ERI 11 Urban District of Erith. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER, For the Year 1920, BY A. E. JERMAN, M.B., D.P.H. Public Health Committee, 1920. Chairman—Councillor Salmon. Councillor Downer Councillor Holmes. „ Grubb. ,, Robinson. „ Hampton. Maternity and Child Welfare Committee, 1920. Chairman—Councillor Robinson. Councillor Clark. Councillor Holmes. ,, Gough. ,, Higgins. „ Grubb. ,, Wilkinson. ,, Hampton. Co-opted Members— Mrs. Cross. Mrs. Pooler. „ Humphries. ,, Udbll. Education Committee. Chairman—Councillor Clark. Councillor Downer. Councillor Holmes. ,, Gough ,, Robinson. Hampton. „ Salmon. ,, Higgins. „ Wilkinson. Co-opted Members. Miss Goodiff. Mr. Bell. „ Murphy. „ Udell. Mr. Chubb. „ Walkbr. 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. Dayies, O.K. San. Inst. Assistant Sanitary Inspector— T. Vaughan, C.R. San. Inst. Health Visitors— Nurse Crouch. „ Denson School Nurses— Nurse Lange. „ Clarke. Clerks — Health Dept.—Mr. E T. Castree. 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. 4 Council Offices, Erith. July 23rd, 1921. The Chairman anil Members of the Urban District Council of Erith. Ladies and Gentlemen, I have the honour to submit to you my Annual Report for the year 1920, in accordance with the Regulations of the Ministry of Health. I regret the delay that has arisen in its preparation, but it was unavoidable. The Report on the School Medical Service for the year has been prepared by Dr. Hardie, the Assistant School Medical Officer. I am, Your obedient Servant, A. E. JERMAN. 5 Annual Report for 1920. A.—Natural and Social Conditions of the District. At the Census of 1911 the population was 27,750, viz.:—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 largely increased by the influx of men and women, working at the various factories. Several large houses and institutions were taken over as Hostels for work people, and in addition 4 large Hostels were formed by the erection of temporary buildings and huts. The population was estimated, by the Registrar-General in 1915, to be 35,232, but this has diminished, and is now estimated to be 31,741 at the middle of 1920. The District is now almost entirely industrial, and is situated south of the River Thames, adjoining the County of London on the west, the urban districts of Crayford on the east, and Bexley on the south. The majority of the population is employed in one or other of the factories, the principal ones being engaged in cable making, gun making, oil refining, manufacture of mining and electrical machinery, and of asbestos and cement slabs. The area of the district is about 3,859 acres, the northern portion of which (1,689 acres) lies along the River Thames; the southern portion rises to about 200 feet above sea level. 6 Vital Statistics. Births.—795 births were registered in the district during- the year 1920, 416 were males and 379 females. The number of births notified during' the same period was 783. The corrected figures as supplied by the RegistrarGeneral after allowing for inward and outward transfers are 813, viz., 430 males and 383 females. of these 27 (13 males and 14 females) were illegitimate. There were 15 still births (11 males and 4 females). The birthrate for the year is 25.61, as compared with a rate of 25.4 for the whole of England and Wales and 24.9 for the 148 smaller towns (Census population 20,000—50,000) including Erith. The illegitimate birthrate is .85 per 1,000 population, and 33.21 per 1,000 births. The birth rate for 1920 is 4.5 per 1,000 higher than that for 1919. Deaths.—The number of deaths registered in the district during 1920 was 226, giving a death rate of 7.1 per 1,000. The deaths of 5 persons whose homes were in other districts must be deducted from this total, but to it must be added 85 deaths of residents who died in other districts, making a nett total of 306 deaths belonging to the district. This gives a nett death rate of 9.64 per 1,000 population as compared with 10.71 in 1919. For purposes of comparison, I give a table showing the provisional figures for England and Wales for 1920 with regard to birth rates, death rates, and infantile mortality rates: — 7  Birth Rate per 1000 total population. Death Rate per 1000 total population. Rate per 1000 Births. Diarrhcea & Enteritis (under 2 years). Total Deaths under 1 year. England and Wales 25.4 12.4 8.3 80 96 great towns, including London (Census population over 50,000) 26.2 12.5 10.4 85 148 smaller towns, including Erith (population 20,000—50,000) 24.9 11.3 7.8 80 London 26.5 12.4 9.5 75 Erith 25.61 9.64 2.46 61.5 It will be seen that the rates for Erith cotnpare very favourably with those given, the birth rate *being slightly above the average, and the death rate, the infantile mortality rate, and the rate for diarrhoea and enteritis being well below the averages. During the first quarter of 1920 the number of deaths was 85, and 92, 52 and 77 during the second, third and fourth quarters, respectively, as compared with 110, 74, 61 and 82 in the corresponding quarters of 1919. There were 10 deaths in Public Institutions in the district, 9 being those of 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. 1919 327 38 12 19 18 18 50 77 95 1920 306 50 11 7 16 19 37 80 86 The chief causes of death during (ho year were: — Organic Heart Disease 47 Cancer 32 Pulmonary Tuberculosis 26 Premature Birth, Congenital Debility, &c. 23 Pneumonia (all f'orrfis) 25 Bronchitis 20 8 Inquests.—There were 19 Inquests held during the year; the causes of death are as shown : — Natural Causes 9 Suicide 4 Violent Deaths 4 Drowning 2 19 Cancer. The number of deaths due to cancer was 32, viz.: 16 males and 16 females. Table showing age and sex distribution of deaths from Malignant Disease (Cancer) during past 7 years. 0—1 1—2 2—5 1 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 V. 4 6 8 18 1916 M. 1 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 1920 M. 1 10 5 16 32 1.00 F. 2 10 4 16 Infantile Mortality. During 1920 the number of deaths of children under one year of age was 50, between 1 and 2 years 11, and between 2 and 5 years 7, as compared with 38, 12 and 19 during 1919. 9 The death rate for children under 1 year of age per 1,000 births is 61.5 as compared with 56.71 for 1919. During the 10 years 1895—1904 the Infantile Mortality rate averaged 132.6, with a maximum of 200 in 1898, and a minimum of 93.0 in 1903. During the five years 1905—1909 the average was 83. 71, for 1910—1914 it was 76.19, and for the years 1915—1919 it was 68.33. The decrease has been very steady during the past 15 years. Of the 50 deaths under 1 year of age registered in 1920, 26 occurred in the first 4 weeks of life, and 36 during the first six months. Table showing Births and Deaths under 1 year, and Infantile Mortality rates for the 10 years 1895—1904, for 3 subsequent periods of 5 years, and for 1920. Births. Deaths under 1 year. Infantile Mortality Bate. 10 Years 1895—1904 7795 1034 132.6 5 ,, 1905—1909 4144 347 83,71 „ „ 1910—1914 3675 280 76.19 „ „ 1915—1919 3629 249 68.33 „ „ 1920 813 50 61.5 If the Infantile Mortality rates of legitimate and illegitimate children are compared, it will be seen that as a rule the rate for illegitimate children is very much higher than that for legitimate ones. For the year 1920, however, this does not hold good. During 1920 there were in this district 786 legitimate births and 49 deaths, giving a rate of 62.34 per 1,000 legitimate births, while there were 27 illegitimate births, and only 1 death during that period, giving a rate of 37 only. The subjoined table shows numbers of legitimate and illegitimate births with mortality rates for the past 10 years. 10 Year. Number of Births of Illegitimate Children. Total number of Births. Bate of Illegitimate Births per 1,000 Births. Number of Deaths of Illegitimate Children. Mortality Rate of Illegitimate Infants per 1,000 Illegitimate Births. Mortality Bate of Legitimate Children per 1,000 Legitimate Births. 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 1920 27 813 33.21 1 37 0 62.34 Table IV shows the cause of deaths of children from birth to 1 year of age. Twenty deaths, that is 40 per cent., took place during the first week of life, and 20, or 52 per cent., during the first 4 weeks. Twenty-three deaths were duo to premature birth, including congenital debility and malformation, 0 to pneumonia, and 5 to bronchitis. 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 Eailway 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 11 Works at Anchor Bay. No ejectors are required 011 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. 2 45 h.p. motor electrically driven air compressors. 2 6-in. and 1 4-in. 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. There are a number of houses built on the marsh, near Belvedere Station, and on the high ground at Abbey Wood, which are drained into cesspools, owing to there being no sewer available. These cesspools on the 12 Marsh have always been a source of trouble, as they cannot be made watertight, and fill up with subsoil water atsoon as they are emptied, and in addition, during the winter and wet weather, the Marsh land is in such a water-logged condition as to make it extremely difficult, and sometimes impossible for the cesspool emptying vans to reach the places where the cesspool matter may be deposited. During the past year the Council have had under consideration a project for sewering this area, and the Surveyor has been instructed to prepare the necessary plans. (3) Closet Accommodation. Nearly every house in the district is provided with a water closet. 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. During 1920 the number of loads of house refuse removed was 6,463, as compared with 6,321 in 1919. Before the war when in the course of inspection a house was found to be without a proper sanitary dustbin, notice was served on the owner to provide the same. This procedure had been in abeyance for the past 4 years, but has been resumed again during 1920. 