan Road.—Contract entered into for enlargement and improvement of Hoys' Department. Contract entered into for improvement of structure of lavatories of all Departments. Mid-day meal arrangements provided from September. Central.—Drinking water from mains and properly trapped hand basins provided; trough W.C.'s replaced by independent W.C.'s, and urinal slabs renewed. Valley.—Drinking water from mains provided. Electric lighting provided. Aylesbury.—Drinking water from mains provided. Allotments converted into grass playing space. Seating.—The Committee have continued to displace obsolete scholars' desks by modern dual locker desks during 1935. New desks for 380 scholars were supplied. It is pleasing to note that there is a greater tendency to consider the importance of a hygienic environment as an aid to correct progress in education. Quite apart from structural improvement in the schools, there has been in recent years an improvement in the cleanliness and hygienic habit of the children attending these schools. Whilst these improvements are obvious in the more modern type of school, where the environment is all that one would desire, there is still much to be done in the little Church schools of the district. An endeavour was made later in the year to abolish roller towels, which, in my view, are a source of spread of catarrhal infectious diseases. The adoption of paper towels was tried, but they were found to be rather expensive. It seems to be obvious, if one is to have hygienic practice among the scholars that each child should have its own towel. This is a matter which at the present time is receiving the attention of the Education Committee. Medical Inspection. The routine inspection of elementary school children in the routine age groups has continued, on the child's 92 entry to school, on reaching the age of seven years and again at twelve years of age. A further age group of ten years old children was incorporated in the age groups, but time available to the staff has unavoidably prevented the carrying out of this work. A routine medical examination of employed children is carried out. Under the Bye-laws no child is allowed to be employed until a medical certificate from the School Medical Officer, certifying fitness to be employed, has been granted. Further special medical examinations of children are carried out at the schools and school clinics. Including routine medical inspections and other inspections a total of 7,153 were made during 1935. All children with defects are given an appointment to attend the School Clinic, where the defects are investigated and whenever possible alleviated. All abnormal children referred by head teachers, school attendance officers or by the school nurses likewise come under special medical supervision. The Juvenile Court also refers certain cases for medical opinion. Where a school attendance officer finds it difficult to obtain a medical certificate after illness the child is referred to be medically examined prior to return to school. All these examinations offer a very wide field for preventive service, and I am convinced that the sum total has the effect of improving the standard of health of the elementary school child. The mere medical inspection is but the beginning of the putting into action of those services that are offered through the special clinics, viz., Eye Clinic, Orthopaedic Clinic, Dental Clinic, Ear, Nose and Throat Clinic, Sunlight Clinic, and various other accessory services offered by voluntary associations in the Borough. I would refer the reader to the appendix of this report where Table I. gives the number of children examined at routine medical inspections at school and the number of children examined at the school clinic. The particular defects discovered are under Table II., where it will be seen 93 that by far the greater number of defects come under the headings of ear, nose and throat. There is obviously in this field a great source of investigation as to the real causation of such defects, which, if abolished, would lead to greater fitness in the child. It will also be noticed from these returns that ten per cent. of the children suffer from visual defect, and here again I would like to see a greater reduction of the incidence of this serious defect. What part minor infectious diseases play in this defect is not definitely known. Far too lightly do we treat diseases such as measles and whooping cough, little realising that the aftermath of these infectious diseases is not always obvious until very late in convalescence. I personally would stress that greater recognition should be given to the health of the child immediately following any type of infectious disease, by lengthy convalescence, by increased nutrition and possibly change of environment. There is also a tendency after any illness to hurry the child back to school before complete recovery of health. We are ourselves culpable in this direction, by demanding the child's return to school if it cannot produce a medical certificate. There is again the fetish of a high school attendance figure, but at the same time I do recognise that in certain instances the school environment is a preferable one to