44-12 (1) Bromley Borough of Bromley. 1938 ANNUAL REPORT medical officer of health and school medical officer BROMLEY, KENT: Strong & Sons, Ltd., North Street. Borough of Bromley 1938 ANNUAL REPORT medical officer of health and school medical officer BROMLEY, KENT: Strong & Sons, Ltd., North Street. 2 CONTENTS. page Members of the Health and Maternity and Child Welfare Committee 6 Staff 7 Prefatory Letter 11 Section A. Statistics and Social Conditions of the Area. Summary of Statistics 14 Social Conditions 15 Meteorology 17 Unemployment 17 Occupations 18 Population 18 Vital Statistics :— Births 19 Stillbirths 20 Deaths 20 Infantile Mortality 21 Maternal Mortality 24 Section B. (I). General Provision of Health Services for the Area. Laboratory Facilities 26 Ambulance Facilities 26 Nursing in the Home 26 Bromley and District Nursing Association 26 Hayes and West Wickham Nursing Association 26 Treatment Centres and Clinics provided by the Local Authority 28 Tuberculosis Dispensary 29 Venereal Diseases Treatment Centres 29 Hospitals—Public and Voluntary 29 Public Health Act, 1936, Sec. 187/195, Nursing Homes 30 Nursing Homes and Hospitals Tabulation ... 31 Other Institutions Section B. (II). Maternity and Child Welfare. Details of Services 34 Ante-Natal Clinics 35 Domiciliary Midwifery Service 36 Midwives 36 Administration of the Midwives Act, 1902-1936 37 Institutional Provision for Mothers and Children 38 Maternity Hospital 38 Puerperal Fever, Isolation and Treatment 39 Maternity and Nursing Homes 39 Post-Natal Services :— Health Visitors—Home Visiting 39 Welfare Centres 39 3 PAGE Milk in necessitous cases 40 Clinic Treatments of Children under five years, and Mothers 41 Public Health (Ophthalmia Neonatorum) Regulations, 1926 41 Epidemic Diarrhoea 41 Public Health Act, 1936, Child Life Protection 42 Section C. Sanitary Circumstances of the Area. Water 44 Drainage and Sewerage 44 Cesspool Drainage 45 Rivers and Streams 45 Public Cleansing 45 Sanitary Inspection of the Area 45 Shops Act, 1912-1936 46 Smoke Abatement 47 Factories 48 Swimming Baths and Pools 48 Verminous Houses . 49 Rats and Mice Destruction Act, 1919 49 Public Elementary Schools 50 Section D. Housing. Housing Act, 1936—Part IV., Overcrowding 52 Tabulation—overcrowding 52 Section E. Inspection and Supervision of Food. Milk Supply 54 The Milk (Special Designations) Order, 1936 54 Meat and Other Foods 55 Meat—Tables A., B., C. and D 55-57 Unsound and Unwholesome Food Surrendered 57 Foods and Drugs Adulteration Act, 1928 58 Section F. Prevalence of. and Control over, Infectious and Other Diseases. Scarlet Fever 60 Diphtheria 60 Puerperal Pyrexia 61 Acute Poliomyelitis 61 Dysentery 61 Typhoid Fever 61 Cerebro Spinal Fever 61 Measles 61 Tuberculosis 62 Public Health (Prevention of Tuberculosis) Regulations, 1925 63 Public Health Act, 1936, Sec. 172 63 Efficiency of Notification of Tuberculosis 63 Tuberculosis Dispensary—Summary of Work 63 4 page Propaganda 64 Section G. Other Services Supervised by the Health Department. Diseases of Animals Acts 66 Registries for Female Domestic Servants 66 Petroleum Acts 67 Retail Market 68 Appendix. Tables I. to XV. 70-89 SCHOOL MEDICAL SERVICE. Members of the Education Committee 92 Introduction 93 Summary of Statistics 94 Staff 95 Co-ordination 95 Hygiene of Schools 95 Accommodation of Bromley Elementary Schools 96 Section A. Medical Inspection and Findings at Medical Inspections. Medical Inspection 98 Findings at Medical Inspections :— Malnutrition 99 Uncleanliness 100 Minor Ailments 101 Visual Defects and External Eye Disease 101 Nose and Throat Defects 102 Ear Disease and Defective Hearing 102 Dental Defects 102 Orthopaedic and Postural Defects 102 Heart Disease and Rheumatism 103 Tuberculosis 103 Other Defects and Diseases 103 Skin Diseases 104 Following-up 104 Section B. Treatment, Minor Ailment Clinic and Special Clinics. Treatment of Minor Ailments 106 Eye Clinic, Report on the Work of the 106 Orthoptic Clinic, Report on the Work of the 107 Ear, Nose and Throat Clinic, Report on the Work of the 108 Orthopaedic Clinic, Report on the work of the 110 Ultra Violet Ray Clinics 110 Dental Clinic, Reports on the work of the 113 Dental Clinic, Summary of Statistics 116 5 page Section C. Infectious Diseases 118 Medical Certificates of Exclusion from School 119 Open Air Education 120 Physical Training, Report of Organisers of 120-125 Co-operation of Parents, Teachers and Others 126 Section D. Blind, Deaf and Epileptic Children 128 Nursery Schools 128 Secondary Schools 128 Parents' Payments 129 Health Education 129 Special Enquiries—Enuresis 129 Section E. Occupation Centre 132 Employment of Children and Young Persons 132 After-Care Work 132 Bromley Children's Care Committee Report 133 Section F. Appendix. Statistical Tables. Table I. A. Routine Medical Inspections 136 B. Other Inspections 136 C. Children found to require treatment 136 Table II. A. Return of Defects 137-138 B. Classification of the Nutrition of Children 139 Table III. Return of Exceptional Children 139-141 Table IV. Group I. Minor Ailments 142 II. Defective Vision and Squint 143 III. Treatment of Defects of Nose and Throat 144 IV. Orthopaedic and Postural Delects 145 Table V. Dental Inspection and Treatment 146 Table VI. Uncleanliness 147 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-Chairman). Her Worship the Mayor (Councillor M. Stafford Smith, m.b.e., b.a., j.p.). Alderman W. F. Skilton. Councillor G. Allen. Councillor E. C. De'Ath. Councillor George Griffin. Councillor W. J. Guthrie, j.p. Councillor P. Jones. Councillor A. W. Knight. MATERNITY AND CHILD WELFARE COMMITTEE:— Councillor E. C. De'Ath (Chairman). Her Worship the Mayor (Councillor M. Stafford Smith, m.b.e., b.a., j.p.). Alderman W. F. Skilton. Councillor G. Allen. Councillor George Griffin. Councillor W. J. Guthrie, j.p. Councillor F. L. Harris. Councillor S. G. Humerston. Councillor P. Jones. Councillor A. W. Knight. Co-opted Members:— Mrs. A. M. Howe (Vice-Chairman). Mrs. A. G. Mann, b.a., j.p. Mrs. M. Pearce. Miss V. Vincent. Mrs. E. Yolland. 7 PUBLIC HEALTH STAFF, 1938. medical Officer of Health and School Medical Officer 2 K. E. tapper, o.b.e., m.b., Ch.b., d.p.h. Assistant Medical Officers of Health and Assistant School Medical Officers 2 Miss G. H. Stinson, m.rc.s., l.r.c.p. 2 N. M. Macdonald, m.b., Ch.b., d.p.h. (Appointed 14/2/38). Orthopsedic Surgeon 2 1 H. J Seddon, f.r.c.s. Eear, Nose and Throat Specialist 21 Charles C. Beney, m.a., m.b.. Ch.b., (Camb.). m.rc.s. Eye Specialist 21 Eric Lyle, m.a., m.d., Ch.b., d.o.m.S. Anæsthetist 2 N. M. Macdonald, m.b., Ch.b., d.p.h. (Appointed 14/2/38). Consulting Gynaecologist 21 Alistair L. Gunn, m.d.. f.r.c.s. (Appointed 5/7/38). School Dental Surgeon . 2 T. S. Latham, l.d.s., r.c.s. 21 Fairman J. Ordish, l.d.s., r.c.s. Chief Sanitary Inspector 5 4 3 2 G. R. Woods, m.s.i.a., a.r.san. i. District Sanitary Inspectors 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. 0 4 3 2 E. R. H. Hodge, m.s.i.a., m.r san.i. 8 PUBLIC HEALTH STAFF—continued. Health Visitors and 8 7 6 2 Miss L. A. Briggs. School Nurses 8 7 6 2 Miss E. B. Crowe. 8 7 6 2 Miss J. E. B. Dunn. 8 7 6 2 Miss E. Oakes (Appointed 5/12/38) 8 7 6 2 Miss D. Prime. 8 7 6 2 Miss E. Rhodes. 8 7 62 Miss E. Connor (Resigned 31/11/38). Municipal Midwives 7 6 2 Miss S. A. Garner. 7 6 2 Miss M. R. Jenkins (Appointed 1/11/38) 7 6 2 Miss E. Smith. 7 2 Miss A. M. Winter. 7 6 2 Miss J. H. Eastman (Resigned 31/10/38). Orthopaedic Nurse 2 1 Miss M. Dodge, c.s.m.m.g. Orthoptic Nurse 2 1 Miss J. Bradley. Inspector under the Diseases of Animals Acts, and the Petroleum G. R. Woods, m.s.i.a. Acts a.r.san. i. General Office Staff: Chief Clerk 2 H. E. Lawley. Clerks 2 W. S. Denoh. 9 2 D. L. Corder. 2 E. H. Andrews. 2 Miss J. L. H. Huntley. 2 Miss R. Brock. Temporary Clerk Miss D. E. THOMAS (Appointed 17/10/38) 9 Dental Clinic Assistants 2 Miss E. Colin. 2 1 Miss J. Staden. Outdoor Staff: Drain Tester and Disin- fector J. W. Seager Market Superintendent 1 F. J. Ephgrave. 1. Denotes part-time. 6. Three years Hospital Trained. State 2. Exchequer Grants (including Board Registered Nurse. of Education). 7. State Certificate Midwife. 3. Certificate of the Royal Sanitary 8. Royal Sanitary Institute Health Visitors' Institute and Sanitary Inspectors' Certificate. Joint Examination Board 9. Diploma of Royal Institute of Public Royal Sanitary Institute Certificate Health and Hygiene. for Meat and Other Foods. 0. Royal Sanitary Institute Certificate in 5. Royal Sanitary Institute Smoke Sanitary Science as applied to Building Certificate. and Public Works. 11 BOROUGH OF BROMLEY. Report of the Medical Officer of Health for the year 1938. To the Mayor, Aldermen and Councillors of the Borough of Bromley. Madam Mayor, Madam and Gentlemen, I beg to submit the Annual Report upon the Health Services of the Borough for the year 1938. The late publication of the report is due to the stress of extra work entailed under the Air Raid Precaution Services, and it is to the credit of the staff that the report is able to be issued at all. The report is, however, curtailed as much as possible. A general survey indicates a steady maintenance of the health of the people and a continued desire to use the services, especially the Municipal Midwifery Service, offered by the Local Authority. The many new Public Health Acts and Orders and duties under Civil Defence has increased the strain on Department during times of national anxiety, but it is good for all of us that we have been able to face up to the difficulties of the past twelve months. This report could well be filled with a record of the work done successfully I believe, to provide a casualty service the event of hostile air attack. There was during 1938 a fall in the incidence of the common types of infectious disease. There were sporadic cases of food-poisoning, poliomyelitis and cerebro-spinal fever, but happily none assumed epidemic proportions. 12 Our expenditure has advanced with the increased work encountered during the year, but unlike other services, public health requires little money from capital. There is much still to be accomplished in small maters, such as improvement in the distribution of milk, the wrapping of bread and the hygienic handling of other food-stuffs. There is, too, the gross overcrowding in rail transport and the consequent spreading of catarrhal infections. I believe the standard of living of the poorer sections of the community is improving and there is a greater knowledge and practice of the things that make for health and a happy and contented people. The following vital statistics of the year will be of interest, the figures in parenthesis being the corresponding ones of the previous year (1937): — Death Rate 9.5 (9.9) Birth Rate 13.1 (13.2) Infant Mortality Rate 49 (47) Maternal Mortality Rate 3.69 (3.78) Scarlet Fever 1.19 (1.71) Diphtheria 0.32 (0.69) I am not sure that I can look back on 1938 as a successful year of Public Health work; our energy and efforts have been side-tracked from their main objective in order that the Civil Defence may be strengthened.so that we may continue to enjoy our heritage of individual independence. Again I convey to the Committee my grateful appreciation of their help to me and the staff; and to the staff for their very loyal application to their multiple duties. I am, Madam Mayor, Madam and Gentlemen Your obedient servant, K. E. TAPPER, Medical Officer of Health July, 1938. SECTION A. Statistics and Social Conditions of the Area. 14 SECTION A.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA, 1938. Statistics. Area (in acres) 6.519 Population—Mid-year 1938 (Registrar General's estimated) 59,470 Number of inhabited houses— Census, 1931 10,764 End December, 1938 (Valuation figure, 81.3.1939) 11,075 Rateable Value (31st March, 1939) £712,072 The sum represented by a Penny Rate (estimated for the year ending 31/3/1940) £2,880 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 supplied by tie Registrar General: — Live Births. Total. Male. Female Birth Rate Per 1,000 of the estimated population: 13.1. Legitimate 737 391 346 Illegitimate 45 24 21 782 415 367 Stillbirths. Legitimate 27 15 12 Rate per 1,000 total (live and still) births: 36.9. Illegitimate 3 2 1 30 17 13 Deaths 583 279 304 Death Rate per 1,000 of the estimated population: (as adjusted by the Areal Comparability tor 0.97) 9.5. 15 Deaths from Puerperal Causes : — ("Rate per 1,000 total (live and still) births : Number of deaths. From sepsis 1 1.23 From other causes 2 2.46 Total 3 3.69 Death Rate of Infants under 1 year of age: — All infants per 1,000 live births 49.8 Legitimate infants per 1,000 live births 49.8 Illegitimate infants per 1,000 illegitimate live births — Deaths from Cancer (all ages) 98 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) — Deaths from Diarrhæpa (under 2 years of age) 3 Happily it cannot be reported that there were any Causes of sickness or invalidity in the area, during the year, which call for special mention. There are no Conditions of occupation or environment which would appear to exert prejudicial effects on the health of the inhabitants generally. Social Conditions. In my Annual Report for 1937, I referred at some length to the growing practice of transforming houses originally built for single families into so-called flats house two or more families. Often there is little or no structural alteration made to provide separate sanitary, cooking and washing facilities. It is not my intention to labour the point again here beyond iterating that sub-divided dwellings will unquestionably create undesirable social conditions. The number of assessed flats in Bromley is l,387, and one cannot help but view with a certain amount of misgiving the appearance of blocks of flats in Bromley. As a solution of acute housing and social problems in many large cities, perhaps this type of housing accommodation is unavoidable, and one also realises that the 16 transport factor enters into the problem, but where space is available for building to the ideal of " one family, one house," local authorities might well have been invested with more definite restrictive powers. In vulnerable areas where adequate air raid protection has to be devised, the congregating of many families into large blocks of buildings would appear to increase the problem of the best protective measures to be adopted. The encouraging of the. housing of the populace in single house units would appear to be a policy to be adopted so long as civil defence measures are imperative, and, incidentally, evacuation of population would in part be achieved. The following table shows that 595 acres of land have been secured or reserved for public recreation within the Borough: — Acres. Roods. Poles. Acres. Roods. Poles. Commons and Open Spaces: Elmstead Woods 61 1 36 Keston Common 55 1 24 Hayes Common (including Pickhurst Green) 213 1 32 Hollydale 6 1 0 New Street Hill 11 2 8 Southborough 6 0 0 Turpington 1 3 10 355 3 30 Public Recreation Grounds: King's Meadow 9 1 0 Martin's Hill 12 0 29 Oakley Road 2 0 0 Queen's Mead 10 3 15 Widmore 3 1 28 Whitehall 17 1 6 Norman Park (reserved) 56 0 0 110 3 38 Public Gardens and Grounds: Church House Ground 12 3 20 Hayes (Old) Rectory Grounds 2 0 25 Husseywell Crescent 2 1 30 Library Gardens 1 2 0 Queen's Garden 2 1 4 The Knoll 4 1 39 25 2 38 492 2 26 Golf Course: Bromley and Bickley (subject to lease) 103 1 0 17 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 1938: Total rainfall 19.78 inches Mean maximum daily temperature 59.5° F. Mean minimum daily temperature 44.3° F. Highest maximum temperature recorded 84° F. on 6th August Lowest minimum temperature recorded 20° F. on 21st December Lowest grass minimum temperature recorded 20° F. on 18th December Unemployment. The Manager of the Employment Exchange has kindly furnished the following details: — 1. Recorded unemployment at the end of December, 1938: — (a) Men 1173 (b) Women 149 1322 Highest figures reached during 1938 :— (a) Men 1219 (on 12/12/1938) (b) Women 171 (on 21/11/1938) The Manager of the Exchange remarks : —'' There have been no outstanding features of unemployment in the area during the year, but the curtailing of speculative building has contributed to the numbers of workPeople unemployed in the Building Industry. The severe weather experienced in the last two weeks of the year caused almost complete stoppage of building operat ions, but the effect on the live register was partially offset by the numbers of men engaged for temporary Christmas postal work." 18 Occupations. On page 15 of my Annual Report for 1934 will be found details of occupations within the Borough according to the last Census taken in 1931. Population. The following figures of population show the increase of population since as far back as 1831:— Year. Population. 