Urban district of Beckenbam. REPORT HEALTH OF the DISTRICT DURING 1925, INCLUDING THE Report on the Medical Inspection the Elementary Schools J. M. CLEMENTS, M.D., D.P.H., Medical Officer of Health. School Medical Officer. Urban District of Beckenbam. REPORT on the HEALTH OF the DISTRICT DURING 1925, including the Report on the Medical Inspection of Children in the Elementary Schools BY J. M. CLEMENTS, M.D., D.P.H., Medical Officer of Health. School Medical Officer. Urban District of Beckenham. 1925. GENERAL PURPOSES COMMITTEE Chairman J. CREASE. Vice-Chairman Dr. G. ELAM. S. Baylis. G. T. Evans. Dr. J. H. Bennett, J.P. G. L. F. Grece. F. G. Billett. C. G. Izard. J. Caikns. B. T. Parker. C. A. Campbell. K. 0. Roberts-Wray T. C. Cole. H. Bayford Stone, M.A. J A Collister. W. A. W. Suddaby. A. H. Dykes. C. Vince. C. A. Eloood F. W. Gedney, Clerk of the Council. EDUCATION COMMITTEE. Chairman C. A. Elgood. Vice-Chairman S. Baylis. F. G. Billett. G L. F. Greoe Mis. Brazil, B.A. T. Lyle, M.A. C. A. Campbell. G. W. Neal, B.Sc. T. C. Colk F. W. Payne, J.P. J. A. Collister. K. O. Roberts-Wray. J. Crease Mrs. Howard Smith. Dr. G. Elam. W. A. W. Sdddaby. The Rev. R. S. Fleming, M.A. Miss M. Vian, J,P, J. R. Hambridge, Secretary. OFFICIALS OF THE HEALTH DEPARTMENT. Medical Officer of Health J. M. Clements, M.D., D.P.H.8 Chief Sanitary Inspector E. G. Moore. 28 SanHtary Inspector H. G. Richards.1238 Health Visitors Miss M. A. Cusack. 148 Miss M. E. Chapplf,. 148 School Dentist R. A. Waters.5 Dental Nurse Mrs. E. F. Richards.167 Clerks S. W. Collett. C. J. Caspell. 1 A. S. Evans. 1. Associate of' the Royal Sanitary Institute. 2. Member of the Sanitary Inspector*' Association. 3. Certificated Meat and Food Inspector. 4. Certificate of the Central Midwives' Board. 5. Licentiate of the Dental Section, Royal College of Surgeons. 6. State Registered Nurse. 7. Certificated Nurse. 8. A contribution is made by the Ministry of Health towards the salaries of these officers, 4 SUMMARY OF STATISTICS, 1925. Area of District (in acres) 3883 Population (as estimated by Registrar-General in June, 1925) 33850 Rateable value £296843 Sum represented by a penny rate £1200 Density of population (i.e., number of persons per acre) 8.66 Number of houses in occupation 7987 Number of houses erected in 1925 294 Number of Births registered:— Males. Females. Legitimate 241 231 [Total 486 Illegitimate 11 3 Birth rate 14.3 Number of deaths—Males, 177; Females, 171 348 Death rate per 1,000 living 10.2 Death rate from seven Zymotic Diseases per 1,000 living 0.2 Death rate per 1,000 living from Phthisis 0.44 Death rate per 1,000 living from other forms of Tuberculosis 0.26 Death rate from disease of Respiratory Organs (excluding Tuberculosis) 1.40 Death rate from Cancer per 1,000 living 1.32 Infantile Mortality rate (deaths under one year per 1,000 Births) 63.8 Legitimate Babies born 472 Legitimate Babies died 30 Illegitimate Babies born 14 Illegitimate Babies died 1 Deaths from:— Measles (all ages) 1 Whooping Cough (all ages) 4 Diarrhoea (under 2 years of age) Nil 5 To the Chairman and Members of the Public Health and General Purposes Committee. Gentlemen, I submit for your consideration my Annual Report on the health and sanitary condition of the district for the year 1925. The report follows very closely the outline and arrangement suggested in Circular No. 648, issued by the Ministry of Health in December, 1925. This circular states that the report for the year should be a "survey" report, and should review the progress and development of the health services during the last five years. In this connection it will be remembered that the period under review has been one of great financial strain and difficulty, and that strict economy has had to be observed in the health as in other public services—expansion which appeared necessary or desirable has had to be abandoned or very much curtailed. At the same time it should be pointed out that during this period there has been a large amount of new health legislation, more especially dealing with milk and food supplies, and that the adoption and putting into practice of this legislation has in itself involved a considerable expansion of the work of the health department. The most urgent need at the moment is the provision of larger and better accommodation for the Infant Welfare Centre and for the clinics connected with the School Medical Service, and I hope the Committee will seriously consider this problem at an early date. Advances have been made in the period under review for attending to the health of expectant and nursing mothers. An ante natal clinic is now held weekly, and the Joint Maternity Home for the Districts of Beckenham and Penge, which was opened at the beginning of the period, is now utilised to its fullest capacity. The demand for beds in the Home has amply proved the need that existed for such provision, and it became available at a time when, owing to shortage of houses and overcrowding in the homes of the 6 working classes, it was urgently required. Last year further provision was made for the isolation and hospital treatment of cases of Puerperal Fever. These developments are the outcome of the interest and attention that has been given to the subject of Maternal Mortality. While a great reduction has taken place in infant mortality during the last quarter of a century, no corresponding reduction has taken place in the deaths of 'mothers from diseases and accidents of childbirth. Health Authorities are directing their attention to the causes of these deaths and are concentrating on the measures that as likely to remove them and so render the function of childbearing as free from accidents and dangers as it is possible to make it. In giving prominence to the needs and the work of Maternity and Child Welfare we must not overlook other causes and diseases which figure very largely in our records of disease and death. Heart disease, cancer, and tuberculosis still occupy the leading places in the mortality bill, and they call for increasing labour and investigation in order to reduce the death rate from these diseases. More attention is being given to the prevention of heart disease, and especially to acute rheumatism, which is the cause of much disability and fatal heart disease. Special treatment in institutions of children suffering from acute rheumatism will, it is hoped, lead to a reduction in the amount of heart disease attributable to this cause. The information and advice now given to the Public with regard to the early signs of cancer should lead to the recognition of this disease in its earliest stages and result in its being brought under treatment at a time when appropriate treatment 'may bring about a cure. The death rate from Tuberculosis is declining slowly, but steadily, and this disease is now being attacked from many sides. Some of the recent Orders and Regulations of the Ministry aim at the prevention of its spread by channels which have contributed to the spread of the disease in the past. For instance, the following:— 7 (a) Section 62 of the Public Health Act, 1925, provides for the removal to institutions of cases of pulmonary tuberculosis who are a danger to others in their homes owing to inadequate care and isolation. (b) The Public Health (Prevention of Tuberculosis) Regulations, 1925, prohibit persons suffering from tuberculosis of the respiratory tract taking part in the milking of cows, the Handling of milk or milk vessels. (c) The Tuberculosis Order No. 1, 1925, makes provision for the discovery of tubercular cattle, their exclusion from milking herds, for their slaughter and for compensation to the owner. In the body of the report I have referred to other recent Acts of Parliament and Orders of the Ministry under the heading of the subject to which they relate. There was one important communication sent by the Ministry of Health to Local Authorities during the year which, although it does not deal directly with the prevention of any particular disease, will have very far-reaching effects on the Public Health Services, and it may be appropriate to refer to it here. It is entitled, "Provisional proposals for Poor Law Reform prepared in the Ministry of Health for circulation to the London County Council, Associations of Local Authorities, and others concerned as a basis for consideration and discussion.'' The proposals embody very great changes in the present system of administration, and if adopted will affect very seriously the status of many Local Sanitary Authorities, especially those autonomous areas within Counties such as large Urban Districts and Municipal Boroughs. The changes involved are considered under two headings:— (1) The transfer of the duties of Boards of Guardians to County Councils and to County Borough Councils. (2) The conferring upon County Councils of the duty of supervising and controlling all health services in the County outside the County Borough. Apart from the question whether the changes contemplated under heading (2) will lead to more economical and more efficient 8 services, upon which points there are conflicting views, there can be little doubt that these changes will have a bad effect on the status and constitution of the Councils of Municipal Boroughs and Urban Districts. These Authorities will be deprived of some of their most important powers and functions, or, at any rate, will be seriously fettered in their administration by a supervising authority, and it is hardly to be expected that the leading men in the District, who in the past have brought much ability and given much time to the consideration of local affairs, will consent to give their ti'me to an authority deprived of its more important powers and restricted in its action by the directions of a supervising authority, possibly not very conversant with local needs. It is hoped that all Local Authorities will take advantage of the invitation of the Minister to supply him with reasoned statements for and against these proposals so that he may have an opportunity of considering them before drafting a Bill on the lines he has indicated to place before Parliament. I am, Gentlemen, Your obedient servant, J. M. CLEMENTS. NATURAL AND SOCIAL CONDITIONS. Beckenham is a residential suburb of London situaced in the County of Kent, in the extreme North West corner of the County, and just outside the Metropolitan area. It is about eight miles from Charing Cross. On its North and West borders it touches the Metropolitan Boroughs of Lewisham, Camberwell, and Lambeth, on its West and South sides the Urban District of Penge, the County Borough of Croydon and Codstone Rural District, on its East and South East sides the Borough of Bromley and the Bromley Rural District. The total area of the District, including all land and inland water, is 3;883 acres. Its elevation varies from 100 to 300 feet above 9 sea level. The District generally is flat, with rising ground on the West towards the Crystal Palace and Sydenham, and again on the East towards Lewisham and Bromley. With regard to the geological formation of the District, about half the area consists of "Blackheath Pebble Beds" and the remaining half of "London Clay'' with beds of "Valley Gravel'' following the course of the streams known as the Chaffinch Brook and the Ravensbourne River. The climate is comparatively mild and the rainfall is low, averaging 28.02 inches during the last 10 years. 1925. Meteorology. Meteorological Observations taken at the Recreation Ground Croydon Road. (Supplied by J. A. Angell, Esq., A.M.I.C.E.) Month. Mean reading of Barometer at 9 a.m. Sell-registering thermometers. Rainfall total per month. Max. in air. Min. in air. F° F° inches. January 30.15 54 22 2.01 February 29.56 54 28 4.30 March 30.06 54 24 .75 April 29.77 63 28 2.37 May 29.76 78 34 2.08 June 30.13 88 38 .25 July 29.93 89 46 4.00 August 29.97 82 44 2.62 September 30.20 68 36 2.82 October 29.91 72 32 3.15 November 29.81 60 24 2.32 December 29.65 56 20 3.11 Mean for the year 29.91 68.33 31.33 (Total) 29.78 Population.—The Census population in June, 1921, was 33,350, and the Registrar General estimates the population at the middle of the year 1925 to be 33,850. Considering that 780 new dwelling houses have been erected since 1921, and are now in occupation, and that a considerable 10 number of the larger houses are undergoing a transformation into self contained flats, 1 venture to think that the population in 1925 is underestimated. Density.—A little more than half the area is built upon, so that there is a wide difference in the number of persons per acre in the seven Wards into which the district is divided. The average number of persons per acre for the whole District is 8.6, with variations from 3.1 in the Langley Park Ward to 29.1 in Lawrie Park Ward. In some parts of the District, as in the Copers Cope Ward, large areas have been taken over by Athletic Clubs for Games and imports, and they are likely to be kept for these purposes for many years to come, thus ensuring plenty of open space in these localities. In addition the District Council have provided a number of Parks and Recreation Grounds. In the portion of this Report dealing with the School Medical Service I have referred to the provision of playing fields and open spaces, and now that the building trade has revived and several of the unbuilt portions of the District are being laid out for building purposes, the time is appropriate for the Council to consider which of these areas require Parks and Open Spaces. In those new areas where the houses are likely to be thickly on the ground it is unnecessary to emphasise the need for open spaces for the purpose of recreation and play. Number of Rooms pee Dwelling. Four per cent, of the dwellings contain 1 to 3 rooms. Thirty-two per cent. ,, ,, 4 to 5 ,, Forty-four per cent. ,, ,, 6 to 8 ,, Twenty per cent. ,, ,, 9 or more rooms. Note.—The rooms counted are the normal living rooms, including kitchen and bedrooms, but excluding sculleries, bathrooms, boxrooms, and rooms used for business and professional purposes. 11 On the Census night there were 194 families living in one room dwellings, 451 families living in two rooms, and 847 families living in three rooms. The families were very small, but in about 140 instances the overcrowding was serious. The Census figures show that in respect of room accommodation Beckenham claims the first place in the County with a general average of 6.76 rooms per dwelling, which indicates the high residential character of the District. Principal Occupations 1921 Census. Males. Females. Total Population 14169 19176 Under 12 years of age 3009 3050 Aged 12 years or over 11160 16126 Total occupied aged 12 years or over 9526 5793 Total unoccupied or retired aged 12 years or over 1634 10333 Principal Occupations. Agricultural Occupations 451 7 Metal Workers (not electro plate or precious metals) 589 11 Electrical Apparatus Makers and Fitters and Electricians 237 23 Makers of Textile Goods and Articles of Dress 176 336 Makers of Food, Drink, and Tobacco 97 27 Workers in Paper, Printers, Bookbinders, Photographers, etc. 357 62 Builders, Bricklayers, and Contractors 390 2 Painters and Decorators 252 Persons employed in Transport and Communication 11150 89 Commercial, Finance, and Insurance Occupations (excluding Clerks) 1740 440 12 Males. Females. Persons employed in Public Administration and Defence (excluding professional men and typists) 526 137 Persons engaged in Personal Service '243 2940 (Domestic Servants 2639) Clerks, Draughtsmen (not Civil Service or Local Authority), and typists 1379 1034 Warehousemen, Storekeepers, and Packers 229 53 Retired, or not gainfully occupied 1634 10333 Comments. It will be observed that the female population is greatly in excess of the male, there being 5000 more females than males. This in equality, however, only applies to the population over the age of 12. The population under the age of 12 shows a more equal distribution of the sexes, the numbers being 3009 males and 3050 females. The increase in females after the age of 12 is largely due to the immigration of large numbers of female domestic servants, the number in this class being 2639, a larger number than in any other occupation. At the 1911 Census the number of female domestic servants was considerably higher, being 3538 in a smaller population. There are practically no industries in the District employing any considerable number of workers, and' the great majority of the occupied males find employment in London. The principal occupations in the order of numbers employed are classed under the following headings—commercial, clerks, communication and transport, metal workers, printing, and building trades 13 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. Hospitals.—1. Tuberculosis.—The Dispensary Service for this area of the County, comprising Beckenham, Penge, West Wickham, Anerley, and uppper Norwood, has its centre in the old Sanitary Offices adjoining the Beckenham Fire Station, and the Tuberculosis Officer for the area is the Medical Officer of Health of Beckenham. Sanatoria and Hospitals for Tuberculosis are provided by the County Council. 2. Maternity.—Maternity Home.—The Urban Districts of Beckenham and Penge have provided a Joint Maternity Home at 80, Croydon Road, Beckenham. The Ministry of Health have approved of the accommodation for 14 beds. 3. Children.—The Council do not provide, nor do they directly subsidize any Hospital for children. The Education Committee has made arrangements with the South Eastern Hospital for Children, Sydenham, to carry out certain treatment arising out of School Medical Inspection. Many children obtain hospital treatment, both in- and out-patient, at the London Hospitals. There is, however, a need for further provision locally. The Infant Welfare Centre and the School Clinics would be greatly assisted in their work if they had at their disposal a few hospital beds or cots to which infants and young children could be sent who require hospital treatment. I recommend the Council to consider the making of further provision on these lines. 4. Fever Hospitals.—The Bromley and Beckenham Joint Hospital Board provides Fever Hospital accommodation for Beckenham and a number of other districts. The Board have erected two Hospitals, one for the isolation of Smallpox and the other for certain infectious diseases. In previous reports I have given details of the position, accommodation, staff, and cost to the District Council of these Hospitals. 