Journal Rebind Co. Ltd Unit 4, Pier Wharf, Grays, Essex E 4412(1) BROLEY BRO 33 BOROUGH OF BROMLEY. 1937 ANNUAL REPORT. MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER, BROMLEY, KENT. The Bromley Printing Co., Bromley, Kent. 68610 BOROUGH OF BROMLEY. 1937 ANNUAL REPORT. MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER. BROMLEY, KENT. THE Bromley Printing Co., Bromley, Kent. 2 CONTENTS. PAGE Members of the Health and Maternity and Child Welfare Committees 6 Staff 7 Prefatory Letter 10 Section A. Statistics and Social Conditions of the. Area. Summary of Statistics 16 Social Conditions 17 Meteorology 19 Unemployment 19 Occupations 20 Population 20 Vital Statistics:— Births 21 Stillbirths 22 Deaths 23 Infantile Mortality 24 Maternal Mortality 26 Section B. (I). General Provision of Health Services for the Area. Laboratory Facilities 28 Ambulance Facilities 28 Nursing in the Home 28 Bromley and District Nursing Association 28 Haves and West Wickham Nursing Association 29 Treatment Centres and Clinics provided by the Local Authority 31 Tuberculosis Dispensary 32 Venereal Diseases Treatment Centres 32 Hospitals—Public and Voluntary 32 Nursing Homes, Public Health Act. 1936, Sec. 187/105 33 Nursing Homes and Hospitals Tabulation 34 Other Institutions 35 Section B. (II). Maternity and Child Welfare. Details of Services 38 Ante-Natal Clinics 39 Natal Services:— Domiciliary Midwifery Service 40 Mid wives 41 Administration of the Midwives Acts, 1902-1936 41 Inspection of Midwives 42 Institutional Provision for Mothers and Children:— Infants 44 Maternity Hospital 44 Puerperal Fever, Isolation and Treatment 45 3 PAGE Maternity and Nursing Homes 45 Post-Natal Services:— Health Visitors—Home Visiting 45 Burnt Ash Area Report 46 Bromley Common Area Report 46 Hayes and Keston Areas Report 51 Welfare Centres 52 Milk in necessitous cases 53 Clinic Treatments of Children under five years, and Mothers 53 Public Health (Ophthalmia Neonatorum) Regulations, 1920 53 Epidemic Diarrhoea 54 Public Health Act, 1936, Child Life Protection 54 Section C. Sanitary Circumstances of the Area. Water 58 Drainage and Sewerage 59 Cesspool Drainage 59 Rivers and Streams 60 Public Cleansing 60 Sanitary Inspection of the Area 60 Shops Acts, 1912-1934 61 Smoke Abatement 62 Factories and Workshops 62 Swimming Baths and Pools02 Verminous Houses 63 Rats and Mice Destruction Act, 1919 64 Public Elementary Schools 65 Section D. Housing. Housing 08 Housing Act, 1930—Part IV., Overcrowding 68 Tabulation—overcrowding 68 Section E. Inspection and Supervision of Food. Milk Supply 72 The Milk (Special Designations) Order, 1930 72 Meat and Other Foods 73 Meat—Tables A., B., C. and D 74-75 Unsound and Unwholesome Food Surrendered 76 Food and Drugs Adulteration Act, 1928 76 Section F. Prevalence of, and Control over, Infectious and Other Diseases. Scarlet Fever 78 Diphtheria 78 Puerperal Pyrexia and Puerperal Fever 78 Acute Poliomyelitis 81 4 PAGE Dysentery 82 Typhoid Fever 82 Other Notifiable Infectious Diseases 82 Tuberculosis 82 Public Health (Prevention of Tuberculosis) Regulations, 1925 84 Public Health Act, 1936, Sec. 172 84 Efficiency of Notification of Tuberculosis 84 Tuberculosis Dispensary—Summary of Work 84 Propaganda 85 Section G. Other Services Supervised by the Heath Department. Diseases of Animals Acts 88 Tuberculosis Order of 1925 88 Rag Flock Acts, 1911-1928 88 Registries for Female Domestic Servants 88 Petroleum Acts 89 Retail Market 90 Appendix. Tables I. to XV 92-111 SCHOOL MEDICAL SERVICE. Members of the Education Committee 114 Introduction 115 Summary of Statistics 116 Staff 117 Co-ordination 117 Hygiene of Schools 118 Section A. Medical Inspection and Findings at Medical Inspections. Medical Inspection 122 Findings at Medical Inspections:— Malnutrition 123 Uncleanliness 123 Minor Ailments 124 Visual Defects and External Eye Disease 124 Nose and Throat Defects 125 Ear Disease and Defective Hearing 125 Dental Defects 126 Orthopaedic and Postural Defects 126 Heart Disease and Rheumatism 126 Tuberculosis 126 Other Defects and Diseases 127 Following-up 127 5 PAGE Section B. Thkatment, Minor Ailment Clinic and Special Clinics. Treatment of Minor Ailments 130 Eye Clinic, Report on the Work of the 130 Orthoptic Clinic, Report on the Work of the 131 Ear, Nose and Throat Clinic, Report on the Work of the 132 Orthopaedic Clinic, Report on the Work of the 133 Ultra Violet Ray Clinics 134 Dental Clinic, Report on the Work of the 136 Dental Clinic, Summary of Statistics 138 Section C. Infectious Disease 140 Medical Certificates of Exclusion from School 141 Open Air Education 142 Physical Training 142 Provision of Meals 143 Co-operation of Parents, Teachers and Others 144 Section D. Blind, Deaf, Defective and Epileptic Children 146 Nursery Schools 146 Secondary Schools 147 Parents' Payments 147 Health Education 147 Special Enquiries 148 Section E. Occupation Centre 150 Employment of Children and Young Persons 150 After-Care Work 150 Bromley Children's Care Committee Report 151 Section F. Appendix. Statistical Tables. Table I. A. Routine Medical Inspections 154 B. Other Inspections 154 C. Children Found to Require Treatment 154 Table II. A. Return of Defects 155 B. Classification of the Nutrition of Children 157 Table III. Return of Exceptional Children 157 Table TV. Group I. Minor Ailments 160 II. Defective Vision and Squint 161 III. Treatment of Defects of Nose and Throat 162 IV. Orthopaedic and Postural Defects 163 Table V. Dental Inspection and Treatment 164 Table VI. Uncleanliness 165 6 MEMBERS OF THE HEALTH AND MATERNITY AND CHILD WELFARE COMMITTEES, 1937-1938. HEALTH COMMITTEE:— Councillor S. G. Humerston (Chairman). Councillor F. L. Harris, f.b.o.a., f.s.m.c., f.i.o. ( Vice-C h a irman). His Worship the Mayor (Councillor W. J. Guthrie, j.p.). Alderman W. F. Skilton. Councillor G. Allen. Councillor E. C. De' Ath. Councillor G. T. Evans. Councillor George Griffin. Councillor A. W. Knight. Councillor M. Stafford Smtth, m.b.e., b.a. MATERNITY AND CHILD WELFARE COMMITTEE. Councillor E. C. De'Ath (Chairman). Councillor M. Stafford Smtth, m.b.e., b.a. (Vice-Chairman). His Worship the Mayor (Councillor W. .T. Guthrie, t.p.). Alderman W. F. Skilton. Councillor G. Allen. Councillor G. T. Evans. Councillor Geobge Griffin. Councillor F. L. Harris, f.b.o.a., f.s.m.c., f.i.o. Councillor S. G. Humerston. Councillor A. W. Knight. Co-opted Member:— Mrs. A. M. Howe. Mrs. A. G. Mann, b.a., j.p Mrs. M. Pearce. Miss V. Vincent. Mrs. E. Yolland. 7 PUBLIC HEALTH STAFF, 1937. Medical Officer of Health and School Medical Officer Assistant Medical Officer of Health and Assistant School Medical Officer Orthopaedic Specialist Ear, Nose and Throat Specialist Eye Specialist Anaesthetist Consulting Gynaecologist School Dental Surgeons Chief Sanitary Inspector Sanitary Inspectors Health Visitors and School Nurses Municipal Midwives 2 K. E. Tapper, o.b.e.. m.b., ch.b., d.p.h. 2 Miss G. H. Stinson, m.r.c.s., l.r.c.p. 2 1 H. J. Seddon, f.r.c.s. 2 1 Charles C. Beney, m.a., m.b., ch.b., (Camb.), m.r.c.s. 2 1 Eric Lyle, m.a., m.d., b.ch., d.o.m.s. 2 1 F. G. France, m.b., b.s.Lond., M.R.C.s., L.R.C.P. 2 1 J. Bright Banister, m.a., m.d., f.R.c.P., f.r.c.s. 2 T. S. Latham, l.d.s., r.c.s. 2 1 Fairman J. Ordish, l.d.s., r.c.s. 8432 G. R. Woods, m.s.i.a., a.r.san.i. 5 4 3 2 T. C. Towersey, m.s.i.a. 5 4 3 2 W. H. Sayers, m.s.i.a. a.r.san.i. 4 3 2 E. R. H. Hodge, m.s.i.a., m.r.san .I. 5 4 3 2 C. J. Clark. (Resigned 31 /3/1937). 8 7 6 2 Miss L. A. Briggs. 8 7 6 2 Miss E. Connor . 8 7 6 2 Miss E. B. Crowe. 8 7 6 2 Miss J. E. B. Dunn. 8 7 6 2 Miss D. Prime. 8 7 1 2 Miss E. Rhodes. 7 1 2 Miss J. H. Eastman. (Appointed 1/11/1937). 8 Municipal Midwives Orthopaedic Nurse Orthoptic Nurse Veterinary S u rgeo 11 under the Diseases of Animals Acts ... Inspector under the Diseases of Animals Acts and Petroleum Acts General Office Staff : Chief Clerk Junior Clerks Temporary Clerk Dental Clinic Assistants 762 Miss S. A. Garner. (Appointed 1/11/1937). 7 6 2 Miss E. Smith. (Appointed 1/11/1937). 7 2 Miss A. M. Winter. (Appointed 1/11/1937). 21 Miss M. Dodge, c.s.m.m.g. 2 1 Miss J. Bradley. 1 P. J. Turner, m.r.c.v.s. G. R. Woods, m.s.i.a., a.r.san.i. 2 H. E. Lawley. 2 W. S. Dench. 2 D. L. Corder. 2 E. H. Andrews. 2 Miss J. L. H. Huntley. (Appointed 16/12/1937). 2 Miss R. Brock. (Appointed 1/5/1937). 2 Miss B. C. Tucker (Resigned 20/11/1937). 2 Miss L. P. Thorpe (Resigned 30/4/1937) G. C. Dickinson. 2 Miss E. Colin. (Appointed 8/1/1938). 21 Miss J. Staden. (Appointed 1/4/1937). 2 Miss A. M. Penman (Resigned 31/3/1937). 2 Miss E. Roberts (Previously part-time from 2/9/1936 to 31/3/1937 Appointed full - time 1/4/1937 and resigned 31/12/1937). 9 Outdoor Staff: Drain Tester and fector Market Superintendent 1. Denotes part-tim. 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. State Registered Nurse. 7. State Certified Midwife. 8. Royal Sanitary Institute Health Visitors' Certificate. J. W. Seager. 1 F. J. Ephgrave. 10 Borough of Bromley. Report of the Medical Officer of Health for the year 1937. To the Mayor, Aldermen and Councillors. Ma. Mayor, Madam and Gentlemen, The year upon which I am now submitting my report to you is to be particularly noted for its meteorological condition; a high rainfall followed by a comparatively dry season. It may seem strange that a statement of such a nature should be made in a Health Report, but the pioneers of Public Health laid great stress on this as a factor in the epidemic constitution. So the year 1937 adds some proof to their contention; we had the Croydon Epidemic of Typhoid; the wide-spread prevalence of Sonne's Bacillary Dysentery; an increase in Poliomyelitis and in the incidence of intestinal infections. The year too was noteworthy in that the Central Government gave prominence to Health as a policy of national importance, and sought to stimulate public interest by means of wide-spread propaganda in a " Fitter Britain " movement. The main item of advice to the public was to use the various clinics and services provided by the local authorities. The public in Bromley need no such encouragement, and I advised against propaganda in Bromley for the services are, in my view, sufficiently efficient to advertise themselves as is shown by the large attendances made at the centres and clinics. I have enough trust in public opinion to know that they would not use a service that was not of value to them. The year will be memorable too for the fact that the new Public Health Act, 1936, came into operation during 1937, re-placing our well-tried and trustworthy friend of 1875. Other Acts, such as the Factory Act, Shops (Sunday 11 Trading Restriction) Act, 1936, and new regulations and orders continue to flow from Parliament to the local government officer. We had too, placed upon us, without our seeking or advice, the responsibility of controlling casualties in Air Raid Precaution schemes — an entirely new and unwelcome service for local government officers. From the viewpoint of the local health services the year 1937 will remain noteworthy in that we began the Municipal Midwifery Service. This long existing gap in our services has now been filled, and in the years ahead I hope to be able to show that the safe-guarding of motherhood, and the prevention of stillbirths and premature births will result from the merging of this service into the general health services of the Borough. We failed, however, to obtain the sanction of the Ministry of Health to provide a doctor at the confinement, except in the case of an emergency when he would he called in by the midwife. It is hoped that legislation will eventually come so that we can incorporate into all maternity schemes a medical practitioner service for the confinement, apart from its emergency provision. In spite of all these new services, we have not left undone what might be called the fundamentals of a Public Health Service. Progress was made with the abolition of cesspools, and of 360 cesspools that existed in the Borough with the extension of our area to include Hayes and Keston, 109 now remain. Until the whole area is sewered and cesspools abolished we cannot be satisfied that the environment is a safe one. Gross overcrowding in houses is rapidly disappearing, but there has been a slowing up in the building of new houses. The results of our work are not always apparent, but that improvement in public health practice does occur can be demonstrated even in small matters. Some fourteen years ago I took steps to discourage the dip-can method of milk distribution, and to encourage the distribution of bottled pasteurised milk from the place of production. This method of distribution is now for all practical purposes universal in Bromley—this is progress, but not finality. The misuse of bottles by the public and the carelessness in collection by the distributors has led to a state of' affairs which is by no means satisfactory. The remedy 12 of this now appears to lie in the distribution of milk in cartons—a method possessing many obvious advantages to the dealers and consumers. A further needed improvement is the distribution of milk in vans with refrigeration equipment. The delivery of milk to the customer in the summer months in open vans leads to high temperature and earlier deterioration, a fact which would be overcome by milk distributors taking a lesson from the ice-cream vendors. Fortunately, in this country, the public demand is invariably satisfied, and it is hoped that in the next few years a public demand for vans so equipped will be met by the large milk distributing firms. Another improvement needed in the care of foodstuffs is a more widespread use of the household refrigerator which is very much neglected in this country. The mishandling of bread continues to be unhygienic. Not only is bread delivered in dust-collecting vans, but it is handled far too frequently by hands none too clean, before it reaches the consumer. I wonder how long this is to continue before the public demand reasonable care in the handling of a food liable to carry infection? Further legislation is necessary tor the prevention of soiling public foot-paths by dogs, and the all too prevalent habit of taking dogs into restaurants. Higher taxation I know would be unpopular, but unless dog owners exercise better control of their animals this taxation would appear to be one method of lessening the evil. The foregoing is merely a preamble, and a study of the Report as a whole will give the reader a better idea of the local activities that are contributing towards the ideal of a " Fitter Britain." A few vital statistics for the year under review will be of interest, the figures in parentheses being the corresponding rates for England and Wales:— Death Kate 9.9 (12.4) Birth Kate 13.2 (14.9) Infant Mortality Kate ... 47 (58) Maternal Mortality Hate ... 3.78 (3.11) Scarlet Fever ... ... 1.77 (2.33) Diphtheria 0.69 (1.49) 13 I would like to express to the various Committees of the Town Council my personal appreciation of the assistance they have been to me in my work, and to my colleagues for their helpful co-operation at all times. 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. 16 SECTION A.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA, 1937. Statistics. Area (in acres) 6,519 Population—Mid-year 1937 (Registrar General's estimate) 58,700 Number of inhabited houses— Census, 1931 10,764 End December, 1937 (Rate Books) 16,545 Rateable Value (31st March, 1938) £692,807 The sum represented by a Penny Rate (estimated for the Year ending 31/3/1939) £2,800 Vital Statistics. The following extracts from the statistics for the year relate to the net births and deaths after correction for inward and outward transfers, as furnished by the Registrar General:— Live Births. Total. Male. Female Legitimate 739 373 366 Birth Rate per 1,000 of the estimated population: 1.3.2 Illegitimate 39 14 25 778 387 391 Stillbirths. Legitimate 13 5 8 Bate per 1,000 total (live and still) births: 18.9 Illegitimate 2 2 — 15 7 8 Deaths 605 291 314 Death Rate per 1,000 of tlx estimated population : (as adjusted by Areal Comparability Factor 0.97) 9.9 17 Deaths from Puerperal Causes: No. of Deaths. Rate per 1,000 total (live and still) births: From sepsis 1 1.26 From other causes 2 2.52 Total 3 3.78 Death Kate of Infants under 1 year of age:— All infants per 1,000 live births 47. Legitimate infants per 1,000 legitimate live births 47. Illegitimate infants per 1,000 illegitimate live births 51. Deaths from cancer (all ages) 88 Deaths from measles (all ages) Nil. Deaths from whooping cough (all ages) 1 Deaths from diarrhoea (under 2 years of age) 7 Social Conditions. An anti-social feature from which Bromley is by no means exempt, is the number of houses, originally designed for occupation by a single family, that are, with little or no structural alteration, being occupied by two or more families. This sub-division of houses whether they be large or small in type is to be deprecated. Apart from being detrimental to the amenities of a residential town, there are distinct disadvantages from the health aspect, for these sub-divided dwellings usually lack separate sanitary, cooking and washing facilities. The practice of subletting six-room houses into so called flats is becoming too prevalent. It is a form of housing evil which can continue to exist without the knowledge of the local authority. The remedy would appear to be the institution of regulations which would require prior information to the authority when sub-division of a dwelling-house is proposed; appropriate supervision could then be exercised and so ensure that proper structural alterations were made to provide normal living requirements. The foregoing commentary is mainly a housing problem, but nevertheless it does affect the social conditions of a town. 18 The Borough Engineer reports that the number of houses for which plans have been approved during the year 1937 is 462 and all erected by private enterprise. This figure shows a considerable falling off compared with 741 for 1936. At the time of writing the Local Authority had completed negotiations for the acquisition of 103 acres of open space in the Bromley Common area. The Local Authority deserves congratulation on their enterprise in securing to posterity yet another precious tract of land as a health giving open space. Especially noteworthy is the disappearance during 1937 of the old unsightly refuse tip at Tylney Road, which had for years been a source of nuisance and annoyance to the neighbourhood, and one must pay tribute to those who have been responsible for its remarkable transformation into a delightful recreation ground comprising over three acres. With the acquisition of the old Rectory and grounds at Hayes, the town receives an additional two acres of pleasure ground, while two roods of land at Widmore House Gardens disappears to make room for the necessary extensions to the Municipal Offices. The following- table shows that 490 acres of land have been secured for public recreation within the Borough without taking- into account the 103 acres recently secured in reservation for the Bromley Common area. Acres. Roods. Poles. Acres. Roods. Poles. Commons and Open Spares: Elmstead Woods 61 1 36 Keston Common 55 1 24 Hayes Common (including Pickhunst Green) 213 1 32 Hill Crest 1 0 1 Hollydale 6 1 0 Husseywell Crescent 2 1 30 New Street Hill 11 2 8 South borough 6 0 0 The Knoll 4 1 39 Turpington 1 3 10 363 3 20 19 Acres. Roods. Poles. Acres. Roods. Poles. Public Recrcation Grounds : King's Meadow 9 1 0 Martin's Hill 11 0 5 Oakley Road 2 0 0 Queen's Mead 10 3 15 Tylnev Road 3 1 28 Whitehall 17 1 6 Norman Park (reserved) 56 0 0 109 3 14 Public Gardens and Grounds : Church House Grounds 10 3 10 Hayes (Old) Rectory 2 0 0 Library Gardens 1 2 0 Queen's Garden 2 1 4 16 2 14 490 1 8 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 1937:— total rainfall 30.80 inches. Mean maximum daily temperature 57.6 degrees F. Mean minimum daily temperature 43.9 degrees F. Highest maximum temperature recorded 87 degrees F. on 6th August. Lowest minimum temperature recorded 24 degrees F. on 20th December. Lowest grass minimum temperature recorded 21 degrees F. on 30th March. Unemployment. The Manager of the Employment Exchange has kindly furnished the following details:— 1. Recorded unemployment at the end of December, 1937:— (a) Men 817 (b) Women 94 911 20 This figure of 911 compares with a total of 502 at the same period of the year 1936. 2. Highest figure readied in 1937:— (a) Men 817 (On 20/12/1937) (b) Women 125 (On 8/11/1937) The Manager of the Exchange remarks: " There have been no marked features of unemployment in the area during 1937. The completion of many building estates has resulted in a smaller demand for building trade workers as regards men. In the women's department there has been little change in the composition of the live register. The increase is mainly due to the additional work-people moving to the new L.C.C. Estates outside the Borough boundary, but within the Employment Exchange area." 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. No special industrial undertakings have been introduced into the Borough since the Census of 1931, and it may be taken that the occupational characteristics of the town at the present time remain unchanged. Population. The following figures of population show the increase in population over a long period of time:— Year. Population. 1831 4,002 1901 27,354 1911 33,646 1921 35,052 1931 45,374 1936 57,850 1937 58,700 The Registrar General gives 58,700 as the estimated resident population of Bromley at the middle of the year 21 1937. This figure is accepted as the basic standard on which all vital statistical rates for the Borough are calculated for the year under review. The number of inhabited houses according to the rate books at the end of 1937 was 16,545, and by calculating on the-basis of 3.61 persons per house, which was the figure disclosed as a result of the Housing Survey in 1936, we get an approximate population figure of 59,727 at tlve end of 1937. VITAL STATISTICS. Births. The Birth Kate for 1937 is 13.2 per 1,000 population. During the year 836 births were -notified under the Notification of Births Act, 1907, and Section 203 of the Public Health Act, 1936. It may be noted in passing that the Notification of Births Act, 1907, was repealed as from 1st October, 1937, but its provisions are continued under the Public Health Act, 1936, Section 203. It has been found necessary to draw the attention of all concerned to the obligation of notifying births within 36 hours of occurrence, as there had been undue delay in notifying in 61 instances during 1937. None were flagrant breaches of the statutory requirements, but in practically every instance failure to notify promptly, appears to have arisen through the tendency of the doctor and maternity nurse to leave notification to each other. rhe figure of 836 notified births comprises 822 live births and 14 stillbirths, and of the total, 366 were notified by midwives and 470 by doctors and parents. Of the 822 live births occurring in Bromley 211 concerned residents outside the Bromley area. This figure was offset by the fact that another 225 babies of Bromley residents were born outside the area. 1 tie Registrar General gives the number of registered births in the area for the calendar year and modified by inward and outward residence transfers as 778 live births, 22 which together with 15 registered stillbirths gives a total of 793 live and still births registered in respect of Bromley for 1937. These figures are taken as the official bases for the purposes of calculating the vital rates. The following table gives a comparison of birth rates during the immediate past decennial period:— Year. Bromley. Birth Rates. England and Wales. 