negligent home surroundings. Apart from all this, parents to-day are becoming rapidly "health conscious," and this factor will play its part in correction of any culpability on our part. During the past year I have endeavoured to fill the gap between the maternity and child welfare examination and the school medical examination by the adoption of an inspection of the 4 year old child at the welfare centre. The numbers, however, are too small to give any indication of its value. The bridging of the gap from the school leaving age to the employment age is an outstanding problem. The contemplated raising of the school leaving age will help to alter this defect and permit of another age group being added to the routine medical inspections. At the request of the Board of Education another table has been added regarding the nutritional standard of 94 children examined. This table is included in the appendix (Table II.B.) where it will be seen that out of a total of 1,767 children inspected the following classification of nutrition resulted:— (a) Excellent nutrition 148. 8.4 per rent. (b) Normal nutrition 1297. 73.4 „ ,, (c) Slightly subnormal nutrition 309. 17.5 ,, ,, (d) Bad nutrition 13. 0.7 ,, ,, It is not an easy matter, owing to the various standards set, to tabulate a child as of (a) or (b) physique, the opinion recorded being to a great extent merely the impression of the medical examiner that a child appears to be in a particular group on comparison with other children. In other words where the normal standard of physique is a good one in an area, one is apt to obtain a false impression when comparing these tables with those of other areas. There does not, however, appear to be any set method on which to base the standard1 of nutrition scientifically. My general impression in Bromley is that the nutrition of children attending elementary schools is good, and when one finds low grade nutrition it is generally due to either the existence of a debilitating defect, or is constitutional in the family, that is to say, not due to lack of nutritive diet, nor does change of diet have any effect upon this type of nutrition. There are of course cases where the diet is an inefficient one, and when extra nourishment is provided either through the scheme of milk provision at school, or at home, improvement becomes at once apparent. Treatment. The School Medical Service provides through its special clinics treatment of all those defects discovered at routine medical inspections. A strict line of demarcation is made between domiciliary treatment provided by the general practitioner and clinic treatment provided through the special services.. The work of the special clinics is tabulated in the appendix and will be found in Table IV. (Group I, Group II, Group III and Group IV.) and Table V. 95 It would perhaps be clearer if each group is discussed in greater detail in the report. The treatment of these cases, however, does not end with these services. The reference of children to their own doctor for domiciliary treatment, or to general hospitals for investigation. occupies a great deal of the school medical officers' work. The following-up of children in their own homes and at school by the school nurses is a further extension, and it is only by co-ordination of each clinic that a child can obtain the full benefits of the services offered by the Local Authority. These groups do not by any means complete the supervision of the child. The exceptional child, the mentally deficient child, the blind child, the deaf child, the epileptic child, and the physically defective child, all require not only special medical treatment but also special methods of education. This latter particularly occupies much time and incurs much expense, but it is natural that when these facilities cannot be provided privately, the Local Authority should fulfil their obligation. There is too the child requiring moral correction and a change of environment in order to correct the faulty management at home. This latter type of defect is obviously one requiring the co-operation of all persons concerned with the welfare of society. Table IV. Group I. Minor Ailment Clinic. (Page 118). By reference to Table IV, Group I, it will be seen that no less than 1,563 defects in children were treated at the routine medical clinic by the school nurses, and a further 150 defects were otherwise treated, that is, treatment at home by the parent under direction of the clinic staff. It will he observed that apart from minor illnesses among school children the main treatment is given for such minor ailments as skin diseases. It has been found that children treated at the School Clinic for such defects are returned more rapidly to school than those treated at home; thus is economy of school time achieved. Where treatment can be made more efficacious so is it possible to return the child more expeditiously to school for continuous education. There are cases, however. where regularity of treatment is not maintained, through carelessness of the parent, or misdemeanours of the child. 