14 The Joint Hospital Board do not receive for treatment or isolation all the notifiable diseases mentioned in the 1889 Act. For instance, no provision has yet been made for cases of Puerperal Fever. On the other hand, diseases not included in the 1889 Act which have been made notifiable by the Ministry of Health, by Special Order or otherwise, such as Cerebro Spinal Fever and Encephalitis Lethargica are admitted to the Fever Hospital. Cases of Measles are also admitted from Beckenham by special arrangement with the Joint Board. 5. Other Hospitals. The Beckenham Cottage Hospital.—This Hospital is situated in Croydon Road and is the General Hospital for the District. It is supported by voluntary contributions and certain charges made to the patients. It has recently been much enlarged and modernised and has now accommodation for 42 patients. The operative treatment for tonsils and adenoids in Elementary School Children is carried out at this Hospital. The South Eastern Hospital for Children.—This Hospital is situated in Sydenham Road about ¾ of a mile from the Beckenham Boundary and is in the Borough of Lewisham. It serves the lower end of the District and is easily accessible. It has recently been extended and generally very 'much improved and brought up-to-date, and contains 60 beds. The Education Committee have entered into an arrangement with this Hospital for the operative treatment of tonsils and adenoids in Elementary School Children. London Hospitals.—Many Beckenham residents receive hospital treatment, both in- and out-patient treatment, at the London Hospitals, more especially at the following:— King's College Hospital, Denmark Hill. Great Ormond Street Children's Hospital. London Hospital, Mile End. 15 Institutional Provision for:— (a) Unmarried Mothers and Illegitimate Infants.—Those in need of assistance have had provision made for them at the Home which is organised by the Women's Council of the Evangelical Free Churches, and which is now situated at Ross Road, Upper Norwood, a convenient site for this area. The Mother and Baby remain in the Home a certain time and then the Home takes charge of the Baby and the Mother returns to work. (b) Homeless Children.—There are two voluntary institutions in the district which provide excellent accommodation and care for a number of orphaned and homeless children. St. Hilda's Home, Crescent Road.—This Home, which is managed by the Waifs and Strays Society, has accommodation for 30 girls aged from 1 to 12. The Home of Compassion, Bromley Road.—This Home has accommodation for 18 girls aged 5 to 15. Any class of child is accepted. The Bonaker Children's Hostel. This is a home provided by private enterprise and is intended for children of wellto-do parents. There is accommodation for 20 children, and there were at the time of enquiry 7 boys and 7 girls in the Home aged from 7 weeks to 5 years. AMBULANCE FACILITIES. 1. For Infectious Diseases.—The Bromley and Beckenham Joint Hospital Board provide motor Ambulances for the removal of Fever cases to hospital, and during the year have made additional arrangements to return cases to their homes when discharged. Tubercular patients requiring an Ambulance are removed to Sanatoria by the Metropolitan Asylums Board Ambulance at fixed charges. 16 2. For Non-Infectious and Accident Cases.—The District Council maintain a Motor Ambulance for the removal of accident cases and cases of sudden disability to hospital free of charge. Other cases pay fees according to a scale. TTiei Ambulance is available at any time, day or night. Clinics and Treatment Centres. Clinic or Centre. Address. Nature of accommodation. By whom provided. Maternity and Child Welfare Centre 73-75, High St. Waiting Room, Weighing Room, Consultation Room. Beckenham District Council School Clinics Inspection Treatment 73-75, High St. „ „ Waiting Room and Ditto Optlialmic „ „ Consultation Room Denral Balgowan Road School 3 Rooms Tuberculosis Dispensary Bromley Road Waiting and Consultation Rooms Kent County Council Venereal Diseases.—There is no treatment Centre in the area for these diseases. Patients usually attend some of the treatment Centres provided by the London and Home Counties Joint Scheme. The nearest Centre is at King's College Hospital, Denmark Hill. NURSING ARRANGEMENTS. Professional Nursing in the Home. (a) General.—(1) The Beckenham District Nursing Association supplies two trained nurses for general district work. These nurses are available for all who require their services in their homes. A small fee is paid depending on the circumstances of the patient. (2) In addition to the above several of the Churches provide a District Nurse. The work is limited to the parishioners of the respective Churches. 17 (b) Infectious Diseases.—The Health Visitors of the District Council visit cases of the minor infectious diseases at their homes and give appropriate advice as to management and treatment. The Council have also made an arrangement with the District Nursing Association for the District Nurses to visit daily such cases of measles, whooping cough, etc., as the Medical Officer of Health 'may notify to them. Midwives.—There are two certified midwives practising midwifery in the district, and a number of unqualified persons who go out as monthly nurses under the supervision of the Doctor in charge of the case. With regard to the latter there is need, in the interests of the mothers and infants, of the Midwives' Acts being amended so as to limit as far as possible unqualified persons doing this work, except in emergencies, and to define more precisely the degree of supervision that shall be given by the Doctor in charge of the case. The Beckenham and Penge Maternity Home employs a number of qualified Midwives on the Staff, some of whom attend extern cases in the patients' homes. An arrangement has also been made by the Home whereby certain extern cases are attended by the two Midwives who are practising in the district, and it has also been arranged that probationer nurses obtaining their training at the Heme will receive experience in district work under the supervision of these latter. CHEMICAL WORK. The Public Analyst for the Kent County Council carries out any analyses or examinations required under the Sale of Food and Drugs Acts or for other purposes. The results of examination of samples taken under the Sale of Food and Drugs Acts are set out in tabular form on page 38. 18 LIST OF THE ADOPTIVE ACTS, BYE-LAWS AND LOCAL REGULATIONS RELATING TO PUBLIC HEALTH. Local Acts. The Beckenham Urban District Council Act, 1903. Part V. Infectious Disease. Part VI. Tuberculosis. Part VII. Streets, Buildings, and Sewers. Part IX. Sanitary Provisions. General Adoptive Acts. Infectious Diseases Prevention Act, 1890. Public Health Amendment Act, 1890. Part in. Public Health Acts, Amendment Act, 1907. Part II. Sections 21, 22, 23, 26, 28, 33. Part III. Sections 34, 35, 45, 49, 50, 51. Part IV. Sections 52. 53, 59, 61, 62, 63, 65, 68. Part VI. Sections 76, 77, 85, 86, 90. Public Health Act., 1925. Parts II. to V. The Infectious Diseases (Notification) Act, 1889, has been extended to apply to "Summer Diarrhoea" for the period of each year dating from 15th July to 15th October. By-Laws. Slaughter Houses, 1883. Houses let in Lodgings, 1883. New Streets and Buildings, 1892, 1910, and 1914 Removal of Offensive or Noxious Matters, 1893 Employment of Children Act (1903), 1904. Occupation of New Buildings, 1905. Fire Escapes in Factories and Workshops, 1907. Cleansing of Cisterns, 1909. Nuisances, 1911. Offensive Trade of Fish Frier, 1913. Regulations. Dairies, Cowsheds, and Milk Shops, 1899 Construction of New Streets and Sewers. Theatres and Buildings Licensed for Stage Plays, &c., 1911. 19 SANITARY CIRCUMSTANCES OF THE AREA. This section of the Report deals with such important services from a health point of view as water supply, sewerage, drainage, and scavenging. I have in several previous reports described these in detail, and seeing that this is a survey report it will be appropriate to summarise them again and refer to improvements, if any, that appear to be required. Formerly the sphere of action of those engaged in health work was confined to a large extent to these elementary health services which have now been developed to a very high degree of excellence. At the present time the term health work has a much wider significance, and the Health Department is concerned not only with the sanitation of houses and their surroundings, but is concentrating more and more on the personal hygiene of the individual, the giving of instruction on healthy ways of living, how to avoid and prevent disease, and generally how to attain the highest degree of health and physical fitness that our present knowledge will permit. A consideration of the matters dealt with under the sections into which this Report is divided will indicate the extent of the field of preventive 'medicine and how numerous and varied are the influences which affect the health of the community. Water Supply. The whole of the District is supplied with water by the Metropolitan Water Board. The water is derived from two sources : (a) The greater part of the District being supplied from the Lambeth Section of the Board's service, and (b) a small part approximately confined to the Shortlands Ward receiving its supply from deep wells sunk in the chalk, and known as the "Kent Wells." The Lambeth supply consists of water taken from the River Thames, which, after a period of storage, followed by filtration, is delivered for use. There is a constant service of water to every house, and most of the houses have a pipe direct from the main for drinking 20 poses, so that the water can be obtained as pure as possible and not exposed to the dangers attendant on storage cisterns. There are three houses in the District situated at such a distance from the mains of the M.W.B. that it is not possible at present to lay the water on to these houses; they are supplied by private wells. Samples of the water from these wells are analysed from time to time, and the results have been satisfactory. From the point of view of health the water supplied by the Metropolitan Water Board is probably the safest in the world. The reports supplied to the Council from time to time by the Director, Sir Alexander Houston, indicate the methods adopted to render the water safe, and the daily examinations that are made to detect contamination or the presence of matter injurious to health. Sewerage and Drainage. The Sewage and excreta of the District are removed by the Water Carriage System. The sewers are on the "separate system," that is to say, there is one set of pipes for sewage and another for surface and storm water. For the purposes of sewage removal, Beckenham is divided into two Districts, namely, the Metropolitan Sewerage Area and the West Kent Area. The former district comprises the Kent House and Lawrie Park Wards (area 567 acres), and the latter the remainder of the District (area 3,314 acres). The dividing line between the two areas is the Crystal Palace branch of the Soutnern Railway, the Poole River, and a short length of the South Eastern and Chatham Railway. The Drainage of the Beckenham sewerage area discharges into the Penge and Bell Green Sewer, which latter sewer (taking also the sewage from Penge) connects to the Metropolitan Sewers at Lewisham, the main outfall of which Metropolitan Sewer is situate at Crossness on the River Thames. The Sewers of the West Kent area discharge at several points into the two main sewers of the West Kent Sewerage Board, the 21 sewage being eventually collected at Dartford, where, after purification. it is discharged into the Thames. The Sewers are ventilated by means of man-holes opening on the surface of the streets and by shafts carried several feet above the level of the ground. Cesspools:— In the year 1882 and subsequent years the sewering of the Dis trict was carried out and the old system of house drainage to Cess pools was practically abandoned. Isolated houses which were too far from the Sewer continued to be drained to a Cesspool, but as the District extended and new roads and sewers were laid these gradually were connected up to the Sewers. At the present time there are 8 houses in the District connected to a cesspit, and these are in every instance beyond the legal distance within which the Owners can be called upon to connect them with the District Sewers. All Cesspools are properly constructed and cleansed when necessary. RIVERS AND STREAMS. Beckenham is intersected or bordered by four main streams, the Birkbeck Stream, Chaffinch Brook, Beck River (these three joining to form the Poole River), and the Ravensbourne River, into which latter the Poole River discharges at Lewisham. Into these main streams or their tributaries the whole of the surface water of Beckenham is discharged, either by open ditches or, in the case of roads, by pipe drains. Pollution of Streams. With the exceptions mentioned below, the streams as a whole are clean, the water is clear and free from suspended matters which putrify or cause offence. There are no industries in the area which turn out waste or dye waters that would lead to pollution of the streams. 22 The exceptions to the above statement arise in connection with:— (a) The Carpet Beating Factory, Elmers End. A complaint was made during the year re the discharge of dye water from this factory. This dye water no longer discharges into the stream. It is now connected to and empties into the Sewer. (b) The Croydon Sewage Farm. This Farm adjoins the boundary of the District in the neighbourhood of the Elmers End Road, and the effluent from the Farm discharges into the Chaffinch Brook, which flows through the Manor House Ward and Kent House Ward to discharge into the Poole River. The effluent from the Farm is at times very unsatisfactory, as the following report from the Public Analyst will confirm. Three samples were recently taken from the stream where it enters the Beckenham District, and the Analyst states that in respect of two of these—"they are merely weak sewages." The condition of the Sewage Farm at Elmers End has in the past given rise to many complaints from suffering residents in its vicinity. It has been the subject of frequent representations by Beckenha'm to Croydon, and these in the year 1922 culminated in a local enquiry by the Minister of Health, who, as a result, stated that the complaints of Beckenham were well founded. Croydon at this time, and indeed, on all occasions when representations were made, promised to deal with the matter by erecting new machinery which would abate the nuisance. They have carried out their promises by laying down new plant in the form of screens, tanks, and filter beds, but the effluent turned out is still unsatisfactory from which I infer that the provision made is not yet adequate. It may be that the heavy clay soil of the farm is not suited to deal with sewage, or that the farm has not yet recovered from the way in which it was overworked in the past. There is no doubt it has been sewage-logged and the matter left exposed on the surface has given rise to evil smells. 23 It would appear by a recent letter from the Town Clerk of Croydon that the number of filter beds laid down are not yet capable of dealing with the dry weather flow of sewage, so that it is not surprising that the effluent at times is no better than dilute sewage SCAVENGING. Every occupied house in the District is provided with a galvanised iron dustbin for the reception of house refuse in accordance with the Beckenham Urban District Council Act, 1903. The dustbins are emptied once a week and their contents carted to the Destructor. Special arrangements exist for the frequent removal of trade refuse. The Destructor is situated at the Electricity Works in Churchfields Road and consists of six cells with back feed. About 115 loads of refuse are burnt weekly, and the heat is utilised to generate steam and supply power to the engines of the Electricity Works. The burnt clinker is converted into road making material by the Surveyor's Department. The weekly collection of house refuse is efficient and satisfactory during the winter months, but during the summer months when refuse and vegetable matter decomposes rapidly a bi-weekly collection is desirable. For a period immediately preceding the War a bi-weekly collection was in force during the months of July, August, and September, and was much appreciated by the rate payers. It is hoped the Council will soon be able to revert to this practice. It is also desirable that householders should be encouraged to burn as much of the house refuse as they possibly can. This practice improves the sanitation of their homes by the daily destruc tion of decaying matter, and saves the Rates by diminishing the cost of collection. 