1928 15.9 16.7 1929 14.8 16.3 193U 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 1937 13.2 14.9 Stillbirths. The following tabulation gives the number of stillbirths occurring in Bromley, together with the rates per 1,000 births, during the past ten years:— Year. No. of Stillbirths. Rate per 1,000 Births. 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 1937 15 18.9 In all cases of stillbirths, enquiries are made into the probable cause, but these enquiries are of negligible value unless post-mortem examination of the stillbirth is made. It is part of this Maternity and Child Welfare Service to endeavour to prevent this high return which from the 23 above statistics does not indicate any progressive improvement. These deaths and premature birtli deaths require concerted preventive action if we are to reduce the rate in keeping with the reductions that have already been made in the infantile death rate. Of the stillbirths occurring in Bromley during 1937, there were nine hospital confinements, two in nursing homes and three at home. A doctor conducted the confinement in 12 cases. Deaths. The Death Bate for 1937 is 9.9 as adjusted by the comparability factor (0.97), or, as it is now styled, the Areal Comparability Factor (A.C.F.). This factor applies to the crude rate for " All Causes " only, and not to individual cause rates. In the following table the crude death rates for Bromley are set down in comparison with the death rates published for England and Wales during the past ten years:— Year. Bromley Crude Death Rates. England and Wales Death Rates. 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 1937 10.3 12.4 I'he uniformly low death rate certainly supports the truth of the claim that Bromley is a healthy locality, but, as I have pointed out in previous reports, age grouping and sex distribution of the population are important factors which should be taken into account when comparing death rates. These factors have not been taken into consideration in the above table. A higher death rate 24 prevails in the population of the higher age groups than in the population of middle or younger age groups, unless a severe form of epidemic disease lias caused exceptional mortality. Fortunately, we in Bromley, did not experience in 19-37 excessive mortality from disease in epidemic form. Table III in the Appendix is a reproduction of the short list of causes of death as classified by the Registrar General. It is to be noted that the main causes of death in Bromley during 1937 are attributed to: Heart Disease 170 and Cancer 88. 170 and Cancer 88. In the following table, which covers the past five years, it will be seen that these two diseases stand out as pre-eminent causes of death:— Rates per 1,000 population. 1933 1934 1935 1930 1937 Respiratory disease 0.9 0.8 0.6 1.02 0.6 Heart disease 3.2 2.8 3.2 2.9 2.9 Cancer 1.4 1.3 1.5 1.5 1.5 Tuberculosis 0.7 0.3 0.5 0.6 0.5 Premature births 0.2 0.3 0.2 0.3 0.3 Infectious disease 0.04 0.1 0.1 0.3 0.07 Influenza 0.3 0.1 0.2 0.1 0.4 Infantile Mortality. The Infantile Mortality Rate for 1937 is 47 per 1,000 live births. Tables II, IV, V and VI in the Appendix may be referred to for statistical details relative to infant mortality. The following graph of five-yearly rates illustrates the rapid fall in mortality rates. 25 26 The rise in the Infantile Mortality Rate in the fiveyears period 1916—1920 was due to the influenza epidemic of 1918. The reduction in the rate has occurred mainly in the age group over one week of age, whereas the rate of deaths in the newly-born remains constant, and there has been no reduction since 1910 when the keeping of detailed records was commenced. It is generally claimed that the Infantile Mortality Rate is the gauge by which the public health services of a locality may be measured. If we are to judge the effectiveness of our own efforts on this standard of measurement then we may safely claim that the test does credit to our services in Bromley. The lowest Infantile Mortality Rate ever recorded in Bromley was in 193.5 when it fell to 27. I reported then that the rate was an abnormally low one and could not continue on that low level. A rise duly occurred in 1936 and again in 1937. The rise in 1937 was due to the increase in the deaths of young infants from intestinal infection, co-inciding with the epidemic of dysentery in the latter half of the year. Maternal Mortality. Quinquennial periods : Sepsis. Accidents of pregnancy, etc. Rate per 1,000 births 1911-1915 4 5 2 1916-1920 9 9 6 1921-1925 6 7 4 1926-1930 4 6 3 1931-1935 6 9 4 Biennial: 1936 & 1937 ... 2 ... 4 ... 4 Tables II, III and VI in the Appendix will be found to contain statistical data regarding maternal mortality. Whilst no immediate reduction in the rate may be expected as a result of the new Maternity Service, it is hoped that when the service has been functioning over a few years that a reduction will occur not only in maternal deaths, but also in the deaths allied to maternity such as stillbirths and neo-natal deaths of infants, SECTION B (I). General Provision of Health Services for the Area. 28 SECTION B (I).—GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Laboratory Facilities. The testing of throat swabs in urgent cases is undertaken by the West Kent Isolation Hospital, and the arrangements continue to function satisfactorily. For the examination of clinical material (sputum, swabs, etc.), water, milk and foodstuffs, the Kent County Council maintains an efficient service at the County Laboratory at Maidstone. Ambulance Facilities. (1) For Infectious Diseases Cases: Provided by the est Kent Joint Hospital Board at their Hospital at Leonard 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. An ambulance may not in any case be used for removal to a place more than 25 miles (by road) from the Fire Station. There are reciprocal arrangements with the Beckenhani and Penge Local Authorities for the use of their ambulances in the event of both our ambulances being in use. The fee for the use of the ambulance may be reduced or remitted entirely in necessitous cases. Nursing in the Home. (1) The Bromley District Nursing Association was formed in 1907 with the objects of providing skilled general nursing for the sick poor in their ow n homes and for those who cannot provide it for themselves, and skilled maternity nursing and midwifery at a small cost. Since the 1st November, 1937, the Association ceased to carry out maternity and midwifery work, and their staff of three midwives were taken over by the Local Authority under the Municipal Midwifery Service which was instituted by virtue of the provisions of the Midwives Act, 1936. 29 The following is a summary of the work carried out during the year 1937 :— Cases on the Register, January, 1937 26 New cases during the year 443 Visits Paid. General nursing 4862 Ante-natal visits to October 31st 1183 Maternity and Midwifery to October 31st 3276 Casual 714 10035 Analysis of New Cases. Medical 142 Surgical 122 Maternity (with Doctor) to October 31st 42 Midwifery to October 31st 136 Abortion 1 443 Cases sent by: Doctors 192 Visitors and others 31 Applied 220 443 Result of Cases Nursed. Convalescent 354 Sent to Hospital or transferred 28 Died (general cases) 45 Still on Register 16 443 (2) The Hayes and West Wickham Nursing Association. This body provides nursing facilities for the areas of Hayes and Keston. Their sphere of activity also .30 covers West Wickham, which is within the area of the Borough of Beckenham. The midwifery and maternity work hitherto carried on by this association was taken over by the Municipal Midwifery Service of the Local Authority as from the 1st November, 1937. Details of Nursing Visits for the year ended 31st March, 19.38. General Nursing 2884 Midwifery 982 Ante-natal 288 Casual 267 Dental 71 4492 31 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) Mornings (daily) M or Ailment Treatment Mornings (daily) Mornings (daily) Ear, Nose and Throat Clinic (Operations and Consultations) Wednesdays (a.m.) Dental Clinic Mornings and afternoons Two sessions per week (On Wednesday and /or Friday) rvye.wdcvn Eye Clinic Wednesdays (a.m.) (Also Fridays (p.m.) as required). ~ Orthoptic Clinic Tuesday;- (p.m.) and Fridays (a.m.) Orthopedic Clinic Surgeon attends 1st Monday and 3rd Tuesday (monthly) Message and Remedial Exercises Mondays (a.m.) Tuesdays (all day) Thursdays (p.m.) Fridays (p.m.) Ultra Violet Ray Clinic Tuesdays and Fridays (P >"■) Mondays and Thursdays (p.m.) Diphtheria Immunisation Mondays (p.m.) Thursdays and Fridays (a.m.) Dental Treatment for Nursing and expectant Mothers Saturdays (a.m.) — 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 and Thursdays, at 2 30 p.m. PIistow School Clinic, Station Road, Bromley North 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, Bromley North 1st, 2nd, 3rd (and 5th if occurring) Thursday of the month do. School Clinic, Princes Plain 4th Thursday of the month Specialist Clinic, AnteNatal School Clinic, Station Road, Bromley North Held once in two months (usually on 2nd Thursday) .32 Tuberculosis Dispensary. The Tuberculosis Dispensary is provided by the Kent County Council, and is held at 2, Park Road, Bromley, on Wednesdays, 1.30 to 3.30 p.m., and Fridays, 5—6 p.m. The Tuberculosis Officer in charge is Dr. B. G. A. Edelston. The arrangement with the Corporation of Bromley to provide the services of a Nurse from the Health Visiting Staff for the Wednesday Clinic was discontinued by the Kent County Council as from 1st December, 1937, consequent on their appointing a fulltime Tuberculosis Nurse. The Health Visitor in attending the Dispensary formed an admirable link between the services of the two authorities, and thus preserved that element of co-ordinated effort so desirable in the public services. Venereal Diseases Treatment Centres. The Kent County Council provides treatment at the various centres in the County. There is no centre in Bromley, but if needs be the close proximity of London affords ample and convenient facilities through the various large general hospitals. Hospitals. Public and Voluntary. (1) Infectious Diseases Hospitals: West Kent Isolation Hospital—I have not been advised of any change in the accommodation at this Hospital, particulars of which were furnished in my previous report (1936), page 29. West Kent Smallpox Hospital—The foregoing: remarks similary apply in this case. (2) General Hospitals: Bromley (Kent and District Hospital 103 beds. Phillips Memorial (Homeopathic) Hospital 20 beds. (3) Maternity Hospital: The Bromley and Chislehurst Maternity Hospital (Voluntary) 19 beds. (In addition there are 2 labour wards and 1 isolation ward). 33 Public Health Act, 1936, Sec. 187/195. Nursing Homes. The Nursing Homes Registration Act, 1927, has been repealed, hut its provisions have been incorporated in the above-mentioned Act. As before, the County Council is the Local Authority concerned, but the delegated powers exercised by this Local Authority have been continued. Two nursing homes have been deleted from the register, consequent on their voluntarily closing down; one closed during 1937, and the other in the early part of 1938. Each registered nursing home comes under routine inspection quarterly by the Assistant Medical Officer of Health. It is satisfactory to record that those responsible for these nursing homes are alive to their responsibilities under the law, and exhibit a readiness at all times to co-operate in maintaining satisfactory conditions in their nursing homes. No serious breach of the regulations has been reported in the area since the inception of the legislation controlling these institutions. The following tabulation gives particulars of maternity and nursing homes registered by the Local Authority as at the 31st December, 1937, and for convenience of recording I have included details of the larger hospitals which are exempt from registration under the provisions of the Act. 34 Address. Total No of Beds. Vlaternty Beds Patients received 1937. Nursing Staff. Type of case taken Maternity- Surgical Medical Total. Resident Living Out. Qualifications. 77, Avondale Road 6 2 20 22 26 4 1 3 1 Gen. Trainedand S.C.M. 3 Gen. Trained. Mixed 89, Bromley Common 10 4 37 60 15 5 5 — 2 Gen.TrainedandS.C.M. 1 S.C.M 2 Assistants. Mixed "Greta," Blytli Road 10 — — 98 50 5 3 2 1 Gen. Trained and S.C.M. 3 Gen. Trained. 1 Assistant. Nursing 24, Elmfield Road 10 2 15 — 7 4 4 — 1 Gen. Trained 3 Assistants. Mixed 29, King's Avenue 2 — — 1 2 2 — 1 Gen. Trained. 1 Masseuse. Nursing "Frascati," Masons Hill 19 6 60 27 45 10 10 — 3 Gen. Trained and S.C.M. 1 Gen. Trained. 2 S.C.M. 4 Asst. Nurses. Mixed 16, Sundridge Avenue 4 — — — 17 — — (Home under supervision of Resident Medical practitioner). Nursing 13, Tweedy Road 5 — No ret urns re ceived 1 Gen. Trained. Nursing Maternity Hospital, 118, Widmore Road 19 19 371 — — 11 11 — 5 Gen.TrainedandS.C.M. 2 S.C.M. 4 Asst. Nurses. Maternity Bromley (Kent) and District Hospital, Cromwell Avenue 103 — — 899 569 45 45 — 14Gen.TrainedandS C M. 1 Gen. Trained. 30 Untrained. General Hospital cases Phillips Memorial Hospital, 20 — 1 148 64 7 7 — 2 Gen.TrainedandS.C.M. 3 Asst. Nurses. Probationers. General Hospital 35 Other Institutions. (1) The Rochester Diocesan Society for Befriending Women and Girls lias 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 County Hospital, Farnborougli, which is a 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, was opened in September, 1933, by the Bromley National Council of Women, for women and girls. The Hostel is maintained by voluntary subscriptions, and receives no subsidy from public funds. " The fact that the beds have been occupied 1,697 times by 183 residents during the past twelve months proves the need of such an institution." SECTION B (II). Maternity and Child Welfare. 38 SECTION B (II).—MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare services comprise the following;— (1) Maternity and Child Welfare. (a) Six full-time Health Visitors are employed on School Medical Service duties and Maternity and Child Welfare Service duties; tlieir time being equally divided between the two services. They attend the centres and carry out the teaching of mothercraft in the homes. (b) Nine welfare sessions are held weekly, with a doctor in attendance. (c) Free milk for necessitous cases. (d) Home visiting of boarded-out children under the Public Health Act, 1930, Child Life Protection. (2) Municipal Midwifery Service. (a) Four midwives are employed full-time to attend confinements in the home, with or without a doctor. (b) Home helps are provided during the lying-in period. (c) Domiciliary attendance by doctors for ante-natal and post-natal supervision. (d) Ante-natal Clinics are held four times monthly with doctor, midwife and health visitor in attendance. (e) Consultant Gynaecologist holds an Ante-Natal Clinic bi-monthly, and is available for emergency general obstetric work. (f) Dental treatment for expectant and nursing mothers. (g) Maternity Hospital provision for necessitous cases. (h) Consultant Pathologist whose services became available in 1936. (i) Hospital treatment, isolation and Consultant Gynaecologist for Puerperal Fever and Pyrexia. (3) Midwives Acts, 1902-1930, Administration of. 39 (4) Public Health Act, 1930, Nuhsing Homes, Administration of. (5) Treatment Schemes and Clinics for Children under 5 years. (a) Consultant Surgeon and Orthopaedic Treatment for the crippled child. (b) Minor Ailment Treatment at the School Clinics. (c) Ear, Nose and Throat Consultant and Surgeon. Operative treatment at the School Clinic. (d) Ophthalmologist for defective vision cases. (e) Dental Treatment. (f) Provision of hospital treatment for cases of Ophthalmia Neonatorum and for acute cases of measles. (g) Diphtheria Immunisation. (h) Fltra Violet Ray Clinics. Full details of Clinics and Welfare Centres appear under the heading Treatment Centres and Clinics. Ante-Natal Clinics. The following table indicates in quinquennial periods, 1926-1935, together with the past two years separately, the progress of work carried out at the Ante-Natal Clinics:— Quinquennial periods. Individual Attendances. Total Attendances. Medical Consultations. Clinic Sessions held. 1926-1930 558 885 883 108 1931-1935 661 1099 1080 142 1936 193 272 266 38 1937 224 348 345 42 An Ante-natal Clinic is held weekly with the Assistant Medical Officer of Health, Dr. G. H. Stinson, in attendance, and once in two months the Consultant gynaecologist attends a special clinic to advise on cases specially referred by general practitioners, or by the Department. A comprehensive midwifery service, ineluding the general practitioner and the Consultant 40 Obstetrician, as envisaged in the Midwives Act, 1936, is now in actual operation in Bromley. The constant stress that I have in the past made upon the vital need of regular and efficient ante-natal examination, as an all important factor in the campaign to reduce maternal mortality, maternal morbidity, stillbirths and premature births, is now functioning in full. Natal Services. Domiciliary Midwifery Service. The Municipal Midwifery Service began to operate on 1st November, 1937, after considerable delay caused by the appeal of the District Nursing Association. The service provides in addition to four full-time midwives, a home help service, and a general practitioner service for ante-natal and post-natal examinations. I hope in my next Annual Report to be able to submit a more detailed report under this heading. To the 31st December, 1937, 138 cases were booked in connection with the Municipal Midwifery Service, and the midwives attended 50 confinements. The number of antenatal visits paid by the four midwives was 344, and tiie number of post-natal visits paid during the same period was 751. From the 1st November to 31st December, 1937, there were 71 notified cases of births where the confinements were at home, and as 50 of these were in connection with the Service, the percentage is 70 per cent. During the same period there were 77 births in nursing homes in this Borough (58 being in the Maternity Hospital), of which 20 had home addresses out of the area. Of the 138 cases hooked up to the end of the year, 30 of them required the service of a home help. This, however, is not a fair proportion as many of the cases were handed over by the District Nursing Association, and a number of the cases were completed before the service was actually running smoothly. The cost of each case to the Borough, based on 60 patients per midwife per year and the services of doctor 41 and home help, is £5 His. 8d., which is made up as follows:— £ s. d. Midwife 3 16 8 Doctor 10 0 Home Help 1 10 0 The fees are recovered from the patient according to income, and it may he said that the average fee recoverable for the full service is approximately £2 18s. Od. The service has the complete co-operation of the Bromley and district general practitioners. It is difficult to judge a service which has been in existence only for two months; the figures show the necessity for such a service. It can be said, however, that with the co-operation of all parties responsible for the service, it is hoped to reduce considerably the incidence of maternal deaths and deaths of the newly born. Midwives. (i) The number of midwives practising in the area of the Local Supervising Authority at the 31st December, 1937 22 (a) Employed by the Local vising Authority 4 (b) Employed by Voluntary bodies 12 (c) In private practice 6 (ii) Number of cases attended by midwives 836 (a) As midwives 348 (b) As Maternity Nurses 488 (iii) Number of cases in which medical aid was summoned bv a midwife under Sec. 14 (1) of the Midwives Act, 1918 86 (a) Engaged in domiciliary practice 40 (b) In institutional practice 46 (iv) Number of domiciliary births during the year in the area of the Local Supervising Authority 316 Administration of the Midwives Acts, 1902-1936. No. of midwives practising in Bromley at the end of the year 1936 23 42 No. of midwives giving- notice of intention to practice during the year 1937 32 No. of midwives removed from the local register having left the district during 1937 9 Cancellation of certificate under Sec. 5 of the Midwives Act, 1936, on compensation by the Local Authority for surrendered certificate 1 No. of midwives registered by the Local Supervising Authority as practising in the area at the end of the year 1937 22 Notifications received. Notices summoning medical aid 86 (i) Mothers 68 (ii) Infants 18 Notices of Artificial Feeding 2 Stillbirths 3 Deaths 1 Laying out a Dead Body 1 Source of Infection 11 Summary of Reasons for sending for Medical Aid. Ruptured perineum 23 Delayed labour 12 Varicose veins and leg swellings 7 Inertia 3 Placenta, adherent 1 Abnormal presentation 3 Haemorrhage 5 Rise of temperature (puerperal pyrexia) 9 Other causes 5 Infants—Feeble, premature, etc. 11 Cyanosis 1 Eye discharge 4 Malformation 2 Total 86 Inspection of Midwives. Midwives in practice are periodically inspected at their work and at their homes. This not only applies to the midwives on our own staff who now-work as members 43 of the Department, but also to those midwives in independent practice. Dr. Gertrude 11. Stinson, Assistant Medical Officer of Health, reports:— "The Municipal Midwifery Service was launched in November, 1937, when the midwives came into the service of the Town Council. We have four midwives each doing excellent work; two for the Bromley Common area; one for Hayes and Shortlands areas, and one for Plaistow and Burnt Ash areas. The response on the district has been good. The number of cases booked has quite come up to expectations, and the midwives are kept busy, but not yet overworked. Their work is good, and their services appear to be greatly appreciated. They have settled down to their new regulations very willingly and happily, and realise that they