13 Under the Erith Improvement Act, 1920, the Council obtained power to specify the material of which sanitary dustbins may be made, and the size of the same, and have exercised this power. (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 741 Houses inspected under the Housing and Town Planning Act 1030 Slaughterhouses 95 Cowsheds, Dairies and Milkshops 39 Workshops 67 Outworkers' premises 7 Bakehouses 33 Offensive trades 25 Vans, tents and sheds 127 Complaints enquired into 310 2474 Result of above Inspections. Nuisances detected 689 Preliminary notices served to abate nuisances 314 Statutory notices served to abate nuisances 84 Nuisances abated Notices issued under the Factory and Workshops Act 573 1 Notices complied with 1 Notices issued to provide proper receptacles for house refuse 304 Notices complied with 286 Notices issued to provide sufficient drainage (Section 23, P.H. Act, 1875) 11 Notices complied with 11 Notices issued under the Cowsheds, Dairies and Milkshops Order 1 |Notices complied with 1 14 Nuisances. Showing the number and nature of the nuisances dealt with during the year:— Defective and choked drains 311 Damp and dilapidated dwellings 142 Defective rain-water gutters and down pipes 73 Insanitary water storage cisterns 32 Defective scullery sinks 14 Defective flush to closets 54 Insanitary urinals 3 Foul accumulations ?q Dirty premises 15 Overcrowding 4 Animals so kept as to be a nuisance 12 689 Cleansing. Number of cesspools emptied 391 Number of loads of house refuse removed 6463 Infectious Disease. Number of cases enquired into 225 Number of cases removed to the Sanatorium 214 Number of cases removed to the Long Reach Hospital, Dartford 5 Number of houses disinfected 231 Food Inspection. The following articles of food were surrendered to me as unfit for human consumption:— Fish. Meat. Other Articles. 13 boxes of Herrings. 2641bs. of Beef. 241 tins of Condensed Milk. 7 boxes of Haddocks. 621bs. of Mutton. 4 boxes of Bloaters 1021bs. of Livers. 73 tins of Tomatoes. 2 boxes of Mackerel. 281bs. of Bacon. 1241bs. of Cheese. ½ bushels of Winkles. 35 boxes of Rabbits. 5 bags of Onions. 3 stone of Dabs. 9 Geese. 561bs. of Chestnuts. 1 box of Coal Fish. 13 jars of Potted Meat. 1 box of Hake. 1 box of Dates. 6 stone of Skate. 15 (6) Premises and Occupations which can be controlled by Bye-laws and Regulations. Tents, Vans and Sheds. As stated in previous reports, there are still a number of vans and sheds situated on the marshes at Abbey Wood. The condition of some of these is good, but others are dirty, and the ground about is sodden with slopwater. The Council's Bye-laws require the owner of the land to provide a proper and sufficient water supply and an earth closet, but many of these vans stand on plots, all trace of whose owners has been lost. During 1920 the District Council promoted a Bill in Parliament, and in that Bill is a clause giving some extended powers for dealing with these tents and vans, this is shown below, but no case necessitating its use has yet occurred. " (1) If any squatter or gipsy or other person dwelling in a tent or van or other similar structure and occupying any land within three hundred yards of any dwelling-house within the District shall cause injury or annoyance to residents in the neighbourhood or be a nuisance or dangerous or injurious to health a court of summary jurisdiction may on complaint by the Council make an order prohibiting (either absolutely or subject to conditions) the further occupation of such land or any other land within a radius of one thousand yards thereof by such squatter gipsy or other person and if the order be not complied with the owner or lessee of the land or other person who suffers the land to be so occupied and the squatter gipsy or other person shall each be liable to a penalty not exceeding five pounds and to a further penalty not exceeding twenty shillings for every day on which the land shall be so occupied after the date from which the said order takes effect. 16 "(2) The Council before making any complaint shall give to the said owner or lessee or other person who has suffered land to be so occupied not less than twenty-four hours' notice in writing of their intention so to complain and shall at the same time give a similar notice to any squatter gipsy or other person who shall then be occupying the land with regard to whom the complaint is intended to be made. "(3) This section shall not apply to any person dwelling in a tent or van or other similar structure who is a roundabout proprietor or showman or stallholder (not being a pedlar or hawker) nor to any owner or lessee or other person who suffers any land to be occupied by such persons in such manner aforesaid." 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 declaring 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 matter, and the manufacture of animal charcoal. The Bye-laws regxilating 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 arc carried on have been periodically inspected during the year and found in satisfactory condition. 17 (7) Schools. The sanitary conditions of the Schools in the district are good on the whole. The water supply is obtained from the Metropolitan Water Board. There has been no epidemic, and no particular incidence of infectious disease on any School. Classes were examined frequently, where children were absent owing to notifiable infectious disease, with a view to finding "missed" cases, and two were so found. C.—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 64 cows. The cows are periodically inspected by the Veterinary Surgeon appointed by the Council, and a report on their condition is furnished quarterly. During 1920 no case of Tuberculosis was detected. The cowsheds and milkshops are regularly inspected, and on one occasion it was found necessary to issue a notice to cleanse a cowshed. Samples of the milk sold in the district were taken by the Inspector of the Kent County Council, and 39 samples so taken were all found to be genuine, one sample was found to contain 9.1 per cent, of added water and to be deficient in milk fat. In this case proceedings resulted in a conviction, a penalty of £5 being imposed. (2) Milk (Mothers & Children) Orders, 1918 & 1920. When this Order was issued, the Council laid down a scale as follows:— 18 (1) 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 per cent, of the cost being paid by the Council. (3) Up to 8s. per head per week milk was granted, the Council paying 50 per cent, of the cost. Above 8s. no assistance was given. This scale was in force at the beginning of 1920, but early in the year, owing to the increased cost of living, it was raised by 50 per cent., so that the limits became 10s. 6d., 11s. 3d. and 12s. 6d. The case of each applicant was considered by the Committee, and where assistance was granted the necessary order was issued to the milk purveyor. In the majority of cases fresh milk was granted, but there were a certain number of cases of infants under 18 months old where dried milk was issued, on a certificate either by the Medical Officer of the Infant Welfare Centres, or by myself. The number of families supplied with fresh milk during the year was 171, and the quantity of milk 3,966 gallons; 29 families were supplied with 1,087 packets of dried milk, and the approximate total cost was £800. (3) Slaughter Houses. There are 2 slaughter houses on the register; 95 visits of inspection were paid to these, both at slaughtering times and other times, but no tuberculous meat was detected. (4) Bakehouses. There are 11 bakehouses in the district, none of them underground. They have been regularly inspected and found in satisfactory condition. 19 (5) Other Foods. Premises where food is prepared have been inspected during the year and found satisfactory. A summary of the various articles surrendered by the vendors to the Inspector of Nuisances as unfit for human consumption is given on page 14. (6) Sale of Food and Drugs Acts. The Local Authority for the administration of these is the Kent County Council. I have obtained from the Clerk to the Kent County Council a return showing the number of samples taken in the district during 1920, with the result of the examination, and any subsequent action taken. The return shows that 110 samples were taken, and found to be genuine (including 39 of fresh milk, 8 butter, 16 margarine, 9 lard), while only two were found to be adulterated. One, a sample of milk referred to above, and the other a sample of cream, which contained a borax preservative amounting to .26 per cent, calculated as boric acid. A caution was given in this case. (7) Workshops, Workplaces, Etc. There are 95 of these on the Register, but a number are "domestic" workshops, where only members of the family are employed. These have been inspected, and in 1 case a notice was served in respect of unsuitable sanitary accommodation. This notice was complied with. Fourteen lists of outworkers were received from other Local Authorities, but none from employers in the district. The premises occupied by these outworkers have been inspected and found satisfactory. 20 D.—Prevalence of and Control over Infectious Diseases. There were 406 cases of infectious disease notified during 1920, viz.:—Small Pox 5, Scarlet Fever 132, Diphtheria 95, Pulmonary Tuberculosis 47, other forms of Tuberculosis 18, Pneumonia 26, Erysipelas 23, Chicken Pox 48, Malaria 5, Enteric Fever 3, Ophthalmia Neonatorum 3, Puerperal Fever 1. On the 1st of January, 1920, Measles ceased to be a notifiable disease, and in April, owing to an outbreak of Small Pox, Chicken Pox was made notifiable for a period of 3 months by special resolution of the Council. Comparative returns of Infectious Diseases notified during past 10 years (not including Tuberculosis):— Disease. 