ERI 010 Urban District of Erith. I ANNUAL REPORT of the Medical Officer of Health and School Medical Officer, For the Year 1919, by A. E. JERMAN, M B., D.P.H. Public Health Committee, 1919. Chairman—Councillor A. U. Fletcher. Councillor Bayley. Councillor Salmon. „ Ling. „ Watson. ,, Reeves. ,, Wilson. Maternity & Child Welfare Committee, 1919. Chairman—Councillor Wilson. Councillor Clark. Councillor Martin. „ Fletcher. „ Palmer. „ Gough. ,, Reeves. ,, Hampton. Co-opted Members. Lady Callender. Mrs. Reeves. Mrs. Humphries. Nurse Robinson. Education Committee, 1919. Chairman—Councillor Martin. Councillor Button. Councillor Holland. Clark. ,, Kibblewhite. ,, Fletcher. „ Matthews. ,, Gough. „ Reeves. Co-opted Members. Mrs. Flack. Mr. Charlesworth. ,, Matthews. „ Dyer. Mr. Ayling. „ Weeks. STAFF. Medical Officer of Health, School Medical Officer, and Medical Officer in charge of Sanatorium for Infectious Diseases— A. E. Jerman, M.B., D.P.H. Assistant School Medical Officer— J. Hardie, M.B., C.M. Lady Medical Officer of Infant Welfare Centres and Antenatal Clinic— Dr. J. Lorimer Hawthorne. Inspector of Nuisances— D. B. Davies, C.R. San. Inst. Assistant Sanitary Inspector—T. Vaughan, C.R. San. Inst. Health Visitors— Nurse Cruise. ,, Crouch. School Nurse— Nurse Lange. Clerks— Maternity & Child Welfare Dept.—Miss C. Vaughan. School Medical Service—Miss Hardie. Dental Surgeon—R. A. Presslie, L.D.S. Ophthalmic Surgeon—A. E. Reynolds, M.R.C.S, Etc. 5 Council Offices, Erith. April 20th, 1920. To the Chairman and Members of the Urban District Council of Erith. Gentlemen, I have the honour to submit to you my Annual Report for the year 1919, in accordance with the Regulations of the Ministry of Health. As you are aware I was absent on Military Service for 4½ years from August, 1914, and I resumed my appointment as your Medical Officer of Health and School Medical Officer at the beginning of February, 1919, after demobilisation. I have to thank the Council for keeping my appointment vacant for me during my absence. I found that there had been considerable development in various directions in the work of my department. The Maternity and Child Welfare work had increased very much. The Notification of Births Act had only been put in force in the district for 4 months when I was called up for Military Service in 1914, and there was only one Health Visitor employed, and she devoted part of her time to the duties of School Nurse. On my return 1 found that two Welfare Centres, and an antenatal clinic were in full working order, and the staff employed on them was a part time Lady Medical Officer, two Health Visitors and a clerk. In the School Medical service a similar expansion had taken place. Your School Clinic, with departments for minor Ailments, Dental and Ophthalmic work, was being carried on by the Acting School Medical Officer, Dr. J. Hardie, with a whole time School Nurse and a records clerk. 6 Soon after my return you decided that the School Medical service was sufficiently developed to require the services of a whole time Assistant School Medical Officer, and in July Dr. Hardie was appointed to that post taking up his duties on October 1st. Before that he had been acting as part time Assistant School Medical Officer since my resumption of my post. Such developments as have taken place during the past year are referred to in the Report. The report of the School Medical work of the year is principally the work of Dr. Hardie. I am Gentlemen, Your obedient Servant, A. E. JERMAN. 7 Annual Report for 1919. A.—Natural and Social Conditions of the District. Population. At the Census of 1911 the population was found to be 27,750. made up of 14,143 males and 13,607 females. The number of inhabited buildings was 5,129 and the number of separate occupiers 5,897. The average number of persons per inhabited building was 5.41 as compared with 4.85 for all Urban Districts (excluding London and the County Boroughs), and 5.05 for the whole of England and Wales. During the years of the war, the district was a munition area, and the population was much increased by the influx of workmen and women. Several large houses and institutions were taken over as Hostels for the workpeople, and in addition 4 large hostels were formed by the erection of temporary buildings and huts. The population was estimated to be 35,232 in 1915 by the Registrar General, but has now diminished owing to the cessation of war work, and at present is estimated at 30,525 by the Registrar General for the Death rate, and at 31,798 for the Birth rate. The district is almost entirely industrial, and the large majority of the population is employed in the factories in the district, the principal ones being engaged in cable making, gun making, oil refining, manufacture of mining and other machinery, and of asbestos and cement slabs. Physical Features and General Character of the District. The district of Erith is about 3,859 acres in extent, and is situated on the South side of the River Thames immediately adjacent to the County of London which 8 forms the western boundary ; it has a river frontage of about 4½ miles, and the northern portion of the distuct which lies along the river is about 1,689 acres in extent, and consists of marsh land, the level varying generally between 3 and 7 feet above ordnance datum, and being below that of high water in the river. The southern part of the district rises gradually to about 200 feet above sea level. B.—Sanitary circumstances of the District. (1) Water Supply. This is obtained from the Metropolitan Water Board. The water is very hard, but of good quality, and the supply is ample (2) Drainage and Sewerage. The main portion of the sewage of the district is carried by a sewer which was completed and opened in 1898. This sewer consists of two portions, one taking sewage from the low-lying areas and running from the western boundary near Abbey Wood Railway Station to Erith, and the other draining the upper part of Belvedere and Northumberland Heath. The first mentioned portion is worked by the Shone Pneumatic System, ejectors being situated about every half-mile throughout its length, and worked by compressed air from the Outfall Works at Anchor Bay. No ejectors are required on the second portion, as there is a very good fall throughout the whole length of the sewer. The Sewage Outfall Works is situated at Anchor Bay at the eastern end of the district, and after treatment by septic tanks, aeration beds and percolating filters, the effluent is discharged into the River Thames. There are 6 percolating filters with revolving distributors. The plant at the Outfall Works consists of:— 1 50 h.p. gas engine working air compressor. 9 2 45 h.p. motor electrically driven air compressors. 2 6m. and 1 4in. electrically driven centrifugal pumps for lifting effluent from the septic tank to the filters, and " Pressure gas " producing plant in duplicate for working the gas engine. The effluent is discharged at low tides into the River Thames; the sludge left is placed in sludge lagoons of which there are five, and allowed to dry. It is then dug out and carted away for use by farmers and allotment holders, The Port of London Authority periodically takes samples of the effluent from these works for analysis, but for many years past there has been no complaint made as to the character of the effluent discharged into the River Thames. There are now very few houses left connected to the old brick sewer which discharges on the foreshore of the river, and the sewer is mainly used for surface water drainage. Houses built on the Marsh in the neighbourhood of Belvedere Station are provided with cesspools as no sewer is available for their drainage. These cesspools have been a source of trouble and nuisance since they were built, as they cannot be made watertight and fill up with subsoil water as soon as they are emptied, and in addition during winter and wet weather the marsh land is in such a condition as to render it very difficult and sometimes impossible for the cesspool emptying vans to reach the places where the cesspool matter may be deposited. No houses have been built on the Marshes for some years past, and none should be built until some scheme for the proper drainage and sewerage of that area has been inaugurated. (3) Closet Accommodation. Nearly every house in the district is provided with a water closet. 10 There are no privy middens, and only eight houses with earth closets. Some of the larger Factories situated on the Marshes have a system of earth closets as have most of the smaller ones. (4) Scavenging. Before the war all house refuse was collected by the Council twice a week from movable sanitary dustbins, but during the war the difficulty of obtaining labour, and the necessary horses and vehicles obliged the Council to restrict the collection to once a week. The collected refuse is deposited on various shoots on the Marshes, but the advisability of some other method of disposal is at present under consideration. During 1919 the number of loads of house refuse removed was 6,321 as compared with 6,225 in 1918. Before the war when in the course of inspection a house was found to be without a proper sanitary bustbin notice was served on the owner to provide the same. This procedure has been in abeyance for the past 4 years, but is being resumed again during the coming year. (5) Sanitary Inspections of the District. The following tables have been prepared by the Inspector of Nuisances, and summarise the work done during the year:— Inspections made during the year. Houses visited for the detection of nuisances 627 Houses inspected under the Housing and Town Planning Act 457 Slaughterhouses 123 Cowsheds, Dairies and Milkshops 33 Workshops 54 Outworkers'premises 5 Bakehouses 31 Offensive Trades 25 Vans, Tents and Sheds 78 Complaints enquired into 139 11 Result of above Inspections. Nuisances detected 540 Preliminary notices served to abate nuisances 257 Statutory notices served to abate nuisances 56 Nuisances abated 461 Notices issued in respect of vans, tents and sheds 21 Notices complied with 21 Notices issued under the Dairies, Cowsheds and Milkshops Order 1 Notices complied with 1 Notices issued under the Factory & Workshops Act 6 Notices complied with 6 Notices issued under Section 36 P.H. Act 1875 1 Notices complied with 1 Number of prosecutions nil Nuisances. Showing the number and nature of the nuisances dealt with during the year:— Defective and choked drains 243 Damp and dilapidated dwellings 102 Defective rainwater guttering and downpipes 67 Insanitary water cisterns 21 Defective scullery sinks 29 Defective flush to w.c.'s 32 Insanitary urinals 3 Foul accumulations 18 Dirty premises 12 Overcrowding 1 Animals, &c., so kept as to be a nuisance 12 540 Cleansing. Number of cesspools emptied 417 Number of loads of house refuse removed 6321 12 Food Inspection. The following articles of food were surrended to me as unfit for human consumption :— Fish. Meat. Other Articles. 3 boxes of Cod. 121bs. of Mutton. 11 boxes of Dates. 2 boxes of Roes. 211bs. of Yeal. 2 boxes of Currants. 5 boxes of Mackerel. 241bs. of I iamb. 1 box of Butter. 2 boxes of Bream. 4 boxes of Livers. 1 tin of Salmon. 6 boxes of Haddocks. 125lbs. of Bacon. 1 bushel of Pears. 1 box of Hake. 2 boxes of Frozen Rabbits. 