are a valuable and necessary part of the Borough's Health Services. They are well equipped, and their equipment is kept in good order. Their uniforms, both indoor arid outdoor, are professional and suitable. The sterilising of all necessary equipment such as gowns, masks, gloves, towels, etc., is done at the School Clinic, and as each batch is used and re-laundered the container is repacked and brought to be sterilised again ready for use. The midwives are inspected frequently, and I think they welcome,an inspection as it gives them an opportunity to discuss any problem or matter arising in their work. As the Borough now has its own midwifery service there is very little to report, since the work done by the independent midwives is now almost negligible. The midwives are inspected both at work and in their homes; their books, charts and bags are seen, and these are invariably found to be kept up to date and in good order. There has not been any breach of rules, and everything has been found to be quite satisfactory." Poxt-Cfrtificd tc Course. Arrangements were made for midwives to attend the Course of Post-Certificate Training at Maidstone during 44 October, 1937. Facilities to attend were granted by the Local Supervising Authority, and 14 midwives attended the Course. Institutional Provision for Mothers and Children. Infants. So far as the child is concerned there are no special institutional services. Acute cases are of course referred to hospitals, either in Bromley or in London, and certain young children needing change of environment by means of convalescent treatment are referred to the Queen's Reign Commemoration Fund for convalescent home treatment. We certainly lack in Bromley adequate provision tor the treatment and observation of the young baby, as for example, the baby who requires corrective feeding and who cannot be adequately supervised at home. The provision of an open-air ward for a limited number of these cases would overcome many of our difficulties. Maternity Hospital. The Bromley and Chislehurst Maternity Hospital has 19 beds and during 1937 accepted '171 cases. The agreement between this hospital and the Local Authority is for the reservation of four beds for the patient who cannot with safety be confined at home. Some of the cases referred to the Maternity Hospital by us are financially assisted, ten such cases received financial aid during 1937. The present day tendency for patients to seek hospital accommodation for normal confinement is, in my view, not entirely satisfactory, as many of them could have their confinements at home without risk. Hospitals should be restricted for tlie use of abnormal cases, but there is a growing tendency to depart from this principle. There is without doubt always the possible danger of a puerperal infected patient affecting other patients, a fact that would not be so frequent in cases confined at home. It is for this reason that domiciliary midwifery is to be encouraged for the normal patient, provided that facilities exist for hospital treatment in emergency, or for the early admission of patients who show signs of abnormality in the antenatal period. This danger of puerperal infection passing 45 from one patient to another occurred in the Maternity Hospital early in 1937, when one patient infected six others in the same ward. Other maternity bed accommodation is provided at the County Hospital, Farnborough, and at the various nursinghomes in Bromley as indicated on page 34. The London Hospitals also extend their facilities to Bromley patients. Puerperal Fever, Isolation and Treatment. A standing arrangement with Queen Charlotte's Maternity Hospital, Isolation Block, Havenscourt Square, Hammersmith, exists whereby this Hospital accepts from us all puerperal fever cases requiring treatment or investigation. Ambulance facilities exist, through the Ambulance Service of the London County Council, for the removal of our cases, and seven cases were transferred to Queen Charlotte's Hospital for treatment in their Isolation Section, during the year 1937. The consultant services of the Gynaecological Specialist are available in cases of doubt, or where the cause of pyrexia is not of a minor character. During 1937 his services were required on two occasions. Maternity and Nursing Homes. Details of these institutions appear in the tabulation on page 34. These homes are periodically inspected by the Assistant Medical Officer of Health, and a report on the administration of nursing homes appears under the paragraph Public Health Act, 1936, Sec. 187/19.5, Nursing Homes. Post-Natal Services. Health Visitors—Home Visiting. This year 1 am submitting the following personal reports of the Health Visitors on their work of health visiting. I have taken Miss E. B. Crowe's report on Burnt Ash, Miss E. Connor's report on Bromley Common, and Miss E. Rhodes' report on Hayes and Keston. These 46 reports give an indication of the difficulties encountered and the general effect of health visiting of the child under 5 years of age. I have excluded from their reports matters other than health visiting under the Maternity and Child Welfare Service. Burnt Ash Area. Miss Crowe reports: "In the last few years, with the building of so many houses for sale, the character of the Burnt Ash area has altered. Half the population being now young people buying their own houses and starting families; the other half being "London" mothers with children at school, and perhaps one or two under school age. There are two distinct types to visit; on the one hand we have the young, hopeful, enthusiastic mother starting life and bringing up her babies, asking for and appreciating detailed advice, instruction, and an explanation of the health services of the Borough to which she has just come. On the other hand there is the older, but by no means wiser mother, tired out after bringing up a large family accompanied by a struggle to make ends meet. The latter type needs cheerful visiting, encouragement, simple advice, which she has the means to carry out, and very often extra nourishment. It is a very rare occurrence to experience an ineffectual visit and most of them coming under this category are really " out." At the moment there are five ineffectual visiting homes; one dirty and slummy—the mother does not believe in welfare or visits; two homes have their own doctor following-up the babies; one, a Midland's mother, suspicious of "nosey-parkers," and lastly a superior mother who "keeps herself to herself." Each new baby is visited at the fourteenth day, or a' soon as possible afterwards, until the mother and baby are satisfactory or are attending the welfare centre; the records of the case in card form are kept in the Health Visitors wallet and re-visited. After the primary visits it takes from eighteen months to two years to revisit the whole area, 47 There are in this area approximately (100) babies under school age; 1,200 school children, and about 30 tuberculosis cases. During the year the following defects in toddlers were discovered when home visiting: Strabismus, 2; Teeth needing attention, 22; Knock knee, 10; Outward curvature tibia, 2; Pigeon toed, 1; Enlarged Tonsils, 2; Adenoids, 1; Skin diseases, 12; and other conditions, 25. The printed list of defects on the visiting record card is a definite help when visiting toddlers. The welfare centres are attended by the young mother anxious to have their babies weighed, see the doctor and learn all they can, but attendance by the older mother is, I am sorry to say, more often when they want something, and a good less often I fear when they do not want anything. The numbers attending the welfare centre should he better than they are, having regard to the size of the area and the number of babies. Six nursing mothers were referred to the School Dentist during the year. The machinery for obtaining dentures for the mothers is still very cumbersome. The foster mothers in the area are most satisfactory, largely due to the fact that, they are each allowed to take only one child, thus discouraging money making foster mothers. The childless couple frequently seeks the Health Visitor's advice with regard to the adoption of a child, and is advised to take the child as 'boarded out' before finally leciding on adoption. Thus it is possible to ascertain if a child will be acceptable in the family circle. This method is proving successful. Children received from institutions and boarded out with foster parents invariably show marked improvement after a few months of home life, and this is plainly demonstrated if' one sees a child on arrival at its new home and again a few months later. There were six infant deaths in my visiting area as follows: (a) Under one week of age, had double hare lip and cleft palate; (b) Under one week of age, had cerebral haemorrhage; (c) Under two weeks of age, had bronchopneumonia; (d) Eleven months of age, had pyelitis; (e) Nine months of age, had broncho pneumonia; and (f) Two 48 and a half years of age, asphyxiation, swallowed raw meat two inches long. Although propaganda has been disseminated for years with regard to diphtheria immunisation, there are still families who have been missed and say they have never heard of it. In this area in 1937 there were five cases of diphtheria, and one child of seven years died. In the last eight years, four apparently healthy children, ages: 11, 8, 11 and 7 years, have died in this area—all preventable deaths. Seventy visits to tubercular patients were paid last year and were appreciated. It is most regrettable, and certainly not progressive, to separate the home visits to the tuberculosis case from the visits to the mother, baby and school child. A good health visitor is taught to enter a house when asked in, and to deal with everyone in that house from a public health point of view. The recent decision of the County Council to appoint their own Dispensary Nurse has, with regard to the visitation of tuberculosis cases, had the effect of disturbing the co-ordination scheme of the Medical Officer of Health which provided that one health visitor should enter the house and deal with everyone and be a friend of the family. At the present time this area does not appear to have a tuberculosis visitor, and, therefore, cases both old and new continue to come to the health visitor for advice and information. Six talks were given on the new Municipal Midwifery Service to women's organisations; great interest was shown at all the meetings, and open discussions were held. There are now six home helps in Downham, all have been visited and recommended by the Health Visitor. Of overcrowding there is little or none—no family in one room and very few in two rooms. Most of the population is living in 5, 4 and 3 room houses, possessing adequate lavatory, bathroom and pantry accommodation, and also small garden. The area is an interesting one to work in ; there is so much to be done; the people are lively and appreciative: the district is healthy, and the housing good," 49 Bromley Common Area. Miss Connor reports: "On the whole Area 5 is very responsive to health visiting. I cannot recall one instance where I was refused admittance. The "door-step" visit is fast disappearing, and even where the reception is not brimming with welcome, one can usually get over the doorstep in the end. Though this is very gratifying and makes the day's work much easier for the health visitor, there are many difficulties to confront one, which retard progress very much. To fully explain these I shall divide my district into three groups or classes. (i) The Poorer Classes.—Here the mother often goes out to work—the baby is left either with the grandmother, who can give no useful information about the baby and who generally is not interested in what one has to say, or the child is left with a friend or neighbour, and it is difficult to trace. In this home one gets repeated ineffective visits. The only time to find the mother in is at the midday meal, when she is busy preparing the meal for the children at school, or feeding the baby. I fear this is a very serious problem in my area because of the existence of laundries. These afford a constant source of employmeat which mothers think can easily be done as well as running a home. Quite a number too, during the season, work on the land, while a considerable number do daily cleaning. In this type of home one usually sees the mother at the primary visit and after that contact is lost. It is obvious that the upbringing of her children is not her primary consideration, nor does instruction interest her very much at any time. The only solution to the problem would be to make it an offence to employ women with children under one year of age. I find the other type of poor—those who do not work either in their own homes or for wages—usually dull, lazy and slovenly in habits. They seem not to be able to make ends meet on the small wage of the husband, and they lose heart. H ere one can at least keep in touch with the mother, but one must be satisfied with a very low standard. If one assumes a critical attitude then admission is refused. I11 fact shutting one's eyes to a lot and finding something 50 which deserves praise often seems to get the best, results. Strangely enough the children seem to thrive in the morbid environment. (ii) Better Working Classes.—Here visiting presents few difficulties with the exception of a few " cranks." The standard of mothercraft is good with both parents anxious to gain knowledge—the upbringing of children is their chief aim in life. It is from this section of the community that we fill our welfare centres. On visiting one is greeted with intelligent questions, not only concerning: babycraft, but the Health Visitor's opinion on radio talks, air raid precautions, suitable schools, suitable treatment in certain behaviour, holiday equipment for the baby, at what age can he go to the sea, etc. These visits are very tiring, but most satisfying. (iii). The Middle Classes.—There is in this class a lack of helpful co-operation between the practitioner and the health visitor. In the morning, if this type of mother has a maid, she is out shopping. If not, she is doing the housework, and has but little time for interview with the health visitor. Apart, however, from the primary visit when the services are explained, the visiting of such cases is not a matter of great worry. I am glad to state that, during the year, I have had several requests for visits, and I am trying very hard on my district to encourage this practice as I think it is a step in the right direction. It ensures: (1) Visiting at the right moment. (2) Finding the mother in. (3) It gives the mother the confidence that there is a person available who will give advice whenever necessary. Unless the health visitor has the full co-operation of the parent it is extremely difficult for her to examine the child in its own home. During half the year at least the health visitor has to work in wet and cold weather. Suitably clad this does not affect the health visitor to any great extent, but it does affect the home where she visits. It does not require a vivid imagination to picture a health visitor after, say, fifteen minutes in pouring rain either on bicycle or waiting for a bus with a further journey on foot, and on appearing 51 thus she is unwelcome when she visits children after an operation, or babies fourteen days old. One cannot avoid all visiting on wet days, there are some visits which must be done whatever the state of the weather, and these are usually the kind which requires a health visitor to be at her best. I cannot fail to think that in many homes we are very unwelcome visitors on wet days, and, for my own part, I never go in on those days as I feel that the harm I should do would far exceed the good derived from my advice." Hayes and Keston Area. Miss Rhodes reports: My visiting area comprises Hayes and Keston. Hayes is a typical instance of a housing estate imposed upon an existing village. This leads to two different types of visiting, one to the older resident who in the main is content to live as his forebears lived, and the other, to the new resident building up a new home, and in the process anxious to receive all possible help and instruction. Many of the latter being new to their environment seek contact with their neighbours through the welfare centre and through the health visitor, so that their response to visiting has been an exceedingly pleasing me and their attendance at the welfare centres regular. One finds them versed in babycraft gained from the reading of many periodicals and papers, but their knowledge befogged by excessive paper advice, and it is to these cases that I find my visiting of value and appreciated. Keston is somewhat different, for here we have quite a number of non-visiting homes, some middle class, and some rather poor, but on the whole the area responds well to visiting. Good attendances are made at the centres in spite of the distance for most of the mothers. find many of the old fashioned type among the poorer class, who believe that because they themselves had, for example, bow legs when young, the child must of necessity be the same, but "will grow out of it." I find in visiting the better class homes that they are very grateful for visits, and seek the advice we are able to give, once they realise that the visit is in no way an inquisitorial one. 52 The most "difficult" is that to the mother who already has a grown-up family, and believes that she knows all that can he known about babies, is not receptive to new ideas and knowledge, and who persists in wrong feeding of the baby who to all outward appearance requires corrective diet. This is often the "grandmother" type, who is so full of advice to the young married mother that she cannot resist giving this unwanted advice." Welfare Centres. Nine centres are held weekly, and the following statistics give an indication of the extent of the work carried out at the welfare centres. They are provided and controlled by the Local Authority, and are staffed by the Health Visitors who are assisted by Voluntary Workers whose work is quite invaluable and about which I cannot give too high praise. Table XIII. in the Appendix gives statistical details of the work of the centres. The following extracts of figures relate to work at the centres during 1937:— (a) Total number of attendances at all centres during 1937 22,486 (i) By children under 1 year of age 9,732 (ii) By children between the ages of 1 and 5 12,754 (b) Total number of children who attended at the centres for the first time during 1937 620 (i) Children under 1 year of age 463 (ii) Children between the ages of and 5 157 (c) Total number of children who were in attendance at the centres at the end of the year 1937 2,306 (i) Children under 1 year of age 356 (ii) Children between the ages of 1 and 5 years 1950 53 Milk in Necessitous Cases. 158 applicants were "ranted one pint of milk (pasteurised) per day for varying periods during 1937. The total quantity supplied was 1,(527 gallons, and a small quantity of dried milk in lieu of liquid milk was granted to the extent of 31 lbs. Milk is granted on medical grounds, and only to those cases whose family income does not exceed the following scale: Father and Mother £2., for the 1st child, 5/-., and for any subsequent child, 2/6. Clinic Treatments of Children under 5 Years, and Mothers. For some years past the services provided through the School Medical Service have been available to children under 5 years of age. The special clinics and the services of the specialists are available to the Maternity and Child Welfare Services and their use is encouraged so that maladjustments are treated early and corrected before the child reaches school age. (a) Children under 5 years:— No. of cases treated. Tonsil and Adenoid Clinic 19 Eye Clinic 59 Dental Clinic 120 Minor Ailments Clinic 178 Orthopaedic Clinic— At the Special Clinic 53 Hospital—inpatient treatment 2 (b) Mothers:— Dental Clinic 55 Maternity— Assisted Hospital Scheme 10 Other hospitals, referred cases 26 Public Health (Ophthalmia Neonatorum) Regulations, 1926. It is usual under this heading of the report to give a special account of the working of these Regulations. Notification is forthcoming in most cases of discharging of the young baby, but in many minor cases there 54 is failure to notify. These latter cases are, as a rule, of a temporary character, hut the line of demarcation between the mild case and the early acute case of ophthalmia is so ill-defined that every case requires notification if proper supervision and prevention is to he exercised. Three cases were notified under the Regulations in 1937, and in all cases treatment was carried out in the homes of the patients with satisfactory terminations. Epidemic Diarrhoea. At the end of the year an epidemic of Sonne's Bacillus Dysentery was widespread, not only in Bromley, but also over the whole country. This disease affected even breast fed babies, and was the cause of an increased death rate of epidemic diarrhoea, and was also the main cause of the increase in our Infantile Mortality Rate for 1937. There were seven deaths of infants from this cause—a cause of deaths which had been absent in Bromley for many years. Every effort was made to trace the origin of this bacillus not only by myself, but by most medical officers of health throughout the country. All efforts produced negative results. There appeared to be no common source of infection, and, as in the case of influenza, the spread was mainly due to infection from already infected persons. This does not, however, satisfactorily explain the disease in breast fed babies being the only case in the family, or friends of that family. At one stage I suspected tomato juice, often given to babies as an antiscorbutic. As most of the tomatoes at that time were imported from Teneriffe, they appeared to he a possible source of' infection, but further investigation proved negative. Although this disease in adults does not lead to fatal results, in the case of young infants the lowering of resistance by an acute attack gives rise frequently to superimposed diseases terminating in death. Public Health Act, 1936. Child Life Protection. The principle laid down in Bromley that only one foster child be allowed to one foster parent works well and 55 prevents much abuse which might otherwise arise if this restriction were not imposed. This rule is varied in the case of related children from one family. The class of foster parents is an excellent one, and all children boarded-out make satisfactory progress under their good management. There are in Bromley 45 foster-parents and 56 foster children, of whom 14 are hoarders under nine years of age in private hoarding schools. No statutory action was needed for any offence under the Act; minor irregularities of delay in notification were readily corrected. The Health Visitors are all Child Protection Visitors, who make periodic visits to the homes of these children. Child Life Protection now falls under Sections 200 to 220 of the new Public Health Act of 1930. SECTION C. Sanitary Circumstances of the Area. 58 SECTION C.