24 SANITARY INSPECTION OF THE DISTRICT. Nature of Nuisances or Defects Discovered. No. of premises at which defects were found. Drainage and Sanitary Arrangements:— Choked drains 57 Defective drains 42 Waste pipes, defective or untrapped 28 Defective channels to wastes and gullies 16 Rain water pipes, defective 27 House sinks, defective — Water closets or flushing apparatus, defective 58 W.C. apartments, dirty or defective 54 Soil pipes, defective 3 Ventilating shafts, choked or defective 14 Manhole covers, defective or unsealed 14 Public urinals, dirty — Water supply cisterns, uncovered 12 ,, ,, ,, dirty or defective 4 Galvanised iron dustbins, defective or absent 89 Defective fresh air inlets 23 Insufficient ventilation to houses 4 Defective sanitary fittings 46 Overflowing cesspool 2 Dwelling Houses: — Rooms requiring fumigation 161 Walls, floors, and ceilings, defective 94 Houses damp 161 Roofs and gutters, defective 149 Houses or parts, dirty 150 Yard paving, absent or defective 50 Stoves, defective 31 Miscellaneous 63 Miscellaneous Nuisances:— Smoke nuisances - Keeping of animals contrary to the Bye-Laws 27 Accumulation of offensive material 32 Absence of manure pit or pit uncovered 12 Contamination of streams — Dirty yards 13 Dirty rooms 4 25 Smoke Abatement:— Observation has been kept during the year on the following chimneys which are within the District or adjacent to the Boundary:— Oriental Rug Improvement Company, Croydon Road. The Electricity Works, B.U.D.C., Churchfields Road. The Metropolitan Water Board Works, Valley Road, Shortlands. The Dust Destructor, Lewisham Borough Council. At the Electricity Works, where the process of burning House refuse is combined with the generation of electricity, special attention has been given to stoking, and the smoke and fumes are now passed through a chamber where the temperature is raised to a very high point with very good results, so far as reducing the smoke nuisance is concerned. It was not necessary to take action in respect of any of the above mentioned chimneys during 1925. Premises Controlled by Bye-Laws. The following Table supplies particulars of the premises and the occupations in the District which are controlled by Bye-Laws or Regulations:— Character of Premises. No. Bye-Laws or Regulations affecting same. Action Taken and Result. Cowsheds 5 Regulations under Contagious Diseases (Animals) Acts, 1878 and Dairies, Cowsheds and Milkshops Orders, 1885 & 1886 One hundred and seventy-six inspections have been made of these premises and no notices were necessary. Milkshops 18 26 Character of Premises. No. Bye-Laws or Regulations affecting same. Action Taken and Result. Bakehouses 13 Factory & Work shops Act, 1901 Eighty-one inspections have been made of these premises. Two of the premises required cleansing. Notices were served upon the occupiers and duly complied with. Slaughterhouses 2 Bye-Laws under Sec. 169, Public Health Act, 1875 Ninety-five inspections have been made of these premises and on 6 occasions nuisances were found. The occupiers were notified and the necessary works put in hand immediately. Fried Fish Shops 6 Bye-Laws under Sections 112-115, Public Health Act, 1875. and Sec. 51 Public Health Acts (Amendment) Act, 1907 Thirty-five inspections have been made of these premises and in one case it was necessary to serve a notice on the) occupier. The work required was put in hand immediately. Meat Shops Public Health (Meat) Regulations, 1924. Four hundred and twenty-six visits were paid to these premises. Butchers 23 Other shops 45 Slaughterhouses 2 ditto These premises were visited on eighty-one occasions when slaughtering was in progress, when the following carcases were inspected:— Bovines 39 Sheep 417 Pigs 86 Total 542 27 Character of Premises. No. Bye-Laws or Regulations affecting same. Action Taken and Result. Ice-cream Shops 27 Section 88, Becken ham Urban District Council Act, 1903 Ninety-two inspections have been made of these premises and in one instance it was necessary to serve a notice upon the owner to abate a nuisance. This was duly complied with. All premises Bye-Laws respecting Keeping of Animals, dated 1911 Contravention of these Bye-Laws were found on 27 premises during the year and notices were served upon the occupiers to abate the nuisance. These notices were all complied with. All premises Bye-Laws respecting Cleansing and Covering of Domestic Water Supply Cisterns made under Section 139 of the Beckenham U.D.C. Act, 1903 Contravention of these Bye-Laws were found on 16 premises and notices were served for cleansing or covering as required and these notices have been complied with. Stables (Manure pits) 42 Bye-Laws Regulating stables and keeping of manure, 1911 Two hundred and fifty-three inspections were made of these premises. Contravention of the Bye-Laws were found on 18 premises and notices were served in each case and complied with. 28 Disinfection of Premises. Month. ROOMS FUMIGATED. Scarlet Fever. Typhoid Fever. Diphtheria and Membranous Croup. Cancer. Phthisis. Pneumonia. Measles. Miscellaneous. Total January 6 ... ... 2 4 ... ... 3 15 February 5 ... 1 ... ... ... ... 1 7 March 10 2 1 ... 4 ... ... 2 19 April 4 3 1 1 4 ... ... 4 17 May 3 1 ... ... 3 ... ... 3 10 June 3 ... 1 4 2 ... ... ... 10 July 6 1 1 2 1 ... ... 3 14 August ... 1 2 ... 3 ... ... 3 9 September 1 ... 2 ... 5 ... ... ... 8 October 2 ... 1 4 2 ... ... 2 11 November 6 ... ... 2 3 ... ... 4 15 December 5 1 4 2 5 ... ... 9 26 Totals 51 9 14 17 36 ... ... 34 161 SCHOOLS—(See page 67.) HOUSING. 1. General Housing Conditions.—The houses in a large portion of the District are large and detached or sermi-detached dwellings, well built and of a high residential character. There is no property in the District which could be classed as "Slum'' property. In those areas where the so-called working classes reside the houses are, generally speaking, well built and in good repair. There has been a tendency in recent years to convert some of the larger houses into self-contained Hats. (See also page 9, population and density.) 2. (a) Shortage of Houses.—Like many other Districts there has been since the War a definite shortage of houses. The number of houses in which we find from two to four families living, as compared with the number in pre-war days, has increased very 29 siderably. The class of house to which I now refer is not the converted house with self-contained tenements, but ordinary dwellings where rooms are sub-let by the principal tenant to other families. Many of these families regard their accommodation as only temporary and are waiting and anxious to obtain suitable houses. 2. (b) Measures Taken to Meet Shortage.—During the War building was practically at a standstill. From the year 1916 to 1919 inclusive only four houses were erected. The subjoined table gives the new houses erected from the year 1920 to 1925: — Year. Number of houses erected. 1920 8 1921 133 1922 92 1923 56 1924 205 1925 294 The District Council were the first to commence building, and during the last three years building by private enterprise has been steadily increasing. The Council acquired two estates, one at Elmers End and one at Shortlands. On the former 196 houses were erected and completed by the end of the year 1922. The Scheme for developing the Shortlands site has been held up for various reasons, chiefly the restriction imposed by the Ministry of Health. This has now been removed, and the Council propose to erect 60 houses on this estate immediately. During the years 1924 and 1925 100 houses were erected by various builders with the assistance of grants made under the Housing Acts. 3. Changes in Population.—No change has taken place in the general character of the population of the District, but there are indications that parts of the District are rapidly losing their semirural appearance. The land that is still unbuilt upon is being plotted out for building purposes, and there will probably be a considerable increase in the population during the next few years. 30 4. Overcrowding.—The number of houses that are overcrowded, judged by pre-war standards, is estimated at 152. The causes of this overcrowding are the natural increase of the population, and, to some extent, immigration. The provision of new houses has not kept pace with the needs of the District. (See also p. 10, Rooms per dwelling.) There are many Districts where the degree of overcrowding is very much worse than in Beckenham, but the standard of housing here has always been a high one. The measures taken to meet this overcrowding have been indicated above, viz., the houses erected by the Council and by private enterprise. It is doubtful if the houses erected by the Council relieved to any extent the class amongst whom overcrowding was most prevalent. There is an impression that in selecting tenants for their new houses the Council were influenced as much by the capacity of the applicant to pay the rent and prove a good tenant as by his need for more and better accommodation. Further, the rents of the Council houses were prohibitive to some of the small wage earners. This remark applies even 'more to the houses erected by private enterprise, which were designed for "sale" and not "to let," moreover, they cater for a class better off financially than the ordinary working class family. From these remarks it will be gathered that there is a need in the District for houses which can be let at lower rentals than those prevailing at present if the overcrowding amongst the poorest section of the population is to be relieved. Principal Cases of Overcrowding and Action Taken.—The degree of overcrowding varies, one of the worst cases was the following: — A small house in the occupation of two families. One familyconsisting of the father and mother and six children, ranging from 11 years to 1 year, occupied one small kitchen, and all slept in the one bedroom. 31 Since the above case was reported to the Council one of the families has been provided with a new house on the Council's estate at Elmers End. In nine other cases the degree of overcrowding was very bad. No statutory action has been taken by the Council; it is realised that the difficulties of these families in overcrowded houses are already very great, and legal proceedings would not lead to any improvement in their condition and would only harass them unnecessarily. Fitness of Houses.—It has already been stated that the general standard of housing in the District is a high one. The character of the defects found were of a structural nature, and except in a few instances were not very serious, and were remedied after informal representation had been made to the owner. Legal proceedings had to be taken in respect of nine houses, chiefly on account of damp walls and defective roofs. In one case the summons was dismissed without costs, and in the 8 remaining summonses, penalties and costs were imposed amounting to £19 16s. Od. and an order was made for the necessary work to be completed within a specified time. Unhealthy Areas.—Nil. Rye-Laws.—The revision of Bye-Laws re Houses Let in Lodgings was considered during the year, and the new Bye-Laws will came into force during 1926. HOUSING STATISTICS. Number of New Houses erected during the year: — (a) Total 294 (b) With State assistance under the Housing Acts: — (1) By; Local Authority Nil (2) By other bodies or persons 70 32 1.—Unfit Dwelling Houses. 1.—Inspection. (1) Total number of Dwelling Houses inspected for housing defects (under Public Health or Housing Acts) 709 (2) Number of Dwelling Houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 161 (3) Number of Houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil (4) Number of Dwelling Houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation ... 519 2.—Remedy of Defects without Service of Formal Notice. Number of Dwelling Houses rendered fit in consequence of informal action by the Local Authority or their Officers 471 3.—Action under Statutory Powers. (a) Proceedings under Section 3 of the Housing Act, 1925: — (1) Number of Dwelling Houses in respect of which notices were served requiring repairs Nil (2) Number of Dwelling Houses which were rendered fit: — (a) By Owners Nil (b) By Local Authority in default of Owners Nil (3) Number of Dwelling Houses in respect of which Closing Orders became operative in pursuance of declarations by Owners of intention to close Nil (b) Proceedings under Public Health Acts: — (1) Number of Dwelling Houses in respect of which notices were served requiring defects to be remedied 48 (2) Number of Dwelling Houses in which defects were remedied:— (a) By Owners 48 (b) By Local Authority in default of Owners Nil 33 (c) Proceedings under Sees. 11, 14, and 15 of the Housing Act, 1925: — (1) Number of representations made with a view to making of Closing Orders Nil (2) Number of Dwelling Houses in respect of which Closing Orders were made Nil (3) Number of Dwelling Houses in respect of which Closing Orders were determined, the Dwelling Houses having been rendered fit Nil (4) Number of Dwelling Houses in respect of which Demolition Orders were made Nil (5) Number of Dwelling Houses demolished in pursuance of Demolition Orders Nil INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—The amount of milk that is produced locally from cows kept at dairy farms within the District is a diminishing quantity, and is likely to be still further reduced in the near future as the land at present available for grazing is taken up for building purposes. I estimate that nine-tenths of the milk supply is brought in by rail and only one-tenth is produced locally. In the year 1911 there were seven registered cowkeepers and 201 cows in the District, as compared with four cowkeepers and 73 cows at the end of 1925. The arrangements for collecting and storing milk at the dairy farms within the District are, on the whole, fairly satisfactory, and I have no doubt that milk produced locally is much cleaner than that imported. The buildings are clean and well ventilated, and the floors are impervious. They are all provided with steam, or other facilities for boiling water, to cleanse the milk cans and utensils, and have 34 some arrangement for cooling the milk. In the cowsheds there is provision for the milkers to wash their hands and the udders of the cows, and a number of the milkers wear clean washable overalls. The dairies and cowsheds are subject to systematic inspection, and the Orders and Regulations which relate to them are enforced. The Milk and Dairies (Consolidation) Act, 1915.—This Act, which was passed in the year 1915, has, after two postponements, been brought into operation on the 1st September, 1925. It is a Consolidating Act, and probably its most valuable sections are (a) those which give power to the Minister of Health to make what are to be known as the "Milk and Dairies Orders" for the purposes set out in the first section of the Act, and (b) the three sections designed to prevent the sale of tuberculous milk. The Act makes certain amendments in the Sale of Food and Drugs Acts as to sampling milk in course of delivery, and it attempts to amend the provisions of the Sale of Food and Drugs Acts with regard to the "Warranty Defence." The procedure for this latter purpose is cumbersome and the whole attempt is lamentably weak. Milk (Special Designations) Order, 1923.—Under the Milk and Dairies (Amendment) Act, 1922, and the above Order the following licences have been granted by the District Council to distributors of milk: — Licences to sell "certified" milk 5 Licences to sell "pasteurised'' milk 1 In accordance with the arrangements of the Ministry of Health 4 samples of "certified" milk were taken and submitted to bacteriological examination. The "certified" milk sold in the District comes from 5 different producers, but it is only in respect of the milk of one of these that the District Council has to take samples for bacteriological examination. One licence has been granted for "pasteurising" milk, the apparatus in this instance is the "positive holder" type, and 35 plies with the requirements of the Ministry, viz., "the heat must raise the temperature of the whole volume of the milk to not less than 145 degrees Fahrenheit and not more than 150 degrees Fahrenheit, and must maintain it at this temperature for a period of thirty minutes, and that the milk should then be immediately cooled." Results of Analysis. Designation of Milk. Date sample taken. Age of sample in hours. Number of Bacteria per cubic centimetre. Number of Bacillus Coli. After 48 hours. After 3 days. In 1 c.c. moth c.c. 1 c.c. l/10th c.c Certified 19.5.25 5 2,126 Absent A bsent Absent Absent Certified 29.6.25 10 10,900 „ „ „ „ Certified 25.8.25 7 6,466 „ „ „ „ Certified 30.9.25 19 1,636 „ „ „ „ Pasteurised 19.5.25 5½ 7,833 Absent Absent Absent Absent Pasteurised 29.6.25 24 21,000 Positive „ Positive „ Pasteurised 23.8.25 27 29,366 „ „ „ „ Meat.—A large proportion of the meat sold in Beckenham is prepared elsewhere, chiefly in London, and is delivered to local butchers for retail. There are only two slaughterhouses in the District, as the following statement, which is required by the Ministry, indicates: — In January, In December, In 1920. 1925. 1925. Registered 2 2 2 Licensed — — — Total 2 2 2 An important event during the year was the coming into force on the 1st April of the Public Health (Meat) Regulations, 1924. These Regulations are based on the recommendations of the Departmental Committee on Meat Inspection and are designed to 36 secure more adequate inspection of animals before and after slaughter, more cleanly methods of handling the meat, and improvement in the methods for protecting the meat from contamination by dirt, dust, and flies, etc. Copies of the Regulations were sent to butchers and others in the District affected by them, and in the month of June the Chairman of the General Purposes Committee and the Medical Officer of Health arranged a Conference with the local butchers which was held (at the Council Offices) in order to discuss the Regulations and any difficulties the trade might have in putting them into force. The representatives of the trade expressed their approval of the Regulations and their willingness to carry out the details required. There was one point on which complete unanimity was not reached, and that was the action necessary to protect meat exposed for sale from dust and flies. It was suggested that glass fronts to the shops would be required, and objection was raised to this on the ground that the glass would prevent the free circulation of fresh air around the meat, and that it would also raise the temperature and thus hasten decomposition. The following statement indicates that an effort is being made to carry out the Regulations in an effective way: — There are twenty-three Butchers' Shops and a large number of general stores where bacon and hams are exposed for sale. In every instance some attempt has been made to protect the meat from dust and flies, either by glass covers, muslin covers, glass fronts to the shops, or electric fans. With regard to the butchers' shops, three have fitted new glass fronts, six have installed fans, two have had movable glass fronts for some time, one has fixed a glass front and a fan. At the time the Regulations came into force there was one meat stall in the street from which meat was sold, this has now been given up so that there are no meat stalls in the street in any part of the District. 37 Notification of Time of Slaughter.—Sections 8 and 9 of the Regulations provide for notice being given to the Local Authority (Health Department) not less than three hours before the time of slaughtering so that an Inspector may be present and examine the carcases and internal organs. Eighty one such notices were received, and a Sanitary Inspector was present at the time or immediately after slaughter. Attendance by the Sanitary Inspector at the slaughter houses involves a considerable amount of work outside office hours, as slaughtering is frequently carried out in the evenings. Unsound Food.—The following quantities of food exposed for sale were found to be unsound and unfit for food and were seized or surrendered and destroyed: — 232 lbs. Meat (including: Pig carcase, 96 lbs.; and Pig Head, 12 lbs., affected with tuberculosis). 24 Cauliflowers. 40 lbs. Apples. Food Poisoning.—No instance of food poisoning was brought to our notice during the year. Two instances where patients have contracted para-typhoid fever from infected pastry or cakes are referred to on pag'e 47. Bakehouses.