1831 4,002 1901 27,354 1911 33,646 1921 35,052 1931 45,374 1936 57,850 1937 58,700 1938 59,470 The Registrar General gives 59,470 as the estimated resident population of Bromley, mid-year 1938. all vital statistical rates for the Borough are based on this figure for the year under review. The population as estimated by the Registrar General shows an increase of 770 over the previous year. It may be of interest to compare the Registrar General's estimate of population, 59,470, with our on estimated figure of 60,377, which has been calculated from the records of local assessments, as follows: — No. of houses, flats, etc., in Bromley (old boundaries. i.e., excluding Haves and Keston areas): Houses 13,062 Flats 1,319 Farm houses 13 Public houses 34 14,428 No. of houses, flats, etc., in Hayes and Keston areas: — Houses 2,573 Flats 68 Farm houses 1 Public houses 5 2,647 Total 17,075 19 The foregoing figure, 17,075 dwellings, on a basis of 3.61 persons per house, represents a potential population of 61,640, but as allowance must be made for there being some 350 voids (i.e., empty houses) at any one time, we arrive at the net figure of 60,377 as mentioned above. VITAL STATISTICS. Births. The Birth Rate for 1938 is 13.1 per 1,000 population. Under the provision of the Public Health Act, 1936, Section 203, during the year, 834 births were notified to me, of which 812 were live births and 22 stillbirths; of these 641 were notified by midwives and 193 by doctors and parents. The Registrar General gives the number of registered births in the area for the calendar year as 782 live births, which together with 30 stillbirths, gives a total of 812 births (live and still) for 1938. The apparent discrepancies between local figures and those furnished by the Registrar General cannot be reconciled because, on the one hand, births must be notified within 36 hours of occurrence, whereas, on the other hand, the law allows a lapse of six weeks before registration need be effected; a further complication ensues in that adjustments for inward and outward transfers of births are made, and thus it is that anomalies continue to exist. Uniformity is preserved, however, in the calculation of all vital statistics, as the accepted bases for calculations are the figures furnished bv the Registrar General. The following table gives a comparison of birth rates during the last ten years: — Year. Bromley. Birth Rates. England and Wales. 1929 14.8 16.3 1930 14.3 16.3 1931 13.5 15.8 1932 12.9 15.3 1933 12.3 14.4 1934 13.3 14.8 1935 13.5 14.7 1936 13.5 14.8 1937 13.2 14.9 1938 13.1 15.1 20 Stillbirths. The following figures show the number of stillbirths which have occurred in Bromley, together with rates per 1,000 births, during the past ten years: — Year. No. of Stillbirths. Rate per 1,000 Births. 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 1938 30 36.9 This rise in the Stillbirth Rate is a disturbing factor. Deaths. The Death Rate for 1938 is 9.5, which has been adjusted by the Areal Comparability Factor (0.97). This factor applies to the crude rate for " All Causes" only, and not to individual cause rates. The crude death rates for Bromley are set down in comparison with the death rates for England and Wales in the following' table: — Year. Bromley Crude Death Rates. England and Wales Death Rates. 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 1938 9.8 11.6 In Table III, in the Appendix, deaths are classified according' to the list furnished by the Registrar 21 General, from which it will be noted that Heart Disease, 158, and Cancer 98, together accounting for 43 per cent. of all deaths. The following table which covers the last five years, shows how these two diseases stand out as predominating causes of death: Rate per 1,000 population. 1934 1935 1936 1937 1938 Respiratory disease 0.8 0.6 1.02 0.6 1.0 Heart disease 2.8 3.2 2.9 2.9 2.6 Cancer 1.3 1.5 1.5 1.5 1.6 Tuberculosis 0.3 0.5 0.6 0.5 0.3 Congenital causes, etc. 0.3 0.2 0.3 0.3 0.4 Infectious disease .., 0.1 0.1 0.3 0.07 0.03 Influenza 0.1 0.2 0.1 0.4 0.03 Infantile Mortality. The Infantile Mortality Rate for 1938 is 49 per 1,000 live births. Statistical details relating to infant mortality are recorded in the Appendix of Tables (II, IV, V and VI). The following graph of five-yearly rates illustrates the rapid fall in mortality rates :— 22 23 The rise in the Infantile Mortality Rate in the five years 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, 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 commenced. As I reported in 1937, the low level reached in 1935, when the rate was 27, could not be expected to continue, hut although the rate has risen to 49 per 1,000 for 1938 with 47 for 1937, we still happily naintain a much lower rate in comparison with the rest of the country, which stands at 53 for 1938. 39 infant deaths were recorded in Bromley during 1938, and some interesting facts emerge from an analysis of this figure, as follows: — Inward transfers (i.e., babies dying outside the area) 23 Babies who died in Bromley 16 39 Of these 39 deaths, only 6 came under the Municipal Midwifery Service, and the causes of these 6 deaths were: prematurity, debility, etc. 3, malformation 1, suffocation in pram 1, and broncho-pneumonia 1. nquiries into the causes of the remaining 33 deaths lisclosed, as far as could be ascertained, no systematic ante-natal and post-natal medical supervision. 59 per lent. of the 39 deaths were caused through prematurity, congenital debility and malformation—causes which indicate the great need of ante-natal supervision. A feature of our Municipal Midwifery Service is the provision of this supervision as a routine in all cases. The inference to be drawn from these figures is that a saving in mortality might have been achieved had the facilities of the Midwifery Service been available to these 33 cases. 24 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 Triennial period: 1936-1938 3 6 4 Tables II, III and VI in the Appendix will be found to contain statistical data regarding maternal mortality. SECTION B (I). General Provision of Health Services for the Area. 26 SECTION B (I).—GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Laboratory Facilities. The 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 Disease Cases.—Provided by the West Kent Joint Hospital Board at their Hospital at Lennard Road, Bromley Common. (2) For Non-Infectious and Accident CasesThe 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 Beckenham 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 own 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. 27 (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 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. 28 Treatment Centres and Clinics provided by the Local Authority. Medical Clinics. Situation of Clinic or Centre. School Clinic, Station Road, Bromley North. School Clinic, Princes Plain Bromley Comm. Days and Times. Days and Times Medical Inspection Mornings (daily) Weds. excepted. Mornings (daily) Weds. excepted Minor Ailment Treatment Mornings (daily) Mornings (daily) Ear, Nose and Throat Clinic (Operations and Consultations) Wednesdays (a.m.) — Dental Clinic Mornings and afternoons Mondays and/??? Wednesdays week Eye Clinic Wednesdays (a.m.) and alternate Fridays (p.m.) — Orthoptic Clinic Tuesdays (p.m.) and Fridays (a.m.) — Orthopaedic Clinic Surgeon attends 1st and 3rd Mondays monthly (p.m.) — Massage and Remedial Exercises Tuesdays (all day) Thursdays (all day) Fridays (p.m.) — Ultra Violet Ray Clinic Tuesdays and Fridays (p.m.) " Mondays and Thursdays (p.m) Diphtheria Immunisation Mondays (p.m.) Wednesdays (a.m) Dental Treatment for Nursing and Expectant Mothers Thursdays (p.m.) and Saturdays (a.m.) — Infant Welfare Centres. Situation. Days and Times Bromley Common School Clinic, Princes Plain Tuesdays and Friday at 2.30 p.m. Burnt Ash Burnt Ash Branch Library, Burnt Ash Lane Tuesdays and Wed. days, at 2.30 p.m Hayes and Keston Village Hall, Hayes Tuesdays and Thr. days, at 2.30 p.m Plaistow 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 Every Thursday at 2 p.m. Specialist Clinic, Ante-Natal School Clinic, Station Road, Bromley North Held once in two ??? (usually on 2nd ??? days). 29 Tuberculosis Dispensary. The Tuberculosis Dispensary is provided by the Kent County Council and is held at 2, Park Road, Bromley, as follows : — Wednesdays 10.0 a.m.—12.30 p.m. *Fridays 5.0 p.m. 7.0 p.m. (* These sessions are confined to patients who are unable to attend the other sessions on account of their employment). The Tuberculosis Officer in charge is Dr. S. Roy C. Price. A brief summary of the work of the Dispensary appears later under Section F of this Report. Venereal Diseases Treatment Centres. The Kent County Council provides treatment at the rarious 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 rarious large general hospitals. Hospitals. Public and Voluntary. (1) Infectious Disease Hospitals : West Kent Isolation Hospital—I have not been advised of any change in the accommodation at the Hospital, particulars of which were furnished in my report of 1936, page 29. However, alterations were proceeding at the end of the year to provide additional accommodation. West Kent Smallp Hospital—The foregoing remarks similarly apply in this case. (2) General Hospitals: Bromley (Kent and District Hospital) 103 beds Phillips Memorial (Homœopathic) Hospital 20 beds 30 (3) Maternity Hospital : The Bromley and Chislehurst Maternity Hospital (Voluntary) 19 beds (In addition there are 2 labour wards and 1 isolation ward). Public Health Act, 1936, Sec. 187/195. Nursing Homes. Two nursing homes were registered during 1938, and two were voluntarily closed. There are at the present time 8 nursing homes on the register. Nursing homes are inspected quarterly and there have been no matters which have called for report to the Local Authority. The following tabulation gives particulars of maternity and nursing homes registered by the Local Authority as at the 31st December, 1938, and for convenience of recording I have included the two general hospitals, which are exempt from registration under the provisions of the Act. 31 Address Total No. of Beds ity beds Patients received in 1938. Total. Resident. Nursing Staff. Types of cases taken ity Surgical Medical Living out Qualifications. 89, Bromley Common 12 5 53 50 7 5 5 — 1 Gen Trained Mixed 2 S.C.M. 2 Assistants "Greta," Blyth Road (voluntarily closed end 1938) 10 — 2 81 27 5 2 3 1 Gen. trained and S.C. M. Nursing 4 General Trained "Walcot," Blyth Road 4 — — — — 3 2 1 3 S.R.N. Nursing 24, Elmfield Road 10 2 17 1 8 4 4 — 1 Gen. Trained Mixed Northfield, Elmstead Lane 11 — — 18 9 6 5 1 1 Gen. trained and S.C.M. Nursing 5 Assistants 29, Kings Avenue 2 — — — — 2 2 — 2 Masseuses (C.S.M.M.G.) Nursing "Frascati," Masons Hill 18 6 44 24 49 10 9 1 4 Gen. Trained and S.C.M. Mixed 1 General Trained 1 S.C.M. 4 Assistants 16, Sundridge Avenue (voluntarily closed end 1938) 4 — — — 13 1 1 — 1 untrained Nursing 13, Tweedy Road 4 — — — 6 3 1 — 2 Gen. Trained. Nursing 1 Assistant (staff engaged as required) Maternity Hospital, 118, Widmore Road 19 19 375 — — 12 12 5 Gen. Trained and S.C.M. Nursing Maternity 4 S.C.M. 3 Asst. Nurses Bromley (Kent) and District Hospital, Cromwell Avenue 103 — — 1294 362 47 47 8 Gen. Trained and S.C.M. Gen. Hospital cases 8 Gen. Trained 29 untrained 2 Masseuses Phillips Memorial Hospital, Lowndes Avenue 20 — — 144 64 7 7 2 Gen. Trained and S.C.M. Gen. Hospital cases 3 Asst. Nurses 2 Probationers 32 Other Institutions. (1) The Rochester Diocesan Society for Befriending Women and Girls has a Home at 29, Ravensbourne Road, which was opened in October, 1912. Here unmarried expectant mothers are received and arrangements made for their confinements in maternity homes or in the County Hospital, Farnborough, 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, fostermothers 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. Demands on the accommodation of this Hostel continue to be great. SECTION B (II). Maternity and Child Welfare. 34 SECTION B (II).—MATERNITY AND CHILD WELFARE. The Maternity and Child Welfare Services comprise the following: — (1) Maternity and Child Welfare. (a) Six full-time Health Visitors are employed on School Medical Service duties and Maternity and Child Welfare Service duties, their 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, 1936, 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 and provision of dentures 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. 35 (3) Midwives Acts, 1902-1936, Administration of. (4) Public Health Act, 1936, Nursing Homes, Administration of. (5) Treatment Schemes and Clinics for Children under 5 Years. (a) Consultant Surgeon and Orthopædic 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) Ultra 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 three 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 1938 132 253 233 47 36 Natal Services. Domiciliary Midwifery Service. This service has now been functioning since October, 1937, and has continued to function with increased efficiency. The work of independent midwives is negligible so that we may safely say that domiciliary midwifery is now operated by the local authority. The service is a complete one giving a free choice of midwife, the choice of a doctor for the ante-natal and post-natal examinations in the home of the patient, and the services of a home help if required. Ancillary services comprise dental attention, the provision of dentures, and extra nourishment where advised. Hospital accommodation is available where the home circumstances are unsuitable or the case cannot with safety be confined at home, and the services of a consultant where complications of pregnancy arise. It is of interest to note that 65 per cent. of cases received ante-natal and post-natal attention under the General Practitioner Scheme, and 33 per cent. received the services of a home help. There has been a remarkable fall in the incidences of medical aid being called for by the midwives at the confinements—a fact which indicates that the services are effective in the prevention of complications. Dr. Stinson, the Inspector of Midwives, reports that the work of the midwives gives entire satisfaction. Their records are well kept and their equipment always of a high standard. She states, "I believe they are very interested and happy in their work and I would like to congratulate them on the splendid 'Esprit de Corps' which exists among them. They are always ready to help each other if necessary." Midwives. (i) The number of midwives practising in the area of the Local Supervising Authority at 31st December, 1938 (a) Employed by the Local Supervising Authority 4 (b) Employed by Voluntary Bodies 15 (c) In private practice 5 37 (ii) Number of cases attended by midwives 822 (a) As midwives 413 (b) As Maternity Nurses 409 (iii) Number of cases in which medical aid was summoned by a midwife under Section. 14 (i) of the Midwives Act, 1918 50 (a) In domiciliary practice 49 (b) In Institutional practice 1 (iv) Number of domiciliary births during the year in the area of the Local Supervising Authority 304 Administration of the Midwives Acts, 1902-1936. No. of midwives practising in Bromley at the end of the year 1937 22 No. who gave notice of intention to practice during 1938 26 No. removed from register having left the district during 1938 1 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 1938 24 Notifications Received. Notices summoning medical aid 50 (i) Mothers 39 (ii) Infants 11 Notices of Artificial Feeding 7 Stillbirths 3 Deaths 1 Laying out a Dead Body 1 Source of Infection 4 38 Summary of Reasons for sending for Medical Aid. Albuminuria 5 Ruptured perineum 7 Delayed labour 3 Varicose veins and leg swellings 4 Placenta adherent 1 Abnormal presentation 3 Haemorrhage 3 Rise of temperature 5 Other causes 8 Infants—Cyanosis 1 Eye discharge 4 Feebleness 2 Malformation 2 Rash 2 Post-Certificate Course. A Course of Post Certificate Training held at Maidstone during October, 1938, was attended by 15 midwives from Bromley. The usual facilities to attend were granted by the Local Supervising Authority. Institutional Provision for Mothers and Children. There is no special provision for sick or ailing children, or for convalescent home treatment for mothers and babies, but no difficulty arises in obtaining hospital treatment for acute cases either in Bromley or London. Thirty-one babies needing hospital treatment were so dealt with during the year, and two mothers and their babies were sent for convalescent treatment through the agency of voluntary associations. Maternity Hospital. The Bromley and Chislehurst Maternity Hospital admitted to their beds no less than 375 women for confinements ; of this number the Municipal Midwifery Service referred 22, which were all cases of complied 39 confinements. In addition the Department referred 16 cases, which showed signs of abnormality, to the County Hospital. Puerperal Pyrexia, Isolation and Treatment. The arrangements with Queen Charlotte's Maternity Hospital, Isolation Block, Hammersmith, for isolation and treatment of puerperal pyrexia cases occurring in the area, still stand, and ambulance facilities for removal exist through the Ambulance Service of the London County Council. Thirteen cases of puerperal pyrexia were notified Ruling the year, of which six were removed to Queen Charlotte's Hospital, six to the County Hospital, and one was home nursed. Maternity and Nursing Homes. Reference to these institutions will be found under ihe paragraph Public Health Act, 1936, Sec. 187/195. Nursing Homes. Post-Natal Services. Health Visitors—Home Visiting. Table XII n the appendix indicates to some extent the work which the Health Visitors have been able to accomplish during the year, and it is satisfactory to note that notwithstanding the many duties to be carried out by the Health Visitors at School Clinics and Welfare Centres, which during the year were further stressed by civil defence duties outside their usual office hours, there has been no lessening in the number of visits paid. Welfare Centres. Nine sessions are held weekly at the six Welfare Centres provided by the Corporation. Table XIII in the appendix shows an all-round increase in attendances. The work carried out at the Centres by the Voluntary 40 Workers is of inestimable value and is greatly appreciated by the permanent staff. The work carried out by these ladies week by week contributes in no small measure to the. success which attends the work of the Welfare Centres. The following extracts from the statistics compiled indicate to some extent the activities undertaken at the Centres during 1938 : — (a) Total number of attendances at Centres during 1938 27,105 (i) by children under 1 year of age 11,013 (ii) by children between the ages of 1 and 5 16,092 (b) Total number of children who attended at the centres for the first time during 1938 786 (i) children under 1 year 567 (ii) children between the ages of 1 and 5 219 (c) Total number of children who were in attendance at the centres at. the end of 1938 2,749 (i) children under 1 year 417 (ii) children between the ages of 1 and 5 2,332 Milk in Necessitous Cases. Milk is granted on medical grounds to cases whose family conforms to a scale of income not exceedingFather and Mother £2, for the first child 5/-, and for any subsequent child 2/6. One hundred and fifty-two applicants were granted milk for varying periods during 1938. The total quantity supplied was 2,156 gallons (liquid) and 136 lbs. (dried). 