—SANITARY CIRCUMSTANCES OF THE AREA. Water. There is nothing to add to the particulars of public water supply as given on page 43 of my Annual Report for 1935. The following details have been extracted from the Metropolitan Water Board's Report for 1936, showing results of bacteriological and chemical examinations of deep well water, being averages for twelve months ended 31st December, 1936:— Shortlands Wells. Bacteriological Examinations— No. of samples 31 Average No. of microbes per ml. 0.02 B. Coli test 100 per cent. negative in 100 nil. Chemical Examinations— Averages for 12 months ended 31st December, 1936 : Shortlands. No. 1. No. 2. No. 3. No. of samples 3 2 2 Ammoniacal Nitrogen 0.0005 0.0005 0.0006 Albuminoid Nitrogen 0.0019 0.0017 0.0021 Oxidised Nitrogen 0.44 0.41 0.53 Chlorides expressed as Chlorine 1.79 1.79 1.79 Oxygen absorbed in 3 hours 0.006 0.006 0.001 Total Hardness 26.5 26.3 26.0 Permanent Hardness 6.5 6.2 6.5 The analyses show that the steps taken by the Metropolitan Water Board to safeguard and provide a pure water supply are effective, and that water taken direct from the main is safe to drink. In actual practice the public not infrequently take water direct from the household cistern which for many reasons cannot be guaranteed a safe water to drink without being previously boiled. This is especially true in times of typhoid epidemic. The same can be said of water that passes through water softeners, and a case in point occurred during the year in 59 Bromley An epidemic of Sonne's Bacillus Dysentery broke out in a residential hotel. Water was taken for analysis from the main tap and from the cisterns. The main tap supply showed impurity and the cistern greater impurity. In the investigation of the main supply tap water it was found that a softener had been inserted between the mains water supply and the main supply tap, thus contaminating an already pure water supply. Samples of well water were taken on two occasions and were submitted for bacteriological examination and chemical analysis. The bacterial counts were high, which were ascribed to abnormal rainfall, and the chemical analyses indicated the water to be only of fair organic quality. The users were advised to boil the water before thinking, there being no main water supply available within reasonable distance. Drainage and Sewerage. The main drainage of the Borough links up with the undertaking of the West Kent Main Sewerage Board, whose purification works are at Dartford. No important extensions or re-constructions of surface water drainage system were carried out in 1937, other than the culverting of certain water courses. Cesspool Drainage. Two houses were erected with cesspool drainage during 1937. It is accepted that cesspools in an urban area are, from their very nature, objectionable and liable to give rise to nuisance unless periodically cleansed. The existence of cesspools over chalk formations are an ever present source danger to main water supply wells, especially if the construction of a cesspool is faulty. This Local Authority is alive to this danger, and, since the extension of the boundaries to include Hayes and Keston, no effort has been spared to utilise the somewhat limited powers possessed to secure the abolition of cesspools in the area. Considerable success has attended our efforts in this direction, and at the end of 1937 I was able to report that no less than 251 out 60 of 280 premises with sewer available have been converted by the owners to main drainage. There still remain, however, 20 cesspools where there is a sewer within 100 feet, 9 cesspools with sewer over 100 feet distant, and 80 cesspools without a sewer available. Rivers and Streams. During 1937 a re-inforced concrete culvert was proceeded with for a length of approximately 480 yards at Southborough, between Blenheim Road and Crown Lane. The inspectorial staff carried out 16 inspections of streams and water courses in the area, and discovered on four occasions that pollution existed. The service of informal notices secured the abatement of the nuisance in each instance. Public Cleansing. There was no alteration in the system of refuse collection and disposal. This service was extended to new properties. A 10-cubic yard moving floor vehicle was purchased in 1937. SANITARY INSPECTION OF THE AREA. Tables VII., VIII. and XV. indicate the varied extent of the sanitary inspection of the area carried out by the Sanitary Inspectors. 810 dwelling houses were inspected during 1937, which involved 4,696 visits for primary inspections and subsequent re-inspections. Of these 810 houses 655 were found not to be in all respects reasonably fit for human habitation. During 1937, 744 houses were rendered fit in consequence of informal action. It will be noted 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 earlier months of the next year. In addition to the above figures it will be noted that 429 houses were visited for the following reasons: 169 for infectious disease; 124 for disinfection; 19 for the presence 61 of vermin; 5 for dirty conditions; 34 for cesspool drainage; and 83 special visits for report on overcrowding under the Housing Act. SHOPS ACTS, 1912-1934. During 1937, 569 inspections were carried out, and in the following tabulation it is shown that the contraventions were, in the main, due to the absence of certain prescribed forms. In all cases informal action sufficed to secure compliance with the requirements of the Acts. In a number of instances it was found that assistants under 18 years of age were working slightly over the prescribed number of hours, but these irregularities were rectified without resort to statutory action. It is pleasing to record that the shop keepers in Bromley conscientiously endeavour to comply with the provisions of the Shops Acts. Particulars of Contraventions found under the Shops Acts. Unsatisfactory conditions relating to— Washing facilities 5 Ventilation – Temperature 6 Sanitary conveniences 8 Absence of statutory forms— Assistants' Half-holiday forms 42 Closing declaration 4 Form F (Daily hours to be worked by young persons) 22 Form (t (To be used only in connection with Form F) 19 Statutory Closing Notice (if partially exempt) 6 Form II (Abstract of provisions of the Shops Act relating to hours of employment of young persons for retail shops 22 Form K (Notice with regard to the provision of seats for female workers) 23 62 Other unsatisfactory conditions— Meals rest interval unsatisfactory 1 Unsuitable and insufficient means for meals No seats for females 3 The Shops (Sunday Trading Restriction) Act, 1936, came into operation on 1st May, 1937, which accounts for (the increase in the number of inspections for 1937 compared with the figure for 1936. One occupier of a shop was proceeded against for selling after the statutory hour of closing by retail sales hy auction, incurring a fine of 40/-. SMOKE ABATEMENT. Three Sanitary Inspectors on the staff hold the special certificate of the Royal Sanitary Institute for smoke inspection. Six special inspections were made in connection with nuisances arising out of the emission of smoke. In four instances the complaints were confirmed, and these were remedied by improved methods of stoking or change of fuel being adopted on the advice of the inspectors. As has been stressed before in these pages, increased use of electricity and gas for heating and cooking for domestic purposes will do much to solve the problem of smoke pollution of the atmosphere. Bromley is not a factory town, and, therefore, smoke pollution of the atmosphere within the area must of necessity be ascribed in the main to the domestic use of fuel. FACTORIES AND WORKSHOPS. Table XIV. in the Appendix supplies statistical data relative to the inspection of, and defects found in, factories, workshops, workplaces, and outwork premises. SWIMMING BATHS AND POOLS. (a) Public Open Air Bath.—Owing to re-construction work, the Corporation's Open Air Swimming Bath was only available to the public for approximately one month 63 during the season. The filtration plant and ehlorination plant continue to work satisfactorily, and daily teats are taken by the attendants for the purpose of ascertaining the presence of free chlorine and to ensure that a slight alkalinity is maintained. (b) Privately Owned Baths.—Two samples of water were taken from privately owned baths; B.Coli were absent in both samples, but high counts of organisms found in both samples indicated insufficiency of ehlorination. The owners' attention was drawn to this defect with a view to steps being taken to remedy the conditions found. VERMINOUS HOUSES. In 19 instances houses were specially inspected for verminous conditions, of which fourteen were found affected, and remediable measures were advised and carried out. (i). The number of Council houses found to be— (a) Infested 10 (b) Disinfested10 (ii). The methods employed for the above were— (a) Houses treated with Liquid Hydrogen Cyanide 6 (b) Houses sprayed out with an insecticide 4 (iii). No steps are taken for ensuring that the ings of tenants are free from vermin before removal to Council houses as no provision is made for inspection before acceptance of a tenant. (iv). The work of disinfestation is carried out by fumigation with liquid hydrogen cyanide by contractors under contract. Spraying is carried out by the Local Authority in respect of Council houses. (v). Where houses are found to be infested the tenants are instructed in the steps necessary to keep beds and rooms free from re-infestation. Frequent inspections are made. 64 RATS AND MICE DESTRUCTION ACT, 1919. Propaganda, before and during Rat Week, 1937, was intensified. In addition to the usual procedure being followed, such as displaying of large and small posters issued by the Ministry of Agriculture and Fisheries, the distribution of official leaflets and pamphlets and the insertion of special notices in the local press, an effort was made to ensure that householders, in districts where bad rat infestations were known to exist, were correctly informed of the best methods of exterminating this pest. A Corporation employee visited the houses in these districts, distributing matter relative to the destruction of rats and mice, and. when possible, personally inviting the householders to take advantage of the facilities offered them during Rat Week. The window space of a vacant shop, centrally situated, w as used during Rat Week for an exhibition of stuffed rats, rat poison products, and propaganda matter, and this attracted a deal of attention. As in the past the co-operation of the local chemists was invited and favourable reports have since been received (oncerning their sales of poison, etc. The Borough Engineer arranged for baiting of the sewers and other parts of the Council's property where there was likelihood of harbourage for rats, and also displayed posters on the refuse collection and various other vehicles owned by the Local Authority. Although the weather was unfavourable for the greater part of the week, the response from the public was much more gratifying than in previous years, and we may note with satisfaction a record in the number of private householders who applied for free poison. On the other hand the tradesmen did not respond to the appeal made during Rat Week, as one would expect, especially bavin" regard to the damage done to stock by rats. In thisrespect there is a definite lack of interest considering the large number of trade premises in the Borough; while a minority seriously endeavour to exterminate the pests the majority appear to regard any effort made in this direct as a waste of time, 65 Below are the comparative statistics relative to Rat Weeks 1936 and 1937:— 1936. 1937. Total number of applicants for poison during Rat Week 111 196 (a) From Trade premises 40 23 (b) From private residents 71 173 No. of bottles of Red Squill given free 159 284 No. of tins of Red Squill biscuits given free 30 21 During the past year the Sanitary Inspectors have continned to follow up complaints of rat infestations received from time to time, giving advice and obtaining cooperation between all concerned where serious and extenlive infestations are discovered. Generally the results have proved satisfactory, but, in some instances, we find that certain persons are at first very enthusiastic in their efforts to rid their premises of rats, but failing to notice any immediate material evidence of success, their zeal wanes and consequently further efforts on their part cease —possibly at the time when a little more trouble would have resulted in bringing about the desired consequences. . The following figures show to some extent the activ- ities of the officers of the department during 1937:— Total No. of inspections made ... 453 Total No. of infestations discovered ... 129 Total No. of infestations abated ... 88 PUBLIC ELEMENTARY SCHOOLS. The sanitary condition of the elementary schools is dealt with in the School Medical Service section of this Report, where is stated the hygienic improvements carried out, and indicates the standard to be aimed at in the older type of school which fall short of modern standards. SECTION D. Housing. 68 SECTION D.—HOUSING. Table XV. in the Appendix gives particulars of action taken during the year. It will there be seen that of the 810 houses inspected during the year 655 were found to have defects upon which notice was given to the owners. Speaking generally, the working class living conditions can definitely be said to be of a high residential character. There are the three housing schemes of the Local Authority: Turpington Estate, Southborough Estate, and Hayes Estate, and that at Downham under the I ondon County Council, make up 13.36 of the total of 16,545 houses in Bromley, i.e, 8 per cent. The activity in the building of new houses has been considerably reduced during 1937, and it would appear for the time being that saturation point has been reached. There are no slums, but there remain a few houses which have been scheduled as unfit owing to their having become worn out through age. These bouses have been closed to habitation and in due course will be demolished. Housing Act, 1936, Part IV.—Overcrowding. So far as overcrowding is concerned, this is being rapidly abated. The return at the end of the year shows that of the 210 houses overcrowded at the 1936 survey only 98 now remain. The following tables give further particulars:— Housing Act, 1936—Overcrowding. Particulars up to 31st December, 1937. Description. Total. Abated. Still overcrowded. Borough Council Houses ... 20 4 16 li.C.C. (Downham) 60 28 32 Other houses 136 86 50 Totals 216* 118 98 ♦Original figure at January, 1936, Survey. 69 (a). (i) Number of dwellings overcrowded at the end of the year 98 (ii) Number of families dwelling therein 112 (iii) Number of persons dwelling therein 657 (b). Number of new cases of overcrowding ported during the year 2 (c). (i) Number of cases of overcrowing heved during the year 118 (ii) Number of persons concerned in such cases 708 (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. The problem is now one of overcrowding of persons into bedrooms, against which we have no legal means of correction. A greater problem is the sub-division of houses, erected for the use of one family, being occupied by two or more families where the sanitary and necessary facilities are sufficient for one family only. SECTION E. inspection and Supervision of Food. 72 SECTION E.—INSPECTION AND SUPERVISION OF FOOD. Milk Supply. The current register of dairies, milk stores, etc., is made up as follows:— (i) Premises within the Borough 82 (ii) Premises outside the Borough 26 The Milk (Special Designations) Order, 1936. The Loral Authority has issued the following licences for graded milk :— Pasteuriser's Licence 1 Dealers' Licences: "Pasteurised" milk 14 "Tuberculin Tested " milk 9 Supplementary Dealers' Licences: "Pasteurised" milk 3 "Tuberculin Tested" milk 4 In my preamble to this Annual Report I have touched on the question of misuse of bottles used in the distribution of milk, and on the carelessness in the collection of empty bottles by the distributors. There, also, I have referred to the advantages of distribution of milk in cartons, and the disadvantages arising from the vise of open vans for milk delivery to customers, and the improvement that would result from the use of refrigeration equipment in delivery vans. There is, therefore, no more that I can usefully offer on this subject for consideration under tinheading at the present time. The sanitary inspectors have made 90 visits during 1937 to dairies, cowsheds and milk shops, and the remedying of defective conditions in four instances have been secured. Milk in the course of delivery has been examined on 21 occasions. Samples of milk have been taken regularly throughout the year for the examination of bacterial count, and tubercle bacilli. 73 Bacteriological examinations—ordinary 35 graded milk 40 Tubercle bacilli 5 The presence of bacillus coli in 20 of the ordinary milk samples taken was an unsatisfactory feature in the reports on these samples. Attention was paid to the milk supplied to schools, and samples were taken periodically as follows: (a) Elementary Schools 9, and (b) Secondary Schools and Technical School 9. Milk. Contraventions. No contraventions came to the notice of the Department which called for statutory action. Meat and Other Foods. There are five registered slaughter-houses and three licensed slaughter-houses in the area. The Local Authority granted 21 licences to slaughtermen during 1937 under the provisions of the Slaughter of Animals Act, 1933. It has been our practice in previous Annual Reports to include five special tables (A to E) showing various details of animals slaughtered for food in the Borough. This year these tables undergo revision, in order to meet the requirements of the form of tabulation now suggested by the Ministry of Health in Circular 1650. The continuity of our previous tabulations is not, however, disturbed to any great extent, as the form suggested by the Ministry (Table A) embodies in a condensed form much of the information I have hitherto submitted. 74 Table A. Carcases Inspected and Condemned. Total. Cattle (excluding Cows). Cows. Calves. Sheep and Lambs. Pigs Number killed (if known) 3188 258 — 137 1452 1341 Number inspected 3177 258 — 137 1441 1341 All Diseases except Tuberculosis. Whole carcases condemned 3 — — — 1 2 Carcases of which some part or organ was condemned 310 53 — 2 69 186 Percentage of the number inspected affected with disegse other than tuberculosis 9.85% 20.54% — 1.45% 4 85% 14.01% Tuberculosis only. Whole carcases condemned 5 2 — — — 3 Carcases of which some part or organ was condemned 98 21 — — — 77 Percentage of the number inspected affected with tuberculosis 3.23% 8.9% — — — 5.96% 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). 3188 3177 103 313 416 3.23 (percent) (9.85percent) 75 Table C. Total weight of carcases, parts of carcases, offal, etc. rejected for all diseases. Tons. Cots. Qrs. lbs. Total in lbs. Carcases .... 14 3 14 1658 Parts of carcases — 11 2 27 1307 Offal — 12 1 8 1380 Total 1 18 3 21 4345 Table D. Carcases, parts of carcases and offal, inspected at request of butchers. Inspected. Condemned. Disease Weight in lbs. Carcases. Parts and/or Organs Carcases. Parts. Organs Tuberculosis Other than Tuberculosis Cattle (excluding cows) 1 11 — 10 2 — 12 563 Cows — — — — — — — — Calves 12 — — — — — — — Sheep and Lambs 19 11 — — 11 — 11 16 Pigs 196 19 — 18 6 9 15 158 Total 228 41 — 28 19 9 38 737 Meat Contraventions. No serious contraventions of the Meat Regulations were encountered during the year 1937 which called for statutory action. 76 Unsound and Unwholesome Food Surrendered. Article of Food. Weight. Meat (See Table D above) Poultry 181 lbs. Fish 59 „ Vegetables 80 „ Tinned Goods. Quantity. Vegetables 64 tins approx. 480 lbs. Fruit 356 „ Fish 27 „ Milk, Cream 65 „ Meat 37 ,, Miscellaneous 7 „ Food and Drugs (Adulteration) Act, 1928. The Food and Drugs Inspector (Mr. E. II.- Granger) lias kindly furnished me with the following details of liis work in Bromley during 1937:— RETURN OF SAMPLES TAKEN IN THE BOROUGH OF BROMLEY. Year ended 31st December, 1937. Arrowroot 1 Rice 1 Brandy 1 Sausages 2 Butter 4 Suet 1 Cinnamon, Ground 1 Sugar Cocoa 2 Tapioca 1 Coffee 3 Whisky 1 Cornflour 1 Camphorated Oil 1 Cream 2 Iodine, Tine, of 1 Flour 2 Linseed, crushed 1 Fruit, Dried 2 Quinine, Amm. Tinc. 1 Gin 1 Cream of Tartar 1 Ginger, Ground 1 Cooked meats 1 Jam 1 Lobster Fish Paste 1 Lard 4 Mixed spice 1 Margarine 4 Aspirin tablets 3 Milk 61 Mincemeat 1 Oatmeal 1 Total 115 Olive Oil 1 Pepper 1 All samples were reported to be "genuine." SECTION F. Prevalence of, and Control over, Infectious and other Diseases. 