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Srrall-pox 5 Diphtheria 35 42 38 86 105 118 55 20 31 95 Measles Not No tifia ble. 131 616 207 236 German Measles Erysipelas 19 21 11 7 21 15 13 4 9 23 Scarlet Fever 99 68 115 307 231 182 35 68 74 132 Enteric Fever 5 7 10 22 3 4 7 3 2 3 Continued Fever 1 Paerperal Fever 2 2 2 1 2 1 2 1 Ophthalmia Neonatorum 4 5 4 9 3 Poliomyelitis 1 1 1 Cerebro Spinal Fever 1 4 1 Malaria Not Notifia ble. 6 5 Pneumonia & Influenzal Pneumonia Not Notifia ble. 43 26 Chicken-pox 48 159 141 176 425 366 454 733 307 414 341 Small Pox. There was a small outbreak of this disease in March. The first case occurred in a child of 4 years of age, who had never been vaccinated. No source of infection could be found after exhaustive enquiry. This case infected 3 other persons in the same house, 2 children and 1 adult. The fifth case was apparently an independent infection. All the cases recovered. 21 The first case notified was unvaccinated, 3 children (previously unvacciiiated) and 1 adudt who had been in direct contact with this were vaccinated, but 2 children developed Small Pox, the attack in each case being very mild. The adult, a woman between 50 and 60, who was also infected by this case, had not been vaccinated since infancy. The fifth case occurred in a woman of about 40 who had not been re-vaccinated since infancy. Scarlet Fever. There were 132 cases of Scarlet Fever, as compared with 74 in 1919. Of these 86 were in children between 5 and 15 years of age, 29 in children under 5, and 17 in persons over 15. This increase in the number of cases coincided with the general increase all over the country. There was no special incidence on any School, and classes were inspected on numerous occasions where cases of Scarlet Fever had occurred, and 2 children were found to be desquamating. The attack rate for the disease was 4.15 per 1,000 population, and there were 2 deaths, giving a case mortality of 1.5 per cent., and a death rate of .06 per 1,000. One hundred and eighteen cases were removed to hospital for treatment, a percentage of 89.3. Diphtheria. There were 95 cases of Diphtheria notified in 1920, as compared with 31 in 1919. Of these 55 were in children of school age, 27 in children under school age; and 13 in persons over school age. This increase also coincided with the general increase in the number of cases all over the country. There was no special incidence on any school. The attack rate for the disease was 2.99 per 1,000 population, and the number of deaths was 5, giving a case mortality of 5.26 per cent., and a death rate of .15 per 1,000 population. Ninety-three cases were removed to the Sanatorium for treatment, a percentage of 97.8. 22 Enteric Fever. Three cases were notified during the year, all were removed to hospital, and recovered. One proved to be a case of Paratyphoid B. Measles. This was not notifiable, and there was no great prevalence of the disease at any time. Chicken Pox. This was notifiable for 3 months, and during that period 48 cases were notified. Malaria. Five cases only were notified, all in demobilised soldiers, and contracted abroad. Ophthalmia Neonatorum. Three cases only were notified as compared with 9 in 1919. They were all visited and kept under observation, in no case was there any permanent injury to vision. Tuberculosis. The number of notifications of fresh cases of this disease during 1920 was 65, viz.: —47 pulmonary, and 18 of other forms, as compared with 122 (86 pulmonary and 36 other forms in 1919. The following table shows the number of cases of Tuberculosis notified each year since 1913 when notification was made compulsory. 1913 1914 1915 1916 1917 1918 1919 1920 Pulmonary 63 52 45 50 69 58 86 47 Other forms of Tuberculosis 17 10 11 9 17 15 36 18 Total 80 62 56 59 86 73 122 65 23 The number of deaths from Tuberculosis during 1920 was 33, as compared with 40 during 1919. Of these 26 were due to Pulmonary Tuberculosis, 4 to Tuberculous Meningitis, and 3 to other Tuberculous diseases. The death rate from all forms of Tuberculosis was 1.04 per 1,000 in 1920, as compared with 1.31 in 1919, while that from the pulmonary form was .82 per 1,000 as compared with 1.04. There is a Tuberculosis Dispensary established by the Kent County Council, and a large majority of notified cases attend there; in addition cases of suspected Tuberculosis among contacts with notified cases attend. There is also a Sanatorium established by the Kent County Council at Lenham, where suitable cases are sent for treatment, and some cases are sent to Sanatoria in other parts of the country. Twenty-seven patients were admitted to various Sanatoria and Hospitals during 1920. E.—Maternity and Child Welfare. The Midwives' Act is administered by the Kent County Council. There are four midwives practising in the District, and 3 midwives working at the Council's Maternity Home, "Hainault." The Council employ two Health Visitors, who carry out under my supervision, the visiting of houses where births are notified, or for other reasons, and they also assist in the work at the Infant Welfare Centres, and the Ante-natal Clinic. There are two Infant Welfare Centres, one at Erith, and one at Belvedere, and an ante-natal Clinic. Each of these is open once a week, when a lady Medical Officer attends, who has had great experience in such work. At the beginning of the year the work of alteration was in progress at " Hainault" to make it suitable for use as a Maternity Home and School Clinic, and in April it was opened for use as a Maternity and Child Welfare Centre, and the Infant Welfare Centre, for 24 Erith, and the Ante-natal Clinic were transferred here to premises far more pleasant and suitable than those hitherto occupied. Notification of Births. During 1920, 783 births were notified as having' occurred in the district (including 15 still births), the number registered in the district was 795. Twenty-seven (13 males and 14 females) were illegitimate. Houses where births have occurred are visited by the Health Visitors, usually after the 10th day, but occasionally visits are paid earlier where there appears to be sufficient reason, such as the notification of ophthalmia. As a rule they are well received. The time of second and subsequent visits depends on the conditions found at their first visit, some cases requiring more frequent visits than others. Mothers are encouraged to bring their children to the Welfare Centres and advice is given them as to clothing and feeding, and as to the care they should take of their own health. The Health Visitors paid a total of 5,441 visits in 1920, made up as follows: 1st visits 905, subsequent visits 3,514, ante-natal 446, visits to Tuberculous and other infectious cases, including Ophthalmia, 522, and visits to dental cases 54; these figures compare favourably with those for 1919, viz.: 4,738, 592, 3,044, 452, 557, and 93. The Infant Welfare Centres were opened each week during the year (except those in which a Bank Holiday occurred). The total number of attendances was 4,188 (Erith Centre 2,167, Belvedere 2,021), as compared with 2,897 the previous year (Erith 1,514, Belvedere 1,383). The ante-natal clinic was open the same number of times, and 180 expectant mothers made 253 attendances. 25 A Dental Clinic for nursing and expectant mothers is also in existence, and open once a week, and 57 mothers made 165 attendances. Assistance is also given by the Council in the provision of dentures for nursing or expectant mothers where there appears to be necessity, and this was given in 9 cases during 1920. Recommendations for dental treatment are made by the Lady Medical Officer who attends the Ante-natal Clinic, or by the Medical Officer of Health, and after their first visit to the Dental Clinic, patients attend as directed by the Dental Surgeom A stock of the following foods, etc., is kept and sold at the centres at cost price: — Glaxo Ambrosia Dried Milks Cow and Gate J Marylebone Cream. Lactagol. Cod Liver Oil and Malt. Virol. Roboleine. Chymol. The amount received by the sale of these foods during 1920 was £797 1s. 4d. Patterns of model baby clothing are also kept and sold to the mothers attending the Centres and Ante-natal Clinic. During 1920 the Maternity Home at "Hainault" was opened for maternity work. The first case was admitted in June, and up to the end of the year 22 cases had been admitted. The ground floor is used for the Infant Welfare Centre for Erith, and the Ante-natal and Dental Clinics, and also for the purpose of a School Clinic for minor ailments, dental and ophthalmia work. 26 The first floor is occupied by the Maternity Wards, Labour Room and necessary annexes. A charge of £1 1s. 0d. per week was fixed for patients, and this could be reduced or remitted at the discretion of the Committee-in-Gharge. Towards the end of the year, however, a modification in the charges was introduced, and a scale fixed varying according to the number in family of the person seeking admission. The staff at the home comprised at first two Nurse Midwives with a Wardmaid and Cook, but at the end of the year another Nurse Midwife was appointed. There is also a caretaker, who lives on the premises. F.—Sanitary Administration. (1) Staff, Work of Inspectors, &c. The Statf consists of myself, as Medical Officer of Health, School Medical Officer, and Medical Officer in charge of the Sanatorium for Infectious Diseases; D. 1$. 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. During the year Mr. E. J. Castree was appointed Clerk in the Public Health Department. In addition there are a part-time Lady Medical Officer, Dr. J. Lorimer Hawthorne, two full-time Health Visitors, and a female clerk, whose work chiefly lies in connection with the Maternity and Child Welfare Department. The two Health Visitors at the beginning of the year were Nurses Cruise and Crouch, but during the year Nurse Cruise resigned her post, and Miss Denson was appointed to the vacancy. 27 (2) Hospital Accommodation. The Sanatorium for Infectious Diseases is situated at Little Heath, Belvedere, near the centre of the Southern Boundary of the District. 