—There are 13 Bakehouses in the District, and these were systematically inspected and cleansing carried out v here necessary. SALE OF FOOD AND DRUGS ACTS. Eighty-one samples were purchased during the year under these Acts and submitted to analysis. The results were as follows: — 38 Nature of Sample. Number Taken. Analyst's Report thereon. Butter 5 Genuine New Milk 37 „ of these 26 were were reported to be of good quality, 8 of fair quality and 3 of poor quality. Cream 6 „ Shredded Suet 2 „ Sausages 1 „ Syrup 1 „ Breakfast Sausage 1 „ Pepper 3 „ Margarine 2 „ Cayenne 1 „ Self Raising Flour 2 „ Malt Vinegar 1 „ Lard 2 „ Demarara Sugar 1 „ Cocoa 2 „ Mustard 1 „ Flaked Rice 1 „ Ground Ginger 2 „ Coffee Essence 1 „ Sponge Cake 1 „ Ground Rice 1 „ Fish Paste 2 „ Lemon Cheese 1 „ Tinned Sardines 1 „ Sugar Pieces 1 „ Mince Meat 1 „ Condensed Milk 1 „ Total 81 Milk and Cream Regulations, 1912 and 1917. Six samples of Preserved Cream were taken during the year and submitted to analysis. In every instance the Analyst reported them to be genuine and they complied with the Regulations. 39 INFECTIOUS DISEASES. During the five years under review there has not been any serious epidemic of infectious disease. On the whole the number of cases and the mortality are less than for previous quinquennial periods. Reference will be made to these points under each disease. Bacteriological Examinations.—The laboratory continues to be a useful adjunct to the machinery for dealing with infectious disease, and the number of examinations made will indicate the extent to which Medical Practitioners in the District make use of the facilities provided. It should be remembered that in years when Diphtheria is prevalent the number of bacteriological examinations will be larger, as it is in connection w ith this disease that the large proportion of examinations are made. The following statement shows the number and results of the examinations made during 1925, with comparative figures for the previous years: — Diseases suspected. Results for 1925. Total Examinations made. Positive. Negative. 1925. 1924. 1923. 1922. 1921. Diphtheria 54 322 376 313 261 500 430 Tuberculosis 50 164 214 203 191 173 184 Typhoid Fever 1 5 6 23 6 2 8 Other Diseases 16 29 45 59 81 47 70 Totals 121 520 641 598 539 722 692 Fever Hospitals: — An analysis of the subjoined Table will show that the Fever Hospitals are used chiefly for the isolation and treatment of two diseases, viz., Scarlet Fever and Diphtheria. During the last twentyfive years from 70 to 80 per cent. of these two diseases have been removed to Hospital. The cases of Typhoid Fever are comparatively few, and the proportion removed to hospital is not so high. Other infectious 40 diseases that occur more rarely, such as Cerebro-Spinal Fever, Encephalitis Lethargica, and Small Pox are also provided for at the Fever Hospitals, and Beckenham by special arrangement may send selected cases of Measles to the Hospital on the recommendation of the Medical Officer of Health. Hospital Isolation. 1921. 1922. 1923. 1924. 1925. Disease. Cases Notified Cases Removed Cases Notified Oases Removed Cases Notified Cases Removed Cases Notified Cases Removed Cases Notified Cases Removed Scarlet Fever 118 94 80 58 35 28 64 54 53 42 Diphtheria 32 22 23 12 15 15 18 14 11 8 Typhoid Fever (including Paratyphoid "A" & "B") 4 2 4 1 7 0 8 4 5 2 Cerebro-Spinal Fever 1 1 1 0 0 0 1 1 0 0 Encephalitis Lethargica 6 0 - — 2 - 5 — 5 1 Measles 11 0 266 0 234 0 582 1 29 0 Totals 172 119 374 71 293 43 678 74 163 53 In my Annual Report for 1921 I discussed the effects of hospital isolation on Scarlet Fever and Diphtheria and the cost of this form of treatment to the District. The institutional treatment of any disease is a costly proceeding, and it is hoped that some more effective and less costly methods may be devised of controlling Scarlet Fever and Diphtheria. In the case of Small Pox, which is not an endemic disease in this country, the advantages of being able to isolate the first cases when the disease breaks out are very considerable, but even here we have in vaccination a preventive agent incomparably more effective and valuable than hospital isolation. 41 SCARLET FEVER.—During 1925, 53 cases of Scarlet Fever were notified, 26 males and 27 females, and 42 were removed to hospital. No deaths occurred. The age distribution of those attacked is as follows : 0-1 1-2 2 3 3-4 4 6 5-10 10-15 15-25 25-45 45-65 005 0 3 26 11 5 2 1 This is the fourth year in succession without a death from this disease. One death occurred in 1921; the patient was in the seventh week of Scarlet Fever and developed Tubercular Meningitis, which proved fatal. With this exception, which cannot be wholly attributed to Scarlet Fever, there are five consecutive years without a death from this disease in Beckenham. This is not a record in the history of Scarlet Fever. I find on reviewing the records that amongst an almost similar number of cases notified during the years 1901 to 1904 no death occurred. There is no doubt, however, that the disease is now much milder than formerly, and a survey of the returns since 1891 confirms this. During the decade 1891 to 1900, 765 notified cases gave 20 deaths, the following decade 782 cases gave 6 deaths, in the decade 1911 to 1920, 619 cases gave 6 deaths, and the last five years 350 cases gave 1 death. It will be noted that although the death rate has fallen that the number of cases still remains high; in this connection due allowance should be made for the increase in population from 20,705 in 1891 to 33,850 in 1925. Return Cases.- Frequent reference has been made in past reports to these cases and the measures adopted to prevent infection by those discharged from the Fever Hospital. The following Table gives the number of return cases over the years mentioned. The figures for 1915 to 1918 are not available. 42 Table Showing Return Cases since 1903. Year. No. of Cases Notified. No. removed to Hospital. No. of "Return" Infecting Cases. No. Infected by "Return" Infecting Cases. 1903 51 42 4 4 1904 38 31 1 1 1905 57 42 — — 1906 90 83 3 3 1907 115 106 2 3 1908 132 107 4 5 1909 140 124 5 11 1910 34 26 2 3 1911 59 50 4 9 1912 70 63 3 10 1913 62 51 3 3 1914 98 87 6 6 1915 55 411 No Records available. 1916 56 39 1917 16 9 1918 29 21 1919 57 42 1 1 1920 117 92 10 11 1921 118 94 3 3 1922 80 58 8 10 1923 35 28 2 2 1924 64 54 4 5 1925 53 42 4 3 The subject of immunisation in connection with the infectious fevers is one that is of the greatest interest to those in the practice of preventive 'medicine. The success which has attended immunisation against Small Pox and Typhoid Fever leads us to look to the application of kindred methods against the other infectious diseases for which at present we have no reliable prophylactic. Dick Test.—During the last two or three years much interest has developed in a test which was introduced by the Dicks in America and investigated by 'many workers in this country, notably by Dr. R. A. O'Brien and others at the Wellcome Research Laboratories in this District. It is claimed for this test that it enables us to detect persons who are susceptible to the infection of Scarlet Fever in a similar way to the Schick Test for Diphtheria. 43 The substance used in the test is a toxin prepared from hæmolytic streptococci isolated from the throat of Scarlet Fever patients and is injected into the skin. If certain changes occur in the skin in and around the site of injection it indicates that the patient is susceptible to Scarlet Fever. Scarlet Fever Statistics since 1891. Year. Population Cases Notified. Deaths from Scarlet Fever. Mortality per cent. Attack Kate per 1000. Death Rate per 1,000 Living. Per cent. Isolated in Hospital. 1891 20,705 29 0 0.0 1.4 .00 51.8 1892 21,666 86 0 0.0 4.0 .00 72.1 1893 21,840 159 8 5.0 7.3 .36 60.4 1894 22,470 68 1 1.5 3.0 .04 70.6 1895 23,070 87 5 5.7 3.7 .21 70.0 1896 23,579 72 0 0.0 3.0 .00 71.0 1897 24,300 66 3 4.5 2 7 .12 75.7 1898 24,730 29 0 0.0 1.2 .00 79.0 1899 26,075 92 2 2.1 3.5 .07 65.2 1900 26,556 77 1 1.3 2.8 .03 71.4 765 1901 26,453 62 0 0.0 2.3 0.00 59.6 1902 26,958 63 0 0.0 2.3 0.00 79.3 1903 27,452 51 0 0.0 1.8 0.00 82.3 1904 27,965 38 0 0.0 1.3 0.00 81.6 1905 28,489 57 1 1.7 2.0 .03 73.7 1906 29.022 90 0 0.0 3.1 0.00 92.2 1907 29,565 115 2 1.7 2.8 .06 92.1 1908 30,119 132 1 0.8 4.3 .03 81.0 1909 30,681 140 1 0.7 4.5 .03 88.5 1910 31,255 34 0 0.0 1.0 0.00 76.4 782 1911 31,480 59 1 1.6 1.8 .03 84.7 1912 32,408 70 2 2.8 2.1 .06 90.0 1913 32,987 62 0 0.0 1.8 .00 82.2 1914 33,572 98 1 10 2.9 .02 88.7 1915 33,796 55 0 0.0 1.6 .00 74.5 1916 30,774 56 0 0.0 1.8 .00 70.8 1917 30.612 16 0 0.0 .5 .00 56.2 1918 29,425 29 1 3.4 1.0 .03 72.4 1919 32,516 57 0 0.0 1.4 .00 73.5 1920 33,812 117 1 0.9 3.4 .02 78.6 619 1921 33,350 118 1 0.9 3.5 .02 77.1 1922 33,160 80 0 0.0 2.4 .00 72.5 1923 33,170 35 0 0.0 1.0 .00 80.0 1924 33,460 64 0 0.0 1.9 .00 84.37 1925 33,850 53 0 0.0 1.56 .00 79.24 44 This test has been followed up by using a toxin mixture for immunising those who are susceptible to the disease, and good results have been obtained in fever hospitals by protecting probationer Nurses and other susceptible persons who are daily in contact with Scarlet Fever. It is also claimed that injections of a toxin mixture reduces the severity of the disease and cuts short the pyrexial period. Much of this work is in the experimental stage, but the outlook is promising, and it is hoped that further research will add to our knowledge in a way that will indicate to us practical methods of protection against an attack and of reducing its severity when it occurs. DIPHTHERIA.—Eleven cases of Diphtheria—3 males and 8 females—were notified during the year, and one death occurred, a girl aged 6 year. The following are the ages in age-period of those attacked: — 1-5 5-10 10-15 15-25 25-45 0 5 1 3 2 The diagnosis of Diphtheria was confirmed by bacteriological examination in all of the cases notified. The incidence of this disease has been on the decline of late years, the annual numbers since 1921 being 32, 23, 15, 18, and 11 respectively. With the exception of the year 1916, when only 10 cases were notified, this year's notifications are lower than any year since 1890, when notification became compulsory. The number of cases notified and the deaths during the last three decades are as follows: — Decade. No. of Oases. No. of Deaths. 1896-1906 343 44 1906-1915 650 44 1916-1925 260 17 45 Diphtheria Statistics since 1891. Population Year. Diphtheria Cases fled. Deaths from Diphtheria. Mortality per cent. Attack rate per 1,000 Living. Death Rate per 1,000 Living. Per cent. Isolated in Hospital. 20,705 1891 14 2 140 0.6 .09 ... 21,666 1892 21 1 4.7 0.9 .04 ... 21,840 1893 50 9 18.0 2.2 .41 32.0 22,470 1894 61 4 6.5 2.7 .17 23.0 23,070 1895 28 7 24.1 1.2 .303 35.7 23,579 1896 25 4 16.0 1.0 .16 40.0 24,300 1897 23 3 13.0 0.9 .12 34.8 24,730 1898 22 4 18.0 0.8 .16 18.1 26,075 1899 54 6 11.1 2.0 .23 62.9 26,556 1900 45 10 22.2 1.6 .38 62.2 26,453 1901 29 5 17.2 1.1 .18 55.1 26,958 1902 37 3 8.1 1.3 .11 59.4 27,452 1903 28 2 7.1 1.0 .07 78.5 27,965 1904 33 4 12.1 1.1 .14 69.0 28,489 1905 47 3 6.3 1.6 .07 80.8 29,022 1906 21 1 4.7 0.7 .03 95.2 29,565 1907 73 7 9.5 2 4 .23 84.9 30,119 1908 93 6 0.4 3.0 .19 88.1 30,681 1909 51 4 7.8 1.6 .13 76.4 31,255 1910 62 2 3.2 1.9 .06 91.9 31,848 1911 67 4 5.9 2.1 .12 89.5 32,408 1912 71 •r> 7.0 2.1 15 94.3 32,987 1913 79 4 5.0 2.3 .12 65.8 33 572 1914 98 10 9.8 2.6 .29 71.4 33,796 1915 35 1 2.8 1.0 .03 77.0 30,774 1916 10 0 0.0 0.3 .00 50.0 30,612 1917 18 1 5.5 0.5 .02 100.0 29,425 1918 42 3 7.1 1.4 .10 60.6 32.516 1919 42 0 0.0 1.2 .00 85.7 32,812 1920 59 2 3.4 1.7 .06 70.3 33,350 1921 32 3 9.3 0.9 .09 68.7 33,160 1922 23 3 13.0 0.7 .09 52.2 33,170 1923 15 1 6.6 0.45 .03 100.0 33,460 1924 18 3 16.6 0.53 .08 77.7 33,850 1925 11 1 9.09 0.32 .029 72.7 Anti-Toxin Order, 1910.-A supply of Diphtheria Anti-Toxin is kept in an ice chest at the Health Department and is given free to Doctors for use in Diphtheria. During 1925 40,000 units were used for curative purposes and 136,000 units for prophylactic purposes. 46 The following table gives some particulars relating to contacts, carriers, and the number of home contacts who received a prophylactic injection of anti-toxin. The figures for the War years are not available. Diphtheria Statistics. 1911 1912 1913 1914 1919 1920 1921 1922 1923 1924 1925 No. of Cases notified 67 71 79 98 42 59 32 23 15 18 11 „ „ houses infected 55 67 67 88 37 51 27 19 10 17 11 „ ,, contacts in the home 270 428 309 465 168* 264 158 175 63 96 80 „ „ "home contacts" examined bacteriologically 140 352 266 306 109* 192 61 98 29 64 65 No. of "contact carriers'' 22 17 12 32 0 8 7 12 4 0 0 „ „ contacts injected with Antitoxin 115 250 193 251 32 37 57 37 25 29 17 *These numbers do not include 98 "School Contacts" amongst whom 12 carriers were found. The practice of using Anti-toxin as a prophylactic is on the decline, and our experience is that it is not a reliable preventive. Schick Test.—No suitable opportunity for using this test occurred during the year. This method of detecting those susceptible to Diphtheria and immunizing them by injection of toxinanti-toxin mixture has only been tried on one occasion in the District, viz., in 1922, in a large private school for boys. To carry out this method properly demands a large amount of time and requires the services of one person for a considerable period. TYPHOID AND PARATYPHOID FEVER.—Five cases of Typhoid Fever—1 male and 4 females—were notified during the year. This number compares with ft in 1924, 7 in 1923, 4 in 1922, and 4 in 1921. The ages of those attacked were: Females 5, 23, 35, and 36 years respectively, and one male aged 20 years. One case, a female aged 36 years, terminated fatally 47 In 3 cases the blood of the patient agglutinated the Bacillus para-typhosus "B'' in high dilutions, and in one case the blood agglutinated Bacillus typhosus and also the Bacillus para-typhosus "B" in all dilutions used. In the case which proved fatal several blood tests gave negative results, the clinical symptoms of typhoid fever were, however, very pronounced. Source of Infection.—Two of the cases were associated with an outbreak of Paratyphoid Fever which occurred in the neighbouring Districts of Croydon and Lewisham. There were a considerable number of cases at the time in Croydon, and Dr. Newsholme, the Medical Officer of Health of Croydon, wrote to me at an early stage in the outbreak that he suspected the disease to be due to infected pastry supplied by a particular firm of bakers. He subsequently confirmed these suspicions by being able to demonstrate that a pastry cook employed by the firm had suffered from an unrecognised attack of Paratyphoid Fever, and that he continued at work while so suffering. The two patients above mentioned had eaten confectionery obtained from this firm during the incubation period. Of the remaining three cases, one probably contracted the disease outside the District. He was a man aged 20, employed as a kitchen hand on a boat that plied between London and Ramsgate. The patient had all his meals on board, and only slept in Beckenham. A steward on the boat was removed to hospital about the same time suffering from "ptomaine poisoning." In the remaining two cases, which were notified in January and February respectively, the source of infection could not be traced Other Infectious Diseases.—The following table gives the number of cases of other infectious diseases that were notified or 48 came to our knowledge during the year. The figures since 1921 are given for comparison. Notifiable Diseases. Diseases. Cases Notified 1925. Number removed to Hospital Number of Deaths. 1924. Cases Notified 1923. Cases Notified 1922. Cases Notified 1921. Cases Notified Diphtheria 11 8 1 18 15 23 32 Scarlet Fever 53 42 — 64 35 80 118 Enteric Fever (including Paratyphoid "A" and "B") 5 2 3 8 7 4 4 Puerperal Fever 2 - - 3 — — — Pneumonia 42 - 15 28 17 23 16 Cerebro-Spinal Fever 0 0 0 1 - 1 1 Encephalitis Lethargica 5 1 3 5 2 - 6 Erysipelas 9 — — 5 5 9 8 Malaria 1 - — 1 2 1 1 Trench Fever - - - — — - 1 Opthalmia Neonatorum - - - - 2 - - Acute Poliomyelitis - - -. - 1 - - Smallpox - - - - - - - PUERPERAL FEVER.—The question of providing hospital isolation for cases of this disease was under consideration during the year. The matter has been under discussion for some time by the Maternity Home Committee, and as the Fever Hospital Board were unable to take these cases on the grounds that they had no room for them it was necessary to make arrangements elsewhere. An agreement was in consequence entered into with the Beckenham Cottage Hospital to receive such cases of this disease as might occur, and be recommended for isolation and treatment by the Medical Officer of Health, on payment of the sum of one guinea per day per patient, the fees and board of any special nurses required to be in addition to the charge. 49 Measles.—This is not now a notifiable disease, but by arrangement with the School Teachers, School Attendance Officers, the Infant Welfare Centre, etc., and by a special arrangement whereby a fee of 1s. per notification is paid to the Doctors in respect of children of school age, information is received of a large proportion of the cases occurring among children up to the age of 14 years. Through these channels 29 cases—13 males and 16 females—came to our notice during the year. One death occurred, a female aged 10 months. By an arrangement with the Joint Hospital Board, severe cases of Measles, where the home conditions are unsatisfactory, can be removed to the Isolation Hospital for treatment, provided the Medical Officer of Health certifies that this course is necessary. No case was removed to hospital during the year. The School Nurse visits all cases which come to our notice and gives suitable advice as to management and treatment. The following statement gives the ages in age-periods of those attacked: — 0 1 1-2 2-3 3-4 4-5 5 10 10-15 3 1 2 3 1 12 7 Whooping Cough.—Information relating to cases of Whooping Cough is received from the same sources as in the case of Measles, and the School Nurse also visits the homes, obtains certain particulars, and gives appropriate advice. One hundred and seventy-four cases were notified—79 males and 95 females—and three children died, 2 males aged 1 month and 10 months respectively, and one female aged one and a half years. The following statement gives the ages in age-periods of those attacked: — 0-1 1-2 2-3 3 4 4-5 5-10 10-15 II 17 19 22 20 |80 5 50 Chicken-Pox and Mumps.—Sixty-six cases of Chicken-Pox and 139 cases of Mumps were notified during the year. The large proportion of these were children of school age. Encephalitis Letharoica.