AC 4412 (1) BROMLEY M. BRO. 32 BOROUGH OF BROMLEY. 1936 ANNUAL REPORT. MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER. BROMLEY, KENT. The Bromley Printing Co., Sherman Road. BOROUGH OF BROMLEY. 1936 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 Staff 6 Prefatory Letter 8 Section A. Statistics and Social Conditions of the Area. Summary of Statistics 14 Social Conditions 15 Meteorology 17 Unemployment 17 Occupations 17 Population 18 Vital Statistics 18 Births 18 Stillbirths 19 Deaths 20 Infantile Mortality 21 Maternal Mortality 22 Section B. (I). General Provision of Health Services for the Area. Laboratory Facilities 26 Ambulance Facilities 26 Nursing in the Home 26 Bromley District Nursing Association 26 Hayes and West Wickham Nursing Association 27 Treatment Centres and Clinics provided by the Local Authority 28 Tuberculosis Dispensary 29 Venereal Diseases Treatment Centres 29 Hospitals—Public and Voluntary 29 Nursing Homes Registration Act, 1927 29 Nursing Homes and Hospitals Tabulation 31 Other Institutions 32 Section B. (II). Maternity and Child Welfare. Details of Services 34 Ante-Natal Clinic 35 Natal Services 36 Midwives 37 Mid wives Acts, Administration of 37 Midwives, Inspection of 38 Institutional Provision for Mothers and Children 39 Maternity Hospital 39 Maternity and Nursing Homes 39 Institutional and Convalescent Treatment 39 Puerperal Fever and Puerperal Pyrexia 39 Post-Natal Service 40. Health Visitors—Home Visiting 40 Welfare Centres 42 3 PAGE Milk in necessitous cases 43 Clinic and Institutional Treatments 43 Minor Ailments Clinic—children under 5 years 43 Dental Clinic—children under 5 years 43 Orthopaedic Clinic—children under 5 years 43 Dental Clinic—mothers 44 Maternity In-patients 44 Public Health (Ophthalmia Neonatorum) Regulations, 1926 44 Epidemic Diarrhoea 44 Infant Life Protection 44 Section C. Sanitary Circumstances of the Area. Water 48 Drainage and Sewerage 48 Cesspool Drainage 48 Rivers and Streams 48 Public Cleansing 49 Sanitary Inspection of the Area 49 Shops Acts, 1912-1934 50 Smoke Abatement 51 Factories and Workshops 51 Swimming Baths and Pools 51 Verminous Houses 51 Rats and Mice Destruction Act, 1919 52 Public Elementary Schools 53 Section D. Housing 56 Section E. Inspection and Supervision of Food. Milk Supply 60 Milk—Bacteriological Examinations 61 Meat—Tables A., B., C., D. and E 61-64 Unsound and Unwholesome Food Surrendered 64 Food and Drugs (Adulteration) Act, 1928 64 Section F. Prevalence of, and Control over, Infectious Diseases. Scarlet Fever 68 Diphtheria 69 Other Notifiable Infectious Diseases 70 Tuberculosis 70 Propaganda 72 Section G. Other Services Supervised by the Health Department. Diseases of Animals Acts 74 Rag Flock Acts, 1911-1928 74 Registries for Female Domestic Servants 74 Petroleum Acts 75 Retail Market 76 Appendix. Tables I. to XV 78-97 4 SCHOOL MEDICAL SERVICE. PAGE Members of the Education Committee 100 Introduction 101 Summary of Statistics 102 Co-operation 103 Hygiene of Schools 103 Medical Inspection 104 Findings at Medical Inspections 105 Malnutrition 105 Uncleanliness 106 Minor Ailments and Diseases of the Skin 107 Visual Defects 107 Nose and Throat 108 Ear Disease and Defective Hearing 108 Dental Defects 108 Orthopaedic and Postural Defects 108 Heart Disease and Rheumatism 109 Tuberculosis 109 Other Defects 110 Following-up 110 TREATMENT 110 Treatment of Minor Ailments 111 Report on the Work of the Eya Clinic 111 Report on the Work of the Ear, Nose and Throat Clinic 112 Report on the Work of the Orthopaedic Clinic 112 Report of the School Dental Surgeon 113 Summary of Dental Statistics 115 Ultra Violet Ray Clinic 116 Infectious Disease in the- Schools 117 Medical Certificates of Exclusion from School 118 Employment of Children and Young Persons 118 Physical Training 119 Provision of Meals 120 Open Air Schools 120 Occupation Centre 1™ After-Care Work 12j Report of the Bromley Children's Care Committee 121 Appendix :— Table I. Medical Inspection Returns 121 Table II. Return of Defects 125 Table III. Return of Exceptional Children 127 Table IV. Group I. Minor Ailments 13" Table IV. Group II. Defective Vision 131 Table IV. Group III. Ear, Nose and Throat Clinic 132 Table IV. Group IV. Orthopaedic Defects 133 Table V. Dental Inspection 131 Table VI. Uncleanliness and Verminous Conditions 135 MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1936-1937. HEALTH COMMITTEE:— Councillor M. Stafford Smith, m.b.e., b.a. (Chairman). Alderman W. F. Skilton (Vice-Chairman). His Worship the Mayor (Councillor E. J. Bettson, f.c.a., j.p.). Councillor G. Allen. Councillor E. C. De'Ath. 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 S. G. Humerston. Councillor S. L. Lyle. MATERNITY AND CHILD WELFARE COMMITTEE:— Councillor S. G. Humerston (Chairman). Mrs. A. M. Howe (Vice-Chairman). His Worship the Mayor (Councillor E. J. Bettson, f.c.a., j.p.). Alderman W. F. Skilton. Councillor G. Allen. Councillor E. C. De'Ath. 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 S. L. Lyle. Councillor M. Stafford Smith, m.b.e., b.a. Co-opted Members:— Mrs. A. M. Howe (Vice-Chairman). Mrs. A. G. Mann, b.a., j.p. Mrs. M. Pearce. Miss V. Vincent. Mrs. E. Tolland. 5 6 PUBLIC HEALTH STAFF, 1936. Medical Officer of Health and School Medical 2 K. E. Tapper, o.b.e., Officer m.b., ch.b., d.p.h. Assistant Medical Officer of Health and School 2 Miss G. H. Stinson, Medical Officer m.r.c.s., l.r.c.p. Orthopedic Specialist 2 1 H. J. Seddon, f.r.c.s. Ear, Nose and Throat 2 1 Charles C. Bexey, m.a., Specialist m.b., ch.b., (Canib.), m.r.c.s. Eye Specialist 2 1 Eric Lyle, m.a., h.d., b.ch., d.o.m.s. Anaesthetist 2 1 E. G. France, m.b., B.s.Lond., m.r.c.s., l.r.c.p. Consulting Gy nomologist 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. 2 1 Fairman J. Ordish, l.d.s., R.c.s. (Appointed 2/9/1936). 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. 5432 W. H. Sayers, m.s.i.a. a.r.san.i. (Appointed 6/7/1936). 4 3 2 H. Handscomb, m.s.i.a. (Resigned 31/5/1936). Health Visitors and 8 7 6 2 Miss L. A. Briggs, s.r.n. School Nurses 8762 Miss E. Connor, s.r.n. 8 7 6 2 Miss E. B. Crowe, s.r.n. 8 7 8 2 Miss J. E. B. Dunn, s.r.n. 8 7 6 2 Miss D. Prime, s.r.n. 87S2 Miss E. Rhodes, s.r.n. 7 Orthopædic 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.sax.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. Temporary Clerk (Housing Survey) G. C. Dickinson. Dental Clinic Assistants 2 Miss A. M. Penman. 21 Miss E. Roberts (Appointed 2/9/1936). Outdoor Staff: Drain Tester and Disinfector J. W. Seager. Market Superintendent 1 F. J. Ephgrave. i. 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. 3. Royal Sanitary Institute Health Visitors' Certificate (under Memo. joi/MCW). 8 To the Mayor, Aldermen and Councillors. Mr. Mayor, Madam and Gentlemen, I have deemed it expedient to revise the general arrangement of the Annual Report so as to conform as far aS possible with the general directions indicated in the Minister of Health's Circular 1561, dated 16th October, 1936. The Report now falls under the main heads suggested, viz., A. Statistics and Social Conditions of the Area. B (I). General Provision of Health Services for the Area. B (II). Maternity and Child Welfare. C. Sanitary Circumstances of the Area. D. Housing. E. Inspection and Supervision of Food. F. Prevalence of, and Control over, Infectious and Other Diseases. G. Other Services Supervised by the Health ment. It will be found that continuity with the reports of previous years has not been greatly disturbed by the re-arrangement, and in order to facilitate easy reference, the Tables of statistics following section G have been retained, as in previous years, in the form of an appendix. The year under review indicates no outstanding event in so far as the health, or ill-health, of the people of Bromley is concerned. From the administrative viewpoint the operation of the Housing Act, 1935, which Borough of Bromley. Report of the Medical Officer of Health for the year 1936. 9 functioned as from the 1st January, 1936, placed upon the Department the responsibility of a Housing Survey and the remedying of overcrowding in houses. A preliminary statement was issued in the Report for 1935, and later in this Report further details are submitted on the work carried out during the year. It is to be noted that the Housing Act, 1935, together with the previous Housing Acts, have now been embodied in the consolidating measure—Housing Act, 1936. The following list of Acts, Orders, Regulations and Memoranda issued during 1936 indicates the ever increasing Health administration work placed on the Local Authority by the Central Authority. Housing. Ministry of Health—Form H256 received quarterly requiring progress report under the Housing Act, 1930. Ministry of Health—Form H256a requiring half yearly returns of progress under programmes in connection with the Housing Act, 1930. Ministry of Health—Circular 1539 with regard to fixing (inter alia) the Appointed day for overcrowding purposes under the Housing Act, 1935. Housing Act, 1935—report on overcrowding survey in England and Wales. Housing. Abatement of Overcrowding Statutory Rules and Orders 1936, No. 1017. Housing Act, 1936—consolidating measure. Housing Acts (Overcrowding and miscellaneous forms) Regulations, 1936. The Housing Act (Form of Orders and Notices) Regulations, 1936. Memorandum H256c. Housing. Requesting continuance of records for progress return at 31/3/1937. Housing Act, 1935 (Operation of overcrowding Provisions) Order, 1936. Statutory Rules and Orders, 1936, No. 1935. Public Health, General. Second Interim Report of the Local Government and Public Health Consolidation Committee and accompanying draft Public Health Bill, with reference to the consolidation of Public Health Law. Ministry of Health Circular 1544 with reference to the use of Orthodichlorbenzene in inhabited houses for extermination of bugs. Ministry of Health Circular 1561 as to the contents and arrangement of Annual Reports of Medical Officers of Health. 10 Public Health Act, 1936. Consolidating measure coming into operation on 1st October, 1937. Ministry of Health Circular 1576, Public Health Act, 1936, inviting attention to certain changes in the law brought about by the new Act. Ministry of Health Circular 1586 enclosing Memo 166/Metl with respect to administrative measures desirable on the occurrence of cases of acute poliomyelitis. Milk. Memorandum "The Nutritive Value of Milk" by the Advisory Committee on Nutrition. Ministry of Health Circular 1533, the Milk (Special Designations) Order, 1936, revising the system of milk grading as from 1st June, 1936, and Memo. 197/Foods relative thereto. Ministry of Health Circular 1568 forwarding questionnaire relating to supply of milk during 1935-6 to expectant and nursing mothers. The Milk (Special Designations) Order, 1936. Circular 1580 and revised edition of Memo. 139/Foods, prescribing method of carrying out bacteriological tests in samples of milk taken on and after let January, 1937. Maternity and Child Welfare. Ministry of Health Circular 1550 stressing the need for medical attention for children under school age. Midwives Act, 1936. Circular 1569 drawing attention to the provisions and general scope of financial arrangements of the Act. Nursing Homes Registration Act, 1927. Circular 1574 directing the attention of Local Authorities to responsibilities under that Aci and suggesting steps for bringing to light the existence of unregistered homes. Ministry of Health Circular 1582 and Statutory Rules and Orders No. 1112 and Regulations fixing scale of fees to be paid by Local Supervising Authorities to medical practitioners called in by midwives. Ministry of Health Circular 1584 enclosing forms for Annual returns with respect to Maternity and Child Welfare. Various. Fowl Pest Order of 1936. Diseases of Animals (Importation of Therapeutic Substances) Order of 1936. Employment of Women and Young Persons Act, 1936. Shops Act, 1936. Retail Meat Dealers' Shops (Sunday Closing) Act, 1936. Petroleum (Transfer of Licences) Act, 1936. 11 The foregoing- list is not intended to be an exhaustive one giving details of all official documents which bear upon the work of the Health Department, and therefore should be regarded as a record only of the most important ones issued during 1936. Two prominent activities during the year have been the publicity given to the need of generalised physical training and the promotion of knowledge and practice of correct nutrition of the people. As both of these factors play an important part in every day health, they must be closely allied to the services of the Local Sanitary Authority. One does, however, feel that there is a tendency to exaggeration, both in the press and on public platforms of the low state of nutrition of the nation, but it is significant that diseases, such as tuberculosis, associated with under-nourishment are actually declining in incidence while diseases largely due to over-nourishment, such as cardio-vascular disease and diabetes, are increasing. Nevertheless much new knowledge in the scientific principles of correct feeding and the prevention of diseases has been developed within recent years, but has not yet been put into practice. One finds for example that when the family income suffers reduction the first item to be curtailed is the quality and quantity of food purchased—milk is deleted from the dietary thus depriving the individual of one of the basic foods. As a palliative to the ill-effects of sedentary life and work of to-day, physical training must be encouraged. There are many who seek recreation by watching others at games, and mental relaxation is sought in closely crowded indoor amusements. The speed of life which modern times require of us, and the fact that we work, travel and amuse ourselves in crowded conditions, must tend to increase mass infection and physical and mental ill-health. We cannot change our mode of life, thus we must continue to stress the need for open air exercise and sound nutrition. Air raid precautions placed a voluntary service upon the Officers of the Department, but it is found increasingly difficult to give adequate time to these services. Preliminary advice has been tendered, and a beginning 12 made in establishing- a scheme of protection against gas injuries. The vital statistics of the year show a Death Kate of 9.4 (12.1), a Birth Bate of 13.5 (14.8) and an Infantile Mortality Rate of 37 (59), the figures in parenthesis being the corresponding rates for England and Wales. Maternal mortality, upon which I have reported more fully in the body of this Report, has been a subject to which the Ministry of Health and Parliament gave much attention during 1936, and the enactment of the Midwives Act during the year has placed upon the Local Authority the responsibility of providing an adequate salaried service of midwives for domiciliary care of the mother. Three Bromley mothers died in childbirth in 1936. The medical services of Maternity and Child Welfare and of the Schools are being increasingly used by the public, and this being so there is no apparent need to undertake propaganda directing attention to these services; health education is better given individually than by widespread propaganda. Infectious diseases still claim their victims, although the year under review showed a diminution in the incidence of Scarlet Fever and Diphtheria. Measles and Whooping Cough are still returning a high morbidity rate and call for the establishment of Home Nursing Service during the time of epidemics. I would like to express to the Committees my appreciation of their help and advice to me at all times, and to the Staff for their continuous interest in their multiple duties to promote the health and wellbeing of the people of Bromley. I am, Mr. Mayor, Madam and Gentlemen, Your Obedient Servant, K. E, TAPPER, Medical Officer of Health. SECTION A. Statistics and Social Conditions of the Area. 14 SECTION A.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA, 1936. Statistics. Area (in acres) 6,519 Population—Mid-year 1936 (Registrar General's estimate) 57,850 Number of inhabited houses— Census, 1931 10,764 End December, 1936 (Rate Books) 15,965 Rateable Value (31st March, 1937) £675,647 The sum represented by a Penny Rate (estimated for the year ending 31st March, 1938) £2,710 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. Birth Rate per 1,000 of the 'estimated population: 13.5. Total Male. Female Legitimate 750 379 371 Illegitimate 30 13 17 780 392 388 Stillbirths. Legitimate 26 11 15 Rate per 1,000 total (live and still) births : 32. Illegitimate - - - 26 11 15 Deaths 567 258 309 Death Rate per 1,000 of the estimated population: 9.4, (as adjusted according to comparability factor: 0.97.) 15 Death Rate of Infants under 1 year of age:— All infants per 1,000 live births 37. Legitimate infants per 1,000 legitimate live births 36. Illegitimate infants per 1,000 illegitimate live births 66.6 Deaths from cancer (all ages) 88. Deaths from measles (all ages) 9. Deaths from whooping cough (all ages) 2. Deaths from diarrhœa (under 2 years of age) 1. Social Conditions. Building operations have proceeded steadily throughout the year. Large estates are fast disappearing and neat roads with small residential property are taking their place. The Borough Surveyor reports the erection of 741 houses during 1936. Traffic congestion through the main roads of the town has, through the widening of High Street and Hayes Lane, been considerably alleviated. The potentialities of Bromley as a shopping centre for the surrounding small towns and villages have been readily appreciated by the large shop builder, whose activities in recent years are apparent in the main shopping streets of the town. The inevitable tendency for business premises to extend in a southerly direction along the main road is a natural consequence of street widening and of the building developments taking place in the added area and in the southern portion of the Borough. The policy of the Local Authority in wisely adhering to the restrictions embodied in the Town Planning Scheme Deaths from Puerperal Causes No. of Deaths. Rate total still) per 1,000 live and births: From sepsis From other causes ... 