41 Clinic Treatments of Children under 5 Years, and Mothers. (a) Children under. 5 Years. No. of cases treated. Tonsil and Adenoid Clinic 21 Eye Clinic 54 Dental Clinic 153 Minor Ailments 76 Orthopaedic Clinic: At the Special Clinic 56 Hospital—in-patient treatment 5 Ophthalmia Neonatorum—Hospital treatment 3 (b) Mothers. Dental Clinic 65 Maternity— Assisted Hospital Scheme 22 Other hospital 16 Public Health (Ophthalmia Neonatorum) Regulations, 1926. Under these Regulations five cases were notified during 1938, of whom three received hospital treatment. All cases cleared up with vision unimpaired. Epidemic Diarrhoea. The epidemic of Sonne's Bacillus Dysentry fortu- nately abated in 1938, following the widespread infec- tion throughout the country in 1937. Twelve cases were notified early in 1938, which included five children under five years of age, and happily mortality among cases absent. Four deaths from Diarrhœa appear in the classification of causes of death (Table III in the appendix), three of whom were children under two years of age and one was classified as two years and over. 42 Public Health Act, 1936, Child Life Protection. Persons registered as foster-parents under the above Act in Bromley are showing satisfactory management and appreciation of their duties in connexion with the boarding out of children. We had no occasion to institute proceedings, and very few minor irregularities of delay in notifying reception and removal of infants occurred. The number of persons who had children under their care at the end of 1938 was 23, and the number of children boarded-out was 40, which included a number of children under the age of 9 years resident in boarding schools. SECTION C. Sanitary Circumstances of the Area. 44 SECTION C.—SANITARY CIRCUMSTANCES OF THE AREA. Water. I am indebted to the Clerk of the Metropolitan Water Board for the following information: — "The supply is derived from the Board's Shortlands and Orpington wells and from the River Thames. No new source of public supply has been instituted beyond the bringing into commission of a new pumping plant at Shortlands which permits of the distribution of Thames derived water into the Borough, and no important extensions of mains has taken place. The whole of the supply to the Borough is regularly chloraminated, and bacteriological tests are made on every working day. The results of the bacteriological tests for 193S were as follows: — Average number of colonies on Agar at 37° C. Percentage number of samples containing no Bact. coli in 100 ml. Shortlands 0.1 98.8 Orpington 0.2 99.2 Thames supply 3.8 96.4 It will be seen, therefore, that the supply to the Borough is of remarkably high hygienic purity. It has also been satisfactory in quantity." 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. A new soil sewer was constructed, connecting properties in Beech Dell and Pine Glade to the main sewer in Croydon Road. 45 Cesspool Drainage. Four houses were constructed with cesspool drainage during 1938, and do not enter into the following figures. The work of securing the abolition of cesspools in the areas of Hayes and Keston has progressed satisfactorily, as by the end of the year under review 261 out of 280 premises with sewer available have been converted by owners to main drainage. There remain 12 cesspools where there is a sewer within 100 feet, and 7 cesspools with sewer over 100 feet distant. There also exist 65 cesspools without a sewer available. It should be noted that the latter figure stood at 80 at the end of 1937, and during 1938 the construction of the new soil sewer in Beech Dell and Pine Glade, as mentioned above, secured the abolition of 15 cesspools. It will, therefore, be seen that 276 cesspools have been abolished since taking over these areas in 1934. Rivers and Streams. A reinforced concrete culvert was provided for a length of watercourse between Blenheim Road and the Southern Railway (at Waldo Road Corporation Depot). During the year 11 inspections were carried out and abatement of nuisances was secured in 6 instances. Public Cleansing. No alterations were carried out to the refuse collection and disposal system other than extension to new properties. A modern type of road sweeper was put into commission. SANITARY INSPECTION OF THE AREA. Tables VII, VIII and XV show the very varied duties involved in sanitary inspection of the area as carried out by the Sanitary Inspectors. 972 dwelling houses were inspected during 1938, and in connection with this work the Inspectors made no less than 4,456 visits for primary inspections and subsequent 46 re-inspections. Of these 972 houses, 806 were found not in all respects reasonably fit for habitation. Informal notices were issued in 750 instances and the remainder were dealt with satisfactorily by mutual co-operation between owners and the inspectors. The great majority of houses under notice during the year were made fit, and at the time of writing the outstanding defects at the end of the year have, with the exception of a few minor matters, been satisfactorily remedied. In addition to the foregoing figures it should be noted that 342 houses were inspected as follows : Overcrowding, 6; verminous conditions. 37; dirty conditions, 5; water supply, 1; cesspool drainage, 77; infectious disease, 122; disinfection purposes, 83; and disinfestation purposes, 11. SHOPS ACTS, 1912-1936. The Shops Act of 1934 which came into operation on 31st December, 1934, regulates the number of hours during which young- persons under the age of 18 years may be employed, and provides generally for the health and welfare of the workers. The Shops Act, 1936. brings lending libraries, with certain exceptions, within the purview of the Shops Acts. The Retail Meat Dealers (Sunday Closing) Act, 1936, requires that butchers' shops shall be closed on Sundays, with certain exemptions with regard to selling of kosher meat. The Shops (Sunday Training Restriction) Act, 1M> restricts the opening of shops and trading on Sunday. The Act contains provision for granting partial exemption orders and special provisions regarding the Jewisn Sabbath. Where assistants are employed on Sundays the Act provides for holidays on week-days in lieU thereof. These enactments are all designed to minimise a> far as possible any conditions which militate againsttw health of shop assistants and employees, and as tar as 47 Bromley is concerned, the infringements encountered have been of a minor character, and shopkeepers have readily complied with requirements. During 1938, 299 inspections were made, and the following tabulation indicates the prevalent type of contravention encountered :— Unsatisfactory conditions relating to: Washing facilities 1 Ventilation 3 Temperature 4 Sanitary conveniences 2 Absence of statutory forms: Assistants' Half-holiday Forms 26 Closing Declaration 7 Form F (daily hours to be worked by young persons) 18 Form G (to be used only in connection with Form F) 17 Statutory Closing Notice (if partially exempt) 7 Form H (abstract of provisions of the Shops Act relating to hours of employment of young persons for retail shops) 18 Form K (notice with regard to the provision of seats for female workers) 13 Other unsatisfactory conditions:' Meals rest interval unsatisfactory 1 I nsuitable and insufficient means for meals — No seats for females 5 Miscellaneous 7 SMOKE ABATEMENT. Three Sanitary Inspectors on the staff hold the special certificate of the Royal Sanitary Institute for smoke inspection. 44 inspections were made with regard to 9 instances of nuisance from smoke, which were all abated. 48 FACTORIES. The Factories Act of 1937, which came into force on 1st July, 1938, is a consolidating and amending measure and replaces the Factory and Workshop Act of 1901 and various later Acts. Broadly speaking, the Act still requires Local Authorities to enforce various general provisions for protecting the health of persons employed in establishments where mechanical power is not used, and they still must exercise special functions relative to means of escape in case of fire, keeping records of outworkers and prevention of homework in unwholesome premises. The Act, however, extends their duties in other important respects, all of which are designed for the betterment and general welfare of employees in these establishments. Table XIV, in the Appendix, indicates the work done during 1938. SWIMMING BATHS AND POOLS. (a) Public Open-Air Bath. The reconstruction at the Open-Air Bath, which included the entire reconstruction of the dressing accommodation, provision of sun-bathing terraces, new refreshment buffet, offices and lavatories, was completed during the latter part of 1937, and the Bath was available throughout the season. The basket system of clothes storage is now in operation and foot baths are provided for the use of bathers entering the Bath. The fitration and chlorination plant continued to work satisfactorily, and tests are taken twice daily to ascertain the presence of free chlorine and to ensure that a slight alkalinity is maintained. Samples of the water are taken and tested at intervals for bacterial content and such tests have shewn the quality of the water to be entirely suitable. (b) Privately Owned Baths. Fourteen samples of water from privately owned swimming baths were taken by the Department during 49 the year and submitted to the Kent County Council Laboratory for examination. The reports were unsatisfactory in seven instances and immediate steps were taken to effect improvement; subsequent tests have been satisfactory. VERMINOUS HOUSES. 37 houses were inspected for verminous conditions and remedial measures were advised and carried out. (i) The number of Council houses found to be: (a) Infested 2 (b) Disinfested 2 (ii) The method employed in disinfesting the above was by power spray and "Pyagra" insecticide, after removal of woodwork in rooms infested. (iii) No method of ensuring that the belongings of tenants are free from vermin before removal to Council houses is in force, as there is no provision for the necessary visiting and inspection of the applicants' present houses. (iv) The disinfestation is carried out by the tractors' meD under the direct supervision of the Property Manager. (v) To prevent re-infestation, premises are ally inspected and every help given to the tenant to continue treatment if and when necessary. To prevent infestation tenants are give to understand that advice and assistance is always available of the housing staff and the general principles of cleanliness are pointed out, if deemed advisable, on inspection. RATS AND MICE DESTRUCTION ACT, 1919. Propaganda and activities in connection with Rat Week had of necessity to be curtailed in Bromley owing to the additional work occasioned by the September Crisis; thus we were not able to attract the attention of 50 the public to such an extent as in previous years. There was, however, a considerable amount of work done. Official posters, leaflets and pamphlets were distributed, and special notices were inserted in the local press. The local chemists again willingly co-operated, but, from their reports, it would appear that very little interest was shewn by the public. The tradesman takes apparently but very little interest in rat destruction efforts, and this perhaps is surprising having regard to the very material damage caused to stocks by rats. The following figures are comparative and relative to Rat Weeks, 1937 and 1938:— 1937. 19.38. Total number of applicants for poison during Rat Week 196 85 (a) from Trade premises 23 16 (b) from Private residents 173 69 No. of bottles of Red Squill given free 284 182 No. of tins of Red Squill biscuits given free 21 6 The figures below indicate to some extent the activities of the Inspectors of the Department during 1938:— Total No. of inspections made 447 Total No. of infestations discovered 107 Total No. of infestations abated 110 Preliminary Notices served 93 PUBLIC ELEMENTARY SCHOOLS. The sanitary condition of the elementary schools is dealt with in the School Medical Service section of this Report under the head "Hygiene of Schools.'' SECTION D. Housing. 52 SECTION D.—HOUSING. Table XV. in the Appendix gives particulars of action taken during the year. Housing Act, 1936—Overcrowding. Particulars up to 31st December, 1938. Description. Total. Abated. Still overcrowded. Borough Council Houses 20 6 14 L.C.C. (Downham) 60 36 24 Other houses 136 91 45 Totals 216* 133 83 *Original figure at January, 1936, Survey. (a) (i) Number of dwellings overcrowded at the end of the year 83 (ii) Number of families dwelling therein 90 (iii) Number of persons dwelling therein 556 (b) Number of new cases of overcrowding reported during the year 2 (c) (i) Number of cases} of overcrowding relieved during the year 15 (ii) Number of persons concerned in such cases 90 (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 SECTION E. Inspection and Supervision of Food. 54 SECTION E.—INSPECTION AND SUPERVISION OF FOOD. Milk Supply. The current register of dairies, milk stores, etc., contains the following figures of registrations:— (i) Premises within the Borough 83 (ii) Premises outside the Borough 26 The Milk (Special Designations) Orders, 1936-1938. The Local 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 The Sanitary Inspectors during 1938 made 75 inspections of dairies and milk shops, and defective conditions were remedied in 12 instances. Samples of milk have been taken systematically throughout the year as follows:— Bacteriological examinations—ordinary 25 graded milk 33 Tubercle bacilli 11 The presence of bacillus coli in 16 of the ordinary milk samples taken was an unsatisfactory feature in the reports on these samples, and 3 samples of pasteurised milk showed presence of B. coli in a lesser degree. Milk supplied to schools was subjected to sampling on 11 occasions, and 2 samples were reported below standard. Milk. Contraventions. No contraventions arose which called for statutory action. 55 Meat and Other Foods. There are five registered slaughterhouses and three licensed slaughterhouses in the area. Under the provisions of the Slaughter of Animals Act, 1933, the Local Authority granted 19 licences to slaughtermen during 1938. The following Tables (A—D) give details of figures relating to carcases inspected and condemned during 1938:— Table A. Carcases Inspected and Condemned. Total Cattle (excluding Cows) Cows Calves Sheep and Lambs Pigs Number killed (if known) 4897 328 37 228 2758 1546 Number inspected 4883 328 37 224 2753 1541 All Diseases except Tuberculosis Whole carcases condemned 11 — — 2 - 9 Carcases of which some part organ was condemned 361 67 11 1 114 168 Percentage of the number inspected affected with disease other than tuberculosis 7.62% 20.43% 29.72% 1.33% 4.14% 11.49% Tuberculosis only. Whole carcases condemned 12 2 5 — — 5 Carcases of which some part of organ was condemned 157 19 20 1 — 117 Percentage of the number inspected affected with tuberculosis 3.46% 6.40% 67.5% 0.45% - 7.85% 56 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). 4897 4883 169 (3.46%) 372 (7.62%) 541 Table C. Total weight of carcases, parts of carcases, offal, etc., rejected for all diseases. Tons. Cwts. Qtrs. lbs. Total in lbs. Carcases 2 13 3 18 6038 Parts of Carcases — 11 1 23 1283 Offal — 18 3 25 2125 Total 4 4 1 10 9446 57 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) - 23 - 22 1 - 23 1850 Cows — 1 — — 1 — 1 17 Calves 3 10 — — 10 — 10 13 Sheep 12 6 6 — 6 — 12 165 Pigs 60 6 — 7 3 4 6 71 Total 75 46 6 29 21 4 52 2116 Meat. Contraventions. No statutory action was called for in connection with contraventions of the Meat Regulations. Unsound and Unwholesome Food Surrendered. Article of Food. Weight (in lbs.). Meat 1803 (imported, etc.) Poultry 53 Rabbits 154 Fish 260 Vegetables 110 Fruit 62 Tinned Goods. Quantity. Vegetables 7 tins approx. 1,130 lbs. Fruit 124 „ Fish 870 „ Milk, Cream 95 Meat 30 „ Chicken 112 „ Miscellaneous 9 „ 58 Food and Drugs (Adulteration) Act, 1928. The Food and Drugs Inspector (Mr. E. R. Granger) has kindly furnished me with the following details of his work in Bromley during 1938:— RETURN OF SAMPLES TAKEN IN THE BOROUGH OF BROMLEY. Year ended 31st December, 1938. Arrowroot 1 Tapioca 1 Brandy 1 Whisky 1 Butter 4 Camphorated Oil 1 Cocoa 2 Iodine, Tine, of 1 Coffee 3 Linseed, Crushed 1 Cornflour 1 Quinine Amm. Tine. of 1 Cream 1 Flour 2 Sweets 1 Fruit, Dried 1 Beef Dripping 1 Gin 1 Golden Syrup 1 Jam 1 Fish Dressing 1 Lard 3 Aspirin Tablets 1 Margarine 3 Friars Balsam 1 Milk 60 Sild in Pure Olive Oil 2 Oatmeal 1 Brisling in Pure Olive Oil 1 Olive Oil 1 Pepper 1 Fresh Cream Sandwich 1 Rice 1 Sausages 1 Suet, Shredded 1 Total 108 Sugar 2 One Milk sample was reported to he "Inferior, all other samples "Genuine." SECTION F. Prevalence of, and Control over, Infectious and other Diseases. 