ERI 18 URBAN DISTRICT OF ERITH. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer FOR THE YEAR ENDED 1937 by A. WALLACE JOHNS, M.R.C.S., L.R.C.P., D.P.H. URBAN DISTRICT OF ERITH. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer FOR THE YEAR ENDED 1937 by A. WALLACE JOHNS, M.R.C.S., L.R.C.P., D.P.H, Arrangement of Report. Section Page A Statistics and Social C onditions of the Area. 1. General Summary of Statistics. (a) General 6 (b) Births 6 (c) Deaths 6 (d) Infantile Mortality 7 (e) Vital Statistics of District 8 (f) Causes of Death 9 (g) Birth Rates, Death Rates and Analysis of Mortality 10 2. Population 11 3. Births 11 4. Deaths 11 5. Maternal Mortality 11 6. Infant Mortality 12 7. Natural and Social Conditions of the Area 13 8. Unemployment figures and comments 14 9. Riverside Promenade 14 B Maternity and Child Welfare Services. 1. The Maternity and Child Welfare Scheme 18 2. Notification of Births 19 3. Child Welfare Centres 20 4. Home visits by Health Visitors 22 5. Maternity Services 22 (a) Maternity Home—Hainault 22 (b) Ante-natal Clinic 22 (c) Ante-natal In-Patient Accommodation 23 (d) Abnormal Cases 23 6. Infant Life Protection 24 7. Midwives 24 8. Maternity and Nursing Homes 24 9. Nursing in the Home 24 (a) General 24 (b) Infectious 25 10. National Society for the Prevention of Cruelty to Children 25 C Prevalence of and Control over Notifiable Infectious Diseases. 1. Infectious Diseases Hospital 25 2. Tables (a) Notifications 25 (b) Age Distribution 26 i Section C (continued). 3. School Incidence of Infectious Disease 27 4. Comments on : (a) Diphtheria 28 (b) Scarlet Fever 28 (c) Enteric Fever 28 (d) Measles (e) Provision of Serum for Cases of Measles 28 (f) Puerperal Fever and Puerperal Pyrexia 28 (g) Ophthalmia Neonatorum 29 (h) Smallpox 29 (i) Diarrhoea and Vomiting 29 5. Disinfection of premises after Infectious Disease 29 6. Laboratory Facilities 30 7. Tuberculosis. (a) Treatment and Hospital tion 30 (b) Table (i) Particulars of new cases and deaths 31 (ii) Quarterly Statements 32 8. Consultations with local Medical titioners 33 9. Arrangements for operations for Ear, Nose and Throat conditions 33 10. Clinics and Treatment centres 34 D Hospital Facilities. 1. General 2. Venereal Diseases 35 3. Children 35 4. Ambulance Facilities 35 E Sanitary Circumstances of the Area. 1. Collection and Disposal of House Refuse 35 (a) Details of Refuse Collection and Staff 36 (b) Details of Tonnage 36 2. Trade Refuse 36 3. Water Supply 37 4. Drainage and Sewerage 37 5. Closet Accommodation and Cesspools 37 6. Swimming Baths 38 7. Hop Pickers 38 8. Inspection of Schools 38 9. Rag Flock Act 38 10. Smoke Abatement 38 ii Section E (continued). Page 11. Health Education— (a) Rat Week 38 (b) National Health Campaign 38 12. Cleansing of Verminous Persons 30 13. Housing: (a) Fitness of Houses 39 (b) Unhealthy Areas 39 (c) Overcrowding & General Observations 39 (d) Survey of Encampment at Belvedere Marsh 42 F Inspection and Supervision of Food. 1. Meat Inspection 43 2. Slaughter of Animals Act, 1933 44 3. Milk 44 4. Other Foods 45 5. Offensive Trades 45 G Sanitary Inspection of the Area. 1. Routine Visiting 46 2. Nuisances and defects remedied during year 46 3. Housing Inspections. (a) Number of new houses erected 47 (b) Inspection of dwelling houses 47 (c) Remedy of Defects 47 (d) Action under Statutory Powers 47 4. Overcrowding (Housing Act 1936, Part iv) 48 5. Eradication of Bed Bugs 48 6. Factories, Workshops and Workplaces 50 II General. 1. Letter by Medical Officer of Health 2 2. Members of Committee 4 3. Staff of Public Health Department 5 4. Bedonwell Clinic 14 5. Legislation 51 iii 2 H(1). Public Health Department, Council Offices, Erith. To the Chairman and Members of the Erith Urban District Council. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Annual Report on the work carried out by the Health and School Medical Services of the Council for the year 1937. I am sure that it would be the wish of the Council to place 011 record our sorrow over the loss of our late Senior Sanitary Inspector, Mr. Pearson. The work of the Public Health Services of the Council continues to increase in scope and value. Mr. Pearson's illness and death, coming at a time when the growth of the work on the Sanitary side of the Public Health Department has got beyond the capacity of two Sanitary Inspectors, threw a considerable strain on the rest of the Staff, although as far as possible temporary Staff were secured. While it is a great temptation to put on record extensions of services that have recently been put into operation and are in our minds at the moment, such as the Diphtheria Immunisation Scheme, admission of Measles and Whooping Cough to the Infectious Diseases Hospital, the Home Help Service, etc., it must be remembered that this report deals with matters up to December, 1937, and it will be realised that any such omissions are due to this fact. Notable extensions of services put into operation during 1937, however, are the Orthopaedic Scheme, and the extension of the facilities offered by the School Medical Service to the preschool child. In this way Minor ailment treatment, specialist advice and treatment for such conditions as Orthopaedic defects, eye defects, &c., can be obtained for the infant, thus bringing these cases under treatment at the earliest possible moment and avoiding the position that something might have been done if they had been seen earlier. 3 A noteworthy feature of the year is the prominent place Air Raid Precautions have now achieved in Local Government, and the corresponding increased proportion that it has been exacting of our time and work. Infectious Disease. The figures for 1937 show little variation in the incidence of the common Infectious Diseases. An epidemic of a mild type of dysentery is mentioned in the body of the report. The only other noteworthy feature during the year was the unusually large number of cases of Acute Poliomyelitis throughout the country; this district escaped with one case only. Vital Statistics. The vital statistics of the year show a Death Rate of 10.8,5 (12.4), a Birth Rate of 15.8 (14.9) and an Infantile Mortality Rate of 46.3 (58,) the figures in parenthesis being the corresponding figures for England and Wales. I would like to express my gratitude to the Committees for their interest in the work of my Department, and my thanks for the willing help of my staff on whose loyal support, the success of the Department depends in no small measure. I am, Your "obedient Servant, A. WALLACE JOHNS, Medical Officer of Health. June, 1938 4 H(2). MEMBERS OF COMMITTEES. Health and Buildings Committee. Chairman—Councillor Grant. Councillor Bates. Councillor Selfe. ,, Firmin. ,, Wilson, J.P. ,, Munns. ,, Wilkinson. Maternity and Child Welfare Committee. Chairman—Councillor Nichols. Councillor Corsan. Councillor Dunkley. ,, Firmin. ,, Emes. ,, Morling. ,, Woodcock. Co-opted Members. Mesdames Grant, Munns and Reeves. 5 H(3). STAFF. 1. Whole-time. Medical Officer of Health, School Medical Officer, Medical Officer in Charge of Sanatorium for Infectious Diseases and Maternity and Child Welfare A. W. Johns, M.R.C.S., L.R.C.P., D.P.H. (1) Deputy Medical Officer of Health and Assistant School Medical Officer (part-time)— I). S. Clark, M.B., B.S., D.P.H. (1) (Resigned Aug., 1937.) H. M. Evans, M.R.C.S., L.R.C.P., D.P.H. (Appointed September, 1937.) Senior Sanitary Inspector— D. A. Pearson, Certificate of Royal Sanitary Institute. (1) (Died December, 1937.) Sanitary Inspector— W. E. Moses, Certificate of Royal Sanitary Institute. (1) Meat Inspector's Certificate. Sanitary Foreman and Disinfecting Officer— H. W. Cooper. Health Visitors— Miss M. Jones, H. V. Cert. R.S.I., and S.C.M. (1). Miss T. M. Torpie, S.R.N., New H. V. Cert. R.S.I., and S.C.M. (1) Matron, Infectious Diseases Hospital— Miss P. Jay, S.R.N. Sister-in-Charge, Maternity Home— Miss M. Gambrill, S.R.N., S.C.M. (Resigned Aug., 1937,) Miss M. Currie, S.R.N., S.C.M. (Appointed Nov., 1937.) Clerks- Chief Clerk—H. M. Coles. Miss O. R. Reeves. (1) R. C. Durey. 2. Part-time. Consulting Surgeon for Aural Diseases— F. C. W. Capps, F.R.C.S.(Eng.). Consulting Obstetrician (Maternity Home and Puerperal Fever Regulations)— A. Galletly, M.C., M.B., F.R.C.S.(Ed.). (1) Dental Surgeon—Maternity and Child Welfare— R. A. Presslie, L.D.S.(Ed.). (1) Details of members of the staff of the School Medical Service are embodied in the report to the Education Committee. (1) = Exchequer Grants. 6 SECTION A.—STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Annual Report, 1937. A(l). SUMMARY OF STATISTICS. A(l)a. General. Area.—1,607 acres. Population.—38,240 (Estimated 1937.) Density of population, i.e., number of persons per acre.—8.30. Number of inhabited houses.