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 onebed wards for observation purposes. There is also a block of two wards (4 beds in each) which can be utilised 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. At the end of the year the Council decided to obtain a motor ambulance for the removal of Infectious Cases. The staff at the Sanatorium consists of a matron, a charge nurse, 3 assistant nurses and 2 probationers, with the necessary domestic staff, a laundress, and porter who resides in the porter's lodge. During the year Miss Bellinger, the matron, resigned owing to ill-health, after 7 years' service, and her place was filled by the appointment of Miss Jones, from the Great Ormond Street Children's Hospital. During 1919 there had been some difficulty in obtaining nurses for the Sanatorium, but this passed off during 1920. On January 1st, 1920, there were in the Hospital 17 cases of Scarlet Fever and 2 cases of Diphtheria, a total of 19. During the year there were admitted 115 cases of Scarlet Fever, 92 cases of Diphtheria, 3 of Enteric Fever, and 2 of other diseases. 28 Two cases of Scarlet Fever died during the year, one case of Tuberculous Meningitis and 4 cases of Diphtheria. The remaining cases recovered, and on December 31st, 1920, there were in Hospital 16 cases of Scarlet Fever and 9 of Diphtheria, a total of 25. No patient who has had Diphtheria is discharged from hospital until a bacteriological examination of a swab from the throat (and also from the nose or ear if any nasal or aural discharge has been present) shows that the Diphtheria Bacillus is absent, and at least two consecutive negative results are required. The examinations are carried out by the Kent County Laboratory at Maidstone, and 274 swabs were so examined during 1920, 47 were positive, 9 doubtful, and 218 negative. In addition one patient's blood was examined for Enteric Fever, and it was found that he was suffering from Paratyphoid Fever. The average stay of Scarlet Fever cases was 43 days, and of Diphtheria 33 days. The longest period for which a case of Scarlet Fever was detained was 101 days, and of Diphtheria 85 days. There is no accommodation for Small Pox or Cerebrospinal Fever, but arrangements have been in force for some years with the Metropolitan Asylums Board whereby such cases are sent to their Hospital at Joyce Green, Dartford. Motor Ambulance. There is a motor ambulance service carried on in conjunction with the Fire Brigade in the District, which has proved a great boon. It conveys acute cases from the district to the London Hospitals, and patients who have sustained accidents to their homes or to Hospital. During the year 1920 the Ambulance was in use on 535 occasions. (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 29 fectious 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. There is also a new " Erith Improvement Act, 1920," embodying clauses giving more power to the Council in various matters relating to Public Health. (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. G.—Housing. (i) General Housing Conditions in the District. The majority of the houses in the district are cottages containing G 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 hotises were built. 30 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 ampty. 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 1920 the Registrar-General estimated the population to be 31,741. Work has been commenced on the Housing Schemes proposed by the Council, and on one site about 90 houses are in course of erection. (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. 31 During the last 2 or 3 years of the war no systematic housing inspections were undertaken, but in July, 19J 9, this was again started, and a list made of the worst properties in the district with a view to their inspection. During 1920, 1,030 houses were inspected under the Housing and Town Planning Acts, and in 969 cases notices were served requiring some work to be done. In 219 the work had been completed, in 231 it was in hand, but in 519 nothing had been done. A Table is given at the end showing in detail the defects found. The character of the defects found is precisely the same as I have noted in former reports. Of the 969 defective houses 210 had some defect in water supply, 491 in closet accommodation, 302 in drainage, 106 in ventilation, 389 in state of the yard, 552 were damp to some extent, and 376 were defective in disposal of refuse. The number of visits for re-inspection was 2,443. Water Supply. There was some defect in this in 210 houses. In the large majority of cases the water was obtained from a cistern which was badly placed, or had no proper cover. All houses should have a tap direct from the main for supplying drinking water. Closet Accommodation. In 491 there was some defect. Dilapidated walls and doors, defective flushing cisterns and leaky joints were the principal ones. Drainage. The defects in this, 302 in number, were chiefly absence of fresh air inlets, broken gullies and channels, and badly jointed vent pipes. Ventilation. The defects in this, 106 in number, were all defects in ventilation of spaces below the ground floors. 32 Dampness. There was dampness of walls in 552 cases, due to various causes, porosity of bricks, aspect of walls, condition of pointing, leaky gutters and down-pipes, and absence of proper damp-proof courses. Yard Paving. In 389 houses the yard paving was absent or broken and dilapidated. Refuse Disposal. In 376 houses there was a lack of a proper sanitary dustbin. Notices to provide these are served on all owners. Other Defects. In 830 houses some defect other than those mentioned was found. Dilapidated walls and ceilings, broken floors, absence of lain-water gutters, defective roofs, and broken window and door frames. Where inspection revealed defects, informal notices were served in the first instance, detailing the defects found, and asking the owner to have these remedied. In 450 cases this resulted in the work being done. Where nothing was done, notices under Section 28 of the Housing and Town Planning Act, 1919, were served where the conditions required it, and in all 138 such notices were served. Three owners served notices of their intention to close the premises on the Council—in two cases 1 house each, the other referring to 9 cottages. The Council appealed to the Ministry of Health, and the matter was under consideration at the close of the year. In 43 cases the work had been completed, in 21 it was in hand, but in 74 nothing had been done. 33 APPENDICES. 1.—General. 1. Estimated population 31,741 2. General death rate 9.64 3. Death rate from Tuberculosis 1.04 4. Infantile mortality rate 61.5 5. No. of dwelling-houses 5,700 6. No. of working-class dwelling-houses 5,000 7. No. of new working-class houses erected 90 II.—Unfit Dwelling Houses. (I) Inspection. (a) No. of dwelling-houses inspected and corded under the Housing (Inspection of District) Regulations, 1910 1,030 (b) No. of dwelling-houses found to be unfit for human habitation nil. (c) No. of dwelling-houses found not to be in all respects reasonably fit for human habitation 138 (2) Remedy of defects without services of formal notices. Number of dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 450 (3) Action under Statutory Powers. A.—Proceedings under Section 28 of the Housing and Town Planning Act, 1919: — 1. No. of houses in respect of which notices were served 138 2. No. of houses rendered fit: (a) by Owners (completed) 43 (in hand) 21 (b) by Local Authority nil. 34 3. No. of houses in respect of which ClosingOrders became operative in pursuance of declarations by owners 11 B.—Proceedings under Sections 17 and 18 of the Housing & Town Planning Act, 1909: — 1. No. of Representations made with a view to making of Closing Orders nil. 2. No. of Closing Orders made nil. 3. No. of Closing Orders determined 3 4. No. of Demolition Orders made nil. 5. No. of houses demolished nil. 111.—Unhealthy Areas. No. areas were represented as unhealthy. 35 Table I.—Vital Statistics of Whole District during 1920 and previous years. Year. Population estimated to middle of each year. Births. Ttl. Deaths registrd. in the Distr't. 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 Agre Number Rate. No. Rate per 1000 nett Births No. Rate 1 2 3 4 5 6 7 8 9 10 11 12 13 1915 35,232 724 738 20.94 305 8.65 5 78 54 73.17 373 10.58 1916 (a) 38,093 807 807 21.71 307 8.48 21 95 48 58.04 381 10.88 (b) 35,011 1917 (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 .. 1920 31,741 795 813 25.61 226 7.1 5 85 50 61.5 306 9.64 (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. 36 Table II.—Cases of Infectious Disease notified during the Year 1920. Notifiable Disease. Number of caess notified. Total cases removed to Hospital. At Ages—Years. At all Ages. Under 1 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 3 24 55 9 4 95 93 Erysipelas 1 1 7 11 3 23 Scarlet Fever 3 26 86 13 4 132 118 Enteric Fever 1 1 1 3 3 Puerperal Fever 1 1 Ophthalmia Neonatorum 3 3 Pneumonia and InfluenzalPneumonia 1 6 3 2 4 8 2 26 Malaria 4 1 5 *Chicken-pox 5 13 30 48 Small-pox 1 2 1 1 5 5 Tuberculosis: — Pulmonary 7 20 18 2 47 Other forms 3 5 2 7 1 18 Totals 15 74 189 48 51 24 5 406 219 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. * Chicken-pox was notifiable for 3 months only. 37 Table III.—Causes of, and Ages at Death during the year 1920. 