96 Under the heading miscellaneous (905 children) is included cases of minor illness brought mainly to the clinic directly by the parent. These cases tend to interfere with and lead to abuse of, the proper functions of the clinic, by the parents regarding the clinic in the nature of an Outpatients' Department. Table IV. Group II. Defective Vision Clinic (Page 119). This table indicates the work of the Consulting Ophthalmic Surgeon over a period of one year. It is with regret that I have to record the death of Mr. A. M. Hickley who gave such splendid service to the Committee, and whose work was so greatly appreciated by the parents. Mr. E. Lyle, his successor, is very ably continuing his good services. All cases discovered at routine and special inspections are referred to the Specialist, who carries out refraction and directs the provision of glasses. He also advises on the treatment of special eye diseases. During the year 398 cases attended the Vision Clinic. Of this number there were— 234 refractions. 111 re-inspections. 262 glasses were prescribed. In necessitous cases parents are referred to the Bromley Children's Care Committee, who have an arrangement with a local firm of opticians for the provision of glasses at a specially reduced cost. Thus we are able to secure full success in the provision of glasses. Cases not remediable by the provision of glasses, or cases with high myopic condition, come under special educational facilities by arrangement made with the London County Council. It was found during the year that we were notable to cope fully with the refraction and re-inspection of cases. In the current year this has been remedied by additional eye clinics, for it is obvious that the full benefits of our educational facilities cannot be applied if children are permitted to continue school attendance with short sight defect uncorrected. 97 Table IV. Group III. Ear, Nose and Throat Clinic (Page 120). A weekly session of the Ear. Nose and Throat Clinic is held at the North Clinic, Station Road, under Mr. C. Beney, Ear, Nose and Throat Specialist. Children requiring tonsil and adenoid operations are retained for twenty-four hours at the Clinic, and return home by private conveyance, where they are visited daily by the school nurses during convalescence. The prevalence of enlarged tonsils and adenoids as a defect of school children has already been reported upon. It does not in any way appear to become less frequent. The selection of cases for operation is made by the School Medical Officers. These cases are referred to the Specialist for his direction, and finally the operation is arranged either by dissection, or by the ordinary guillotine method. Fifteen cases were found to be unsuitable for operation at the Clinic, and were referred for operation in hospital. It is interesting to note that no less than 302 children passed through the Clinic. I am greatly indebted to Miss V. Vincent and Miss Price for the valuable services they give at each operation session. Mr. Beney submits the following report:— There is little comment to make this year on the work of the Ear, Nose and Throat Clinic, except that an increasing number of cases was seen and treated. Thirty-nine clinics were held. One hundred and fifty six operations were successfully performed and again no cases of any serious complications occurred. There were one hundred and seventy consultations with the Assistant Medical Officer of Health. A certain number of cases were referred to their own doctors for treatment, and I am glad to say that fewer cases had to be admitted to my beds at St. John's Hospital, Lewisham. During the last eight years since I was first appointed to do the work of this Clinic, over one thousand cases have received operative treatment, with no serious complications. This is a very high standard indeed and is largely due to the skill of those who administer the anaesthetics, to the care of the nursing staff, and splendid co-operation of the voluntary workers." Charles Beney, m.a., m.b., b.ch., m.r.c.s. 98 Table IV. Group IV. Orthopaedic Defects (Page 121). This table gives statistical details of the Orthopaedic Clinic. The Clinic supervises the treatment of all children suffering from crippling defects. Five sessions are held weekly with a Masseuse in attendance. Incorporated with this Clinic is an Ultra Violet Ray Clinic at which 1,511 attendances for treatment were made during the year 1935. Mr. H.J. Seddon, Orthopaedic Surgeon, attends twice monthly, and cases requiring hospital treatment are referred by him to the Royal National Orthopaedic Hospital, Stanmore, Middlesex. It is pleasing to note that major crippling defects are seldom found, but minor defects continue to make up by far the greater portion of cases discovered. It is apparent that if crippling conditions are to be prevented children must attend as soon as such defects are discovered, and only thus may permanent crippling be prevented. The reference of maternity and child welfare cases to this Clinic, as is similarly done to all other clinics, has led to such cases receiving early expert treatment when the condition is most easily remediable. Table IV. (Group IV.) shows that 396 children attended this Clinic for treatment. Mr. H. J. Seddon reports as follows:— "The enlargement of the Orthopaedic room at the Clinic