78 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 occurring in Bromley during 1937. Three hundred and twenty-eight cases were notified, of which 155 were treated in Hospital. Scarlet Fever. There was a definite fall in incidence compared with the previous year, an attack rate per 1,000 population being 1.8, compared with 2.4 and 2.97 of the immediate preceding years. Our rate of 1.8 compares with a rate of 2.09 for the London County Council area. There was one death, being complicated by an acute appendix. Of the 104 cases notified, 87 were transferred to Hospital, 83 per cent. of cases. This compares with 70 per cent. of the previous year, and, in my view, contrary to the accepted opinion that mild cases of' scarlet fever should be nursed at home. Diphtheria. Forty cases w ere notified, 39 of which were transferred to the Hospital. These 40 cases gave an incidence rate of 0.68 per 1,000 population compared with 0.40 of the previous year. The rate in the London County Council area was 1.93. The main areas of the Borough affected were the Town and Plaistow wards. The type of disease was mild for Diphtheria, but there were two deaths occurring on the third day of the disease. The Diphtheria Immunization Clinic continues to he held each Monday afternoon, and the response of the public continues good. Tt does not, however, reach the desired aim that every child should be immunised before entry into school life. Puerperal Pyrexia and Puerperal Fever. Ten cases were notified during the year; six of these cases occurred at the Maternity Hospital, and I am submitting herewith extracts of my report to the Health 79 Committee, as it indicates the difficulty of tracing the true origin of infection in cases of Puerperal Pyrexia in a voluntary hospital. The case, Mrs. C., was admitted with ruptured membranes at 12.30 a.m. on January 26th to Ward IV. (which at that time contained four empty beds), and delivered of a normal child at 1.10 p.m. on the same day, a Doctor and a Nurse (1) being in attendance. The temperature and pulse rate remained normal on the 20th, 27th and 28th January, but on the evening of Friday, 29th January, the temperature rose to 100 degrees. The Doctor was informed by telephone, and on the following day the patient, whose temperature was now 104 degrees, was removed by the Matron from Ward IV. on January 30th for isolation in a single-bed ward. The temperature remained constant on Sunday, 31st January, and I was for the first time informed at 1.30 p.m., three days after the rise of temperature, by the Doctor in attendance that the case was, in ltis opinion, one of Puerperal Fever. I immediately hud the case removed to Queen Charlotte's Hospital (Isolation Block), and the Maternity Hospital placed in isolation and closed to admission of further patients. On enquiring into this case I found that five other patients, of the sixteen in the Hospital, had become direct contacts in the same ward as the infected case. One Nurse (2), who had recently had influenza, complained of sore throat, and swabs were taken of her and of the whole of the staff. Suspected members of the staff were isolated and suspended from duty pending investigation. On the following day, 2nd February, four of the five contact patients showed rising temperatures. In the evening swabs were taken for haemolytic streptococci, and eventually all these proved positive. On 3rd February, pending the result of the bacteriological examinations, these four patients continued under observation and isolation with a view to their transfer to Queen Charlotte's Isolation Hospital. That evening I was called in to see one of the nurses (Nurse 3) who had an acute streptococcal throat, and I removed this patient to the Bromley Isolation Hospital. On 4th February the temperature of the patients not showing signs of abatement, 80 ments were made for their removal to Queen Charlotte's Isolation Hospital. No other patient had become infected, and the Hospital was by 7th February completely empty of patients except for one who was making normal progress, and who left the Hospital on Friday, 12th February. Or the departure of this patient, the whole Hospital and contents were disinfected, and the Hospital remained closed pending the Spring decorations. When one conies to the investigation of the actual origin of the infection, one is faced with difficulties. The possibility of the first case being an auto-infection is not to be overlooked, although this must be considered unusual, and that she herself spread the infection to the other patients in the ward. It is also to be noted that she herself arrived in Hospital with labour advanced and membranes ruptured prior to admission. In no other ward did the infection arise. At the beginning of the infection I suspected Nurse (1), who attended as a midwife to Ward IV., but swabs from her proved negative. She was, however, immediately suspended for the four days pending the results of the swahs being received. Two assistant nurses, (4) and (3), were the only nurses to have positive swab results, these being received by telephone on Thursday, 4th February. Nurse (4) was immediately suspended from duty and sent home Nurse (3) had already contracted an acute throat and had been admitted to the Isolation Hospital. Nurse (4) had attended Ward IV. as an assistant nurse, but had also attended patients in other wards, and this tends to shovf that site was not the infecting person as no patient other than in Ward IV. contracted a temperature. Both Nurse (4) and Nurse (3) were "grouped" for type of infection Nurse (2), midwife, who was the Nurse previously mentioned with a history of headache but no temperature on the 27th January had been placed off duty on that day, but returned to duty on Friday, 29tli January. A swab taken from her on the 31st January proved positive on 3rd February. This suggests a possible source of infection in the Hospital, but so far as I am able to find out she did 81 not attend at any time on any patient in Ward IV., but it is believed that she visited the Labour Ward during the time of Mrs. C.'s confinement on 26th January who had at normal puerperium. With a view to ascertaining if infection had been present in the Hospital prior to the case of Mrs. C., I investigated all cases in the Hospital, they all showed a normal puerperium except in three cases. They were:— (a) Mrs. F. A Doctor's case, attended by Nurse (2). Caesarean section case. Had irregular temperature between 15/1.37 and 30.1.37. This patient occupied a single-bed ward and the temperature course did not indicate any septic condition. (b) Mrs. H. A Doctor's case, attended by Nurse (5) Rave a 24-hour rise of 100 degrees—102 degrees, due to inflamed breast ; otherwise a normal puerperium. (c) Mrs. T. A Doctor's case, attended by Nurses (1) and (5) showed a rising temperature between 22nd and 26th January due to B. Coli urinary infection, otherwise a normal puerperium. All the patients eventually recovered. The bacteriological investigation of the six patients showed identical cultures of Group A. Acute Poliomyelitis. Six cases of acute poliomyelitis were notified over a period of three months. None of these cases were related one to the other except that two cases occurred in a private school. Even in these instances the two cases were widely separated in the period of attack, and, in spite of the difficulties of tracing the infection, it is probable that each contracted this infection independently and apart from the residential school. In both cases recovery was complete. The other four cases were widely scattered and had no association with each other either in time or district. The infection in all cases was mild and sequelae negligible. 82 Dysentery. A widespread epidemic of Sonne's Bacillary Dysentery affected the country in the early part of the year. Bromley did not escape, and 25 cases were notified, but there were many other cases which came to my notice. Bacteriological investigation indicated Sonne's Bacillus. The tracing of this infection proved negative to a common source, and I have not heard anywhere that the source of infection has been traced. The attacks were severe in many cases, although of short duration, and only in the case of the very young did it have serious results. Deaths under two years of age increased in consequencefive cases dying under one year of age. Typhoid Fever. One case of Typhoid Fever was notified in Bromley during the year. The case was true typhoid, and, from the evidence before me, contracted the infection in France. W e escaped the Croydon infection, in spite of our close proximity and inter-change of inhabitants. Much of the credit for this must be given to the Croydon Corporation who were able to localise the infection to the Croydon area. Other Notifiable Infectious Disease. The year was comparatively free of measles, but epidemics of chicken pox and whooping cough affected the schools to a considerable degree. The control of these infections is difficult, especially when the public are careless in spreading the infection in buses, trains, places of amusement and other public places. Tuberculosis. Tables IX. and X. give incidence and details of cases of tuberculosis in Bromley for the year 1937. At the 31st December, 1937, there was a total of 44. names of persons who have been notified as suffering from tuberculosis. An analysis of this total gives the following particulars of sex of patients and type of disease:— 83  Total of both types. Respiratory Tuberculosis. Other forms of Tuberculosis. Males 231 164 07 Females 211 139 72 Total 442 303 139 The total of 442 gives a rate of 7.5 per 1,000 population, which compares with 7.2 for the year 1936. Eighty-four new cases were notified, or otherwise revealed to me during 1937, which is one less than the previous year; of this figure 71 were pulmonary tuberculosis cases, 41 males and 30 females, and the remainder, 13, were other forms of tuberculosis, seven males and six females. No part of the district had a predominance of cases, the incidence being fairly evenly spread throughout the wards. The total of 442 cases compares with 410 cases for 1936. Although there is a decrease of one in the number of cases notified to me during 1937, this does not take into account adjustment to be made in the register for deaths, recovered patients and removals from the area; these in all amounted to 52 during 1937, thus leaving a net increase in the register of 32 cases at the end of the year. Thirty-two deaths were recorded, of which 27 were from tuberculosis of the respiratory system (19 males and eight females) and five from other forms of tuberculosis (four males and one female). The following table of incidence rates and death rates of tuberculosis since 1928:— Year. New cases Incidence per 1,000 population. Death Rate. Pulm. Non-Pulm. Pulm. Non-Pulm. 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 1937 1.2 0.2 0.4 0.08 84 Public Health (Prevention of Tuberculosis) Regulations, 1925. These regulations relate to persons suffering from pulmonary tuberculosis employed in the milk trade. No case arose in Bromley during 1937 necessitating our taking action under these Regulations. Public Health Act, 1936, Section 172. Section 172 of the above-mentioned Act relates to the compulsory removal to hospital of persons suffering from tuberculosis. Prior to 1st October, 1937, Section 62 of the Public Health Act, 1925, governed any action appropriate in these cases, but the new Act of 1936 now includes this provision. Fortunately, no case came to our knowledge during 1937 requiring action in this respect. Efficiency of Notification of Tuberculosis. Efficiency of notification of tuberculosis is well maintained in this area, no instance of wilful neglect or refusal to notify has ever arisen here within my knowledge Although there were four cases of un-notified tuberculosis amongst the thirty-seven deaths from tuberculosis recorded during 1937, giving a ratio of 1 in 9, a rather high proportion, there had been, however, no wilful neglect to notify. Tuberculosis Dispensary. ])r. B. G. A. Edelston, Tuberculosis Officer, has kindly supplied me with the following brief summary of the work carried out at the Dispensary during 1937 BOROUGH OF BROMLEY. New Cases attending the Dispensary for the first time for Examination during 1937. Adults. Children. Male. Female. Male. Female. Pulmonary 25 18 — 1 N on-pulmonary 3 2 2 1 Negative 16 19 4 1 Totals 44 39 6 3 85 No. of contacts examined during 1937 30 No. of contacts found to be positive (not included above) Total No. of attendances at the Dispensary during 1937 2093 No. of patients who received residential treatment during 1937 140 PROPAGANDA. The work of the Department is its own publicity; it does not, in my view, require propaganda in the usual sense of the term. Instruction is a fundamental of all our services, and I am convinced as far as Bromley is concerned that pamphlets, posters and such like are not required. There is, I believe, a business axiom that reads, "A good article sells itself." SECTION G. Other Services Supervised by the Health Department. 88 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 198 Animals concerned— (i) Pigs 1522 (ii) Sheep, lambs 484 Sheep Dipping. Certificates issued by the Local Authority No. of sheep double dipped—141 2 282 Foot and Mouth Disease. No. of Movement Licences issued by the Local Authority 40 (i) Pigs 148 (ii) Beasts, calves, etc. 35 (iii) Sheep, Goats 38 No. of inspections made in connection with the above-mentioned details 67 No. of interviews in connection therewith 172 Tuberculosis Order of 1925. No occasion arose during 1937 necessitating action being taken under this Order. RAG FLOCK ACTS, 1911-1928. No rag flock samples were submitted for analysis in 1937, as upholstery firms in the district have ceased to use any rag flock. REGISTRIES FOR FEMALE DOMESTIC SERVANTS. The Chief Sanitary Inspector made 22 periodical inspections of registry offices during 1937, and found one minor contravention under the Bye-laws with respect to Female Domestic Servants, which was remedied forthwith. The practice of shop-keepers affixing advertising panels outside their shops, in which they display advertisements for a weekly payment, and including therein advertisements for female domestic servants, occurs from time to time. In cases where advertisements for domestic servants have been included, the shop-keepers have been 89 informed that they are contravening the Bye-laws unless they are duly registered. In all cases, rather than become registered, they have refrained from accepting such advertisements. There were nine Registry Offices on the register for the Borough at the end of the year 1937. PETROLEUM ACTS. Number of licences issued 107 Licences issued by way of transfer on change in proprietorship 7 (i) For Petroleum Spirit 113 (ii) For Carbide of Calcium 1 Total quantity of petroleum spirit in gallons 192,205 (i) Bulk storage, in gallons 179,575 (ii) Two-gallon can storage, in gallons 12,630 Carbide of Calcium, in lbs. 300 Of the 114 licences issued, 105 were renewals, two were new or additional licences, and seven original licences were transferred owing to change of occupiers of licensed premises. Two hundred and twenty-seven inspections were made during 1937. Fifty-four contraventions were observed, and these were remedied forthwith. 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 1937 192,205 107 90 RETAIL MARKET. The Retail Market is held on Thursdays at t lie Car Park, Station ltoad, under the control of the Market Superintendent. The administrative supervision is under the Health Committee. The Market still retains an unwaning popularity with the purchasing public, especially with the housewife. The attendance 011 market days is consistently good, only falling below the average in the event of inclement weather. The receipts are £16 in excess of the total for t he previous year, and the average per month lias advanced from £44 to £45 7s. fid. Total amount of Tolls and Storage Fees collected during 1937. £ s. d. January 25 10 0 February 27 17 6 March 36 7 6 April 58 13 0 May 42 13 0 June 51 4 0 July 67 0 6 August 48 15 0 September 50 4 0 October 46 14 0 November 47 13 0 December 41 19 0 £544 10 6 Average per month, £45 7s. 6d. APPENDIX. Tables I. to XV. 92 TABLE 1. SUMMARY OF STATISTICS, 1937. Population (mid-year 1937, Registrar General) 58,700 Birth Rate 13.2 Death Rate (adjusted) 9.9 (crude) 10.3 Infantile Mortality Rate 47 Number of Births (live) 778 Number of Stillbirths 15 Number of Deaths 605 Number of Infant Deaths (under 1 year) 37 Death Rate of Respiratory Diseases 0.6 ,, ,, ,, Tuberculosis 0.5 „ „ ,, Cancer 1.5 ,, ,, ,, Zymotic Diseases 0.06 Notifications of Scarlet Fever 104 ,, ,, Diphtheria 40 ,, ,, Pneumonia 48 ,, ,, Tuberculosis 84 Number of Deaths from Measles - ,, ,, ,, ,, Scarlet Fever 1 ,, ,, ,, ,, Diarrhoea (under 2 years) 7 ,, ,, ,, ,, Child Birth 3 Number of visits by Sanitary Inspectors 10,726 ,, ,, ,, „ Health Visitors 8,481 Number of Babies on the Registers at the Welfare Centres, end December, 1937 2,306 93 TABLE II. Birth Rates, Death Rates, Analysis of Mortality, Maternal Death Rates, and Case-Rates for certain Infectious Diseases in the Year 1937 (Provisional Figures based on Weekly and Quarterly Returns) Bromley. England and Wales. 125 County Boroughs and Great Towns including London. 148 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census) London Administrative County. Births :- Rates. per 1000 Population. Live 13.2 14.9 14.9 15.3 13.3 Still 0.25 0.60 0.67 0.64 0.54 Deaths :- All causes 9.9 12.4 12.5 11.9 12.3 Typhoid and Paratyphoid Fevers — 0.00 0.01 0.00 0.00 Smallpox — — — — — Measles — 0.02 0.03 0.02 0.01 Scarlet Fever 0.01 0.01 0.01 0.01 0.01 Whooping cough 0.01 0.04 0.04 0.03 0.06 Diphtheria 0.03 0.07 0.08 0 05 0.05 Influenza 0.37 0.45 0.39 0.42 0.38 Violence 0.54 0.54 0.45 0.42 0.51 Notifications:— Smallpox — 0.00 — 0.00 — Scarlet Fever 1.77 2.33 2.56 2.42 2.09 Diphtheria 0.68 1.49 1.81 1.38 1.93 Enteric Fever 0.01 0.05 0.06 0.04 0.05 Erysipelas 0.10 0.37 0.43 0.34 0.44 Pneumonia 0.81 1.36 1.58 1.20 1.18 Deaths under 1 year of age Rates per 1000 Live Births. 47 58 62 55 60 Deaths from Diarrhœa and Enteritis under 2 years of age 8.9 5.8 7.9 3.2 12.0 Maternal Mortality:— Not avail- able. Puerperal Sepsis 1.28 0.97 Others 2.57 2.26 Total 3.85 3.23 Maternal Mortality. Rates per 1000 Total Births (i.e.. Live and Still). Puerperal Sepsis 1.26 0.94 Not avail- able. Others 2.52 2.17 Total 3.78 3.11 Notifications: Puerperal Fever Puerperal Pyrexia 12.61 13.93 17.59 11.52 4.15 14.34 94 TABLE III. Causes of Death, 1937. Males. Females. Total. 1. Typhoid Fever, etc. — — — 2. Measles — — — 3. Scarlet Fever 1 — 1 4. Whooping Cough — 1 1 5. Diphtheria — 2 2 6. Influenza 8 14 22 7. Encephalitis Lethargica — — — 8. Cerebro-spinal Fever — — — 9. Respiratory Tuberculosis 19 8 27 10. Other Tuberculosis 4 1 5 11. Syphilis — — — 12. General paralysis of insane, etc. 2 — 2 13. Cancer 39 49 88 14. Diabetes 3 8 11 15. Cerebral haemorrhage 9 15 24 16. Heart disease 81 89 170 17. Aneurysm 1 1 2 18. Other circulatory diseases 11 8 19 19. Bronchitis 7 4 11 20. Pneumonia 13 13 26 21. Other respiratory — 1 1 22. Peptic Ulcer 5 5 10 23. Diarrhoea, etc. (under 2 years) 6 1 7 24. Appendicitis 3 1 4 25. Cirrhosis of liver — 2 2 26. Other liver diseases — 1 1 27. Other digestive diseases 7 8 15 28. Nephritis 6 8 14 29. Puerperal sepsis 1 1 30. Other puerperal causes — 2 2 31. Congenital causes, etc. 13 7 20 32. Senility 7 11 18 33. Suicide 5 3 8 34. Other violence 10 14 24 35. Other defined causes 31 36 67 36. Ill-defined causes — — — Totals 291 314 605 95 TABLE IV. Infant Mortality, 1937. (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 under 3 months. 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 ... ... ... ... ... 1 ... ... ... 1 Tuberculosis ... ... ... ... ... ... ... ... ... ... Convulsions ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... 1 1 Pneumonia ... ... ... ... 1 1 2 ... 2 6 Diarrhoea ... ... ... ... ... ... ... ... ... ... Gastro-Enteritis ... ... ... ... ... 3 1 1 ... 5 Suffocation ... ... ... ... ... ... ... ... ... ... Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis 2 ... ... ... 2 ... ... ... ... 2 Malformation 3 ... ... 1 4 ... ... 1 ... 5 Premature Birth 6 ... 1 l 8 2 ... ... ... 10 Marasmus, etc. ... ... ... ... ... ... 2 ... ... 2 Other Causes 1 ... ... ... l ... 1 1 1 4 Syphilis ... ... ... ... ... ... ... ... ... ... Congenital Heait Disease l ... ... ... 1 ... ... ... ... 1 Totals 13 1 1 2 17 7 6 3 4 37 96 TABLE V. Analysis of Causes of Infant Deaths, 1933-1937. 1933 1931 1935 1936 1937 Total No. of Births 598 706 758 780 778 Infantile Mortality Kale 41 43 27 37 47 Malformation 4 7 7 3 7 28 Premature Births 5 5 4 6 10 30 Respiratory Diseases 6 5 4 9 7 31 Marasmus and General Debility 4 2 2 2 2 12 Infectious Disease 1 ... ... ... 1 2 Gastro Enteritis ... 4 1 2 5 12 Convulsions ... 2 ... 2 ... 4 Other Causes 5 6 3 3 5 22 Totals 25 31 21 27 37 141 This table shows that Premature Births, Congenital Debility and Malformation caused 49 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. 97 Four quinquennial periods are taken—Pre-War, 1910-1914. five years to 1925. five years to 1930, five year to 1935, and the years 1936-1937 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 1937 778 47 37 13 4 20 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. 98 TABLE VII. Summary of Work of Sanitary Inspectors for the Year 1937. TYPE OF INSPECTIONS. No. of Inspections. Nuisances and Defects found. On Complaint. Routine Inspections. Re- Inspections. Total. Inspections. Houses Visited— Under Insp. of District Reg 1135 — 115 1380 1495 Housing Act, 1936. Sec. 9 1 1 — 86 87 Sec. 11 1 1 2 60 63 Sec. 62 3 — 3 — 3 Sec. 4 2 — 2 — 2 For nuisances 2308 695 64 2081 2840 (No. not confirmed, 83) Overcrowding 1 6 1 22 29 Verminous houses 14 16 3 49 bo Dirty conditions 2 3 2 17 22 Water supply 1 2 — 3 5 Cesspools 8 8 26 77 111 Earth closets — — — — — Privy pails — — — 19 19 Privy bins — — — — — Infectious disease — — 169 11 180 Disinfection purposes — 1 124 6 131 Disinfestation purposes 1 2 21 4 27 Special visits re overcrowding 31 — 83 2 85 Totals 3508 735 615 3817 5167 Food Preparing Places-— Bakehouses—Factories 25 1 50 15 66 Workshops 5 — 22 8 30 Butchers' shops 21 4 1298 17 1319 Confectionery shops 1 2 30 4 36 Dairies, Cowsheds, etc 4 — 74 16 90 Fish shops 10 — 259 — 259 Fried Fish shops 3 1 16 4 21 Food hawkers — — 96 — 96 Greengrocery, Fruiterers 9 2 137 8 147 Grocery shops 14 1 322 3 326 Hotels, Restaurants, etc 19 — 55 9 64 Ice Cream premises — — 17 — 17 Milk Sampling—Bact. Ord — — 35 — 35 ,, graded — — 40 — 40 Tuberc. — — 5 — 5 Milk examined on highway — — 21 — 21 Retail market — — 50 — 50 Slaughterhouses 1 — 636 — 636 Totals 112 11 3163 84 3258 99 TYPF. OF INSPECTIONS. Nuisances and Defects found. No of Inspections. On Complaint. Routine Inspections. Re- Inspections. Total Inspections. Trade Premises— Factories — — 35 7 42 Workshops 21 1 22 10 33 Outworkers premises — — 26 — 26 Under Shops Acts 161 6 563 19 588 Dnder Petroleum Acts 54 — 208 19 227 Registry Offices 1 2 20 2 24 Diseases of Animals Acts— Inspections — — 67 — 67 Interviews (172) Offensive trades — — 13 — 13 Theatres, etc. 1 1 1 11 13 Rag Flock enquiries — — 2 — 2 Totals 238 10 957 68 1035 Miscellaneous— Accumulations 53 26 33 122 181 Drain tests—Smoke — — 2 3 5 Water — — 7 8 15 Colour — — 8 3 11 Chemical — — — — — Mirror — — 2 4 6 Food poisoning enquiries — — 2 2 Piggeries 6 1 23 7 31 Rag and Bone dealers — — 3 3 Rate and Mice Destruction Act 129 105 104 244 453 Schools — 1 — 1 Coal Gas poisoning — 1 1 Smoke 4 2 4 2 8 Special visits — — 481 — 481 Sotables 2 — 11 1 12 streams 4 4 7 5 16 Swimming Baths—Water samples — _ 2 2 Urinals 4 — 12 5 17 Interviews, owners, agents (1969) Water sampling — — 4 — 4 A.R.P. visits — — 17 — 17 Totals 202 139 723 404 1266 Grand Totals 4060 895 5458 4373 10726 100 TABLE VIII. Nuisances Abated, 1937. HOUSING: Drainage— Premises Re-drained and connected to sewer 7 Cesspools abolished 9 l'rivy pails abolished 9 Drains relaid or repaired 37 Drains unstopped 82 Inspection chambers provided 20 W.C.s additional or separate provided 6 ,, buildings re-constructed 5 ,, ,, repaired 10 ,, pans renewed or provided 54 ,, pans cleansed 9 ,, box seats removed 63 Soil pipes, vent pipes, renewed or repaired 14 Sinks renewed or provided 69 Sink or bath waste pipes renewed or repaired 211 Cesspools emptied 5 Surface water drainage provided 1 Baths provided 1 Dampness— Hoofs repaired or renewed 181 Rain water pipes, guttering, etc., repaired or renewed 157 Damp courses:— Yertical plinths provided 40 Walls rendered 73 Horizontal d.c. provided 34 Solutioning 14 Earth removed from walls 6 Walls repointed 200 Dry areas constructed 2 Sites concreted 2 Subfloor ventilation provided or improved 25 Brickwork renewed or repaired 22 General— Rooms cleansed 347 W.C. walls, etc., cleansed 42 101 Entrance hall and staircase 43 Bathrooms cleansed 3 Light and ventilation of rooms improved 67 Plastering repaired or renewed 243 Floors 77 Window frames, etc,, repaired or renewed 157 Sash cords 137 Putty pointing 45 Doors 47 Stoves 78 Coppers 31 Handrails 21 Stairtreads, etc. 7 Dustbins provided 167 Dirty conditions remedied 12 Overcrowding abated 12 Defective chimneys repaired 30 External woodwork painted 21 Food stores—Provided 63 Ventilated 20 Yard paving renewed or provided 81 Houses disinf'ested 32 Water Supply— Drinking water service supplied direct from main 19 Fittings renewed, etc. 12 Supply re-instated 2 Flushing cisterns repaired or renewed 45 Miscellaneous Items 121 TRADE PREMISES: factories and Workshops— Want of cleanliness — Want of drainage to floors — Other nuisances 10 Sanitary accommodation— Insufficient 2 Unsuitable and defective 4 1 Not separate for sexes 1 Petroleum Acts—contraventions 54 Milk and Dairies—contraventions — 102 Shops Acts—contraventions— Ventilation — Temperature 6 Sanitary conveniences 8 Absence of statutory forms 138 Washing facilities not satisfactory 5 Meals rest interval unsatisfactory 1 Seats for female workers 3 Registry Office—contraventions 1 FOOD PREPARING PLACES: Defects and nuisances remedied in— Butchers' shops 30 Bakehouses 30 Confectionery 4 Dairies, etc. 4 Fish shops 1 Fried Fish shops 6 Grocery shops 22 Greengrocery shops 10 Hotels, restaurants, etc. 19 Slaughterhouses 1 MISCELLANEOUS: Accumulations removed 56 Nuisances from keeping animals 3 Manure removed 3 Manure receptacles 1 Rats and Mice nuisances 88 Smoke nuisances 1 Stables cleansed and sanitary conditions improved 2 Urinal structurally improved 1 Stream pollutions 2 Piggeries cleansed, etc. 3 ,, reconstructed 2 ,, abolished 1 Total 3864 NOTICES ISSUED: Housing. Others. Preliminary 744 203 Statutory — — Totals 744 203 103 TABLE IX ??? 