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- Total All ages. Under 1 year. 1 and uuder 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 Certified 305 50 11 7 16 19 37 79 86 10 causes Uncertified 1 Enteric Fever Small-pox Measles 3 2 1 Scarlet Fever 2 1 1 2 Whooping Cough 3 2 1 Diphtheria 5 1 1 3 4 Influenza 1 1 Meningitis 1 1 Phthisis 26 2 1 2 9 9 3 Tuberculous Meningitis 4 1 2 1 1 Other Tuberculous Diseases 3 1 1 1 Rheumatic Fever 1 1 1 Cancer 32 3 20 9 Bronchitis 20 5 1 1 6 7 Broncho-pneumonia 12 5 4 3 Pneumonia 13 1 1 1 2 1 5 2 Other respiratory diseases 3 2 1 2 Diarrhoea and Enteritis 3 3 1 Appendicitis 1 1 Alcoholism Cirrhosis of Liver 2 1 1 Nephritis 12 2 7 3 Puerperal Fever 3 3 Other accidents & diseases of pregnancy 3 1 2 Congenital Debility and Malformation 23 23 Violence 8 1 1 2 3 1 1 Suicide 5 3 2 Organic Heart Disease 47 1 2 6 15 23 Other Defined Diseases 70 5 1 5 1 5 18 35 Totals 306 50 11 7 16 19 37 80 86 10 38 Table IV. —Infantile Mortality during the Year 1920- 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 Certified causes (Uncertified 20 1 3 2 26 7 3 9 5 50 1 1 Whooping Cough 1 1 2 Diarrhoea 1 1 Enteritis 1 1 1 2 Tuberculous Meningitis 1 1 Abdominal Tuberculosis 1 1 Other Tuberculous Diseases 1 1 2 Congenital Malformation 1 1 1 2 Premature birth 15 2 1 18 2 20 Atrophy, Debility and Marasmus 1 1 Atelectasis Convulsions 3 1 3 1 3 1 Bronchitis Pneumonia (all forms) Other causes 1 i 1 1 6 1 6 2 Totals 20 i 3 2 26 7 3 9 5 50 Legitimate 786. Nett Births in the year Illegitimate 27 , 1 Legitimate Infants, 49. Nett deaths in the year of Illegitimae Infants, 1. 41 Factory and Workshop Act, 1901 Factories, Workshops, Workplaces and Homework. 1.—Inspection of Factories, Workshops and Workplaces (including inspections made by Sanitary Inspectors or Inspectors of Nuisances). Premises. No. of Inspections. No. of Written Notices. 1 2 3 Factories (including Factory Laundries) Workshops (including Workshop Laundvies 25 67 Nil. 1 Total 92 1 2. —Defects found in Factories, Workshops & Workplaces. Particulars. No. of Defects Found. No. of Defects Remedied. 1 2 3 Nuisances under the Public Health Acts— Sanitary accommodation: Unsuitable or defective 1 1 Total 1 1 3.—Home Work—Outworkers, Lists received from other Local Authorities, and not from Employers within the Urban District of Erith. Wearing Apparel— Making, &c. 6 Button Manufacture 6 Backet and Tennis Balls 2 14 4.—Registered Workshops. Workshops on the Register at the end of the year. 1 Number 2 Bakehouses 11 Dressmaking 18 Boot Repairing 20 Others 46 Total number of Workshops on Register 95 5.—Other Matters.—(Nil). Housing, Town Planning, &c., Act, 1909. Summary of work done under the Housing (Inspection of District) Regulations, 1910, for period January 1st to December 31st. 1920. Situation of Premises. Number of Houses inspected. Defects found in Number of Preliminary Noticesserved. Result of Notices. Water Supply. Closet Accommodation. Drainage. Ventilation. Cleanliness. Condition of yard. Dampness. Disposal of Refuse. Other Matters. Work done. Work in hand. Work not done. Corinthian Road 29 19 20 14 1 29 22 18 20 28 29 4 9 16 Station Rd., Abbey Wood 2 1 2 1 2 1 2 2 West Street 6 1 1 5 3 5 3 5 5 5 2 3 St. Fidelia Road 12 12 9 12 12 12 8 12 12 12 Bexley Road, Belvedere 10 2 5 2 4 4 3 9 6 10 10 5 5 Bexley Road, Erith. 29 3 13 7 2 3 6 17 13 27 27 27 Picardy Street 60 16 42 14 7 60 28 41 16 58 60 4 14 42 Lyndon Road 5 4 2 4 1 3 5 4 5 5 5 Cray ford Road 94 7 9 22 12 11 10 47 26 57 87 6 81 Lower Road 5 5 2 2 3 4 2 1 3 5 2 2 1 Victoria Road 1 1 1 1 1 1 1 Kentish Road 5 3 3 3 4 2 4 5 2 3 Albert Road 5 2 3 2 5 3 5 2 5 5 3 2 Cheshunt Road 22 6 4 6 2 5 3 5 1 16 22 22 Brook Street 148 30 69 43 19 72 46 61 57 126 128 20 17 91 Hoddesdon Road 18 1 2 5 10 4 16 7 17 18 10 8 Grove Road 6 5 2 4 2 6 5 6 6 Upper Grove Road 30 9 8 10 12 8 6 13 27 7 20 Ripley Road 7 6 5 6 7 3 6 7 7 Upper Abbey Road 5 1 1 5 3 5 5 Abbey Road 1 1 1 1 1 1 St. Francis Road 11 8 2 5 5 7 11 2 11 11 7 4 Gladeswood Road 12 6 7 6 2 8 2 12 12 9 3 Maxim Road 18 8 10 8 6 4 13 1 18 18 18 Bedonwell Hill 2 1 2 1 2 2 2 2 Bedonwell Road 23 4 3 4 11 6 3 4 12 19 19 Lessness Park 2 2 1 1 1 2 1 2 2 2 Northumberland Park 65 9 56 23 49 34 35 38 62 62 46 16 Riverdale Road 6 3 1 1 1 3 3 4 4 6 6 6 Charlieville Road 14 2 3 13 4 4 7 11 13 13 Colebrook Street 2 1 2 1 2 2 2 2 2 2 2 2 Gilbert Road 1 1 1 1 1 1 1 1 1 Horsa Road 3 3 1 2 2 1 1 1 2 3 3 Nelson Road 1 1 1 1 I 1 1 Paroma Road 39 1 23 6 12 16 11 18 22 24 39 39 Sussex Road 21 1 11 1 7 9 5 14 1 19 19 19 St. Paul's Road 11 1 10 7 6 8 7 10 11 11 9 2 St Augustine's Road 6 6 3 6 4 4 4 4 6 6 Manor Road 7 6 3 3 7 6 5 6 7 7 Holly Hill Terrace 58 58 48 22 5 42 27 24 9 58 58 5H 5 Queen Street 13 7 2 3 3 3 2 10 13 13 Coleman Road 2 1 1 1 1 2 2 2 2 Stonecroft Road 10 1 4 2 6 5 7 10 8 10 10 10 Crabtree Manorway 2 1 1 2 2 1 1 2 2 Mill Road 53 4 20 18 8 17 15 13 21 30 46 17 29 Heron Hill 4 1 1 1 1 2 4 4 4 Railway Road 24 1 11 6 17 19 17 11 22 24 24 Queen's Road, Belvedere 1 1 1 1 1 1 Oak Road 15 4 2 3 4 7 7 9 11 15 15 University Place 20 4 2 2 10 4 18 5 19 18 18 Becton Flace 9 3 1 8 5 2 5 9 9 Dalmeny Road 7 1 3 3 2 1 4 4 4 7 2 5 Barnfield Road 1 1 1 1 1 1 1 1 1 1 Paroma Road 36 15 20 12 21 19 25 9 31 36 36 Sydney Road 31 8 7 10 8 11 10 15 22 9 13 Totals 1030 210 491 302 106 515 389 552 376 830 969 219 231 519 Erith Urban District Council. Annual Report OF THE School Medical Officer FOR THE YEAR 1920. STAFF. School Medical Officer: A. E. JERMAN, m,b., d.p.h. Assistant School Medical Officer: J. HARDIE, m.b.c.m. Ophthalmic Surgeon : A. E. REYNOLDS, m.r.c.s., &c. Dental Surgeon: R, PRESSLIE, l.d.s. edin. Throat and Nose Specialist : C. WATNEY ROE, m.r.c.s., &c. School Nurses : Mrs. LANGE and Miss CLARKE. Records Clerk : Miss HARDIE. Report of School Medical Officer. School Medical Service in relation to Public Elementary Schools. Under the Authority of the Erith Education Committee there are nine provided schools, with nineteen departments, and two non-provided schools, with three departments. The accommodation of these schools provides for 6,818 scholars. The number on the roll is 5,558, with an average attendance of 5,200. These schools are of modern type, and are well situated as regards their open-air spaces and play-grounds. Their sanitary conveniences and lavatories are for the most part in efficient and good order—the one exception brought to your notice during the latter part of the year is being remedied. The drinking-water supply is off the main direct, while the water for washing purposes comes from cisterns. The general mode of heating these schools is by stoves, and in some few cases is not quite adequate for the purpose. Where defects have been present these have been pointed out, and are being made good. In these schools there is no provision made for drying the wet clothing of the children during the school hours, but where the schools are heated by pipes or hot air, provision has been made. The artificial lighting of the schools is also of varied character, some being served with electricity and others by gas. In these latter schools the conditions might be improved by the general use of incandescent burners. Much controversy has been raised amongst the teachers as to the efficacy of Dustolio in preventing the schools from becoming very dusty, and this agent has been left off for the last two months of the year, and the school floors thoroughly scrubbed and washed at regular 4 intervals. Sufficient time has not yet elapsed to form an opinion as to the wisdom or otherwise of this course. The Assistant School Medical Officer visited each department of the schools twice during the year for the purpose of enquiring into the general hygienics and sanitary conditions of these schools. Medical Inspection The general routine Medical Inspection has been carried out as in former years, and according to the Board of Education's full schedule for the Medical Inspection of School Children. The record card which is used is that suggested by the Board. These routine inspections are carried out during the afternoons by the Assistant School Medical Officer. The Head Teacher of the school which is to be visited is notified of the fact, and the parents of the children to be examined are asked to be present on the occasion of the Doctor's visit, if they so desire. A room is generally provided for this examination of the children, at which the Head Teacher is also present, and suggestions are sometimes made for the benefit of the child by the Medical Officer, and he often receives an account of any peculiarities noticed or any defects suspected by the teacher. These are heartily welcomed by him as of great importance in the examination. These arrangements do not seem to disturb the general routine of school life to any extent, as the children are brought up and prepared in batches at a time, and are then dismissed back to their classes when the examination is finished. On the occasion of the visits for Routine Inspection special cases are often brought to the notice of the Medical Officer by the head teachers themselves, or they are invited to do so by the Doctor. But the great proportion of cases requiring any special attention are sent as soon as they become known to the teachers, direct to the Medical Officer at the Clinic for examination and advice. A child therefore does not require to wait for the routine visit of the Medical Officer to his school if any ailment or ailing condition be suspected. In this way crippling de- 5 fects of the children are early ascertained, treated, if possible, or recommended for treatment to suitable Institutions. Four groups of children were medically examined during the year. The absentees on those occasions were visited later, so that no child escaped medical notice. They were selected thus:— I.—Entrants, 5—6 years. II.—8 years. III.—11 years. IV.