60 SECTION F— PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES. Tables IX, IXa X and XI in the Appendix give statistical data in connection with notifications of infectious disease and tuberculosis during 1938. Scarlet Fever. The incidence of Scarlet Fever continued at a low level and we are in the trough of the periodic wave. There was a further reduction in the incidence rate from 1.7 to 1.19. Scarlet Fever to-day can be looked upon as a variety of infections and not as a single disease. The varieties of the infecting germ are multiple in type, and consequent signs are not always to type. This further complicates the question of hospital admission previously discussed in my annual reports and further strengthens the policy of home isolation. In spite of this, 57 of the 71 notified cases were admitted for hospital treatment, i.e., 80 per cent. of cases as compared with 83 per cent. in the previous year. Cases should only be admitted to hospital if they cannot be satisfactorily nursed at home or if the severity of the infection warrants hospital treatment. The cost of hospital treatment is a high one for Bromley. Diphtheria. A marked fall in the incidence of diphtheria is again reported—19 cases compared with 40 of the previous year; and incidence rate of .32 as compared with .6 for 1937. There were no deaths. Diphtheria immunisation is progressive, but I am not yet prepared to say that the control of the infection is due entirely to this. I can say, at this stage, that immunisation is of immense value and a great help in the investigation and control of an outbreak of infection in schools. 61 Puerperal Pyrexia. During the year, 13 cases were notified to me, 6 of whom I admitted to hospital at Isolation Block of Queen Charlotte's, Hammersmith, 6 to the County Hospital, Farn borough, and one was home nursed. There was one death which occurred in hospital. Nine of the cases occurred in hospitals or nursing homes, one was a doctor's case in private attendance, and three were midwives' cases in domiciliary confinement, one of which was a municipal case. Acute Poliomyelitis. Two sporadic cases of Infantile Paralysis occurred during the year, both now suffering from mild sequelae. Dysentery. Sonne's dysentery cases continued into early part of 1938, 12 cases being notified. Typhoid Fever. One case notified during the year. This case was a wild paratyphoid B nursed at home and associated with a few mild cases in Lewisham. The case made an uneventful recovery. Cerebro-spinal Fever. Two cases notified during the year, both of which were admitted to hospital. One of the cases was not confirmed in hospital, being a pneumococcal infection, and no source of infection could be traced in the other case. Measles. Owing to the epidemic of measles in the early months of 1938, a special measles nurse was appointed on March 2nd, and the appointment terminated on May 21st. The work she did was invaluable, and I am convinced that it was due to her services that the complications in this epidemic were kept to a minimum. Much valuable instruction work was also done. She paid 62 during' the time of her employment 1,219 nursing visits to 562 cases. Seventy-two of these cases showed complications and it was necessary to send 5 cases to hospital. In comparison with other epidemics of measles, the record of this one is especially pleasing in that complications were fewer and that there were no deaths. Much of this was due entirely to the work of Mrs. Kingston. Tuberculosis. Tables IX and X give incidence and mortality figures for 1938. The total number of cases on the register at the 31st December, 1938, was as follows:— Respiratory. Other forms. Total No. of cases. Male. Female. Male. Female. 165 156 67 80 468 Sixty-five new cases were taken on the register during the year, of whom 30 were patients moving into the district from other parts. Twenty-two deaths occurred during the year and 17 patients either left the district or were deleted from the register as cases recovered. The following table of incidence rates and death rates of tuberculosis are given for comparison:— Year. New cases Incidence per 1.000 population. Death Rate. Pulm. Non-Pulm. Pulm. Non-Pulm. 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 1938 0.8 0.2 0.3 0.08 63 Public Health (Prevention of Tuberculosis) Regulations, 1925. Public Health Act, 1936, Section 172. No action was necessary under the above enactments during 1938. Efficiency of Notification of Tuberculosis. There were six cases of unnotified tuberculosis amongst the twenty-two deaths from tuberculosis, but as these six cases concerned deaths which occurred outside the area, little could be discovered regarding the history of the cases, their residence here having been apparently of a transitory character. Thus too much importance should not be attached to the rather high proportion shown, and must not be interpreted as indicating laxity in notification—actually the contrary exists in the area. Tuberculosis Dispensary. The Tuberculosis Officer, Dr. S. Roy C. Price, has kindly furnished me with the following brief summary of work carried out at the Dispensary during 1938: BOROUGH OF BROMLEY. New cases attending the dispensary for the first time during 1938. Adults. Children. Male. Female. Male. Female. Pulmonary 20 18 1 - Non-pulmonary — 8 — 1 Negative 14 17 6 5 Total 34 43 7 6 of contacts examined during 1938 35 No. of contacts found to be positive (not included above) — total number of attendances at the Dispensary during 1938 2538 No. of patients who completed a course of residential treatment during 1938 137 64 PROPAGANDA. No active propaganda was carried out during the year. A good service continues to advertise itself, as is indicated by a study of the statistics of the individuals attending the various clinics. SECTION G. Other Services Supervised by the Health Department. 66 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 202 Animals concerned— (i) Pigs 1947 (ii) Sheep, lambs 506 Sheep Dipping. Certificates issued by the Local Authority Nil. No. of sheep double-dipped Nil. Foot and Mouth Disease. No. of Movement Licences issued by the Local Authority Nil Swine Fever. An outbreak of Swine Fever occurred at a pig keeper's premises during November. At the time there were 66 live pigs on his premises and up to the end of the year he lost 17 infected pigs. The infection was brought into the Borough by pigs purchased from an outside source, and 10 of the 17 infected pigs were from this source. All the prescribed precautions were exercised and only the one pig was infected on the farm. No. of inspections made in connection with the above-mentioned details 84 No. of interviews in connection therewith 134 REGISTRIES FOR FEMALE DOMESTIC SERVANTS. The chief Sanitary Inspector made seven periodical inspections of registry offices during 1938 and found no contraventions under the Bye-laws with respect to Female Domestic Servants. There were ten Registry Offices on the register for the Borough at the end of the year 1938. 67 PETROLEUM ACTS. Number of licences issued 113 Number of licences in force at end of year 1938 110 Licences issued by way of transfer on change of proprietorship 5 (i) For Petroleum Spirit 112 (ii) For Carbide of Calcium 1 Total quantity of petroleum spirit in gallons 203,950 (i) Bulk storage, in gallons 191,075 (ii) Two-gallon can storage, in gallons 12,875 Carbide of Calcium, in lbs. 300 Of the 113 licences issued, 107 were renewals, three sere new or additional licences and three original licences were transferred owing to change of occupiers of licensed premises. Two hundred and ten inspections were made during 1938. One hundred and six contraventions were observed, and these were duly remedied. The following figures show the increase in licensed 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 1938 203,950 109 68 RETAIL MARKET. The Retail Market is held on Thursdays at the Car Park, Station Road, under the control of the Market Superintendent. The administrative supervision is under the Health Committee. It is interesting to note that the receipts of 1938 are £115 14s. 6d. in excess of the total for the previous year, and the average per month has advanced from £45 7s. 6d. to £55 0s. 5d. This may be taken as evidence ot the still increasing popularity of the Market with the shopping public. Total amount of Tolls and Storage Fees collected during 1938. £ s. d. January 34 15 0 February 33 18 6 March 67 19 6 April 51 18 6 May 56 11 0 June 67 13 6 July 58 4 0 August 57 2 6 September 68 1 6 October 50 15 0 November 57 6 0 December 56 10 0 £660 5 0 Average per month, £55 0s. 5d. APPENDIX. Tables I. to XV. 70 TABLE I. SUMMARY OF STATISTICS, 1938. Population (mid-year 1938, Registrar General) 59,470 Birth Rate 13.1 Death Rate (adjusted) 9.5 (Crude) 9.8 Infantile Mortality Rate 49.8 Number of Births (live) ... 782 Number of Stillbirths 30 Number of Deaths ... 583 Number of Infant Deaths (under 1 year) 39 Death Rate of Respiratory Diseases 1.0 ,, ,, ,, Tuberculosis 0.3 ,, ,, ,, Cancer 1.6 ,, ,, ,, Zymotic Diseases 0.01 Notifications of Scarlet Fever 71 ,, ,, Diphtheria 19 ,, ,, Pneumonia 31 ,, ,, Tuberculosis 65 Number of Deaths from Measles 1 Number of Deaths from Scarlet Fever - ,, ,, ,, ,, Diarrhœa (under 2 years) 3 ,, ,, ,, ,, Child Birth 3 Number of visits by Sanitary Inspectors 9,660 ,, ,, ,, ,, Health Visitors 8,851 Number of Babies on the Registers at the Welfare Centres, end December, 1938 2,749 71 TABLE II. Birth-rates, Death rates, Analysis of Mortality, Maternal Death-rates, and Case-rates for certain Infectious Diseases in the year 1938. England & Wales, London, 126 Great Towns and 148 smaller Towns. Provisional Figures based on Weekly and Quarterly Returns). Bromley England and Wales. 126 County Boroughs and Great Towns including London. 148 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census) London Administrative County. Births:- Live 13.1 15.1 15.0 15.4 13.4 Still 0.50 0.60 0.65 0.60 0.48 Deaths:- All Causes 9.5 11.6 11.7 11.0 11.4 Typhoid and Paratyphoid fevers - 0.00 0.00 0.00 0.00 Smallpox — 0.00 - 0.00 - Measles 0.01 0.04 0.05 0.03 0.06 Scarlet Fever - 0.01 0.01 0.01 0.01 Whooping Cough — 0.03 0.03 0.02 0.03 Diphtheria — 0.07 0.07 0.06 0.05 Influenza 0.03 0.11 0.10 0.11 0.06 Notification:- Smallpox - 0.00 0.00 0.00 - Scarlet Fever 1.19 2.41 2.60 2.58 2.05 Diphtheria 0.32 1.58 1.85 1.53 1.90 Enteric Fever 0.01 0.03 0.03 0.04 0.05 Erysipelas 0.18 0.40 0.46 0.39 0.46 Pneumonia 0.52 1.10 1.28 0.98 0.98 Deaths under 1 year of age 49 Hates per 1,000 Live Births. 57 53 57 51 Deaths from Diarrhœa and Enteritis under 2 years of age 3.8 5.5 7.8 3.6 13.1 Maternal Mortality:- Puerperal Sepsis 1.28 0.89 Not available. Other 2.55 2.19 Total 3.83 3.08 Materanal Mortality Bates per 1,000 Total Births (i.e. Live and Still). Puerperal Sepsis 1.23 0.86 Not available. Others 2.46 2.11 Total 3.69 2.97 Notifications:- Puerperal Fever 16.0 14.42 18.08 3.53 Puerperal Pyrexia 12.51 5.46 72 TABLE III. Causes of Death, 1938. Male. Female. Total. 1. Typhoid Fever, etc. — — - 2. Measles 1 — 1 3. Scarlet Fever — — — 4. Whooping Cough - — - 5. Diphtheria — — — 6. Influenza 1 1 2 7. Encephalitis Lethargica — — - 8. Cerebro-spinal Fever — — — 9. Respiratory Tuberculosis 14 4 18 10. Other Tuberculosis 2 2 4 11. Spyhilis 1 1 2 12. General paralysis of insane, etc. — — — 13. Cancer 39 59 98 14. Diabetes 3 8 11 15. Cerebral hæmorrhage 10 13 23 16. Heart disease 70 88 158 17. Aneurysm 1 1 2 18. Other circulatory diseases 18 28 46 19. Bronchitis 14 7 21 20. Pneumonia 21 12 33 21. Other respiratory 2 4 6 22. Peptic Ulcer 4 2 6 23. Diarrhoea, etc. (under 2 years) 2 1 3 23a. Diarrhoea (2 years and over) — 1 1 24. Appendicitis 3 2 5 25. Cirrhosis of liver 1 3 4 26. Other liver diseases 2 2 4 27. Other digestive diseases 6 5 11 28. Nephritis 2 9 11 29. Puerperal sepsis — 1 1 30. Other puerperal causes — 2 2 31. Congenital causes, etc. 21 5 26 32. Senility 2 14 16 33. Suicide 4 3 7 34. Other violence 10 4 14 35. Other defined causes 25 22 47 36. Ill-defined causes — - - Totals 279 304 583 73 TABLE IV. INFANT MORTALITY, 1938. (Compiled from Local Returns). CAUSES OF DEATH. Under 1 Week. 1 and under 2 Weeks. 2 and under 3 Weeks. 8 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 .. .. .. .. .. .. .. .. .. .. Tuberculosis .. .. .. .. .. .. .. .. .. .. Convulsions .. .. .. .. .. .. .. .. .. .. Bronchitis .. .. .. .. .. .. .. .. .. .. Pneumonia 1 .. 1 .. .. .. .. 1 1 6 Diarrhœa .. .. .. .. .. .. .. .. .. .. Gastro- Enteritis .. .. .. .. .. .. 1 1 1 3 Suffocation .. .. .. .. .. .. 1 .. .. 1 Injury at Birth .. .. .. .. .. .. .. .. .. .. Atelectasis 1 .. .. .. 1 .. .. .. .. 1 Malformation 5 .. .. 1 6 1 .. .. .. 7 Premature Birth 11 .. 2 .. 13 .. .. .. .. 13 Marasmus, etc. 1 .. .. .. 1 1 .. .. .. 2 Other Causes .. .. .. 1 1 1 .. .. 1 4 Syphilis .. .. .. .. .. .. .. .. .. .. Congenital Heart Disease • • .. .. .. .. 1 .. .. 1 2 Totals 19 •• 3 3 25 5 2 3 4 39 74 TABLE V. Analysis of Causes of Infant Deaths, 1934-1938. 1934 193ft 1936 1937 1938 No. of Births (live) 706 758 780 778 782 Total Infant Mortality Bate 43 27 37 47 49 Malformation 7 7 3 7 7 31 Premature Births 5 4 6 10 13 33 Respiratory Diseases 5 4 9 7 6 31 Marasmus and General Debility 2 2 2 2 2 10 Infectious Disease .. .. .. 1 .. 1 Gastro Enteritis 4 1 2 5 3 15 Convulsions 2 .. 2 .. .. 4 Other Causes 6 3 3 5 3 35 Totals 31 21 27 37 39 155 This table shows that Premature Births, Congenital Debility and Malformation caused 51 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. 75 Four quinquennial periods ore taken—Pre-War, 1910-1914, five- years to 1925, five years to 1930, five years to 1936, and the years 1936-1938. 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 1935 780 37 29* 13 1 13 1 2 1937 778 47 37 13 4 20 1 2 1938 782 49 39 19 6 14 1 2 * (R.G's. returns, 2t», 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 one week of age. 2. Increase in the deaths of infants under one week of age. Rate 1910-1914, 28 per cent. Rate 1926-1930, 38 per cent. 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. 76 TABLE VII. Summary of Work of Sanitary Inspectors for the Year 1938. TYPE OF INSPECTIONS. Nuisances and Defects found. No. of Inspections. On Complaint. Routine Inspections. Inspection. Total Inspection. Houses Visited— Under Insp. of District Reg 1058 — 179 912 1061 Housing Act, 1936. Sec. 9 — — 3 115 118 Sec. 11 101 1 — 13 14 Sec. 62 — — 3 2 5 For nuisances (No. not confirmed, 166) 2120 786 58 2384 3228 Overcrowding 2 3 3 12 18 Verminous houses 46 34 3 33 AJ Dirty conditions 7 4 1 4 9 Water supply — 1 — 8 9 Cesspools 5 3 74 57 134 Earth closets — — — Privy pails — — 3 3 Infectious disease enquiries 6 — 122 13 135 Disinfection purposes — 1 82 1 84 on Disinfestation purposes — 1 10 9 a) Totals 3345 834 538 3566 4938 Food Preparing Places— Bakehouses—Factories 13 3 35 7 45 Workshops 2 2 91 3 96 Butchers' shops 41 — 1061 3 1064 Confectionery shops — – 30 4 34 Dairies, Cowsheds, etc. 12 — 66 9 75 Fish shops 1 — 239 — 239 Fried Fish shops — — 24 – 24 Food hawkers — — 110 0 110 Greengrocery, Fruiterers 2 — 110 6 116 Grocery shops — 2 202 1 206 Hotels, restaurants, etc. 2 2 31 2 35 Ice cream premises — — 77 11 88 Meat Regulations (special visits) — — 2 8 10 Milk sampling—Bact. Ord — — 25 – 25 „ Graded — — 33 – 33 Tuberc. — — 11 – 11 Ice cream sampling — — 31 – 31 Milk examined on highway — — 23 – 23 Retail market — — 41 – 41 Slaughterhouses — — 598 – 598 Totals 73 9 2840 54 2903 77 TYPE OF INSPECTIONS. Nuisances and Defects found. No. of Inspection*. On Complaint. Routine Inspections. Re- Inspections. Total Inspections. Trailt Premises— Factories 5 2 38 4 44 Outworkers' premises — — 41 — 41 Under Shops Acts 98 7 275 17 299 Under Petroleum Acts 106 — 197 13 210 Registry Offices — — 7 — 7 Diseases of Animals Acts— Inspections — — 83 1 84 Interviews (134) Offensive trades 3 — 3 Workshops 7 — 11 2 Totals ... 216 9 655 37 701 Miscellaneous— Accumulations 27 15 24 48 87 Drain tests—Smoke — 2 15 — 17 Water — — 18 7 25 Colour — — 1 — 1 Chemical — — — — — Mirror — — 11 1 12 food poisoning enquiries — — 2 3 5 Piggeries 1 — 18 3 21 Rats and Mice Destruction Act 107 100 70 277 447 Schools 2 2 — — 2 Smallpox—visits Contacts seen (11 — — 1 — 1 Smoke 9 24 10 10 44 Special visits 15 349 — 364 Stables 4 1 13 — 14 Streams 6 — 10 1 11 Tents. Vans and Sheds 4 1 20 5 26 Urinals 1 — 13 1 14 Interviews, owners, agents (1897) Water sampling (chemical) – 3 — 3 Swimming Bath water sampling — — 21 — 21 Cinemas 1 1 — — 1 Water samples from streams — — 2 — 2 Totals 162 161 601 356 1118 Grand Totals 3796 1013 4634 4013 9660 7S TABLE VIII. Nuisances Abated, 1938. HOUSING: Drainage— Premises Re-drained and connected to sewer 26 Cesspools abolished (one cesspool serving 2 houses) 22 Privy pails abolished 2 Drains relaid or repaired 41 Drains unstopped 72 Inspection chambers provided 35 W.C'.'s additional or separate provided 2 ,, building's reconstructed 3 ,, ,, repaired 6 ,, pans renewed or provided 29 ,, pans cleansed 1 ,, box seats removed 70 Soil pipes, vent pipes, renewed or repaired 17 Sinks renewed or provided 45 Sink or bath waste pipes renewed or repaired 156 Cesspools emptied 9 Dampness— Roofs repaired or renewed 214 Rain water pipes, guttering, etc., repaired or renewed 145 Damp courses:— Vertical plinths provided 28 Walls rendered 71 Horizontal d.c. provided 24 Solutioning 17 Earth removed from walls 16 Walls repointed 171 Dry areas constructed 3 Subfloor ventilation provided or improved 25 Brickwork renewed or repaired 31 General— Rooms cleansed 439 W.C. walls, etc., cleansed 46 Entrance halls and staircases cleansed 74 Bathrooms cleansed 2 Light and ventilation of rooms improved 67 79 Plastering: repaired or renewed 290 Floors ,, ,, 85 Window frames, etc., repaired or renewed 187 Sash cords renewed 109 Putty pointing repaired or renewed 65 Doors ,, ,, 46 Stoves ,, ,, 87 Coppers ,, ,, 30 Handrails ,, ,, 28 Stairtreads, etc. ,, ,, 11 Dustbins provided 136 Dirty conditions remedied 7 Overcrowding abated 3 Defective chimneys repaired 29 External woodwork painted 51 Food stores—Provided 30 Ventilated 10 Yard paving renewed or provided 70 Houses disinfested 29 1 ater Supply— Drinking water service supplied direct from the main 27 Fittings renewed, etc. 10 Supply reinstated 5 Flushing cisterns repaired or renewed 38 Separate and additional water supply provided 2 Miscellaneous Items 44 TRADE PREMISES: Factories— A\ ant of cleanliness 8 Overcrowding 6 1 nreasonable temperature — Inadequate ventilation 3 Ineffective drainage of floors 3 Sanitary conveniences— Insufficient 2 Unsuitable and defective 3 Not separate-for sexes — Other offences 10 Petroleum Acts—contraventions 106 Milk and Dairies—contraventions — 80 Shops Acts—contraventions Ventilation 3 Temperature 4 Sanitary conveniences 2 Absence of statutory forms 106 Washing facilities not satisfactory 1 Meals rest interval unsatisfactory 1 Seats for female workers 5 Other 7 Registry Offices—contraventions — FOOD PREPARING PLACES: Defects and nuisances remedied in— Butchers' shops 41 Bakehouses 15 Confectionery 1 Dairies, etc. 12 Fish shops 1 Fried fish shops — Grocery shops 8 Greengrocery shops 2 Hotels, restaurants, etc. 6 Slaughterhouses 1 MISCELLANEOUS— Accumulations removed 46 Manure removed 3 Rats and mice nuisances 110 Smoke nuisances 9 Urinal structurally improved 1 Stream pollutions 6 Piggeries, cleansed, etc. 1 Housing Act, 1936. Sections 4 and 62 47 Total 3924 NOTICES ISSUED: Housing. Other Preliminary 750 160 Statutory 1 – Totals 751 166 81 ????? Disease Total M. F. Cases removed to Hospital Attack Rat per 1,000 population No. of Deaths Death Rate Plaistow Martin's Hill Town Sundridge Bickley Bromley Common Keston anc Hayes Scarlet Fever 71 33 38 27 4 5 3 8 14 10 57 1.19 — — Diphtheria 19 8 11 3 4 — 3 — 7 2 17 0.32 – — Pneumonia 31 23 8 3 9 4 4 3 7 1 15 0.52 33* 0.55 Puerperal Pyrexia 13 — 13 1 — 1 3 2 3 3 12 16.0 † 1 1.23† Dysentery 12 8 4 4 — — — 1 1 6 — 0.2 — — Erysipelas 13 4 9 1 — 1 3 3 2 3 3 0.18 — — Ophthalmia Neonatorum 5 1 4 1 " — — 2 — 2 — 3 6.2 † — — Acute Poliomyelitis 2 1 1 — — — 1 — 1 — 1 0.03 — — Typhoid Fever 1 1 — — — 1 — — — — 1 0.01 — — Cerebral Spinal Fever 2 1 1 — — — 1 1 — — 2 0.03 — — Tuberculosis—Lungs 52 24 28 12 4 4 6 7 14 5 — 0 8 18 03 Tuberculosis—other forms 13 3 10 4 1 — 1 1 5 1 — 0.2 4 0.08 Totals 234 107 127 56 22 16 27 26 56 31 111 3.9 56 0.9 *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 1,000 births, and not population. 