—Five cases of this disease were notified during the year as compared with five cases in 1924. Four males aged 24, 26, 50, and 54 years respectively, and one female aged 17 years. The period of the year in which they occurred was as follows: February 1, April 1, May 3. One case was removed to the Infectious Hospital and the remaining 4 were nursed at home. Three males died, aged 24, 50, and 54 respectively. The source of infection could not be traced. The cases were widely scattered over the District, and no connection could be established between them. Pneumonia.—Forty-two cases—22 males and 20 females—of Primary Pneumonia were notified. Ophthalmia Neonatorum.—No cases were notified during the year. TUBERCULOSIS.—The following table gives the new cases of Tuberculosis and deaths occurring during the year, classified according to age, sex, and Wards:— 51 TUBERCULOSIS.—TABLE OF NOTIFICATIONS AND DEATHS, 1925. Notifications. Sex. Total. Ages. Wards. M. F. 0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to ] 10 10 to 15 15 to 20 80 to 25 25 to 35 35 to t 45 45 to 55 55 to 65 65 and up Copers Cope. Eden Park. Langley Park. Shortlands. Manor House. Kent House. Laurie Park. Pulmonary 21 18 39 ... ... 1 ... ... ... 3 7 13 6 7 1 1 4 6 1 2 9 6 11 Glandular 3 4 7 ... ... ... ... 1 5 1 ... ... ... ... ... ... ... ... 1 ... 1 1 2 2 Osseous 1 ... 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... ... ... Other Forms 3 3 6 ... 1 1 1 ... ... ... ... ... 2 1 ... ... ... ... ... 1 ... 2 2 1 Totals 28 25 53 ... 1 2 1 1 5 1 3 8 15 7 7 1 1 4 7 3 3 12 10 14 Deaths. Pulmonary 8 7 15 ... ... ... ... ... ... ... ... 1 4 3 3 4 ... 1 1 ... 2 5 2 4 Glandular ... 1 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... Osseus 2 ... 2 ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... ... ... 1 1 ... ... Other Forms 2 4 6 1 1 1 1 ... ... ... ... ... ... l ... ... 1 ... 1 1 ... 1 3 ... Totals 12 12 24 1 1 1 1 ... ... 1 ... 1 4 5 3 5 1 1 2 1 3 8 5 4 52 Removal to Hospital of Infectious Persons Suffering from Pulmonary Tuberculosis. The Public Health Act, 1925, Section 62, enables a Local Authority to apply to a Court of Summary Jurisdiction for an Order for the removal to Hospital or Institution of any person suffering from Pulmonary Tuberculosis, who is in an infectious state, and for his detention and maintenance therein for such period, not exceeding three months, as the Court think fit. The powers of removal to and detention in an Institution may be exercised contrary to the wishes of the patient, and are therefore made subject to certain safeguards. The Section applies to those patients whose lodging or accommodation prevents the adoption of proper precautions to guard against the spread of infection, or who are not taking such precautions. It was not necessary during 1925 to take action for the compulsory removal of a patient under this Section. Public Health (Prevention of Tuberculosis) Regulations, 1925. These Regulations are another important advance in our preventive measures for dealing with Tuberculosis. They were issued by the Ministry of Health on the 31st July, 1925, and came into force on that date. Section 4 of the Regulations is as follows: — "No person who is aware that he is suffering from Tuberculosis of the respiratory tract shall enter upon any employment or occupation in connection with a Dairy which would involve the milking of cows, the treatment of milk, or the handling of vessels used for containing milk." 53 The Regulations provide for the enforcement of this Section, and also compensation for damages where the person concerned is not in default. There is at present no notified case of pulmonary tuberculosis in the District engaged in the Milk trade. Tuberculosis Order No. 1, 1925. This is an Order embodying the Tuberculosis Order, 1914, which was suspended during the War. The Order of 1925 which is enforced by the County Councils aims at the discovery of Tubercular Cattle and their exclusion from milking herds, and indirectly their slaughter. Any carcases of animals slaughtered under the requirements of the Act shall not be removed or allowed to be used for human consumption without the permission of the Medical Officer of the Local Authority in whose district the slaughter takes place. 54 Tuberculosis Statistics since 1891. Year No of Deaths from Phthisis. Deaths from other Tubercular Diseases. Total Deaths all forms of Tubercular Disease. Total Tubercular Death Rate per 1,000 population. Phthisis Death Rate per 1,000 population. 1891 19 - - - .9 1892 19 - — — .9 1893 9 — — — .4 1894 12 — — — .5 1895 12 - — — .5 1896 21 — - — .9 1897 18 — - - .7 1898 27 - — - 1.7 1899 22 — — — .8 1900 9 9 18 .7 .3 1901 19 6 25 .9 .7 1902 12 6 18 .6 .4 1903 15 10 25 .9 .5 1904 12 10 22 .7 .4 1905 21 9 30 1.0 .7 1906 21 5 26 .8 .7 1907 4 13 17 .5 .1 1908 10 18 28 .9 .3 1909 15 7 22 .7 .4 1910 21 4 25 .8 .6 1911 17 5 22 .6 .5 1912 20 9 29 .8 .6 1913 18 9 27 .8 .5 1914 23 4 27 .8 .6 1915 14 10 24 .7 .4 1916 28 8 36 1.1 .9 1917 27 11 38 1.2 .4 1918 27 17 44 1.4 .9 1919 22 9 31 .9 .6 1920 15 5 20 .6 .4 1921 26 2 28 .8 .77 1922 22 4 26 .78 .66 1923 19 — 19 .57 .57 1924 19 5 24 .71 .56 1925 15 9 24 .70 .44 55 MATERNITY AND CHILD WELFARE. Infant Welfare Centre.—This Centre is held at 73, High Street, and the work is carried on under difficulties owing to insufficient accommodation. It is hoped that this drawback will be remedied in the near future and allow of much needed developments and improvements. The Centre is open on Thursdays from 2 to 5 p.m., and is attended by mothers and babies and expectant mothers. The Medical Officer is in attendance, and during the year examined 442 babies and 124 expectant mothers. In addition to the Thursday afternoon session the Centre is open every morning from 9 to 10.30 a.m., and on Saturdays to 12 a.m., in order that mothers may consult the Health Visitor. A supply of dried milk or milk foods can be obtained during the above hours. Voluntary Helpers.—It would be difficult to carry on the work of the Centre without the help of our voluntary workers. We are very fortunate in having secured such able assistance as is given by Miss Lovegrove, who acts as Secretary, Mrs. Stocker, who is a trained nurse and assists the Health Visitor, Miss Firmin and Mrs. Webster, who are responsible for the w eighing of the babies, and Miss A. Chappie, who keeps the Register. Sewing Class.—A sewing class for mothers was started at the Centre during the year. Miss E. Bullett was appointed by the Council as Instructress. The class is necessarily small owing to the size of the room, but we hope to develop this branch of the work. Whist Drive.—A Whist Drive was held in December, 1924, and £30 was raised. This money has been very useful during 1925 in helping needy cases with warm garments and extra comforts where required. Provision of Milk, Milk Foods, and Drugs.—During the year £70 was spent on providing fresh cow's milk for necessitous cases and £33 on dried milk and milk foods. 56 Free milk is only given after a full enquiry into the circumstances of the family and subject to the total weekly income falling within the scale laid down by the Council. A stock of dried milks and milk foods is kept at the Centre and sold to Mothers attending the Centre at cost price. During the year £500 worth of these milk foods were sold. Dental Treatment.—Provision is made for the dental treatment of Expectant Mothers, and of young children up to the age of 5 years. The School Dentist gives Saturday mornings to this work, and the following Report indicates the amount of dental treatment of Mothers and young children during the year. I append below the report of the work done during the year under the above Scheme. This work is increasing greatly, and it has been impossible to confine all of it to Saturday mornings only, and I suggest that for purposes of estimating the cost of this work that a further 24 sessions should be added to the 48 Saturday morning sessions. Maternity and Infant Welfare Dental Report. No. of Attendances 526 No. of Extractions— Permanent Teeth 400 Temporary Teeth 40 440 No. of Fillings— Permanent Teeth 56 Temporary Teeth 56 112 No. of Dressings 60 No. Treated with Silver Nitrate 58 No. of Impressions 200 No. of Scalings 24 No. of Nitrous Oxide Administrations 76 No. of Dentures supplied 66 No. of Repairs to Dentures 10 ROBERT A. WATERS, L.D.S., Eng. 57 Orthopaedic Cases.—Seven children under the age of 5 required hospital treatment for deformities as follows: — Talipes 1, congenital dislocation of hip 1, rickets 2, spastic diplegia 1, spine 1, cleft palate 1. Six of these have obtained hospital treatment through the Clinic. The baby with a cleft palate died during the year; it also suffered from congenital heart disease. During the year the County Medical Officer held a Conference at Maidstone for the purpose of initiating a scheme to provide clinic and institutional treatment for all orthopaedic cases in the County. This scheme will be of great benefit to the County as a whole, but Beckenham, owing to its proximity to the London Hospitals, has hitherto been able to obtain the necessary treatment in London, and will probably find it more convenient to make use of the facilities for treatment provided by the London Hospitals. Unmarried Mothers.—In a few instances the Centre has been able to give assistance and help to unmarried Mothers. Arrangements were made by the Centre for the confinement and the taking over of the baby afterwards. The Council does not provide a Home for orphan or illegitimate children, but there is one private home in the District where babies and young children are taken to be nursed. This Home is under supervision by the Guardians and not by the Authority for the Maternity and Child Welfare Act, 1918. This is one of the anomalies of health administration, and it is hoped that future legislation will place the inspection and supervision of such Homes under the Authority that is appointed by statute to look after the welfare of infants and young children. One illegitimate baby died in the above Home during the year. The age was 4 months; the cause of death as returned by a Coroner's inquest was "syncope due to enlarged Thymus Gland.'' 58 Infantile Mortality.—During the years 1923 and 1924 we were able to record the very low infant death rates of 32.9 and 42.2 respectively. In 1925 the death rate rose again to 63.8 per one thousand births. This rate represents the deaths of 31 infants under the age of twelve months. An analysis of these deaths again focusses attention on the large number which die within a few days or hours of birth. Fifteen deaths occurred within the first week of life and ten of them died during the twenty four hours following birth, including three sets of premature twins. In these cases death was attributed to the following causes: — Premature birth 9, convulsions 1, congenital heart disease 1, suffocation 1, atelectasis 1, congenital malformation 1, atrophy debility and marasmus 1. Five of the above deaths occurred in the Maternity Home, and enquiry into the remainder does not indicate any lack of care or attention connected with child birth. Of the remaining 16 deaths which occurred at later periods of the first year of life 1 death was due to Measles and 2 to Whooping Cough. In all 3 a Doctor was in attendance. The Measles case was removed to the Beckenham Cottage Hospital and the District Nurses attended the home under the Council's arrangement. Two deaths were attributed to Influenza and 3 to Bronchitis and Pneumonia. One death followed operation for intussusception. Still Births.—Three still births were notified during the year as compared with 10 in 1924 and 15 in 1923. Placenta Praevia was the cause of the still birth in one case and in the remaining two the cause was unknown. Notifiable Diseases.—No case of Ophthalmia Neonatorum, Poliomyelitis, or Epidemic Diarrhœa was notified during the year. 59 Notification of Births. Births Notified 582 Births not Notified 16 Number of Still Births 3 Outward Transfer Births 118 Inward Transfer Births 15 Total Number in Register 598 No. of Births Notified by Doctors and Parents 201 No. of Births Notified by Midwives 281 There were 5 sets of twins born in Beckenham during the year. Visits by Health Visitor. No. of 1st Visits to children under 1 year 439 Total No. of Visits to children under 1 year 1631 Total No. of Visits to children over 1 year 1020 Total No. of Visits to Expectant Mothers 206 Infant Welfare Centre Attendances. Individual No. of children who attended the Centre 540 Total Attendances of children at the Centre 3176 New Cases admitted to the Centre Roll 285 Individual No. of Expectant Mothers who attended the Centre 124 Total attendances of Expectant Mothers at Centre 188 Number of Cases seen by the Medical Officer at Centre 566 Average weekly attendance of children at Centre over 50 Sessions 63 Average attendance of Expectant Mothers 41 In addition to the above attendances which relate to Thursday afternoon Clinics there were 1247 attendances of Mothers and Children at other times. 60 DISTRICT OF BECKENHAM. Infant Mortality. 1925. Nett Deaths from Stated Causes at Various Ages Under 1 Year of Age. CAUSE OF DEATH. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks. 4 weeks & under 3 months. 3 months & under 6 months. 6 months & under 9 months. ' 9 months & under 12 months. Total Deaths under One Year. ] All Causes Certified 15 ... ... 1 16 5 1 5 4 31 Uncertified ... ... ... ... ... ... ... ... ... ... Small-pox ... ... ... ... ... ... ... ... ... ... /Chicken-pox ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... 1 1 Scarlet Fever ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... 1 2 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... Influenza ... ... ... ... ... ... ... 1 1 2 Erysipelas ... ... ... ... ... ... ... ... ... ... Tubercular Meningitis ... ... ... ... ... ... ... 1 ... 1 Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... Meningitis (Not Tuberculous) ... ... ... ... ... ... ... ... ... ... Convulsions 1 ... ... 1 2 1 ... ...... ... 3 Organic Heart Disease 1 ... ... ... 1 ... ... ... ... 1 Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... 1 ... 1 Pneumonia (all forms) ... ... ... ... ... 2 ... ... ... 2 Diarrhœa ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... ... ... ... ... Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying 1 ... ... ... 1 1 ... ... ... 2 Injury at Birth ... ... ... ... ... ... ... ... ... ... Atelectasis 1 ... ... ... 1 ... ... ... ... 1 Congenital Malformations 1 ... ... ... 1 ... ... 1 ... 2 Premature Birth 9 ... ... ... 9 ... ... ... 1 10 Atrophy, Debility & Marasmus 1 ... ... ... 1 ... ... ... ... 1 Other causes ... ... ... ... ... ... 1 1 ... 2 Dentition ... ... ... ... ... ... ... ... ... ... Totals 15 ... ... l 16 5 1 5 4 31 Nett Births in the year egitimate 472, illegitimate 14. Nett Deaths in the year legitimate infants 30, illegitimate 1. 61 Maternity Home.—Details of this Home, which is situated at 80, Croydon Road, have been given in previous reports. The following statement of cases indicates the use that is being made of the Home: — Numbers admitted. Year. 31 1920 (Five months only.) 173 1921 183 1922 238 1923 240 1924 272 1925 The accommodation was at first limited to 10 beds, but this has been extended to 14 beds. Of the 272 patients admitted in 1925, 82 belonged to the Urban District of Penge, 156 to Beckenham, and 34 were outside these areas. Sixty of the Beckenham cases passed through the Ante-natal Clinic and were charged at the Clinic Rate, viz., £2 0s. 0d. for the period of 14 days. Puerperal Fever.—The difficulty which the Home experienced in making provision for the removal of cases of puerperal fever, should this occur, has now been surmounted, and an agreement has been entered into with the Beckenham Cottage Hospital to take any case of this disease on payment of a sum of Seven Guineas per week. This arrangement only applies to cases belonging to the Urban District of Beckenham; if the case belongs to the District of Penge that Authority has made its own arrangements for removal and isolation. URBAN DISTRICT OF BECKENHAM. TABLE SHEWING CAUSES OF DEATHS AT DIFFERENT AGE PERIODS OF RESIDENTS DURING THE YEAR 1925. Causes of Death. All Ages. 0 to 1 1 to 2 2 to 5 5 to 15 15 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 to 75 75 to 85 85 and over Copers Cope Ward Eden Park Ward Langley Park Ward Shortlands Ward Manor House Ward Kent House Ward Lawrie Park Ward Total Male Female Total 1. Enteric Fever ... 1 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... ... 1 2. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3, Measles ... l 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 4. Scarlet Fever 1 ... 1 ... ... ... ... ... ... ... 1 ... ... ... ... 1 ... ... ... ... ... ... 1 5. Whooping Cough 3 1 4 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4 ... ... 4 6. Diphtheria ... 1 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 7. Influenza 7 8 15 2 ... ... 1 1 ... 2 4 1 2 1 1 1 1 2 1 5 2 3 15 8. Encephalitis Lethargica 3 ... 3 ... ... ... ... 1 ... ... 1 1 ... ... ... ... 1 ... ... 1 1 ... 3 9. Meningococcal Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 10. Tuberculosis of Respiratory System 8 7 15 ... ... ... ... 1 4 3 3 4 ... ... ... 1 1 ... 2 5 2 4 15 11. Other Tuberculous Diseases 4 5 9 1 1 2 1 ... ... 2 ... 1 1 ... ... ... 1 1 1 3 3 ... 9 12. Cancer, Malignant Disease 20 25 45 ... ... ... ... ... ... 3 9 11 14 8 ... 5 4 4 1 16 9 6 45 13. Rheumatic Fever ... 1 1 ... ... ... 1... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 14. Diabetes 3 4 7 ... ... ... ... ... ... ... ... 2 3 1 1 2 1 1 1 ... 1 1 7 15. Cerebral Haemorrhage, etc 10 13 23 ... ... ... ... ... ... ... ... 8 9 6 ... 4 6 2 ... 3 5 3 23 16. Heart Disease 22 31 53 1 ... ... l ... 2 ... 4 12 14 13 6 5 6 3 1 14 14 10 53 17. Arterio-Sclerosis 9 3 12 ... ... ... ... ... ... ... ... 3 1 8 ... 1 2 ... 1 5 1 2 12 18. Bronchitis 10 18 28 1 ... 1 ... ... ... ... ... 4 4 13 5 3 3 1 ... 8 7 6 28 19. Pneumonia, all forms 5 10 15 2 ... 2 ... 1 1 1 1 ... 5 2 ... 2 1 2 1 4 4 1 15 20. Other Respiratory Diseases 4 1 5 ... ... ... ... ... ...... l ... 2 ... ... 2 1 ... ... ... 2 ... 2 5 21. Ulcer of Stomach or Duodenum 4 ... 4 ... ... ... ... ... 1 1 ... 1 ... ... 1 ... ... 1 ... 2 ... 1 4 22. Diarrhœa, &c. (under 2 yrs). ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 23. Appendicitis & Typhlitis 2 2 4 ... ... ... 1 1 ... l ... 1 ... ... ... 3 ... ... ... ... ... 1 4 24. Cirrhosis of Liver ... 1 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... 1 25. Acute & Chronic Nephritis 9 2 11 ... ... ... ... 2 2 ... ... ... l 6 ... ... 3 ... 1 1 2 4 11 26. Puerperal Sepsis ... 3 3 ... ... ... ... 1 1 1 ... ... ... ... ... ... 1 1 ... ... 1 ... 3 27. Other accidents, etc. of pregnancy and parturition ... 