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 104 45 69 19 14 17 8 14 26 6 87 1.7 1 0.01 Diphtheria 40 16 24 13 4 14 4 2 2 1 39 0.6 2 0.03 Pneumonia 48 19 29 6 10 5 9 7 11 — 17 0.8 26* 0.4 Peurperal Fever & Pyrexia 10 — 10 — — 1 8 — 1 — 9 12.6† 1 1.26† Dysentery 25 9 16 1 1 4 — — 2 17 1 0.4 5 0.08 Erysipelas 7 4 3 1 3 2 — — 1 — — 0.1 — — Ophthalmia Neonatorum 3 1 2 - — — 1 2 — — — 3.8† — — Acute Poliomyelitis 6 4 2 — — — 1 — - 5 2 0.1 — — Typhoid fever 1 — 1 — 1 — — — — — — 0.01 — — Tuberculosis—lungs 71 41 30 14 15 8 9 7 11 7 — 1.2 27 0.4 Tuberculosis — other forms 13 7 6 5 — — 2 1 3 2 — 0.2 5 0.08 Totals 328 146 182 59 48 51 42 33 57 38 155 5.8 67 1.1 * Includes Pneumonia (all forms), whereas notifiable types include only acute primary pneumonia and acute influenzal pneumonia. †These figures are based on the attack rate per 1000 births, and not population. 104 TABLE IXa. Notifiable Infectious Disease, 1937. Age Groups. Disease Total 0-1 1 2 2 3 3-4 4-5 5-10 10-15 15-20 20-35 35-45 45-66 65 & over Scarlet Fever 104 — — 6 5 8 44 23 6 8 4 — — Diphtheria 40 — 1 1 1 2 15 4 4 10 1 1 — Pneumonia 48 — 1 — 2 1 3 3 — 10 8 10 10 Puerperal Fever and Pyrexia 10 — — — — — — — — 7 3 — — Dysentery 25 — 1 — 1 — 5 2 2 10 3 1 — Erysipelas 7 — — — — — — — — — — 6 1 Ophthalmia Neonatorum 3 3 — — — — — — — — — — — Acute Poliomyelitis 6 — 2 — — — 2 — 2 — — — — Typhoid Fever 1 — — — — — — — — 1 — — — Totals 244 3 5 7 9 11 69 32 14 46 19 18 11 105 TABLE X. Tuberculosis. New Cases and Mortality during tlie Year 1937. Age Periods. New cases notified or otherwise revealed. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M F. Under 1 ... ... ... ... ... ... ... ... 1— 5 ... ... ... ... ... ... ... ... 5—15 ... 3 3 2 ... ... 1 1 15—25 6 3 1 1 2 ... I ... 25—35 14 15 1 ... 5 4 l ... 35—45 9 5 ... 1 5 1 l ... 45—55 7 2 1 2 3 3 ... 55—65 5 2 ... ... 4 ... ... ... 65 and over ... ... 1 ... ... ... ... ... Totals 41 30 7 6 19 8 4 1 TABLE XI. Ophthalmia Neonatorum, 1937. Cases. Vision unimpaired. Vision impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 3 3 ... 3 ... ... ... 106 TABLE XII. Summary of Health Visitors' Work, 1937. Areas. Total. Ineffectual Visits. Under one year. Revisits over one year. Expectant Mothers. School Children. Baby Deaths. Stillbirths Tuberculosis Special Visits. M'wives Acts enquiries Boarded out Children. Primary Revisits Area No. 1 1029 206 85 125 427 37 138 4 1 70 141 1 12 Area No. 2 1173 252 102 321 436 40 185 4 54 27 4 12 Area No. 3 1437 141 121 242 796 21 133 5 3 66 22 28 28 Area No. 4 1235 164 114 232 587 48 194 ... 1 29 29 1 8 Area No. 5 1066 226 108 179 533 13 96 2 1 73 41 20 16 Area No. 6 1374 278 123 309 608 66 100 ... 2 51 13 2 10 Totals 7214 (Net) 1267‡ 653 1408 3387 225 846 15 8 343 273 56 86* * 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, 8,481. TUBERCULOSIS DISPENSARY WORK, 1937. Patients on the Dispensary Roll at end of November, 1937 178 Health Visitor's attendances at Dispensary 46 Total No. of special visits to Patients 188 (N.B.—The arrangement for a Health Visitor to attend the Tuberculosis Dispensary was terminated at 30/11/1937). 107 TABLE XIII. Welfare Centres, Attendances, 1937. CENTRE. No. of Babies on the Rolls at the end of the Year, 1937. Total Attendances. No. of Sessions held. Medical Consultations. Total No of Weighings. Babies. Mothers. Total Examined. No. of Sessions held. PLAISTOW 375 3315 2872 49 355 29 3013 WIDMORE 197 2444 2086 51 256 24 2173 MASONS HILL 420 3257 2956 48 337 27 2852 BURNT ASH 534 3750 3142 93 462 40 3302 BROMLEY COMMON 383 5396 4374 100 749 64 4817 HAYES & KESTON 397 4324 3899 50 434 33 3975 Totals 2306 22486 19329 391 2593 217 20132 Ante-Natal Clinics, 1937. Total Attendances. Medical Consultations. Sessions held. 348 345 42 Dental Clinic, 1937. Discharged treatment. Children. Mothers. 120 55 108 TABLE XIV. Factories, Workshops and Workplaces, 1937. 1.—I nspections. Premises. Number of Inspections. Written Notices. Occupiers prosecuted. Factories 116 17 ... Workshops 65 14 ... Workplaces 102 12 ... Total 283 43 ... II.—Defects. Particulars. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts*- Want of Cleanliness 17 17 ... Want of ventilation 2 2 ... Overcrowding ... Want of drainage to floors ... Other nuisances 50 50 ... Sanitary accommodation. insufficient 4 4 ... unsuitable or defective 4 4 ... not separate for sexes 1 1 ... Total 78 78 ... * Including those specified in sections 2, 3, 7 and 8 of the Factory and Workshop Act, 1901, as remediable under the Public Health Acis 109 TABLE XV. Housing Statistics for the Year, 1937. Total number of inhabited houses at 31st December, 1937 (according to rate books) 16545 The number of houses for which plans have been approved during 1937 is as follows:— (a) By private enterprise 462 (b) By Local Authorities Nil. 1- Inspection of Ilt/vl/ing-liouses during the year-.— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 810 (b) Number of inspections made for the purpose 4696 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 115 (b) Number of inspections made for the purpose 1495 (•3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation *15 (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 655 Remedy of Defects during the Year without Servioe of Formal Notices :— dumber of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 744 * Informal action to secure closure of these 15 houses is proceeding satisfactorily. 110 3. Action itwdv.r Statutory Powers during the Year:— (a) Proceedings under sections 9, 10 and 16 of the Housing Act, 1936:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs - (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners - (b) By local authority in default of owners - (b) Proceedings under the Public Health Acts:— (I) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied - (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners ... - (t>) By local authority in default of owners - (c) Proceedings under sections 11 and 13 of the Housing Act, 1936:— (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 12 of the Housing Act, 1936:— (1) Number of separate tenements or tinderground rooms in respect of which Closing Orders were made - † As a result of informal action, progress under llie Housing Act, 1936, up to 31/12/1937 showed that 29 houses have been demolish" and 32 houses closed to habitation. 111 (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, 1936.—Part IV. OvercrmocUng. (a) (i) Number of dwellings overcrowded at the end of the year ... 98 (ii) Number of families dwelling therein 112 (iii) Number of persons dwelling therein 657 (b) Number of new cases of overcrowding reported during the year 2 (c) (i) Number of cases of overcrowding relieved during the year 118 (ii) Number of persons concerned in such cases 708 (d) Particulars of any cases in which dwellinghouses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding Nil. (e) Any other particulars with respect to overcrowding 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 1937 114 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1937-1938. Alderman F. W. Isard (Chairman of the Education Committee). *D. Copping, Esq. *A. Cowdhy, Esq. Councillor E. C. De'Ath. Councillor H. L. Et.piiick. Councillor lit.-Colonel G. A. Fulchfr, o.b.e. *Mrs. M. D. Fry. *Rev. H. Glaisyer, m.a. Councillor George Griffin. *G. J. Gully, Esq., j.p. *Rev. .T. T. Gurney. His Worship the Mayor, Councillor W. J. Guthrie, j.p. *Lt.-Colonel E. J. Hf.it.bhon. Councillor S. G. Humerston. 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 Smith, m.b.e., b.a. Councillor F. G. Hamilton Spratt. Councillor F. Sutcliffe, f.r.i.b.a. *Rev. 0. G. Whitfield, m.a. "Co-opted Members. 115 Introduction. I have the honour to report on the work of the School Medical Service during 1937. The report must, be taken in conjunction with the work of the Health Department as a whole, as the services of Health, Maternity and Child Welfare and School Medical are inter-related and function as a co-ordinated unit. A report on the School Medical Service can be, and is, a repetition of the services of previous years, and is not to be taken as a means of comparison with the work of the preceding year. It is, as a report, largely statistical, as can be seen from the tables in the Appendix, which have already been submitted to the Hoard of Education earlier in the year. A study of these tables will give an indication of the extent of the work carried out by the staff, and must indicate to the Committee that, so far as the elementary school child is concerned the Service is a complete one, and that with the exception of domiciliary treatment, which we are precluded by statute from performing, there is no medical treatment either routine or specialised that the child cannot obtain through these services. For this fact I am greatly indebted to the Committee for the helpful manner in which they have received my recommendations over the many years of my service as their School Medical Officer. The line of demarcation that existed between Maternity and Child Welfare and School Medical Services lias in Bromley long disappeared; the School Medical Service is now the treatment service for all children under sixteen years of age, with two exceptions, firstly, it is after five years of age limited to the child in attendance at elementary schools, and secondly, it takes no part in domiciliary treatment of' the sick child. The extension of the Service in these two directions would be tantamount to a State Medical Service, which stage has not yet been reached in "lis country. Because of the extension of the School Medical Service into the realms of medical treatment, we are apt to neglect its more important function, that is the prevention of illliealth and crippling disease. The treatment of teeth and of other minor ailments in their early stages of disease do lead to the maintenance of health and the prevention of 116 chronic ill-health. Further, the development of physical training, organised games, modern school buildings and equipment, and the practising of hygiene by the children whilst at school, all play their part in keeping the child in a state of health both in body and mind and fit to receive the education provided by the Local Edxication Authority. There is, in Bromley, an increasing need for the provision of nursery classes for the guidance of the " nervous child," who is now so common among the three and four years of age children, and who make manifest their condition by night terrors, bed-wetting and other forms of anxiety. The rapid improvement these children make on entry to school life indicates the value of early admission to school. 1 would like to make special reference to Mr. T. S. Latham's report on the Dental Service, which is included in this Report, and I am personally indebted to the Staff, both permanent and part-time, for the interest they have taken in their various duties, and also to the Chief Education Officer for Lis assistance in the many administrative problems that arise from time to time. Summary of Statistics, 1937. School Roll 5603 No. of individual children who attended medical clinics 2458 No. of individual children medically examined at schools 1815 No. of medical examinations at the clinics 9535 (a) North Clinic 5140 (b) South Clinic 4395 No. of attendances for treatment at clinics by (he School Nurses 8771 (a) North Clinic 4204 (b) South Clinic 4567 No. of attendances for treatment at the Dental Clinics 4764 No. of treatments at the Eye Clinic 661 117 No. of operations for Tonsils and Adenoids 107 No. of attendances at the Orthopaedic Clinic'1664 (i) For Consultations 687 (ii) For Treatments, Massage, etc. 2977 No. of attendances at the Ultra Violet Bay Clinics 2601 No. of children referred to the Care Committee 232 Staff. Full particulars of the staff of the School Medical Service are included under the heading Public Health Staff' (page 7). There were no changes in the medical and nursing staffs during .1937. It became imperative, however, that an increase in medical staffing should be made if the complete absorption of my time for administrative duties was to be avoided. Stress of routine work was being occasioned by the ever increasing use which the public is making of the health services. Other factors leading to increased work were the extension of the School Medical Services to all children of 2—5 years of age, work at the new South Clinic, Princes Plain, and the extension of special clinics. Thus it vas decided at the end of the year to appoint an additional Assistant Medical Officer, who commenced his duties in February, 1938. The following is the allocation of medical staff time to the School Medical Services: Medical Officer of Health—2/8ths ; first Assistant Medical Officer—5/8ths; second Assistant Medical Officei 6/8ths. 1 be nursing staff and clerical staff have half their time allocated to the School Medical Service. Co-ordination. The oik of the School Medical Service is closely co-ordiiiated with those of the other Health Services, and, being controlled by one Department, complete absence of overlapping is secured. 118 Hygiene of Schools. 1 have stressed in my previous reports the importance of securing for the child a healthy school environment, for without it the physical welfare of the child is at stake. We still have a certain number of Church Schools in the Borough, which, although possessing the virtues attaching to tradition and antiquity, certainly do not possess entirely satisfactory hygienic conditions, having regard to their surroundings, ventilation, lighting, heating equipment, and sanitation. We must be satisfied that the type and conditions of desks, sanitary conveniences, lavatories, playgrounds, washing facilities, drinking fountains, cleanliness of classrooms and cloakrooms, drying facilities for clothes and boots, do not fall short of the modern conception of what constitutes a sound hygienic environment for imparting a sound modern education. Anything falling below this standard is to be deprecated as educationally unsound as well as uneconomic. All things cannot be done at once, but during the past few years Bromley has made great progress in the provision of new schools and the abolition of schools unable to provide the necessary hygienic environment. During 1937 progress in replacement of the older type of school has been made by the opening of the new Hayes Council School in June, 1937 ; the old Hayes Church School being closed in the same month ; the Managers of the Addison Road Church School have decided to close their school upon the opening of the Southborough Council School, which it is anticipated will take place in September, 1938. This new school will accommodate 401) mixed juniors and infants.. The new Hayes Council School has accommodation for 400 mixed juniors and infants, and a canteen for the provision of scholars' mid-day meals is operating on an experimental basis. The canteen is conducted bv a Canteen Committee, and the scholars are expected to defray the cost of meals, wages of kitchen staff, and the electricity consumed. The Education Committee provided the initial equipment, and will maintain the equipment up to an agreed cost per annum, and assist in the payment of electricity accounts if necessary. At Burnt Ash Council School the lighting arrangements have been improved throughout the school, and one 119 additional drinking fountain lias been provided for the Girls' Department. The members of tlie Education Committee have during the year given consideration to the question of the provision and maintenance of school playgrounds with a view to overcoming difficulties experienced at the present time, and, with the Board of Education's approval, have decided experimentally to provide concrete playgrounds at the new Southborough Council School. The progress made during the year with reference to playing fields is dealt with under Physical Education. SECTION A MEDICAL INSPECTION AND FINDINGS AT MEDICAL INSPECTIONS. 122 Medical Inspection. The statistical particulars appear in Table I. of the Appendix. 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 at the school clinic and referred through the necessary channels for treatment. The medical inspections are not limited to routine inspections, hut extended to the special inspections at the school clinics and special clinics. During the yean no less than 0,778 cases came under medical inspection (including the specialists' consultations but excluding dental inspections), and these figures give some indication of the extent of the work of the School Medical Services. The routine medical inspections are carried out on the school premises, with the exception of those schools, such as, Plaistow St. Mary's and Parish Schools, where there is no available accommodation for the inspection, necessitating the children and parents attending the School Clinic for thp inspection. It is pleasing to learn that in the re-organisation of elementary education in Bromley these schools will shortly be re-modelled to provide better medical examination facilities. In addition there is the medical examination of 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. The medical inspection at school is a routine one:it brings to light defects that are apparent to the medical examiner, hut it fails to give us an indication of the normal or abnormal physiological functioning of the child Before the medical examiner can give a complete opinion on these lines, it would be necessary not only to have the presence of the child and the parent, but the class teacher the previous medical history of the child, the family medical history, a knowledge of the child's life outside school hours, and finally a report of a social worker on the 123 home environment. Having obtained all this, physiologi- cal tests would still be required, and unfortunately standardised tests for true functioning of the separate organs are not yet available. We can, therefore, but continue with the present system of three routine medical inspections adding a further inspection for the child just prior to leaving school. Findings at Medical Inspections. These are recorded in detail in the Appendix. (a) Mahvutrition. Table IIb. (page 157). Of the 1,816 children medically examined at school 0.5 per cent, showed bad nutrition, and a further 8.6 per cent, sub-normal nutrition. This does not, however, take into account the children attending the special inspections at the Clinics, but must not be taken to mean that 13 per cent of children at school are of sub-normal nutrition. Cases of malnutrition attend the school clinics where continuous observation is kept and adequate treatment provided. Where the case is one of lack of nutrition owing to poverty, the case is referred to the Bromley Children's Care Committee for extra nourishment at home, or at school, or the child may be sent to a residential home for convalescent treatment. (b) Uncleanliness. Table VI. (page 165). One continues to find that the vermin inspections at schools by the school nurses result largely in the re-discovery of the child who is " chronically verminous." Fourteen thousand nine hundred and sixty-seven examinations were made during the year, and vermin were found either in the form of live vermin, or the eggs of vermin, in 320 children. This remains a fairly constant figure over the past few years, and, although eight prosecutions were taken under the School Attendance Rye-laws in 1937, little improvement results in these eases. The fact that uncleanliness should exist at all in these days is incomprehensible to many of us, b t while housing conditions exist without bathroom accommodation one must expect a lack of cleanliness in certnin families. 