82 TABLE IXa. Notifiable Infectious Disease, 1938. Age Groups. Disease. Total 0-1 1-2 2-3 3 4 4-5 5-10 10-15 15-20 20-35 35-45 45-65 65 and over Scarlet Fever 71 — 2 1 5 8 33 5 3 10 2 2 – Diphtheria 19 — — — 1 — 5 5 8 – – – Pneumonia 31 2 2 1 — — 4 1 2 4 5 6 4 Puerperal Fever & Pyrexia 13 — — — — — — — – 11 2 – – Dysentery 12 — — 3 2 — — 2 3 2 – Erysipelas 13 — — — — — — — — 2 3 5 3 Ophthalmia Neonatorum 5 5 — — — – – – – – – Cerebro Spinal Fever 2 — — — — 1 – – 1 – – – Acute Poliomyelitis 2 — — — – – 1 – 1 – – – Typhoid Fever 1 – — — — — – — — 1 — — — Totals 169 7 4 5 8 8 43 12 5 40 16 15 7 83 TABLE X. Tuberculosis. New Cases and Mortality during the Year 1938. New cases notified or otherwise revealed. Deaths. Age periods. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. P. M. P. M. P. M. F. Under 1 .. .. .. .. .. .. .. .. 1–5 .. .. 1 1 .. .. .. 2 5-15 .. .. 1 3 .. .. .. .. 15-25 2 8 1 2 4 .. .. .. 25-35 10 11 .. 8 3 .. .. .. 35-45 6 5 .. .. 3 .. .. .. 45-55 4 4 .. .. 3 .. .. .. 55—65 2 .. 1 1 .. .. .. 65 and over .. .. .. .. .. .. .. .. Totals 24 28 3 10 14 4 2 2 I ABLE XI. Ophthalmia Neonatorum, 1938. Cases. Vision unimpaired Vision impaired Total Blindness Deaths. Notified. Treated. At Home. In Hospital. 5 2 3 6 .. .. .. 84 TABLE XII. Summary of Health Visitors' Work, 1938. Areas Total Ineffectual Visits Under one year He visits over 1 year Expectant Mothers School Children Baby Deaths StillBirths Tuberculosis Special Visits M' wives Acts enquiries Boaided- out Children Primary Revisits Area No. 1 1255 256 91 179 503 23 176 5 3 69 203 3 23 Area No. 2 1116 248 96 331 455 16 183 1 2 7 24 1 8 Area No. 3 1439 128 159 310 736 7 176 3 3 19 24 2 22 Area No. 4 1368 180 120 257 608 39 270 4 4 12 54 — 19 Area No. 5 1030 145 101 192 540 10 127 2 — 2 54 2 15 Area No. 6 1552 134 111 414 887 4 98 1 1 19 12 5 15 Totals. 7700 (Net) 1091† 678 1683 3729 99 1030 16 13 128 371 13 102* *Also included in routine visits under the various headings. + "Ineffectual" visits are those where no answer received, discovered removed from district or where visits are resented, and. are not included in total of the first column. The aggregated total of visits is, therefore, 8851 . 85 TABLE XIII. Welfare Centres, Attendances, 1938. Centre. No. of Babies on Rolls at the end of Year 1938. Total Attendances. No. of Sessions held. Medical Consultations. Total No. of Weighings. Babies. Mothers. Total Examined No. of Sessions held. LAISTOW 469 3503 2945 50 483 39 3095 VIDMORE 254 3194 2677 50 515 45 2927 LAOSNS HILL 518 4010 3434 50 541 45 3404 BURNT ASH 575 4607 3977 98 866 83 4095 BROMLY COMMON 504 6041 4816 99 962 85 5239 HAYES & KESTON 429 5750 5115 89 807 79 5251 Totals 2749 27105 22964 436 4174 376 24011 Ante-Natal Clinics, 1938. Total Attendances. Medical Consultations. Sessions held. 239 219 47 *14 14 4 253 233 51 Dental Clinic, 1938. Discharged Treatment. Children. Mothers. 153 65 *Specialists' Clinics. 86 TABLE XIV. Factories, 1938. I. Inspections for purposes as to provisions of health. Premises. Number of Inspections Written Notices. Occupiers Prosecuted Factories with mechanical • power 80 11 .. Factories without mechanical power 35 16 .. Other premises 67 10 .. Total 182 37 .. 17. Defects found. Particulars. Number of Defects. Found Remitted. Referred to H M. Inspector Want of Cleanliness (S.l.) 8 8 .. Overcrowding (S.2.) .. .. .. Unreasonable temperature (S.3.) .. .. .. Inadequate ventilation (S.4.) 3 3 .. Ineffective drainage of floors (S.6.) .. .. .. , insufficient 2 2 .. Sanitary Conveniences (S.7.)' unsuitable or defective 3 3 .. not separate for sexes .. .. .. Other offences 25 5 .. Total 41 41 .. 87 TABLE XV. Housing Statistics for the Year, 1938. Total number of inhabited houses at 31st December, 1938 17075 The number of houses erected during 1938 is as follows:— (a) By private enterprise 634 (b) By Local Authorities Nil . Inspection of Dwelling-houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing- Acts) 972 (b) No. of inspections made for the purpose 4456 (2) (a) No. of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consoldated Regulations, 1925 179 (b) No. of inspections made for the purpose 1091 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation *11 (4) No. of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 806 2. Remedy of Defects during the Year without Service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 750 *Closed voluntarily. 88 3. Action under Statutory Powers during the Year:— (a) Proceedings under Sections 9, 10 and 16 of 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:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 1 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners *1 (b) 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 underground rooms in respect of which Closing Orders were made - (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit - *Work done after Abatement Order was issued by Court 89 4. Housing Act, 1936. Part IV. Overcrowding. (a) (i) Number of dwellings overcrowded at the end of the year 83 (ii) Number of families dwelling therein 95 (iii) Number of persons dwelling therein 556 (b) Number of new cases of overcrowding reported during the year 2 (c) (i) Number of cases of overcrowding relieved during the year 15 (ii) Number of persons concerned in such cases 90 (d) Particulars of any cases in which dwelling-houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding Nil (e) Any other particulars with respect to overcrowding conditions upon which the Medical Officer of Health may consider it desirable to report (see Section D— Housing). † As a result of informal action, progress under the Housing Act, 1936, up to 31/12/38 showed tnat 36 houses have been demolished and 36 houses closed to habitation. BOROUGH OF BROMLEY. ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR 1938. 92 MEMBERS OF THE EDUCATION COMMITTEE OF THE BOROUGH OF BROMLEY, 1938-1939. Alderman F. W. Isard (Chairman of the Education Committee). *Rev. F. W. Armstrong, m.a. *Mrs. Arreger. *D. Copping, Esq. Councillor E. C. De'Ath. Councillor H. L. Elphick. Councillor Lt.-Colonel (Jr. A. Fulcher, o.b.k. *Rev. H. Glaisyer, m.a. Councillor George Griffin. *G. J. Gully, Esq., j.p. *Rev. J. T. Gurney. Councillor W. .1. Guthrie, j.p. *Lieut.-Colonel E. J. Heilbron. Councillor S. G. Humerston. Councillor S. Ii. Lyle. *L. Harvey Lowe, Esq. *Mrs. A. G. Mann, b.a., j.p. *Mrs. E. J. Munn. *Eev. Prebendary B. F. Relton, m.a. Councillor L. A. Simmons. Her Worship the Mayor. Councillor M. Stafford Smith, m.b.e., b.a- Councillor F. G. Hamilton Spratt. Councillor F. Sutci.iife, f.r.i.b.a. *Co-opted Members. 93 Introduction. In spite of the many anxieties of 1938, I have much satisfaction in reporting that the School Medical Service continued to function during the year as a co-ordinated unit of the Health Services of the Borough. The work was, however, curtailed in that many hoped-for investigations into the health of the school child were prevented by our efforts to make civil defence, so far as casualty services were concerned, an efficient force. The investigation by Dr. Macdonald into the rather common complaint of enuresis in school children could not be continued owing to this fact. The leisure time of the staff outside the routine hours of duty has been given without stint and the Local Authority must be duly appreciative of the service given. The appointment of Dr. Macdonald in February of 1938 was the only addition to the medical staff during the year and his services were invaluable to me in the Air Raid Precautions services. The report follows on the lines of previous reports, and although I regret the delay in publication there has not been sufficient time available to complete it earlier. The statistics which follow the report are the best indication of the amount of work carried out during the year. There still remains much work to be done in the School Medical Service, especially in the provision for the early admission to school of the unbalanced, nervous child. I would, however, make special reference in this introduction to the nutrition of children. The subject is bristling with difficulties not only in the classification of children but also in the best method of treatment of the fluid who has been classified as mal-nourished. There is no physiological standard upon which to base the normal child but I can sav this without hesitation: that the nutrition of the school child Bromley is high and where nutrition does fall below the average it is not due to lack of tood but rather to constitutional and environmental actors. The school meal is being provided in three school in Bromley at the very small cost of 3d. per head. 94 The question of free meals is at the time of writing receiving the attention of the Board of Education and of the Education Committee, but it is my view that free meals will not solve the problem of malnutrition. The establishment of a new school at Southborough is a step towards the abolition of those schools which haw outworn their use and which no longer afford hygienic conditions. The development of physical training and organised games is progressing rapidly. The school playing fields are functioning with the resulting improvement in the mind and body of the elementary school child. 1 would again make special reference to Mr. T. S. Latham's report which is included in this report of mine and it is to be noted that the extension of the Dental Service by extra clinics and the assistance of Mr. Ordish has now made the Service adequate to the demands made on it. I am grateful to the Committee for their help and j interest and to the staff for their untiring efforts. Summary of Statistics, 1938. School Boll 5520 No. of individual children who attended medical clinics 2137 No. of individual children medically examined at schools 1777 No. of medical examinations at the clinics 9355 (a) North Clinic 5040 (b) South Clinic 4315 No. of attendances for treatment at clinics by the School Nurses 84.34 (a) North Clinic 4446 (b) South Clinic 3988 No. of attendances for treatment at the Dental Clinics 5438 95 No. of treatments at the Eye Clinic 731 No. of operations for Tonsils and Adenoids 151 No. of attendances at the Orthopredic Clinic 3303 (i) For Consultations 748 (ii) For Treatments, Massage, etc. 2555 No. of attendances at the Ultra-Violet Ray Clinics 2434 No. of children referred to the Care Committee 228 Staff. Full particulars of the School Medical Service Staff are included under the Heading of Public Health Staff on page 7. Following on my report of the previous year, the Focal Authority appointed in February, 1938, an additional Medical Officer, six-eighths of whose time is allocated to the School Medical Service. Co-ordination. The School Medical Service is fully co-ordinated with the services of the Health Department. The services come under my jurisdiction and all clerical work is centralised under one records department. The supervision of the fluid is thus continuous from birth to school-leaving age. The school clinics, of which there are two, function as Health Clinics for maternity and child welfare, school medical service and public health. Hygiene of Schools. A healthv school environment is a sine qua. non of a sound school medical service but there are still running one or two old schools which do not come up to the modern standards required by the educationalist. 96 The new school at Southborough became occupied in 1938. It has accommodation for 400 mixed juniors and infants. Extensions and alterations were carried out at Raglan Road School, providing it with modern facilities for education and sanitation. Roller towels are a somewhat minor item but nevertheless important. They have now largely gone out of use with a resulting lessening in the occurrence of contagious diseases common to school children. Accommodation of Bromley Elementary Schools. Valley Girls' 222 Valley Infants' 222 Raglan Road Boys' 480 Raglan Road Juniors' 396 Raglan Road Infants' 342 Burnt Ash Boys' 320 Burnt Ash Girls' 400 Burnt Ash Infants' 400 Central 350 Princes Plain Girls' 480 Princes Plain Juniors' and Infants' 400 Parish Boys' 263 Parish Girls' 224 Parish Infants' 156 Mason's Hill 340 Plaistow St. Mary's 100 Bickley and Widmore Juniors' and Infants' 290 Southborough 400 St. Joseph's 184 Hayes 400 Keston 170 SECTION A. medical inspection and findings at medical inspections. 98 Medical Inspection. The statistical tables appear in the appendix under Table I. It will be noted that 1,777 children came under routine inspection and no less than 9,355 other inspections were made of children attending school clinics and of children at school. Routine inspection continues to be carried out at school in three age groups, but most of the work of investigation is done at the school clinics, which are held daily at the North Clinic, Station Road, and the South Clinic, Princes Plain. Much medical time is taken up by the examination of the child with a special defect—the mentally retarded child, the physically defective child, the blind child the deaf and the maladjusted child. Children are also examined before the issue of the necessary employment certificates. I am glad to say that parents show a great interest in the examinations, are regular in their attendance at the routine inspections at the schools, and only on rare occasions do we receive from them refusals to submit their children to examination. I am not, however, satisfied that the routine inspection at school fulfils its purpose. Unless one can obtain a true view of the physiological functioning of the child the routine medical examination cannot be fully satisfactory. It certainly brings to light abnormalities, the greater of which appear to be defects of the nose, throat and vision; it certainly also brings to our notice defective children who have not been brought by their parents to the school clinic, and I believe I can safely say this: that once we have discovered a defect in a child, either of a major or minor character, adequate steps are taken to see that that defect is remedied, either by the childs attendance at the school clinic or at the special clinics or by reference at the parent's wish to the child's own private doctor. 