—13 years or leavers. For number of children inspected, see Table I. Findings of Medical Inspection A Review of the facts disclosed by the inspection of the children is here given in a short form. Table II. at the end of the Report gives fuller details. Uncleanliness. The number of children found with verminous heads or unclean bodies or clothing is a very small one, and only amounts to 2.2 per cent. of the children examined. It is very gratifying to us to think that our labours in this direction are not altogether in vain. I believe that this improved condition is greatly due to the energetic work done by both Nurses in visiting the schools with such regularity. No doubt this accounts for the low percentage of cases found on my Routine Inspection of the children. You will notice in the summary of the Nurse's work we have had 171 cases excluded for vermin during the whole year (a percentage of 1.3 per cent. of the children examined by them), many of these, as I have already stated, being old familiar ones. The exclusion cases are sent to me for inspection at the School Clinic. Many of them after such a warning have been cleansed and are fit to return to school straight away. Others are offered advice, and many require severe remonstrances in writing to their parents. The majority of the children are so cleansed and improved that they are able to return 6 to school within an average of 4 days. But alas! there are a stubborn few parents who tell you flatly that their children breed them, and so they are not to blame for the condition, and make no attempt or little at all to get rid of them. Remonstrances, admonition, entreaties have no effect upon these people, they dally from day to day with the condition, and thus the child is hindered in its education, for how can you seat a child of this description beside a clean child in school, to the detriment of all the members of the class? Tonsils and Adenoids, The percentage amongst the younger children affected with enlarged tonsils and adenoids is still large, but amongst the older ones advantage has been taken of the Committee's arrangements with the London Hospitals during the last 2 years, and many of these children have had them removed and are now, in consequence, in far healthier condition. This has reduced the percentage to 20 per cent. over all those examined, and includes slight cases which do not call for operation. Tuberculosis. Seven cases of pulmonary tuberculosis were met with during the Routine Inspection of the children. These were at once brought to the notice of the Tuberculosis Dispensary, and are visited by the School Nurses. Skin Diseases. There are very few cases of these to be met with at the time of Inspection. Whenever one occurs the child is sent at once to the School Clinic, either by their teachers or by the nurses on the occasion of their periodic visits. External Eye Disease. The same may be said regarding the presence of any external disease of the eyes. Only 4 cases were recorded for the year, although it will be seen that we have treated many more which were sent to us at the Clinic. 7 Vision. A comparatively small number of the children examined during this year's Routine Inspection were found to be suffering from defective vision who were not provided with spectacles, the number being 191, or 9 per cent. of the whole. It is very gratifying to feel that the parents are now more willing to have their children's eyesight attended to than formerly, and this, no doubt, at the solicitation of the children themselves. On many occasions I hear how much the child has benefited by the use of spec tacles in its school work, and the greater ease with which they are able to do this. I have noticed amongst these little folks who wear spectacles a greater alertness and enjoyment of life. Their faces denote a more eager outlook on things, and I have no doubt in my own mind they are better able to pick up and enjoy their surroundings because they see. The children probably talk to one another about this, and the parents share in their knowledge of its benefits, and thus we have many inquiries from parents who are anxious to have their children's eyesight tested, apart from the Routine Inspection. Ear Disease. Few cases are here recorded—only 10 in all. Under the heading of " The Clinic " many more will be seen to have been treated there during the year. Dental Defects. 32 per cent. of the children are still suffering from defective teeth. This includes from 1 carious tooth to several. Here again, the percentage is lowered, because of our past efforts in this direction. Very many of the older children, 11 and 13 years of age, have now clean, healthy mouths, many with complete dentures, many showing evidence of attention having been given to them in the past. The difference between the children of 5 years ago and those of the present year is very marked. Formerly the condition of their mouths was not only unsightly, but foul from oral sepsis—the result of carious 8 and discharging teeth. It was most disagreeable to examine them, but now it is a pleasure to see the result oi the treatment by the School Dentist, and is one of the greatest encouragements to carry on the work. In future we propose to confine our attention mainly to the younger children of ti and 8 years old. We believe in this way we shall be better able to preserve the teeth from becoming carious and so prevent the necessity for many permanent teeth being extracted. Infectious Diseases.—Review of the action taken to detect and prevent the spread of Infectious Disease. There has been no great epidemic of infectious disease amongst the school children during the year. It was therefore unnecessary to close any of the schools for that cause. But during the year many visits have been paid to the schools in search of the probable cause of infection to children who have been notified as suffering from infectious disease. Classes have been examined individually, and any suspicious child removed. On two such occasions a child was found to be peeling after a mild attack of scarlet fever, and had in all probability been the cause of several cases which had occurred amongst the children of the same class. On their removal to an isolation hospital, no more cases occurred amongst the other children. At times suspicious cases of sore throats are sent down to the School Clinic by the teachers for their inspection by the Medical Officer, and in like manner all children who have been the subject of or in contact with any infectious disease are not allowed to return to school without previous examination and certification of their fitness. In the early part of the year a family whose children (3) attended one of our schools was attacked by small-pox. The school children belonging to the several classes were visited and kept under observation for three weeks as a safeguard against any further outbreak, fortunately no other case arose in that school. 9 Following-up.—A Review of the arrangements for the Following-up of Children suffering from Physical Defects, including a Summary of Work undertaken by the School Nurses. The discovery alone of physical defects in the school child is not the sole purpose of the School Medical Service. If the child is to receive any benefit from such examination it follows that the recommendations given at the time should be carried out and the defective condition, if at all possible, remedied. The parents are therefore notified of the presence of any defect found in their child, and are recommended at once to give it their attention, either through their own private Doctor or through the School Clinic. Those children having defects are put upon record, and are not allowed to slip past without some effort being made to remedy their condition. Some of the parents are very ready indeed to accept our advice or our aid, but others unfortunately, do not. They do not see the necessity for it or are indifferent to the possible ill results to the child from their want of attention. These latter are the eases which require to be " followed up " time after time with patience and tact. It is here that the qualities of your nurses are tried. They visit the homes of the children to impress upon the parents the necessity for dealing with these defects, in order that their child may be fitted for the battle of life. Their persuasive powers are on many occasions successful, so that we at the School Clinic are able to give relief by the Dentist, the Ophthalmic Surgeon, the Operating Surgeon for Tonsils, etc., and where necessary the examination of children who want a little advice or guidance in health. If one visit by the nurse does not succeed, we hope to succeed by another. If promises are made by the parents the nurse calls in a few weeks' time to ascertain if these have been kept, and the defect remedied. Especially are the tuberculous children kept under our notice, either those with pulmonary tuberculosis or 10 suffering from gland trouble, to see that the directions given are carried out, and that the child is having a fair chance of recovery. I may be permitted here to give an outline of the work done by the School Nurses. The Committee appointed a second nurse early in the year, so that we have now two trained nurses at work. Each morning they are in attendance at the School Clinic engaged in either the Minor Ailments Department or the Dental Department as the occasion may be. At the Minor Ailments they are dressing and attending to skin conditions and sores upon the children, washing and applying remedies to eye conditions and syringing discharging ears, together with other minor ailments, under the direct supervision of the Assistant School Medical Officer. On the morning and afternoon of the Dentist's visit one is present with the child in the Dentist's room whilst the other is looking after the general welfare and comfort of the little patient after extraction. They are similarly occupied in rendering services to the children and the Ophthalmic Surgeon on the occasion of his visit once a fortnight. During the afternoons not engaged at the Clinic on these duties, they visit the schools for the purpose of examining the children for cleanliness. Each nurse has her own set of schools to attend to, and they have visited each department at least four times in the school year, and examined every child for cleanliness of person and clothing. By this constant attention we have succeeded in reducing the number of verminous cases to a considerable extent. Indeed, the great majority of such cases are what may