361bs. of Plums' 1 box of Herrings. Infectious Disease. Number of cases enquired into 536 Number of cases removed to Sanatorium 97 Number of houses disinfected 125 (6) Premises and Occupations which can be controlled by Bye-laws and Regulations. Tents, Vans and Tents. There are a number of vans and sheds situated on the Marshes at Abbey Wood which are permanently occupied by persons carrying on the Trade of Hawkers. During the period of the war the number has been materially augmented by the arrival of men who went to work in the local munition factories, or at the Woolwich Arsenal. These have in several cases remained although the men no longer work in the factories, and there are now probably twice as many vansand inmates as in 1913. The condition of some of the vans and the ground about is good, in other cases they are extremely dirty, and the ground all round the vans is sodden with slop water. The Council's Bye-laws require the owner of the ground on which the vans stand to provide a proper and sufficient water supply and an earth closet, but many of these vans stand on plots of land sold years ago, and all trace of the owner is lost. 13 The water supply is usually a pipe sunk 25 to 30 feet into the marsh with a pump for raising the water. In former years samples of the water have been examined on many occasions, and these have in a number of cases been found to be unfit for drinking. Where this was so proceedings have been taken to close the pump successfully. Some of the people living in these sheds have been there well over 20 years, and can be regarded as permanent residents. In the great majority of these cases the man owns the plot on which his van or shed stands, and they are clean, and properly looked after. . In the cases where the people are nomadic, and only remain a few days or weeks at most, they are very careless of their surroundings and very dirty, but it is difficult to take any action in these cases as before any notice can expire they have left the district. Factories, Offensive Trades. In 1911 Section 51 of the Public Health Acts Amendment Act 1907 was adopted in the district, and in July, 1912, the Council made an order declating each of the following trades and businesses to be an Offensive Trade :—Blood Drier, Tanner, Leather Dresser, Fat Melter or Fat Extractor, Glue Maker, Size Maker, Gut Scraper, Fish Frier, Manufacturer of Manure from fish, fish offal, blood or other putrescible animal mattter, and the manufacture of animal charcoal. The Bye-laws regulating the carrying on of these trades were revised, and afterwards received the consent of the Local Government Board ; these are now in force in the district. The trades of this description at present carried on in the district are:—Fish Frier, Fat Extractor, and the Manufacture of Manure from fish and fish offal. The various premises at which these trades are carried on have been periodically inspected during the year and found in fairly satisfactory condition. 14 (7) Schools. The sanitary conditions of the schools in the district are good. The water supply is obtained from the Metropolitan Water Board. During the early part of the year there was a small epidemic of measles, but very little other infectious disease. At the close of the year there were also a good many cases of mumps of a very mild type. No schools were closed during the year. Classes from which children were away ill with notifiable infectious disease were examined on numerous occasions with a view of detecting " missed " cases, but none were found. There was no special incidence of disease in any particular school during the year with the exception of the cases of mumps which were chiefly confined to one school. The other diseases were spread about among the schools generally. Food. (1) Milk Supply. There are 5 cowsheds in the occupation of 5 cowkeepers, and 21 dairymen and purveyors of milk in the district, and about 70 cows. The cows are periodically inspected by the Veterinary Surgeon appointed by the Council, and a report on their condition is furnished quarterly. During 1919 no case of Tuberculosis was detected. The cowsheds and milkshops are inspected regularly, and on the whole have been found in satisfactory condition. There was some shortage of supply during the year, but during the Railway Strike one of the dairymen utilised a motor lorry for the collection of milk from farmers in Kent, and the shortage at that time was much less than in many other districts. 15 Samples of the milk sold in the district were taken by the Inspector of the Kent County Council, and out of '24 so taken all were found to be genuine. Twenty-four samples during the year appears to be a totally inadequate number for a district such as this, and it is to be hoped that now the war is over, the prewar number at least will be taken. (2) Milk (Mothers and Children) Order, 1918. When this Order was issued, the Council laid down a scale as follows:— tl) Where the family income was seven shillings per head per week or less milk was granted free of cost to the applicant. (2) Where the income exceeded 7s., but was not more than 7s. 6d. per head per week milk was granted 75% of the cost being paid by the Council. (3) Up to 8s. per head per week milk was granted, the Council paying 50% of the cost. Above 8s. no assistance was given. This scale was in force throughout 1919. The case of each applicant was investigated and considered by the Committee, and where assistance was granted the necessary order was issued to the milk purveyor. Before each Committee meeting each person to whom assistance was given was visited and enquiries made as to any change in the circumstances of the family, and the assistance continued or otherwise in accordance with the result of the enquiries. Thirteen families were assisted under this scale up to September. On the outbreak of the strike of moulders the number of applications for assistance to the families of men on strike, and of those who were in consequence thrown out of work or put on short time, was much increased, and during the latter 3 months of the year an additional 58 families were assisted in the provision of milk. 16 (3) Slaughter Houses. There are two slaughter-houses on the Register, but during the period of food control only one was in use. The owner was called on to carry out certain alterations and repairs to render it more suitable for its purpose, and these were carried oat. Inspections have been made both at times of . slaughtering and other times, but no tuberculous meat was discovered during the year. (4) Bakehouse. There are 11 Bakehouses in the district, none of them underground. These have been kept under regular inspection, and have been found clean and satisfactory with four exceptions ; in 3 cases limewashing was required, and in one case the floor required repair. (6) Other Foods, Other premises where food is prepared, stored or exposed for sale have been kept under observation during the year, and were found on the whole satisfactory. A number of complaints were received as to the quality of the bacon supplied at ope period. These were all investigated, and it was found that while the bacon was not in such a condition as to require condemnation as unfit for human consumption, it was nevertheless preserved in such a manner as to render the flavour most unappetising if not positively nauseous. Some consignments of Rabbits and Fish were surrendered by the vendors to the Inspector of Nuisances as unfit for human consumption, and a full list of food so surrendered is given in the summary of his work (on page 12). (5) Sale of Foods and Drugs Acts. The Local Authority for the administration of these Acts is the Kent County Council. 17 I have obtained from the Clerk to the County Council a return showing the number of samples taken in this district during 1919, with the result of the examination of the samples, and any subsequent action taken in connection therewith. The return shows that 144 samples were taken, of these 133 were genuine, and 11 adulterated. In 2 cases margarine was sold without properly labelled wrappers. In one case coffee contained at least 15% of chicory, and the seller was cautioned only as the packet was properly labelled, in the remaining 8 cases the samples were of various spirits, and in each case the vendor was prosecuted and fined £50 and £75 with costs. Table showing number and description of samples taken during 1919. 18 Article. Number of Samples taken. Number Genuine. Number Adulterated Remarks. Milk 24 24 Batter 11 11 Margarine 16 14 2 Unlabel led Wrappers. Cautioned. Coffee 15 14 1 15 per cent. Chicory. Cautioned. Cocoa 5 5 Ground Rice 3 3 Flour 3 3 Mustard 8 8 Lard 14 14 Baking Powder 5 5 Pepper 7 7 Olive Oil 1 1 Salmon and Shrimp Paste 1 1 Potted Meat 1 1 Jam 2 2 Ground Ginger 2 2 Tartaric Acid 1 1 Cream of Tartar 1 1 Arrowroot 2 2 Ground Cinnamon 1 1 Dripping 1 1 Malt Vinegar 1 1 Scotch Whisky 5 4 1 1 Scotch Whisky 28.24 u.p. sold in public bar at Is. instead of 7¼d. Fined £75 and costs £5 5s. Od. Irish Whisky 1 1 1 Irish Whisky 36.9 u psold in public bar for Is. instead of 6fd. Fined £75 and costs £5 5s Od. Gin 5 2 3 1 Gin sold in public bar for lOd. instead of 83/4d. Fined £50 and costs £5 5s. Od.of 2 samples of Gin and 3 Rum 6 3 3 Rum were also the cause of proceedings, but cases were withdrawn on payment of costs. Brandy 2 2 Totals 144 133 11 19 (7) Workshops, Workplaces, &c. There are 95 Workshops and Workplaces on the Register, which is required to be kept by the Local Authority, but of these a number are "Domestic" Workshops where only members of the family are employed. These have all been inspected during the year, and notices were served in 6 cases. These were all complied with. Five lists of "Outworkers" were received from other Local Authorities, but none from employers in the district. The premises occupied by these outworkers were inspected and found satisfactory. C.—Prevalence of and Control over Infectious Diseases. There were 536 cases of Infectious Disease notified during 1919, viz.: Measles 236, Pulmonary Tuberculosis 86, other forms of Tuberculosis 36, Scarlet Fever 74, Diphtheria 31, Erysipelas 9, Enteric Fever 2, Puerperal Fever 2, Ophthalmia Neonatorum 9, Pneumonia and Influenzal Pneumonia) 43, Malaria 6, Acute Poliomyelitis 1, and Cerebro Spinal Fever 1, Comparative returns of Infectious Diseases notified during past 10 years (not including Tuberculosis) :— Disease. 1910 1911 1912 1913 1914 1915 19161917 1918 1919 Diphtheria :32 35 42 38 86 105 118 55 20 31 Measles Not No tifia ble. 131 616 207 236 German Measles Erysipelas 20 19 21 11 7 21 15 13 4 9 Scarlet Fever 129 99 68 115 307 231 182 35 68 74 Enteric Fever 3 5 7 10 22 3 4 7 3 2 Continued Fever 1 Puerperal Fever 1 2 2 2 1 2 1 2 Ophthalmia Neonatorum 4 5 4 9 Poliomyelitis 1 1 1 Cerebro Spinal Fever 1 4 1 Malaria Not No tifia ble. 6 Pneumonia & Inrtuenzal Pneumonia Not No tifia ble. 43 185 159 141 176 425 366 454 733 307 414 20 Scarlet Fever. There were 74 cases of Scarlet Fever notified during 1919 as compared with 68 in 1918. Of these 47 were children between 5 and 15 years of age, and 14 children under 5. Thirteen cases occurred in persons over the age of 15. The majority of the cases occurred during the last 3 months of the year, 16 children of school age suffering from the disease during the first nine months, and 31 during the last 3 months. There was no special incidence on any school the largest number being 11 cases from one school during the year (including Boys', Girls' and Infants' Departments). Classes were inspected on many occasions where a case of Scarlet Fever had occurred in that class, but no cases causing any suspicion were detected. On 3 or 4 occasions, however, children attending the school clinic were found to have a rash, or to be desquamating. The number of houses affected by the disease was 63 ; in 6 houses there were 2 cases, in 1 house 3, and in 1 house 4. The attack rate for the disease was 2.02 per 1,000 population, and there were no deaths from the disease. Sixty-six of the cases were removed to hospital for treatment a percentage of 89 2. There were no return cases. Two cases occurred in children who had been patients in a London Hospital for at least 7 weeks. Diphtheria. There were 31 cases of Diphtheria notified during 1919 as compared with 20 in 1918. Of these 18 occurred in children of school age, and 10 in children under 5. 