99 Findings at Medical Inspections. These are reported in detail in the appendix. (a) Malnutrition. Table IIb (page 139). This table must be taken with some reserve. As I have previously stated, since there are varieties of opinion as to what constitutes normal physique, and as there is no physiological standard of what constitutes the normal, the table is merely an indication of the physical fitness of the child as it appears to the medical examiner. There are so many factors, the least of which is, in my opinion, underfeeding. The environmental factor, the family constitution and inherent physique must be obliterated before the suspected cause of nialnutrition can be limited to underfeeding. It is true also that it is not the quantitv of food, but the unsuitability of food to which malnutrition is due. It is the experience of most of us also that the financial circumstances of the parent is a factor which might almost be neglected in the consideration of an adequate nourisliment. The delayed investigation into the nutritional state of children in Bromley should bring to light some important factors in this question, which is causing so many of us administrative anxiety. However, referring to Table lib, only 15 out of 1,777 children examined showed a nutrition as bad, while 178 children showed nutrition below the so-called normal. The provision of a mid-day meal at school is helpful and is to be encouraged, but I am not satisfied in my own mind that I would advise the Education Authority to provide these meals free of cost to the " necessitous parents. Parents in Bromley prefer to keep their individual independence, and I believe would desire to pay for what is considerably more valuable to them than the present charge of 1s. 3d. per week. the scheme for the distribution of milk in schools continues to function without complications, though, while the percentage of children taking milk remains at its present fairly low level, one cannot say that full use is made of the service. It must, however, not be overlooked that milk is anathema to something like 5 per cent. of children, and there is a further unknown per- 100 centage in whom nourishment in the morning is detrimental to the mid-day appetite. However, at the present time 46 per cent. of children are receiving milk at school. The following table shows the extent of the provision of milk in schools in the year 1938-39. School. No. receiving. Milk. Percentage of number receiving milk over average roll. Valley Girls' 49 30 Valley Infants' 122 88 Raglan Road Boys' 104 34 Raglan Road Juniors' 195 50 Raglan Road Infants' 177 50 Burnt Ash Boys' 122 32 Burnt Ash Girls' 135 37 Burnt Ash Infants' 232 64 Princes Plain Girls' 56 21 Princes Plain Juniors' 200 45 Central 45 18 Hayes 163 58 Southborough 215 50 Parish Boys' 81 34 Parish Girls' 112 53 Parish Infants' 96 78 Mason's Hill 123 40 Plaistow St. Mary's 58 59 Bickley and Widmore 145 63 St. Joseph's 81 76 Keston 67 42 Total 2,578 46 (b) Uncleanliness. Table VI. (page 147). The chronically verminous child and gross vermin infection is rapidly disappearing from our schools. School Nurses carried out no less than 15,458 101 tions, and in only one case was it found necessary to take legal action under the School Attendance byelaws. Negligent parents we shall always have with us, but it is a constant delight to those of us who have been in the School Medical Service for so many years to see the vast improvement that has taken place in the hearing and cleanliness of the children in attendance at elementary schools. (c) Minor Ailments. Table IIa, page 1.37, shows the various defects discovered, while Table IV, Group I, gives details of treatments carried out at the School Clinics. The consistency in the number of children who attend the clinic for treatment is an indication in itself of the success of the School Medical Service. Over 2,100 children received treatment from the School Nurses during the year, and over 9,000 attendances were made by children at the various clinics. It must be clearly understood that where a child requires domiciliary treatment the mother is advised to take him or her to her own practitioner. The clinic itself acts more in the nature of an outpatient department, medical direction being given, and where the. ailment is a minor one, treatments are carried out at the treatment clinics, Where the case requires further specialist advice for orthopædic, ear, nose, throat or eye defects, it is automatically referred to the specialist. We may therefore say that no child need suffer for lack of treatment, for the provisions made by the Education Committee are complete. (d) Visual Defects and External Eye Disease. In Table IV, Group II (Page 143) will be found the statistics for the year. Of the children examined at the Routine Medical Inspections at the schools, 8.4 per cent. showed defective vision requiring corrective treatment. This is a fall on the previous year's figures, but still appears to be a prevalent defect into which little causal investigation is being made. Dr. Eric Lyle's report on the treatment of bye defects follows later in this report, together with the report on the year's work f' the Orthoptic clinic. 102 (e) Nose and Throat Defects. Table IV., Group III. (page 144). Nose and throat defects continue to swell the returns of defective children, though in less than 5 per cent. of children examined at school there were defects requiring treatment. It is to be noted that no case was referred for operative treatment direct from the routine clinic inspection, but underwent further examination at the School Clinic or by Mr. Beney, whose report follows later in this report. (f) Ear Disease and Defective Hearing. Statistical information for the year is given in Table IIa (page 137) and Table IV, Group I (page 137). At the routine inspections, 5 children were found to have chronic, ear disease, with the resultant defective hearing, and had up to the time of the inspection had no treatment. Some 250, in addition to these, attended school clinics for special inspection with "running ears" or defective hearing, and were referred for routine treatment. Many of' these conditions are of a temporary nature consequent upon catarrhal infection, but there are others where the discharge persists. causing damage to hearing. These cases are referred for Mr. Beney's advice. There is still a tendency in parents to delay the seeking of advice on these conditions with the result that curative treatment is delayed and much damage done to the child's hearing. If one could control the catarrhal infection in schools, one could do much in the prevention of this crippling ailment. (g) Dental Defects. Table V (page 146). Mr. Latham's report follows later in this report. The Dental Service is complete, and valuable work in being done by the Dental Surgeons. (h) Orthopadic and Postural Defects. Table IV, Group IV (page 145). Ninety-one children were found at the Routine Medical Inspection to be in need ot remedial exercises or for further inspection by the Orthopaedic Specialist. 103 There is a fall in this defect compared with previous years' figures, many of the minor conditions having: been remedied by the development of physical training, which has now been given in Bromley schools under the Physical Training Organisers for some two years. (i) Heart. Disease and Rheumatism. One case of organic heart disease was discovered at Routine Inspections, and 25 children were found to require further investigation. Sixteen children are under treatment and observation at the school clinics, which is under the supervision of Dr. Schlesinger, the heart specialist. The condition of these children fluctuates from time to time, and where the condition is at all active, the children are referred to the Heartsease Hospital, which is under the supervision of Dr. Schlesinger, the heart specialist. Once the heart has been damaged, the weakness will persist, and it not infrequently results in permanentin capacity. It is a practice with some authorities to establish Rheumatism clinics in order that these crippling defects may be prevented, and much valuable work has been done by the London County Council in this respect. The establishment of such a clinic in Bromley is a matter worthy of the consideration of the Authority. (j) Tuberculosis. No case of tuberculosis was found in the Routine Inspections in 1938. (k) Other Defects and Diseases. Diseases of the nervous system and those conditions which are largely seasonal, swell the returns of the fecial inspections. Nervous conditions or an unbalance attitude to their environment are to be noted among many children who attend school for the first time. Such conditions are especially marked in the preschool child, and the opening of nursery classes for these children is recommended to the Authority. 104 (1) Skin Diseases. It is interesting to note at the present time the infrequency of skin diseases in children actually attending school. Ringworm of the scalp, a condition which at one time caused much loss of school time, is now almost a rarity. Scabies seldom occurs, and when it has occurred, has been controlled. Skin diseases are prevalent at the School Clinics. Response to treatment is slow and the presence of urticaria common. The work of the school nurses at the clinics is largely concerned with these conditions. There was a fall in the incidence of Impetigo during the year, only 75 patients attending the clinics for treatment compared with double this number in the previous year. Following-up. All cases referred from the clinics for domiciliary treatment are followed up by the School Nurses, who see that the recommended action has been carried out by the parent. Parents respond well to advice and as a rule bring the child back to the clinic before his return to school. Cases requiring extra nourishment or convalescent home treatment are referred to the Bromley Children's Care Committee, who take the necessary action and are doing valuable work in this direction. W here a child fails to attend the clinics for treatment, the parent is interviewed by the school nurses or the case is referred to the School Attendance Officers for their investigation. We find the help of Head Teachers invaluable, also, in this direction, with the result that few children fail to receive adequate treatment. When a child ceases to attend school at the school leaving age, the value of the clinics is lost except in those cases where the Juvenile Employment Bureau seeks our assistance. If an organisation existed whereby treatment which began at the school clinic could continue under the National Health Insurance, containuous treatment would prove successful in cure and prevent much of the "quack treatment" which still persists among the unenlightened. Patent medicines continue to have a vogue with little beneficial effect upon the patient. SECTION B. TREATMENT. minor ailment clinic and special clinics. 106 TREATMENT. The two clinics were in full function during the year and exclusive of attendances at Maternity and Child Welfare Centres, no less than 29,790 attendances were made. A tabulation of treatment is given in the Appendix (Table IV.). The clinics are open daily and provide in addition to the Specialist medical clinics, minor ailment treatment clinics, clinics for dental, orthopedic, massage and remedial exercises, eye, ear, nose and throat and ultra violet ray treatment. Treatment of Minor Ailments. Any child, whether attending school or in attendance at Maternity and Child Welfare Centres, may receive treatment at any of these clinics. Certain children of the necessitous class attending secondary schools in the Borough also have these facilities. A doctor is in attendance each morning at the clinic and is assisted by two school nurses and the necessary clerical staff. The specialist clinics are staffed by specialists in their various spheres. Report on the Work of the Eye Clinic. The Eye Clinic was held on 68 occasions during the year and was attended by Dr. Eric Lyle, whose report follows. Associated with the Eye Clinic is the Orthoptic clinic under Miss Bradley, for the treatment of squint. Dr. Lyle also gives his valued services for any acute case which may arise between his special sessions, either at his own surgery or at the hospital which he attends. Dr. Eric Lyle reports as follows:— "During the past year, Eye Clinics have been held regularly on Wednesday mornings and on alternate Friday afternoons. Six hundred and eighty-one children attended for errors of refraction and 50 for other defects and diseases. A certain number of the latter have been admitted for in-patient treatment at the Bromley Hospital. I am 107 grateful to the hospital for allowing me facilities for admitting these cases there, and so keeping them under my own care. A large number of squints have again been treated this year. The Orthoptic Department has been doing very useful work in helping with the treatment of these cases, many of which require a great deal of patience and tact. I should like to express my thanks to Miss Bradley for the able way in which she conducts the Clinic, and for her untiring efforts on the patients' behalf. When orthoptic treatment has reached its limits, and if the case is not cured by that time, then operation is considered. We have had quite a successful year with our squint cases with this combined treatment, twelve operations having been performed. Several interesting cases have been met. Among these was a case of Interstitial Keratitis, a case of Ruptured Choroid, a case of Traumatic Cataract, a case of very severe penetrating wound of the Cornea with prolapse of the Iris, and a case of Congenital WordBlindness. In conclusion I wish to record my sincere thanks to Mrs. Cornwall, the voluntary helper, who so efficiently manages the Clinic on Fridays. She has the way of making the Clinic run on oiied wheels and she keeps the children both quiet and happy." Eric Lyle, M.D. Report on the Work of the Orthoptic Clinic. In spite of the many attendances required and the long period of treatment, parents are responding extremely well to the treatment of their children at the clinic, a treatment which is proving a valuable adjunct to the work of the Eye Clinic. Miss Bradley reports as follows:— "The total number of attendances at the Orthoptic Clinic from mid-April, 1938, to mid-March, 1939, amounts 108 to 373. The Clinics continue to be held twice weekly, and six children are scheduled to receive treatment each session. The percentage of attendances as compared with the full capacity number works out at 75 per cent. during this period, and may be considered satisfactory, as there are bound to be failures owing to illness, etc. 34 children have been examined during- the past year. 12 of these cases were examined as requested by Dr. Eric Lyle, and reports written. 6 required operations after a course of treatment. 2 failed to attend regularly. 4 cases were given a trial course and failed to improve, but operations were not desired. 4 cases were discharged cured. 6 cases remain to be accounted for, and are at present receiving treatment. Vacancies occasioned by discharge are immediately filled—there are the names of a few very young children on the waiting list, for whom regular treatment will not be considered until later. Although the numbers treated appear small, yet the time at the disposal of the Clinic is fully occupied, and indicates that the treatment is prolonged, and requires patience and perseverance on the part of patients and parents. The year's work is encouraging, and it is very gratifying to find so many parents willing to co-operate with home-work exercises for the children, which forms an essential part of the treatment." J. Bradlet. Report on the Work of the Ear, Nose and Throat Clinic. The special ear, nose and throat clinic is held once a week, under Mr. Charles Beney, to whom all cases are referred before operative treatment and also those children who are not responding to routine treatment at 109 the clinic. Operations are held at the clinic each week and patients are retained there for twenty-four hours after the operation. Mr. Beney's report follows:— "The number of cases seen in consultation, or operated on, appears to be very much the same as last year. There were 34 operation clinics, at which 151 operations were carried out for the removal of tonsils and adenoids. Four special consultation clinics were held, at which 119 patients were examined. I hope that the number of consultation clinics will he increased next year, as it is only by frequent examination of certain doubtful cases that a correct opinion can be formed as to whether operative treatment is necessary or not. Thirty-eight cases were operated on elsewhere, either by their own doctors or at hospitals. Examination of the nasal accessory sinuses has now become almost a routine in all cases suffering from chronic catarrhal conditions. At present, these cases have to be referred to hospital for X-ray and operative treatment— most of them go into my beds at St. John's Hospital. Lewisham. In the majority of these cases, the cost of X-rays, etc., is not recovered by the hospital. If the X-rays can be paid for by the Education Committee, and a few necessary inexpensive instruments purchased, I do not see why these cases could not be dealt with at the Clinic, even although it might involve one or two extra sessions. In conclusion, I should like to express my gratitude to the Nursing Staff, and the voluntary workers who have given up so much of their time to help us at the clinic, and without whose help it would be very difficult indeed to carry one. Dr. Macdonald is now giving anaesthetics in place of Dr. France." Charles Beney, M.A., M.B., B.Ch., M.R.C.S. 110 Report on the Work of the Orthopaedic Clinic. Mr. H. J. Seddon, the Orthopaedic Specialist, attends at the Clinic twice in every month when cases selected by the School Medical Officers are called up for his advice. He gave 748 consultations during the year, and the following is a summary of the cases he saw:— 1. Congenital Defects. Club foot 2 Dislocation of hip — Spastic paralysis 1 Other conditions 24 2. Birth Injuries. Nerve injuries — Fractures — Torticollis — Other conditions — 3. Rickety deformities. Bow legs 9 Knock knees 1 Other conditions — 4. Knock Knees (non- rickety) 37 O.C.T. 6 5. Postural Defects of the Spine 20 6. Structural Curvature of the Spine 1 7. Flat Feet 36 8. Infantile Paralysis 1 9. Sequelæ of Acute Fevers - 10. Fractures 10 11. Tuberculosis— Joints 1 12. Other bone diseases. Epiphysitis of the spine Perthes Disease 2 Schlatters disease 1 Apophysitis of the Os Calcis. &c. - Other 2 13. Osteomyelitis 1 14. .Tot Classified 38 In addition, massage and remedial exercises, ultraviolet ray and infra-red ray treatments are provided at the clinic for cases selected for these forms of treatment. The work is carried out by Miss Dodge, under the supervision of the Orthopaedic Specialist. In all, no less than 2,555 attendances were made for massage and remedial exercises and 2,434 attendances for ultra-violet and infra-red ray treatment during the year. 111 Mr. Seddon reports that no outstanding case of note occurred at the clinic during the year 1938, and the work of the clinic continues to go smoothly. Infra-red ray treatment was an extension of the services provided during the year. An additional ultra-violet ray lamp was provided at the South Clinic. The following summaries indicate the type of case referred for ultra-violet ray treatment during the year and the general results of the treatment:— North Clinic. New cases treated, 171. Attendances, 1899. General Debility, 108. All cases responded to treatment. Gain in weight and improvement in appetite was recorded. Nervous Cases, 27. Most of these showed improvement in general condition and parents reported that children were "not so nervy." Alopcecia, 1. Did not show much improvement. Rheumatism, 5. All showed considerable improvement. Eczema, 4. Three cases showed great improvement after a few treatments. One did not benefit. Asthma, 9. Attacks reported not so frequent. General condition improved. Impetigo, 6. All cases responded to treatment after 3 or 4 applications. Catarrh, 6. Four reported great improvement, but two did not respond so well. Chilblains, 3. All cases cured after a few applications. Boils, 2. Both responded to treatment and general Condition was much improved. 