1 2 1.24 2.48 Total 3 3.72 16 is doing much to preserve the amenities of the town as a desirable residential area. It also tends to check the complete "suburbanisation" which Bromley ever stands in risk of through its close proximity to the London Metropolis. By the acquisition of 61 acres of woodland at Elmstead Woods the Local Authority is to be congratulated on securing a natural barrier to preserve its residential amenities as well as adding yet another precious tract of land as an open space for the public. A further six acres at Southborougli and three acres at Tylney Road have been added to the open spaces of the town. The following table shows that over 488 acres have now been secured for public recreation within the Borough:— Acres. Roods. Poles Acres, Roods. Poles. Commons and Open Spaces : Elmstead Woods 61 1 36 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 Southborough 6 0 0 The Knoll 4 1 39 Turpington 1 3 10 363 3 20 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 Tylney Road 3 1 28 Whitehall 17 1 6 Norman Park (reserved) 56 0 0 109 3 14 Public Gardens and Grounds: Church House Ground 10 3 10 Library Gardens 1 2 0 Queen's Garden 2 1 4 Widmore House Gardens 2 0 15 0 14 488 3 8 17 The high figure of 785 men was due in the main to stoppage of the building trade owing to frost. As many of the women are employed out of the district it is not possible to state any definite reason for the fluctuation shown in the above figures. Occupations. On page 15 of my Annual Report for 1934 will be found details of occupations within the Borough according to the Census returns of 1931. Meteorology. I am indebted to the Borough Engineer for the following details extracted from the records kept by his department at the Climatological Station at Church House Grounds for the year ended 31st December, 1936:— Total rainfall 25.30 inches Mean maximum daily tempera- 56.58 degrees ture Mean minimum daily tempera- 43.48 degrees ture Highest maximum temperature 87.0 degrees on 20th recorded June Lowest minimum temperature 18.0 degrees on 12th recorded and 13tli February Lowest grass minimum tem- 11.0 degrees on 12th perature February Unemployment. The Manager of the Employment Exchange has kindly supplied the following particulars:— 1. Recorded unemployment at the end of 1936: (a) Men 439 (b) Women 63 Total 502 2. Highest figure reached in 1936: (a) Men 785 20/1/1936 (b) Women 180 31/3/1936 18 Population. The following figures show the growth of population over a very wide period of time:— Year. Population. 1831 4,002 1901 27,354 1911 33,646 1921 35,052 1931 45,374 1936 57,850 The Registrar General gives the mid-year 1936 figure of population for Bromley as 57,850. This figure approximates very closely to the estimated figure of 57,260 compiled recently from the statistical records of this Department. Taking the figure of 15,965 inhabited houses as shown on the rate books at the end of 1936, it is interesting to note that on the present population of 57,850 the average number of persons per house is 3.62 as compared with 3.61, which was the figure disclosed as a result of the Housing Survey in January, 1936. The Housing Survey also showed the population to be made up of 16,710 families and 844 of' these families took in lodgers, and of these families 1,375 were living as sub-tenants. VITAL STATISTICS. Births. The Birth Bate for 1936 is 13.5 per 1,000 population. The number of births notified, in the Borough under the Notification of Births Act, 1907, was 820, as follows, viz.:— Live Births 799 Stillbirths 21 820 The Registrar General allots to this area 780 live births and 26 stillbirths. These figures are calculated on the number of births registered during the year. Although we are put in possession of certain information regarding 19 inward and outward transfers of births notified during the course of the year, it would be fallacious to attempt to arrive at the actual net figure of babies born to Bromley parents because the machinery for notifying inward and outward transfers between local authorities does not pursue a systematic routine. We are thus dependant upon registration rather than notification, although occasionally a notified birth is found not to have been registered. The Health Visitor not infrequently encounters the "discovered on visit" case in the course of routine work, and again one finds the case of the child entering school life who has fortuitously escaped all visitation up to five years of age; and unfortunately often a case suffering from defect which has escaped corrective measures. The following comparative table of birth rates shows the decline which has been taking place during the past ten years. It will be noted, however, that there is a slight upward tendency since 1932 coinciding with the taking over of the added areas of Hayes and Keston. The deduction here would appear to be that influx of population of young married persons to the building estates in these areas and other parts of the Borough tends to inflate the rates. It would, therefore, be unwise in these circumstances to attach any importance to the slight rise of the Birth Rate. Birth Rates. Year. Bromley. England and Wales. 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 1936 13.5 14.8 Stillbirths. The following table shows the number of stillbirths occurring in Bromley, together with the rates per 1,000 births, chiring the past ten years:— 20 Rate per 1,000 Year. Stillbirths. 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 23.5 1935 15 19.4 1936 26 32.2 This continued high stillbirth rate is a disturbing factor, and not one to be ignored in the consideration of conditions of child birth in Bromley. The cause of stillbirths cannot be correctly stated in each case unless postmortem examination is made, but generally speaking the deaths are preventable by adequate attention to the Ante-natal and Natal conditions of the mother. The three mortality rates of stillbirths, maternal and neo-natal are one problem and are not to be considered separately. Deaths. The Death Kate for 1936 is 9.4 as corrected by the comparabilitv factor. A similar rate was recorded for 1935. The following table gives the crude death rates for Bromley in comparison with the death rates for England and Wales during the past ten years:— Year. Bromley Crude Death Rates. England and Wales Death Rates. 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 1936 9.8 12.1 21 Table III. in the Appendix gives all causes of deaths. The following details have been included for comparison purposes:— Rates per 1,000 population. 1930 1931 1932 1933 1934 1935 1930 Respiratory disease . 0.7 0.9 0.9 0.9 0.8 0.6 1.02 Heart disease 2.3 2,6 3.1 3.2 2.8 3.2 2.9 Cancer 1.5 1.5 1.6 1.4 1.3 1.5 1.5 Tuberculosis 0.9 0.7 0.7 0.7 0.3 0.5 0.6 Premature births 0.3 0.2 0.2 0.2 0.3 0.2 0.3 Infectious disease 0.1 0.1 0.1 0.04 0.1 0.1 0.3 Influenza 0.06 0.1 0.3 0.3 0.1 0.2 0.1 Infantile Mortality. The Infantile Mortality Rate for 1936 is 37 per 1,000 births. Tables II., IV., Y. and VI. in the Appendix should be referred to for statistical material relating to infantile mortality, and for comparison purposes the following details will be found of interest:— Year. Bromley. England and Wales. 1927 50 69 1928 49 65 1929 46 74 1930 41 60 1931 47 66 1932 33 65 1933 41 64 1934 43 59 1935 27 57 1936 37 59 It has more than once been said that the Infantile Mortality Rate is an indication of the health of a locality. If this be true, and there is no reason to doubt it, then Bromley is in truth a healthy town. We have, I believe, good reason to be proud of our Maternity and Child Welfare Service, for in the low Infantile Mortality Rate we see part of the return for the money and energy expended in this service. The saving in child life and the improvement in the health of the child is the foundation of the Nation's happiness—it is in fact its very life. In giving consideration to infantile mortality one should also include other deaths, those that die before 22 birth, i.e., stillbirths, and those that die within one week of lite, i.e., neo-natal deaths. These are in fact due to ante-natal and natal conditions and are, if adequate care and service be given, largely preventable. It is in this sphere, now that we have within 20 years halved the infant death rate, that we must concentrate our attention, for whatever we have done in the past has not resulted in any reduction in stillbirths and deaths of children under one week of age. The stillbirth rate and neo-natal death rate per 1,000 births is given in the following table:— Stillbirth. Neo-Natal. 1910-1914 — 19 1921-1925 — 22 1926-1930 25 17 1931-1935 29 38 1936 32 17 Maternal Mortality. Quinquennial periods: Sepsis. Accidentsof 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 1936 1 2 3 Tables II., III. and IV. in the appendix will be found to contain statistical material relating- to maternal mortality.. Of the three deaths recorded in 1936 two occurred in maternity institutions and one at home. The cause of deaths were, ante-partum haemorrhage (blood transfusion), acute streptococcal pneumonia and eclampsia. It is reasonable to state that two of these deaths came under a preventable cause. It has more than once been stated that 50 per cent. of all maternal deaths are preventable, and if preventable why not prevented? The passing of the Midwives Act, 1936, which operates in 1937, is the first step towards an improved service of adequate domiciliary care of the mother during confinement. Under the Act the Local Authority proposes to 23 appoint under their direct control, salaried midwives, home helps, and a domiciliary service of general practitioners in each case. Their desire is to provide the best available attention at the confinement and to relieve the mother of all anxiety of home care during the lying-in period, and at the same time to unify the maternity service and child welfare service. This is a long needed reform in our services if we are to combat a high maternal mortality rate of three per 1,000 births, a stillbirth rate of 32 per 1,000 births and a neo-natal rate of 17 per 1,000 births. It is in the reduction of these rates that scope for work lies waiting—a work which can only be successful by a unified effort by all associated with the welfare of the mother and young baby. SECTION B (I). General Provision of Health Services for the Area. 26 SECTION B (I).—GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Laboratory Facilities. The West Kent Isolation Hospital undertakes the testing of throat swabs in urgent cases, and the arrangements continue to work satisfactorily. The facilities provided by the Kent County Council are used for the examination or analysis of clinical material (sputum, swabs, etc.), water, milk and foodstuffs. 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. Nursing in the Home. (1) The Bromley District Nursing Association was formed in 1907 with the objects of (a) providing skilled general nursing for the sick poor and for those who cannot provide it for themselves, and (b) skilled maternity nursing and midwifery at a small cost. Nursing Staff. (i) General Nurses 2 (ii) Midwives 3 Summary for the Year, 1936. Cases on the register, January, 1936 25 New cases during the year 475 Visits Paid. General nursing 4,368 Ante-natal visits 1,460 Maternity and midwifery 3,364 Casual visits 970 27 Analysis of New Cases. Medical 128 Surgical 141 Maternity (with Doctor) 47 Midwifery 152 Abortions 7 Cases sent in by: Doctors 207 Visitors and others 2 Applied 266 Result of Cases Nursed. Convalescent 403 Sent to Hospital, Infirmary or transferred 45 Died 26 Still on register 26 (2) The Hayes and West Wickham Nursing Association provides nursing and midwifery facilities for the areas of Hayes and Keston. Their sphere of activity also covers West Wickham, which is within the area of the Borough of Beckenham. Nursing Staff. (i) General Nurses 1 (ii) Midwives 1 Details of nursing visits for the year ended 31/3/1937. General nursing 2,578 Midwifery 618 Ante-Natal 415 Casual 196 Total 3,807 28 Treatment Centres and Clinics provided by the Local Authority. Medical Clinics Situation of Clinic or Centre. School Clinic, Station Road, Bromley North. School Clinic, Princes Plain, Bromley Common. Days and Times. Days and Times. Medical Inspection Mornings (daily) Wednesday excepted Mornings (daily) Minor Ailment Treatment Mornings (daily) Mornings (daily) Ear, Nose and Throat Clinic Wednesdays (morning) — (Operations and Consultations) Dental Clinic Mornings and afternoons One day per week (two sessions, usually Wednesdays) Eye Clinic Wednesday mornings and 2nd and 4th Thursdays of the month in afternoon. - Orthopaedic Clinic Surgeon attends 1st Monday and 3rd Tuesday (monthly) - Massage and Remedial Exercises Mondays (morning) Tuesdays (all day) Thursdays (afternoon) Fridays (afternoon) - Ultra Violet Ray Clinic Tuesdays and Fridays (afternoons) Mondays and Thursdays (afternoons) Diphtheria Immunisation Mondays (afternoon) — Dental Treatment for Mothers Saturdays (morning) - Infant Welfare Centres. Situation. Days and Times. Bromley Common School Clinic, Princes Plain Tuesdays and Fridays, at 2.30 p.m. Burnt Ash Burnt Ash Branch Library, Burnt Ash Lane Tuesdays and Wednesdays, at 2.30 p.m. Hayes and Keston Village Hall, Hayes Tuesdays, at 2.30 p.m. Plaistow School Clinic, Station Road Wednesdays, at 2.30 p.m. Masons Hill St. Mark's Church Hall, Masons Hill Thursdays, at 3 p.m. Widmore Wesleyan Hall, Tylney Road Fridays, at 2.30 p.m. Ante-Natal Clinic School Clinic, Station Road 1st and 3rd Thursdays (monthly) do. School Clinic, Princes Plain 2nd Thursday (monthly) do. Maternity Hospital, 118, Widmore Road 4th Thursday (monthly) 29 Tuberculosis Dispensary. The Tuberculosis Dispensary is provided and maintained by the Kent County Council, and is held at 2, Park Road, Bromley, on Wednesdays, 1.30 to 3.30 p.m., and Fridays at 5 to 6 p.m. The Tuberculosis Officer in charge is Dr. B. G. A. Edelston, and the Corporation of Bromley supplies a nurse from the Health Visiting staff for the Wednesday Dispensary. Home visiting of patients is carried out by the Health Visitor. Venereal Diseases Treatment Centres. The Kent County Council provides 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. Hospitals. Public and Voluntary. (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. 9 cots. (2) General Hospitals (Voluntary) : Bromley (Kent) and District Hospital 99 beds. Phillips Memorial (Homeopathic) Hospital 20 beds. (3) Maternity Hospital (Voluntary) : The Bromley and Chislehurst Maternity Hospital 19 beds. (In addition there are 2 labour wards and 1 isolation ward). Nursing Homes Registration Act, 1927. The Minister of Health in his Circular 1574 dated 30th September, 1936, stressed the importance of ascertaining 30 promptly the existence of any unregistered Nursing Homes and suggested that Local Authorities should take steps to secure co-operation of medical practitioners. Local practitioners were advised as to the terms of the circular, hut there is no reason to suppose that premises are being illegally used as nursing homes in this area, as the supervision exercised by the Department has been particularly vigilant. The Assistant Medical Officer of Health inspects each registered nursing home once a quarter. Bye-laws were adopted in 1928 which prescribe the register of particulars to be kept; type of case records; receipt books, and requires notifications relative to deaths and infectious disease. Since the inception of the Act no flagrant breach of the law has been reported in the area, and at all times nursing home keepers have shown an admirable spirit of co-operation in conforming to legal requirements, and in carrying out improvements for the betterment of the hygienic conditions of their premises. One new nursing home was registered in 1936, making in all 11 nursing homes on the register, of which six are classified as maternity institutions whilst the remainder take general nursing cases. The following table gives particulars of maternity and nursing homes registered by the Local authority, and for convenience of tabulation I have included details of the larger hospitals which are exempt from registration under the provisions of the Act 31 Address. Total No of Beds. ity Bed Patients received 1936. Nursing Staff. Type of case taken Maternity. Surgical Medical Total. Resident Living Out. Qualifications. 77, Avondale Road 6 4 4 23 17 4 1 3 1 Gen. Trained and S.C.M. 3 Gen. Trained. Mixed 40, Bromley Common 10 4 39 52 11 5 5 - 3 Gen. Trained and S.C.M 1 Gen. Trained. 1 Assistant. Mixed "Greta," Blyth Road 10 - - 100 50 7 3 4 1 Gen. Trained and S.C.M 4 Gen. Trained. 1 Assistant, 1 not stated. Nursing 24, Elmfield Road 10 2 8 — 6 4 4 — 2 Gen. Trained 2 Assistants. Mixed 3, Elmstead Lane 8 1 2 25 13 4 4 — 4 Gen Trained. Mixed 29, King's Avenue 2 — — — 1 1 — 1 Gen. Trained. Nursing "Frascati," Masons Hill 23 5 45 29 77 10 10 3 3 Gen. Trained and S.C.M. 2 Gen. Trained. 2 S.C.M. 3 Asst. Nurses. Mixed 126, Princes Plain 2 — — — 3 1 1 — 1 Gen. Trained. Nursing 16, Sundridge Avenue 4 - - - 15 - - - (Home under supervision of Resident Medical practitioner). Nursing 13, Tweedy Road 5 — — — 2 1 1 — 1 Gen. Trained. Nursing Maternity Hospital, 118, Widmore Road 19 19 397 - - 11 11 - 3 Gen. Trained and S.C.M. 4 S.C.M. 4 Asst. Nurses. Maternity Bromley (Kent) and District Hospital, Cromwell Avenue 99 - 11 608 297 35 35 - 5 Gen. Trained and S.C.M. 8 Gen. Trained. 2 Masseuse. 20 Untrained. General Hospital cases Phillips Memorial Hospital, Lownds Avenue 20 - 1 174 67 7 7 - 2 Gen. Trained and S.C.M. 2 Gen. Trained. 1 Asst. Nurse. 2 Probationer. General Hospital cases. 32 Other Institutions. (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. SECTION B (II). Maternity and Child Welfare. 34 SECTION B (II).—MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare services comprise the following:— 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 1936. 7. Hospital treatment, isolation, and Consultant Gynaecologist for Puerperal Fever and Pyrexia. 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 Orthopaedic treatment for the crippled child. 12. Minor Ailment treatment. 13. Ear, Nose and Throat Consultant and Surgeon. Operative treatment at the School Clinic. 14. Ophthalmologist for defective vision cases. 15. Provision of hospital treatment for cases of Ophthalmia Neonatorum, and for acute cases of complicated measles. 16. Supervision of midwives under the Midwives Acts. 35 17. Registration and inspection of Nursing Homes under the Nursing Homes Registration Act, 1927. Details of Clinics and Welfare Centres are given under the heading of Treatment Centres and Clinics. Ante-Natal Clinic. The following table gives figures of attendances made during the past ten years, viz., 1927-1936:— Year. Individual Attendances. Total Attendances. Medical Consultations. Sessions held. 