21 One case was a child who showed no symptoms beyond a slight nasal discharge, he was a contact with others admitted to the Sanatorium, as suffering from Scarlet Fever, and who were found after admission to be carrying the Diphtheria Bacillus though not showing any clinical signs or symptoms. The number of houses affected was '2(6), and in 5 houses two cases occurred. The attack rate of the disease was 1.01 per 1,000, and there were 5 deaths, giving a case mortality of 16.1 per cent. Thirty of the cases were removed to the Sanatorium for treatment, a percentage of 97. The remaining case was too ill to be removed and died at home. No return cases occurred. Table showing the number of cases of Scarlet Fever and Diphtheria in any particular school in 1919. School. Scarlet Fever. Diphtheria. Brook Street 9 7 West Street 4 5 Crescent Road 2 — Manor Road 2 — St. Augustine's Road 11 1 All Saints' 4 1 Picardy 8 — Central — 1 St. Fidelis 2 — Belvedere Boys 1 1 County Ac- 3 — Private 2 3 Not at any School 26 12 74 31 Enteric Fever. Two cases of this disease occurred during the year. Both were removed to Hospital and both recovered. It was not possible to trace where the infection came from ; the only suggestion is that they contracted it playing on the river bank, and in one case bathing in the River Thames. The attack rate was .06 per 1,000. Measles. This was prevalent during the early part of the year ; 236 cases were notified, and of these 221 occurred during the first six months, only 15 occurring from July to December; 145 cases occurred in children of school age, and 84 in children below that age. Five children died from Measles a case mortality of 2.11 per cent. One case was removed to Hospital for treatment. In 29 cases notification was received only from the parents of the children ; all other cases were notified by medical men. Whooping Cough. There was little or no whooping cough in the district before the end of the year when a few cases were heard of through the Health Visitors and medical men. Influenza. This disease had been very prevalent and fatal in the latter part of 1918 when 69 deaths were recorded during October, November and December. During the early months of 1919 another wave of infection swept over the district, but this was much less severe and fatal. Twenty-eight cases of Influenzal Pneumonia were notified during March and April, but none after that. Seventeen deaths occurred, one in January, 4 in February, 8 in March, and 4 in April. In 3 cases the disease was the cause of Bronchon-peumonia, in 1 Appendicitis, in 1 Diarrhoea and Vomiting, in 9 Pneumonia, and in two it caused heart failure. 23 Deaths occurred at the following ages:— Under 1 1-5 5—15 15—25 25—45 45—65 Over 65 Males - 2 1 — 4 1 3 Females - — 3 1 2 — — Total — 2 4 1 6 1 3 Ophthalmia Neonatorum. Nine cases of This disease were notified during 1919 as compared with 4 in 1918. The cases were kept under observation by the Health Visitors, and in no case was there any permanent injury to vision. Malaria. Six cases were notified to be suffering from Malaria. These were all demobilized soldiers, and the disease had been contracted with the Expeditionary Force. No case of Malaria contracted in the district occurred. Poliomyelitis. One case occurred in a child between 1 and 5 years of age. It was a very mild case notified from a London Hospital, and the sequel was slight facial paresis which was recovering well under treatment. Cerebro-Spinal Fever. One case occurred in a boy, this was sent to Hospital and a good recovery was made. No source of infection could be discovered. Another case was sent to Hospital as a case of cerebro spinal fever, but it was found post mortem to be a case of acute miliary tuberculosis. Tuberculosis. The number of notifications of fresh cases of Tuberculosis during 1919 was 122, viz.:—86 pulmonary and 36 of other forms, as compared with 73 and 86 in 1918 and 1917 respectively. The following table shows the number of cases of Tuberculosis notified each year since 1913 when notification was made compulsory. 24  1913 1914 1915 1916 1917 1918 1919 Pulmonary 63 52 45 50 69 58 86 Other forms of Tuberculosis 17 10 11 9 17 15 36 Total 80 63 56 59 86 73 122 The age and sex distribution of the cases notified is shown in the following tables:— Pulmonary Tuberculosis. 0-1 1-5 1 5—15 15—25 25—45 45—65 Over 65 Total Males - 1 6 13 22 5 47 Females - 6 12 19 1 1 39 Total - 1 12 25 41 6 1 86 Other Forms of Tuberculosis. I 0-1 1—5 5—15 15-25 25-45 45-65 Over 65 Total Glands M. 2 9 1 12 F. 1 8 1 10 Abdomen M. F. 1 1 2 Bones M. 2 1 3 F. 2 1 1 4 Other M. 1 1 1 3 F. 1 1 2 Totals 1 6 22 3 3 1 36 The number of deaths from Tuberculosis during 1919 was 40 as compared with 51 during 1918, and an average of 40.5 during the past 6 years. Of these 32 were due to Pulmonary Tuberculosis, and 8 to other forms of Tuberculosis. The death rate from all forms of Tuberculosis was 1.31 per 1,000 as compared with 1.58 in 1918 while that from the pulmonary form was 1.04 per 1,000 as compared with 1.25 in 1918. On page 25 I give a table showing the deaths from Tuberculosis classified according to age and sex during the past 6 years. 1914 MALES. FEMALES. Total M. & F. all Ages. 0-1 1—2 2—5 5-15 15—25 25—45 45—65 Ov. 65 Total all Ages. 0—1 1—2 2—5 1 5- 15 15—25 25—45 45—65 Ov. 65 Total all Ages. Phthisis 2 9 5 16 1 6 7 3 17 33 Tab. Meningitis 1 1 1 1 2 3 Other Tub. Diseases 1 1 2 1 i 2 4 1 1 1 2 9 5 19 2 1 2 6 7 3 21 40 1915 Phthisis 4 8 1 13 1 2 3 6 1 13 26 Tub. Meningitis 2 1 3 3 Other Tub. Diseases 1 1 1 1 4 4 4 8 1 13 1 2 2 4 4 1 20 33 1916 Phthisis 1 7 7 i 16 1 1 2 5 1 10 26 Tub. Meningitis 2 1 1 1 5 1 1 1 3 8 Other Tub. Diseases 1 2 3 3 2 1 1 1 8 7 1 21 1 3 3 1 2 5 1 37 37 1917 Phthisis 7 6 3 1 17 2 7 4 3 1 17 34 Tub. Meningitis 1 2 1 4 1 1 5 Other Tub. Diseases 1 1 1 3 3 1 1 9 8 4 1 24 1 2 7 4 3 1 18 42 1918 Phthisis 3 3 11 4 21 1 7 12 20 41 Tub. Meningitis 1 1 1 3 1 1 2 5 Other Tub. Diseases 3 3 1 1 5 3 1 4 4 11 4 27 1 2 8 13 24 51 1919 Phthisis 1 1 3 5 10 1 21 1 4 5 1 11 32 Tub. Meningitis 2 2 1 1 3 Other Tub. Diseases 1 1 1 1 1 1 4 . 5 2 2 1 3 5 10 1 24 1 1 2 5 6 1 16 40 26 The Kent County Council in 1913 established a Dispensary in the district for the treatment of Tuberculous patients, and a large majority of cases notified attend there, as well as a number of patients who are contacts with definite cases of Tuberculosis, though they have not yet been definitely diagnosed as suffering from the disease, and have not been notified. During the War there appears to have been some difficulty in giving Sanatorium Benefit, but the County Council have now opened a Sanatorium at Lenham, and it is hoped that this difficulty will be largely obviated in future. There is no doubt judging from the number of notifications that there has been a considerable increase in the number of persons suffering from this disease ; the causes of this are not clear, but no doubt the strain of the war period, and the shortage of food (especially fats) have had a great influence, and in addition the shortage of housing accommodation with its consequent overcrowding is perhaps in a measure accoantable. Small-pox. There has not been a case of this disease in the district for many years. No vaccination or re-vaccinations have been performed by the Medical Officer of Health under the Public Health (Small-pox) Regulations of 1917. D.—Maternity and Child Welfare. The Midwives Act is administered by the Kent County Council. There are four Midwives practising in the District. The Council employ two Health Visitors who carry out, under the supervision of your Medical Officer of Health, the visiting of houses where births are notified and for various other reasons ; they also assist in the work at the Infant Welfare Centres and the Antenatal Clinic. 27 There are two Welfare Centres, one at Erith and one at Belvedere, and the Antenatal Clinic is held at the Offices of the Medical Officer of Health. Each of these is open once a week when a Lady Medical Officer with a large experience of such work attends. Notification of Births. During 1919, 614 births were notified as occurring iu the district, viz., 332 males and 282 females. The number of births registered in the district during the fifty-two weeks ended December 27th, .1919, was 597, viz., 314 males and 283 females. The Registrar-General has supplied the correct figures for the year, after allowing for transferable births, and these are 347 males, 323 females, total 670. Of these 15 males and 22 females, a total of 37, were illegitimate. Early in 1919 it was found from returns supplied by the Registrar of Births that there were a number of births which had not been notified in accordance with the requirements of the Act. Several persons were prosecuted for failure to notify, but as these were the first prosecutions undertaken by the Council the cases were not pressed, and were dismissed on payment of costs. The result was good, as there was a distinct improvement in the notifications, both as to number and the interval allowed to lapse after the birth before notification. Houses where births have occurred are visited by the Health Visitors usually after the 10th day. but earlier in cases where there appears to be any reason for doing so such as the notification of Ophthalmia. As a rule they are well received, and are able to be of some assistance to the mothers. The time of their second and subsequent visits depends on the conditions found at the first visit, some cases requiring visits at shorter intervals than others. Mothers are encouraged to bring their children to the Welfare Centres, and advice is given as to. clothing and feeding them, and as to the care the mothers should take of their own health. 28 The Health Visitors paid 4,738 visits during 1919, made up as follows :—1st visits after notification of births 592 ; 2nd and subsequent visits 3,044 ; visits to Antenatal cases 452 ; visits to Tuberculous and other infectious cases (including Ophthalmia Neonatorum) 557, and visits to Dental cases 93. The Infant Welfare centres at Erith and Belvedere were opened each week except Easter and Whit weeks, the third week in July (when a Baby week with a Health and Child Welfare Exhibition was held), and four weeks in August. The number of attendances at the Centres was 2,897 (Erith 1514, Belvedere 1383). The Antenatal Clinic was open the same number of times, and 130 expectant mothers made 268 attendances. During 1919 arrangements were made with a dental surgeon for attention to be given to the teeth of nursing and expectant mothers and children under five years of age. This was opened on May 1st, and 65 cases made 103 attendances. The Council made arrangements also to assist in the provision of dentures for such mothers as required them. This assistance was given in 10 cases during the year, the Council paying either part or the whole of the cost of the dentures. Recommendations for dental treatment are made by the Lady Medical Officer who attends the Antenatal Clinic, or by the Medical Officer of Health, and after their first visit to the dental clinic patients attend as directed by the Dental Surgeon. A stock of the following foods, &c., is kept and sold at the Centres at cost price :— Glaxo Marylebone Cream Ambrosia Dried Milks Lactagol Cow & Gate Cod Liver Oil & Mall Virol, Roboleine and Chymol. 