is most welcome. Considerable space is necessary for the proper examination of orthopaedic patients and there is no doubt that the room used until recently was much too small for the purpose. Furthermore, the Masseuse can now deal far more efficiently with the cases requiring treatment. The out-patient work has run smoothly during the past year and there is no evidence indicating laxity in the inspection of school children, nor indifference on the part of the parents. Thirteen cases were admitted for treatment or for the completion of hospital treatment begun in the previous year. Successful results were obtained in all the ten cases where operation or manipulation and plaster was required. One child, P.M., was of outstanding interest. Benign inflammation of the head of the femur, a condition known as osteochondritis is relatively common, and we have dealt with a number of such cases from Bromley and other Clinics. This child was admitted on account of swelling of the knee, and we find that she has a similar condition involving the lower end of the 99 femur. This is the first example of this disease that has been seen in this hospital. The child is still in hospital and there seems a good prospect of a perfect result being obtained without recourse to operation." New Cases seen at the Clinic during 1935. 1. Congenital. 4. Knock knees 9 Spastic paralysis 1 8. Postural defects 12 Congenital dislocation of the hip 1 7. Flat Chest 2 Flat Foot. Metatarsal varus 3 Hallux valgus 3 Hammer toes 2 Irregular toes 3 8. Infantile Paralysis 2 Pes arcuatus 1 9. Fractures 7 Pes calcaneo-valgus 3 Other injuries 26 2. Birth Injuries. 10. T.B. Joints 1 Fractured humerus 1 11. Osteomyelitis (old) 2 Torticollis (both slight) 2 12. Unclassified 16 Delayed walking 1 3. Rickets. Clicking patella 1 Active rickets 1 Exostoses heels 1 Bow legs 10 Rheumatoid arthritis (Still's disease) 1 Knock knees 2 Ultra Violet Ray Clinic. This Clinic is held on Tuesdays and Fridays at the North Clinic. There were 1,511 treatments during the year 1935, of which 139 were new cases. The Ultra Violet Ray Clinic is used as an ancillary treatment to those cases not responding to the usual hygienic treatment carried out through the School Medical Service. The results have proved satisfactory; those children with poor muscle tone following acute illness and cases of the irritable nervous type; all have improved under continuous treatment. Skin conditions, especially impetigo, give rapid response to this form of treatment with bi-weekly application. I am personally satisfied that in ultra violet ray treatment we possess a useful adjunct to the treatments provided through the Public Health Services, 100 Report of the School Dental Surgeon for the Year 1935. (Table V. Page 122). Inspection. During the year 1935 a dental inspection was carried out in 20 schools by the dental nurse and myself; the teeth of 3,975 individual children were examined, and it was found that 2,246 of these children required dental attention, i.e., 56 per cent. It is to be noted that five schools, namely, Raglan Road Boys', Princes Plain Girls', Princes Plain Juniors', Parish Boys', and Parish Girls' have received no dental inspection this year—a matter of some 1,600 children. Until the year 1934 we were able to inspect every school child and treat all those who required treatment once a year, according to the accepted principle that inspection and the relative treatment should be on an annual basis. In 1934, however, the round of schools took 14 months to complete, so that the 1935 circuit was not commenced until March and will probably not be finished before April, 1936. The reason we are no longer able to deal with our school population on an annual basis is as follows. • The Board of Education in a recent statement consider that a full-time dental officer can be expected to serve a school population of not more than 5,000, and this figure is based on the fact that in England and Wales only about 63 per cent. of those children considered to need treatment actually avail themselves of the facilities provided. In this Borough our school population is about 5,700 —in excess of the Board's figure by 700—and, moreover, 80 per cent. of those considered to need treatment actually seek to obtain it at the Dental Clinic, that is 7 per cent. more than the average. It will be seen from these figures that our Dental Scheme is now seriously incomplete, and to put it again on a proper basis of annual inspection and treatment for every scholar, some assistance has become necessary. 