1 1 ... ... ... ... ... ... l ... ... ... ... ... ... ... ... ... ... 1 ... 1 28. Congenital debility and malformation, premature birth 7 7 14 14 ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... 6 4 2 14 29. Suicide 1 2 3 ... ... ... ... ... ... ... 1 2 ... ... ... ... ... 3 ... ... ... ... 3 30. Other deaths from violence 2 2 4 1 ... ... 1 ... ... 1 ... ... ... 1 ... ... 1 ... ... 1 2 ... 4 31. Other defined diseases 43 21 64 6 1 1 ... 1 1 6 8 4 3 21 12 4 7 6 4 17 12 14 64 32. Causes ill-defined or known ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 177 171 348 31 4 6 7 9 12 24 32 58 57 80 28 33 41 27 14 101 72 60 348 urban District of Beckenham. Report on the Medical Inspection of Children in the Elementary Schools during 1925. 64 To the Chairman and Members of the Education Committee Ladies and Gentlemen, I have the honour to submit for your consideration my Annual Report on the Medical Inspection and Treatment of School Children during the year 1925. The arrangement of the report follows closely the suggestions and headings given in the Schedule Form 6.M. issued by the Board of Education in November, 1925. During the year the Treatment Scheme was amended by extending to the South Eastern Hospital the same arrangements for the operative treatment of Tonsils and Adenoids as are in force at the Beckenham Cottage Hospital. Proposals for the treatment of "Running Ears" by the method known as Ionisation were adopted by the Committee and are now awaiting the approval of the Board of Education. The attendances at the various Clinics for Inspection and Treatment are maintained, and I would like to emphasise the value of the work that is being done at the Dental and Eye Clinics. Mr. Waters, the School Dentist, is able to inspect at least once a year, and carry out the necessary treatment for every child in the Elementary Schools that requires and will take advantage of such treatment. The contrast between the healthy condition of the teeth and mouth of the children now, as compared with the early days of Medical Inspection is very striking, and is reflected in the reduction in the number of children with enlarged glands and abscesses in the neck, and I believe has contributed to the reduced incidence of tuberculosis in the glands of the neck. The work of the Eye Clinic under Mr. A. E. A. Looseley, F. R.C.S., continues to be done in a very thorough and expeditious way, at a minimum cost and loss of time to the parents. If there is any Elementary School child with a defect in eyesight that admits of remedy or improvement by suitable glasses, it is not the fault of the School Medical Service if this has not been remedied. 65 It is noteworthy that this is the first year that I have been able to report that no cases of Ringworm of the Scalp or Body were found. In the year 1910 and the three succeeeding years, when I commenced the work of School Medical Inspection in Beckenham, there was a yearly average of over 100 Children excluded from School for shorter or longer periods on account of this condition. It will be gratifying to the Committee to realise that the rigid methods then adopted for exclusion, and the X-Ray Treatment provided, have resulted in a steady diminution of cases, and we have now had a full year without a single case. This is probably the first time since the School population of the district reached any size that the Schools have been free from the disease. The arrangements made in 1924 for sending debilitated and under-nourished children for short periods to the Parkstone Home at Bournemouth were continued during 1925, and were utilised to the fullest extent. The provision of four places was extended during the year to six places so that four boys and two girls are now under constant treatment. All the children sent to the Home have benefited, and the results in some cases were very striking, showing the influence of environment and suitable food. The above, and other considerations, lead me to believe that School Medical Inspection and Treatment is contributing its share to the improvement that has been noticed in the general health of the people, and to the considerable increase that has taken place in the average duration of life. I have the honour to be, Ladies and Gentlemen, Your obedient servant, J. M. CLEMENTS, School Medical Officer. 66 STATISTICS IN RELATION TO EDUCATION. Estimated population of Beckenham 33850 Number of Public Elementary Schools 5 Number of Departments 14 Accommodation 3523 Number on Roll 3080 Special Day School for the Mentally Defective 1 Other Schools: — County Secondary School (Boys) 1 County Secondary School (Girls) 1 Trade School 1 Private Schools 20 One Penny Rate produces for Elementary Education £1240 STAFF ENGAGED IN MEDICAL INSPECTION. School Medical Officer (approximately half time). J. M. Clements, M.D., D.P.H. School Dentist (nine-tenths of time to school work). R. A. Waters, L.D.S., R.C.S., Eng. Anæthetist to Dental Clinic (part time). P. J. Curtis, M.R.C.S., L.R.C.P., Lond. Opthalmic Surgeon (part time). A. E. A. Looseley, F.R.C.S., Eng. School Nurse. Miss M. E. Chappie, A.R.S.I., C.M.B. Dental Nurse. Mrs. E. F. Richards, S.R.N., C.N., C.M.B. Co-ordination of the Work of School Medical Service with that of other Health Services. Infant and Child Welfare.—The Maternity and Child Welfare Service is held in the same building as the School Clinic, and is 67 under the supervision of the School Medical Officer. The work of the various Clinics is intimately associated, and the School Nurse assists at the Infant Welfare Centre when required, and similarly the Health Visitor in the absence of the School Nurse takes charge of the Minor Ailment Clinic. The Care of Debilitated Children under School Age.— Children up to the age of five years attend the Infant Welfare Centre, and as soon as they attain the age of five they are transferred to the School Service. The large proportion of the children commence to attend the Welfare Centre in early infancy, cards are made out on which a record of their health is kept and any treatment required or provided. These cards are filed according to age and after the age of twelve months, when their visits to the Centre are not so frequent, they are visited in their homes at fixed intervals every year by the Health Visitor until the age of five is reached, and thus supervision is maintained until they come under the care of the School Medical Service. SCHOOL HYGIENE. "Review of the. hygienic condition of the Schools in the area, with particular reference to their surroundings, ventilation, lighting, warming equipment, and sanitation ; observations on the type and condition of desks and blackboards, sanitary convenience and lavatories, water supply for washing and drinking purposes, cleanliness of schoolrooms and cloakrooms, arrangements for drying children's boots and clothes, arrangements for (i.) the warming up of meals brought to school by the children, (ii.) the supervision of children during the meals, and (iii.) the service of the meals, and the relation of the generaI arrangements of the school to the health of the children. I do not propose to enter into the subject of this heading in any very great detail, especially as the Committee went carefully into a report made by me some years ago dealing with these 'matters. At that time plans of the schoolrooms and playgrounds were prepared and all the facilities for ventilation, lighting, and heating the class rooms, the suitability of the school furniture, the cloakroom 68 accommodation, etc., were tabulated, defects pointed out, and remedies suggested. The list of defects and suggested remedies have been reviewed from time to time, and as the necessary improvements have been made they were recorded on the plans. It would have been impossible to remedy all the defects mentioned in one year, but improvements proceeded steadily, and practically all the important defects were remedied except such as involved pulling down and rebuilding. Speaking generally, all the five elementary schools are in a satisfactory condition from a hygienic point of view. The Balgowan, the Churchfields Road, and the Bromley Road Schools are modern buildings built and suited to their purpose. They stand in their own playgrounds, the classrooms are well arranged with good provision for ventilation and lighting, both natural and artificial, and those accessory services which one frequently finds so poorly provided in older schools, such as efficient methods of heating, lavatory and cloakroom accommodation, and school furniture, are all very good and up-to-date. The Alexandra and St. James's Schools, viewed from the hygienic standpoint, are not quite so satisfactory as the others. Many improvements have been made, especially at the Alexandra School in recent years, but certain defects are of a character that nothing short of re-building will rectify. MEDICAL INSPECTION. A. Routine Inspections Routine Inspections are those made on the School premises of the groups of children prescribed for examination by the Board of Education. The number of children examined at these inspections during the year 1925 was as follows: — Entrants 517 Leavers 330 Intermediate Group 217 69 The "Entrants" include all children who have attained the age of five years and in addition all others outside the five year agegroup who are entering an elementary school for the first time. The "Intermediate" group includes the children who have attained the age of eight years at the time of the Medical Inspection. The "Leavers" include those who have attained the age of twelve years, or who have not been medically examined since attaining the age of twelve. B. Other Inspections. In addition to the above groups, 574 "Special" Inspections were made of children referred to the Medical Inspector, either at the School or School Clinic, for examination. These "Special" cases were selected by the Teachers, School Nurses, School Attendance Officers, Parents, or by the Medical Inspector during a visit to the School, on account of some obvious or suspected disease or defect. Five hundred and fifty-three re-inspections were made of the above routine or special cases. FINDINGS OF MEDICAL INSPECTION The results of Medical Inspection and Treatment are summarised in Tables I. to IV., pages 92 to 99. An analysis of the figures given under the principal headings in Table II. is given below, together with the results of "Followingup" and the nature of the treatment provided. Malnutrition.—Forty-one children were classified as badly nourished, of whom 31 were referred for treatment and 10 for observation. The following information is available regarding these at the end of the year—9 boys and 1 girl were sent for a period of 70 6 weeks to the Parkstone Convalescent Home, Bournemouth (see page 82) and 5 are waiting their turn for admission. Two are having treatment at home, one attends great Ormond Street Hospital, and two have left the District. The remaining 11 of the cases referred for treatment have attended the Clinic for advice, weighing, etc. Of the 10 cases referred for observation, 1 is attending a London Hospital and 9 have attended the Clinic. SKIN DISEASES. Ringworm.—No Case of Ringworm of the Scalp or Body was discovered in 1925, This is the first time since 1910, when I commenced the work of Medical Inspection, that the Schools have been free from this disease, I referred in my last year's report to the steady way in which Ringworm has diminished since the Education Committee adopted vigorous methods of dealing with it. During the years 1911, 1912, and 1913, the numbers of children excluded from School for Ringworm were respectively 133, 99, and 63. One wonders how long it will be before the School Medical Officer will be able to present a clean sheet for a whole year in respect of verminous children, a condition that is much more easily eradicated than Ringworm and which is closely associated with the cause of many of the minor ailments of school life. Scabies.- Only one case was discovered during the year, and was quickly cured by appropriate treatment. Impetigo.- Seventeen cases were found at the Routine and Special Inspections. Ten were cured by treatment at the Clinic, four received home treatment, and three are still attending the clinic for treatment. (In addition to the above many other cases attended the daily clinic for treatment, see page 79.) Other Skin Diseases.—The 45 cases under this heading consist mainly of Urticaria, Eczema, Psoriasis, and Ichthyosis. Twenty- 71 eight were reported cured at the end of the year. A large proportion of the remainder are chronic or recurring conditions which resist treatment. Blepharitis.—Thirteen cases were found and referred for treatment. Seven were reported cured at the end of the year, and the remaining six are still undergoing treatment, five of whom attend the treatment Clinic and one is being treated by a private Doctor at home. Two of the above cases required glasses which were provided through the Eye Clinic. Conjunctivitis.—Nine children were referred for treatment for this condition, six were reported better at the end of the year, and three continue under treatment. In one case glasses were prescribed and obtained through the Eye Clinic. Defective Vision and Squint.—One hundred and six children were suffering from defective vision or squint and were dealt with as follows: Forty-six were referred at once to the Eye Clinic for treatment and 60 were referred for observation or further examination. Of the 46 referred for treatment the position at the end of the year is summarised below: — Provided with spectacles at the Eye Clinic 36 Waiting appointments at the Eye Clinic 3 Spectacles not required 3 Spectacles provided by private arrangement 1 Treatment refused 2 Appointments continually broken 1 46 Of the 60 cases referred for observation or a further examination, 42 were wearing glasses which were found to be suitable, DISEASES OF THE EYE. 72 and they will continue to be examined at the Eye Clinic at fixed intervals. The remaining 18 were not wearing glasses and were dealt with as follows:— Five were re-tested and found not to require glasses, three were provided with glasses through the Clinic, three were re-tested and are waiting further appointments, two obtained glasses from an Optician, one is waiting for an operation for squint, and four are waiting an appointment for testing. DISEASES OF THE EAR. Defective Hearing.—The hearing was found to be impaired in 15 children, and the defect was due to (a) accumulation of wax in the ear in two cases, the wax was removed at the treatment clinic, (b) enlarged Tonsils and/or Adenoids in nine cases—three of these have been cured by operation under the Committee's scheme, four were prescribed a course of breathing exercises, and in two cases nothing has been done owing to the objection of the parents; (c) Middle Ear Disease in four cases, these latter attended the Treatment Clinic for a course of treatment. Middle Ear Disease ("Running Ears").—Thirty-three children (including the four mentioned under the previous heading) were discovered with "running ears," and 27 were referred for treatment. Of those referred for treatment 12 attended the treatment clinic, and in 8 cases the disease appears temporarily arrested, and in 4 cases the condition persists. In 5 cases the Tonsils and/or Adenoids were removed with good results. In the remaining 10 cases there is no improvement, 5 are having treatment at home, 2 are carrying out breathing exercises, and in 3 no treatment has been obtained. Treatment BY Ionization.—Good results have been recorded recently from this form of treatment in Middle Ear Disease, and as the usual methods of treatment of this condition are not very satisfactory, one is glad to welcome any new treatment that will give a higher percentage of cures. The Education Committee 73 approved a scheme in December for carrying out treatment by Ionization in the case of children attending the Elementary Schools and available also for children under the age of five. The scheme is at present awaiting the approval of the Board of Education. TONSILS AND ADENOIDS. Tonsils and Adenoids.—One hundred and fifty-nine children were returned as suffering from one or both of these conditions. In 71 cases the condition was regarded as in need of treatment at once, and in 88 cases the condition was to be kept under observation. Of the 71 referred for treatment, 33 have had operative treatment under the Committee's scheme—11 at the Beckenham Cottage Hospital, and 22 at the South Eastern Hospital. In 10 other cases treatment by operation has been provided by the parents privately or at a London Hospital. In 7 cases the parents have refused treatment, 5 are awaiting operation, 9 are carrying out a course of breathing exercises, and 7 cases had not been followed up at the end of the year. HEART DISEASE. (a) Organic.—Seven children, two of whom were found at the Routine Inspections, are under observation for organic heart disease In two cases the disease is due to Chorea and in four to acute Rheumatism. (b) Functional.—In 27 children the variations of the hearl from normal was classified as functional. All the above cases are kept under supervision through the School Clinic which they attend at intervals. 74 ANÆMIA. Eight children were suffering from Anaemia, one was sent to a Convalescent Home for a period and returned much improved, the remaining seven obtained advice and treatment through the Clinic. TUBERCULOSIS. Tuberculosis.