29 The amount received by the sale of these foods during 1919 was £397 7s. 10d. Patterns of model baby clothing are also kept and sold to the mothers attending the Centres and Antenatal Clinic; demonstrations in cutting out garments have also been given by Mrs. Reeves one of the members of the Maternity and Child Welfare Committee. In the third week in July a Baby week was held and a Health and Child Welfare Exhibition (kindly lent by the National Council of Women of Great Britain and Ireland) was opened for 3 days. The exhibition committee sent down two ladies as organizers and lecturers, and their talks to the mothers were greatly appreciated. The exhibition was opened on successive days by Lady Callender, Dr. A. Greenwood, M.O.H. for Kent County, and Dr. Sidney Davies, M.O.H. for Woolwich. The attendances were very good, and the exhibition most successful. Valuable assistance was given by the members of the Women's Co-operative Guilds at Erith and Belvedere. The exhibition had a very good effect in increasing the interest of mothers in the Welfare Centres as shown by the increased attendances. Early in 1919 the Council took into consideration the question of purchasing a house for the purpose of coordinating their School Medical and Child Welfare services. In February Dr. Eichholz, Chief Assistant Medical Officer of the Board of Education, came down to Erith and inspected the premises; he reported favourably, and the Council decided to buy the house (Hainault) with a little more than 2 acres of ground at a cost of £1,800. Plans for the alteration and adaptation of the house for the required purpose were submitted to the Ministry of Health and the Board of Education, and finally approved after a consultation between representatives of the Ministry, the Board, and the Council, and the work was put in hand. The building should be ready for occupation shortly. 30 The ground floor will be used for the Child Welfare Centre for Erith and the Antenatal and Dental Clinics, and also for the purpose of a school clinic for minor ailments, dental and opthalmic work. Tne first floor will be occupied by the maternity beds and children's cots with necessary annexes. The stable and coach house is to be converted into an operating theatre for adenoids and tonsils with a room for patients to lie down and recover in after operation. It is proposed to provide one maternity ward with 3 beds, an observation ward (1 bed) and a children's cot ward with 5 beds, with labour room, ward kitchen, bathroom, &c. Preference is to be given to necessitous cases, and one bed is to be reserved for emergency cases. A small charge has been fixed for cases admitted, but this can be reduced or remitted entirely where the circumstances of the patient are such as to render it necessary. It will be possible when these new premises are opened to hold classes for mothers in various subjects such as personal hygiene, care of infants and older children, making of (suitable clothing, &c. I have asked Dr. J. Lorimer Hawthorne to write a few notes on the work of the Infant Welfare Centres, and the Antenatal Clinic, and these are inserted here. " A glance at the figures given on pages 27 and 28 will. convince the readers that we are justified in believing that the Infant Welfare work during the past year has been a success. " The increasingnumbers that attend all the clinics prove that the establishment of these clinics was desirable and indeed necessary. " When the centres at Erith and Belvedere were first opened, the attendance was composed principally 31 of babies in arms, with a sprinkling of older children, that is children under school age. Very soon, however, these latter increased in number to such an extent that the infants were not receiving so much attention as at the beginning—it was therefore decided to set aside one day in each month when the toddlers might have first place. This arrangement has been a success from the beginning, and has proved satisfactory to the parents and guardians, and to the officials. The mothers whose children are no longer infants feel that their youngsters are receiving the attention due to them, and indeed the transference of Baby to the Toddlers' Day is quite an interesting promotion, and the little ones themselves feel the importance of the occasion ! " The Antenatal Clinic which takes place every Tuesday morning at the Council Offices, Erith, is quite a success, if one may judge by the number of expectant mothers who attend. But I should like to emphasize the fact that the clinic is in no sense a treatment centre. It exists for the purpose of giving advice on questions of personal hygiene, on how to maintain health, on how to prepare for the satisfactory feeding of the new arrival, as well as how to train baby when he does arrive. " It is astonishing how little is known by the young mother of the needs of her first born, but it is at this stage that we are able to teach a few of the vital facts of this important subject. " In the near future.we hope to have a few cots at our disposal in the new centre at " Hainault " where it will be possible to superintend the feeding and general treatment of the babies, and at the same time provide some teaching for those mothers who are anxious to learn. " Since the Dental Clinic has been in existence an immense amount of good work has been accomplished 32 which has far reaching results. In many cases of inability to breast-feed baby it has been found that the state of the teeth and consequently the septic condition of the mouth have been the undeniable cause of this deplorable state of affairs. One bad tooth can be responsible for serious ill-health both in the mother and the child. It has been difficult to impress the truth of this upon those moat nearly concerned, but now we begin to notice there is less difficulty in persuading the mothers to attend the Dental Clinic. When it is realised that a bad tooth may cause a state of chronic poisoning in botb mother and child we may hope for better things." J. Lorimer Hawthorne. E.—Sanitary Administration. (1) Staff, Work of Inspectors, &c. The Staff consists of myself, as Medical Officer of Health, School Medical Officer, and Medical Officer in charge of the Sanatorium for Infectious Diseases; D. B. Davies, Inspector of Nuisances, holding certificates from the Royal Sanitary Institute as Inspector of Nuisances, and for the inspection of meat and other foods; T. Vaughan, Assistant Sanitary Inspector, holding the same certificate ; his duties have been chiefly the inspection of houses under the Housing and Town Planning Acts. In addition to these there are a part-time Lady Medical Officer, Dr. J. Lorimer Hawthorne, two full time Health Visitors, Nurses Cruise and Crouch, and a female clerk, whose work chiefly lies in connection with the Maternity and Child Welfare Department. (2). Hospital Accommodation. The Sanatorium for Infectious Diseases is situated at Little Heath, Belvedere, near the centre of the Southern Boundary of the District. 33 It consists of an administration block, two wards for Scarlet Fever, 14 beds in each, a block for Diphtheria with two wards of 6 beds each, and two small one-bed wards for observation purposes. There is also a block of two wards (4 beds in each) which can be utilized for other diseases or for observation purposes. These are all brick built. There are also a Porter's Lodge, a laundry and drying room, ambulance sheds, steam disinfector and mortuary. One ambulance is kept and a van (zinc lined) for the removal of infected bedding. No horses are kept at the Sanatorium, but are hired from a local contractor as required. The provision of a motor ambulance is desirable. The staff at the Sanatorium consists of a Matron, 1 Sister and 4 Nurses, with the necessary domestic staff; a laundress, and porter who resides in the porter's lodge. There has been some difficulty recently in obtaining narses, the isolated situation of the buildings being a great drawback from this point of view though very desirable from the point of view of infection. On January 1st, 1919, there was only 1 patient in hospital suffering from Scarlet Fever. During the year there were admitted 66 cases of Scarlet Fever, '29 Diphtheria, 1 Measles, and 1 Fnteric Fever, and there were discharged 49 cases of Scarlet Fever, 23 Diphtheria, 1 Measles, and 1 Enteric Fever. Four cases of Diphtheria died, as did one case which had been admitted as Scarlet Fever, but in this case the cause of death was Septic Pneumonia and Septicaemia due to an injury to the scalp received accidentally before admission. This case was possibly not Scarlet Fever at all, and the rash which occurred may have been a septic rash due to the injury. Death took place too soon to admit of a definite decision on this point. No patient who has had Diphtheria is discharged from hospital until a bacteriological examination of a 34 swab from the throat (and also from the nose if any nasal discharge has been present) shows that the Bacillus of Diphtheria is absent, at least two consecutive negative results are required. These Bacteriological Examinations are carried out by the Kent County Laboratory at Maidstone, and 89 examinations were so made during 1919 ; 65 of these being negative. Table showing the number of patients treated at the Sanatorium during the year. Scarlet Fever. Diphtheria- Enteric Fever. Measles. Total. In Hospital, Jan. 1st 1919 1 - - - 1 Admitted during year 66 29 1 1 97 Discharged 49 23 1 1 74 Died 1 4 — — 5 In Hospital Dec. 31st, 1919 17 2 — — 19 The average stay in hospital of Scarlet Fever patients, who had completed their stay in hospital during the year was 39 days, and of Diphtheria patients 35 days. The longest period for which a Scarlet Fever patient was detained was 52 days, and diphtheria 96 days. There is no accommodation for Smallpox or Cerebrospinal Fever, but arrangements have been in force for some years with the Metropolitan Asylums Board whereby cases of these diseases are admitted to their Hospital at Joyce Green, Dartford. Motor Ambulance. During the year the Council have purchased a motor ambulance for the use of persons in the district. It conveys acute cases from the district to the various London Hospitals, and patients who have sustained accidents at one of the factories to their homes or to Hospital. It has proved a great boon, and was in use on 186 occasions up to December 31st, 1919, 110 patients were removed to various London Hospitals, 35 34 to the Erith Cottage Hospital, and 42 were removed from and to various addresses in the Urban District of Erith. 3. Local Acts & General adopted Acts in force in the District. The Erith Tramways and Improvements Act 1904, the Public Health Acts Amendment Act 1890, the Infectious Disease (Prevention) Act 1890, and sections 19, 21, 22,23, 25, 31, 33 and 51 of the Public Health Acts Amendment Act 1907 are in force in the district. 4. Chemical and Bacteriological Work. No Laboratory is attached to the Public Health Department, but the County Laboratory at Maidstone carries out any necessary Bacteriological Examinations. Under present arrangements each medical man practising in the district is supplied by the County Medical Officer with the requisite apparatus for taking swabs or blood, and when taken these are forwarded to the Laboratory at Maidstone for examination. Reports on the results found are forwarded to the medical man concerned, and also to myself as Medical Officer of Health, and at the same time fresh apparatus is sent to the medical man to replace the one used. During 1919 1.17 swabs were sent for examination for Diphtheria Bacilli. Of these 28 were sent by medical men, 8 with positive results, 19 with negative ones and 1 doubtful, 89 swabs were sent from the Sanatorium from convalescent cases, in 24 cases the result was positive, and in 65 negative. During the same period 32 specimens of sputum were sent up for examination for Tubercle, in 3 only was it found. One specimen of blood was sent up for the Widal test for Enteric Fever with a positive result. In a case of suspected Cerebro-spinal Meningitis the County Bacteriologist came to Erith, and swabbed 3 persons who had been in contact with the case. In two the result was negative. and in one doubtful ; the case 36 itself was sent into Hospital where it died next day, and post mortem examination showed that the cause of death was Acute Tuberculosis. F.