—10,036 (as per Rate Book). Rateable value, 1937.—£281,858. Sum produced by a penny rate, 1937.—£1,074. A(l)b. Births. TOTAL. Male. Female. Live Births. Legitimate 596 301 295 Illegitimate 9 4 5 605 305 300 Live birth rate per 1,000 of population (1937 estimated). —15.82. Corresponding rate for 1936—14.18. TOTAL. Male. Female. Still Births. Legitimate 18 10 8 Illegitimate 2 2 — 20 12 8 Still Birth rate per 1,000 total births.—33.57. A(l)c. Deaths. Males 249. Females 166. Total 415. Death rate per 1,000 of population (estimated 1937).— 10.852. Corresponding rate for 1936.—11.324. Number of women dying in, or in consequence of, childbirth—1. Maternal Mortality per 1,000 total registered births—1.52. 7 A(1)d. Infantile Mortality. Deaths of infants under one year of age. TOTAL. Male. Female. Legitimate 24 19 5 Illegitimate 4 1 3 28 20 8 Death rate of infants under one year of age per 1,000 live births.—46.28. Total number of deaths from : 1936 1937 Measles (all ages) 6 — Whooping Cough (all ages) 2 — Diarrhoea (under 2 years) — 8 8 8 8 A(1)e. Vital Statistics of Whole District during 1937 and previous years. Year Population estimated to middle of each year Eirths Total Deaths registered in the District Transferable Deaths Nett Deaths belonging to the District Uncorrected Number Nett of Non-residents registered in the District of residents not registered in the District Under 1 year of age At all Ages Number Rate Number Rate No. Rate per 1000 nett Births No. Rate 1 2 3 4 5 6 7 8 9 10 11 12 13 1929 33,420 463 547 16.36 274 8.19 16 l6l 45 82.44 419 12053 1930 33,420 456 488 14.60 209 6.25 6 145 32 65.5 348 10.4 1931 32,920 432 492 14.94 258 7.67 10 119 37 75.2 362 10.99 1932 34,250 486 475 13.8 236 6.89 13 137 30 63.1 360 10.51 19 33 34,950 514 492 14.07 262 6.95 17 142 35 71.1 387 11.00 1934 35,020 531 481 13.7 230 6.56 18 140 21 43.6 347 9.9 1935 35,760 572 525 14.6 212 5.93 10 158 21 40.0 360 10.06 1936 36,380 580 510 14.18 243 0.67 17 186 30 58.82 412 11.324 1937 38,240 656 605 15.82 262 6.85 27 180 28 46.28 415 10.852 9 A(l)f. Table showing Summary of Causes of Death during the year ended 31st December, 1937. Cause of Death Males Females Total 1 Typhoid Fever, etc. — — — 2 Measles — — — 3 Scarlet Fever — — — 4 Whooping Cough — — — 5 Diphtheria — 1 1 6 Influenza 8 7 15 7 Encephalitis Lethargica l — 1 8 Cerebro-spinal fever — — — 9 Respiratory Tuberculosis 17 6 23 10 Other Tuberculosis 2 — 2 11 Syphilis 3 1 4 12 General paralysis of insane, etc. 2 — 2 13 Cancer 31 22 53 14 Diabetes 3 2 5 15 Cerebral haemorrhage 7 5 12 16 Heart disease 59 48 107 17 Aneurysm 2 1 3 18 Other circulatory diseases 20 9 29 19 Bronchitis 8 4 12 20 Pneumonia 19 11 30 21 Other respiratory diseases 2 — 2 22 Peptic ulcer 3 2 5 23 Diarrhoea, etc. (under 2 years) 6 2 8 24 Appendicitis 3 2 5 25 Cirrhosis of liver — — — 26 Other liver diseases 2 — 2 27 Other digestive diseases 4 3 7 28 Nephritis 7 6 13 29 Puerperal sepsis — — — 30 Other puerperal causes — 1 1 31 Congenital causes, etc. 6 3 9 32 Senility — 4 4 33 Suicide 2 6 8 34 Other violence 13 3 16 35 Other defined causes 18 16 34 36 Ill-defined causes 1 1 2 Total All Causes 249 166 415 10 A(l)g. Table showing Birth-rate, Death-rate, and Analysis of Mortality during the year 1937. Provisional figures. The mortality rates for England and Wales refer to the whole population, but for London and the towns to civilians only Kate per 1,000 total population Annual Death-rate per 1,000 population Rate per 1,000 Live Births Live Births Still Births All Causes Enteric Fever Sinall-pox Measles Scarlet Fever Whooping Cough Diphtheria Violence Influenza Diarrhoea & Enteritis (under Two years) Total Deaths under one year England and Wales 14.9 0.60 12.4 0.00 0.00 0.02 0.01 0.04 0.07 0.54 0.45 5.8 58 125 County Boroughs and Great Towns, including London 14.9 0.67 12.5 0.01 0.00 0.03 0.01 0.04 0.08 0.45 0.39 7.9 62 148 smaller towns (1931) adjusted populations 25,000—50,000 15.3 0.64 11.9 0.00 0.00 0.02 0.01 0.03 0.05 0.42 0.42 3.2 55 London 13.3 0.54 12.3 0.00 0.00 0.01 0.01 0.06 0.05 0.51 0.38 12.0 60 Erith (Estimated population 38,240) 15.82 0.52 10.852 0 00 0.00 0.00 0.00 0.00 0.026 0.419 0.39 13.22 46.28 11 A(2). Population. From a perusal of the statistics in the foregoing pages, the figure which once again calls for a comment is that of the population. From these statistics, also, it will he observed that during 1937, 872 houses were erected. It is rather interesting to reflect that these two figures have a definite hearing one on the other, for now that new houses are being erected at a constant rate of some 70 per month, the influx of population to the new estates is and will continue to grow in much the same way. A(3). Births. During 1937, the number of births under the Notification of Births Act, was 605. Twenty stillbirths were also registered, giving a stillbirth rate of 33.57 per 1,000 total births. The live birth rate presents another most interesting feature, inasmuch as that, it has a definite bearing on the paragraph referring to population. Upon reflection it does appear that now this newly-populated district is settling down, the number of births are increasing in a like ratio to the inward trend of population. A(4). Deaths. The total number of deaths was 415, 249 being males and 166 females. This is after allowing for inward and outward transfers. The Death Rate for 1937 is 10.852. The largest number of deaths attributed to one cause was due to Heart Disease, accounting for 107. The next most common cause was cancer accounting for 53. These figures closely follow figures recorded in previous years and they present no unusual features. A(5). Maternal Mortality. One death was recorded in Erith during 1937, under this heading. 12 Since 1920 there have been 9,469 births with 25 maternal deaths, as shown below, giving a Maternal Mortality rate of 2.603. Year Maternal Deaths Total Births (including still births) Registered Live Births 1921 3 735 717 1922 3 644 621 1923 1 623 595 1924 1 558 526 1925 — 602 548 1926 3 546 497 1927 — 532 532 1928 3 513 513 1929 1 558 547 1930 2 505 488 1931 — 501 492 1932 2 491 475 1933 1 502 492 1934 1 498 481 1935 2 544 525 1936 1 580 564 1937 1 671 656 Total 25 9603 9469 Maternal deaths are investigated by the Medical Officer of Health in collaboration with the medical practitioner and midwife concerned. A(6). Infant Mortality. 28 infants died before reaching one year of age, giving an infant mortality of 46.28. The comparable figure for the whole country is 58. 13 Analysis of the causes of death of this age group reveals the following figures : — Deaths from 1936 1937 Pneumonia 7 7 Whooping Cough 2 — Bronchitis 1 — Neo-Natal 14 3 Other causes 6 4 Gastro-Enteritis — 4 30 18 I have included a table showing the Infant Mortality at 5 year intervals for the past 25 years and for 1937. Erith England and Wales 1910 70.91 130 1915 73.17 91 1920 61.5 83 1925 56.48 75 1930 61.05 66 1935 40.0 59 1937 46.28 58 A(7). Natural and Social Conditions of the Area. Erith is situated south of the river Thames, adjoining the County of London on the West and the Urban Districts of Crayford on the East, and Bexley on the South. A large number of the population are employed in the several large factories, situate in the neighbourhood. The principal industries being Cable Making, Oil Refining, and the manufacture of Mining and Electrical Machinery, Asbestos and Cement Slabs. The District has a frontage to the river of about 6 miles. The northern part lying alongside the river, is mostly below the level of high tide in the river, and is marshy. The southern portion rises fairly rapidly to about 200 feet above sea level, 14 In parts of the Area, new estates of the residential suburban type, have been growing up in the past few years, with a socalled "dormitory population." A(8). Unemployment Figures and Comments. With the courteous co-operation of the Manager of the Erith Employment Exchange, it once again is possible to give definite figures on the state of unemployment in the District, as shown in the following table. A perusal of this table shows that an increase in employment has occurred mainly in the adult male group, though not to such an extent as during 1936. It should be again pointed out that it is most desirable that any reduction in unemployment should be from the adult male group. It has happened, that new industrial undertakings come into a District, and take on a large number of young persons between the ages of 16 to 18 years, thus reducing the total unemployment figures, but not affecting the adult males, which, from the social point of view, is the most important group. The following table shows, in figures, this reduction as against the figures for 1934, 1935 and 1936 : — Adults Young Persons