101 Treatment. The attendance at the School Dental Clinic during the year 1935 numbered 3,808, and 2,274 individual children received treatment; this means that on an average each child made 1.6 visits. Some children need only make one attendance while others make perhaps three visits to get their teeth into proper condition. Sixty clinics were held for gas extractions, and the anaesthetist administered gas on 1,115 occasions. The number of teeth extracted was 4,528, a record number, but this in my humble opinion is a matter of regret rather than of credit. As regards fillings, 1,903 were inserted in permanent teeth and 452 in temporary teeth. Dental Education. At the school inspections parents are invited to be present. I am able on these occasions to give a short talk on dental matters; sometimes 1 come across a perfect set of teetli during the course of my inspection, and I am able to show the parents what Nature intended us all to possess. During the holiday period, the dental nurse makes visits to the homes of children who have repeatedly failed to attend, and often persuades parents to avail themselves of the services of the dental clinic, and to take a regular and proper interest in their children's dental welfare. I understand that in the dental schemes of some authorities, children who fail to keep their appointments are ruthlessly dropped from the scheme, and that if later on they do appear at the Clinic because of acute pain they are sent away untreated. This in my opinion is a very improper course. In the first place the child is penalised, and not the parent, who is the responsible party; secondly it must be remembered that not all parents are sufficiently enlightened to appreciate that regular conservative treatment anticipates and insures against future toothache. The fact that such parents seek treatment at all is often an advance, for not so long ago a very large proportion of 102 the school population received no dental attention whatever. Time and propaganda will enlighten such parents, hut to offer them a rebuff when they are in need of relief is hardly the way to encourage them. Other Services. On Saturday mornings a session is held for mothers and infants referred from the various welfare centres and the ante-natal clinic. Forty-two expectant and nursing mothers, and 51 infants from 2 to 5 years of age, received attention. Conclusion. Lastly, I must express my appreciation of the assistance given me by the Committee and the Staff; nor must I forget our voluntary helpers who give up their time to assist us to deal with such a large number of children. 103 Summary of Dental Statistics for Year 1935, with Comparisons. 1932 1933 1934 1935 Remarks. Inspections. No. of Sessions 28 24 29 22 All schools inspected in 1934. 1,825 children not examined in 1935. No. examined 4531 4685 5158 3975 Referred for Treatment 2653 (50%) 2539 (54%) 2785 (55%) 2246 (56%) Treatment. No. of Sessions 391 393 372 380 Individuals discharged 2387 2268 2352 2274 51 under 5 years of age included in 1935 figure. Attendances 3827 3992 4101 3808 Away ill. Jubilee holidays, etc. (per Session) 9 10 11 10 Visits per Child 1.6 1.7 1.6 1.6 Gas Cases 962 1103 1201 1115 60 sessions. (total per Session) 16 19 18 18 Extractions 3616 3910 4100 4528 Fillings 2244 2221 2368 2355 Local anaesthetics 1194 1022 880 1142 Nurses Visits 613 989 684 450 WORK PER 100 CHILDREN TREATED. Average for the Country (Board of Education figures). Borough of Bromley. Permanent teeth filled 67 88 Temporary teeth filled 7 19 Permanent teeth extracted 33 27 Temporary teeth extracted 155 171 104 Table VI. Uncleanliness and Verminous Conditions. The school nurses visit each school and examine every child for cleanliness each term. Table VI. in the appendix gives the total number of examinations of children for the year as 14,663. The total number of individual children found unclean was 455, and in only five cases was itnecessary to resort to action under the School Attendance Byelaws. It is nowadays only necessary to take extreme measures with the few "hardened offenders" remaining. That we have not yet eliminated verminous conditions from the schools is principally due to these hardened offenders and the careless parent who are so stubborn in not taking steps to rid their children's heads of vermin. Our aim has always been to maintain a high standard of cleanliness, and thus there is recorded in the above figure, 455, many children with but one or two nits only. Blind, Deaf, Defective and Epileptic Children. Table III. (page 115) in the appendix gives a tabulation of these children specially certified by the School Medical Officer as requiring special education or special medical supervision. The education of these children means a heavy burden on the cost of the School Medical Service. One hundred and seven children came under supervision and classification for these special defects, 31 of them being maintained at residential schools or institutions, and 11 of these being at special day schools. The details given in Table III. do not call for further elaboration. Physical Training. This subject again came under the consideration of the Education Committee during the year, and a scheme for the appointment of physical training organisers for the combined areas of Bromley, lieckenham, Penge, Erith and Gravesend is at the present time receiving attention. When this scheme is finally put into operation, together with the extension of playing fields, it will fulfil the long standing needs of the child in attendance at our elementary school. I hope in the report for 1936 to be in a position to discuss more fully the effects of the scheme. 