—Housing. (i) General Housing Conditions in the District. The majority of the houses in the district are cottages containing 6 or 7 rooms, some built in terraces, some in flats of two stories, others detached or semidetached. A large number of these were built about 1900 in accordance with the bye-laws of the Council, and these have ample air space, both in front and at the back. Some of the older houses, however, are somewhat cramped at the back. At the Census of 1911 there were 5,129 inhabited houses, and 507 empty, a total of 5,636. During the years following the Census before the outbreak of war about 40 or 50 houses were erected, so that at the outbreak of war there were about 5,680 houses in the district. During the 4 years 1915-1918 only 12 houses were built. In 1900 the works in the district were very busy, and practically every house was occupied, while building proceeded rapidly to supply the demand for houses to accommodate the workmen who came into the district. About 1906, however, slackness of work and labour troubles caused the emigration of a number of workmen, and at one time about 750 houses were empty. In the year 1913 only a few houses were empty, but with the outbreak of war, the large factories here were occupied in munition making, and there was a big influx of workmen, so that the population went up to well over 35,000 in 1915 and 1916. In 1917 and 1918 it decreased again, and in 1919 the Registrar General estimated the civilian population to be 30,525. It is anticipated that in the near future the South Suburban Gas Co. and an Electric Co. will erect a gas 37 works and a large electric generating station on the Marshes, and when this takes place there will probably be a certain increase of population. Even as things are at present there is a considerable shortage of houses in the district, and it is proposed to carry out a housing scheme and build 1,000 houses during the next 3 years. (ii) Overcrowding. It is estimated that there are about 120 houses in the district which are over crowded taking as a standard more than two persons per room. There are also approximately 400 houses which are occupied (without having been specially adapted) by two or more families. The principal cause of overcrowding is of course the shortage of houses, and in view of this little or nothing can be done to abate the trouble until more houses are built. (iii) Fitness of Houses. (1) (a) The general standard of housing is good ; before the war it was better than at present. Probably half the houses in the district have been built during the past 25 years under the Council's bye-laws, and the large majority of these have remained in good condition. Many of the older houses have, however, owing to want of timely repairs, due to war and post-war conditions, not been maintained at their pre-war standard. During the last 2 or 3 years of the war no systematic housing inspections were undertaken, but in July, 1919, this was again started, and a list made of the worst properties in the district with a view to their inspection. From that time till the end of December 465 houses were inspected, and a table is given at the end showing the results of the inspections. Twentytwo houses were found to be in good condition, the remainder having one or more defects; 138 in water 38 supply, 247 in closet accommodation, 172 in drainage, 83 in ventilation, 249 in cleanliness, 359 in dampness of the walls, 164 in the condition of the yard, 108 in disposal of refuse, and 329 in some other matter than those specified. Where any defect is found, a preliminary notice is sent to the owner, pointing out the defects found at the inspection, and asking him to have them remedied. In some cases this was done, but if on re-inspection it was found that no steps were being taken to remedy defects statutory noticcs were served under the Public Health Act where possible, or under the Housing Acts. It was found that there was considerable difficulty in carrying out the work required by the notices. Shortage 6f labour and material and the high cost thereof, together with transport difficulties had all to be reckoned with, and in many cases the cost of renovating a small house let at 5/- to 7/- a week would take the whole of the rent for more than twelve months. Forty houses were scheduled under Section 28 of the Housing Act 1919, and orders made. Some of these houses were under repair at the close of the year. The number of visits for re-inapection was 525. Water Supply. Some defect in this was found in 138 houses. In the large majority of these cases the drinking water was obtained from a cistern which had no proper cover; in many cases also the cistern was found to be fixed in an unsuitable position, such as in an outhouse, or so near the ceiling of a scullery as to be totally inaccessible for proper cleaning. The Metropolitan Water Board require every house to have a storage cistern, but it is always advisable to have in addition a tap supplying drinking water direct from the main. Cisterns should always be fixed so as to be easily accessible for cleaning, they should be cleaned out regularly, and have a proper cover. 39 Closet Accommodation. In 247 houses there was some defect. In many cases the walls were dilapidated, and doors and windows broken, in others the flush arm joint leaked, or the flushing cistern was out of order. Drainage. There was some defect in the drainage of 172 houses; principally absence of fresh air inlets, broken gullies and channels, badly jointed vent pipes; occasionally a drain was found to be checked. Lighting and Ventilation. In 83 cases there was lack of proper ventilation of the space under the ground floor. Dampness. There was appreciable dampness of the walls, &c., in 359 houses. This was due to various causes, porosity of bricks, aspect of the walls, condition of pointing, leakages from defective gutters and down pipes, defective roofs, and absence of proper damp-proof courses above the foundations. Yard Paving. In 164 houses the yard paving.was absent or broken and dilapidated. Refuse Disposal. One hundred and eight houses were found to lack proper sanitary dustbins. Where this is found to be the case notices to provide the same are served on the owner. Other Defects. In 329 houses some defect other than those mentioned was found. Dilapidations in walls, plaster and ceilings, broken floors, absence of rain water gutters and downpipes, defeotive curbs to gullies, defective roofs and broken window and door frames. 40 (iv) Unhealthy Arears. There are no unhealthy arears in the district. (v) Bye-laws relating to Houses, Tents, Vans and Sheds and Houses let in Lodgings. An account of the bye-laws as to tents, vans and sheds, and the working thereof is given on page 12. There are no bye-laws in force in the district with regard to houses let in lodgings. (vi) Statistics. (1) Action under Section 17 of Housing Act of 1919. (a) Number of houses inspected 465 (b) Number of houses considered fit for habitation 18 (c) Number of houses the defects in which were remedied without closing orders (completed by end of year) 28 In hand at end of year 69 (2) Action under Section 28 of the Housing Act 1919. (a) Number of orders for repair 40 (b) Number of cases in which repairs carried out by local authority 0 (c) Number of houses voluntarily closed by owner. 0 (3) Closing Orders. (a) Number of representations made to local authority with a view to the making of closing orders 18 (b) Number of closing orders made 14 (c) Number of closing orders mined 0 No demolition orders were made, no dwelling houses were demolished voluntarily, and no representations were made with regard to obstructive buildings. G.—Vital Statistics. 41 Births. The number of births registered in the district dur1919 was 597, viz., 314 males and 283 females. After correction by transference of births outside the district, but belonging to it, there were 670 births, viz., 347 males and 323 females. This gives a birth rate of 21.07 per 1,000 population, 2 57 above the rate for the 148 smaller towns including Erith (Census population between 20,000 and 50,000). Of these births 37 were illegitimate, viz., 16 males and 22 females, giving a birth rate of 1.1 per 1,000 population, and 55.22 per 1,000 births. The birth rate for 1919 is 3.09 per 1,000 higher than in.1918, and the natural increase of population, i.e., the excess of births over deaths was 343. There were 15 stillbirths notified in 1919. Deaths. The number of deaths registered in the district during 1919 was 249 giving a death rate of 8.12 per 1,000 civilian population. The deaths of 8 persons whose homes were in other districts must be deducted from this number, but to it must be added 86 deaths of residents who died in other districts making a nett total of 327 deaths belonging to the district ; this gives a nett death rate of 10.71 per 1,000 population as compared with 13.18 for 1918. For purposes of comparison I give a table showing the provisional figures for England and Wales for 1919 with regard to birth rates, death rates and infantile mortality. 42  Birth Rate per 1000 total population. Death Rate per 1000 civilian population. Rate per 1000 births. Diarrhœa & Enteritis (under 2 years). Total Deaths under 1 year. England and Wales 18.5 13.8 9.59 89 96 Great Towns, including London (populations exceeding 50,000) 19.0 13.8 12.24 93 148 smaller Towns, including Erith (populations 20,000—50,000) 18.3 12.6 8.67 90 London 18.3 13.4 16.22 85 Erith 21.07 10.71 4.47 56.71 It will be seen that the rates for Erith compare very favourably with those given, the birth rate being higher than the average, and the death rate, the infantile mortality rate and the rate for diarrhoea and enteritis being all much below the average. Of the 86 deaths of residents occurring outside the district 14 took place at Guy's Hospital, 31 at Bermondsey Infirmary and allied institutions, 4 at Woolwich Infirmary, and 26 at various London and other Hospitals and Sanatoria; 4 occurred at the County Lunatic Asylum, Maidstone, and the remainder at various addresses. During the first Quarter of 1919 there were 110 deaths, and 74. 61 and 82 during the second, third and fourth quarters respectively. There were 11 deaths in Public Institutions in the district, 8 being those of residents, and 3 non-residents. Table showing ages at which deaths have occurred compared with the previous year :— Year. All Ages. Under 1 year. 1—2 years. 2—5 years. 5—15 years. 15—25 years. 25—45 years. 45—65 years. 