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 1936 193 272 266 38 An Ante-Natal Clinic is held weekly with the Assistant Medical Officer of Health in attendance. Cases who are admitted to the Maternity Hospital may attend the Ante-Natal Clinics held there under the supervision of the Hospital nursing staff. With regard to the year's activities of the Ante-Natal Clinic under the control of the Local Authority, although we record an increase in individual attendances, viz., 193 in 1936 as against 162 in 1935, the average of individuals attending remains stationary at five per session for both years. The attendance of 193 mothers represents only 24 per cent. of the total notified births (live and still) for 1936. It is regrettable, therefore, to find that the use of facilities provided still falls far short of the extent to which they should be utilised. Public Health authorities are constantly stressing the vital need of regular and efficient ante-natal examination by skilled medical practitioners as an all-important factor in any attempt to reduce maternal mortality. In any 36 scheme which has been built up to combat maternal mortality and maternal morbidity, the Ante-Natal Service must be regarded as the keystone of that structure. The road to safer maternity lies through an efficient Ante-Natal Service, and this fundamental fact, unfortunately, is not yet appreciated even by some engaged professionally in maternity work. Where it is appreciated it is not stressed with sufficient conviction to encourage the young expectant mother to seek out a service so vital to her interests. This problem will, in my view, be solved, when midwives come under the salaried control of the Local Authority, and when a comprehensive midwifery scheme including the general practitioner and the consultant obstetrician as envisaged in the Midwives Act, 1936, is in operation. Natal Services. Eight hundred and twenty births (live and still) were known to have occurred in Bromley during 1936, and were notified as follows:— By midwives 365 By doctors and parents 455 820 Included in the figure 455 above are 31 "un-notified'' births, which is an unusually high figure (3.8 per cent. of the total). Investigation was instituted in each case, and almost without exception it transpired that a doctor and midwife were attending in each case and the duty of notifying had, through misunderstanding, broken down between them. It is noteworthy that of the 820 births, 507 confinements took place in hospitals and nursing homes, while 313 were confined in their own homes. By far the greater proportion of the 507 confinements in institutions occurred in the Maternity Hospital which dealt with 397 cases, of whom 257 were Bromley residents and 140 from other areas. 37 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 1936 was 23 (b) Number (i) employed by the Council — (ii) directly subsidised by the Council — (iii) employed by Voluntary Associations 12 (c) Number of cases during the year in which Council paid or contributed to the fee of a midwife — II. (a) Number of cases attended by midwives during 1936:— (i) as midwives 365 (ii) as maternity nurses 414 (b) Number of cases during 1936 in which medical aid was summoned by a midwife under Section 14 (1) of the Midwives Act, 1918 65 Administration of the Midwives Acts, 1902-1926. No. of midwives practising in Bromley at the end of the year 1935 19 No. of midwives giving notice of intention to practice during the year 1936 31 No. of midwives removed from the local register having left the district during 1936 8 No. of midwives practising in the area at the end of the year 1936 23 Notifications Received. Notices summoning medical aid 65 (a) Mothers 58 (b) Infants 7 Notices of Artificial Feeding 2 Stillbirths 2 Deaths 6 Laying out a Dead Body 6 Source of Infection 5 38 Summary of Reasons for sending for Medical Help. Ruptured perineum 22 Delayed labour 11 Varicose veins and leg swellings 2 Inertia 2 Placenta, adherent 3 Abnormal presentation 4 Haemorrhage 2 Ante-natal examination 3 Rise of temperature (puerperal pyrexia) 3 Other causes 6 Infants—Feeble, premature, etc. 3 Cyanosis 1 Eye discharge 3 65 Inspection of Midwives. Dr. G. H. Stinson, Assistant Medical Officer of Health, reports as follows:— "The inspection of midwives has been carried out every quarter and their work found satisfactory. There have been more calls for medical aid on the part of some of the midwives than there used to be, which is a point to the good. It shows greater realisation that prevention is better than cure. Their records are well kept and their equipment is satisfactory in every way. There is every evidence of keenness in their work, and they are interested and anxious to talk over points concerning cases they have in hand or have attended. They are helpful in the matter of persuading the mothers to attend the welfare centres after they themselves have completed their duties with the mothers. I should like to thank them all for their help in making my inspection a pleasant and interesting task." Post- Certiflcate Course. Arrangements were made for midwives to attend the Course of Post-Certificate training at Maidstone during October, 1936. Eighteen midwives availed themselves of the facilities granted by the Local Authority. 39 Institutional Provision for Mothers and Children. Maternity Hospital. The Maternity Hospital admitted 397 patients to their 19 beds during 1936. The Local Authority has an agreement with this Hospital for the reservation of four beds to which maternity cases are admitted under the provisions of an assisted maternity scheme. Cases eligible under this scheme must be dealt with through the AnteNatal service and medically certified as suitable cases for admission either on the grounds of environmental necessity or physical necessity, or both. During 1936 we had occasion to refer with financial assistance 12 cases under the scheme on the following grounds, viz.:— Environment 4 Physical condition 5 Physical and environment 3 In addition 50 cases were referred to other hospitals for treatment. Maternity and Nursing Homes. Details of these institutions appear in the tabulation on page 31 and under the heading Nursing Homes Registration Act, 1927, page 29. Institutional and Convalescent Treatment. We had occasion to refer 32 infants to hospitals for sick or ailing children from the welfare centres, and we are indebted to the local as well as the London hospitals who readily accept cases for treatment, or advice. Puerperal Fever and Puerperal Pyrexia. The Local Authority has an arrangement with Queen Charlotte's Maternity Hospital, Isolation Block, Ravenscourt Square, Hammersmith, to take cases arising in Bromley. Cases are conveyed by ambulance by arrangement with the London Ambulance Service of the London County Council. No cases were treated under the scheme during 1936. 40 The consultant services of the Specialist, Mr. Bright Banister, are available in cases of doubt, or where the cause of pyrexia is not of a minor character. During 1936 his services were required on two occasions. Post-Natal Service. Health Visitors—Home Visiting. The Local Authority has a Nursing Staff comprising six full-time Health Visitors, who divide their time equally between the Maternity and Child Welfare and School Medical Services. One Health Visitor attends the Tuberculosis Dispensary once a week. The Health Visitors are all general trained hospital nurses who also possess the special certificates required by the State for the practice of midwifery and health visiting. Each Health Visitor on the staff took a course of training during 1936 in First Aid in Chemical Warfare and obtained by examination the certificate granted by the British Red Cross Society. The importance of home visiting cannot be over emphasised, for when the midwife has concluded her duties after a confinement the young mother may then have the benefit of professional advice in the principles of babycraft. Home visitation has an advantage over Welfare Centres in the fact that the visitor sees the existing conditions in the home and is able to advise accordingly. Table XII. in the Appendix sets out in detail the statistics of home visitation in the six areas of the Borough allotted to the Health Visitors. The aggregate total of home visits for 1936 was 8,654. This figure includes 1,290 "ineffectual" visits, such as where the family is found to have removed, where no answer is received or where visits meet with no appreciation. These visits play no useful part in child welfare work, and therefore it has been our practice to record them apart from the general statistics relating to mothercraft and babycraft. Table XII. discloses a decrease of 888 effective visits for the year 1936 as compared with 1935. This unfortunately was inevitable having regard to the increased duties 41 of attendances to be made by the health visitors at the new School Clinic, Princes Plain, and it has been necessary to make inroads into the time available for home visitation. An analysis of the figures of Table XII. shows that of 820 births (live and still) known to have occurred in Bromley in 1936, no less than 78 per cent. have received visitation. This percentage is based oil a net figure of 784 births after making adjustment as regards inward and outward transfers of births. "Ineffectual" visits have not been taken into account in arriving at this percentage figure. There were 509 new enrolments of babies under one year of age at welfare centres and this figure represents 64 per cent. of all notified births. Six hundred and sixteen first visits to babies together with a further 1,427 following-up visits to these children makes a total of 2,043 visits to children under one year of age during 1936. Of the aggregate total of 8,654 visits, 6,901 were in connection with ante-natal, post-natal and welfare generally of the mother, or the child under five years of age. Under the Ministry of Health Circular 1550 dated 29th May, 1936, Local Authorities were requested to review their arrangements for supervising the health of young children under school age, as it was apparent in many areas that insufficient attention was given to the health of young children between the ages of 18 months and five years. Previous arrangements for treatment at the School Clinics have been available for Bromley children of preschool age who had attended infant welfare centres, and also visitation by the health visitors had been carried out. The scope of health visiting has, however, been intensified in the manner suggested by the Minister of Health so that all such children visited may be examined at home by the health visitor and full treatment is available at the special clinics of the School Medical Service—irrespective as to whether the child attended welfare centre or not. This extension of work was put into operation during the latter half of the year 1936. 42 The visiting' of these children is not void of difficulty, either the children are not always available to the visitor, or parents seek to postpone treatment of minor ailments until the age of school entry arrives. With health visiting time more than fully occupied, I fear this extension is already putting a stress on the amount of time which can be devoted to health visiting work. The establishment of nursery schools would appear to be more necessary now than previously, especially since children under five years of age are not now admitted to school owing to the lack of classroom accommodation. At the present time we are dependent upon health visiting for the discovery of the defective child, who does not attend a Centre, but requires correction and treatment. Welfare Centres. The following extracts of figures relate to work at the Centres during the year 1936:— (a) The total number of attendances at all centres during 1936 20,334 (i) By children under 1 year of age 8,969 (ii) By children between the ages of 1 and 5 11,365 (b) The total number of children who attended at the centres for the first time during 1936 746 (i) Children under 1 year of age 509 (ii) Children between the ages of 1 and 5 237 (c) Total number of children who were in attendance at the centres at the end of 1936 2,518 (i) Children under 1 year of age 385 (ii) Children between the ages of 1 and 5 2133 Table XIII. in the Appendix gives full statistical details of the work of the centres during 1936. 43 The following comparative table of figures over the past five years shows in broad outline the growth of the centres:— 1932. 1933. 1934. 1935. 1936. No. of infants on registers 1421 1473 1779 2081 2518 Total attendances of babies 13138 14595 15186 19315 20334 No. of weighings 9726 11381 12432 16536 17620 No. of welfare sessions 291 325 362 399 401 The foregoing extracts of figures show to some extent the progress in the work of the welfare centres, and indicate clearly their increasing popularity. It is here that I must refer with appreciation to the excellent work undertaken by the voluntary workers at the centres and clinics; coupled with the agreeable social atmosphere which their presence brings to the work, there is also the valuable assistance they give in the weighing of babies, the recording of attendances and results of weighings, and the booking of drug, etc., sales. In connection with this work it is to be noted that no less than 17,620 weighings were recorded during 1936—an average of 44 per session. It is evident to all associated with the work that these welfare centres are of first importance in the prevention of disease—they play a smaller part in treatment. Milk in Necessitous Cases. The number of applicants who were granted assisted milk supply during 1936 was 74. The total quantity of milk supplied during the year was 784 gallons (liquid) and 231bs. (dried). Clinic and Institutional Treatments. No. of cases treated. (a) Children under 5 years:— Minor Ailments Clinic 118 Dental Clinic 108 Orthopaedic Clinic Treatment:— (a) At the Special Clinic 16 (b) Hospital— inpatient treatment 4 Ophthalmia Neonatorum 1 44 (b) Mothers:— Dental Clinic 41 Maternity:— (i) Maternity Assisted Scheme— inpatients 12 (ii) Other hospitals — referred cases 50 Public Health (Ophthalmia Neonatorum) Regulations, 1926. Two cases were notified under the above-mentioned Regulations. In one case treatment was given in hospital. Both cases have cleared up well with vision unimpaired. Epidemic Diarrhœa. It is with satisfaction that one can in these days record comparative freedom from this hitherto troublesome infection which took such a serious toll of infants in the past. Only one death was recorded in Bromley during 1936, which gives a mortality rate of 1.3 per 1,000 births. The following table shows the mortality rate, per 1,000 births, for Bromley, in comparison with the rates of the country as a whole:— Mortality per 1,000 live births. England and Wales 5.9 122 County Boroughs and Great Towns including London 8.2 143 Smaller Towns 3.4 London 14.4 BROMLEY 1.3 Infant Life Protection. The following details have been extracted from the records kept in connection with the administration of Part I. of the Children Act, 1908, as amended by Part V. of the Children and Young Persons Act, 1932. (a) No. of persons receiving children for reward and registered at the end of 1936 50 (b) No. of children on the register at the end of 1936 64 45 The staff of six Health Visitors are Infant Protection Visitors for the purposes of the Act. They visit boardedout children at regular intervals, and make investigation into the home circumstances for report on the suitability of prospective foster-parents before certificate of sanction is granted. There were no instances found of breaches of the regulations. SECTION C. Sanitary Circumstances of the Area. 48 SECTION C.— SANITARY CIRCUMSTANCES OF THE AREA. Water. There is nothing to add to the particulars of public water supply given on page 43 of my Annual Report for 1935, where details also of the most recent results of bacteriological and chemical examinations carried out by the Metropolitan Water Board will be found. 