—All children found suffering from, or suspected to be suffering from Tuberculosis are sent to the Tuberculosis Dispensary for observation and treatment. As the School Medical Officer is also Tuberculosis Officer for this area of Kent, the following up of these children is simplified. During the year 29 children attended the Dispensary, and the following statement classifies them according to the form of disease from which they were suffering and gives some details as to the severity of the disease, fitness for school, and treatment . Nine cases appear under the heading of suspected pulmonary disease, 12 as disease of glands, 1 as disease of the spine, 1 lupus of face, 2 disease of hip joint, and 4 of the peritoneum. Of the nine suspected pulmonary cases four have physical signs of enlarged glands at the root of the lung, 4 have been classed as Pulmonary A (i.e., no tubercle bacilli have been found in the sputum after repeated examinations), and 1 is under observation. No case of pulmonary disease with tubercle bacilli in the sputum was found during the year. This group of children, who are usually of poor physique, with signs and symptoms of bronchial irritation, cough, sputum, and perhaps the physical signs associated with enlarged glands at the root of the lung, is one where it is difficult to be certain of the actual pathological condition. Many of them come from homes where 75 there have been adult cases of open pulmonary tuberculosis. On reviewing the history of such children, the records of which have been kept during the last 15 years, comparatively few develop undoubted symptoms of pulmonary tuberculosis, and when they do so the course of the disease, in my experience, proceeds rapidly to a fatal termination. Very few of the latter cases (as compared with the number suspected) have been recorded during the last 15 years, but in this connection it should be remembered that Pulmonary Tuberculosis is at its lowest incidence, as judged from mortality returns, at School ages (5 to 14), and this remark also applies to the non-pulmonary forms of tuberculosis. When one considers the percentage of children in Urban areas which give a positive Von Pirquet or other tuberculin test indicating an infection with the tubercle bacillus, and the numbers of children found at post mortem examinations which show signs of latent or active tubercular lesions, one is obliged to conclude that many of those infected do not show physical signs of active disease. In any event, Pulmonary Tuberculosis is not a frequent cause of death during Elementary School life. Of the Non-Pulmonary cases 12 had glandular infection and three of these were excluded from school, and the remaining 9 were allowed to attend school and at the same time carried out appropriate treatment One case of spinal disease is now quiescent and able to attend school. One case of lupus of the face had "Light" treatment at a London Hospital and is now apparently cured and back at school. The two cases of hip-joint disease have had institutional treatment during the year, one is now at school and the other is still excluded. The four children with infection ol the peritoneum and mesenteric glands are classified as quiescent disease and are attending school. 70 NERVOUS SYSTEM. Epilepsy.—One girl was discovered at the Routine Inspections who gave a history of epileptic fits. The fits occur at long intervals, and so far they have not interfered with her attendance at school. Chorea.—Seven children were suffering from this disease, and five were excluded from School for varying periods. Of these, three had in-patient treatment in hospital and are reported cured. One is attending the German Hospital in Eondon and is still excluded from school, one is in a Poor Law Convalescent Home, and two cases where the symptoms were very mild are attending school and are under observation through the Clinic. The danger of heart complications makes this a grave disease in children, and in two of the seven cases of organic heart disease previously reported the heart lesion was due to this disease. DEFORMITIES. Forty-one children presented deformities or defects as follows:— Chest 25 Paralysis 5 Cleft Palate 1 Hare Lip 1 Flat Feet 5 Leg (Osteomyelitis) 1 Rickets 1 Spinal Curvature 1 Osteal Tumour 1 The children with defects or poor development of the chest arc given special physical exercises both at school and at home. 77 There were five children where deformities were the result of paralysis of muscles. One was a case of Erb's paralysis, three were the result of Anterior Myelitis (infantile paralysis), and one was due to paralysis of the facial muscles. All these cases have had various forms of treatment, massage, electrical, etc. One has had an operation for nerve grafting. Five children had deformity of the feet, in one the deformity involved the foot and leg, and this boy received treatment by operation at an Orthopaedic Hospital; the remaining four were cases of flat feet which were treated by exercises and gave good results. INFECTIOUS DISEASES. The methods by which information of sickness, infectious or non-infectious, amongst school children is notified to the School Medical Officer have been described in previous reports, and are working satisfactorily. By these methods the School Medical Officer learns of practically every case of illness in a school child, and the home is visited by the School Nurse and appropriate advice given. During the year the School Nurse made 2759 visits to the homes of children who were reported absent on account of sickness. Whooping Cough and Mumps were prevalent during the year, and the following Exclusion Table shows the numbers excluded from school for these diseases. School Closure.—No School or Department was closed during the year on account of infectious disease. Exclusions.—The following Table gives the numbers of children excluded from school under Article 53 (b) of the Code, or other statutory provisions, during the year: — 78 Condition for which excluded. Nos. excluded. Name of Schools. Bromley Road. Alexandra. Churchfelds. St. James's Balgowan. Other Schools. Diphtheria 5 1 1 2 ... ... 1 ,, contacts 15 3 4 4 ... 2 2 Scarlet Fever 38 5 6 6 7 5 9 „ contacts 38 6 3 10 6 2 11 Measles 32 8 6 7 1 6 4 Whooping Cough 121 3 20 51 11 31 5 Mumps 161 1 21 127 2 8 2 Chicken Pox 58 8 30 17 ... ... 3 Eye Disease 9 1 ... 7 ... ... 1 Impetigo 13 ... 5 6 ... 2 ... Verminous Conditions, etc 104 2 47 41 14 ... ... Ear Disease 6 2 ... 4 ... ... ... Bronchitis 42 5 6 27 ... 3 1 Scabies 1 ... ... ... 1 ... ... Influenza 55 16 14 18 2 5 ... Diseases of the Nose and Throat 42 7 10 16 6 3 ... Other Skin Diseases 5 1 1 2 1 ... ... Tuberculosis 2 ... 2 ... ... ... ... Chorea 10 1 7 2 ... ... Miscellaneous 318 39 84 163 9 17 6 Totals 1075 108 261 515 62 84 45 TREATMENT OF MINOR AILMENTS. The Clinic for the treatment of Minor Ailments is open on week-days from 9 to 12 in the morning. The School Nurse is in charge of the Clinic, and she is assisted by V.A.D. Nurses from the Beckenham Voluntary Aid Detachment No. 86. The latter continue to give valuable and entirely voluntary service, which is much appreciated. The following statement gives the number of children who attended during the year and the conditions for whidx treatment was given:— 79 INSPECTION CLINIC. This Clinic continues to be held every Tuesday afternoon, and the principal diseases and the number of attendances made are set out below: — Diseases. Total Attendances. Diseases of the Ear 58 Diseases of the Eye 48 Diseases of the Nose and Throat 427 Defective Hearing 19 Defective Vision 29 Defective Speech 4 Anaemia 2 Enlarged Glands 60 Impetigo 12 Malnutrition 145 Heart Disease 57 Non-Tubercular Lung Disease 159 Other Skin Diseases 129 Nervous Disease 31 Chorea 6 Scabies 2 Miscellaneous 468 Ringworm Nil. Scabies 2 Impetigo 126 Other Skin Disease 61 Minor Eye Defects 79 Minor Ear Defects 99 Miscellaneous 214 581 80 EYE CLINIC. The Eye Clinic held 26 Sessions during the year as compared with 23 in the previous year, and the following is a summary of the work done: — Number of Children examined 180 Number of attendances 634 Spectacles prescribed 129 Spectacles provided 126 DENTAL REPORT FOR 1925. I have the honour to present the Dental Report for the year 1925. Each School has been visited for Dental Inspection, and 3191 children were inspected. These inspections entailed 35 visits. Of the children inspected 2377 were found to require treatment, and 1790 were actually treated during the year. Five hundred and eighty-seven children did not receive treatment at the Dental Clinic, but a small number were treated privately. The percentage of refusals is considerably lower, being 25 per cent, in comparison with 30 per cent, the previous year. There has been an increased attendance, the total being 2806. The attendances are now getting back to those of thei years preceding the payment scheme. The year 1924 being the first full year under the payment scheme, the attendances were much lower, and it is gratifying to find that things are becoming more normal. Parents are bringing the smaller children for treatment much better than they used to do, and one is able to retain more of the 91 temporary teeth than was formerly the case. A comparison with 1923 brings out this point: — 1923 Temporary teeth extracted 1966 1925 Temporary teeth extracted 1640 1923 Temporary teeth filled 571 1925 Temporary teeth filled 942 I have taken 1923 as an example because it was a more normal year than 1924, but even that year showed an increase of fillings in the temporary teeth. I regard the retention of the temporary or "baby" molars as of the greatest importance. The loss of these molars too early leads to a great amount of crowding in the permanent teeth, and this is brought about in two ways. By the lack of growth in the jaws due to an impaired masticating surface and to the encroachment of the first permanent molar (which is usually well erupted by the age of seven) into the space normally occupied by the temporary molars. Instruction in the proper method of cleaning, etc., teeth is given at the schools and individually at the Dental Clinic. The number of children who do not possess a toothbrush is decreasing, but there are quite a number who, possessing a toothbrush, regard it rather as an ornament than the necessary article of use it should be. But, as I have pointed out in previous reports, good mastication of hard foods is Nature's remedy against dental disease. I regret that we are losing the services of Mrs. Richards, the Dental Nurse, as she has carried out her duties very satisfactorily. My thanks are due to Dr. J. M. Clements and Dr. P. J. Curtis for their help during the year, and to the Head Teachers in the Schools for their co-operation and interest in the Dental work. ROBERT A. WATERS, L.D.S., R.C.S., Eng. School Dental Officer, 82 SUMMARY OF DENTAL REPORTS SUPPLIED TO THE EDUCATION COMMITTEE. Number of children inspected 3191 New cases 1790 Old Cases 799 Casuals 217 2806 Fillings, Permanent Teeth 1492 Temporary Teeth 942 Root 9 2442 Extractions, Permanent Teeth 177 Temporary Teeth 1640 1817 Scalings 131 Dressings 522 Silver Nitrate 394 Crowns 4 Regulation appliances 14 Nitrous Oxide administrations 158 ROBERT A. WATERS. L.D.S., Eng. School Dental Officer. PARKSTONE CONVALESCENT HOME. In last year's report I gave details of the arrangements made by the Education Committee with the Shaftesbury Society for four places in the above Home to be reserved for Beckenham School Children. These four places could only be filled by boys, and no provision at that time was available for girls. Since then, owing to extension of the Home, an opportunity occurred of securing two further places for girls, so that the Committee have now six places in the Home. 83 Selected children are. sent in batches of six, and remain for a period of six weeks. They are all debilitated children suffering from defective nutrition and are underweight. In five cases they had been in contact at home with an open case of Pulmonary Tuberculosis. Twenty-nine children were admitted during 1925, and in two special cases the period of stay was extended to twelve weeks. They returned much improved, the gain in weight being as much as 5 to 8 pounds in a number of cases. TREATMENT SCHEME. Additional Arrangements for Treatment.—During the year the Committee entered into an agreement with the South Easterr Hospital for the operative treatment of children suffering from Adenoids and Enlarged Tonsils. The terms are the same as those in force at the Beckenham Cottage Hospital. They are briefly as follows:— Cases to b,e selected for operation by the School Medical Officer The operation to be carried out in the Hospital by a member of the Staff of the Hospital who has had special experience in the operation of enucleation—the form of treatment to be adopted. Fees to be paid by the Education Committee per operation are—to the operator 10s. 6d., to the anaesthetist 10s. 6d., and to the funds of the hospital 10s. 6d. If the patient is detained in the Hospital after the operation a further donation of 5s. per day is paid to the Hospital up to a maximum of two days. This new arrangement is appreciated by many of the parents who live in the neighbourhood of the South Eastern Hospital, or who can get easily to the hospital by omnibus. OPEN-AIR EDUCATION. (a) Playground Classes.—Classes are occasionally taken in the playground at all schools during the summer months. 84 (b) School Journeys.—Children visit the local recreation grounds and the parks with their teachers. (c) School Camps.—No arrangement has been made for School Camps. (d) Open-Air Class Rooms.—None have been provided, but shelters in the playgrounds at Bromley Road and Alexandra Schools are used for this purpose. (e) Open-Air Day Schools.—Nil. (f) Residential Open-Air Schools.—The Education Committee does not provide an open-air residential school, but they have an arrangement with the Parkstone Home, Bournemouth, which is practically an open-air residential school, whereby six selected children—four boys and two girls—are sent for periods of six weeks, (see page 82). PHYSICAL TRAINING. The work of physical training is carried out by the Teaching Staff. An area organiser of Physical Training has not been appointed. The Teachers follow, as far as possible, the syllabus of special instruction in physical drill issued by the Board of Education. Children requiring remedial exercises for the correction of physical defects found during medical inspection are referred to the Teachers for special drill. Outdoor Games.—In previous reports I have referred to the importance of organised outdoor games on the health, development, and character of the children. It is very satisfactory and encouraging that the Education Committee do not under-estimate the influence on child life of adequate playing and sports grounds, and the part that is played by outdoor exercises on the moral and physical development of the children. 85 The Committee are looking ahead and have secured suitable grounds which will meet the present and future needs of the District in this respect. Fortunately suitable ground is still available for this purpose, but it is probable that at no very distant date practically all the vacant land will be built over, so that it is essentiai for those concerned to maintain a forward looking policy in such matters. PROVISION OF MEALS. The supply of meals to children attending the Special Day School is referreel to on page 91. The School Medical Officer occasionally visits the School during the mid day meal, he certifies as to the suitability of children selected for free meals, and approves the dietary. During the year the Education Committee made arrangements which were approved by the Board of Education for the supply of meals to children in attendance at the Balgowan Road Central School who may require such meals. A School Canteen Committee was formed of which the School Medical Officer is a member. The receipts from the sale of food during the year balance the expenditure on food, and the working expenses, such as equipment wages of cook anel kitchen maid, are borne by the Education Committee. The following is a statement of the meals supplied and the cost thereof during the period 1st June to 19th December, 1925:— Average number of daily'meals 38 Total number of meals supplied 4404 Annual Cost £136 (food only) Cost per Meal 7.4d. (food only) Scale of Charges Single dinners 8d. Weekly tickets for five Weekly tickets for five dinners 3s. Equipment and Staff Provided by the Committee Annual Cost About £100 86 SCHOOL BATHS AND SWIMMING. Baths are not provided at the Elementary Schools and are not required so long as the excellent arrangements that have been made by the Education Committee for children to attend the Public Baths are in force. In my last report I referred to a report by the Baths Superintendent on the continuous Filtration of the Swimming Bath Water. It is satisfactory to record that the Baths Committee have adopted a scheme for continuous filtration and that the plant will shortly be installed. The new arrangement is, I believe, likely to lead to economy, and it can certainly be recommended on hygienic grounds. Complaints from parents frequently reach the School Medical Officer that children develop diseases of various kinds as a result of attending the Baths. I have never been able to find any justification for these complaints, but it may help to allay suspicion if one can say that the most modern methods are adopted to keep the Bath Water as pure and as clean as possible. Swimming.—The high standard of instruction that is given in Swimming and the proficiency attained is again borne out in 1925 by the successes of the School children in open competition; as, for instance, in the Southern Counties Championships, the Kent County Championships, and All-London Schools. The Baths Superintendent states that 205 children attended "life-saving" classes, and 181 passed examinations at one or more stages. Five boys and seven girls of the elder scholars at Balgowan School passed the tests for the Bronze Medallion of the Royal Life Saving Society. The total number of life-saving awards gained was 240. EVENING PLAY CENTRE. The Play Centre at the Alexandra Schools was open on 35 evenings during the winter months from October to March. The 87 following particulars are taken from the Report of the Honorary Secretary, Mrs. M. Howard Smith. During the first Session there were 125 children on the Roll— 75 boys and 50 girls—the average attendance being 115. The attend ance during the second Session was much reduced owing to the influenza epidemic. Classes were held in dancing, raffia work, painting, leather work, dramatic reading, dressmaking, singing, and organised games. The success of the Centre is due to the enthusiasm and work of the voluntary helpers. CO-OPERATION OF PARENTS. Parents are notified of the date and time of Routine Medical Inspections, and both parents are invited to attend. Usually the Mother only attends. The nature of any defects found is explained to the Mother, and advice is given as to treatment and how it should be obtained. A printed card with the days and hours of the various Clinics is given to the parent. CO-OPERATION OF TEACHERS. The Head Teacher is, as a rule, present during the Routine Inspections and makes a note of all the defects found. Where children require special exercises for physical defects the Head Teacher sees that the appropriate drill is given. They select cases who appear to require medical examination, they influence the parents in obtaining treatment, and they send children to the Clinics who require advice and treatment. 