Total Men Women Men Women December, 1934 926 113 62 33 1134 December, 1935 784 128 27 37 976 December, 1936 514 101 19 14 648 December, 1937 501 94 20 8 623 A(9). Riverside Promenade. As indicated in my last report, the Council acquired a site on the river frontage, and this has now been completed as a Riverside Promenade, enabling an excellent view to be obtained of this most interesting stretch of river. H(4). BEDONWELL CLINIC. The new All-Purpose Clinic at Bedonwell was completed, and sessions of Infant Welfare, School, Ante-natal, Dental, Remedial Exercises and Orthopaedic Clinics, commenced there during the year, 15 With the permission of Mr. F. Evans, M.A., M.B.E., Chief Education Officer, I am placing on record, in this report, a precis of an article contributed by him to the September issue of the "Town & County Councillor," which, to my mind fully describes the functions of our new clinic. The Clinic at Bedonwell Hill is in the vicinity of extensive housing estates which have grown up very rapidly within the last three years or so. The central clinic in the town was too far away from this growing section of the urban district but, in addition to the actual requirements of the medical inspection and treatment of school children, it was clearly necessary to provide accommodation for ante-natal and child welfare work, including dental treatment and the issue of auxiliary foods and milk. The following photographs and plan will clearly illustrate the description. The plan shows the layout, and it will be seen that provision has been made for a suitable circulation of patients and parents. When the clinic is used as a maternity and child welfare clinic, the mothers bring their perambulators into the pram shelter indicated on the plan. In the pram shelter also are cloakrooms for both visitors and nursing staff, these being fitted with hot and cold water lavatories, radiators and water closets. M irrors and a good supply of towels are provided. Three Purpose Waiting Room. The waiting room was purposely made larger than usual as its use in connection with the orthopaedic scheme was anticipated. It has large windows on two sides, one set being of the French type and made to open on to a crazy-paved terrace leading to the lawn. In the walls and in the ferro-concrete beams of the ceiling have been included fittings for the attachment of gymnastic equipment to be used in the remedial exercises prescribed and provided for children who come under the orthopaedic scheme. These fittings provide for wall ribstalls of two types, a suspended beam or boom, swinging rings, head suspension apparatus and vertical parallel bars. 16 Cubicles that Ensure Privacy. On the long side of the waiting room opposite the entrance from the pram shelter, can be seen in the plan, a suite of three cubicles with two doors to each leading on one side from the waiting room and on the other side in to the consulting room of the doctor. One cubicle is larger than the other two, can be darkened and it fitted with additional electric light points for the attachment of instruments used in optical examinations. The doors are fitted with "engaged" and "vacant telltales, and not only do the cubicles afford full privacy for the undressing and dressing necessary with ante-natal patients, but the way in which they have been placed to insulate the waiting room from the consulting room ensures that conversations cannot be overheard in the waiting room. In addition to the cubicles there is a communication passage into the consulting room from the waiting room, this having, also for the sake of privacy, two baize-covered doors. In the cubicles, mirrors, small shelves, pegs, revolving stools and lights are provided. Good Vantage Point. On this side of the waiting room also is placed the servery and record office. It has openings either by hatchway, sashwindow or door into the waiting room, the vestibule and the recovery room respectively. In the servery a sink, gas point for gas urn, shelves for foods and crockery, and cabinets for card indices are provided. Here, too, is the main telephone with extensions in to the school and in to the caretaker's flat above. Uses of Consulting Room. The Consulting Room has to serve a variety of purposes— for ante-natal examinations and consultations, for maternity and child welfare purposes, for school medical inspections, and minor ailment treatment, and for other such purposes. It is so designed that it has glass almost completely on two adjoining sides, the lower panes being glazed with prismatic obscure glass which does not reduce the light, A General View from the south, showing (right) the staff entrance and the consulting room windows, and (left) the French windows of the waiting-room. The Waiting-Room, looking through the cubicles into the consulting room. note the gymnastic apparatus for remedial exercises, and (left centre) the servery hatch. 17 There is a consultant's desk and chair with two chairs for patients. There is a slab made of rustless steel for a small electric steriliser with nearby a wash basin in to which hot water is supplied by an electric water heater fixed to the wall above. An alcove is provided in which alternatively can be stored the dental chair and the examination couch. Other equipment provided in this room includes a spittoon fitted on a bracket to the dental chair. A portable gas apparatus, a Terry's angle-poise portable high powered lamp, an electric dental engine, lazy tongs type fixed to the wall, and a fitted dental cabinet. Small glass-topped tables are also available as well as instrument cabinets. A curtain rack enables the consulting part of this room to be shut off if necessary from the part containing the examination couch and dental chair. Special Entrance for Staff. It will be noted from the plan that to the consulting room the doctor and dental surgeon have their own entrance from outside. Leading from the consulting room is the recovery room. I nder the window are three small bowls, supplied with cold and tepid water taps and fixed against white glazed tiles where, after dental work, esi>ecially extractions, patients can rinse their mouths. Recovery Room Set Apart. It will be noted that the servery and the vestibule separate widely this part of the clinic from the waiting room. In the recovery room also is a metal slab for a large steriliser, a large footbath, and a wash basin. To both the latter a supply of hot water is laid from a large electric water heater. Rotating adjustable stools, rubber link mats, chairs, one or two glass-topped tables, towel rails and screens complete the equipment of this room. The plan will show that it opens out into the vestibule which communicates also with the waiting room. A circulation of patients, especially dental patients, is therefore ensured by this plan of clinic. Access to it does not necessitate crossing the school playground and its entrances are all detached and separate from those of the school. 18 Above is a flat in which the caretaker lives, with which the clinic staff can communicate by telephone. Attractive Exterior. The Clinic block is designed in the modern style where horizontal bands of blue and red brick are blended with the white lines of concrete lintels and flats. The windows are horizontal in type in the design of their panes, so that the whole is in keeping with modern simplicity and utility. The cost of the clinic was <£'2,184 and of the equipment £310. SECTION B.—MATERNITY AND CHILD WELFARE SERVICES. B(l). Maternity and Child Welfare Scheme. The Maternity and Child Welfare Scheme is comparatively a complete one, and provides the following services : 1. Ante-natal clinic—one session per week at Hainault. one session per week at Bedonwell. 2. Provision of an Obstetric Consultant for difficulties and emergencies arising during pregnancy and labour. 3. Hospital provision for cases of Puerperal Pyrexia and Ophthalmia Neonatorum. 4. The facilities for the provision of Free Milk for necessitous expectant, and nursing mothers were extended during the year in accordance with the suggestions contained in Circular 1519, to include the whole period of pregnancy. 5. Provision for dental treatment of children under school age and nursing and pregnant women at a session held fortnightly at the School Dental Clinic. 6. Four Infant Welfare Centres holding fourteen sessions per month. 