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. A relief branch main sewer 2,370 yards in length and 30 inches in diameter has been laid from Shortlands Bridge to Bromley Road to provide further outfall facilities for the soil drainage of properties in the valley of the Ravensbourne. Contracts have also been entered into for the duplication of the Sludge Digestion Works inaugurated in 1935 and the work has commenced. The surface water drainage system was extended during the re-construction of Hayes Lane, Pickhurst Lane, Baston Road and Hayes Street, and a soil sewer was laid in Lennard Road. Cesspool Drainage. One new house was erected with cesspool drainage during 1936. We may take credit for much improvement achieved in the sanitation of the added areas of Hayes and Keston, where there were 360 premises not connected to main drainage at the time these areas were taken over by the Borough. No less than 249 have been connected to main drainage, leaving a balance of 111 not yet connected, and of these 57 have no sewer available. Rivers and Streams. Apart from the normal piping of small streams by estate developers, culverting operations were carried out to the Bourne and part of the Ravensbourne streams. A reinforced concrete culvert was provided for a length of 49 one mile, and a 36 inch diameter concrete pipe was laid for a length of ¼ of a mile in Southborough Lane, and culverting operations were commenced on a portion of the Princes Plain Stream. Informal notices were served in four instances of pollution, and these have since been abated. In the course of these investigations two samples were submitted for analytical examination, one of which proved to be water of very bad organic quality with evidence of very considerable pollution, and the other was reported to be of inferior organic quality. Public Cleansing. The public cleansing services have been functioning normally throughout the year, and there is no extension or improvement in refuse collection to report other than the purchase of a 15 cubic yard moving floor vehicle. SANITARY INSPECTION OF THE AREA. Tables VII., VIII. and XV. indicate the very varied extent of the sanitary inspection of the area which is carried out by the Sanitary Inspectors. Eight hundred and thirty-six dwelling-houses were inspected during 1936 and these involved 6,670 visits for primary inspections and subsequent re-inspections. Of these 836 houses 642 were found not to be in all respects reasonably fit for human habitation. Seven hundred and thirty-nine houses were rendered fit in consequence of informal action. It will be noticed that this figure exceeds the number of houses found not to be in all respects reasonably fit for human habitation, and this is due to the fact that houses inspected in the later months of the previous year were made fit in the early months of the next year. In addition to the above figures it will be noted that 549 houses were visited for the following purposes: 156 for infectious diseases, 80 for disinfection, 9 for the presence of vermin and 304 houses measured for purposes of the overcrowding sections of the Housing Act. 50 SHOPS ACTS, 1912-1934. During 1936, 244 inspections were made and the following1 tabulation shows that the contraventions found were principally due to the absence of certain prescribed forms. Informal action secured the compliance with the requirements of the Acts in all cases. In a few instances it was found that assistants under 18 years of age were working slightly over the prescribed number of hours, but these were rectified immediately the shop-keepers' notice was drawn to this contravention. It is pleasing to record that shop-keepers conscientiously endeavour to comply with the provisions of these Acts in Bromley. Particulars of Contraventions found under the Shops Acts. Unsatisfactory conditions relating to— Ventilation 1 Temperature 10 Sanitary conveniences 9 Absence of statutory forms— Assistants' Half-Holiday forms 14 Closing declaration 2 Form F (Daily hours to be worked by young persons) 16 Form Gr (To be used only in connection with Form F) 14 Statutory Closing Notice (if partially exempt) 9 Form H (Abstract of provisions of the Shops Act relating to hours of employment of young persons— for retail shops) 14 Form K (Notice with regard to the provision of seats for female workers) 14 Other unsatisfactory conditions found— Unsuitable and insufficient means for meals 1 No seats for females 1 51 SMOKE ABATEMENT. The Sanitary Inspectors all hold the special certificate of the Royal Sanitary Institute for smoke inspection. Seven special inspections were made in connection with nuisances arising out of the emission of smoke. In three instances the complaints were confirmed, and these were remedied by improved method of stoking or change of fuel. The increased use of electricity and gas for heating and cooking for domestic purposes will do much to prevent the pollution of the atmosphere. Bromley is not a factory area, and, therefore, smoke pollution of the atmosphere must necessarily be more from the domestic use of fuel. FACTORIES AND WORKSHOPS. Table XIV. in the Appendix gives details of statistics with regard to inspections of, and defects found, in factories, workshops, workplaces and outwork premises. SWIMMING BATHS AND POOLS. The filtration and chlorination plant at the Corporation's Swimming Bath at Southlands lioad continues to work satisfactorily, and at the time of writing the extensive alterations and improvements are nearing completion. Samples of water taken from the four private pools have proved on the various occasions satisfactory. VERMINOUS HOUSES. In nine instances houses were specially inspected for verminous conditions. In addition 33 houses were found to have vermin present during the course of ordinary inspections which were being made for housing defects. It has been our practice for a number of years to encourage occupiers to take remediable measures to eradicate from their houses conditions which should not exist. 52 During the year 19-36, five houses on the Corporation's estates were treated by the hydrogen cyanide gas method, and in no case has there been a recurrence of vermin. Due to propaganda carried out by the Department for many years, occupiers and owners now voluntarily seek advice on this subject. RATS AND MICE DESTRUCTION ACT, 1919. The usual procedure as regards propaganda during Rat Week, 1936, was followed; large and small posters issued by the 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. The Chief Sanitary Inspector, as in previous years, again organised an exhibition of stuffed rats, poison products and propaganda matter, and those who took advantage of visiting the exhibition were grateful for the advice given them. Although much was done to enlist the support and co-operation of the general public, their response was not as gratifying as in 1935. It will be seen from the comparative statistics below that the number of applicants from private premises was less than that of the preceding year, and tradesmen did not appear to show the interest in Rat Week one would have anticipated, having regard to the losses they incur annually through damage caused by rats and mice. The following are comparative statistics relating to Rat Weeks of 1935 and 1936:- 1935. 1936. Total No of applicants for poison during Rat Week 120 111 (a) From trade premises 38 40 (b) From private premises 82 71 No. of bottles of Red Squill given free 219 159 No. of tins of Red Squill biscuits given free 27 30 53 Much work is done throughout the year by the Sanitary Inspectors to combat the rat nuisance. Applications made during Rat Week are often instrumental in bringing to light infestations which have hitherto remained unknown, and the Inspectors are able to investigate and institute the necessary remediable measures. Steps are taken to obtain co-operation between all concerned where serious infestations are found to exist and many good results have been achieved. The following figures show to some extent the activities of the officers of the Department during 1936:— Total number of inspections made 346 Total number of infestations discovered 96 Total number of infestations abated (some of' which were discovered during 1935) 100 PUBLIC ELEMENTARY SCHOOLS. The sanitary condition of the elementary schools is reported on in the School Medical Service section of this Report, where is indicated the improvements carried out by the Local Education Authority, and the necessity to improve the hygienic conditions existing in the older Church schools which do not meet the requirements of modern standards. SECTION D. Housing. 56 SECTION D.—HOUSING. Table XV. in the Appendix sets out in detail the housing statistics for the year 1936. The Borough Engineer reports that the number of houses for which plans have been approved during the year 1936 is as follows:— (a) By private enterprise 725 (b) By Local Authorities (London County Council) 16 741 In the Annual Report for 1935 I submitted a preliminary report on the Housing Survey under the Housing Act. Since then houses overcrowded have been measured and the inserted Table indicates the true condition of overcrowding as a result of the measuring. It will be seen that 216 houses, including sub-tenant houses, were found to be overcrowded. At the time of writing (May 31st) 2,700 certificates of permitted numbers have been issued to the owners, and the numbers entered in the rent books. Further certificates remain to be issued in approximately 5,000 instances. Houses found to be overcrowded by the measurement survey have been visited, and the following Table indicates the condition of overcrowding and the abatement of overcrowding at the end of May, 1937:— Description. Total. Abated. Still overcrowded. Borough of Bromley, Housing Estate 20 4 16 L.C.C. (Downham) Estate 60 21 39 Other houses 87 36 51 Houses not yet investigated 49 - 49 Totals 216 61 155 Consideration has not yet been given to the dwelling houses where the "Equivalent Number" was equal to the "Permitted Number," and these will undoubtedly OVERCROWDING SURVEY REPORT, JUNE, 1936. (Amended Preliminary Survey Report of January, 1936, and shewing position after measurement of houses). No. of "persons'' in family. 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. Families. 1 1½ 2 2½ 3 3½ 4 4½ 5 5½ 6 6½ 7 7½ 8 8½ 9 9½ 10 10½ 11 11½ 12 Overcrowded. (A) Uncrowded. (B) Total. (c) 1 314 23 215 17 1 164 2 5 136 1 1 130 47 1 22 1079 1079 1½ 5 4 3 3 3 18 18 2 17 10 355 55 639 6 33 2 861 4 12 10 1635 576 201 17 4399 4416 2½ 4 19 55 1 189 5 57 3 277 1 2 22 485 1 165 1 31 4 1314 1318 3 3 8 24 245 1 135 18 646 5 7 74 1327 1 4 650 1 278 11 3416 3427 3½ 4 7 42 1 54 5 133 6 2 44 281 1 5 116 1 52 11 743 754 4 1 14 4 9 5 94 7 297 4 8 64 804 2 8 432 2 227 1 2 19 1966 1985 4½ 3 2 2 1 42 10 66 1 3 17 178 2 6 71 48 1 7 446 453 5 2 2 1 8 2 45 6 104 3 7 25 357 2 11 198 1 112 15 871 886 5½ 2 1 19 4 40 3 4 6 61 2 4 36 9 1 22 170 192 57 become overcrowded when a child of the family attains the age of 10 years, thereby increasing the "Equivalent Number" by½ This will automatically mean that some of these houses will become technically overcrowded. The sub-tenant family still remains a difficulty in many cases where there is not provided the amenities that make for a happy home. The adoption of Bye-laws for Houses let in Lodgings will increase our powers to see that these facilities are provided. In the 1935 survey no less than 1,371 families were living as sub-tenants in houses built with the facilities sufficient only for one family. There is another difficulty which the overcrowding regulations will rather tend to aggravate than to improve, and that is where the "Permitted Number" exceeds the "Equivalent Number" by considerable units. This will encourage the tenant to sub-let up to the permitted number, and this, in fact, has already occurred, thus increasing the number of sub-tenants. Under the Housing Act, 1930, and the corresponding provisions of the Housing Act, 1936, whereby houses unfit for habitation are dealt with either by repair or closure to habitation, considerable progress has been maintained without our resorting to legal proceedings. Progress shews that of 60 houses dealt with under Part II. of the Act (there have been no scheduled clearance areas) 4 have been rendered fit by the owner after extensive repairs, 28 have been demolished and 28 closed to human habitation. It is probable that in due course these 28 will be demolished. Under routine informal sanitary notices, either under the Housing Acts, or Public Health Acts, no less than 739 houses have been rendered fit, following on action by the Department together with helpful co-operation of the owners. SECTION E. Inspection and Supervision of Food. 60 SECTION E.—INSPECTION AND SUPERVISION OF FOOD. Milk Supply. The current register of dairies and milk stores is made up as follows:— (i) Premises within the Borough 77 (ii) Premises outside the Borough 26 Dairies licenced for sale of Graded Milk:— Dealer's Licences: "Pasteurised" milk 15 "Tuberculin Tested" milk 10 Supplementary Licences: "Pasteurised " milk 3 "Tuberculin Tested" 4 The Milk (Special Designations) Order, 1936, which came into force on 1st June, 1936, superseded the Orders of 1923 and 1934. Under the new Order the grades of Special Designations were reduced to three, namely, Tuberculin Tested, Accredited and Pasteurised. Tuberculin Tested replaced the previous designations of Certified and Grade A (Tuberculin Tested) milks; Accredited replaced Grade A milk, and the designation Pasteurised has been retained. The conditions under which the production and sale of milk are regulated in the new Order have not been substantially changed. The Sanitary Inspectors have made 112 visits during 1936 to dairies, cowsheds and milk shops, and the abatement of nine defects and nuisances has been secured. Milk in course of delivery has been examined by the Inspectors on 56 occasions, and sediment contamination has been observed in bottled milk in some instances. The exercising of vigilance in this matter is instrumental in impressing on milk distributors the necessity of maintaining cleanliness in methods of bottling and washing dairy utensils. 61 Samples of milk have been taken regularly throughout the year for the examination of bacterial content and tubercle bacilli as follows:— Bacterial examination—ordinary milk 44 graded milk 74 Tubercle bacilli 13 Milk. Bacteriological Examinations. The results of bacteriological examination are shown in the following table, which includes the samples taken at the request of the Minister of Health from licenced producers of graded milk:— Samples. Total. Satisfactory. Unsatisfactory. Certified 44 43 1 Grade A (T.T.) 3 3 — Grade A 2 — 2 Accredited 3 1 2 Pasteurised 22 22 — Ordinary 44 24 20 Totals 118 93 25 In the 25 instances of unsatisfactory results shown in the above table it was found that the presence of bacillus coli was the prevailing fault. Samples of milk were submitted to test for the presence of tubercle bacilli in 13 instances, and in one case the result was positive and the infected animal was destroyed voluntarily by the farmer. Milk. Contraventions. No contraventions came to the knowledge of the Department which called for statutory action. Meat and Other Foods. There are five registered slaughterhouses and three licensed slaughterhouses in the district. 62 During 1936 the number of animals known to have been killed were 3,078,. and of this number 3,072 of the carcases were inspected by the Sanitary Inspectors. Thus 99.8 per cent. of carcases were examined, and this shows that our endeavour to inspect meat before it reaches the purchasing public has been successful. It is interesting to note there were no cows killed by the butchers for human consumption during 1936. In addition to the above-mentioned particulars, carcases coming into the district from other areas are inspected at the routine visits to local butchers' shops. The continued cordial co-operation between the local butchers and the Department results in the attainment of a very high standard of meat sold to the public in Bromley. The Local Authority granted 24 licences to slaughtermen during 1936 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 and Lambs. Pigs. Animals known to have been kilted 3078 300 (no Cows). 59 1434 1285 Carcases Inspected 3072 300 59 1434 1279 63 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). 3078 3072 168 (5.5 per cent) 205 (6.7 per cent) 373 Table C. Total number of carcases rejected for Tuberculosis and other defined diseases. Disease. Beasts (Heifers). Calves. Sheep and Lambs. Pigs. Total. Tuberculosis 3 — — 7 10 Other defined diseases — — 1 4 5 Total 3 — 1 11 15 Table D. Total number of all carcases, parts of carcases and offal rejected for all diseases. Disease. Carcases. Parts of Carcases. Offal of Carcases. Total number affected. Tuberculosis 10 70 88 168 Other defined diseases 5 16 184 205 Total 15 86 272 373 64 Table E. Total weights of carcases, parts of carcases and offal rejected for all diseases. Tons. Cwts. Qrs. lbs. Total in lbs. Carcases 1 17 0 2 4146 Parts of carcases — 11 1 20 1280 Offal — 10 1 6 1154 Total 2 18 3 0 6580 Meat. Contraventions. No serious contraventions of the Meat Regulations were encountered during the year, 1936. Unsound and Unwholesome Food Surrendered. Article of Food. Weight. Meat 80 lbs. Rabbit 2½ Poultry 12½ „ Vegetables 37 cwts. Tinned Goods. Quantity. Vegetables 35 tins Fruit 541 „ Fish 28 ,, Milk, Cream 57 ,, Meat 53 ,, Miscellaneous 16 ,, 605 lbs. Food and Drugs (Adulteration) Act, 1928. The following tabulation gives particulars of the work of the Food and Drugs Inspector (Mr. E. R. Granger) in Bromley during 1936;— 65  No. of samples. No. of samples. Baking powder 1 Peas, preserved 1 Brandy 1 Rice 3 Butter 6 Sausages 2 Cinnamon, ground 1 Suet, shredded 1 Cocoa 5 Sugar 3 Coffee 4 Tapioca 2 Cream 5 Tea 1 Flour 3 Whisky 2 Fruit, dried 3 Cod liver oil 1 Gin 1 Ammon. Tincture Quinine 1 Ginger, ground 1 J am 2 Horseradish cream 1 Lard 3 Cooked meats 1 Margarine 5 Cream cakes 1 Milk, new 72 Bacon 1 Milk, condensed 2 Tartaric acid 1 Mustard 1 Tinned prawns 1 Olive oil 1 Pepper 1 Total number of samples taken during 1936 141 All the samples were reported to be "Genuine," with the exception of one milk sample, which was reported to be "inferior." Subsequent sampling from the same source showed the necessary improvement in quality of the milk. SECTION F. Prevalence of, and Control over, Infectious and other Diseases. 68 SECTION F.—PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. Tables IX., IXa, X. and XI. in the Appendix give statistical data with reference to notifiable infectious diseases and tuberculosis. Much of our attention is given to notifiable diseases, such as, Scarlet Fever and Diphtheria, which continue to occur in the Borough, but little attention is given officially to the diseases, such as, Measles and Whooping Cough, which cause such high mortality and morbidity among children. During epidemic periods much could be done to alleviate this problem by the employment of an infectious disease Nurse, who would be responsible for giving advice to parents on the necessary care to be exercised in the home nursing of such cases. This is not a new problem, but the matter is, nevertheless, not to be ignored. Taking death rates per 1,000 population during the past year alone; Measles 0.16, Scarlet Fever 0.03, Whooping Cough 0.03 and Diphtheria 0.05, and without taking into account the amount of morbidity caused through these diseases, the question is one for earnest consideration. Another point, an economic one, is the loss of school time occasioned by cases occurring in the elementary schools, as follows: Measles 608 cases, Whooping Cough 220, Scarlet Fever 62 and Diphtheria 9. Scarlet Fever. There was a slight fall in the incidence of Scarlet Fever during 1936, but in spite of all the steps taken to prevent spread of the disease, one found the incidence still a high one. The attack rate is 2.4 per 1,000 population. This compares with a rate of 2.57 for the neighbouring administrative area of the London County Council. Of the 141 cases notified in Bromley, 108 were admitted to Hospital, i.e., 76 per cent., compared with 80 per cent. of the previous year. This is, in the generally accepted view, a reduction in the right direction. The Report of the Medical Research Council issued in 1933 bears out this opinion, as it is therein stated that: 69 (1) Diminution in the Death Rate of Scarlet Fever during the past thirty years is due essentially to the decreased severity of the disease. The present low level may be, for any evidence to the contrary, merely the trough of the wave. (2) During the period studied no evidence has been found to prove that hospital isolation has been effective in reducing the prevalence or mortality from Scarlet Fever. (3) Although Scarlet Fever has a decreasing mortality during the past thirty years, there has been no diminution of prevalence. Further support to this view is given in the Report of the Committee on Local Expenditure issued in 1932, page 89, which states: "There is no reason for prescribing a routine period of detention in hospital of more than four weeks in uncomplicated cases of Scarlet Fever. nothing to suggest an extension of the routine period of detention has any effect on the number of return cases or on the incidence of, or mortality from, the disease. We think that the saving to be secured by adoption of the conclusion—would be of the order of £120,000 per annum." "Careful consideration should also be given to the question whether mild cases of scarlet fever might not be dealt with at home." Table IX. in the Appendix of this Report indicates how the Wards of the Borough were affected by Scarlet Fever during 1936. Diphtheria. The incidence rate fell in 1936 from 0.7 per 1,000 population in 1935 to 0.4 in 1936. There were three deaths in the 23 cases notified, compared with four deaths in the 44 cases notified in 1935. Cases appeared generally to be more severe in type, but the spread of infection was less active. Immunisation against Diphtheria has not yet obtained popularity with the public, and although of proved value and receiving the support of the Ministry of Health, 70 League of Nations, and all closely concerned with the public welfare, the propaganda of the "Anti Societies" appears to be more readily accepted. The fact that 13 per cent. of cases of Diphtheria notified died should be sufficient for the public to encourage any approved action to lessen the severity and incidence of this disease. Other Notifiable Infectious Diseases. Tables IX. and IXa. give the necessary information with reference to such notifiable diseases as Pneumonia, Erysipelas, Acute Poliomyelitis, and Typhoid Fever, none of which appeared in epidemic form in 1936. Tuberculosis. Tables IX. and X. give incidence and particulars of cases of Tuberculosis in Bromley in 1936. The current register contains a total of 410 names of patients who have been notified as suffering from tuberculosis. The following analysis of this total gives details of sex of patients and type of disease:— Total of both types. Respiratory Tuberculosis. Other forms of Tuberculosis. Males 212 149 63 Females 198 128 70 410 277 133 The total of 410 cases gives a rate of 7.2 per 1,000 population which compares unfavourably with the previous year's rate of 6.8, but too much importance should not be attached to this rather high rate of incidence in that quite a good proportion of cases on the register are quiescent and might well be written off as recovered, especially in the cases of those falling under the heading of "Other Forms," which contains glands cases rectified by surgical treatment. Eighty-five new cases were notified or otherwise revealed to me during 1936, of which 70 were pulmonary and 15 non-pulmonary cases, and included in these figures are 17 cases who removed into the area but had been notified elsewhere. There were 36 deaths from tuberculosis 71 in 1936 of which 30 are classified as from respiratorytuberculosis and six from other forms. A perusal of the following table will indicate generally a fall in incidence since 1927. Year. New cases Incidence per 1,000 population. Pulm. Death Rate. Non-Pulm. Pulm. Non-Pulm. 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 1936 1.2 0.3 0.5 0.1 The Health Visitor paid 325 visits to tubercular patients during 1936, giving advice on the care of the patients and on the principles that make for fitness in the contacts. Public Health (Prevention of Tuberculosis) Regulations, 1925. No occasion arose during the year to take action under the above-mentioned Regulations, which relate to persons suffering from pulmonary tuberculosis employed in the milk trade. Public Health Act, 1925, Section 62. It was not necessary to enforce the above-mentioned Section which relates to the compulsory removal to a hospital of persons suffering from tuberculosis in serious infectious state. Tuberculosis Dispensary. Dr. Edelston, Tuberculosis Officer, has kindly furnished me with the following brief summary of the work carried out at the Dispensary during 1936:— 72 BROMLEY BOROUGH. New Cases attending the Dispensary for the first time for Examination during 1936. Adults. Children. Male. Female. Male. Female. Pulmonary 26 21 — — Non-Pulmonary 5 — 2 2 Negative 9 24 6 3 40 45 8 5 No. of contacts examined during 1936 26 No. of contacts found to be positive (not included in the above table) 1 Total No. of attendances at the Dispensary 1,788 No. of patients who received residential treatment 128 PROPAGANDA. No intensive propaganda has been carried out by this Local Authority for some years, and one doubts whether advertising of services would bring any appreciable results. I find our services, even without propaganda, increasingly used and appreciated, and the public in Bromley is well informed with regard to them. The efficiency of a service is its own advertisement, and much valuable work can be done by individual instruction and advice, rather than by advertising the already known advantages of prevention of disease. When a Local Authority undertakes extensive advertising of health services it tends to bring with it a reaction of doubt as to the efficiency of the service. The public will use an efficient service, but it will not use one which produces negative results. The fact that each year sees an increase in attendance at all clinics in Bromley is sufficient proof that the money expended by this Local Authority is being well spent. SECTION G. Other Services Supervised by the Health Department. 74 DISEASES OF ANIMALS ACTS. The Chief Sanitary Inspector acts as Inspector under the Diseases of Animals Acts for the Borough. No. of Movement Licences received 141 Animals inspected— (i) Pigs 1,322 (ii) Sheep, lambs 399 Sheep Dipping. Certificates issued by the Local Authority 2 No. of sheep double dipped—105 210 No. of inspections made in connection with the above details 64 No. of interviews in connection therewith 38 Tuberculosis Order of 1925. There was no necessity to take any action under this Order during 1936. RAG FLOCK ACTS, 1911-1928. Three rag flock samples were submitted for analysis, one of which did not conform to standard, in that it was found to contain 52 parts chlorine per 100,000 parts of flock. Flock is deemed to conform to standard when it does not exceed 30 parts chlorine per 100,000 parts of flock. With regard to the defective sample mentioned, appropriate action was taken, and the stock of flock involved was withdrawn from use by the firm concerned. REGISTRIES FOR FEMALE DOMESTIC SERVANTS. The Chief Sanitary Inspector made periodical inspections of registry offices throughout the year and found no contraventions which called for action under the Bye-laws with respect to Registries for Female Domestic Servants. Shop-keepers who have provided advertising panels outside their shops in which they expose advertisements for a weekly payment have from time to time accepted advertisements for female domestic servants. In these 75 cases they have been informed that unless they are registered keepers for the purposes of the Bye-laws there is a contravention. In every case, rather than become registered, they have refrained from accepting such advertisements. There were six Registry Offices on the register for the Borough at the end of the year, 1936. PETROLEUM ACTS. Number of Licences issued 110 (i) For Petroleum Spirit 108 (ii) For Carbide of Calcium 2 Total quantity of Petroleum Spirit in gallons 191,755 (i) Bulk storage, in gallons 179,090 (ii) Two-gallon can storage, in gallons 12,665 Carbide of Calcium, in lbs. 444 Of the 110 licences issued, 105 were renewals and five were new or additional licences. Included in the total of 110 licences are 15 combined licences for bulk and can storage. Two hundred and fifty-two inspections of storage places were made during 1936. The following figures show the increase in licenced storage since 1926:— Year. Petroleum Spirit. (in gallons). Licences issued. (Petrol only). 1926 66,915 77 1927 103,025 69 1928 159,335 82 1929 159,746 92 1930 166,308 81 1931 168,925 83 1932 176,090 93 1933 170,789 98 1934 174,554 96 1935 189,504 106 1936 191,755 108 76 RETAIL MARKET. The Retail Market is held on Thursdays at the Car Park, Station Road, under the control of the Market Superintendent. The administrative supervision is under the Health Committee. Permanent overhead covering for the Market, or alternatively the stalls, came under consideration during the year, but on the present basis of income the improvement could not be adopted as an economical proposition. More extensive lighting of the Market was also considered, but for similar reasons this additional facility could not be recommended for adoption. Without adequate lighting and covering it is doubtful if the Market will increase in popularity with the public or with the stall-holders. Total amount of Tolls and Storage Fees collected during 1936. £ s. d. January 27 15 0 February 36 10 0 March 33 16 0 April 51 4 6 May 48 14 0 June 49 9 6 July 46 0 0 August 43 4 0 September 42 8 0 October 63 12 6 November 35 1 0 December 50 17 6 £528 12 0 Average per month, £44. APPENDIX. Tables I. to XV. 78 TABLE I. SUMMARY OF STATISTICS, 1936. Population (mid-year 1936, Registrar General) 57,850 Birth Rate 13.5 Death Rate (crude) 9.8 Infantile Mortality Rate 37 Number of Births (live) 780 Number of Stillbirths 26 Number of Deaths 567 Number of Infant Deaths (under 1 year) 29 Death Rate of Respiratory Diseases 1.02 ,, ,, ,, Tuberculosis 0.6 „ „ „ Cancer 1.5 ,, ,, ,, Zymotic Diseases 0.2 Notifications of Scarlet Fever 141 ,, ,, Diphtheria 23 ,, ,, Pneumonia 47 ,, ,, Tuberculosis 85 Number of Deaths from Measles 9 ,, ,, ,, „ Scarlet Fever 2 ,, ,, ,, ,, Diarrhoea (under 2 years) 1 ,, ,, ,, ,, Child Birth 3 Number of visits by Sanitary Inspectors 12,002 ,, ,, ,, „ Health Visitors 8,654 Number of Babies on the Registers at the Welfare Centres, end December, 1936 2,518 79 TABLE II. Birth Kates, Crude Death Rates, Analysis of Mortality, Maternal Death Rates, and Case-Rates for certain Infectious Diseases in the Year 1936 (Provisional Figures based on Weekly and Quarterly Returns). Bromley. England and Wales. 122 County Boroughs and Great Towns including London. 143 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census) London Administrative County. Births:— Rates per 1000 Population. Live 13.5 14.8 14.9 15.0 13.6 Still 0.45 0.61 0.67 0.64 0.53 Deaths:— All causes 9.8 12.1 12.3 11.5 12.5 Typhoid — 0.01 0.01 0.00 0.01 Smallpox Measles 0.15 0.07 0.09 0.04 0.14 Scarlet Fever 0.03 0.01 0.01 0.01 0.01 Whooping cough 0.03 0.05 0.06 0.04 0.06 Diphtheria 0.05 0.07 0.08 0.05 0.05 Influenza 0.10 0.14 0.14 0.15 0.14 Violence 0.36 0.52 0.45 0.39 0.52 Notifications:— Smallpox — — - — — Scarlet Fever 2.43 2.53 2.18 2.48 2.57 Diphtheria 0.39 1.39 1.31 1.26 1.69 Enteric Fever 0.03 0.06 0.05 0.06 0.06 Erysipelas 0.46 0.40 0.38 0.35 0.44 Pneumonia 0.81 1.11 1.10 0.96 0.99 Deaths under 1 year of age Rates per 1000 Live Births. 37 59 63 55 66 Deaths from Diarrhœa and Enteritis under 2 years of age 1.3 5.9 8.2 3.4 14.4 Maternal Mortality:— Puerperal Sepsis 1.28 1.40 Not avail-able. Others 2.56 2.41 Total 3.84 3.81 Maternal Mortality. Rates per | 1000 Total Births {i.e., Live and Still). Puerperal Sepsis 1.24 1.34 Not avail- able. Others 2.48 2.31 Total 3.72 3.65 Notifications: Puerperal Fever 1.24 3.27 3.46 2.80 3.03 Puerperal Pyrexia 6.20 9.64 9.52 7.57 11.15 80 TABLE III. Causes of Death, 1936. Male. Female. Total. 1. Typhoid Fever, etc. — — — 2. Measles 4 5 9 3. Scarlet Fever 1 1 2 4. Whooping Cough 1 1 2 5. Diphtheria — 3 3 6. Influenza 3 3 6 7. Encephalitis Lethargica — — — 8. Cerebro-spinal Fever — — — 9. Respiratory Tuberculosis 17 13 30 10. Other Tuberculosis 4 2 6 11. Syphilis — — — 12. General paralysis of insane, etc. 1 — 1 13. Cancer 35 53 88 14. Diabetes 3 2 5 15. Cerebral hæmorrhage 11 19 30 16. Heart disease 70 101 171 17. Aneurysm 2 — 2 18. Other circulatory diseases 10 11 21 19. Bronchitis 9 9 18 20. Pneumonia 19 17 36 21. Other respiratory 3 2 5 22. Peptic ulcer 3 — 3 23. Diarrhoea, etc. (under 2 years) — 1 1 24. Appendicitis 1 2 3 25. Cirrhosis of liver 1 — 1 26. Other liver diseases 3 3 6 27. Other digestive diseases 6 5 11 28. Nephritis 4 9 13 29. Puerperal sepsis — 1 1 30. Other puerperal causes — 2 2 31. Congenital causes, etc. 10 6 16 32. Senility 6 5 11 33. Suicide 1 2 3 34. Other violence 12 6 18 35. Other defined causes 18 25 43 36. Ill-defined causes — — - Totals 258 309 567 TABLE IV. Infant Mortality, 1936. (Compiled from Local Returns). 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 1 under 3 mouths. 3 months and 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 2 ... ... ... 2 ... ... ... ... 2 Bronchitis ... ... ... ... ... 1 ... ... ... 1 Pneumonia ... ... ... ... ... 2 2 2 2 8 Diarrhœa ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... 1 1 ... ... 2 Gastritis ... ... ... ... ... ... ... ... ... ... Suffocation ... ... ... ... ... ... ... ... ... ... Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis 2 ... ... ... 2 ... ... ... ... 2 Malformation ... ... ... ... ... 1 ... ... ... 1 Premature Birth 5 1 ... ... 6 ... ... ... ... 6 Marasmus, etc. 2 ... ... ... 2 ... ... ... ... 2 Other Causes ... ... ... ... ... 1 ... ... ... 1 Syphilis ... ... ... ... ... ... ... ... ... ... Congenital Heart Disease 2 ... ... ... 2 ... ... ... ... 2 Totals 13 1 ... ... 14 6 3 2 2 27* * Note.—The Registrar General gives 29 deaths for 1936. 81 82 TABLE V. Analysis of Causes of Infant Deaths, 1932-1936. 1932 1933 1934 1935 1936 No. of Births 605 598 706 758 780 Infantile Mortality Rale 33 41 43 27 37 Total Malformation 6 4 7 7 3 27 Premature Births 4 5 5 4 6 24 Respiratory Diseases 5 6 5 4 9 29 Marasmus and General Debility 1 4 2 2 2 11 Infectious Disease ... 1 ... ... ... 1 Gastro Enteritis 1 ... 4 1 2 8 Convulsions ... ... 2 ... 2 4 Other Causes 3 5 6 3 3 20 Totals 20 25 31 21 27 124 This table shows that Premature Births, Congenital Debility and Malformation caused 50 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. TABLE VI. Summary of Infant and Maternal Mortality Statistics. Four quinquennial periods are taken—Pre-War, 1910-1914, five years to 1925. five years to 1930, five years to 1935, and the year 1936. 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—1925 2832 62 177 64 26 87 6 7 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 1936 780 37 29* 13 1 13 1 2 *(R.G.'s returns 29, Local returns 27 in both instances). 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. Rate 1931-1935, 4.5 per 1,000 births. 83 84 TABLE VII. Summary of Work of the Sanitary Inspectors for the Year 1936. Type of Inspections. Nuisances and Defects found. No. of Inspections. On Complaint. Routine Inspections. Re- Inspections. Total Inspections. Houses Visited—- Under Insp. of District Reg 1047 11 125 3644 3780 Housing Act, 1930. Sec. 17 — — — 101 101 Sec. 19 — — 5 77 82 For Nuisances (No. not confirmed, 70) 1656 561 86 1915 2562 Overcrowding — — - 2 2 Verminous houses 34 25 3 47 75 Dirty conditions 3 2 3 14 19 Water supply — — 1 2 3 Cesspools 6 6 2 90 98 Earth closets — — — 1 1 Privy pans — — 1 31 32 Infectious disease — — 156 22 178 Disinfection purposes 1 1 79 7 87 Disinfestation purposes 1 1 8 10 19 Housing Act—measuring — — 304 211 515 Totals 2748 607 773 6174 7554 Food Preparing Places— Bakehouses—Factories 9 — 32 7 39 Workshops 1 — 28 6 34 Butchers' shops 15 2 863 7 872 Confectionery shops - - 8 4 12 Dairies, Cowsheds, etc. 9 — 103 9 112 Fish shops — — 262 1 263 Fried fish shops — — 6 — 6 Food hawkers — — 151 1 152 Greengrocery, Fruiterers 6 — 79 3 82 Grocery shops 1 1 186 4 191 Hotels, restaurants 7 1 17 — 18 Ice cream premises — — 2 — 2 Meat Regs. (spec. visits) — — 5 — 5 Milk sampling—Bact. Ord. — 3 41 — 44 ,, graded — 3 71 — 74 Tuberc. — — 13 — 13 Milk examined on the highway — — 56 — 56 Retail market — — 40 — 40 Slaughterhouses 5 — 611 5 616 Totals 53 10 2574 47 2631 85 Type of Inspections. Nuisances and defects found. No of Inspections. On Complaint. Routine Inspections. Re- Inspections. Total Inspections. Trade Premises— Factories 2 2 9 5 16 Workshops 7 2 19 20 41 Outworkers' premises — — 30 2 32 Under Shops Acts 105 2 191 51 244 Under Petroleum Acts 49 — 241 11 252 Registry Offices — — 5 — 5 Diseases of Animals Acts (Interviews, 11) - — 61 3 64 Offensive trades — — 18 — 18 Rag flock sampling — — 3 — 3 Viscose works, observations made — 1 22 — 23 Cinemas — — 2 — 2 Poisons and pharmacy — — 3 — 3 Totals 163 7 604 92 703 Miscellaneous— Accumulations 41 35 20 194 249 Animal nuisances — 1 - - 1 Drain tests—Smoke — 4 6 1 11 Water — - 88 5 93 Mirror 2 — 10 — 10 Food poisoning enquiries — 2 — 13 15 Piggeries — — 4 4 8 Eats and Mice Destruction Act 96 101 82 163 346 Schools - - 3 - 3 Smoke 5 3 3 1 7 Special visits — 2 325 — 327 Stables — — 11 5 16 Streams - 4 1 2 7 Streams—samples taken — — 2 — 2 Tents, vans and sheds — — — 2 2 Urinals 1 — 15 2 17 (Interviews, owners, agents—2071) Totals 145 152 570 392 1114 GRAND TOTALS 3109 776 4521 6705 12002 86 TABLE VIII. Nuisances Abated, 1936. HOUSING: Drainage— Re-drained and connected to sewer 19 Cesspools abolished 11 Earth closets 1 Privy pails 7 Drains relaid or repaired 98 Drains unstopped 101 Inspection chambers provided 51 W.C.s additional or separate provided 4 ,, disconnected from rooms 4 ,, buildings re-constructed 15 „ „ repaired 12 ,, pans renewed or provided 69 ,, pans cleansed 19 ,, box seats removed 134 Soil pipes, vent pipes, renewed or repaired 17 Sinks renewed 66 Sink or bath waste pipes renewed or repaired 210 Cesspools emptied 4 Sink waste soakaways abolished 13 Surface water drainage provided 2 Baths provided 2 Dampness— Roofs repaired or renewed 270 Rain water pipes, guttering, etc., repaired or renewed 241 Damp courses:— Vertical plinths provided 39 Walls rendered 79 Horizontal d.c. provided 72 Solutioning 25 Earth removed from walls 7 Walls repointed 216 Weather boarding repaired or renewed 3 Dry areas constructed 1 Sites concreted 13 Subfloor ventilation provided or improved 11 Brickwork renewed or repaired 40 87 General— Rooms cleansed 447 W.C. walls, etc., cleansed 64 Entrance hall and staircase 48 Bathrooms cleansed 2 Light and ventilation of rooms improved 50 Plastering repaired or renewed 286 Floors ,, ,, 115 Window frames, etc., repaired or renewed 264 Sash cords ,, ,, 132 Putty pointing „ „ 108 Doors ,, ,, 67 Stoves ,, ,, 104 Coppers „ ,, 49 Handrails ,, ,, 34 Stairtreads, etc. ,, ,, 23 Dustbins provided 122 Dirty conditions remedied 11 Overcrowding abated 5 Defective chimneys repaired 67 External woodwork painted 40 Food stores—Provided 90 Ventilated 18 Cleansed 1 Yard paving renewed