105 At the present time physical training corresponds to the Board's syllabus in so far as the school facilities permit. One notes the greater attention paid to this subject by the staff and especially noticeable is the greater interest shown by the children in the organised games. Provision of Meals. The Local Education Authority does not exercise the facilities under Section 82/84 of the Education Act, 1921. The milk scheme continues to operate successfully in all but one of our schools; the Central School being the exception. The resulting nutritional benefit to the children is especially marked during the winter months. Facilities exist for the heating of meals at Princes Plain Schools, and also at Keston. Bromley being of a strictly residential character, there does not appear to be the necessity for the provision of meals by the Local Authority. Where the child, on medical grounds, requires additional nourishment, the case is referred to the Care Committee for the assistance necessary, which practice continues to operate successfully. Open Air Schools. No special open air school is provided in Bromley, and those children suitable for admission to such schools are either sent on prolonged convalescence, or sent at the cost of the Education Committee to open air schools under the control of other local authorities. This proves economical, as the overhead costs of special open air schools is a high one, and I doubt whether in a district such as Bromley is to-day, an open air school is a necessity, especially when the new schools which have been built for the increasing school population are designed to meet the modern conception of a health maintaining environment, pure air, adequate heating and ventilation, good lighting, and modern hygienic equipment. Nursery Schools. There are no nursery schools in Bromley, and I doubt whether such schools would fulfil any useful purpose in 106 Bromley. There are, however, eleven schools which accept children under the statutory school age of five years, but with the increasing school population and limited school accommodation, the acceptance of these children into elementary schools becomes yearly more difficult. If the care and treatment of the child under five years of age is fully utilised by parents under the maternity and child welfare services there should be no need, as far as medical supervision of the child is concerned, to establish •nursery schools in Bromley. Occupation Centre. An Occupation Centre was opened in Bromley in 1933 under the management of a voluntary committee. This centre accepts mentally defective children who are incapable of receiving education in special schools. At the end of the year there were 28 children in attendance, and valuable work is being done under the Supervisor, Miss H. Wade. Health Education. The handbook of the Board of Education is used in all the schools, but one must doubt whether teaching without practice is entirely of value. There are some schools where the environment does not meet with modern standards, where there are out-of-date desk and seating equipment, and where the sanitary arrangements are by no means creditable. In addition there is still the common drinking vessel, and the roller towel in common use even in our modern schools. One cannot teach hygiene where practice of the teaching is not possible. Infectious Diseases in Schools. The returns received from head teachers during 1935 have been tabulated in the following statement, which indicates a considerable loss of school attendance through notifiable as well as through the minor types of non-notifiable infectious diseases. 107 Infectious Disease Returns from Schools, 1935. Schools. Diphtheria. Scarlet Fever. Measles. Whooping Cough. Mumps. Chicken Pox. Other. Addison Road 1 3 1 — 5 1 — Aylesbury Road 3 11 — — 13 1 — Bickley & Widmore — — — — — — — Burnt Ash 2 37 6 5 13 27 3 Central — 3 — — 8 1 — Hayes — — — 1 — 1 1 Keston 1 1 — — — 5 — Masons Hill — — 10 6 30 1 — Parish 1 1 — — 11 56 — Plaistow, St. Mary's — 1 — — 6 4 — Princes Plain 1 5 — — — 3 — Raglan Road 7 22 10 5 25 17 1 Valley 7 30 2 2 17 — — Plaistow, St. Joseph's — — — — — 1 — This table is taken from the returns submitted under the regulations. Unfortunately it does not give a true return of infectious diseases in schools as the regulations of notification by head teachers is not strictly complied with. Medical Certificates of Exclusion from School. The certificates issued by general practitioners for the exclusion of children from school is summarised in the following list, which shows the type of illness causing loss of school attendance, and may be taken in conjunction with I able II, of the Medical Inspection returns to the Board of Education. The returns again show the prevalence of ear, nose and throat defects. Conditions for which Medical Certificates of Exclusion from School were issued by General Practitioners during 1935. Malnutrition, debility 45 Skin 24 Eyes 4 Ears 17 Nose and throat 149 108 Enlarged cervical glands 14 Heart 8 Lungs (non-tuberculous) 29 Nervous diseases 8 Deformities, accidents, etc. 31 Operations 19 Measles 5 Whooping cough 21 Mumps 40 Influenza 55 Chicken pox 29 Rheumatism 20 Bronchitis 50 Miscellaneous 161 729 After Care. The work of the following-up of the necessitous ailing child, recommended by the School Medical Officer for the provision of extra nourishment, convalescence, etc., is