65 years and over. 1918 432 50 20 18 28 42 88 85 101 1919 327 38 12 19 18 18 50 77 95 43 Of the 95 deaths at the age of 65 and over, 47 (24 males and 23 females) occurred between 65 and 75 years of age, 36 (18 males and 18 females) between 75 and 85, and 12 over 85 (8 males and 4 females) ; one man reached the age of 97 years. It will be noticed that in every age group except that between 2 years and 5 years there was a decrease in the number of deaths. The chief causes of death during the year were:— Organic Heart Disease 41 Cancer 35 Pulmonary Tuberculosis 32 Pneumonia (all forms) 31 Bronchitis 24 Premature Births, Congenital Debility and Malformation 21 . Influenza 17 Inquests. There were 17 inquests held during the year ; the causes of death are as shown in following table :— Natural Causes 8 Suicide 2 Homicide 1 Overlying 1 Drowning 1 Scald 1 Other 3 Deaths registered during each month :— January 19 February 40 March 31 April 30 May 9 June 16 July 14 44 August 19 September 12 October 11 November 20 December 28 Cancer. The number of deaths due to Cancer during 1919 was 35, viz.:—12 males and 23 females. This is a disease which is almost entirely confined to persons of middle age and over. The following tables show :— (1) the deaths from Cancer for 1919 classified according to age, sex, and the organ affected ; (2) number of deaths from Cancer during past 6 years with the site of the disease ; and (3) number of deaths during past 6 years with age and sex distribution. 45 1919 MALES. Total all ages. FEMALES. Total all ages. Total M. & F. all ages. 0—1 1—2 2—5 5—15 15—25 25—45 45—65 Uv. 65 0—1 1—2 2-5 5—15 15—25 25—45 45—65 Ov. 65 Carcinoma Mouth 1 1 1 1 2 Oesophagus 1 1 2 2 Stomach 3 1 4 1 2 3 7 Liver 2 2 2 Intestines 1* 1 1 1 2 4 5 Breast 1 2 1 4 4 Uterus 1 1 1 Ovary 1 1 1 Larnyx 1 1 2 2 3 Prostate 1 1 2 Other 1 1 1 1 1 3 4 Sarcoma 1 1 2 2 8 4 12 1 1 1 3 8 9 23 35 46 Table showing number of deaths from Malignant Disease (Cancer) for past six years with site of the disease. Mouth. Oesophagus. Stomach. Liver. Intestines & Peritoneum. Breast. U Iter us. Larnyx Skin. Others. Totals. 1914 M. 9. 4 3 1 2 1 1 4 18 39 P. 1 2 5 5 6 2 21 1915 M. 3 2 i 2 8 26 F. 2 6 2 6 2 18 1916 M. 2 2 1 1 4 3 13 27 F. 1 2 3 2 5 1 14 1917 M. 1 1 3 1 5 1 12 31 F. 1 2 2 5 4 4 1 19 1918 M. 3 1 4 1 3 14 30 F. 1 2 3 3 2 4 1 16 1919 M. 1 2 4 1 1 3 12 35 F. 1 3 2 4 4 1 2 1 5 23 47 Table showing age and sex distribution of deaths :roru Malignant Disease (Cancer) during past 6 years. 0—1 1—2 2—5 5—15 15—25 25-45 45—65 Ov. 65 Total all ages. Death Rate per 1000 population 1914 M. 1 1 7 9 18 39 1.27 F. 1 4 12 4 21 1915 M. 1 1 2 4 8 26 .73 F. 4 6 8 18 1916 M. 1 3 9 13 27 .77 F. 7 7 14 1917 M. 1 9 2 12 31 .93 F. 5 9 5 19 1918 M. 1 8 5 14 30 .91 F. 1 9 6 16 1919 M. 8 4 12 35 1.09 F 1 1 1 3 8 9 23 Pneumonia (all forms). The number of deaths from all forms of Pneumonia in 1919 was 31, viz. 23 males and 8 females, as compared with 59 in 1918 (25 males and 34 females). I give a table showing the deaths from Broncho Pneumonia and Pneumonia for the past six years. 1914 MALES. FEMALES. Total M. & F. all Ages. 0-1 1—2 2—5 5—15 15—25 25-45 45-65 Ov. 65 Total all Ages. 0—1 1—2 2—5 5- 15 15—25 25-45 45—65 Ov. 65 Total all Ages. Broncho pneumonia 4 1 1 1 2 1 10 1 1 11 Pneumonia 1 1 1 2 3 8 2 1 1 2 2 1 9 17 1915 5 2 1 ] 1 4 4 18 2 1 1 1 2 2 1 10 28 Broncho-pneumonia 5 3 1 2 11 2 2 4 15 Pneumonia 1 1 5 2 9 2 4 1 1 8 17 1916 6 3 1 1 5 4 20 4 2 4 1 1 12 32 Broncho-pneumonia 1 1 3 1 6 4 1 5 11 Pneumonia 1 1 2 3 1 8 1 1 4 4 10 18 1917 1 2 3 2 2 3 1 14 5 1 1 4 4 15 29 Broncho-pneumonia 5 2 1 1 9 3 1 6 15 Pneumonia 1 1 1 5 1 1 2 1 5 10 1918 5 3 1 1 3 1 14 4 2 2 1 11 25 Broncho-pneumonia 4 1 1 1 1 8 4 4 2 1 11 19 Pneumonia 2 2 1 4 7 1 17 1 2 2 1 13 3 1 23 40 1919 4 3 3 1 1 5 7 1 25 4 5 2 4 2 13 3 1 34 59 Broncho-pneumonia 3 3 2 2 10 2 3 1 6 16 Pneumonia 2 1 2 5 1 2 13 1 1 2 15 3 5 1 2 5 3 4 23 2 3 2 1 8 31 49 It will be noticed that for the first four years the average number of deaths was 28, but that in 1918 the totals went up to 59. It was during 1918 that the epidemic of influenza was so severe, and though these deaths from Pneumonia were not stated to be directly the result of Influenza, there can be no doubt but that a large proportion of them were so due. In 1919 the number has approximated very closely to the previous average. Infantile Mortality. Daring 1919 the number of deaths of children under one year of age was 38, between 1 year and 2 years 12, and between 2 years and 5 years 19 as compared with 50, 20 and 18 during 1918. The death rate for children under 1 year per 1,000 births is 56.71 as compared with 75.75 for 1918, and with 74.4 for the past 10 years. This is the lowest figure that has ever been reached iu this district, the nearest approach to it having been 58 in 1916. During the 10 years 1895—1904 the infantile mortality rate averaged 132.6, with a maximum of 200 in 1898, and a minimum of 93.6 in 1903. During the five years 1905—1909 the average was 83.71 ; during the five years 1910—1914 it was 76.19, and for the last five years 1915—1919 (including this vear) it was 68.33. The decrease has been fairly steady during the last 15 years, and this decrease and the figure reached this year are very gratifying. Another point which may be noted is that out of the 38 deaths which occurred during the year only one took place between the ages of 6 and 12 months. The remaining 37 took place before the child had reached the age of 6 months, 29 occurring during the first four weeks of life. Now that our Antenatal Clinic and Infant 50 Table showing Births and Deaths under 1 year, and Infantile Mortality rates for the 10 years 1895 — 1904, for 3 subsequent periods of 5 yerrs, and for 1919. Births. Deaths. under. 1 year. Infantile Mortality Kate. 10 Years 1895—1904 7795 1034 132.6 5 Years 1905—1909 4144 347 83.71 ,, ,, 1910—1914 3675 280 76.19 ,. 1915—1919 3629 249 68.33 1919 670 38 56.71 Welfare Centres are in good working order it may he hoped that this figure will be improved on. If the Infantile Mortality rates of legitimate and illegitimate children are compared it will be seen that the rate for illegitimate children is very much higher than that for legitimate ones. In this district there were 633 legitimate births during 1919, with 33 deaths giving a rate of 52.13 per 1,000 legitimate births, and there were 37 illegitimate births and 5 deaths during the same period giving a rate of 135.1. The subjoined table shows numbers of legitimate and illegitimate births with mortality rates for the past 10 years. Year. Number of Births of Illegitimate Children. Total number of Births. Hate of Illegitimate Births per 1,000 Births. Number of Deaths of Illegitimate Children. Mortality Rate of Illegitimate Infants per 1,000 Illegitimate Births. Mortality Rate of Legitimate Children per 1,000 Legitimate Births, 1910 9 691 13.02 2 222.2 68.91 1911 22 715 30.76 1 45.45 77.77 1912 17 664 25.6 1 58.82 69.55 1913 25 771 32.42 5 200.0 72.38 1914 26 834 31.17 7 269.2 85.39 1915 22 738 29.81 7 318.1 65.64 1916 16 827 19.34 1 62.5 57.95 1917 23 734 31.2 3 130.4 78.74 1918 28 660 42.42 4 142.8 72.78 1919 37 670 55.22 5 135.1 52.13 51 Table IV at the end shows the causes of deaths of children from birth to one year of age. Seventeen deaths, nearly 45 per cent. took plate during the first week of life, and thirteen of these were due to premature birth and congenital debility, while 29, or over 76 per cent. occurred during the first 4 weeks of life. Twenty deaths were due to premature birth, including Congenital Debility and Malformation, 5 to Pneumonia, 3 to Bronchitis, and 1 to Diarrhœa. I have in an earlier part of the Report given an account of the work done by the Child Welfare Department, and I think that the figures with regard to infantile mortality afford unmistakeable evidence of the value of that work. The sanitary conditions of the district are all favourable, there are no slums, no back to back houses, plenty of open spaces and fresh air, there are no industries employing married women to any large extent, and work has been fairly plentiful so that with the exception of that due to the strike of moulders there has been very little unemployment. 52 Table I.—Vital Statistics of Whole District during 1919 and previous years. Year. Population estimated to middle of each year. Births. Ttl. Deaths registrd. in the Distr's. Transferable Deaths. Nett Deaths belonging to the District. Uncorrected Number. Nett. Number. Rate. of Non-residents registered in the District. of Resid'ts not registered in the District. Under 1 year of age. At all Ague, Number Rate. No. Kate per 1000 nett Births. No. Rate 1 2 3 4 5 6 7 8 9 10 11 12 13 1914 30,562 816 834 27.28 290 9.81 103 76 91.1 393 12.85 1915 35,232 724 738 20.94 305 8.65 5 73 54 73.17 373 10.58 1916 (a) 38,093 807 827 21.71 307 8.48 21 95 48 58.04 381 10.88 1917 (b) 35,011 (a) 36,929 695 734 19.87 256 7.72 10 102 59 80.38 348 10.50 (b) 33,129 1918 (a) 36,701 620 660 17.98 334 10.19 6 104 50 75.75 432 13.18 (b) 32,755 1919 (a) 31,798 597 670 21.07 249 8.12 8 86 38 56.71 327 10.71 (b) 30,525 (a) Population including non-civilian population belonging to the District used for calculating Birth rate). (b) Civilian population only (for all rates except the Birth rate). Area of District in Acres 3859.513 Total Population at all Ages 27,750 Number of Inhabited Houses 5,129 Average number of persons per house, 5.41 At Census of 1911. 53 Table II. Cases of Infectious Disease notified during the Year 1919. Notifiable Disease. Number of cases notified. Total cases removed to Hospital. At Ages—Years. At all Ages. Under 1 and under 5 years. 5 and under 15 yrs. 15 and under 25 yrs. 25 and under 45 yrs. 45 and under 65 yrs. 65 and upwards. Diphtheria 10 18 2 1 31 30 Erysipelas 1 1 1 5 1 9 Scarlet Fever 1 13 47 7 5 1 74 66 Enteric Fever 2 2 2 Puerperal Fever 2 2 Measles 73 145 6 1 236 1 Ophthalmia Neonatorum 9 9 Pneumonia and Influenzal Pneumonia 1 2 11 6 14 4 5 43 Malaria 1 5 6 Acute Poliomyelitis 1 1 Cerebrospinal Meningitis 1 1 1 Tuberculosis: — Pulmonary 1 12 25 41 6 1 86 Other forms 1 6 22 2 4 1 36 Totals 24 106 259 50 77 14 6 536 100 Isolation Hospital or Hospitals, Sanatoria, &c. Erith Sanatorium, various London General Hospitals and Special Hospitals, Sanatoria at Bromley, &c. Joyce Green M.A.B. Hospital, Dartford. 54 Table III.—Causes of, and Ages at Death during the year 1919. Causes of Death. Nett Deaths at the subjoined ages of "Residents" whether occurring within or without the district. Tl. deaths whether of Residents or Non-residents in Institutions in the District. All ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 yrs. 15 and under 25 yrs. 25 and under 45 yrs. 45 and under 65 yrs. 65 and upwards. 1 2 3 4 5 6 7 8 9 10 11 All causes Certified Uncertified 327 38 12 19 18 18 50 77 95 11 Measles 5 1 3 1 Whooping Cough 1 1 Diphtheria & Croup 5 3 2 3 Influenza 17 2 4 1 6 1 3 Erysipelas 1 1 Meningitis 2 2 Phthisis (Pul'm'n'ry Tuberculosis) 32 1 2 7 10 11 1 Tuberculous Meningitis 3 2 1 Other Tuberculous Diseases 5 1 2 1 1 Rheumatic Fever 1 1 Organic Heart Disease 41 1 1 4 11 24 Cancer, malignant disease 35 1 1 1 3 16 13 Bronchitis 24 3 1 1 6 13 Broncho-pneumonia 16 5 3 4 2 2 2 Pneumonia (all other forms) 15 3 1 2 6 1 2 Other diseases of respiratory organs 5 2 1 2 Diarrhoea and Enteritis 3 2 1 Appendicitis 2 1 1 Alcoholism 1 1 Nephritis & Bright's Disease 6 4 2 Puerperal Fever 2 1 1 Other accidents & diseases of parturition and pregnancy 4 4 Congenital Debility and Malformation including Premature Birth 21 20 1 Violent Deaths, excluding Suicide 8 1 1 4 2 4 Suicide 3 1 1 1 Other Defined Diseases 68 3 4 1 5 20 35 2 Diseases, ill-defined or unknown 1 1 Totals 327 38 12 19 18 18 50 77 95 11 55 Table IV.—Infantile Mortality during the Year 1919. Nett Deaths from stated causes at various ages under 1 year of age. Causes of Death. Under 1 week. 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 4 weeks, 4 wks. & under 3 months. 3-6 months. 6-9 months. 