7. Provision for Orthopaedic treatment for children under school age. 19 Month Births Sex Legitimacy Notified by B(2). Notification of Births. During 1937, 656 live births and 15 stillbirths, giving a total of G71 were notified to me, as shown in the following table : Live S'born M F Leg. llleg. Midwives Hosp. etc. Doctors M F M F January 51 — — 25 26 51 — 19 30 2 February 47 1 — 28 19 47 — — 26 19 2 March 4G 1 — 24 22 40 — — 19 26 1 April 72 — — 37 35 72 — — 37 28 rr / May 52 1 1 24 28 52 — — 24 27 1 June 55 1 1 26 29 55 — — 26 27 2 July 55 2 1 29 26 52 1 2 25 26 4 August 51 — — 23 28 50 — 1 22 26 3 September 62 1 2 30 32 62 — — 25 35 2 October 57 — 2 28 29 56 1 — 24 27 6 November 59 — — 32 27 58 1 — 25 32 2 December 49 1 — 20 29 47 — — 15 30 4 Total 656 8 7 326 330 648 3 3 287 333 36 20 In every case where a birth is registered and has not been notified the responsible person is requested to furnish an explanation. All stillbirths and deaths of children under the age of five years are investigated by the Health Visitors. B(3). Child Welfare Centres. The basis of child welfare facilities in the Erith Urban District is a system of 3 clinics held 011 one half-day a week, and one clinic held 011 one half-day a fortnight, in various parts of the town. Each Infant Welfare Clinic is attended by a MedicalOfficer, two Health Visitors, and one clerk. The Health Visitors weigh each child who attends, advise mothers in certain cases and refer others to the Medical Officer for consultation, as shown in the Table on page 21. The work of the infant welfare centre is for the most part Educational and advisory, and any ailments of a serious nature are referred to the private medical practitioner, or to a hospital, for treatment. Dried milks are supplied to the mothers, on the advice of the Medical Officer, as a rule at cost price, but where the family income falls below a stated figure, milk may be provided either at half cost or free. Infant Welfare Centres. Month Belvedere Enth Picardy Bedonwell Infants weighed Consultations Infants weighed Consultations Infants weighed Consultations Infants Weighed Consultations Under 1 year 1 to 5 years Under 1 year 1 to 5 years Under 1 Year 1 to 5 years Under 1 Year 1 to 5 years January 230 125 90 167 92 52 39 29 18 — — — February 242 158 71 199 101 60 53 32 22 — — — March 252 138 62 220 81 55 64 39 30 — — — April 275 151 81 251 83 55 45 36 17 — — — May 192 97 51 273 75 61 49 37 21 — — — June 368 171 100 353 98 71 48 34 19 — — — July 281 117 80 246 72 59 38 34 35 — — — August 312 148 72 260 89 60 55 24 35 — — — September 269 151 76 326 111 77 63 46 27 — — — October 216 144 69 274 93 56 56 41 15 129 51 52 November 203 111 47 248 87 44 42 34 18 150 56 46 December 135 64 48 217 68 51 47 35 23 61 28 10 Totals 2975 1578 847 3034 1050 701 599 421 280 340 135 108 4553 4084 1020 475 Grand Total—Infants Weighed 10,132 Consultations 1,936 Under 1 year 6,948. 1—5 years 3,184 21 22 B(4). Home Visits by Health Visitors. 1937 Children Special Visits Expectant Mothers Infant Life Protection Total Visits 1st Visits ReVisits StillBirths Others January 46 534 1 9 17 4 611 February 50 808 — 11 31 2 902 March 42 700 2 2 34 9 789 April 77 845 2 6 22 11 963 May 40 561 2 10 16 8 637 June 59 887 3 7 24 12 992 July 111 1154 3 10 35 17 1330 August September 51 995 2 27 34 15 1124 October 50 772 2 7 25 9 865 November 55 615 1 3 21 2 697 December 53 782 1 16 35 3 890 Total Visits 634 8653 19 108 294 92 9800 23 Ante-natal patients seen by Doctor Erith 1937 Jan. Feb Mr. Apr. Ma\ June July Au^ Sep. Oct. Nov Dec. Total 86 93 74 49 87 137 164 91 124 92 87 79 1163 1217 Bedonwell — — — — — — — — — 8 19 27 54 B(5)c. Ante-Natal In-patient Accommodation. The need for increased institutional accommodation, for maternity cases within the area, has been under consideration during the year. Ihere is no doubt that there is a need in this area, as probably in every other area, for more extended use of antenatal in-patient accommodation. Everybody is agreed that there is need for this, but there seems to be 110 demand, and the demand can only be created through the patient herself. It seems that the reason why many cases of Toxaemia do not secure institutional accommodation earlier, is fundamentally a financial one. The patient herself is attempting to limit the cost of her pregnancy and confinement, within what is generally accepted as the usual cost, and it seems probable that there is often a reluctance among medical attendants, both public and private, to insist on prolonged ante-natal institutional or domiciliary treatment, out of sympathy for her pocket, and the resulting treatment is often a half-hearted compromise between absolute rest and carrying 011 her domestic affairs, until symptoms are sufficiently serious that they must present the ultimatum to her. B(5)d. Abnormal Cases. Accommodation for abnormal maternity cases, in need of hospital treatment is provided for by an arrangement between this Council and the City of London Maternity Hospital. Seven cases were admitted under this arrangement during the year, and, in addition, two cases were transferred to Queen Charlotte's Annexe. 24 The conditions for which they were admitted were as follows : City of London Maternity Hospital Queen ( harlottcs Annexe Toxæmia 2 — Trial Labour 1 — Extended Breech 1 Cardiac Insufficiency 3 — Pyrexia — 2 Total 7 2 B(6). Infant Life Protection. The Health Visitors are responsible for the general execution of Infant Life Protection work. As a general rule they undertake routine visiting in their own districts. Cases in which medical examinations are required, or when doubt arises, are submitted to the Medical Officer of Health. Information with regard to foster children is obtained from the following sources ::— 1. By Health Visitors in the course of Routine Visits. 2. By scrutiny of advertisements in the local newspapers, etc., and explanatory leaflets are available for the guidance of foster mothers upon application to the Public Health Department. Number of faster mothers on register at end of year ... 22 Number of children on register at 31st December, 1937 25 During the year frequent visits were paid to foster children, and in no case was it found necessary to take legal action against any foster parent. B(7). Midwives. The administration of the Midwives Acts is carried out by the Kent County Council which is the Local Supervising Authority. Under the new Midwives Act the County Council employ and supervise midwives working in this area. B(8). Maternity and Nursing Homes. At present there are two registered Nursing Homes in the district. No applications for registration were received during the year. B(9). NURSING IN THE HOME. B(9)a. General. Three voluntary Nursing Associations provide nurses for work in the district. These are not subsidized by the Local Authority, but are supported by weekly contributions by Members of the Associations, and subscriptions from others. 25 The services of these nurses are also available to non-members of the Associations for a small fee per visit. B(9)b. Infectious. No nursing in the homes is carried out by the Staff of the Health Department. It has not been found necessary during the year to make use of the legislation which enables this Authority to compel removal of infectious patients to hospital. B(10). National Society for the Prevention of Cruelty to Children. An account of the Welfare Work of the Department would be incomplete without a mention of the splendid work of and, the valuable assistance given by, the National Society for the Prevention of Cruelty to Children. Cases coming to the notice of the Medical Officer of Health are referred to the local Inspectors. SECTION C— PREVALENCE OF AM) CONTROL OVER NOTIFIABLE INFECTIOUS DISEASES. C(l). Infectious Diseases' Hospital. The Erith Urban District Council provides its own Isolation Hospital. A large portion of admissions are cases of Scarlet Fever and Diphtheria, but any notifiable infectious disease is admitted, with the exception of smallpox and puerperal infections, special arrangement for which are described elsewhere in this report. Cases of measles are admitted during epidemic times. C(2). TABLES. C(2)a. Notifications. The following table shows the total notifications received during the year 1937 : — Disease Total cases notified Cases admitted to infectious diseases hospital Total Deaths Diphtheria 37 34 1 Scarlet Fever 61 50 — Erysipelas 17 — — Pneumonia 42 2 30 Puerperal P. 2 — — Puerperal F. 3 — — Oph. Neon. 2 — — Dysentery 3 — — Paratyphoid 1 — — Poliomyelitis — — — Acute 1 — — 26 C(2)b. Age Distribution. This second table shows, in detail, the age distribution of the notified infectious diseases mentioned above: — Disease Age Groups Totals under 1 1 2 3 4 5 10 15 20 35 45 65 over 65 Diphtheria — 1 4 2 1 9 12 3 3 — 1 1 — 37 Scarlet Fever — 3 2 5 6 31 7 4 — 3 — — 61 Erysipelas 1 1 1 — — — 1 — 3 2 6 2 17 Pneumonia 5 3 3 2 — 6 2 1 4 9 2 2 3 42 Puerperal P. — — — — — — — — 1 1 — — — 2 Puerperal F. — — — — — — — — 1 2 — — — 3 Oph. Neon. 2 — — — — — — — — — — — — 2 Poliomye'is Acute — — — — — — 1 — — — — — — 1 Paratyphoid 'B' — — — 1 — — — — — — — — — 1 Dysentery — — — — 1 — — — — — 2 — — 3 Totals 8 8 10 10 8 46 23 8 12 17 11 3 5 169 27 C(3). School Incidence of Infectious Disease. The following Table gives in detail the prevalence of certain notifiable Infectious Diseases in each of the Schools in the District, along with the number of cases above and below School age (5 years). School Accommoda tion Diphtheria Scarlet Fever Typhoid Total[/] Central Bovs. North. Heath 560 — — — — Picardy 480 3 1 — 4 Central Girls. North. Heath 560 — — — — Picardy 480 1 2 — 3 Junior Bovs. North Heath 200 1 — — 1 St. Augustine's Road 350 1 1 — 2 West Street 300 1 — — 1 Junior Girls. North. Heath 200 3 2 — 5 St. Augustine's Road 350 — 1 — 1 West Street 300 1 3 — 4 Junior Mixed. Bedonwell Hill 290 — 2 — 2 Crescent Road 330 2 3 — 5 All Saints C. of E. 130 — 1 — 1 Junior Mixed and Infants. Crossness 150 — — — — Mixed and Infants St. Fidelis R.C 193 — — — — Infants. Bedonwell Hill 240 — 1 — 1 Belvedere 150 — — — — Crescent Koad 190 — 1 — 1 North. Heath 340 — 4 4 St. Augustines Road 350 3 6 — 9 West Street 350 2 3 — 5 Totals 6490 18 31 — 49 Private and other Schools. Males — 1 — 1 Females — 2 — 2 Schools out of Town Males — 3 — 3 Females — — — — Under School Age Males 6 8 — 14 Females 3 9 — 12 Over School Age Males 2 2 — 4 Females 8 5 — 13 Totals 18 29 — 47 Grand Totals 37 61 — 98 28 C(4). Comments on :— (a) Diphtheria. The number of cases of Diphtheria show once again a decrease, and there has been no grouping of cases. The type of Diphtheria was not unduly severe and there was no special incidence in any school. (b) Scarlet Fever. Although the number of cases of Scarlet Fever was again above those occurring during 1936, there was no epidemic. Cases of Scarlet Fever occurred sporadically throughout the year, and never in such concentration that it was possible to trace severe cases to a common source of infection. Of the 61 cases notified 50 were admitted to hospital for treatment. (c) Enteric Fever. No cases of Typhoid Fever were notified but one case was notified as Paratyphoid 4 B.' (d) Measles. This condition is not notifiable in this district. From school attendance records it is observed that Erith suffered from a mild epidemic of Measles during November and December. During the year this complaint accounted for no deaths. (e) Provision of Serum for Cases of Measles. During the year a scheme was outlined to the Committee, for the provision of protective serum for measles contacts. The Committee agreed to co-operate with the Kent County Council, in a Scheme for the provision of such serum, as follows : 44 Blood to be collected, from donors from the District, at the Maidstone Laboratory or at some other convenient place. The serum to be separated, treated, examined and ampouled ready for distribution from the central 4 store ' at Maidstone. Serum to be supplied on request, by telephone or letter, on the understanding that the Doctor agrees to find donors to replace the serum supplied from the pool, thus ensuring that a supply will always be available. Every ampoule of serum sent out to be labelled with instructions as to when and how to use, etc." It is hoped that this scheme will prove another medium through which the Public Health Department may be able to co-operate with the General Practitioners in the District. (f) Puerperal Fever and Pyrexia. Two cases of Puerperal Pyrexia and three cases of Puerperal Fever were notified during the year, 29 Arrangements have been made to secure admission of these patients either to Queen Charlotte's Annexe or to the North Western Hospital, which is controlled by the London County Council, except when the patient's own practitioner arranges for treatment elsewhere. Under the Public Health (Puerperal Fever) Regulations, a Consulting Obstetrician, Mr. A. Galletly, is available for assistance to Medical Practitioners within the area. (g) Ophthalmia Neonatorum. Two cases of Ophthalmia Neonatorum were notified, one of which was treated at home, the other at Hospital. Vision was unimpaired in both instances. (h) Smallpox. An arrangement exists between the London County Council and the Erith Urban District Council for accommodation for cases of smallpox occurring within the District. (i) Diarrhoea and Vomiting. In common with other Districts, Erith experienced a series of cases of Dysentery, at the latter part of the year, and swabs of faeces were taken from which the Sonne Bacillus was eventually isolated in 2 cases. At the time the first cases were brought to the notice of this Department, towards the beginning of November, 1937, the Medical Practitioners were circularised, asking them to supply details of all cases of Diarrhoea and Vomiting which came to their notice, and in each of these cases a detailed investigation was made. A perusal of the details thus obtained did not reveal any common source of infection. C(5). Disinfection of Premises, Bedding, etc., after Infectious Disease. The Sanitary Foreman also acts as Infectious Disease Enquiry Officer and Disinfecting Officer. Following the removal of cases of infectious disease, tuberculosis, etc., 193 premises were disinfected, whilst enquiries to obtain particulars regarding 65 cases of tuberculosis were undertaken. In the few instances where patients are isolated at home, disinfection is carried out at the request of the Medical Practitioner, who, for the purpose, is supplied with a card stating that the patient has recovered and the room requires disinfection. 30 The Council have a high pressure steam disinfector at the Isolation Hospital, at which clothing, bedding, etc., are disinfected, in addition to the disinfections carried out for the hospital itself. During 1937, batches of bedding, etc., were disinfected, as under :— Article No. disinfected Maitresses 48 Pillows 88 Bolsters 4 Blankets 17 Mattress Covers 1 Total 158 C(6). Laboratory Facilities. Examination of pathological specimens, and other laboratory work for the District, are undertaken by the Kent County Laboratory, Sessions House, Maidstone. During 1937, 317 specimens were sent, as shown below : — Nature of Specimen sent Result Total Positive Negative Swabs for Diphtheria 18 108 126 Sputum for suspected Tuberculosis 32 110 142 Various 19 30 49 69 248 317 C(7). TUBERCULOSIS. C(7)a. Treatment and Hospital Accommodation. The Kent County Council are responsible for cases of Tuberculosis occurring within the district, and also for Sanatorium treatment and hospital accommodation for Erith residents. A dispensary is held twice weekly at 65 Bexley Road, Erith, by a whole-time Tuberculosis Officer. 31 In the tables which follow, particulars of new cases of Tuberculosis and of all deaths from the disease in the area, during 1937, are shown in Table 1, whilst Table 2 shows the quarterly statements of cases on the register, together with the position at the 31st December, 1937. C(7)b. Table (i). Particulars of New Cases and Deaths. Age Periods New Cases Deaths Pulmonary Non-Pulm'n'ry Pulmonary Non-Pulm'n'ry M. F. M. F. M. F. M. F. Under 1 year — — — — — — l — — 1 — — — 1 — 5 — — 2 — — — — — 10 — — — I — — — — 15 4 — — — 1 — — — 20 — 5 1 1 1 — — — 25 4 7 — — 4 3 — — 35 6 3 2 — 6 1 1 — 45 9 — — — 3 2 — — 55 3 3 — — 1 — — — 65& upwards 1 1 — — 1 — — — Totals 27 19 6 2 17 6 2 — 32 Table (ii). Quarterly Statements. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter M F T M F T M F T M F ] Pulmonary T.B. 178 171 349 176 173 349 181 178 359 184 181 365 Number on register New notifications during year 5 6 11 8 4 12 4 5 9 7 7 14 Cases removed, which have been restored — — — — — — — — — — — — Cases added to register other than by notification 2 3 5 2 3 5 1 1 2 2 2 4 Cases removed from register 9 7 16 5 2 7 2 3 5 8 2 10 Cases remaining on register 176 173 349 181 178 359 184 181 365 185 188 373 Non-Pulmonary T.B. Number on register 85 64 149 85 63 148 86 63 149 87 63 150 New notifications during year 2 — 2 1 — 1 2 — 2 1 2 3 Cases removed, which have been restored — — — — — — — — — — — — Cases added to register other than by notification — — — — — — — — — — — — Cases removed from register 2 1 3 — — — 1 — 1 2 — 2 Cases remaining on register 85 63 148 86 63 149 87 63 150 86 65 151 Total Pulmonary and Non-Pulmonary cases on Register at end of year 524 33 C(8). Consultations with local Medical Practitioners. It is pleasing to again record that the relationship between officers of the Health Department and private practitoners is characterised by mutual trust and respect. Practitioners invite the opinion of the Medical Officer of Health in connection with the diagnosis of Infectious Diseases, and by such action greatly facilitate the work of the department. It has been the policy of the department to encourage such a course in every way. As the Medical Officer of Health is also the School Medical Officer complete co-ordination with the Education Department is assured, while after-supervision either by the family doctor or the School Medical Officer is encouraged in every way. C(9). Ear, Nose and Throat. The arrangement made in 1930 by the Education Committee with the Royal Waterloo Hospital to undertake the operative treatment of Tonsils and Adenoids in the school children continues to function satisfactorily. The Health Committee re-appointed Mr. F. C. W. Capps, F.R.C.S., of St. Bartholomews Hospital, as Consulting Aural Surgeon. This appointment is renewable annually and a retaining fee is paid. The services of Mr. Capps are available for his opinion, and for operations on patients in the Sanatorium, as required. 