or provided 80 Houses disinfested 42 Water Supply— Separate and additional supply provided 2 Drinking water service supplied direct from main 20 Fittings renewed, etc. 8 Supply re-instated 6 Flushing cisterns repaired or renewed 46 Miscellaneous Items 267 TRADE PREMISES: Factories and Workshops— Want of cleanliness 7 Want of drainage to floors 1 Other nuisances 14 Sanitary accommodation— Insufficient 1 Unsuitable and defective 4 Not separate for sexes — 83 Outworkers' premises, want of cleanliness 1 Petroleum Acts—contraventions 49 Milk and Dairies—contraventions 2 Shops Acts—contraventions— Ventilation 1 Temperature 10 Sanitary conveniences 9 Absence of statutory forms 83 Washing facilities not satisfactory 1 Seats for female workers 1 FOOD PREPARING PLACES: Defects and nuisances remedied in— Butchers' shops 13 Bakehouses 17 Confectionery 4 Dairies, etc. 9 Fish shops 1 Grocery shops 4 Hotels, restaurants, etc. 6 Slaughterhouses 6 Food hawkers' premises 1 MISCELLANEOUS: Accumulations removed 99 Nuisances from keeping animals 2 Manure removed 1 Manure receptacles 2 Rats and Mice nuisances 100 Smoke nuisances 3 Stables cleansed 1 Urinals cleansed, etc. 3 Piggeries cleansed 5 Stream pollutions 4 offensive trade nuisances 1 Outbuildings—san. condition improved 1 Total 4942 NOTICES ISSUED: Housing. Others. Preliminary 642 216 Statutory 2 - Totals 644 216 TABLE IX. Return of Notifiable Infectious Disease, 1936. Disease. Total. M. F. WARDS. Cases removed to Hospital. Attack Kate per 1,000 population. No. of Deaths. Death Rate. Plaistow Martin's Hill. Town. Sundridge. Bickley. Bromley Common. Keston & Hayes Scarlet Fever 141 65 76 35 29 15 11 11 19 21 108 2.4 2 0.03 Diphtheria 23 10 13 7 5 2 1 3 3 2 21 0.4 3 0.05 Pneumonia 47 22 25 11 5 9 3 6 12 1 30 0.8 36* 0.6 Peurperal Fever 1 — 1 — — - 1 — — — 1 0.02 1† 0.02 Puerperal Pyrexia 5 — 5 1 — 1 - 1 2 — 1 0.09 — — Erysipelas 27 13 14 8 3 4 3 1 6 2 6 0.4 — — Ophthalmia Neonatorum 2 2 — 1 — 1 — — — — — 0.03 — — Acute Poliomyelitis 1 1 — — — 1 - — - — 1 0.02 — — Typhoid fever 2 2 — — — — 1 — — 1 1 0.03 — — Tuberculosis—lungs 70 39 31 17 9 4 5 10 15 10 - 1.2 30 0.5 Tuberculosis — other forms 15 8 7 6 2 — — 2 3 2 — 0.3 6 0.1 Totals 334 162 172 86 53 37 25 34 60 39 169 58 78 1.3 *Includes Pneumonia (all forms), whereas notifiable types include only acute primary pneumonia and acute influenzal pneumonia. †This case was a Bromley resident who was notified outside the area and also died outside the area. 89 90 TABLE IXa. Notifiable Infectious Disease, 1936. Age Groups. Disease Total 0-1 1-2 2-3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-65 65 & over Scarlet Fever 141 — 2 7 8 9 56 29 9 13 5 3 — Diphtheria 23 — 1 2 — 3 5 4 1 4 2 1 - Pneumonia 47 2 4 3 2 4 7 — 1 5 5 8 6 Puerperal Fever 1 — — — — — — — — 1 — — — Puerperal Pyrexia 5 - - - - - - - - 4 1 — — Erysipelas 27 — - 1 — — — — — 4 10 9 3 Ophthalmia Neonatorum 2 2 - - - - - - - - - - - Acute Poliomyelitis 1 - - - - - - - - - - - - Typhoid Fever 2 — 1 — — — 1 — — — — — — Totals 249 4 8 13 10 16 70 33 11 31 23 21 9 91 TABLE X. Tuberculosis. New Cases and Mortality during the Tear, 1936. Age Periods. New cases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M, F. Under 1 ... ... 1 ... ... ... ... ... 1— 5 ... ... ... 1 ... ... 1 ... 5—15 1 ... 2 4 ... 1 1 1 15—25 6 6 1 ... 2 3 ... ... 25—35 12 15 3 ... 6 5 1 ... 35—45 8 8 ... 1 3 2 1 1 45—55 7 ... 1 1 3 1 ... ... 55—65 4 2 ... ... 2 ... ... ... 65 and over 1 ... ... ... 1 1 ... ... Totals 39 31 8 7 17 13 4 2 TABLE XI. Ophthalmia Neonatorum, 1936. Cases. Vision unimpaired. Vision impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 2 1 1 2 ... ... ... TABLE XII. Summary of Health Visitors' Work, 1936. 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. ual Visits. Primary Revisits Area No. 1 1060 96 136 358 40 236 4 2 45 142 1 5 195 Area No. 2 1252 93 304 550 33 182 ... 3 52 33 2 15 240 Area No. 3 1745 121 331 873 21 240 4 8 76 50 21 27 146 Area No. 4 984 106 168 432 34 140 1 3 26 63 11 15 249 Area No. 5 1085 103 181 480 33 115 2 1 70 93 7 17 193 Area No. 6 1238 97 307 589 48 106 4 2 56 28 1 5 267 Totals 7364 616 1427 3282 209 1019 15 19 325 409 43 84* 1290‡ * Also included in routine visits under the various headings. ‡ "Ineffectual" visits are those where no answer is received; discovered removed from district, or where visits are resented, and are not included in the total of the first column. The aggregate total of visits is, therefore, 8,654. 92 TUBERCULOSIS DISPENSARY WORK, 1936. Patients on the Dispensary Roll at end of December, 1936 150 Health Visitor's attendances at Dispensary 51 Total No. of special visits to Patients 139 TABLE XIII. Welfare Centres, Attendances, 1936. CENTRE. No. of Babies on the Rolls at the end of the Year, 1936. Total Attendances. No. of Sessions held. Medical Consultations. Total No. of Weighings. Babies. Mothers. Total Examined. No. of Sessions held. PLAISTOW 522 3164 2672 50 421 30 2792 WIDMORE 310 2171 1905 50 292 27 1894 MASONS HILL 373 2990 2694 50 368 29 2477 BURNT ASH 540 3338 2822 100 466 41 2790 BROMLEY COMMON 421 5372 4467 100 861 65 4598 HAYES & KESTON 352 3299 3007 51 367 34 3069 Totals 2518 20334 17567 401 2775 226 17620 Ante-Natal Clinics, 1936. Dental Clinic, 1936. Total Attendances. Medical Consultations. Sessions held. Discharged treatment. 272 266 38 Children. Mothers. 108 41 93 94 TABLE XIV. Factories, Workshops and Workplaces, 1936. I.—Inspections. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. Factories 85 12 ... Workshops 78 21 ... Workplaces 54 9 ... Total 217 42 ... II.—Dejects. Particulars. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts*— Want of Cleanliness 12 12 ... Want of ventilation 5 5 ... Overcrowding ... ... ... Want of drainage to floors ... ... ... Other nuisances 33 33 ... Sanitary accommodation. insufficient 1 1 ... unsuitable or defective 6 6 ... not separate for sexes ... ... ... Total 57 57 *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. 2 2 ... 95 TABLE XV. Housing Statistics for the Year, 1936. Total number of inhabited houses at 31st December, 1936 (according to rate books) 15965 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) 836 (b) Number of inspections made for the purpose 6670 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 136 (b) Number of inspections made for the purpose 3780 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 5* (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 642 2. Remedy of Defects during the Year without Service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 739 3. Action under Statutory Powers during the Year:— (a) Proceedings under sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs - * Informal action has secured closure in 1 case and demolition in 2 cases, and informal action with regard to the other 2 houses is proceeding satisfactorily. 96 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners — (b) By local authority in default of owners - (b) Proceedings under the Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 2 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 2 (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 -† (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 - 4. Housing Act, 1935.—Overcrowding:— (a) (i) Number of dwellings overcrowded at the end of the year 216 (ii) Number of families dwelling therein 248 (iii) Number of persons dwelling therein 1425 † As a result of informal action, progress under the Housing Act, 1930, up to 31/12/1936 showed that 28 houses has been demolished and 28 houses closed to habitation. 97 (b) Number of new cases of overcrowding reported during the year Nil (c) (i) Number of cases of overcrowding relieved during the year Nil (ii) Number of persons concerned in such cases Nil (d) Particulars of any cases in which dwelling- houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding Nil (e) Any other particulars with respect to crowding conditions upon which the Medical Officer of Health may consider it desirable to report (See Section D—Housing) BOROUGH OF BROMLEY. ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR 1936. 100 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1936-1937. 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. Coimcillor C. H. Gunton. Councillor W. J. Guthrie, j.p. *Rev. J. T. Gurney. Councillor C. A. Holliday, f.s.a.a. Councillor S. G. Humerston. Councillor T. H. Jayes. Councillor S. L. Lyle. *Mrs. A. G. Mann, b.a., j.p. *Mrs. E. J. Munn. *Rev. Prebendary B. F. Relton, m.a. Councillor L. A. Simmons. Councillor M. Stafford Smtth, m.b.e., b.a. Councillor F. G. Hamilton Spratt. Councillor F. Sutcliffe, f.r.i.b.a. *Rev. O. G. Whitfield, m.a. *Co-opted Members. 101 Introduction. The School Medical Service in 1930 again indicated a growing use of the facilities provided by the Local Education Authority, and an ever increasing demand on the services of the staff. It is something more than merely the routine medical inspection and minor ailment treatment of necessitous children. It has extended beyond the so-called " poor law " aspect of a state service, and is to-day an important part of a unified public health scheme, covering not only the individual but the environment of home and school life as well. It is a vital and economical factor in maintaining a good school attendance, and in educating parents in the principles of prevention of disease and the practice of health. The services as provided in past years continued to function to their full capacity, and the year saw their increase by the opening in February of a new Health Centre in the South Clinic, Princes Plain, Bromley Common, and by the establishment of organised Physical Training under two newly appointed Physical Training Organisers in conjunction with other Education Authorities in North West Kent area. The new Clinic provides an additional centre for the investigation and prevention of the causes of ill-health and also for the necessary treatment, while physical training is concerned with the establishment of factors that make for positive health. Coinciding with these two developments in 1936 has been an increased activity in the treatment, under the School Medical Services, of the pre-school child. In this direction there is still much to be done, but it is pleasing to note that the same attention is now paid to the treatment of the child of 2—5 years of age as has been given in the past to the child of school age. I believe we can safely sav of Bromley that the children of all ages now have the facility of receiving treatment and advice at a cost reasonable to the financial circumstances of the family. One distinction should be made, and that is that the services do not provide treatment that could be better obtained under domiciliary conditions, and in no way do they interfere with the services of the general practitioners. They are strictly limited to the minor 102 ailments and to those conditions which can only be provided by specialist officers, such as, orthopaedic, eye, ear, nose and throat, and dental clinics. In medical inspection of school children to-day it is apparent that there is an increase in the anxiety neuroses, brought about by the mental strain of present day life of a child both at home and at school. To combat this, and to fit the child for an adult life under probably greater strain, we must continue to do all in our power to provide for the physical and mental health of the child at school and to educate the parents in the application of common sense psychology. The report follows the usual lines, containing in the appendix the statistical records of the year's work. Summary of Statistics, 1936. School Roll 5,701 Number of individual children who attended medical clinics 2,245 Number of individual children medically examined at schools .1,571 Number of medical examinations at the Clinics 6,579 Number of attendances for treatment at the Clinics 6,549 Number of attendances for treatments at the Dental Clinics. 4,152 Number of treatments at the Eye Clinic 543 Number of operations for Tonsils and Adenoids 143 Total number of attendances at the Orthopaedic Clinic— (i) For Consultations 562 (ii) For Treatments, massage, etc 2,424 Total number of attendances at the Ultra Violet Ray Clinic 1,825 Number of children referred to the Care Committee 142 103 Co-operation. Without the co-operation of the Head Teachers, School Attendance Officers, General Practitioners, other Officers and parents, the work of the School Medical Service could not function with full success. We have always before us two aims, the child must be fit to receive the full benefit of the educational facilities provided by the Local Education Authority, and the health of the child can be and is being improved. To gain these, co-operation must be exercised to the full, and not only must this co-operation exist between persons, but there must also be a linking-up of all Health Services. Happily, in Bromley, the Health Services are unified, both in administration and in practice. For some twelve years past it has been our constant endeavour to see that watertight compartments within the Health Services do not exist, and to-day the services are open to all, functioning as a unit, but co-operation between the clinics and the domiciliary treatment of the sick child is still limited. This latter, can, in my view, only be overcome by an extension of the National Health Service covering the dependent family, or by the development of the services into a State Medical Service. Hygiene of Schools. A sound environment at school makes for sound education and plays an important part in the physical and mental welfare of the child at school. This is an axiom which does not always exist in some of the older church schools in the Borough, which have stood without any extensive change since their erection nearly eighty years ago. It is these schools, which having served their purpose over many years, that must be closed and replaced with Buildings possessing better facilities for the promotion of health giving environments. I am indebted to the Chief Education Officer for the following particulars of improvements carried out in the Council schools during the past year. Princes Plain.—Provision of two drinking taps. Baglan Road..—Provision of two additional drinking fountains. 104 Valley.—Provision of tap for drinking water. Burnt Ash.—Provision of one sink. Uaglan Road.—Removal of galleries from two class rooms. Completion of alterations to building' to accommodate a Senior Boys' Department of 480 children. One would like to see increased attention given to the practice of hygiene by the children. For example, the abolition of roller towels would help to control catarrhal infection and infectious skin conditions, thus teaching the child how to practice prevention of disease, and, further, it should not be necessary in these enlightened days to be compelled to carry out repeated vermin inspection of all children merely because a few suffer from parental neglect. Medical Inspection. All children coming within the three age groups, viz., entrants, second age group (intermediates) and third age group (leavers), are medically inspected at school, and those discovered with defects are re-inspected and referred through the necessary channels for treatment. The medical inspections are not limited to these routine inspections, hut extended to the special inspections at the school clinics and special clinics. During the year no less than 5,015 cases came under medical inspection (excluding Dental inspections), and these figures give some indication of the extent of the work required of the officers of the School Medical Services. In addition there is the medical examination of all employed children, the special examination of the mentally retarded, the physically defective, the blind, the deaf, the maladjusted child, and all requiring special school education. Every child is dentally inspected once a year by the School Dental Surgeon, and each child comes under cleanliness inspection three times each year by the school nurses. The statistical recording of these examinations is largely the recording of defects as required by the Board 105 of Education and is shown in the various tables in the appendix to this report. Rather than showing only the record of defects, one would like to see the tables altered so as to give a clearer indication of the defective children, showing the comparison between those suffering from remediable defects and those which are irremediable. Findings at Medical Inspections. These are recorded in detail in the appendix (Table Ic. and Tables Ila. and lib.), and here one can but draw attention to some of the conditions there recorded. Malnutrition. Table IIb. shows that five per cent, of children examined at routine medical inspections are below the average normal physique of children in Bromley, but as this refers only to some 1,571 children examined, it must not he taken as applying to all children attending school. I have dealt with this defect in previous reports, but I would again stress the fact that this does not necessarily imply that the children are under-nourished as a consequence of incorrect or deficient dietary. In cases where dietary appears to be the cause of malnutrition the scheme for milk in schools is proving of value. In other cases where home circumstances do not permit of the provision of adequate food, either on the grounds of poverty, or of mismanagement, the mother is referred to the Bromley Children's Care Committee, or to the school nurses, who visit the home and provide the necessary assistance and advice. It is seldom indeed that one finds wilful neglect to provide adequate nourishment for the growing child; ignorance is the main factor, and mucli still remains to be done in public education of correct dietary and correct home management. The environmental factors that handicap many families living as one-room sub-tenants, where adequate cooking and washing facilities are not available, are slowly being dealt with by regulations dealing with housing conditions of the people. This is one of the reasons why 106 the Health Services must continue to act as a unit, and anything that leads to disruption of the administrative units can only result in chaos in improving the health of the individual. Fifty-two children attended the special clinics during 1936 and were recorded as suffering from bad malnutrition. All these cases were dealt with in accordance with the known circumstances. A selection of these children, where the home environment fell short of the required standard, were referred for