9-12 months. Total Deaths under 1 year. All causes Certified Uncertified 17 5 3 4 29 4 4 1 38 Diarrhœa 1 1 1 Enteritis 1 1 Abdominal Tuberculosis 1 1 Congenital Malformation 1 1 1 Premature birth 12 3 1 16 16 Atrophy, Debility and Marasmus 1 1 1 1 3 Atelectasis 1 1 Convulsions 2 2 2 Bronchitis 1 1 2 3 Pneumonia (all forms) 1 2 3 1 1 5 Suffocation, overlying 1 1 1 Other causes 1 1 1 3 3 Totals 17 5 3 4 29 4 4 1 38 Nett Births in the year :—Legitimate, M 332 ; F 301; Total 633. Illegitimate, M 15; F 22; Total 37. Nett Deaths in the year:—Legitimate Infants, 33. Illegitimate Infants, 5. STREET. Number of Houses inspected. Number of Houses found in good condition. Number of Houses found defective. Defects found in Number of Preliminary Notices served. Number of Houses represented as unfit for human habitation. Number of Notices served under Sec. 28 Housing & Town Planning Act, 1919. Result of Notices. Water Supply. Closet Accommodation. Drainage. Lighting and Ventilation. Cleauliness. Dampness in walls. Condition of yard. Disposal of Refuse, Other matters. Work done. Work in hand. Work not done. Sutherland Road 21 2 19 5 16 15 12 19 11 5 19 19 2 7 12 Norman Road. 15 15 8 2 6 12 2 1 12 15 1 3 12 Station Road, North 14 14 4 6 2 2 7 14 2 5 14 2 4 10 Caldy Road 36 3 33 7 22 10 12 24 4 13 33 4 6 23 North Road 9 2 7 3 1 2 2 3 7 1 2 1 4 Orient Cottages 14 2 12 2 7 2 7 9 12 2 8 12 1 11 Bedonwell Hill 24 2 22 10 10 16 18 10 22 22 2 1 13 8 Victoria Street 63 3 60 20 30 22 17 37 52 37 41 60 34 2 2 56 Alfred Road 29 29 17 12 10 2 13 16 5 7 18 29 12 17 Gladeswood Road 2 2 1 2 2 2 2 2 2 2 1 2 Eleotric Road 3 3 1 2 3 3 3 3 3 1 3 3 Vickers Road 1 1 1 1 1 Athol Road 3 3 1 2 3 3 3 3 Manor Road 2 2 2 2 2 2 1 2 2 2 South Road 1 1 1 1 1 1 1 1 1 1 1 Friday Road 1 1 1 1 1 1 1 1 1 Appold Street 1 1 1 1 1 1 1 1 1 1 Cheshunt Road 1 1 1 1 1 1 1 1 1 1 1 Upper Abbey Road 36 2 34 10 14 12 19 21 32 7 14 25 34 34 Horsa Road 1 1 1 1 1 1 1 1 1 1 Grosvenor Road 33 33 1 19 8 14 27 10 11 23 33 7 26 Lower Road 11 11 9 8 8 11 11 7 5 9 11 1 8 2 Sydney Road 2 2 2 1 2 2 1 1 2 2 William Street 15 1 14 11 2 14 12 11 10 9 14 14 14 Albert Road 17 1 16 14 9 6 11 16 6 9 16 16 4 12 Barnfield Road 28 4 24 3 5 7 10 22 8 7 23 24 24 Railway Road 1 1 1 1 1 1 1 1 1 Picardy Road 1 1 1 1 1 1 1 1 1 Stapley Road 43 43 25 27 10 6 13 23 10 15 31 43 43 Charleville Road 1 1 1 1 1 1 1 1 1 1 St. Augustine's Road 3 3 2 2 1 3 3 3 3 1 2 Gilbert Road 4 4 3 4 3 4 4 4 4 4 1 3 Bedonwell Road 9 9 9 5 9 9 6 9 9 7 9 9 9 Alexandra Road 1 1 1 1 1 1 I Standard Road 8 8 1 4 1 2 5 5 2 5 6 8 8 Brook Street 3 3 3 3 3 3 3 3 3 3 3 3 3 Bexley Road 1 1 1 1 1 1 1 1 1 Corinthian Road 7 7 7 7 7 7 7 7 7 4 3 Totals 465 22 443 138 247 172 83 249 359 164 108 329 443 14 40 28 69 346 Report of School Medical Officer. A.—General Review or the Hygienic Conditions prevalent in the District. Under the authority of the Erith Education Committee, there are 9 provided Schools with 18 Departments, and 2 non-provided Schools with 3 Departments. The Schools are modern in design, are well situated and surrounded by open spaces with plenty of air. Dustolio is being used on the floors for keeping down the dust. The Central School at Picardy has now been taken over from Messrs. Vickers, who were using it as a Hostel. During the last few months of the year we were again visited by an epidemic of Mumps, but have had no other serious visitation by epidemic disease. B.—Description of the arrangements for the Corelation of the School Medical Service with the Public Health Service, for the organisation and supervision of Medical Inspection, and an account of the Methods of Inspection employed. The arrangements made during the previous years of 1917 and 1918 were continued for the first 2 months of 1919. At that date, March 1st, Dr. Jerman returned from his War Service and took up his duties as Medical Officer of Health. Dr. Hardie, who had been acting as temporary School Medical Officer, was retained to continue the School Medical Service work until such time as a full time officer should be appointed. It was felt that the work had grown in size and importance, and 2 that a whole time assistant should be appointed. This was done on the 1st of October, since which time the whole of the School Service has devolved upon Dr. John Hardie, M.B., who took over the appointment. Nurse Lange still occupies the post of School Nurse, but as the number of school children closely approximates 6,000, it is felt that a second School Nurse is desirable in the interests of the schools and children. The influence of a good nurse spreads far and wide amongst both parents and children, and at present we are admirably served by our present Nurse. (A second Nurse has now been appointed). The Medical Routine Inspections of the children were carried out during the year by both Medical Officers and extended to four groups, viz.:—Entrants, 8 year olds, 11 year olds, and Leavers (13 year olds). The children are inspected at the various schools generally in the afternoon, and a room is provided for the purpose. The record card used is the ordinary one by the Board of Education. Parents are taking an increased interest in these examinations of their children, especially in the case of the entrants. C.—General Statement of the Extent and Scope of the Medical Inspection carried out during the year. 1. Visits paid Schools during the year. The Medical Officer or his Assistant visits the schools every afternoon to carry out inspections, either routine or special cases, and for the re-inspection of defective children for the purpose of finding out if defects have been remedied. During the latter part of the year, when Dr. Hardie had been appointed, the schools were regularly visited for some purpose or another in the Medical Service every day and sometimes twice a day. 3 The Nurse is regular in her visits for purposes of cleanliness and following up cases under the direction of the School Medical Officer. Every afternoon being employed in this when she is not engaged at the Clinic. She thus paid 270 visits to the various schools and examined some 10,036 children. 2. Children selected for Inspection. The following table shows the number thus inspected at the Routine Medical Inspection:— No. of Inspection. Age. Boys. Girls. Total. 1st Inspection 5—6 years. 372 378 750 2nd „ 8 „ 284 280 564 3rd „ 11 „ 247 233 410 4th „ 12½-14 „ 277 288 565 1180 1179 2359 3. Directions for Treatment. The parents are notified by letter or personally by the Assistant School Medical Officer of defects found, and are recommended to have these remedied either privately or at the School Clinic. 4 D.—General Review of the Facts disclosed b Medical Inspection. Previous Medical History. ENTRANTS. Boys Per cent. Girls Per cent. Total Per cent. Number examined 372 378 750 Measles 175 47. 210 55.5 385 51.2 Whooping Cough 110 29.5 141 37.1 251 34.3 Chicken-pox 69 18.5 91 24.1 160 21.3 Scarlet Fever 11 2.9 16 4.2 27 3.5 Diphtheria 5 1.3 8 2.1 13 1.7 Other Diseases 23 6.1 17 4.5 40 5.3 8 YEARS OLD. Number examined 284 280 564 Measles 201 70.8 214 76.4 415 73.6 Whooping Cough 144 50.7 144 51.4 288 26.0 Chicken-pox 99 34.8 83 26.0 182 30.4 Scarlet Fever 18 6.3 19 6.7 37 6.5 Diphtheria 6 2.1 6 2.1 12 2.1 Other Diseases 17 6.0 25 8.9 42 7.5 11 YEARS OLD. Number examined 247 233 480 Measles 199 80.5 210 90.1 409 85.3 Whooping Cough 130 52.6 150 68.6 280 60.6 Chicken-pox 98 39.0 107 45.9 205 42.5 Scarlet Fever 26 10.5 27 11.5 53 11.0 Diphtheria 6 2.4 11 4.7 17 3.5 Other Diseases 41 16.6 49 21.0 90 18.8 LEAVERS. Number exnmined 277 288 565 Measles 225 81.2 245 85.0 470 83.1 Whooping Cough 132 47.6 170 59.0 302 53.3 Chicken-pox 100 36.1 110 38.2 210 37.1 Scarlet Fever 37 13.3 40 13.9 77 13.6 Diphtheria 19 6.8 17 5.9 36 6.3 Other Diseases 45 16.2 34 11.8 79 14.0 GRAND TOTAL. Number examined 1180 1179 2359 Measles 800 67.7 879 71.1 1679 69.4 Whooping Cough 516 43.7 605 51.3 1121 47.5 Chicken-pox 366 31.1 391 33.1 757 32.1 Scarlet Fever 92 7.7 102 8.6 194 8.2 Diphtheria 36 3.6 42 3.7 78 3.6 Other Diseases 126 16.6 125 16.6 251 16.6 5 The following table gives the average age, with the average height and weight of the boys and girls at the time of their inspection:— Inspection. Average. Age. Height. Weight. 1st Inspection Boys 5 yrs, 6 mths 3-ft. 5½-in. 40¾ lbs. „ „ Girls 5 „ 6 „ 3-ft. 5½-in. 39¼ lbs. 2nd „ Boys 7 „ 9 „ 3-ft. 10½-in. 49¼ lbs. „ „ Girls 7 „ 10 „ 3-ft. 10¾-in. 48¾ lbs. 3rd „ Boys 11 3 „ 4-ft. 5-in. 65 lbs. „ „ Girls 11 „ 3 „ 4-ft. 4½-in. 64 lbs. 4th „ Boys 12 „ 8 „ 4-ft 7-in. 73¾ lbs. „ „ Girls 12 „ 8 „ 4-ft. 8 in. 77 lbs. These tables shew an increase in both height and weight with the exception of the elder boys, who have dropped 1 lb. in weight and lost half an inch in height; on the other band the elder girls have gained 3 lbs. in weight. The children do not seem to have suffered from any shortage in food or as a result of the rationing. The following short table gives a short analysis of the principal defects:— 6  Entrants. Age 8. Age 11. Age 13. Total. Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total Boys Girls Total Defective Teeth 174 175 349 202 185 387 140 133 273 111 131 242 627 624 1251 Defective Sight — 5 5 51 48 99 54 50 104 46 56 102 151 159 310 Tonsils and Adenoids 94 108 202 105 83 188 69 53 122 59 71 130 327 315 642 Ear Disease — — — 4 4 6 — — — 2 2 4 4 6 10 Other Defects 20 18 38 17 20 37 9 30 39 16 17 33 62 85 147 *Verminous Heads 6 26 32 2 15 17 7 47 54 — 11 11 17 17 116 Total number of Defects 294 332 626 379 355 734 279 313 592 234 288 522 1188 1288 2476 * Includes cases in which nits alone were present. 7 Entrants are not examined for eyesight defects unless specially brought forward for some obvious defect. Every child who had one or more defective teeth is included, special attention being devoted to the possible preservation of slightly decayed teeth. Many cases of enlarged tonsils are kept on observation for possible increase, although not sufficiently pronounced as to require surgical interference. Other diseases include skin affections and heart and lung affections. Cleanliness of Head and Body. The same difficulty meets us every year in trying to keep down these conditions. It takes an immense amount of effort on the nurse's part to watch over these young people and to induce their parents to spend a little time over keeping the children's heads clean. There is a great objection to having the girls' hair worn short. If this were done we should not have so much trouble with vermin in them. We are constantly meeting the same children time after time. No sooner do we get them clear of these pests than after a few months or even weeks they return as bad as ever through sheer want of attention. Suffering from this condition there were 106 children, a percentage of 4.9 of the total number examined at the Routine Inspection. The School Nurse spends as much time as she possibly can spare from her Clinic duties and has paid during the year 270 visits to the schools, taking them in rotation. She examined 10,036 children for cleanliness of head and person, and reported to me at the Clinic 106 as affected with vermin present in the head. These I excluded till clean. Letters of remonstrance are sent to the parents. Directions are sent and also given personally by the Nurse and remedies to destroy live vermin and make the child fit to associate with other clean children. 8 It is hoped that your Medical Officer will be able to obtain some sort of cleansing place in order that we can demonstrate what can be done with thoroughly washing and disinfecting a child's head to some of the careless mothers. Nutrition. The children do not seem to have suffered in any way from rationing. They have maintained their weight well and have gained in height. Out of the total number examined I find only 5 per cent. to be from 4 lbs. under the average weight. There were 54 boys and 66 girls so classed. Nose and Throats. There are still a considerable number of the children examined affected by enlarged tonsils and adenoids. Many of them have not taken our advice and had them removed. It is hoped that the parents will appreciate the efforts your Committee are making in providing for their removal at their own School Clinic. Teeth. 