112 South Clinic. New cases treated, 28. Attendances, 535. General Debility, 7. Marked improvement. Chest conditions, 6. Five cases showed improvement. One case was treated for asthma, but did not improve and treatment was discontinued. Poor physique, 3. Cases showed marked improvement. Discharging ears, 2. One case cleared up after treatments; treatment of the other is not yet completed. Sleeplessness, 1. This case is improving. Frequent colds and catarrh, 1. This case is improving. Nervous cases, 1. Treatment resulted in gain in weight, cessation of night terrors and less frequent colds. Eneuresis, 1. Treatment not yet completed, but a gain in weight has resulted. Glands of neck, 1. Marked improvement. Acne, 1. This child left school and would not attend for treatment. Alopecia, 1. Cured after 14 treatments. Welfare cases, 3. One rachitis improved, but is not attending regularly. 1 child with discharging ear, a flabby and undersized child, showed marked improvement in every way. 1 child suffering from debility does not attend regularly. All cases attending regularly for treatment showed gains in weight, renewed muscle tone, better sleep and appetite and a brighter outlook on life. Report on the Work of the Dental Clinic. Mr. T. S. Latham reports as follows, and again indicates the full use that is being made of the Dental Service. 113 Report on the School Dental Service in the Year 1938. Inspection. During the year 1938 all the schools of the Education Authority received a dental inspection, with the exception of the new school at Southborough, which will be inspected during the new year. The inspections are carried out on the school premises by the dentist, with the assistance of the dental nurse, and parents are invited to be present. A very gratifying number of parents has attended this year. We make use of the occasion to explain the general working of our scheme and our aim, namely, that as many children as possible are rendered free from pain and septic conditions. We also try to train the children in the care of their teeth so that when they leave school they will continue to give some attention to the condition of their mouths and teeth. It must be remembered that with our dental service we are working not only in the present but for the future and we hope that when the children of to-day become parents themselves they will be in a position to understand what regular dental treatment can do and so encourage their children. Dental treatment is something like an insurance Policy, where to obtain the benefit, premiums must be paid regularly; in other words, in order to obtain comfort in dental matters a visit or so to the dentist must be paid each year. The number of children examined during the year was 5,245, and of this number 54 per cent, required treatment. In 1937 the percentage of children requiring treatment was 60 per cent. This marked improvement is, of course, due to the working of the South Clinic, where Mr. Ordish attended 111 sessions. Treatment. The total attendance has this year passed all records at 5,468, compared with 5,004 last year and 4,368 in 1936; in 1935, when only one dentist was employed, the 114 dance figure was 3,908. This means that we are seeing nearly 1,500 patients more per year than we were three years ago. The amount of work performed for the children can be seen from the table appended and it is encouraging to find that in spite of a somewhat greater number of children treated there is still another reduction in the number of permanent teeth extracted—namely a reduction from 826 to 788. It must also be remembered that quite a good proportion of permanent teeth are extracted not because they are aching or unsound, but in order to relieve crowded mouths with irregular teeth. Orthodontics. There is a continued demand for the treatment of irregularities of the teeth. These cases take rather a long period with many visits, so that the number of cases accepted for treatment has to be limited. The cost of treatment falls entirely on the parent and we have an arrangement with a dental laboratory in the town to make the apparatus and plates for a fixed charge of 7s. 6d. Equipment. An electric engine was provided by the Committee in August for use at the North Clinic. This has been much appreciated by the dentist, and by this the equipment been brought really up to date; the foot engine we had been using was efficient, but at least twenty years behind the times. Welfare. It will be seen from the table that the service for welfare children is appreciated and that the attendances amounted to 326. It is surprising how much sepsis and pain exists in these tiny children, our services being frequently needed to relieve acute abscess at the age of three. Until the last few years it was not realised that children of this tender age could have anything done and no doubt, taking the country as a whole, thousands 115 of' children must have suffered for lack of a service such as we are giving. I am inclined to think that where these young children are concerned, the parent is more relieved than the child when a painful tooth is removed, as a had tooth means many days and nights of distress for the parent as well as the patient. Mothers. The newly established Midwifery Service includes dental treatment in its benefits and so we now have to provide for patients under this service in addition to our Welfare mothers. At present the work is mainly extractions with gas and a certain number of fillings and scalings. With a very large number of these patients no dental treatment has ever been received and we find that at the age of thirty or so the only possible treatment is total extraction. At the moment we rather leave our patients unfinished, as we do not provide artificial teeth of any sort and one feels it is a little unsatisfactory to dismiss them toothless and to take no further interest; perhaps in the near future, arrangements might be considered for provision of dentures. The mothers' attendance this year was 232 and 63 were fully treated with the exception, of course, of dentures. Conclusion. Lastly, may I express by appreciation of the assistance given me by the Committee and the staff. May 1 also express my thanks to the Voluntary Workers who give such practical service; it is a fact that, without their help, we could not carry on the gas sessions. T. S. Latham, L.D.S., Eng., School Dental Officer. 116 Summary of Dental Statistics for Year 1938 (with comparative figures for 1936 and 1937). Inspections. 1936 1937 1938 No. of sessions 25 27 28 New school at Southborough not yet inspected. No. examined 5102 5137 5245 No. for treatment 2744 2980 2665 Net percentage 53 60 54 Treatment. No. of sessions 418 465 462 No. treated 2428 2564 2638 Including children from: Elementary schools, 2,376 Total attendances 4368 5004 ■5468 County ditto, 99. Welfare, 163. Including children from Elementary schools. 4944. County ditto, 198. Welfare, 326. Average number per session 10.4 10.7 11.8 Gas cases 1194 1263 1614 Including children from Elementary schools. 1,431. County ditto, 20. Welfare, 163. Extractions 4528 4605 60???9 Including children from Elementary schools. 5,737. County, 26. Welfare, 326. Fillings 2820 2822 2790 Including children from Elementary schools, 2,670. County ditto, 90. Welfare, 30. Regulations, Scales and Dressings 617 733 800 Attendances for tions, 174. M. and C.W. Children treated 108 120 163 Mothers treated 41 55 63 Children's attendances 326 Mothers' attendances 232 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,I ETC. 118 Infectious Disease. The schools were comparatively free from infectious disease during 1938, with the result that more school time was able to be given by the pupils. Notifiable infectious diseases were few and no spread of infection occurred in schools. Whooping cough, mumps and chicken pox were below the average and contagious diseases such as impetigo considerably lessened. The lessening of impetigo might be, and is possibly, due to the more prevalent use of handtowels and the abolition of roller towels in the schools. No change was made in the regulations governing infectious diseases and the recommendations of the Memorandum on the Closure of and Exclusion from Schools were followed. The following is a summary of the returns of infectious disease received from Head Teachers during 19;3S. Schools. Diphtheria. Scarlet Fever. Measles Whooping Cough. Mumps. Chicken pox. Other. Valley Girls ... ... 1 ... 3 12 ... Valley Infants' 2 1 36 ... 13 27 ... Raglan Boys' 1 4 5 ... 1 3 ... Raglan Juniors' ... 1 1 ... 15 18 ... Raglan Infants' 1 3 128 1 13 41 ... Burnt Ash Boys' ... 2 ... ... ... ... ... Burnt Ash Girls' ... 4 7 1 3 4 3 Burnt Ash Infants' ... 6 92 14 3 10 1 Central ... ... 2 ... 4 16 ... Princes Plain Girls' 1 1 1 ... 4 ... ... Princes Plain Juniors ... 9 36 ... 35 13 1 Parish Boys' ... ... ... ... ... ... ... Parish Girls' ... 1 2 ... 2 4 ... Parish Infants' ... ... 74 ... 2 4 ... Mason's Hill ... ... 44 1 14 28 ... Plaistow St. Mary's ... 2 12 1 18 27 ... Bickley & Widmore ... ... 2 1 ... ... ... Southborough ... ... ... ... ... ... ... St. Joseph's ... ... 1 ... ... 6 ... Hayes ... ... 2 10 3 95 ... Keston ... ... ... ... ... ... ... Addison Road ... ... ... ... 36 4 ... 119 Medical Certificates of Exclusion from School. The following is a summary of the medical certificates issued by general practitioners and gives an indication of the types of illness responsible for loss of school attendance. These figures are in addition to those of children excluded from school through the School Medical Service. Conditions for which Medical Certificates of Exclusion from School were issued by General Practitioners in 1938. Malnutrition 18 Skin 19 Eyes 6 Ears 13 Nose and Throat 67 Enlarged cervical glands 6 Heart 6 Lung (non-tuberculous) 29 Nervous diseases 5 Accidents 7 Operations 3 Measles 41 Whooping cough 5 Mumps 8 Influenza 16 Chicken pox 53 Rheumatism 18 Bronchitis 33 Miscellaneous 54 407 120 Open-Air Education. No special open-air school for defective children is provided in Bromley. A great use was made during the year of convalescent home treatment as provided by the Bromley Children's Care Committee: while this scheme is in operation and use made of it, the need for special open air schools is not imperative, especially when one considers our modern schools with their hygienic construction and the extension of playing fields and outdoor physical training. Physical Training. I am submitting the very interesting report which was made to the Education Committee by the Physical Training Organisers, Miss F. M. Bentley and Mr. G. Atkinson. Report of the Organisers of Physical Edication for the year ended 31 st december, 1938. (1) General. The progress of the development of all branches of physical education in the Elementary Schools of this Borough during the past twelve months has been assisted in no small measure by the recent determined efforts of the Board of Education to secure the wider recognition of the subject's claims. That the physical welfare of the child is of fandamental importance to any scheme of child education is no new theory; yet it is surprising how long it has taken to give practical effect to the principles involved and implied, namely:— (1) That a daily period of physical activity by required for all children. (2) That alternative indoor accommodation for physical exercises is essential during inclement weather. (3) That a satisfactory scheme of exercises for older children necessitates the provision of fully-equipped gymnasia. 121 (4) That the fullest benefits from physical exercises are obtainable only by pupils for whom suitable clothing and footwear are available. (5) That a sound scheme of physical education involves not only physical exercises, but games and athletics, swimming,, dancing, rambling and camping; in fact, all activities which may justly claim to contribute to the child's physical welfare and development. Having regard to the clearly defined principles and requirements of the Board of Education, much has been done to create satisfactory conditions for the development of physical training in the Elementary Schools of this Authority. (2) Physical Exercises. (a) Senior Schools. Interest and enjoyment in the Physical Training Lesson, the keynote of its modern interpretation, is secured in all Senior Schools. Advanced schemes of work, carried out by specially trained teachers are generally adopted, and the resulting improved standard of classperformance has more than justified the provision of portable gymnastic apparatus. The empirical discovery during the past few years of unexpected potentialities for gymnastic skill possessed by the senior school child has established the subject s claim for increased facilities for gymnastic work and that this claim is fully recognised by this Authority may be judged from the fact that in the very near future, two new wellquipped gymnasia will become available for use by two Senior Schools, and, with the completion of the Education Committee's further plans for re-organisation, silimar facilities will be provided for all remaining schools of this type. Successful open-air demonstrations strongly supported by parents and friends were held during the summer Months by two Senior Departments. playing Field activities of all kinds were demonstrated, during which the whole of the school children 122 were actively engaged in major games, agility work, gymnastics or dancing. (b) Junior Schools. Satisfactory progress has been maintained, particularly in the management and practice of the Team System. The further development of the group-leadership method has been well featured, and the ability of children to handle their own group activities is greatly increasing. Although the general standard of class-teaching has shown some improvement, there are still a few teachers who are finding difficulty in appreciating the value of precision in the performance of the more formal type of exercise. As a rule with such teachers there is a general lack of class control which gives their lessons the appearance of looseness and confusion. As the values of physical exercises depend so much on good teaching the need for specialisation in certain Junior Schools is clearly indicated. (c) Infants' Schools. The character and scope of the activities employed in both the "Primary" and "Secondary" lessons for Infants Classes calls for urgent re-consideration of the policy usually adopted in regard to the size of Infants; School Halls. Classes of fifty infants require at least as much room for the physical exercises as is customarily provided for junior classes. In spite, however, of the difficulties of restricted accommodation in certain schools there has been a general improvement in the quality of the instruction given. A more extensive use of music in application to the "Secondary" lesson, and the use of apparatus and a better appreciation of the training values of the "Primary" lesson have yet to be realised. (3) Shoes and Clothing. It is significant that in schools where there has been a really determined attempt on the part of' the teaching staffs to secure the satisfactory equipment of children with 123 shoes and clothing for physical exercises, the resulting benefits to the work have more than justified the efforts employed. The present policy of the Education Committee is to encourage parents to provide these articles for their children. In the case of Senior Schools this arrangement has worked satisfactorily, but much remains to he done before the problems and difficulties of this provision in the Junior and Infants' Schools are properly overcome. Arrangements for the storage of clothing and shoes at schools still present a major problem and until such arrangements are secured, the general practice of changing for physical exercises can never become really established. (4) Equipment. In order to carry out the scheme of work suggested by the Board of Education syllabus of Physical Training, a constant supply of small apparatus is essential, Arrangements have been made for a definite supply to be allocated to every department with a proportionate amount of renewals to he granted each year. (5) Organised Games. One of the most outstanding features of the development of physical education in this Borough during the past year has been the adoption of a scheme to provide weekly visits for organised games for the majority of senior classes and for the upper standards of certain junior schools to the Education Committee's excellent playing fields at Oakley Road and Hayes. The children are conveyed to and from the fields by private motor coach under a time schedule which allows them a forty-minute games period and collects and returns them to their schools with the hour. Future plans include:— (i) the provision of changing rooms and spray bath. at the above fields and 124 (ii) the extension of facilities for school visits to a recently acquired playing field now in the course of preparation. The organisers' assistance in planning and marking of all school playgrounds has been greatly appreciated. The time and labour thus saved is beneficial throughout either a short games lesson or the normal physical training lesson. (6) Swimming. Owing to the Borough's very limited facilities for school swimming—one open-air bath situate a considerable distance from most schools—it has not been practicable to adopt the Board of Education's suggestions in regard to this subject. During the past year, however, arrangements have been made to enable a limited number of classes from schools conveniently situated, to attend during school time for a weekly instruction at the Bromley Municipal Open Air Bath, and by arrangement with the London County Council, at the new enclosed Bath at Downham. Additional arrangements have also been made under a voluntary scheme which provides opportunities for a limited number of non-swimmers to attend the local Bath after school hours to receive organised class instruction under paid teachers appointed by the Education Committee. (7) Dancing. The general standard of English Country Dancing throughout the schools in the Borough is fairly high, and in one senior girls' school the Natural Movement is taught with really excellent results. There is still much score for the subject's development, however, along more interesting and varied lines. A wider range of dance such as is offered by National Dances, Folk dances of Other Lands, and the Central European type of Natural Movement should now be encouraged. 