124 (e) Minor Ailments. Table Ila. (page 155), shows types of defects discovered, while Table IV., Group 1., gives details of treatments carried out at the Treatment Clinics. The large increase in the number treated, and the greater use made of the clinics during the past few years has called for additional medical staffing. The establishment of the South Clinic at Princes Plain has fully justified its erection. The statistics show that approximately 2,500 children passed through the minor ailment clinics in a year, and that these children required 9,500 medical examinations by the medical staff, and 8,700 treatments by the school nurses; thus one can visualise the amount of work carried on, and the benefit that must result from this supervision and treatment of the child under 14 years of age. These figures do not take into account the work of the special clinics. Table Ila. which tabulates the diseases for which the patients received advice or treatment at the clinics during the year, is instructive in that it shows that the 2,500 individual children who attended the clinics suffered from 4,048 defects requiring treatment, and 636 requiring observation—approximately two defects per child.the main defects are skin diseases, diseases of the nose and throat, and defects, such as catarrhal infections, which are not specifically classified. A clinic acts as a clearing house for patients; those that require domiciliary treatment are referred to their own doctor, those requiring hospital investigation are referred to the local hospitals or to the London General Hospitals, and those that can be treated through the special clinics of the School Medical Service. (d) Visual Defects and External Eye Disease. In Table IV., Group II. (page 1 (161) will be found statistics for the year. Of the 1,815 children inspected at the routine medical inspections at schools, 9 per cent, were found to be suffering from defective vision requiring corrective treatment. This figure for Bromley children is a fair ly consistent one over the years, and one feels that little is being done to investigate the cause. It is hoped that the provision of a Measles 125 Nurse, who is giving instruction in the care of the eyes, and prevention of eye-strain, during measles epidemics, will be a factor in the prevention of this somewhat high return. In the care and treatment of squint the Committee established during the year an Orthoptic Clinic, which is proving of undoubted value in treatment. Dr. Eric Lyle's report on the treatment of eye defects follows later in this report. (e) Nose and Throat Defects. Table IV., Group III. (page 1(162), gives the statistics for the year. Defects of the nose and throat continue to swell the returns of defects, especially is this so in the children attending special examinations at the school clinics. Of the 1,815 children examined at routine medical examinations at school, 5 per cent. had defects requiring treatment, while 14 per cent. required further observation before recommendation of operative treatment. Of the 2,500 children who attended special medical examinations, 22 per cent. required treatment, and 10 per cent. required observation. The report of Mr. Charles lieney, Ear, Nose and Throat Specialist, follows later in this report. (f) Ear Disease and Defective Hearing. Table Ila. (page 155) and Table IV., Group I. (page 160) give statistical information for the year. At routine medical examinations 14 children were discovered with chronic ear disease, who were receiving no treatment, or inadequate treatment for their condition, while at the special inspections 249 children were referred to the minor ailment clinics for treatment. This latter figure is dependent upon the prevalence of catarrhal injections, a frequent precursor of ear disease. If these cases can be treated early much chronic ear disease can be prevented, but there remain some chronic cases so resistant to treatment that hospital in-patient treatment is essential. 126 I would refer to Mr. Charles Beney's report on the Special Ear, Nose and Throat Clinic, wherein he states that there is a declining' incidence in the number of chronically discharging ears. (g) Dental Defects. Table V. (page 164). Mr. T. S. Latham, School Dental Surgeon, lias submitted an interesting report which is included later in this report. He reports that, of 5,173 children inspected 60 per cent. required treatment, and that no less than 86 per cent of those who required treatment received it through the School Dental Service. (b) Orthopaedic and Postural Defects. Table IV., Group IV. (page 163). At the routine medical inspections 131 cases were discovered to be in need of some form of orthopiedie treatment, and were in due course referred to the Orthopædie Specialist, Mr. H. J. Seddon, whose report on the work of this Clinic appears later in this report. Many of the postural defects discovered in school children will he self-remedied w hen the physical training scheme has had time to operate. (i) Heart Disease and Rheumatism. Only one new case of heart disease was discovered through the routine medical inspections in 1937, while five new cases were recorded at the special clinics- Twenty-three organic heart cases were under our periodic survey, and while many of these cases remain stationary. some show improvement with advancing years. From time to time new cases are brought to our notice as a consequence of acute rheumatism or scarlet fever infection but there is much yet to be done in the careful supervision of these patients immediately they have completed their active treatment by their own doctors. (j) Tuberculosis. It is not usual to diagnose tuberculosis at a routine medical inspection as the disease is one that requires very careful investigation before diagnosis. All suspected cases 127 are referred to the Tuberculosis Dispensary for the opinion of the Tuberculosis Officer, and it is largely left to him to carry out the necessary investigation and supervision of the confirmed cases. Glandular tuberculosis is not, however, unusual, although it occurs with much less fr equency than in years long past. This is no doubt due to the pasteurisation of milk which has now for some ten' years been almost the only type of milk distributed for sale in Bromley. As a suspected cause of chronic ill-health in children latent glandular infection is by no means uncommon, many of these children being tabulated under malnutrition classification rather than the more fearful diagnosis of latent tuberculosis. (k) Other Defects and Diseases This classification refers mainly to diseases of the nervous system, deformities, and those diseases which are seasonal infections. The incidence of the so-called " nervous child ' is increasing, and appears to be more noted in the early entrant to school. Such children, however, rapidly respond to the school environment.. The damage begins in the 2-5 years of age period, and the opening of nursery classes for these children is to be strongly advocated to the Local Education Authority. Following-up. The following-up of cases in their homes is carried out by the school nurses who co-ordinate their duties with those of Maternity and Child Welfare. Necessitous cases requiring extra nourishment, or convalescence, are referred to the Bromley Childrens Care Committee, whose Annual Report follows later in this report. 846 special visits to school children were made by the school nurses during the year. The following-up of the leaver is now passed to the National Health Insurance records under the new arrangement with the service, and where the medical condition of the child does not permit certain types of employment, the recommendation is made to the Juvenile Employment Bureau. This joining up of the various services is slowly progressive after many years of its advocation. SECTION B. TREATMENT. MINOR AILMENT CLINIC AND SPECIAL CLINICS. 130 TREATMENT. There are two special builildings to provide health treatment clinics, one for each end of the Borough. They have been in full operation during the year as can be seen from the attendances recorded. The total attendances at these clinics, quite apart from their use as maternity and child welfare centres, during 1937, amounted to no less than 29,698. A tabulation of treatments is given in the Appendix (Table IV.), following the School Medical Report. The clinics are open daily and provide in addition to the special medical clinics and minor ailment treatment clinics, special clinics for dental, orthopædic, massage, remedial exercises, eyes, ear. nose and throat, and ultra violet ray therapy. Treatment of Minor Ailments. Cases are referred for treatment from the special medical examination clinics held each morning at both the North Clinic and South Clinic. Provision is also made for cases referred from the Maternit,\ and Child Welfare Service, and for cases referred to us under special arrangements with the County Council. The attendance figure for 1937 for minor ailment treatments by the school nurses is 8,771. Report on the Work of the Eye Clinic. The Eye Clinic is held on 62 occasions during school year, and is attended by Dr. Eric Lyle, whose report follows. To this Clinic are referred all cases of defective vision, except that in the case of a child under 9 years of age the defect must exceed 6/9 in each eye unless symptoms are present. Associated with the Eye Clinic is the Orthoptic Clinic held twice weekly by Miss 1. Bradley under Dr. Lyle's direction. Dr. Eric Lyle reports as follows:— " During the past year the clinics have been well attended. The number of cases which have failed to 131 attend despite being " called up " seems to be lessening appreciably. I am, however, dismayed to find that the work is still behind-hand as regards much of the reinspection of many of the patients. The outstanding feature of this year has been the opening of the Orthoptic Clinic. A large number of squint cases are being treated here. Success depends upon regular and continued attendance. One cannot stress the point too much with the parents, some of whom naturally become a little weary of it all when their children do not lose their squints as rapidly as they would like them to do. Among cases of particular interest there occurred two rather unusual ones: (i) A patient aged 13 years had varicella. Four weeks afterwards she developed a left sided Herpes Zoster affecting the eye, in itself rare in children, and, I imagine, almost unheard of as following upon an attack of varicella in the same patient. (ii) Another case of varicella was complicated by a Keratitis. Here again it is uncommon to find corneal complication of chicken pox. In conclusion I wish to thank the staff for the very excellent way in which the arrangements are made for the running of the Eye Clinic." Eric LytLe, M.D. Report on the Work of the Orthoptic Clinic. The Orthoptic Clinic commenced on june 22nd, 1937, and with the exception of August, two clinics have been held weekly. Six children receive twenty-five minutes' treatment each, and up to the present time 20 children We attended ; the results of treatment ar e as follows:— Six ses are at present receiving treatment. Three cases have been discharged cured. Two cases have been postponed as too young for immediate treatment. 132 Four cases require operation before further treatment. Two cases failed to improve with treatment and operation was not desired. Three cases have been unable to continue their attendance. Of the three cured the average number of treatments required was 20. Miss .j. Bradley in her report states: " The aim of orthoptic treatment is to teach the patient to use both eyes, because when a child squints, only one eye is being used. The child must first be taught to know when he is squinting by recognising diplopia or double vision. Then fusion, or the ability to fuse the images seen by both eyes is taught. In some cases when the fusion faculty is strongly developed the desire to obtain single binocular vision overcomes the squint and the result is perfectly straight eyes. Operation is indicated when the angle of squint is too large to be cured with exercises alone. The faculty of fusing the images seen by the two eyes is a mental one, and, in some cases of squint, this is entire- ly lacking, and these types do not benefit by orthoptic treatment. The number of treatments required to produce a cure varies with the type of squint and the mental ability of the patient. In many cases the squint has been apparent for some years, and so it must take an appreciable time to cure." Report on the Work of the Ear, Nose and Throat Clinic. This treatment clinic is held weekly when five case are selected for operation at the clinic premises. Patient' are retained over twenty-four hours and returned home by conveyance where they are kept under the daily super- vision of the school nurse. Periodic consultation clinics are held to which are referred all cases of ear, nose and throat disorder not responding to treatment, and direction is given by the Consultant, Mr. Charles Beney. His report follows: 133 " The work of the Ear, Nose and Throat Clinic continues unabated. The numbers awaiting operation continues to increase, with the result that cases have a longer waiting time before operation can be undertaken. One hundred and twenty-four patients were seen in consultation with the Medical Officer of Health during the year. One hundred and fifty-seven cases received operative treatment for the removal of enlarged or diseased tonsils and adenoids. Twenty-three other patients referred to their own practitioners, or to hospital for operative treatment. One hundred and fifty-five cases received other forms of treatment. There appears to be a marked decline in the number of chronic discharging ears seen. This I attribute, partly to the earlier operative treatment of diseased tonsils and adenoids, and partly to a more thorough and regular routine ear toilet which is now undertaken. It is noteworthy that, during the past eight years, I have seen no cases of deafness arising from the removal of adenoids at this Clinic. This happy state of affairs, I attribute, partly to the operative technique and partly to the great care exercised by the nurses subsequent to operation. No cases of any serious complication following operation have been reported to me. I very much regret losing Dr. Francis France as Anaesthetist, and should like to thank him for his unfailing kindness and his skill in administering the anaesthetics. My thanks are also due to Miss Price who has given so much of her time and energies in helping on the work of the Clinic, and, lastly but not least, to the Nursing Staff of the Health Department." Charles beney, m.a., m.b., b.ch., M.lt.c.S. Report on the Work of the Orthopaedic Clinic. The Orthopaedic Specialist attends twice monthly when cases are selected for his advice and treatment. 687 consultations were made during the year. Massage, Remedial Exercise Clinic, and Ultra Violet Ray Treatment, are carried out by Miss M. Dodge who attends for five sessions a week. During 1937 we commenced at this Clinic special 134 expiratory breathing exercises for cases of Asthma—the results are promising. 2,977 attendances were made for massage and remedial exercises, and 2,345 for ultra violet ray therapy. These figures show that this branch of the service is fully functioning. Mr. H. J. Seddon reports as follows: " During the past year the work of the Orthopaedic Clinic has been uneventful. There is nothing to indicate that preventive measures have been faulty, nor have there been any unusual cases. Knock knees are still depressingly frequent, and the trouble is that the cause of this condition is still very obscure. Rickets accounted for only three of the 73 new cases. One often finds that there is a history of a fairly severe illness preceding the appearance of the deformity; it is possible that the muscular weakness, which so constantly follows on illness, such as, measles, scarlet fever, pneumonia, or whooping cough, renders the knees unstable and therefore liable to the development of deformity. Fortunately, knock knee deformity, as seen nowadays, is rarely severe, and all the affected children attending the Bromley Clinic have responded readily to relatively simple treatment. The organisation of the work is most satisfactory, and Miss Dodge continues to deal efficiently and kindly with tlie children entrusted to her care." H. J. Seddon, f.R.c.s. ULTRA VIOLET RAY CLINICS. As an adjunct to treatment one finds that Ultra Violet Hay Therapy is a special provision of proved value, particularly during the winter months in the convalescence of general debility and influenza cases. A clinic is held in conjunction with the Orthopædic and Massage Clinic at the North Clinic, where sessions are held twice weekly, and in May, 1937, a clinic was commenced at the South Clinic where one session is held each week. The total number of attendances at the North Clinic were 2,345 and at the South Clinic 256. 135 The following short summary indicates the type of case referred for ultra violet ray treatment, and the general results of such treatment: North Clinic. New cases treated, 182. Attendances, 2,345. General Debility, 91. The majority made good progress and showed increase in weight and improvement in appetite. Chest conditions, 24. Children who attended tor frequent colds and coughs did well, and three were treated for asthma. Chilblains, 3. Much improvement after several applications. Discharging car, one child whilst having treatment at the Minor Ailment Clinic also had sunlight applications to assist in clearing up the condition. Alopecia, 2. These cases did not attend long enough to benefit. Sores, 17. All the cases improved under treatment. Sleeplessness, 17. On the whole all these cases showed marked improvement. Nervous cases, 23. The majority were reported to be much improved. Rhewmatism, 4. General condition much improved. South Clinic. New cases treated, 53. Attendances, 256. General debility, 21. All cases responded to treatment and showed improvement after eight applications. Gain in weight and improvement in appetite was recorded. Infant Welfare eases, 2. One case pale and flabby before treatment showed improvement in muscle tone and general condition after 15 applications. The other case did not attend regularly. Chilblains, 3. All cases showed instant improvement and were quite cured after eight treatments. 136 Alopecia, 2. One case responded quickly and hair commenced to grow. Catarrhal Bronchitis, 4. Cough not so frequent during treatment in three cases, but the fourth case did not respond so well. Nervous cases, 3. No great improvement was reported. Septic skin, 3. These cases responded immediately to treatment after four to six applications. Ears, 3. The discharge became less in all cases and general condition improved. Rhevmatism, 6. Some improvement was shown in these cases. Anaemia, 3. There was great improvement in these cases, lassitude disappeared and general condition im- proved. Gastritis, 1. General condition very much improved. Gland.s, 2. Glands became smaller and general con- dition showed marked improvement. Report on the Work of the Dental Clinic. Mr. T. S. Latham's report follows, and is in itsell indicative of the very valuable work carried out by Mr. Latham, who during the year had the part-time assistance of Mr. Fairman J. Ordish on two sessions a week. Saturday mornings are now allocated to maternity and child welfare cases, and this branch of the Dental Service is increasingly used by the mothers who come under the care of the Municipal Midwifery Service. This dental service to expectant and nursing mothers is an invaluable one, and at the rate of its present growth likely to require more than one session a week. up to the present time the Local Authority does not provide dentures to these cases. Mr. Latham reports as follows: Inspection. " During the year 1937 all schools under the Education Author: received a dental inspection—with one exception. Princes Plain Senior Girls' School—this school will he the first to he inspected in the New Year. In 1935, when we were without the assistance of Mr. Ordish at the South Clinic, Princes Plain, no less than five schools were out 137 standing at the end of the year for inspection. We are now almost on a basis of yearly inspection and treatment, which is the scheme we have arrived at in the re-organisation. Treatment. The total number of attendances for treatment at the two clinics this year has surpassed all records. In 1935, when only one Dentist was at work and there was only one Clinic, the attendances numbered 3,908. This year the figure is 5,004, an increase of 1,096. It will be seen from these figures that the services of the part-time Dentist, who gave 88 sessions at Princes Plain Clinic, have been appreciated by the children. Extractions number 4,605, fillings '2,82'2, and gas administered on 1,263 occasions. It is very encouraging to find that in spite of the greater numbers of children receiving treatment there was an appreciable fall in the number of permanent teeth extracted. Last year there were 910; this year 826. After all. the preservation of permanent teeth is our aim. Orthodontics. There is a growing demand on the part of parents and the older children for orthodontic treatment, that is the regulation of mis placed teeth and the correction of malformed jaws. These cases take much time and many attendances, and for this reason only a limited number can be undertaken. Where regulation plates have to be made the entire cost is borne by the parent. Frequently no plate is required, only judicious extractions. Parents and children are beginning to realise that prominent upper teeth or a receding chin are a very definite handicap both in business and socially. It is hoped that more time will be found for the treatment of these cases. Welfare. As regards children between the ages of two and five years there were 240 attendances. Dental treatment for these children is often of vital importance. One tender tooth can make a child fretty and difficult about its food, but many who are seen at the Clinic preseut four or five badly decayed or abscessed teeth, and it will be seen that the results of treatment are often truly astonishing. An irritable, worrying child, is restored to a normal happv state. Mothers. A total of 55 nursing and expectant mothers attended on Saturday mornings for dental treatment, an increase of 14 on last year. Having regard to the newly established Municipal Midwifery Service there should be a greater increase this coming year, as this scheme is not confined to our regular welfare and ante-natal mothers alone. The dental condition of the majority of these expectant mothers is appalling. If they come for treatment early in their pregnancy we are able to put the teeth and gums in good order and give them a fresh start. if they come towards the last few weeks we often cannot do we should wish, but we can at least make certain that they are free from toothache. 138 Conclusion. Lastly I should like to express my appreciation of the assistance of the Committee and the Staff, and I would again especially thank our Voluntary Workers who spare us so much of their time and give so much real help." T. S. Latham, l.d.s., eng. Summary of Dental Statistics for the year 1937, giving Comparisons with the Years 1935 and 1936. Inspections. 1935 1936 1937 Remarks. No. of Sessions 22 25 27 All schools inspected in 1937. No. Examined 4482 5102 5173 Referred for Treatment Treatment. 