convalescent home treatment, camps, etc., and the results were satisfactory, as the majority showed improvement. The good results are, however, not always maintained. Uncleanliness. Children are periodically inspected in the schools by the school nurses, and those found to be grossly verminous are excluded from attendance at school. In the cases of children discovered with a minor degree of imcleanliness the parents are warned and instructed on the best methods to clear verminous conditions. Where cases fail to respond to warning they are excluded, and returned to school only after re-examination shows them to be clean. Cases excluded for periods longer than 14 days are referred to legal action for non-attendance. There were two cases in which legal proceedings were taken in 1936, and the fines inflicted were ten shillings and five shillings. During the year 1936 out of 16,194 inspections 363 children were found to be verminous, of whom 169 were excluded from school for various periods. It is to be noted that these are not necessarily 169 individual cases, as the same child might be, and frequently is, excluded at each inspection. It seems to me that in these enlightened days the necessity of re-exclusion of children indicates wilful neglect, and is a reflection on the moral sense of duty of these parents. The percentage of verminous children is, however, a small one, and shows a vast improvement on 107 the conditions which prevailed in the early days of the School Medical Service. M trior Ailments and Diseases of the Shin. There is little change to report on these conditions, except perhaps that cases come under earlier treatment than was previously the case, and that methods of treatment have advanced as a consequence of experience gained. The new Clinic at Bromley Common added to the facilities of the School Medical Service, with the result that greater numbers came under the professional treatments provided at the Clinic. Table IIa. shows the type of defect discovered and treated, while Table IV. gives the actual treatments carried out at the Medical Treatment Clinics. No less than 1,963 defects came under treatment during the year calling for 6,549 attendances by the children concerned. All cases requiring specialised treatment are referred to the special clinics provided by the Local Education Authority, or to local or London Hospitals. I would here like to record my appreciation of the help and advice that we have at. all times received from these special sources. V isual Defects. As approximately eight per cent, of children suffer from defective vision it is of paramount importance that discovery of defect should be early and treatment made easily available. To cope with an ever increasing demand for specialised treatment the number of eye clinics were increased during the year, and Mr. Eric Lvle, Consulting Ophthalmic Surgeon, found his time fully occupied. I cannot speak too highly of his work and of the interest lie devotes to the work of the services for the school child. Mr. Lyle's report is included on page 111 of this report. We are dependent upon Head Teachers to refer to us children with doubtful vision, but it is still not infrequent to find at routine medical inspection a child with severe visual defect untreated and unsuspected. As children are inspected only at entrance to school, again at the age of seven years and also at twelve years of age, one can readily understand that to depend only upon these inspections would result in delay in treatment, 108 Nose and Throat. There has been no reduction in the incidence of nose and throat defects. The causes of this pathological state, of which 10 per cent, of children are sufferers, are many and not well defined. Certainly greater attention is now given to the investigation of diseases of the nose and throat and the associated sinuses with an apparent increase in incidence, nevertheless I do not believe that this incidence is increasing. The report of Mr. Charles C. lieney, Ear, Nose and Throat Specialist, appears on page 112. Ear Disease and Defective Hearing. There is a reduction in chronic ear disease, mainly due to the early treatment provided and greater co-operation of parents in bringing their children to the clinics at the onset of disease. This results in the sub-acute ear being treated before the discharge becomes a chronic one. We have made no use of the audiometer testing of children at school. Dental Defects. I would refer here to the interesting report of Mr. T. S. Latham, School Dentist, which appears on page 113. The Dental Services were increased during the year by the engagement of Mr. Fairman J. Ordish for part-time service of five additional days a month. Thus we are now able to deal with all children at the elementary schools within the year. Orthopaedic and Postural Defects. These cases are discovered either at routine medical inspections or at the special inspections carried out at the school clinics. The service is extended to include the preschool child so that we are able to provide treatment at the onset. This results in gross defects in the school child being less frequent than when the orthopaedic services were first commenced. Table II. shows that 36 cases requiring treatment were discovered at the routine medical inspections, and represents a considerable reduction in the previous year s return. One hopes that with the development of organised physical training minor defects will become self-corrected. 109 Mr. H. J. Seddon, Orthopaedic Specialist, submits an interesting report which is included on page 112. New Orthopadic Cases seen at the Clinic durinq 1936. 1 Congenital conditions 20 Birth Injuries— Torticollis 1 Other conditions 3 3. Rickets— Bow legs 18 Knock knees 10 Other conditions 4 4 Knock knees 24 5. Postural defects 24 6. Structural curvature of the spine 2 7. Flat Foot 41 8. Infantile paralysis 1 9. Fractures 12 10. Unclassified 34 Heart Disease and Rheumatism. It is seldom to-day that one discovers heart disease in children which has not previously come to our knowledge through the special clinics. The greatest cause of heart disease in children is rheumatism, and as the child is usually already under observation for this complaint and also the fact that early treatment and advice is given, lessens the incidence of heart impairment. As the onset of heart disease in children is usually insidious, the importance of constant supervision of the rheumatic child is of paramount importance. Fortunately the parents are aware of this necessity, and it is only with their help that one can do something to prevent the severe crippling that can result from a neglected minor degree of disease of the heart. Tuberculosis. There were no cases of tuberculosis discovered it routine medical inspections during the year, but this is not to be understood to mean that of the 1,571 children examined none had any evidence of tuberculosis. To label a child tuberculous without prolonged investigation is not good practice, and again many of the children classified under malnutrition have an underlying tubercular infection, which requires prolonged observation before diagnosis is made. 110 Other Defects. This classification includes such minor conditions a.s catarrh, digestive disorders, influenza, infectious disease and infective disorders. That 98 of the children examined at routine medical inspection were classified under this heading as requiring treatment is an indication that far too many children are in attendance at school in an unfit state to receive educational benefit, and are in many cases spreading catarrhal infection to other normally healthy children. The special inspection (see Table II.) shows that 1,196 out of a total of 3,235 cases were classified under this heading. It is the examination of these sick children and the issuing of the necessary certificates that occupies so much medical time, but many chronic defects are brought to light that would not otherwise be discovered. Folloiving-up. Cases are f'ollowed-up at home, and at school, by the School Nurses, or by School Attendance Officers, according to the nature of the defect discovered at medical inspections, or they may be referred for special inspection at the special clinics. Children requiring material assistance are referred to the Bromley Children's Care Committee, whose valuable contribution to the work of the School Medical Service will be readily appreciated from perusal of their Annual Report which is printed on page 121. In case of wilful neglect, the matter is passed to the N.S.P.C.C. Inspector for his independent action. The transfer of children from one local authority to another calls for the interchange of medical records, and similar procedure applies to children under treatment at hospitals. To-day there is very little overlapping, and the helpful co-operation so necessary for the welfare of the child is functioning automatically. Treatment. The tables of statistics in the appendix give details of cases treated during the year. We now have two special clinic buildings, one opened at Station Road in 1928 111 serving the Northern end of the town, and the other opened in February, 1936, at Princes Plain for the Southern end of the borough. These two buildings provide the facilities for inspection and treatment of any child from birth until the leaving age is reached in the elementary schools. In addition certain facilities are open to secondary school children referred to us by the Kent County Council. A tabulation giving full particulars of all clinics is given on page 28. Treatment of Minor Ailments. Ten sessions per week at both school clinics are devoted to the treatment of minor ailments, and Saturday morning's are allocated to the examination of contacts and hospital discharged cases in connection with infectious disease. The attendance figures for minor ailment treatments during 1936 amounted to no less than 6,549. Table II. under special inspections includes the types of ailments while Table IV. indicates the cases treated by the school nurses at the Clinics. It will there be noted the increase of impetigo during the year (92 in 1934 and 160 in 1935). There is a fall in the number of ear cases, 193 to 147, but an increase in the number of minor injuries 905 to 988. Report on the Work of the Eye Clinic. During the past year no less than 543 cases have been examined and treated. Among this number there were 63 cases of concomitant squint. Of these latter a percentage are cured in the Clinic by the use of suitable spectacles, by occlusion, etc. Some of the remainder have to be treated by operation whilst the rest can be cured by Orthoptic training. At the present time these cases are referred to the Orthoptic departments at the Royal Westminster Ophthalmic Hospital. However, it is hoped that in the near future it may be possible to treat these patients at the Clinic. Three of the squint cases were sent to the above-mentioned Hospital for operation, and the results have been very satisfactory. I am greatly indebted to the Hospital surgeons for the interest they take in cases which are referred to them. Other cases referred for a second opinion or for special operation include:— 112 (1) A case of Intra ocular foreign body. (2) A case of Hysterical amblyopia. (3) A case of Congenital ptosis. (4) A case of Ocular torticollis. Since the opening of the new wards at the Bromley and District Hospital, it has been possible to admit certain cases there and so keep such cases under my own care. In conclusion, I should like to thank very sincerely those who organise the clinic. They carried out their work to such perfection that all the clinics ran smoothly and easily without exception." Eric Lyle, m.d. Report on the Work of the Ear, Nose and Throat Clinic. Once more I have the honour to submit a report of the work of the Ear, Nose and Throat Clinic which continues to work smoothly and efficiently. There were 33 clinics held for operations and 143 operations were performed. Bight clinics were held for consultation, with regard to cases referred by the School Medical Officer, to decide if operation was necessary, and by which method operation should be carried out in those cases requiring surgical treatment. By these means it is possible to make sure that the tonsils are completely removed in over 99 per cent, of cases. One hundred and forty-five cases were seen, and 28 cases were referred to their own doctor or hospital. I am glad to say that fewer cases have had to be dealt with in my beds at St. John's Hospital. My thanks are due to Dr. France who has given the anaesthetics so satisfactorily, and once more I must thank the medical and lay staff for their co-operation." Charles Beney, m.a., m.b., b.ch., m.r.c.s. Report on the Work of the Orthopædic Clinic. ''Orthopaedics is by common consent a slow moving branch of surgery. The treatment of most cases is a matter of months or years. An innovation, however startling, cannot be proved to be a real advance until the new form of diagnosis or treatment has been tried out by a number of observers over a period of several years. Consequently, the annual report on the work of an orthopaedic clinic can but rarely do more than say that the work is progressing satisfactorily. This can be said, without any reservation, of the work at Bromley. The attendance of patients is orderly and regular, and I think that the orthopaedic clinic is appreciated by the parents, many of whom have expressed their thanks in words or by letter. Nevertheless, there are two matters that call for comment. It is not generally known that the dreaded rheumatoid arthritis that attacks adults is sometimes found in children. It is, if anything, even more crippling in children, and treatment is made difficult by our ignorance of the cause of the disease, which has so far eluded the most careful investigations. But, in spite of this, a new form of treatment, the injection of complex salts of gold, has been introduced, and the 113 results so far are most encouraging. The pioneer work was carried out in France by Fore9tier. Two children with this condition have come under our care during the last year, and both are being treated with gold salts. One, a comparatively mild case, is able to walk, and is being treated at the clinic. The other, a severe case, is being dealt with at Stanmore. It is too early yet to give a definite opinion on the value of the treatment in these two cases, but there has been remarkable improvement in the one other child (from another clinic) who has been treated in the same way, and I have seen excellent results in two cases treated by Dr. W. S. C. Copeman. I hope to say more about the Bromley children next year. Chronic arthritis of a single joint in a child always raises the question of it being due to tuberculosis. In the early days of the disease an exact diagnosis is often impossible; X-ray examination may not help in the least and skin tests for tuberculous disease are only helpful if persistently negative. It is trying both for parents and surgeon if this state of doubt continues for many months. Examination of the joint by open operation may settle the matter completely, but this is a procedure that one cannot regard without a little misgiving. It occurred to us some time ago that examination of a lymph gland in the groin might help, seeing that the knee drains into these glands. This little operation, performed under local anæsthesia, has given six positive results in six cases, and it was employed in a child that came to the Bromley Clinic. It promises to be a most valuable procedure." H. J. Seddon, f.r.c.s. Report of the School Dental Surgeon. "The year 1936 has been marked by two important events in the Dental Department. In February the Princes Plain Clinic was opened with a well equipped dental surgery, and in September Mr. Fairman J. Ordish was appointed to carry out dental treatment there. Mr. Ordish gives us one day a week, and, although he only began work in September, the accompanying figures will show how valuable his assistance has been to the Committee. Inspection. During the year an inspection was carried out at every school under the Education Authority except one. It will be remembered that in the previous year. 1935, five schools were carried over to the following year as there was no time for inspecting them; it would appear therefore that we shall shortly be back again on the recommended basis of annual inspection and annual treatment for every school child. A total of 5,102 children received a dental inspection and 2.744 were found to be in need of treatment, i.e., 58 per cent. Treatment. During 1936 the total number of attendances by children at the Station Road Clinic and the Princes Plain Clinic was 4,368. Last year, 114 when only one clinic was in operation, the total number was 3,808. Thus, the figure for 1936 shows an increase of 560 over that for 1935, The new clinic has in many cases halved the cost of dental treatment to the parent, for before it was built many parents from the Southern area of the Borough had to pay not only the usual one shilling for treatment, but also another shilling in bus fares for themselves and their children. In my opinion, this fact, and of course the saving of time, tends to popularise the Princes Plain Clinic. Sixty-seven gas sessions were held, and gas was administered on 1,194 occasions. Extractions numbered 4,528, and fillings 2,843. It will be seen from the attached tables that, compared with last year, extractions have fallen by 72, while fillings have risen by 488. More teeth have been saved and less have been extracted. Other Services. Forty-one nursing or expectant mothers attended on Saturday mornings for dental treatment. These mothers are referred to the Dental Clinic from the ante-natal clincs, and by the nurses. The dental condition of these mothers is almost always very bad indeed, and the treatment usually consists of scaling and gas extractions. As regards the attendance of infants from the Welfare Centres, there has been a great increase over last year. In 1935 the total attendances were 100, while in 1936 they were 216. Dental treatment of these welfare children is not easy, but in the cases that are referred treatment is very necessary. The child benefits by the treatment at the time, and later on starts school with the advantage of a healthy mouth. Conclusion. Lastly, I must express my great appreciation of the assistance given me by the Committee and the Staff, and I would especially thank the Voluntary Helpers who give us so much time and practical help." T. S. Latham, l.d.s., eng. 115 Summary of Dental Statistics for the Year 1936, with Comparisons with the Year 1935. At Princes Plain Clinic: Mr. Ordish gave 34 sessions in all, of which five sessions were gas. Inspections. 