88 They also notify the School Medical Officer of children absent from school on account of illness, and information about cases of non-notifiable infectious diseases comes .mainly from the Head Teachers. I regard the Head Teacher who takes a practical interest in the physical welfare of the children and in the work of medical inspection and treatment—and Beckenham is very fortunate in this respect—as one of the greatest allies that the School Medical Service can obtain. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. The School Attendance Officers take no part in the work of Medical Inspection nor in following up children suffering from defects. They do, however, supply the School Medical Officer with valuable information about children whose absence from school is due to illness, and this leads to the homes being visited by the School Nurse and appropriate advice being given to the 'mother. It also results in a certificate being given by the School Medical Officer as to the length of time the child should be absent from school. CO-OPERATION OF VOLUNTARY BODIES. The Beckenham Charitable Society have given assistance in a number of cases during the year which were brought to their notice, and four children were sent to Convalescent Homes through the aid of the Society. 89 BLIND, DEAF, DEFECTIVE, AND EPILEPTIC CHILDREN. Children who come under any of the above headings are brought to the notice of the School Medical Officer either by parents, School Attendance Officers, the School Nurse, or Head Teachers. If the defect is gross and obvious they are sent at once to the School Clinic, and are then dealt with according to the degree of defect found. Cases of feeble minded children, where the defect is not very pronounced, are usually discovered by the School Medical Officer among the lists of dull and backward children furnished by the Head Teachers. These lists are 'made out once a year, and the Teacher sets out the number of years the child's education is retarded with comments, such as "prolonged absence due to illness," "cannot concentrate,'' etc. Th,e School Medical Officer examines all these children during the Routine Inspections at the school and investigates the mental condition and the cause of backwardness. Sometimes it is necessary to refer the child to the School Clinic for further examination. Blind and Deaf.—With regard to the numbers of Blind and Deaf, there is one girl attending a certified school for the Blind at Upper Norwood and one girl attending a certified school for the Deaf at Margate, these are the only cases known to me belonging to the District. Mentally Defective.—Particulars relating to the feeble minded children will be found under the report on the Special School, page 91. During the year one feeble minded child was notified to the Local Control Authority on leaving the Special School. Three other mentally defective children were notified 10 ths same Authority during the year, viz., two imbeciles- one boy and one girl—and one idiot girl. Of the 19 feeble minded children referred to as in attendance at the Special School, 13 belong to Beckenham and 0 to Penge. 90 Epilepsy.—One case of Epilepsy, that of a girl aged 12, has been under supervision during the year. This girl was one of tfte f'our cases reported last year, one of whom has since died from cpilepsy, the remaining two cases have been free from fits during the year. SCHOOL FOR MENTALLY DEFECTIVE CHILDREN. In my Annual Report of last year I reviewed the methods of dealing with Feeble Minded children in relation to their Education, and 1 also referred to the formation of "Special Classes" in the ordinary Elementary Schools for backward and sub-normal children. A good deal of time and attention was given to this subject by the Sub-Committee to whom it was referred for investigation, and as a result of their enquiries the Committee came to the conclusion that the time was not an opportune one to make any drastic change in the provisions that were already in force for the education of the feeble minded. The Committee were of the opinion that it would be better if the lower grade cases in the Special Day School were transferred to Residential Institutions, but owing to the difficulty of getting children into these institutions, practically all the available places being filled, they were unable to make a recommendation on these lines. The Committee also expressed the view that these lower grade children were unfitted for special classes in the ordinary schools and should not mix with the merely dull and backward children. In the circumstances it was decided to continue the Special Day School and at the same time to encourage the formation of special classes in the Elementary Schools for sub-normal and backward children. The advantages of such classes were referred to in my las' Annual Report. 9l It is not possible at present to dispense with the Special Day School, but should there arise a strong public opinion in favour of the permanent segregation of the helpless feeble-minded, and there are indications that we are progressing in that direction, it may lead to the abolition of these Special Day Schools for this class of child. SPECIAL SCHOOL CHURCHFIELDS ROAD. Number on Roll.—At the beginning of the year there were 18 children in attendance—three were admitted during the year, one was discharged at age 16, and one left the district, so that at the end of the year there were 19 children on the roll, 13 belonging to Beckenham and 6 to Penge. Inspections.—I have visited the School several times each term and every child has been examined on at least two occasions during the year. Remedial defects, including Dental Defects, are carefully followed up and appropriate treatment provided. Indeed, this class of child gets much more attention in the form of medical inspection and treatment than his more normal fellows in the Elementary Schools Provision of Meals.—A mid-day meal is provided at the School for those children who are unable to go to their own homes in the middle of the day. The number of meals served during the year was 2976, an average of 68 per week. The total cost of the meals amounted to £49 13s. Od., about fourpence per meal. The parents contributed £35 9s. lid. towards the cost and the balance of £14 3s. Id. was defrayed by the Education Committee. 92 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. the employment of children of School age consists largely in delivering of Milk and Newspapers. Bye-laws have been made by the Education Committee governing the hours of employment, and every School child seeking employment is obliged to obtain from the School Medical Officer a certificate to the effect that such employment will not be prejudicial to his health or physical development and will not render him unfit to obtain proper benefit from his Education. During the year the following 57 Certificates were issued:— Delivering Newspapers 36 Delivering Milk 11 Miscellaneous, Errands, etc 10 The Juvenile Employment Committee are supplied with the Medical records of children leaving School, and the physical condition of the child is taken into consideration when recommending him for employment. MEDICAL INSPECTION RETURNS. TABLE 1 RETURN OF MEDILAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections:— Entrants 517 Intermediates 217 Leavers 330 Total 1064 Number of other Routine Inspections Nil. B.—Other Inspections. Number of Special Inspections 574 Number of Re-Inspections 553 Total 1127 93 TABLE II. A.—Return of Defects found by Medical Inspection in the Year ended 31st December, 1925. Defect or Disease. Routine Inspections. Special Inspections. So. of Defects. No. of Defects. Requiring Treatment. Requiring to be kept under observation, but not re quiring treatment. Requiring Treatment. Requiring to be kept under observation, but not requiring treatment. 1 2 3 4 5 Malnutrition 18 9 13 1 U ncleanliness— 53 ... ... ... Skin— Ringworm (Scalp) ... ... ... ... (Body) ... ... ... ... Scabies ... ... ... ... Impetigo 7 ... 10 ... Other Diseases (Non-Tuberculous) 1 3 36 5 Eve- Blepharitis 12 ... 1 ... Conjunctivitis 4 ... 5 ... Keratitis ... ... ... ... Corneal Opacities 2 ... ... ... Defective Vision (excluding Squint) 35 43 9 ... Souint 2 17 ... ... Other Conditions ... ... 6 1 Ear- Defective Hearing 4 4 3 4 Otitis Media 7 5 20 1 Other Ear Diseases ... ... ... 2 Nose and Throat— Enlarged Tonsils only 29 67 22 11 Adenoids only 1 3 8 2 Enlarged Tonsils and Adenoids 5 ... 6 5 Other Conditions 8 4 51 2 Enlgd.Cervical Glands(Non-Tiiberculous) 1 5 8 9 Defective Speech 2 9 1 ... Teeth—Dental Diseases 105 ... ... ... Heart and Circulation— Heart Disease (Organic) ... 2 ... 5 (Functional) ... 22 ... 5 Ansemia 4 ... 4 ... Lungs— Bronchitis 14 3 20 ... Other Non-Tuberculous Diseases 3 2 29 5 Tuberculosis— Pulmonary (Definite) ... ... ... ... (Suspected) ... ... 9 ... Non-Pulmonary (Glands) 2 1 7 2 (Spine) ... ... 1 ... (Hip) ... ... 2 ... Other Bones and Joints ... ... ... ... Skin 1 ... ... ... Other Forms ... 2 2 ... Nervous System— Epilepsy ... 1 ... ... Chorea ... 2 5 ... Other Conditions ... 6 5 ... Deformities— Rickets ... 1 ... ... Spinal Curvature 1 ... ... ... Other Forms 26 5 3 5 Other Defects and Diseases 10 14 156 46 94 B.—Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). GROUP. Number of Children. Percentage of Children found to require Treatment. Inspected. Found to require Treatment. 1 2 3 4 Code Groups:— Entran ts 617 59 11.41 Intermediates 217 60 27.64 Leavers 330 31 9.39 Total (Code Groups) 1064 150 14.09 Other Routine Inspections - - - 95 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. - — - Boys. Girls. T otal. Blind (including partially blind). (i) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind ... 1 1 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... (ii) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind ... ... ... Attending Public Elementary Schools ... ... ... At other Intitutions ... ... ... At no School or Institution ... ... ... Deaf (including Deaf and Dumb and partially deaf). (i) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf ... 1 1 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... (ii) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf ... ... ... Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Mentally Defective. Feebleminded (cases not notifiable to the Local Control Authority). Attending Certified Schools for Mentally Defective Children 7 7 14 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Notified to the Local Control Authority, during the year. Feebleminded 1 ... 1 Imbeciles 1 1 2 Idiots ... 1 1 Epileptics. Suffering from severe epilepsy. Attending Certified Schools for Epileptics ... ... ... In Institutions other than Certified Schools ... ... ... Attending Public Elementary Schools ... ... ... At no School or Institution ... ... ... Suffering from epilepsy which is not severe. Attending Public Elementary Schools ... 1 1 At no School or Institution ... ... ... 96 TABLE III.—(continued). — — - Boys. Girls. Total. Infectious pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministryof Health or the Board ... ... ... At other Institutions 1 ... 1 At no School or Institution 1 ... 1 Non - infectious but active pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministryof Health or the Board ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 3 6 9 At other Institutions ... ... ... At no School or Institution ... ... ... Physically Defective Delicate children (e.g., pre-or latenttuberculosis, malnutrition, debility, ameinia, etc.). At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 64 37 101 At other Institutions ... ... ... At no School or Institution ... ... ... Active non-pulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board ... ... ... At Public Elementary Schools 3 2 5 At other Institutions ... ... ... At no School or Institution 1 ... 1 Crippled children (other than those with activetuberculous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease. At Certified Hospital Schools ... ... ... At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... ... ... At Public Elementary Schools 16 13 29 At other Institutions ... ... ... At no School or Institution ... 1 ... 97 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1925. Treatment Table. Group I.—Minor Ailments (excluding Uncleanliness, for which sec Group V). Disease or Defect. Number of defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. 1 2 3 4 Skin— Ringworm—Scalp ... ... ... Ringworm—Body ... ... ... Scabies 2 ... 2 Impetigo 126 ... 126 Other skin disease Minor Eve Deffects (external and other, but excluding cases falling in Group II.) 61 79 ... 61 79 Minor Ear Defects 99 ... 99 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 214 ... 214 Total 581 581 Group II.— Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments- Group I.). No. of Defects dealt with. Defect or Disease. Under the Authority's Scheme. Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) (5) Errors of Refraction (including Squint) (Operations for Squint should be recorded separately in the body of the Report). 172 5 ... 177 Other Defect or Disease of the Eyes (excluding those recorded in Group I.). 8 1 ... 9 Total 180 6 ... 186 98 Total number of children for whom spectacles were prescribed. (a) Under the Authority's Scheme 129 (b) Otherwise 5 Total number of children who obtained or received spectacles. (a) Under the Authority's Scheme 126 (b) Otherwise 5 Group III. -Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Received other Forms of Treatment Total Number Treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. 1 2 3 4 5 33 10 43 57 100 99 Group IV.— Dental Defects. (1) Number of Children who were :— (a) Inspected hv the Dentist: Routine Age Groups. Aged: 5 401 6 324 7 352 8 371 9 338 10 325 11 362 12 279 13 294 114 99 Total, 3,145 Specials 46 Grand Total 3,191 (b) Found to require treatment (c) Actually treated (</) Re-treated during the year as the result of periodical examination 2,377 1,790 873 (2) Half-days devoted to :— Inspection 35 Treatment 364 Total 399 (3) Attendances made by dren for treatment 2,806 (4) Fillings :— Permanent teeth 1,500 Temporary teeth 942 Total 2,442 (5) Extractions:— Permanent teeth 177 Temporary teeth 1,640 Total 1,817 (6) Administrations of general anaesthetics for extractions 158 (7) Other operations :— Permanent teeth 749 Temporary teeth 374 Total 1,123 Group V.—Uncleanliness and Verminous Conditions. (i.) Average number of visits per school made during the year by the School Nurses 28 (ii.) Total number of examinations of children in the Schools by School Nurses 11579 (iii.) Number of individual children found unclean 229 (iv.) Number of children cleansed under arrangements made by the Local Education Authority — (v.) Number of cases in which legal proceedings were taken: — (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-Laws 1 INDEX. page. Acts of Parliament, Orders, Circulars, and Regulations: — List of Acts and Bye-Laws in force in the District 18 Milk and Cream Regulations, 1912 and 1917 38 Milk and Dairies (Consolidation) Act, 1915 34 Milk (Special Designations) Order, 19215 34 Premises controlled by Bye-Laws and Regulations 25-27 Provisional Proposals re Poor Law Reform 7 Public Health Act, 1925 7, 52 Public Health (Meat Regulations), 1924 35-37 Public Health (Prevention of Tuberculosis) Regulations, 1925 7, 52 Sale of Food and Drugs Acts 37-38 Tuberculosis Order No. 1, 1925 7, 53 Analysis of Mortality Table 62 Ambulance Facilities 15 Bacteriological Reports :— Certified Milk 35 Pasteurised Milk 35 Bakehouses 26 Births : — Notified 4 Rate 4 Census Figures—Extract from 10 Cesspools 21 Clinics and Treatment Centres 16 Cowsheds 25 Death Rates 4 Fried Fish Shops 26 Food:— Inspection of 33 Typhoid Fever from 47 Unsound 37 Fumigation of Rooms 28 Health Visitors' Report 59 ii. PAGE. Hospitals:— Isolation 40 Provision of in District 13-14 Treatment of Children at 14 Housing:— Inspection 24 Shortage of Accommodation and Overcrowding 28-33 Statistical Tables re 31 Ice-Cream Shops—Inspection of 27 Infantile Mortality—Causes of 58 Infectious Diseases 39-54 Institutions for Unmarried Mothers and Homeless Children 15 Laboratory Work 30 Maternity and Child Welfare: Attendance at Centre 59 Dental Report 56 Infantile Mortality 58, 60 Provision of Milk Foods 55, 56 Maternity Home 61 Medical Inspection of School Children :— Blind, Deaf, and Epileptic Children 89, 90 Clinics: — Dental 80-82 Eye 80 Inspection 79 Morning Treatment 78-79 Co-ordination with other Services 66 67 Co-ordination of:— Parents 87 School Attendance Officers 88 Teachers 87 Voluntary Bodies 88 Deformities 76 Diseases of:— Ear 72 Eye 71 Heart and Circulation 73 Malnutrition 69, 70 Nervous System 76 iii. PAGE. Medical Inspection of School Children (contd.) : — Diseases of (contd.) : — Nose and Throat 73, 83 Skin 70 Tuberculosis 74-75 Employment of Children 92 Evening Play Centre 86-87 Exclusion from School 88 . Infectious Diseases 77 Mentally Defectives:— School for 90, 92 Provision of Meals for 91 Open-Air Education 83 Parkstone Home 82-83 Physical Ti-aining 84 Provision of Meals at:— Central School 85 Special School 91 Routine Inspections, 1925 68, 69 Statistics relating to Education 66 School Baths and Swimming 86 School Hygiene 67, 68 Staff engaged in School Medical Service 66 Tables showing:— Defects found at Routine Inspections 93 Number of Children Inspected 92 Number of Exceptional Children in Area 95 Summary of Treatment of Defects 97 Treatment of Defects of Nose and Throat 98 Treatment of Dental Defects 99 Treatment of Minor Ailments 97 Treatment of Visual Defects 97 Uncleanliness 99 Meteorological Table 9 Midwives 17 Milk: — Analysis of Samples of 38 Milkshops—Inspection of 25 Supply 33 i'v. PAGE. Milk (contd.) :— Certified and Pasteurised 34-35 Natural and Social Conditions 8 Notifiable Diseases 48 Nursing Arrangements 16-17 Overcrowding 30-31 Poor Law Reform 7-8 Population and Density 9-10 Provision of Free Millc, etc 55-58 Rivers and Streams—Polution of 21-22 Sa'le of Food and Drugs Acts—Samples taken under 37-38 Sanitary Inspection of the District 24-28 Scavenging and Cleansing 23 Sewerage and Drainage 20 Sewage Farm—Croydon Borough Council 22-23 Smoke Abatement 25 Stables—Inspection of 27 Slaughterhouses—Inspection of 26 Statistical Tables showing: — Analysis of Samples 35, 38, 39 Causes of Deaths 62 Diphtheria—Number of Cases 45 Contact Cases 46 Disinfection of Rooms 28 Infantile Mortality 60 Hospital Isolation 40 Housing 31-33 Notifiable Diseases 48 Nuisances 24 Principal Occupations 11 Scarlet Fever—Number of Cases 43 Return Cases 42 Tuberculosis—Notifications 51 Deaths 51 Incidence 54 Summary of Vital Statistics 4 Unsound Food—Seizure of 37 Venereal Disease16 Water Supply 19 The Sydenham Press, 23, By denham Road, S.E. 96.