be termed "old offenders"—appearing time after time with unblushing regularity. No sooner are they clean than, through sheer want of attention to cleanliness, they return to school in the same condition. The nurses are also engaged in visiting cases of skin diseases that have been excluded from school, and should be in attendance at the Clinic. Every child is told to return upon a certain day for continuous treatment until recovered and fit to return to school. Many of the elder 11 children seize this opportunity to stay away from school and their homes are visited by the nurse to secure the child's attendance for proper treatment and attention. Summary of work done by the School Nurses during the year:— Visits paid to schools 379 Children examined 13,651 Children excluded for vermin 171 Visits to homes 801 Visits to Tuberculous children 113 Medical Treatment, Review of the Methods employed or available for the Treatment of Defects and the results attained. As you are aware, a small School Clinic had been carried on in the Old Council Offices, High Street, Erith, for some two or three years in a successful manner, as far as the limited space would permit. It was deemed necessary, for its proper and full working, that it should have larger premises. About the middle of April the School Clinic was removed to "Hainault," Lesney Park Road, where it occupies several rooms on the ground floor of the building. Here there are large and well-appointed waiting rooms for the children who are in attendance, with ample accommodation for their parents also if they desire to come with them. The Inspection Room is also of good size, and is fitted upon one side with four large washing basins, with hot and cold water. The basins are used for cleansing purposes, and for the disinfection and cleansing of children with Scabies on their hands and arms. On the afternoon of the Dentist's visit they are put in use by the children who have had teeth extracted, for the washingout of their mouths. In another corner of this room there is a large cupboard and table with all the necessaries and dressings for minor ailments and skin affections. A desk and small table occupied by the Medical Officer and Clerk takes up the centre of the room, and here it is that children are examined and advice given, and if necessary passed over to the nurses for attention. 12 A second large room is given over entirely to the Dentist and the Eye Specialist on their visiting days. It is fitted up with a dentist's chair and spittoon, a cupboard for all the instruments required in his professional duties, and with the appliance for the administration of gas to the patients. A small portion of this room has been partitioned off to make a dark-room for the Eye Specialist to examine the children's eyes under the proper conditions with his retinoscope. The length of the room also proves suitable to the required distance for the fitting of the proper lenses. There is also a small room suitably furnished in which a child may, if not sufficiently recovered after an extraction of teeth, lie down for a short period of rest. This is called the Rest Room. Apart from the main building a coach-house and stable have been completely altered and re-fitted to form an operating-room for the removal of Tonsils and Adenoids, and a rest-room for recovery. This recoveryroom has 6 beds with complete fittings, so that a child can be made quite comfortable for the two hours necessary for its supervision, and recovery after the operation before it is taken home again. This building is lighted by electricity and heated by hot-water pipes and radiators, and makes a miniature hospital of which the Committee may be proud. The School Clinic is open for Minor Ailments every morning from 9.15 until all the children have been seen and attended to, usually about 11 or 11.30 o'clock. The Dentist's visits are on Tuesday afternoon at 2 o'clock, and on Thursday morning at 10 o'clock—each session lasting approximately 2 hours. The Ophthalmic Surgeon visits the School Clinic every alternate Thursday at 1.30, and sees the cases referred to him by the School Medical Officer for opinion and recommendation. The Committee have made arrangements 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 they assist them by part payment, and in a few cases spectacles are supplied gratis. 13 The Operations on the Throat are undertaken as occasion requires, and arrangements are made with the Operating Surgeon. The advantages of the Clinic are becoming more and more appreciated every year. Many parents bring their children willingly and gladly. The children in the schools themselves are becoming cleaner and freer from minor ailments 949 children were sent to the Clinic either by Teachers or parents for special examination as to their fitness to attend school. Many of these had been suffering from infectious disease or had been in contact with such, and others with a simple enquiry as to the condition of their general health. A total of 696 children attended during the year, and were treated for one or other of the following ailments: Minor Ailments. Under this are included slight injuries sustained at school, or small sores the results of falling, children suffering from swollen glands which proved to be Mumps, and others suffering from Bronchial Catarrh, and such cases as slight sore throats. These children we keep under observation until they are fit to return to school. 208 children attended, and were treated under this heading. Tonsils and Adenoids. During the first portion of the year 25 cases for operation were undertaken at the Royal Free Hospital, London, and when our own operating Clinic was opened we undertook 54 cases successfully—a total of 79. The children were operated upon at an afternoon session bv Dr. Watney Roe, assisted by the Assistant School Medical Officer, and the two school Nurses., The children are those referred for such operation on the occasion of the Routine Inspection, and are prepared accordingly. They remain in the Rest-room safely tucked up in bed with a Nurse in attendance for at least 2 hours 14 after their operation. As opportunity afforded they were sent home in 1 the Council's Motor Ambulance, under supervision. It is hoped that in future we shall be able to do this on every occasion. Tuberculosis. We are in close co-operation with the Tuberculosis Dispensary in this district, and cases either pulmonary or glandular, are at once referred there for special advice and treatment. A register of cases is kept at the Clinic and the children visited from time to time by the school Nurses. Skin Diseases. Among the skin diseases, happily there are very few cases of ringworm of the head or the body. Three suspicious hair specimens were sent to the County Laboratory for examination, and one proved to be ringworm. This case was excluded from school until recovered. There were 74 cases of scabies, the children are made to disinfect and scrub their hands and arms at the Clinic, and are given lysol to use at home. They attend regularly each day so that they may be done efficiently under the Nurses' eyes at least once per day, ointments are also given to them. Impetigo stands high in our number of skin affections. 268 cases were treated by cleansing and the application of remedies by one or other of the Nurses. These children also are kept from school until they are better. External Eye Disease. 62 children suffering from Ophthalmia, Conjunctivitis and Blepharitis, or with slight Corneal Ulcers were sent to us direct from the schools. These were treated appropriately,and some of the more severe cases were referred to our Eye Specialist for further advice, such, of course, is always carried out at the Clinic. ] 5 Vision. 249 Prescriptions for glasses were made by the Specialist, and altogether some 980 attendances were made at this Department for various causes connected with the eyes during the year. Details of the work will he found in the table at the end of this report. Ear Disease This distressing malady is in many cases difficult to treat. Children return to us again and again with their eats discharging and very offensive. As long as they attend the Clinic for treatment they are not excluded from school. But something more than the mere application of remedies and syringing of ears wants to be done in many of these cases. It appears as if only operative interference at one of the London Hospitals would produce anything like satisfactory cures. There were 32 cases treated during the year, and many of these were of a chronic nature, and required regular and renewed attendances at the Clinic. Dental Defects. 1,360 children, comprising 635 boys and 725 girls, were treated by the Dentist either for extraction of carious teeth or for some preventive treatment. This branch of the work is, I believe, greatly appreciated by parents, for of this number 649 children were sent by parents or brought by them direct to the Dentist for his services, and are not therefore included in the Medical Officer's Inspection lists. A total attendance of 1,816 was made by all these children. Full details and nature of the work done bv the Dentist are to be seen on Table IVd. A short summary of the whole work at the Clinic is as follows:— 696 children treated for Minor Ailments made 7387 attendances. 1360 ,, ,, by Dentist ,, 1846 ,, 249 ,, ,, by Oculist ,, 980 ,, 949 ,, ,, for special examination 949 ,, 54 ,, ,, operated on for Tonsils, etc. 54 ,, 3308 children. 11186 attendances. 