1935 1936 Remarks. No. of Sessions 22 25 5 schools not inspected in 1935, and 1 not inspected in 1936. No. Examined 4482 5102 Referred for Treatment Treatment. 2246 (56%) 2744 (53%) No. of Sessions 380 418 34 sessions at Princes Plain Clinic in 1936. No. Discharged 2274 2428 51 were welfare children in 1935. 108 were welfare children in 1936. Total Attendances 3908 4368 100 were welfare children in 1935. 216 were welfare children in 1936. Average Attendance per Session 10 10 Visits per Child 1.6 1.7 No. of Gas Cases 1115 1194 No. of Gas Sessions 60 67 No. of Children per Session 18 18 Extractions 4528 4456 Fillings 2355 2843 Local Anaesthetics 1142 1100 Other Operations 438 617 Mothers. Discharged Treatment 42 41 116 Ultra Violet Ray Clinic. This clinic is held in conjunction with the Orthopaedic and Massage Clinic, and is held twice weekly. As an adjunct to treatment one finds this special provision of great value, especially in the convalescence of influenza and debility cases during the winter months. There were 1,825 attendances during the year, and at times a greater demand than we were able to fulfil. The following short summary indicates the type of case referred for ultra violet ray and the general results of such treatment: Of the total number treated in 1936 there were 147 new cases. These consisted of :— General Debility, 50. Of these12 did not attend .regularly, but the remainder showed great improvement in general health, increase of weight,better appetite and improved muscle tone. Impetigo, 14. These all showed a good reaction to sunlight except one very severe case which was transferred to hospital. Infant Welfare Cases, 24. These showed marked improvement in general physique and gained weight steadily after a few applications. Chilblains, 5. All these cases improved and showed o better circulation. Asthma, 5. On the whole there was apparent improvement in these cases. One parent reported that the child had not had an attack of asthma for over six months, although previously the attacks were frequent. Alopecia, 2. One showed improvement and new hair began to grow after six weeks' treatment. The other did not attend regularly. Coeliac Disease, 1. General health improved and was reported to be much better since having sunlight. Catarrhal Bronchitis, 10. These children showed marked improvement in general health, and the parents reported that they were less susceptible to colds and coughs. 117 Nervous Cases, 15. Three did not continue treatment long 0enough to benefit, but the remainder were said to be sleeping better and were not so irritable. Boils, 5. These cases of multiple boils responded well and were cured after a few applications of sunlight. Ear Discharge, 4. One of these cases was postmastoid where the scar had broken down, but soon healed. In the remaining cases application of ultra violet rays appeared to assist the routine ear treatment. Infectious Disease. The precautions taken to prevent the spread of infectious diseases are in accordance with the recommendations of the "Memorandum on Closure or and Exclusion from School." All contacts excluded from school are examined at the end of ten days prior to their return to school, and patients are examined fourteen days after discharge from hospital. No schools were closed on account of infectious diseases, but in six instances the attendance fell below 60 per cent., mainly on account of measles, and the certificates were issued in accordance with the recommendations of Circular 1348. The following table is a summary of the returns from Head Teachers during 1936:— Infectious Disease Returns from Schools, 1936. Schools. Diphtheria. Scarlet Fever. Measles. Whooping Cough. Mumps. Chicken Pox. Other. Addison Road 1 2 21 7 3 Aylesbuiy Road 1 1 6 — — 2 — Bickley & Widinore — - 6 12 — 1 — Burnt Ash - 13 77 41 3 72 3 Central 1 - 2 2 1 2 2 Hayes - 3 78 19 — — 3 Keston - - 17 — - Masons Hill - 52 - - 2 - Parish - 1 39 7 — — - Plaistow, St. Mary's - 1 3 6 1 — — Princes Plain 1 9 72 55 — 2 2 Raglan Road 3 8 143 46 5 20 1 St. Joseph's R.C. 1 40 11 — 1 — Valley 1 24 52 14 - —- — 118 Medical Certificates of Exclusion from School. The following is a summary of medical certificates issued by general practitioners showing types of illness responsible for loss of school attendance, and may be taken into consideration with Table II. of the Medical Inspection Returns in the Appendix. Conditions for which Medical Certificates of Exclusion from School were issued by General Practitioners during 1936. Malnutrition, debility 39 Skin 19 Eyes 3 Ears 24 Nose and throat 141 Enlarged cervical glands 23 Heart 8 Lungs (non-tuberculous) 63 Nervous diseases 12 Deformities 1 Accidents 21 Operations 6 Measles 114 Whooping cough 95 Mumps 3 Influenza 28 Chicken pox 25 Rheumatism 27 Bronchitis 92 Miscellaneous 102 846 Employment of Children and Young Persons. The Bye-laws under this head were re-modelled in 1935, and during 1936 the number of children examined and for whom medical certificates were issued was as follows:— Total No. examined 174 Fit certificates issued 161 119 The total number of children in employment at 31st December, 1936, was:— Boys— Newspaper delivery 103 Milk delivery 33 Bread delivery 4 Meat delivery 7 Errands 37 Confectionery assistant 1 185 Girls— Housework 1 Total 186 Physical Training. A joint scheme of physical training was established in 1936 for the areas of Beckenham, Bromley, Erith, Gravesend and Penge, and Mr. G. H. Atkinson and Miss I. C. MacLennan have been appointed Organisers of Physical Training. A joint Committee of representatives from the Education Authorities of the areas are responsible for the administration of the scheme so far as matters cf general policy and co-ordination are concerned. Each individual Authority is responsible for the control and organisation of the work of the organisers in its area. The ordinary routine administration work is done at the offices of the Bromley Education Committee. I had hoped in this report to be in a position to discuss in some detail the effects of the scheme, but the organisers did not commence duties until towards the close of the year, and, therefore, it would not be practicable to attempt to examine the effects until the scheme has had ample time to function. With physical training there must be adequate nourishment, for without an adequate dietary, physical training cannot be fully beneficial, in fact it may in certain cases be detrimental to the under-nourished child, causing undue physical and mental fatigue. Much 120 remains to be done, either by the provision of extra nourishment at school, or by education of the parent in providing a qualitative and quantative diet for the growing child sufficient not only for the normal growth of the child, but also for the extra strain placed upon the individual in the improvement of its physical condition. Provision of Meals. The Local Education Authority does not exercise any powers under section 82/84 of the Education Act, 1921. Bromley is strictly a residential area, and there does not appear to be any necessity on medical grounds for this provision. Where undernourishment exists the case ;s reported to the Bromley Children's Care Committee for assistance at home or for free milk at school. This works well, and, as the Committee has made provision in the larger schools for the heating of midday meals provided by the parent, there does not appear to be any urgent necessity to put into operation the above-mentioned sections of the Act. Open Air Schools. No special open air school for defective children is provided in Bromley. It is found to be more economical to provide for free convalescent home treatment to the child requiring this provision. However, there is an increasing demand for special education for the child that is debilitated, crippled, or otherwise physically defective, and no doubt the future will see in Bromley some special school to deal with this increasing number of children. At the present time the demand is met by the use of institutions and schools provided by the larger education authorities. Occupation Centre. An Occupation Centre was opened in Bromley in 1933 under the management of a voluntary committee. Mentally defective children are accepted at this Centre who are incapable of receiving education in special schools. Upwards of 28 children attend who are under the care of Miss H. Wade, Supervisor. 121 After-Care Work. The home environment cannot be excluded in the consideration of the health of the school child, yet the school medical service functions primarily for the child at school or at the school clinics. The medical care of the child at home remains under the care of the private practitioner. The line of demarcation between the two services is a distinct one, and is only partially blended by the co-operation that exists between us. When a child is referred to domiciliary care, the case is followed-up by the school nurses, who in Bromley also act as health visitors, agijd much can be done, and is being done, to give advice on the proper care of the sick child and the correction of a causal element. This especially applies to the maladjusted child. The services of the Bromley Children's Care Committee are invaluable, and I am much indebted to Miss M. A. Isard for the services which she and others render so willingly. Report of the Bromley Children's Care Committee, 1936. "During the year 1986 more milk and extra nourishment was given to necessitous cases, than in the two or three previous years. Fewer children were sent away to Convalescent Homes owing largely to the prevalence of infectious diseases during the early part of the year, and later on some of the Homes had to close down for several weeks for the same reason. Assistance has been given in 288 cases, as follows:.— Milk 103 Extra nourishment 34 Provision of spectacles 17 Fares for taxis to hospitals 19 Provision of boots 77 Convalescent Home letters 26 Medicines 6 Cases sent to the Royal Sea Bathing Hospital 6 288 The distribution of new and cast off clothing is an activity undertaken by members of the Care Committee through the Clothing Room of the Bromley Committee of Social Service, but the figures relating thereto have not been included in the foregoing list. The Care Committee would like to express thanks to all who have helped at the School Clinics so regularly throughout the year, and especially to Miss Fluck, who, at very short notice, willingly took over 122 the duties of Honorary Secretary for three weeks. Thanks are due to Mr. Harris for continuing to supply spectacles to the children at very reduced rates and in some cases free of cost, and also the Committee would like to thank Mr. Harvey Lowe, who, through the Queen's Reign Commemoration Fund, has given Convalescent Home letters." Statement of Accounts, 1936. Receipts. Expenditure. £ s. d. £ s. d. Balance brought forward 2 9 1 Milk 37 15 7 Bromley Benevolent Association 80 0 0 Boots 23 17 2 Royal Sea Bathing Hospital 25 4 0 Bromley Charities Festivities Committee 20 0 0 Clothes 10 0 0 Repaid— Convalescent Homes 5 0 0 Royal Sea Bathing Hospital 2 2 6 Letters— Royal Sea Bathing Hospital 4 4 0 Convalescent Homes 3 15 6 Fares 9 6 Convalescent Homes 4 4 0 Glasses 2 6 Malt and oil 1 10 1 108 19 1 Fares to Convalescent Homes 4 16 6 Deficit 9 5 3 Taxis from Clinic 1 1 0 Glasses 7 0 X-Ray 5 0 £118 4 4 £118 4 4 Amy G. Mann, Chairman and Hon. Treasurer. M. A. Isard, Hon. Secretary. APPENDIX. 124 TABLE 1.—MEDICAL INSPECTION RETURNS for the Year ended 31st December, 1936. A.—ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed Groups:— Entrants 578 Second Age Group (intermediates) 468 Third Age Group (leavers) 497 Total 1543 Number of other Routine Inspections 28 Grand Total 1571 B.—OTHER INSPECTIONS. Number of Special Inspections 3842 Number of lie-inspections 2737 Total 6579 C.—CHILDREN FOUND TO REQUIRE TREATMENT Number of individual children found at Routine Medical Inspection to require treatment (excluding Defects of Nutrition, Uncleanliness and Dental Diseases). Group. For defective vision (excluding squint). For all other conditions recorded in Table IIA. Total. Entrants 24 49 73 Second Age Group 27 34 61 Third Age Group 46 31 77 Total (Prescribed Groups) 97 114 211 Other routine Inspections - - - Grand Total 97 114 211 125 TABLE II. A—Return of Defects found by Medical Inspection in the Year ended 31st December, 1936. 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 2 (2) „ Body 1 — 4 — (3) Scabies — — 11 — (4) Impetigo — — 158 — (5) Other Diseases (non-tuberculous) 8 — 498 19 Total (Heads 1 to 5) 9 - 672 21 Eye (6) Blepharitis 4 — 23 1 (7) Conjunctivitis — — 57 2 (8) Keratitis — — 1 — (9) Corneal Opacities — — 1 1 (10) Other conditions (excluding Defective Vision and Squint) 2 1 109 3 Total (Heads 6 to 10) 6 1 191 7 (11) Defective Vision (excluding squint) 97 65 88 23 (12) Squint 2 1 7 4 Ear (13) Defective hearing 2 — 7 5 (14) Otitis Media 8 1 71 3 (15) Other Ear Diseases 2 1 79 6 Nose and Throat (16) Chronic Tonsillitis only 15 53 131 106 (17) Adenoids only 6 4 8 8 (18) Chronic Tonsillitis and Adenoids 59 56 206 94 (19) Other conditions 14 20 175 35 (20) Enlarged Cervical Glands (non-tuberculous) 8 4 50 28 (21) Defective Speech 1 2 3 6 Heart Disease: Heart and Circulation (22) Organic 1 1 2 5 (23) Functional 4 17 16 17 (24) Anæmia 7 1 12 6 Carried forward 241 227 1718 374 126 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 241 227 1718 374 Lungs (25) Bronchitis - - 53 - (26) Other Non-Tuberculous Diseases 13 6 206 27 Tuberculosis Pulmonary: (27) Definite — — — — (28) Suspected - - - 10 Non-Pulmonary: (29) Glands — — 2 2 (30) Bones and joints - - - — (31) Skin - 1 - — (32) Other forms — — — — Total (Heads 29 to 32) — 1 2 2 Nervous System (33) Epilepsy - 1 1 4 (34) Chorea - 1 17 8 (35) Other conditions 16 13 22 3 Deformities (36) Rickets - - - — (37) Spinal Curvature 10 3 3 3 (38) Other forms 26 16 17 39 (39) Other Defects and Diseases (excluding defects of Nutrition Uncleanliness and Dental Disease) 98 21 1196 389 Total 404 289 3235 859 127 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 578 18 3.1 526 91.0 34 5.9 — — Second Age- Group 468 18 3.8 399 85.3 51 10.9 — — Third Age-Group 497 74 14.8 374 75.4 45 9.0 4 0.8 Other Routine Inspections 28 — — 28 100 — — — — Total 1571 110 7.0 1327 84.5 130 8.3 4 0.2 TABLE III.—Return of all Exceptional Children in the Area, 1936. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 2 — — — 2 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At other Institutions. At no School or Institution Total. 1 6 3 1 — 11 128 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 5 1 — — 6 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. — — 2 — 1 3 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. At Certified Schools for Mentally Defective Children At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 8 1 2 2 13 MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN) REGULATIONS, 1928. Total Number of Children notified during the year 1936 by the Local Education Authority to the Local Mental Deficiency Authority 2 (i) Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots — (b) Imbeciles 2 (c) Others — 129 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 4 — — — 4 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 1 1 — — 2 II.—Children suffering from Non-Pulmonary Tuberculosis 4 3 — 2 9 B. Delicate Children 1 8 2 4 15 C. Crippled Children 7 13 — 1 21 D. Children with Heart Disease 5 11 — 2 18 CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Combination of Defect. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. Blind and Feebleminded 1 — — 1 2 130 TABLE IV.—Group I. Minor Ailments treated during the year 1936. Disease or Defect. Number of Defects treated, or under Treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin- Ringworm—Scalp (i) X-Ray treatment — 1 1 (ii) Other — — — Ringworm—Body 5 — 5 Scabies 8 — 8 Impetigo 158 2 160 Other Skin Diseases 382 22 404 Minor Eye Defects (External and other, but excluding cases falling in Group II) 243 7 250 Minor Ear Detects 138 9 147 Miscellaneous (e.g., Minor injuries, bruises, sores, chilblains, etc.) 841 147 988 Total 1775 188 1963 131 TABLE IV.—Group II. Defective Vision and Squint 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. Total. Under the Authority's Scheme. Otherwise. Total. Errors of Refraction (including squint) 507* 6 513 265 6 271 265 6 271 Other Defect or Disease of the Eyes (excluding those recorded in Group I) 36 3 39 — — — — — — Total 543 9 552 265 6 271 265 6 271 *Of this figure 272 were re-inspections. 132 TABLE IV.—Group III. Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative Treatment. Received other forms of Treatment. Total Number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) — 5 137 1 — — 28 — — 5 165 1 162 333 (i) Tonsils only, (ii) Adenoids only, (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat. 133 TABLE IV.—Group IV. Orthopædic and Postural Defects. Under the Authority's Scheme. Otherwise. Total Number Treated. Residential treatment with Education. Residential treatment without Education. Nonresidential treatment at an Orthopædic Clinic. Residential treatment with Education. Residential treatment without Education. Nonresidential treatment at an Orthopædic Clinic. Number of Children treated 15 — 314 — — — 314 134 TABLE V.—Dental Inspection and Treatment. (1) Number of Children Inspected by the Dentist:— (a) Routine age-groups:— Age. 5 6 7 8 9 10 11 12 13 14 Total. Number 232 397 498 606 512 491 ' 506 512 520 439 4713 (b) Specials 389 (c) Total (Routine and Specials) 5102 (2) Number found to require treatment 2744 (3) Number actually treated 2320 (4) Attendances made by children for treatment 4152 (5) Half-days devoted to:— Inspection 25 Treatment 418 Total 443 (6) Fillings:— Permanent Teeth 2520 Temporary Teeth 300 Total 2820 (7) Extractions:— Permanent Teeth 910 Temporary Teeth 3400 Total 4310 135 (8) Administrations of general anaesthetics for extractions 1194 (9) Other Operations:— Permanent Teeth 384 Temporary Teeth 233 Total 617 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 school nurses 16194 (iii) Number of individual children found unclean 363 (iv) Number of individual children cleansed under Section 87 (2) and (3) of the Education Act, 1921 Nil (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 Nil (b) Under School Attendance Bye-laws 2 JR1/68