under the efficient control of Miss M. Isard, the Hon. Secretary of the Bromley Children's Care Committee, whose Report for the year is appended. I would like to express appreciation of the work Miss Isard, and the many lady helpers of the Care Committee, are doing at the Clinics to co-ordinate with the school medical services the work of After Care which is so essential. They devote a great deal of time daily at the various clinics and centres, and without this public spirited voluntary effort the services would lack to a great extent that very desirable social influence their presence brings to the work; apart from this aspect, the practical work they are able to do, renders valuable assistance to the permanent staff. REPORT OF THE BROMLEY CHILDREN'S CARE COMMITTEE, 1935. During the year voluntary helpers have been extremely regular in attendance at the various clinics. 109 In order to facilitate the work of the clinic a change in routine was tried in the Autumn; the helpers now give practical aid in the treatment room instead of assisting in the nurses' clerical work which is now combined with all the clerical work of the general office staff. Assistance has been given in 195 cases as follows:— Extra nourishment 34 Provision of glasses 11 Eares for taxis after T. and A. Operations 8 Fares to hospitals 6 Provision of boots 82 Convalescent home letters 52 Two children were sent to the Royal Sea Bathing Hospital, one for twelve months and the other for eight months. A child was sent to Broadstairs for twelve weeks, and another for six weeks. An arrangement has heen made with the Hon. Treasurer of the Queen's Reign Commemoration Fund whereby the Care Committee contribute 10s. Od. towards the maintenance expenses of each child sent to convalescent home under letter supplied by the Fund. This scheme has enabled the Fund to supply a larger number of letters. The Committee would like to record their appreciation of the help given by Mr. Harvey Lowe through the Queen's Reign Commemoration Fund, and also of the assistance given by Mr. Harris, who continues to supply spectacles at a very reduced rate to cases referred from the Eye Clinic. Miss Faber, who had helped at the Dental Clinic for a long time, resigned during the year. In conclusion the Committee would thank all those who have given assistance in any way and thus made it possible to carry on the work successfully. 110 Statement of Accounts. 1935. Receipts. £ s. d. Expenditure. £ s. d. Bromley Benevolent Association 70 0 0 Royal Sea Bathing Hospital 54 12 0 Charities Festivities Association 40 0 0 Boots 36 0 3 Milk 14 14 1 Raglan Road Parents' Clothes 10 0 0 Association 4 4 0 Letters — Royal Sea Bathing Hospital 8 8 0 Clinic Box 8 4 Repaid— Fares, etc., Convalescent Homes 12 17 0 Royal Sea Bathing Hospital 15 16 6 Fares to Hospitals 1 0 0 Fares 1 16 2 Convalescent Homes 4 18 0 Convalescent Homes 10 0 Taxis from Clinic 18 3 Dental appliance 6 0 Balance carried forward 2 9 1 Taxi from Clinic 2 0 Balance from 1934 12 13 8 £145 1G 8 £145 16 8 Amy G. Mann, Chairman and Hon. Treasurer. M. A. Isard, Honorary Secretary. APPENDIX. 112 TABLE 1.—MEDICAL INSPECTION RETURNS. Year ended 31st December, 1935. A.—ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed Groups:— Entrants 600 Second Age Group 519 Third Age Group 617 Total 1736 Number of other Routine Inspections 31 Grand Total 1767 B.—OTHER INSPECTIONS. Number of Special Inspections 2976 Number of Re-inspections 2410 Total 5386 C.—CHILDREN FOUND TO REQUIRE TREATMENT. Number of individual children found at Routine Medical Inspection to Require Treatment. Prescribed Groups:— Entrants 145 Second Age Group 102 Third Age Group 124 Total (Prescribed Groups) 371 Other Routine Inspections 4 Grand Total 375 113 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1935. Defect or Disease Routine Inspections Special Inspections No. of Defects No. of Defects Requiring Treatment Requiring observation Requiring Treatment Requiring observation Skin (1) Ringworm—Scalp 1 — 1 — (2) „ Body 2 — 33 1 (3) Scabies 2 — 22 1 (4) Impetigo 2 — 89 — (5) Other Diseases (non-tuberculous) 20 12 305 5 Total (Heads 1 to 6) 27 12 450 7 Eye (6) Blepharitis 5 1 3 — (7) Conjunctivitis 2 — 50 1 (8) Keratitis — — — — (9) Corneal Opacities 2 — 1 — (10) Other conditions (excluding Defective Vision and Squint) 3 2 104 — Total (Heads 6 to 10) 12 3 158 1 (11) Defective Vision (excluding squint) 154 46 74 12 1(12) Squint 4 3 3 — Ear (13) Defective hearing 6 4 5 — (14) Otitis Media 4 — 86 — (15) Other Ear Diseases 2 1 93 7 Nose and Throat (16) Chronic Tonsillitis only 68 211 98 26 (17) Adenoids only 12 19 5 7 (18) Chronic Tonsillitis and Adenoids 47 63 191 88 (19) Other conditions 32 45 140 12 (20) Enlarged Cervical Glands (non-tuberculous)... 13 106 38 11 (21) Defective Speech 3 3 — 1 Heart and Circulation Heart Disease: (22) Organic 5 13 7 — (23) Functional 5 25 41 9 (24) Anaemia 12 5 16 4 Carried forward 406 559 1405 185 114 TABLE II.