16 Open Air Education. The character of the district—scattered houses with' abundant open space—does not demand the same attention with respect to fresh air as more crowded districts. When the weather permits, classes are frequently held in shady parts of the play ground. Junior classes are also taken for nature study walks in Franks Park—a natural Park of over 40 acres. Senior classes have visited Bostall Woods, where the Forester-in-Charge has given much interesting and valuable information. About 30 girls from the Central School paid a fortnight's visit to Yarmouth last year, and explored the vicinity. The results were admirable, every girl but one increased in weight, and many in height. All of them returned much brighter mentally. There are no open-air class rooms, but the Committee propose this year to erect an open-air school for about 40 children in the ample grounds at "Hainault'" for the benefit of a few anaemic and weakly children. Physical Training. This is usually taken by the teaching staff, but the Committee have appointed two special instructors (one man and one woman) both of whom have been specially trained on the latest lines, and they visit the schools in rotation. They are also giving courses of lessons to teachers—nearly 80 attending for this purpose. Provision of Meals. This is continued as in previous years, but this year there has been a greater demand. The children are mostly served at the Municipal Restaurant. The Assistant School Medical Officer has paid surprise visits to this place, as well as to the others, at different times, and was satisfied with the accommodation and the character of the meals supplied. School Baths. There are no school baths, but swimming is taught in nearly all the senior departments with considerable success. 17 Co-operation of Parents, Teachers, etc. When the children are to undergo inspection by the Medical Officer, a notice is always sent to the parents of those children to be examined, stating the time and date, so that they may attend if desirous. Their presence is always welcomed by the Medical Officer, and many do attend. The greater number attend with the younger children, such as 6 years and 8 years. It gives the Medical Officer an opportunity to explain the need for removing any defects which may be found at his examination of the child, as well as pointing out the benefit and advantage of making use of such facilities for treatment as the School Clinic offers. The head teachers are also present at these examinations, and are of great assistance to the Medical Officer in volunteering any facts they are in possession of regarding the family or personal history of the child, and are further a means of communication between the Medical Officer and the parents if they are not present. The greatest sympathy with the whole Medical Service exists in the minds of the teachers in the various schools and the co-operation is of very great value. They are always more than willing to assist in arranging for the children to attend at the Clinic for treatment, and on many occasions send special cases which they are desirous of bringing to the notice of the Doctor for some defect or other. Children who have escaped, through absence or otherwise, the Routine Inspection, are dealt with in a like manner. Blind, Deaf, Defective and Epileptic Children. A glance at Table III at the end of the report will show how many of these are in the district. On such cases becoming known, they are brought to the notice of the Assistant School Medical Officer, and are dealt with as far as we can at present. We have no special schools under the Erith Authority. 18 TABLE I. Number of Children Inspected 1st January, 1920, to 31st December, 1920. A—Routine Medical Inspection. Age. Entrants. 3 4 5 6 Other Ages. Total. Boys 343 343 Girls 302 302 Totals 645 645 Age. Intermediate Group. Leavers. Other Ages. Total. Grand T1. 8 12 13 14 11 Boys 295 280 325 900 1243 Girls 286 264 284 834 1136 Totals 581 544 609 1734 2379 B—Special Inspections. Special Cases. Re-Examination (i.e No. of Children Re-examined. Boys 1645 282 Girls C-Total Number of Individual Children Inspected by the Medical Officer, whether as Routine or Special CASES (no Child being counted more than once in one Year). Number of Individual Children inspected 4024 19 TABLE II. Return of Defects found in the course of Medical Inspection in 1920. Defect or Disease. Routine Inspections. Specials. Number referred for Treatment. Number requiring to be kept under observation, but not referred for Treatment. Number referred for Treatment. Number requiring to be kept under observation, but not referred for Treatment. 1 2 3 4 5 Malnutrition 59 Uncleanliness: Head 38 181 Body 5 Skin:—Ringworm: Head 6 Body 12 Scabies 4 74 Impetigo 8 268 Other Diseases (non-Tubercular) 2 16 Eye :—Blepharitis 4 13 Conjunctivitis 33 Keratitis Corneal Ulcer 16 Corneal Opacities Defective Vision 191 Squint Other Conditions Ear :—Defective Hearing 2 Otitis Media 8 31 Other Ear Diseases 1 Nose and Throat:— Enlarged Tonsils Adenoids Enlarged Tonsils and Adenoids 291 148 Other Conditions 43 Enlarged Cervical Glands (Non-Tubercular) 86 9 Defective Speech Teeth-.—Dental Diseases 674 312 Heart and Circulation:— Heart Disease : Organic 23 Functional Anaemia 7 Lungs:—Bronchitis 32 13 Other Non-Tubercular Diseases 20 TABLE II—Continued. 1 2 3 4 5 Tuberculosis:— - Pulmonary: Definite 7 1 Suspected 2 Non-Pulmonary : Glands 2 Spine Hip 1 Other Bones and Joints Skin 2 1 Other Forms Nervous System:— Epilepsy Chorea 2 Other Conditions Deformities:— Rickets 2 Spinal Curvature 2 Other Forms Other Defects and Diseases 26 139 Number of Individual Children having Defects which required Treatment or to be kept under observation 1185 TABLE III. Numerical Return of all Exceptional Children in the Area in 1920. Boys. Girls Total. Bind (including partially blind)— Attending Public Elementary Schools Attending Certified Schools for the Blind 1 3 4 Not at School 1 1 Deafand Dumb (including partially deaf)— Attending Public Elementary Schools Attending Certified Schools for the Deaf 1 2 3 Not at School Mentally Deficient— Feeble Minded— Attending Public Elementary Schools 1 1 Attending Certified Schools for Mentally Defective Children 2 2 Notified to the Local Control Authority by Local Education Authority during the year Not at School Imbeciles— At School Not at School 1 1 Idiots 21 TABLE III—Continued. Boys. Girls. Total Epileptics— Attending Public Elementary Schools 1 1 Attending Certified Schools for Epileptic In Institutions other than Certified Schools Not at School 1 1 Physically Defective— Pulmonary Tuberculosis— Attending Public Elementary Schools 1 1 Attending Certified Schools for Physically Defective Children In Institutions other than Certified Schools 1 1 Not at School 2 4 6 Crippling due to Tuberculosis— Attending Public Elementary Schools 1 6 7 Attending Certified Schools for Physically Defective Children In Institutions other than Certified Schools 1 1 Not at School 4 2 6 Crippling due to causes other than Tuberculosis, i.e., Paralysis, Rickets, Traumatism— Attending Public Elemeutary Schools 1 1 Attending Certified Schools for Physically Defective Children In Institutions other than Certified Schools Not at School 2 2 Dull or Backward— Retarded 2 years 10 6 16 Retarded 3 years 6 4 10 22 TABLE IV. Treatment of Defects of Children during 1920. A—Treatment of Minor Ailments. Disease or Defect. Number of Children referred for Treatment. Treated under Local Education Authority's Scheme. Skin—Ringworm—Head 6 6 Body 12 12 Scabies 74 74 Impetigo 268 268 Minor Injuries 46 46 Other skin disease 35 35 Ear Disease 32 32 Eye Disease (external and other) 62 62 Miscellaneous 162 162 Total 696 696 B—Treatment of Visual Defect. Number of Children submitted to refraction, under Local Education Authority's Scheme, Clinic or Hospital 237 Number of Children for whom glasses were prescribed 204 Number of Children for whom glasses were provided 192 Recommended for treatment other than by glasses 2 Number of Children for whom no treatment was considered necessary 31 C—Treatment of Defects of Nose and Throat. Number of Children referred for treatment 291 Received operative treatment, under Local Education Authority's Scheme. Clinic or Hospital 79 By Private Practitioner, or Hospital 2 — 81 D—Treatment of Dental defects. 1—Number of Children dealt with. Age Groups, 'Specials" Total. 5 6 7 8 9 10 11 12 13 14 (a) Inspected by Dentist 73 376 449 (6) Referred for treatment 711 649 1360 (c) Actually treated 711 (d) Re-treated * (result of periodical examination) 33 * It is understood that cases under this head are also included under (c) above. 23 2. Particulars of Time given and of Operations undertaken. 1 Number of half-days devoted to inspection 3 2 Number of half-days devoted to treatment 86 3 Total number of attendances made by the children at the Clinic 1683 4 Number of permanent teeth extracted 531 5 Number of permanent teeth filled 168 6 Number of temporary teeth extracted 2808 7 Number of temporary teeth filled — 8 Total number of fillings 168 9 Number of Administrations of General Anesthetics included in (4) and (6) 1301 10 Number of other operations—Permanent Teeth 132 TABLE V. Summary of Treatment of Defects as shown in Table IV. (A, B, C, and D.) Number of Children treated under Local Education Authority's Scheme. Disease or Defect— Minor Ailments 696 Visual Defects 237 Defects of nose and throat 81 Dental Defects 1360 Total 2374 TABLE VI. Summary relating to Children Medically Inspected at the Routine Inspections during the Year 1920. 1 The total number of children medically inspected at the routine inspections 2379 2 The number of children in (1) suffering from— Malnutrition 59 Skin Disease 14 Defective Vision (including Squint) 191 Eye Disease 4 Defective Hearing 2 Ear Disease 8 Nose and Throat Disease 439 Enlarged Cervical Glands (non-tubercular) 86 Defective Speech — Dental Disease 986 Heart Disease- Organic 23 Functional — Anæmia 7 Lung Disease (non-tubercular) 32 24 TABLE VI—Continued. Tuberculosis—Pulmonary—Definite 7 Suspected — Non-pulmonary 3 Disease of the Nervous System — Deformities 4 Other defects and diseases 26 3 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) 492 4 The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) 693 5 The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, &'c.) 711* * Includes 18 children from 1919 list.