125 8) The Further Training of Teachers. The following courses for teachers in the service of the Beckenham, Bromley and Penge authorities have been held during the year under the auspices of the Joint Committee for Organisation of Physical Education for the above and the Erith and Gravesend Authorities. The attendance of Bromley teachers has been highly satisfactory:— (1) A course of Physical Training for men teachers in Junior Schools, held in Bromley each afternoon, from Monday to Friday throughout the period February 7th to 26th. (2) A course in Physical Training for women teachers in Junior Schools, held in Bromley each afternoon, from Monday to Friday throughout the period February 28th to March 18th. Two women teachers have also been afforded facilities to attend the Special Three Months' Course at Southlands College for the purpose of qualifying in more advanced gymnastic work. (9) Conclusion. The continued interest and keenness of the teaching staff generally and their increasing appreciation of the value and importance of their work in Physical Education has resulted in a year of sound progress. The Organisers wish to acknowledge their indebtedto the Education Committee for their continued condence and support, to the Chief Education Officer and his Staff for their invaluable assistance and advice, and also to the head and assistant teachers upon whose loyal co-operation the value of their work must ultimately depend. F. M. Bentley, Geo. H. Atkinson, Organisers of Physical Education. 126 Provision of Meals. I have discussed this matter in dealing with Malnutrition, on page 99. Co-operation of Parents, Teachers and Others. The School Medical Service is to be noted for the happy co-operation from teachers, parents, school attendance officers and voluntary bodies. This is as it should be so that we may safely say that we are improving the fit and making the unfit more able to take advantage of the education provided by the Local Authority. SECTION D. I. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. II. NURSERY SCHOOLS. III. SECONDARY SCHOOLS. IV. PARENTS' PAYMENTS. V. HEALTH EDUCATION. VI. SPECIAL INQUIRIES. 128 Blind, Deaf, Defective and Epileptic Children. We have no special schools in Bromley for these children, and we are dependent upon other and larger authorities for the accommodation required for their education. During 1938 the following children were provided with special education either at day or residential special schools:— Blind 2 Tubercular 4 Partially blind 6 Delicate 3 Deaf 3 Crippled 6 Mentally Defective7 Heart 5 Epileptic 1 Table III in the Appendix gives a complete tabulation of children notified as special under the above headings. Border line children are kept under periodic supervision, a work which entails much expense of medical and administrative time. Nursery Schools. Owing to the lack of accommodation in the ordinary elementary schools in Bromley, it has not been possible during the year to hold nursery classes. The need for nursery classes is, in my view, an urgent one, especially for those 3-5-year-old children showing maladjustment to their environment, and who respond so well admitted to the company of other young children at school. Secondary Schools. the Kent County Council is responsible for the medical inspection and treatment of pupils attending the secondary schools in Bromley. We have, however, on arrangement with them whereby children of the necessitous class in need of treatment are offered the facilities of the school clinics and services provided by the Bromley Education Committee. The following list shows the number of children who took advantage of the arrangement during 1938:— 129 Dental Clinic 98 Eye Clinic 16 Orthopaedic Clinic 5 Tonsil and Adenoid Clinic 1 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. Orthopaedic: 3d. per treatment for exercises, 6d. for treatment for massage. Inpatient treatment, splints, etc., according to means. Eyes: Parents pay a special reduced cost for glasses. 6d. per first attendance on Specialist's examination. Ultra Violent Ray treatment: 6d. per application. Special Education: Weekly contribution according to the income of the parents. Health Education. No special demonstrations or lectures are given on this matter. The practical application of hygiene is more important. Individual instruction to parents on the care and feeding of young children continues, and the response is a progressive one. Special Inquiries. Special investigations into enuresis of children and certain skin diseases begun in 1938, but owing to the national emergency, the work had to be discontinued and cannot be recommenced until there is considerably less disturbance to our normal efforts to improve the health of school child. I am, however, submitting Dr. Macdonald's report on his preliminary tions:- 130 Enuresis. "This is unfortunately a common condition, the causes of which are legion. In many cases it is extremely difficult to bring about any improvement, and this is found to be so chiefly where home conditions are unsatisfactory, where there is overcrowding, friction or unhappiness. "30 cases were investigated during the year. Most of these children attended regularly, but several come to the clinic only at long intervals. Treatment often has to be prolonged over many months, and this some mothers find too much trouble; many mothers also take it for granted that a child will grow out of all its troubles at the age of seven. "The forms of treatment are numerous, and each claims its successes (we have found chronic bed-wetters to become permanently dry immediately following removal of tonsils and adenoids). Despite this, there are some cases which refuse to respond to any treatment whether advised by the clinic or by London children's hospitals. Some of such cases improve at once when taken on holiday. Convalescent homes will not accept enuretic children, so that those children whose home circumstances are such that a change of environment is impossible present the most difficult problems. "A large proportion of enuretics in which no local cause can be found, i.e., threadworms, phimosis, etc., are classified as neuropathic. The bed-wetting here is a manifestation of the child's general nervous instability. Jealousy of a new baby in the household, lack of harmony in the family and other similar factors are sufficient to cause loss of control and the child becomes one of the most difficult enuretics. "A common association of conditions is that of enuresis or threadworm infection, and when the latter is eradicated the child frequently becomes dry. As the child grows older there is a tendency for the enuresis to clear up spontaneously. Of the 30 cases under notice, about half have become dry or shown marked improvement. Of the others, some have not continued with the treatment advised, and some, despite treatment, have not benefited." 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. 132 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. 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 1938, and for whom certificates were issued, was as follows:— Total number examined 141 Fit certificates issued 140 The total number of children in employment at the 31st December, 1938, was:— (a) Boys— Newspaper delivery 157 Milk delivery 37 Delivery of goods and parcels 65 (b) Girls— Newspaper delivery 2 Household help 1 262 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 with the private practitioner. The line of demarcation between the two services is a distinct one, and is only partially blended by the co-operation that exists between us. When a child is referred to domiciliary care, the case is followed up by the school nurses, who in Bromley also act as health visitors, and much can be done, and is being done, to 133 give advice on the proper care of the sick child and the correction of a casual 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, 1938. "In the year ending December, 1938, the Committee gave assistance in 228 cases. Some of the families were very poor and help was continued for two or three months. Some of the parents of children who went to Convalescent Homes were unable to pay their fares, in which cases the Committee advanced the money. There were two or three instances of mothers refusing to let their children go away to Convalescent Homes after convalescent home treatment had been recommended by the doctor, and one boy was fetched home after a week because he fretted. The other children all enjoyed themselves and were much better for the change. Assistance was given as follows:— Boots 60 Milk 70 Extra nourishment 32 Medicine 10 Taxis and fares 12 Vision 15 Convalescent letters 29 228 The clinics have been attended by a number of voluntary Helpers, who all the year round have given help in various ways. The Committee wishes to thank Mr. Harvey Lowe for giving so many Convalescent Home letters, and also Mr. Harris for continuing to supply the children with glasses at such a low cost." 135 SECTION F. APPENDIX. STATISTICAL TABLES. TABLE I. A. Routine Medical Inspections. B. Other Inspections. C. Children Found to Require ment. ABLE 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. 136 TABLE I.—MEDICAL INSPECTION RETURNS for the Year ended 31st December, 1938. A.—Routine Medical Inspections. Number of inspections in the prescribed Groups:— Entrants 586 Second Age Group 493 Third Age Group 569 Total 1,648 Number of other Routine Inspections 129 Grand Total 1,777 B.—Other Inspections. Number of Special Inspections 5,192 Number of Re-Inspections 4,163 Total 9,355 C.—Children Found to Require Treatment. Number of individual children found at Routine Medical Inspection to require treatment (excluding Defects of Nutrition, Uncleanliness and Dental Diseases). Group. For defective vision (excluding squint). For all other conditions recorded in Table IIa. Total Entrants 10 93 101 Second Age Group 51 90 95 Third Age Group 89 109 120 Total (Prescribed Groups) 150 292 316 Other Routine Inspections – 5 5 Grand Total 150 297 321 1.37 TABLE II. A—Return of Defects found by Medical Inspection in the Year ended 31st December, 1938. Routine Inspections. Special Inspections. Defect or Disease. No. of Defects No. of Defects Requiring Treatment. Requiring Observation Requiring Treatment Requiring Observation. Skin (1) Ringworm—Scalp .. .. .. .. (2) „ —Body 1 .. 4 .. (3) Scabies 1 .. 24 .. (4) Impetigo 10 .. 62 3 (5) Other Diseases (Non-tuberculous) 4 .. 405 8 Total (Heads 1 to 5) 16 .. 495 11 Eye (6) Blepharitis 2 1 17 3 (7) Conjunctivitis .. .. 70 .. (8) Keratitis .. .. .. (9) Corneal opacities .. .. 4 .. (10) Other conditions (excluding defective vision and squint) .. .. 89 7 Total (Heads 6 to 10) 2 1 180 10 (11) Defective Vision (excluding squint) 150 106 69 70 (12) Squint 7 2 9 .. Ear (13) Defective Hearing 1 4 7 10 (14) Otitis Media .. .. 30 2 (15) Other Ear Diseases 4 5 168 8 Nose and Throat (16) Chronic Tonsilitis only 15 162 75 55 (17) Adenoids only 2 1 6 7 (18) Chronic Tonsilitis and Adenoids 41 39 115 55 (19) Other Conditions 24 16 187 21 (20) Enlarged Cervical Glands (non-tuberculous) .. 4 43 7 (21) Defective Speech .. .. 3 1 Heart and tion Heart Disease:— (22) Organic 1 6 13 16 (23) Functional .. 20 3 1 (24) Anaemia 9 3 7 .. Carried forward 272 368 1410 274 138 TABLE II. — Continued. Defect or Disease. Routine Inspections Special inspection No. of Defects No. of ??? Requiring Treatment Requiring Observation Requiring Treatment. ??? Brought forward 272 368 1410 ??? Lungs (25) Bronchitis 1 1 80 4 (26) Other Non-Tuberculous Diseases 1 6 252 ??? losis Pulmonary:— (27) Definite .. .. .. .. (28) Suspected Non-Pulmonary:— .. .. 1 .. (29) Glands .. 1 1 1 (30) Bones and Joints .. .. .. .. (31) Skin .. .. .. .. (32) Other Forms .. .. .. 1 Total (Heads 29 to 32) .. 1 .. 2 Nervous System (33) Epilepsy .. .. .. .. (34) Chorea .. .. 5 ??? (35) Other Conditions 19 9 38 ??? Deformities (36) Rickets .. .. .. .. (37) Spinal Curvature 10 4 5 .. (38) Other Forms 81 .. 23 ??? (39) Other Defects and Diseases (excluding Defects of Nutrition, Uncleanliness and Dental Disease) 63 73 1384 ??? Totals 447 462 3199 ??? 139 B.—Classification of the Nutrition of Children Inspected during the Year in the Routine Age Groups. ???Group No. of Children Inspected. A (Excellent) B (Normal). C (Slightly Sub-normal). D (Bad). No. Per Cent. No. Per Cent. No. Per Cent. No. Per Cent. ??? 586 34 5.8 506 86.4 44 7.5 2 0.3 ??? Age-Group 493 29 5.9 396 80.3 60 12.2 8 1.6 ???Age-Group 569 76 13.4 431 75.7 57 10.0 5 0.9 ??? Routine Inspections 129 9 7.0 103 79.8 17 13.2 – – Total 1777 148 8.32 1436 80.81 178 10 .01 15 0.84 TABLE III.—Return of all Exceptional Children in the Area, 1938. BLIND CHILDREN. At Certified School for the Blind. At Public Elementary Schools. At other Institutions At no School or Institution Total 2 — — — 2 PARTIALLY SIGHTED CHILDREN. ]At Certified School for the Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At other Institutions At no School or Institution Total 1 5 2 1 – 9 140 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions At no School or Institution Total 3 – – – 3 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions At no School or Institution Total — – 1 — – 1 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 5 1 3 15 MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN REGULATIONS, 1928. Total Number of Children notified during the year 1938 by the local Education Authority to the Local Mental Deficiency Authority 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 — — – 1 141 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 3 – – 6 B- Delicate Children — 7 3 1 11 C-Crippled Children 6 14 — 1 21 D- Children with Heart Disease 5 8 – 1 14 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 Nil – – — — Nil 142 TABLE IV.—Group I. Minor Ailments treated during Year, 1938. Disease or Defect. Number of defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin— Ringworm—Scalp: (i) X-Ray treatment – – – (ii) Other – – – Ringworm—Body 5 — 5 Scabies 31 — 31 Impetigo 75 1 76 Other Skin Disease 372 6 378 Minor Eye Defects (external and other, but excluding cases falling in Group ii) 287 2 289 Minor Ear Defects 243 4 247 Miscellaneous (e.g., Minor injuries, bruises, sores, chilblains, etc.) 1518 103 1621 Total 2531 116 2647 143 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) 681* – 681 240 – 240 238 – 238 Other Defect or Disease of the Eyes (excluding those rerecorded in Group 1) 50 – 50 — – — — — – Total 731 – 731 | 240 — 240 238 – 238 *Including 430 re-inspections. 144 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 Authority's Scheme. Total. (i) (ii) (iii) (iv) 3 151 (i) (ii) (iii) (iv) 38 (i) (ii) (iii) (iv) 3189 122 311 (i) Tonsils only, (ii) Adenoids only, (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat. 145 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. Non. residential treatment at an Orthopaedic Clinic. Residential treatment with Education. Residential treatment without Education. Nonresidential treatment at an Orthopaedic Clinic. Number of Children treated 6 — 222 — – — 222 14G BOARD OF EDUCATION. Table V. (1) Number of Children Inspected by the Dentist: (a) Pontine age-groups:— Age 5 6 7 8 9 10 11 12 13 14 Total Number 426 483 570 437 764 508 518 418 494 292 4909 (b) Specials 336 (c) Total (Routine and Specials) 5245 (2) Number found to require treatment 2665 (3) Number actually treated 2376 (4) Attendances made by children for treatment 4944 (5) Half-days devoted to:— Inspection 28 Treatment 462 Total 490 (6) Fillings: Permanent teeth 2402 Temporary teeth 268 Total 2670 (7) Extractions: Permanent teeth 788 Temporary teeth 4949 Total 5737 (8) Administrations of gas 1431 (9) Other operations: Permanent teeth 589 Temporary teeth 211 Total 800 147 TABLE VI.—Uncleanliness and Verminous Conditions. (i) Average number of visits per school made during the year by School Nurses 3 (ii) Total number of examinations of children in the Schools by School Nurses 15458 (iii) Number of individual children found unclean 263 (iv) Number of individual children cleansed under Section 87 (2) and (3) of the Education Act, 1921 — (v) Number of cases in which legal ings were taken:— (a) Under the Education Act, 1921 — (b) Under School Attendance Byelaws 1