34 C(10). Clinics and Treatment Centres. Clinics and Treatment Centres. Address. Medical Officer in Attendance. Day and Time. Accommodation. Provided by Ante Natal Clinics Hainault, Lesney Park Road M.O.H. Tuesdays 2—4 Two rooms Erith U.D.C. Bedonwell Clinic M.O.H. Thurs. 9.30—12 " " Infant Welfare Centres (1) Hainault, Lesney Park Road. Assistant M.O.H. Fridays 2—4 Four rooms " " (2) Belvedere Public Hall. Assistant M.O.H. Tuesdays 2—4 Three rooms (3) Primitive Methodist Church, Belvedere Assistant M.O.Il. 1st and 3rd Wed. 2—4 Two rooms " " (4) Bedonwell Clinic. Assistant M.O.H. Mondays 2—4 Three rooms Maternity and Child Welfare Dental Clinic Hainault, Lesney Park Road M.O.H. and 4th Wed 2.30 " " Bedonwell Clinic Mr. R. A. Presslie, L.D.S. 2nd Wed. 2.30 School Clinics (1) Hainault, Lesney Pk. Rd. Assistant S.M.O. Daily at 9.15 Two rooms " " (2) Bedonwell Clinic School Nurse Tuesdays 9.30 One room " " Saturdays 9.30 Ophthalmic Clinic Hainault, Lesney Park Road Mr. N. Howard Allen, 1st and 3rd Three rooms " " M.R.C.S., L.R.C.P. Wed 9.30 School Dental Clinic (Extractions) Hainault, Lesney Park Road Mr. R. A. Presslie, Thursdays 9.30 Three rooms " " L.D.S. Tuesdays ] Thursdays a 2 0 Fridays J Mondays 5—6 School Dental Clinic (Conservation) Hainault, Lesney Park Road Mr. R. A. Presslie, L.D.S. Three rooms " " Tuberculosis Dispensary 65 Bexley Road, Erith. Dr. C. Roper Thursdays 10.30—12.30 Kent C.C. Venereal Diseases Clinic 87 West Hill, Dartford. Drs. Renton and Ockwell. Men. Mondays 4.30 to 6.30 " " Wed sdays 5—6 Women. Tues days 4—6 35 SECTION D.—HOSPITAL FACILITIES. D(l). General. Situated within the area is a hospital of 41 beds which is maintained by voluntary efforts, the building is well equipped and has a visiting staff of local medical practitioners. The special departments are attended by a specialist consultant staff. The services of the large General and Special Hospitals in London are readily accessible to residents in this area. D(2). Venereal Diseases. A Venereal Diseases clinic for this area is held at Dartford and is provided by the Kent County C ouncil. D(3). Children. A ward of 10 beds is provided at the Erith and District Hospital, whilst special hospitals in Woolwich and other parts of London are easily accessible. D(4). Ambulance Facilities. The Ambulance service is under the control of the Captain of the Fire Brigade, and is carried out by a full-time staff. Four ambulances are kept for non-infectious or accident cases and one for the removal of Infectious cases. SECTION E.—SANITARY CIRCUMSTANCES OF THE AREA. E(l). Refuse Collection and Disposal. The arrangements at present existing in connection with the collection and disposal of house refuse continue to work satisfactorily. That the existing fleet of vehicles continue to maintain a weekly collection in spite of the fact that the number of houses being dealt with at the 31st December was an increase of some 850, on the like figure for the previous year, reflects due credit on the administration of this section of the Department. During the year re-organisation of the days of collection was rendered necessary, due to the increase in the number of houses in certain defined districts, and although the service is now working at full pressure, it does, at present, appear adequate. The method of storage is by means of sanitary dust-bins, and some 10,500 are emptied weekly. The dust-bins are provided and maintained by the owners of the properties concerned, the Council securing this by a local act—The Erith Improvement Act, 1920. Disposal is effected by barging under contract, and these arrangements are still working very satisfactorily. 36 The following tables show : 1. Details of the refuse collection vehicles and staff, 2. Details of the tonnage dealt with during the year. E(l)a. Table 1. Vehicle Capacity 1 Dennis Lorry 12 cubic yards 2 Easyloaders 4 " " 2 S. D. Freighters 7 " " These are operated by— 1 Foreman, 5 Drivers and 9 Loaders. E(l)b. Table 2. Month Tonnage Tons Cwt. January, 1937 719 5 February 687 0 March 795 3 April 764 2 May 708 3½ June 645 9½ July 609 8 August 527 19 September 644 12 October 687 15 November 749 14 December 803 6 Total 8341 17 The total tonnage dealt with during the year, as shown above was 8,341 tons 17 cwts., this is an increase of 756 tons 10 cwts. over that of last year. E(2). Trade Refuse. Trade Refuse is collected from the shops by arrangement with the shopkeepers, an agreed charge being made, or it is brought to the wharf by the traders themselves. 37 The growth of this section of the refuse disposal services has been rapid, when it is remembered that 7 years ago approx. 1 16 tons were disposed of while in 1937 the amount reached approx. 200 tons. E(3). Water Supply. The water in this district is almost exclusively supplied by the Metropolitan Water Board. The water, though possessing a considerable degree of hardness, is of good quality and is palatable. The supply in nearly all cases is led into the houses ; standpipes exist on a few premises only. Routine examination of such supplies has been undertaken throughout the year with completely satisfactory results, and arrangements are now in existence, with the Kent County Laboratory, for samples of this supply to be taken monthly from various points in the District. The encampment on Belvedere Marshes derives its water supply chiefly from bore-holes. Extensive sampling of these supplies has resulted in warning letters, regarding the unsuitability, for drinking and culinary purposes until it lias been boiled, of water from a number of wells, being issued. During December a report was submitted with regard to certain of these bacteriological results, when it was resolved that provision of a service pipe for water supply to the encampment should be undertaken. E(4). Drainage and Sewerage. Extensions to the existing drainage systems were made during the year by the completion of 510 yards of new sewer to estates now being developed in the District, and, in addition, there have been many extensions of house drains and connections. E(5). Closet Accommodation and Cesspools. The whole of the closet accommodation in both the older parts of Erith and the newly built up areas is on the main drainage system, there being only 21 premises which are drained into cesspools. Cesspools are emptied once a month by mechanical plant by the Council free of charge, or more frequently as required, when a fee is charged to cover the cost of labour. The contents of these cesspools are discharged into the Council's Sewers. The cesspools which now require the service are scattered throughout the District, and, in the majority of cases, necessitate travelling considerable distances both for pumping out and conveying to the point of disposal. 38 During 1937, cesspools were emptied 011 92 occasions. With the exception of the encampment on Belvedere Marshes it may be said that the district is almost entirely on the water carriage system. E(6). Swimming Baths. An open air swimming bath is provided by the Council. The water is mechanically filtered and regularly sampled. During 1937, three samples were taken for examination and proved satisfactory. Arrangements have been made to sample the bath water during the coming season, two samples per month—one from each end of the bath. E(7). Hop Pickers. There are no hop fields within the district. E(8). Schools. All schools in the district are visited at least twice during the year by a member of my staff and any defects found are reported to the Education Committee. Further details with regard to the schools are given in my report as School Medical Officer. E(9). Rag Flock Act. There are no premises in the district in which rag flock is manufactured, used or sold. E(10). Smoke Abatement. No statutory action was taken during the year with regard to the abatement of nuisances from smoke. The closest cooperation exists between the various factories and the officers of the local authority, a fact which tends to lessen this type of nuisance. E(ll). Health Education. E(ll)a. Rat Week. Rat Week was observed in Erith during the week commencing November 1st. Large posters were displayed on the Council's advertising boards, affixed to various Council vehicles, and announcements were made in the local Press inviting the public to co-operate with the Local Authority in destroying rats and mice. In addition to the help and advice always available from this Department in the destruction of these vermin, free issues of vermicide were available at this time. E(ll)b. National Health Campaign. Erith co-operated on a comprehensive scale in the National Health Campaign. The Council obtained supplies of all the literature offered, and posters were displayed on all the Council hoardings throughout the District. 