53.7 per cent. of the children suffer from decayed teeth. This is rather more than the percentage last year, probably due to the fact that the examination of the child's teeth was more rigid in the hope that even slightly carious teeth might be treated and saved by the Dentist. The Dental treatment now carried out at the Clinic is bound to have good effect as the years pass on. A report is at the end of this. (See Clinic). Ear Disease. 10 cases were noted during the year, but a number had been sent to the Clinic for treatment. As they occur in the Schools, Teachers have instructions to send them on to the School Clinic for treatment. Lyes. There are very few cases of external diseases of the eyes noted, the same remark applying to them as to cases of suppurating ears. 9 Fifteen per cent. of the children are found to require the use of spectacles. Many of them are already supplied with them, so that the percentage of children without them is not so great. Children are sometimes found attending school without their spectacles; either they have broken them, or their parents say they can see as well without them and so leave them off. The fact is that the child may have normal sight in one eye and very defective sight in the other eye, It is to improve and save what there is of sight in the defective eye, that the child has been given glasses to wear. It is not always easy to make parents understand this, and hence they abandon their use on the least provocation. It would save the child an immense amount of headache and eye-strain. There is a fuller report of the work done in this branch at ahe end. (See Clinic). The Committee have a contract with a firm of opticians to supply glasses at a comparatively low figure, and in cases where the parents are unable to pay even this amount, issue glasses at a lower figure, and in a few cases gratis. Deformities. There are no children suffering from any severe deformities, only four with slight lateral curvation of spine, nor have we any cripples. Blind Children. Four children who are blind are attending a Blind School under the help of the Education Committee. E.—General Review of the Relation of Home Circumstances and Social and Industrial Conditions to the Health and Physical Condition of the Children inspected. The social and industrial conditions were on the whole good. Several large factories in the district whieh during the war were employed in munitions have during the past year discharged a number of men, but most of these have left the district. At the end of the year the moulders strike caused a certain amount of 10 short time and unemployment, and while this continued a number of children of school age were provided with free meals. The children on the whole are well fed and of good physique. There is plenty of open country in the district and around it. There is at present some overcrowding owing to the shortage of houses. The general condition of the houses in the district is not so good as it was before the war, but steps are being taken to bring about the necessary improvement, though the cost of materials, &c., somewhat delays matters. The Sanitary condition is fairly good, the Birth Rate is above the average, while the Death Rate and the Infantile Mortality Rate are both well below the average for the country at large and that for similar areas. F.—Review of Methods employed or available for Treatment of Defects, etc. Two years ago a School Clinic for minor ailments, &c., was started in the Old Council Offices, High Street, and in my opinion has been of great benefit to the children of the schools. It has increased in its volume of work and in the number of children attending it. Very many of these are sent direct by their parents, and in many cases are brought by them for advice and treatment for any minor ailment. It has become necessary to have larger premises for the amount of the work that is being done, and so we are looking forward very shortly to occupying our new premises at " Hainault," Lesaey Park Road. We hope there to carry out much that has been hitherto left undone, through lack of accommodation and staff, a second School Nurse proving an absolute necessity, if the condition of the children in the schools is not to be overlooked. We also hope to carry out the necessary treatment in throat cases, and so be independent af the Hospital Authorities in London, who have not always served us well nor kept their promises to the parents who had placed themselves under their treatment. Many who have been sent up during the year have returned to us, 11 because the time was not convenient—this after arrangements had been made with them—and have been asked to wait and been forgotten. We trust to overcome the prejudices of the parents in these cases by doing them in our own Clinic and avoiding vexatious delays and disappointments. The total number of cases that have been treated by the Royal Free Hospital during the year is disappointing, in view of the large number awaiting and the arrangements we made with thh Authorities, only 65 children having been operated upon. There were 23 operated upon privately, by their own doctors or otherwise. In the Minor Ailments and Inspection Clinic, which meets every morning from 9.30 until over (at about 11.30), we are continuing our efforts to treat any skin condition or small ailment that the child is liable to while attending school. It is, I believe, being greatly appreciated by the teachers and by the parents. Much advice is given in other forms of disease to attending parents, and the inspections of children ailing or otherwise is at times very varied in character. We are often able to detect Infectious Disease and separate the child at once from its fellows. In this way we caught 1 Diphtheria, 4 Scarlet Fever, and 6 Chickenpox cases during the year The School Nurse undertakes the treatment of eyes ears and slight sores and injuries, under the direction of your Medical Officer. She is of great assistance in the whole work. She is capable and energetic, her heart is in her work and your Medical Officer is supported in his efforts for the welfare of the children up to the last fraction. Sometimes the work is too much for her alone, and we are hoping when we reach the new Centre we shall be able to secure another nurse to help her in her duties. These are very varied, from visiting the schools almost daily, Clinic-nurse, dental and ophthalmic, to the following up of the children in their own homes. To these she paid 630 visits for some purpose or another, that is following up cases from the Clinic, tendering 12 advice to the parents, or remonstrating with them for the non-attendance of the child regularly for treatment. I must, however, say that the parents are readily assisting us in regular attendance, more so than formerly. The following tables will give some idea of the amount and character of the work done at the whole of the Clinic. Hours and Days for Attendance at Clinic. Minor Ailments— Every morning except Thursday, 9.30 to 11 a.m. Teeth—Tuesday, 2 p.m. Thursday, 9.30 a.m. Sight—The Oculist attends once a fortnight on Friday Afternoons at 1.30. Children for Atropine to attend at 9.30 on Wednesday, Thursday and Friday Mornings before the day fixed for the Oculist's visits. Tonsils—Arrangements for removal of Tonsils to be made with School Nurse. Minor Ailments. Number of Children for Minor Ailments 458 Number of Children inspected 1251 Total 1709 These made a total attendance at the Clinic of 4,758 attendances and were treated as follows:— Impetigo 201 Scabies 43 Tonsilitis 34 External Eye Disease 32 Ear Disease 25 Eczema Cap. 23 Bingworm, Head 10 „ Body 5 Infectious Disease 34 Other Causes 51 Total 458 13 Dental Clinic. Under the direction of Mr. R. A. Preslie, L.D.S. (Edin.) Boys Girls No. of Defectives from Inspection Lists 293 332 No. of Casuals (children suffering from toothache or requiring immediate attention 238 269 531 601 Total number of Children treated as follows: 1132 Attendances for Inspection 158 „ „ Extraction 1306 „ „ Fillings 208 „ „ Scaling and Brush 27 Total number of Attendances 1699 Ophthalmic Clinic. Under the direction of Mr. A. Reynolds (of Moorfields, London). Boys Girls Tl. No. of Defectives from Inspection List 87 81 168 No. of Special Cases recommended 14 29 43 Total number of Children treated 101 110 211 Number of Attendances for Inspection 238 „ „ Atropine 184 „ „ Glasses 115 „ „ Re-examination 160 Total number of Attendances made 697 Summary of Work at Clinic. Total number of children who have received treatment or advice at the Clinic 3052 Total number of attendances made by children at the Clinic 7154 TABLE I. Return of Defects found in the course of Medical Inspection in 1919. defect or disease. No. referred for treatment. No. requiring to be kept under observation, but not referred for treatment. Malnutrition 120 Uncleanliness, Head 116 Body 15 Ringworm—Head 3 SKIN—Scabies 2 Impetigo 3 Other Diseases 6 eyes—Defective Vision and Squint 310 External Eye Diseases 17 ears—Defective Hearing 6 Ear Disease 10 teeth—Dental Disease 630 618 nose and throat— Enlarged Tonsils Enlarged Glands 155 Adenoids Enlarged Tonsils and Adenoids 89 288 265 Defective Speech 2 heart and circulation— Heart Disease— Organic Functional 40 Anæmia 9 LUNGS—Pulmonary Tuberculosis — Definite Suspected 10 Chronic Bronchitis 32 Other Disease nervous System— Epilepsy Chorea 2 Other Disease 3 Non-pulmonary Tuberculosis— Glands 19 Bones and Joints Other Forms Rickets 3 Deformities 3 Other Defects or Diseases 23 TABLE II. Numerical Return of all Exceptional Children in the Area in 1919. blind (including Partially Blind)— Boys. Girls. Total. Attending Certified Schools for the Blind 1 3 4 DEAF and Dumb (including Partially Deaf)— Attending Certified Schools for the Deaf 1 1 2 Mentally Defectives— Feeble Minded, attending Certified Schools for Mentally Defectives 2 2 Idiots 1 1 2 physically defective— Pulmonary Tuberculosis, not at School 4 4 8 Other forms of Tuberculosis— Attending Public Elementary Schools 7 9 16 Not at School 2 3 5 dull or Backward— Detailed examination by proper psychological Tests has not been possible, but teachers report about 5 per cent. retarded 2 years. TABLE III. Inspection, Treatment, &c., of Children during 1919. (l) The total number of children medically inspected 5548 (2) The number of children in (1) suffering from defects (other than uncleanliness or defective clothing or footgear) who require to be kept under observation (but not referred for treatment) 278 (3) The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, &c.) 2198 (4) The number of children in (3) who received treatment for one or more defects (excluding uncleanliness, defective clothing, &c.) 1889 TABLE IV. Treatment of Defects of Children during 1919. Condition. No. of defects found for which treatment was considered necessary. No. of defects for which no report is available. No. of defects treated. Results of Treatment. No- of defects not treated. Per cent. of defects treated. Remedied. Improved. Unchanged. From previous year. New* Total. Clothing Footwear Cleanliness of Head 106 106 106 106 100 per cent. Cleanliness of Body 15 15 15 15 100 „ Nutrition Nose and Throat 288 288 88 88 200 30 „ External Eye Disease 32 32 32 32 100 „ Ear Disease 25 25 25 25 100 „ Teeth 507 625 1132 1132 1132 100 „ Heart and Circulation 40 40 40 40 Lungs 42 42 42 Nervous System Skin 244 244 244 244 100 „ Rickets Deformities Tuberculosis (non-pulmonary) Speech Vision and Squint 243 243 211 211 32 85 „ Hearing Miscellaneous Total 507 1660 2167 40 1853 1828 25 314 85 „ * The return should show comprehensively all defects found during the year, from whatever source derived, which required treatment.