2246 (56%) 2744 53%) 2980 (60%; Rise to 60 per cent. because the largest agegroups were in the 6 and 7 year children No. of Sessions 380 418 465 No. Discharged Treated 2274 2428 2564 Includes welfare children : 51 were welfare children in 1935. 108 were welfare children in 1936. 120 were welfare children in 1937. Total Attendances per Session 3908 4368 5004 Includes welfare attend- ances. 100 welfare at- tendances in 1935 ; 216 in 1936, and 240 in 193'7 Average Attendance per Session 10 10 10 Visits per Child 1.6 1.7 1.9 Gas Cases 1115 1194 1263 Extractions 4456 4528 4605 Fillings 2355 2820 2822 Local Anaesthetics 1142 1100 843 Other Operations 438 617 733 Mothers' Treated 42 41 55 SECTION C. I. INFECTIOUS DISEASE AND OTHER DISEASES. Precautionary and Exclusion Measures. II. OPEN AIR EDUCATION AND PHYSICAL TRAINING. III. PROVISION OF MEALS. IV. CO-OPERATION OF PARENTS, TEACHERS, ETC. 140 Infectious Disease. The recommendations of the " Memorandum on Closure and Exclusion from School " are followed in the precautions taken to prevent the spread of infectious disease. Teachers are advised, in order to prevent the entry of an epidemic into schools, that it is better to exclude provisionally one or two children than to permit them to remain at school and to discover a week later that an epidemic is in progress. When a child is excluded from school owing to an infectious disease, such as measles, whooping cough, mumps, chicken pox, etc., parents are instructed to isolate the infected child at home and to see that the child is kept away from play centres, Sunday schools, and all places where children gather together, until entirely free of infection. It has not infrequently happened, however, that children who have heen excluded from school attendance have been allowed by their parents to travel in buses, trams, etc., and to attend other places where they have spread infection. As these infectious diseaseare not notifiable under the Public Health Act in this area, difficulty of control arises unless the Department has the full co-operation of the parents. A pamphlet is being printed for circulation to parents seeking their co-operation in this aspect of prevention of the spread of infectious disease. The Committee's regulations regarding the control of infectious disease in elementary schools have been amended regarding german measles, whereby children suffering from this disease must he excluded for ten days from the onset of rash, and all children in the same house who have not had the disease are excluded from school for fourteen days from the date of commenecement of the last case in the house. The regulations have now heen further amended in respect of chicken pox and mumps; children who are contacts in the same house and have not previously had these diseases will continue to attend school for a period of fourteen days from the date of commencement of the first case and will then be ex eluded for a period of seven days, 141 The following tabulation summarises the returns of infectious disease received from Head Teachers during 1937:— Schools. Diph theria. Scarlet Fever. Measles. WhoopCough. Mumps. Chicken Pox Other. Addison Road 1 6 2 1 12 22 Aylesbury Road — — — — — — — Bickley & Widniore — — — — — — — Burnt Ash 5 14 2 9 50 2 1 Central - 3 4 — Hayes - 1 — 10 — — Keston - 3 — 8 8 — — Masons Hill — - — 4 — 9 — Parish 2 - — 29 12 5 — plaistow, St. Mary's 3 4 16 2 — — Princes Plain 8 6 69 95 1 Raglan Road 2 20 1 19 138 25 — St. Joseph's R.C 1 — — 1 12 — — Valley - 6 — 1 1 2 - 142 Conditions for which Medical Certificates of Exclusion from School were issued by General Practitioners during 1937. Malnutrition, debility 48 Skin 25 Eyes 7 Ears 26 Nose and Throat 113 Enlarged cervical glands 28 Heart 7 Lung (non-tuberculous) 65 Nervous diseases 17 Accidents 25 Operations 10 Measles 2 Whooping cough 38 Mumps 69 Influenza 79 Chicken pox 42 Rheumatism 15 Bronchitis 72 Miscellaneous 124 812 Open Air Education. jVo special open air school for defective children i> provided in Bromley. The provision of free convalescent home treatment for the child needing it is found to be more economical. There is, however, an ever increasing demand for special education for the debilitated, crippled and otherwise physically defective child, and no doubt at some time in the future a special school will be established in Bromley. At present we meet the demand by using the institutions and schools provided by larger education authorities. Physical Training. During 1937, a site of approximately six acres acquired adjacent to the Valley Council School for use as a playing field for the schools in the central area of the Borough. Arrangements for the preparation of the field 143 are at the present time under consideration. The prepara- tion of the Oakley Road and Southborough sites has proceeded during 1937, and, with the Hayes site, the preparation of which was completed during 1937, these two sites will be taken into use in the near future. Arrangements were made during the year for physical instruction to be given to scholars attending the Keston C.E. School in the Village Hall, Keston, and the scholars attending the Bromley Parish Boys' and Girls' Schools in the Bromley Gymnastic Club. am indebted to Mr. G. H. Atkinson, Organiser of Physical Education, for the following information on the development of Physical Education in Bromley. " Under the supervision of the regional organisers of physical education the interest in and development of improved methods of teaching have resulted in marked progress in the quality of the work in the schools. Advanced physical training schemes have been introduced in all senior departments, the teachers having been trained in the use of portable gymnastic apparatus by attendance at short refresher courses taken in school time. Similar arrangements for teachers in junior departments are now being made. Organised games in school playgrounds show considerable improvement, both in the variety of games played, and in the establishment of the principle that all children, whether athletically " gifted " or not are entitled to the same consideration. The Education Committee's new playing fields at Oakley Road and Southborough (as already referred to above) are nearing completion, and will be available for children's visits in Autumn, 1938. Adequate changing and shower bathing facilities are planned. It is to be hoped that the Committee will find it possible to provide for the conveyance of classes to and from these fields, as otherwise it would appear impossible to ensure their use to the best advantage. New building projects include the provision of four well designed and equipped gymnasia for the Committee's senior schools." Provision of Meals. The Local Education Authority has not found it necessary to exercise the powers permissible under sections 82/84 of the Education Act, 1921, nor does there appear to be be any urgent necessity at the present time to put these sections of the Act into operation. Bromley is essentially a residential area in which there would not appear to be any call, on medical grounds, for this provision. When cases of under-nourisliment are found they are referred to 144 the Bromley Children's Care Committee for assistance at home, or for free milk at school. It may he noted, however, that provision is made in certain schools for heating the scholars' mid-day meals, and as previously mentioned in this Report, under the heading Hygiene of Schools, a canteen is working on an experimental basis at the Hayes Council School, the cost of which is defrayed by the scholars, and for which the Education Authority has provided the initial equipment and making certain agreed contributions towards the running costs. Co-operation of Parents, Teachers and Others. Complete success would not attend the work of the School Medical Service unless we had the co-operation of parents, teachers, school attendance officers, general practitioners, and voluntary bodies. This we have in a marked degree, and thus we are able to co-ordinate our two principle aims, that the child shall be fit to benefit to the fullest extent from the educational facilities provided by the Local Education Authority, and that the health of the child be safeguarded and improved. In a great measure this desirable state of affairs has been achieved through our policy of linking up all the Public Health Services and maintaining them under unified control both in practice and administration. SECTION D. I. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. II. NURSERY SCHOOLS. III. SECONDARY SCHOOLS. IV. PARENTS' PAYMENTS. V. HEALTH EDUCATION. VI. SPECIAL INQUIRIES. 146 Blind, Deaf, Defective and Epileptic Children. These children are brought to my attention firstly through the Maternity and Child Welfare Service, and then through School Attendance Officers, Head Teachers and Voluntary Workers. Certain cases miss our early supervision as there is no machinery for the discovery of cases amongst new residents to the town. Eventually, however, these cases come to our knowledge through various channels. All cases are certified and referred to the appropriate Local Authority for the type of education recommended. We have no special schools in Bromley and are dependent upon the larger neighbouring authorities for the accommodation. During the year the following children were provided with this special education suitable for their condition: Blind 2 Tubercular 4 Partially blind 7 Delicate 2 Deaf 6 Crippled 3 Mentally Defective 7 Heart 8 Epileptic 2 Table III. in the Appendix gives the tabulation of 97 children notified as special under the above headings. In addition to this list there are many children on the border line of certification, and for whom periodic supervision is continuously necessary. Nursery Schools. There are no nursery schools in Broinley, and only a few schools accept children under the statutory age of five years. A need does exist in Broinley for the early entry to school as a form of treatment of the maladjusted child and we hope that with the extension of school premises that nursery classes will be adopted as a means of providing this for selected cases. The provision is not necessarily'1 extensive one, and as Bromley is a residential area it due not require the extent of accommodation as would be case of an industrial town of an equivalent size. 147 Secondary Schools. The Kent County Council is responsible for the provision of medical inspection, following-up and medical treatment for the pupils attending the secondary schools in Bromley. The County Council has entered into an arrangement with the Local Authority whereby secondary school children in need of treatment may use the special facilities provided at the School Clinics by the Bromley Education Committee. The following list shows the number of children so dealt with at our clinics: Dental Clinic 71 Eye Clinic 21 Orthopædic Clinic 4 Parents' Payments. The following charges are made upon parents for treatment:— Dental: 1/- for three months' treatment, including gas extractions. Tonsil and Adenoid Operation: 5/- per case. Urthopædic: 5/- for three months' treatment. Inpatient treatment, splints, etc., according to means. Eyes: Barents pay a special reduced cost for glasses. 6d. per first attendance on Specialist's examination. Ultra Violet Ray: 6d. per application. Special Education: Weekly contribution according to the income of the parents. The total income from payments for the financial year 1936/1937 amounted to £988. 148 endeavour to abolish the use of roller towels and to provide a towel for each child. Parents have been asked to do this, but their response is not universally good, and we still see roller towels as a source of infection. This is specially true at the Valley School, Masons Hill and Plaistow. Other schools have responded well. Special Inquiries. No special investigation was undertaken during the year into the causation, treatment or prevention of any disease, or condition affecting the school child. Time unfortunately does not permit, but the hope still exists that with so much material at hand the Committee will consider the possibility of carrying out these investigations during the coming years. It is hoped in the next report to be able to give some personal investigation by the Staft into the many chronic conditions prevalent among the cases attending the clinics. SECTION E. I. OCCUPATION CENTRE. II. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. III. AFTER-CARE WORK. IV. REPORT OF THE BROMLEY CHILDREN'S CARE COMMITTEE. 150 Occupation Centre. An Occupation Centre was opened in Bromley in 1933 under the management of a Voluntary Committee, and is held at St. Mark's Hall, Masons Hill. Upwards of 28 mentally defective children, who are incapable of receiving education in special schools, are accepted at this Centre, and are under the care of Miss H. Wade, Supervisor. Employment of Children and Young Persons. The number of children medically examined by the School Medical Staff during 1937, and for whom certificates were issued, was as follows:— Total No. examined .153 Fit certificates issued 151 The total number of children in employment at the 31st December, 1937, was:— (a) Boys— Newspaper delivery 71 Milk delivery '21 Delivery of goods and parcels 51 Stable lad 1 150 (b) Girls— Housework Nil 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 151 school nurses, who in Bromley also act as health visitors, and much can he 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 zealous services which she and others render so willingly. Report of the Bromley Children's Care Committee, 1937. "Established upwards of thirty years ago, this Committee may lake justifiable pride in the work it has done, and continues to do. for the welfare of the children attending the public elementary schools of the Borough. Year by year the Health Services have grown, and there has been an ever increasing demand for the attendance of voluntary workers at the clinics and centres. The Committee is much indebted to the members who not only retain a zealous interest in the work of the Committee. but freely sacrifice a lot of their time week by week at the clinics. The officials of the Health Services are extremely appreciative of the very valuable assistance our members are able to give. The Committee regretted the loss of the services of two members this year, who, after several years of valuable assistance in the work, found it necessary to resign. We were fortunate in obtaining two more helpers to fill the vacancies. The Committee again wishes to tender thanks to Mr. Harris for supplying spectacles at specially reduced rates to the children, to Mr. Harvey Lowe, who, through the Queen's Reign Commemoration Fund, has helped with convalescent letters for the children, and also to the Bromley Benevolent Association and the Charities Festivities Committee for those generous monetary grantvs without which the Committee could not have carried on its work effectively. During the year -232 cases were referred by the School Medical Officer for assistance of one kind or another, as follows:— Extra nourishment 97 Kail fares to hospitals, and taxis 14 Virol 2 Convalescent Home Letters 37 Provision of spectacles 4 Provision of boots 78 232 One child was sent to the Lancing Home for a period of three months convalescence. 152 Statement of Accounts, 1937. RECEIPTS EXPNENDITURE. £ s. d. £ s. d From Bromley Benevolent Association 70 0 0 Deficit from 1936 9 5 3 Milk 38 7 8 From Charities Festivities Committee 20 0 0 Boots 27 17 8 Convalescent Homes 11 0 0 Repaid— Fares 4 12 7 Fares 2 4 0 Glasses 2 5 9 Glasses 11 0 Clothes '2 0 0 Clinic Collecting Box 1 6 Virol, etc. 17 4 Deficit carried forward 3 15 3 Taxis from Clinic 5 6 £96 11 9 £96 11 9 Amy G. Mann, Chairman and Hon. Treasurer M. A. Isard. Hon. Secretary SECTION F. APPENDIX. STATISTICAL TABLES. TABLE I. A. Routine Medical Inspections. B. Other Inspections. C. Children Found to Require Treatment. TABLE II. A. Return of Defects found by Medical Inspection. B. Classification of the Nutrition of Children. TABLE III. Return of all Exceptional Children. TABLE IV. GROUP I. Minor Ailments. ,, II. Defective Vision and Squint. ,, III. Treatment of Defects of Nose and Throat. ,, IV. Orthopaedic and Postural Defects. TABLE V. Dental Inspection and Treatment. TABLE VI. Uncleanliness and Verminous Conditions, 154 TABLE 1.—MEDICAL INSPECTION RETURNS for the Year ended 31st December, 1937. A.—ROUTINE MEDICAL INSPECTIONS. Number of inspections in the prescribed Groups:— Entrants 682 Second Age Group (intermediates) 555 Third Age Group (leavers) 525 Total 1,762 Number of other Routine Inspections 53 Grand Total 1,815 B.—OTHER INSPECTIONS. Number of Special Inspections 4,951 Number of Re-Inspections 4,584 Total ... 9,535 C.—CHILDREN FOUND TO REQUIRE TREATMENT Number of indimdwiI children found at Routine Medica Inspection to require treatment (excluding Defects o Nutrition, Uncleanliness and Dental Diseases). Group. For defective vision (excluding squint). For all other conditions recorded in Table IIA. Total. Entrants 7 133 111 Second Age Group 55 153 83 Third Age Group 92 98 116 Total (Prescribed Groups) 154 384 310 Other routine Inspections 10 16 13 Grand Total 164 400 323 165 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1937. 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) „ Body — - 4 — (3) Scabies 1 - 18 — (4) Impetigo — — 127 2 (5) Other Diseases (non-tuberculous) 10 2 506 11 Total (Heads 1 to 6) 11 2 656 13 Eye (6) Blepharitis 6 3 19 (7) Conjunctivitis — — 78 2 (8) Keratitis (9) Corneal Opacities — — 3 — (10) Other conditions (excluding Defective Vision and Squint) 3 — 102 4 Total (Heads 6 to 10) 9 3 202 6 (11) Defective Vision (excluding squint) 164 141 103 43 (12) Squint 8 - 24 2 Ear (13) Defective hearing 3 3 26 10 (14) Otitis Media 8 — 100 9 (15) Other Ear Diseases 3 1 123 13 Nose and Throat (16) Chronic Tonsillitis only 6 135 176 78 (17) Adenoids only 5 6 5 5 (18) Chronic Tonsillitis and Adenoids 61 103 255 100 .(19) Other conditions 23 10 224 37 (20) Enlarged Cervical Glands (non-tuberculous) . 1 11 55 20 (21)Defective Speech — 2 6 5 Heart Disease: Heart and Circulation (22) Organic i 4 5 4 (23) Functional 1 30 16 4 (24) Anaemia 11 - 9 - Carried forward 315 451 1985 349 156 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 315 451 1985 349 Lungs (25) Bronchitis _ 36 — (26) Other Non-Tuberculous Diseases 9 26 226 14 Tuberculosis Pulmonary : (27) Definite — — — — (28) Suspected 2 3 9 Non-Pulmonary : (29) Glands — — 1 3 (30) Bones and joints — — - - (31) Skin — — — — (32) Other forms — — — — Total (Heads 29 to 32) — - 1 3 Nervous System (33) Epilepsy - - 3 2 (34) Chorea 1 — 9 6 (35) Other conditions 30 12 91 19 Deformities '(36) Rickets - — - (37) Spinal Curvature 26 7 2 — (38) Other forms 105 41 52 7 (39) Other Defects and Diseases (excluding defects of Nutrition. Uncleanliness and Dental Disease) 78 69 1640 227 Total Number of Defects 564 608 4048 636 157 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. ent. Entrants 682 17 2.49 622 91.20 41 6.01 2 0.30 Second Group 555 36 6.49 451 81.26 63 11.35 5 0.90 ltd Age-Group 525 37 4 7.05 440 83.81 47 8.95 1 0.19 Other Routine Inspections 53 7.55 42 79.25 6 11.32 1 1.88 Total 1815 94 5.18 1555 85.67 157 8.65 9 0.50 TABLE III.—Return of all Exceptional Children in the Area, 1937. BLIND CHILDREN. At Certified fhools for the Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 2 — — — 2 PARTIALLY SIGHTED CHILDREN. J1 Certified wools for Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At other Institutions. At no School or Institution Total. 1 6 2 1 — 10 158 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 6 - — — 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 orlnstitution Total. — — 3 — 1 4 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. At Certified Schools for Mentally Defective Children At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 6 2 1 2 11 MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN) REGULATIONS, 1928. Total Number of Children notified during tlie year 1937 by the Local Educa- , tion Authority to the Local Mental Deficiency Authority ... 159 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 — 1 — 2 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 3 4 - 2 9 B. Delicate Children — 10 2 3 15 C .Crippled Children 3 13 - — 16 D.Children with Heart Disease 8 7 - 4 19 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 1 160 TABLE IV.—Group 1. Minor Ailments treated during Year 1937. Disease or Defect. Number of Defects treated, or under Treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin — Ringworm—Scalp - (ii X-Ray treatment — — (ii) Other 1 — 1 Ringworm—Body 4 — 4 Scabies 13 5 18 Impetigo 120 2 122 Other Skin Disease 496 20 516 Minor Eye Defects (External and other, but excluding cases fallingin Group II) 285 2 287 Minor Ear Detects 217 15 232 Miscellaneous (e.g., Minor injuries, bruises, sores, chilblains, etc.) 1095 154 1249 Total 2231 198 2429 161 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) 632* 632 305 305 305 — 305 Other Defect or Disease of the Eyes (excluding those recorded in Group I) 29 — 29 — — — — - Total 661 — 661 305 — 305 305 - 305 *Including 327 re-inspections. 162 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) 3154 23 3 177 155 335 (i) Tonsils only, (ii) Adenoids only, (iii) Tonsils and Adenoids. (iv) Other defects of the nose and throat. 163 TABLE IV.—Group IV. Orthopaedic and Postural Defects. Under the Authority's Scheme. Otherwise. Total Number Treated. Residential treatment with Education. Residential treatment without Education. Nonresidential treatment at an Orthopaedic Clinic. Residential treatment with Education. Residential treatment without Education. Nonresidential treatment at an Orthopaedic Clinic. Number of Children treated 10 — 330 - — 1 331 164 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 14 260 Total Number 343 607 599 577 572 517 487 443 345 473 (b) Specials 423 (c) Total (Routine and Specials) 5173 (2) Number found to require treatment 2980 (3) Number actually treated 2444 (4) Attendances made by children for treatment 4764 (5) Half-days devoted to:— Inspection 27 Treatment 465 Total 492 (6) Fillings:— Permanent teeth 2506 Temporary teeth 316 Total 2822 (7) Extractions:— Permanent teeth 826 Temporary teeth 3799 Total 4605 (8) Administrations of general anæsthetics for extractions 1263 165 (9) Other Operations:— Permanent teeth 527 Temporary teeth 209 Total 730 TABLE VI.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by the School Nurses 3 (ii) Total number of examinations of children in the Schools by the School Nurses 14,907 (iii) Number of individual children found clean 320 (iv) Number of individual children cleansed under Section 87 (2) and (3) of the Education Act, 1921 — (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-laws 8