39 Two thousand hook marks were circulated each month through the medium of the Library Department. Circulars were distributed through the Junior and Senior School Children and the Infant Welfare Clinics, and posters were displayed in all Departments and Sections in the Offices, Infant Welfare Clinics, School Clinics and Waiting Rooms, etc. Each poster, circular and book mark was overprinted to the effect that full details of all services could be obtained upon application to the Public Health Department. As far as this District is concerned the Campaign most certainly achieved one of its objects, in that the number of enquiries, regarding the services administered through this Department, increased in a most heartening manner. It is hoped that the results of this enterprise will make itself shown during the coming year, in increased attendance, which is a sure sign of increased interest in the services offered, at the Infant Welfare Clinics, School Clinics, and Dental and Antenatal Schemes. E(12). Cleansing of Verminous Persons. No cleansing station is provided by this Authority but cases requiring treatment can obtain it by arrangement with the Dartford Hospital. E(13). Housing. E(13)a. Fitness of Houses. During the year, in connection with the inspection of existing houses under the Housing Consolidated Regulations, 192."), which make it the duty of a Local Authority to cause systematic inspection of the district to be made, the findings recorded, and any defects discovered to be remedied, 145 records were made of houses necessitating 422 inspections. In addition to these, 491 dwelling houses were found on inspection to be not in all respects reasonably fit for human habitation and in all cases steps were taken to render them so fit. E(13)b. Unhealthy Areas. No action has been taken during the year under the provisions of the Housing Act, 1930, relating to Clearance Areas. E(13)c. Overcrowding & General Observations. (a) Overcrowding. During the first portion of the year under review, activities with regard to the Overcrowding provisions of the Housing Act 1936, were mostly confined to the issue of numbers constituting 4 permitted numbers ' in relation to dwelling houses, and this work has continued steadily throughout the year. 40 At the 31st December, 1937, 937 certificates dealing with 8,499 premises had been issued. At the meeting of the Health and Buildings Committer held during February, 1937, a special report was submitted, re viewing the 59 cases of overcrowding which were outstanding at the 31st December, 1936, and revealing that 39 of these case had been proved to be uncrowded, as shown hereunder, whicl left 20 cases still to be dealt with. Overcrowding abated by— No. of cases Removal ot sub-tenants or lodgers 8 Reduction in number of members of the family 11 Marriage or death of an occupant 7 Removal of tenant to other and adequate premises ... 3 Re-arrangement of occupants or adjustment in allocation of rooms, etc. 10 39 In the course of this review 22 specific review cases were investigated, these were cases which had arisen since the preliminary survey, and which were caused by : — (a) Children attaining the ages of either 1 or 10 years. (b) 4 Borderline ' cases which appeared overcrowded, and in which the premises required measuring. Visits were paid in each case and form ' B ' completed, which proved that in 11 cases the premises were not overcrowded, but that in the remaining 11 cases under this review overcrowding existed. Facts regarding the 20 cases of overcrowding existing from the preliminary survey, together with the 11 cases of overcrowding which arose during the review, are as shown in the following table, which indicates the ratio of overcrowding expressed in persons per house : — No. of persons per house causing overcrowding No. of Cases ½ 12 1 11 1½ 3 2 3 2½ i 4 i Total 31 41 (b) Houses erected since the time of the first Survey. At the meeting of the Health & Buildings Committee held during August, 1987, a request was made for particulars regarding progress and present position of work being carried out under the Housing Act, 1936. A special report was submitted in accordance with this request and following that report a survey of the premises erected since the time of the first Survey was undertaken, and is continuing month by month. (i) A comprehensive index of all properties erected since the time of the first survey was compiled from records obtained in co-operation with the Surveyor's Department ; (ii) A detailed form was sent to the occupier of each premises, together with an explanatory letter, requesting that such form should be filled in and returned within seven days; (iii) From the replies received, a detailed Register has been compiled, which shows not only the type of house concerned but also the owners name and address, the number of occupants, the equivalent number, the 'permitted number' and whether or not the premises are overcrowded. The total number of premises concerned up to 31st December, 1937, was 1,451, and of this number— (a) 1,235 were found to be owned by the occupier, (b) 141 were tenanted; and of the remainder, (c) 4 were occupied by virtue of the service of the occupier to the owner, (d) 63 were unoccupied at the time of visit; whilst (e) 8 were being used as showhouses. (i). Owner/Occupied Premises. Of the owner/occupied premises, one proved to be overcrowded, and, whilst the majority of forms were returned within the specified time given—seven days—in the remainder of this group, "reminder letters" or personal calls were necessitated on one or more occasions in the cases of non-return of forms. (ii). Tenanted Premises. In each of the cases that were found to be tenanted, the Temporary Housing Clerk was instructed to make a personal call, and complete a Housing Form 'B.' In addition to the facts so obtained being recorded in the Register, an explanatory letter and an Official Certificate showing the number constituting the 'permitted number' in relation to each of these premises, has been sent to the Owner of such premises. 42 Difficulty was experienced in a number of cases, in obtaining access to the premises for the purpose of measuring, etc., but by persistent effort, both by letter asking for appointment, and personal calls, each one of these was dealt with. Such information gained, has revealed the fact that, in relation to these premises, overcrowding exists in two cases, and in one other case, review will be necessary. (iii). Unoccupied and Showhouses. As mentioned on page 41, there were 63 unoccupied premises, and 8 houses which were being used as showhouses. These will be visited as they become occupied, with a view to either the owner/occupier form, or the Housing form 'B' (tenants form) being completed. (iv). General. It appears that building in this District will still progress at a fairly average pace, and that lists of completed dwelling houses will continue to be received from the Surveyor's Department for some months to come. These lists average from 50 to 80 premises a month, and now that a routine has been established in dealing with them, this throws a considerable amount of additional administrative and clerical work on the staff of the Department. Having regard to the extent of the number of dwelling houses dealt with, it is pleasing to record the excellent response which was obtained in connection with these enquiry forms. E(13)d. Survey of Encampment at Belvedere Marsh. Towards the latter part of the year the Council decided to undertake a comprehensive survey of the Encampment at Belvedere Marsh. During December, Temporary Staff were appointed to undertake this survey, and the work is proceeding under the direct supervision of this Department. As a preliminary to the actual work of collating statistics, regarding huts, vans, etc., and the population, a comprehensive survey will be undertaken, and each structure is to be accurately plotted on a sketch plan. This work will be supervised in cooperation with the Surveyor's Department. The work of visiting and obtaining details with regard to each plot, which facts will be entered in detail on survey cards, is proceeding. For the purpose of the survey, the encampment will be dealt with in three parts:— 1. East Road. 2. Occupation or New Road. 3. Morton Road, 43 SECTION F.