—Continued. Defect or Disease Routine Inspections Special Inspections No. of Defects No. of Defects Requiring Treatment Requiring observation Requiring Treatment Requiring observation Brought forward 406 559 1405 185 Lungs (25) Bronchitis 4 — 9 — (26) Other Non-Tuberculous Diseases 24 16 125 9 Tuberculosis Pulmonary: (27) Definite — — 1 — (28) Suspected 1 3 31 3 Non-Pulmonary: (29) Glands 1 — 5 — (30) Bones and joints — 1 2 — (31) Skin — 1 — — (32) Other forms — 2 1 — Total (Heads 29 to 32) 1 4 8 Nervous System (33) Epilepsy 1 — 2 — (34) Chorea 4 3 3 — (35) Other conditions 17 38 21 5 Deformities (36) Rickets — 6 — 15 (37) Spinal Curvature 50 26 5 6 (38) Other forms 87 60 43 8 (39) Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 123 66 727 95 Total 718 781 2380 326 115 B.—Classification of the Nutrition of Children Inspected during the Year in the Routine Age Groups. Age-Groups. No. of Children Inspected. A (Excellent). B (Normal). C (Slightly Sub-normal). D (Bad). No. Per cent. No. Per Cent. No. Per cent. No. Per cent. Entrants 600 27 4.5 487 81.2 81 13.5 5 0.8 Second Age- Group 519 38 7.3 378 72.8 99 19.1 4 0,8 Third Age-Group 617 81 13.1 408 66.1 124 20.1 4 0.6 Other Routine Inspections 31 2 6.5 24 77.4 5 16.1 — — Total 1767 148 8.4 1297 73.4 309 17.5 13 0.7 TABLE III.—Return of all Exceptional Children in the Area, 1935. CHILDREN SUFFERING FROM MULTIPLE DEFECTS. At no School or Institution. Mentally Defective and Epileptic 1 Mentally Defective and Partially Blind 1 Mentally Defective and Heart Disease 1 BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 2 — — — 2 116 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools tor the Partially Sighted. At Public Elementary Schools. At other Institutions. At no School or Institution Total. 2 3 2 — 1 8 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 — — — 3 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution Total. — — 4 — — 4 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. 5 2 2 3 12 MENTAL DEFICIENCY (NOTIFICATION OF CHILDKEN) REGULATIONS, 1928. Total Number of Children notified during the year 1935 by the Local Education Authority to the Local Mental Deficiency Authority 3 (i) Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots — (b) Imbeciles 2 boys, 1 girl, (c) Others — 117 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. rtified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 — — — 3 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 - 2 - - 2 11.—Children suffering from Non-Pulmonary Tuberculosis 1 8 - 1 10 B. Delicate Children 1 18 2 21 C. Crippled Children 11 18 - 3 32 D. Children with Heart Disease 1 7 - 2 10 118 TABLE IV.—Group 1. Minor Ailments treated during the year 1935. Disease or Defects. Number of Defects treated, or under Treatment during the year. Under the Authority's Scheme. Otherwise Total. Skin— Ringworm—Scalp (i) X-Ray treatment — — — (ii) Other 2 — 2 Ringworm—Body 32 — 32 Scabies 24 — 24 Impetigo 91 1 92 Other Skin Diseases 271 19 290 Minor Eye Defects (External and other, but excluding cases falling in Group 11) 166 9 175 Minor Ear Defects 179 14 193 Miscellaneous (e.g., Minor injuries, bruises, sores, chilblains, etc.) 798 107 905 Total 1563 150 1713 119 TABLE IV.—Group II. Defective Vision and Squint (Excluding Minor Eye Defects treated as minor ailments—Group I.). No. of Defects dealt with. No. of Children for whom Spectacles were Under the Authority's Scheme. Otherwise. Total. (a) Prescribed. (b) Obtained. Under the Authority's Scheme. Otherwise. Under the Authority's Scheme. Otherwise. Errors of Refraction (including squint) 345 345 262 258 — Other Defect or Disease of the Eyes (excluding those recorded in Group I) 53 — 53 - — — — Total 398 — 398 262 — 258 - 120 TABLE IV.—Group III. Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative Treatment. Received other forms of Treatment. Total N umber treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) — 15 131 10 - 2 13 4 — 17 144 14 127 302 (i) Tonsils only. (ii) Adenoids only, (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat. 121 TABLE IV.—Group IV. Orthopædic and Postural Defects. Under the Authority's Scheme. Otherwise. Total N umber 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 9 - 396 - — — 396 122 TABLE V.—Dental Inspection and Treatment. (1) Number of children inspected by the Dentist:— (a) Routine Age Groups Age: 5 516 " 6 581 " 7 579 " 8 362 " 9 313 „ 10 444 „ 11 „ 12 347 301 „ 13 310 „ 14 222 Total 3975 (b) Specials 507 (c) TOTAL (Routine and Specials) 4482 (2) Number found to require treatment 2246 (3) Number actually treated 2223 (4) Attendances made by children for treatment 3808 (5) Half-davs devoted to:— Inspection 22 Treatment 380 Total 402 (6) Fillings:— Permanent teeth 1903 Temporary teeth 452 Total 2355 (7) Extractions:— Permanent teeth 627 Temporary teeth 3901 Total 4528 123 (8) Administration of general anaesthetics for extractions 1115 (In addition there were 1142 local anaesthetics). (9) Other Operations:— Permanent teeth 306 Temporary teeth Total 132 438 TABLE VI.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses 3 (ii) Total number of examinations of children in the Schools by the School Nurses 14663 (iii) Number of individual children found unclean 455 (iv) Number of children cleansed under arrangements made by the Local Education Authority - (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 ... (b) Under the School Attendance Bye- laws 5