—INSPECTION AND SUPERVISION OF FOOD. The Staff of the Public Health Department continue to take keen interest in the inspection and supervision of food supplies. F(l). Meat. Owing to the scattered situation of the slaughterhouses in the District, and irregular times of slaughter, the present system of meat inspection leaves much to be desired. Supervision by the Inspectors, however, of slaughterhouses, meat shops and stalls, and cooked food and other premises, where food is prepared for sale, has been carried out extensively during the year, when 2 tons 3 cwts. 1 qr. 22 lbs. of food was condemned as unfit for human consumption. The Inspectors keep a detailed record of all meat, etc., inspected and the following table, which is in the prescribed form, shows details of carcases inspected and condemned, during the year:— Cattle excluding Cows Cows Calves Sheep & Lambs Pigs Number killed (if known) – – 33 259 2273 Number inspected – – 33 259 2273 All diseases except Tuberculosis Whole Carcases condemned – – – – 3 Carcases of which some part or organ was condemned – – 4 35 62 Percentage of the number inspected affected with disease other than tuberculosis – – 12 1% 135% 28% Tuberculosis only Whole Carcases condemned – – – – 9 Carcases of which some part or organ was condemned – – – – 87 Percentage of the number inspected affected with tuberculosis – – – – 4.04% 44 No legal action was taken by the Authority with regard to unsound meat during the year. F(2). Slaughter of Animals Act, 1933. The Slaughter of Animals Act, 1933, makes the use of a mechanically operated instrument for stunning compulsory. Previous to the passing of the Act, the use of such an instrument was required and governed by the Council's Bylelaws. During the year one person made application for a licence to slaughter or stun animals in compliance with the terms of the above Act, and was duly licensed. No. of licensed slaughtermen on register at 31st December, 1936 10 No. of slaughtermen licensed during 1937 1 No. of licences not renewed during 1937 1 Total number of licensed slaughtermen on register at 3lst December, 1937 10 F(3). Milk. On the 1st June, 1936, a new order, the Milk (Special Designations) Order 1936 came into operation, which revoked the Milk (Special Designation) Orders of 1923 and 1934, and prescribed the following new special designations for milk. Tuberculin Tested. Milk from cows that have passed the tuberculin test for freedom from Tuberculosis. Tuberculin Tested (certified). Tuberculin tested milk which is bottled on the farm. Tuberculin Tested (Pasteurised). Tuberculin, tested milk which is also pasteurised. Accredited. Milk from cows that have passed a veterinary inspection but not a test for Tuberculosis and which may be bottled on the farm or elsewhere. Pasteurised. Milk that has been heated to 145 deg. Fah, and kept at this temperature for 30 minutes. The following table shows the number of licences issued by this authority under the Order of 1936. Designation No. Tuberculin Tested 'B' (Dealers) licence 2 Pasteurised 'B' (Dealers) licence 1 Pasteuriser's 'C' licence 2 Supplementary licences Pasteurised 7 Tuberculin Tested 2 Tuberculin Tested (Pasteurised) 4 13 45 12 samples of milk were obtained and submitted to the County Bacteriologist for Bacteriological Examination. In any case where an adverse report is received, the Sanitary Inspector visits and advises with a view to improving the method of production and distribution by the Dealer concerned. During the same period three samples of milk were submitted for chemical analysis, and the results proved that all three samples consisted of genuine milk of good quality. F(4). Other Foods. Routine sampling under the Food and Drugs Acts is undertaken by the Kent County Council. The Inspector who takes samples under these Acts is also Inspector of Weights and Measures. Samples of any suspected foods taken by the Sanitary Inspector are submitted to the County Analyst for examination, and during the year one sample of cheese was submitted by the Sanitary Inspector to the County Laboratory, following a complaint from a resident within the District that it was unsound. Upon examination the sample proved to be not adulterated. F(5). Offensive Trades. In addition to the statutory Offensive Trades under the Public Health Act of 1875, Fish Frying, Extracting and Melting Fat and dealing in Rags and Bones were in 1912 declared by Order to be Offensive Trades within the District, and Byelaws have been made under this head. The only Offensive Trade carried out in the District is Fish Frying : there are 15 Fish Fryers carrying on business, and visits are frequently paid in order to ensure that the standard of cleanliness is maintained. Within the area of the Council's Town Planning Scheme, Offensive Trades may be carried on only in certain prescribed zones, and subject to obtaining the consent of the Council. SECTION G.—SANITARY INSPECTION OF THE AREA. In the following tables the work of the Sanitary Inspectors, during the year, is summarized:— 46 G(l). Routine Visiting. Premises visited with the results of such visits:— No. in District No. of visits in 1935 No. of faults and defects found No. of Faults and defects remedied Bakehouses 10 14 11 1 Dairies 14 97 21 19 Slaughter Houses (licensed) 4 492 4 4 Other Food preparing places which are, as such, subject to inspection 24 51 3 3 Factories 15 15 – – Workshops 11 14 – – Workplaces (other than Outworker's homes) 12 12 – – Offensive Trades 15 24 2 2 G(2). Nuisances and Defects Remedied during the year. (other than those enumerated in the above tabulation). Overcrowding 6 Keeping of Animals 2 Sanitary Accommodation—Insufficiency – Other 78 Drainage Reconstruction 5 Do. Cleansing 51 Do. Other 104 Dustbins, &c. 108 Tents, Vans, Sheds, &c. – Smoke Abatement 8 Cesspools Abolished 5 ,, Repaired – Offensive Accumulations 14 Yard Paving 19 Dampness 83 Roofs and Rainwater Pipes 198 Floors 50 Walls and Ceilings 325 Windows and Ventilation 119 Baths, Lavatory Basins and Sinks 30 Water Supplies 6 Others 300 47 The total number of visits of all kinds paid by Inspectors during the year was 3,748. Notices served—Statutory, 10; Informal 421. Number of houses and other premises disinfected 193. Batches of bedding, etc., disinfected 158. G(3). Housing Inspections. G(3)a. Number of New Houses erected during the year. (1) By the Local Authority – (2) By other Local Authorities (3) By other bodies or persons 872 G(3)b. Inspection of Dwelling Houses. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 491 Number of Inspections made 1976 (2) Number of dwelling-houses (included under the preceding heading) which were inspected and recorded under the Housing Consolidated Regulations 1925 145 Number of Inspections made 422 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation – (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 491 G(3)c. Remedy of Defects without Service of Formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 475 G(3)d. Action under Statutory Powers. (a) Proceedings under Section 9, 10 and 16 of the Housing Act, 1936. (1) Number of dwelling-houses in respect of which notices were served requiring repairs 7 (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) By owners 7 (b) By Local Authority in default of owners – 48 (b) Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 10 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:– (a) By owners 10 (b) By Local Authority in default of owners – (c) Proceedings under sections 11 and 13 of the Housing Act, 1936. (1) Number of dwelling-houses in respect of which Demolition Orders were made – (2) Number of dwelling-houses demolished in pursuance of Demolition Orders – (d) Proceedings under section 12 of the Housing Act, 1936. (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made – (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit – G(4). Overcrowding (Housing Act 1936 Part IV). (1) Number of dwellings overcrowded at the end of the year 1937 32 (2) Number of families dwelling therein 37 (3) Number of persons dwelling therein 239½ (4) Number of new cases of overcrowding reported during the year (Specific review cases) 5 (5) Number of cases of overcrowding relieved during the year 6 (6) Number of persons concerned in such cases 42½ (7) Number of cases in which dwellinghouses again became overcrowded after action taken for the abatement of overcrowding Nil G(5). Eradication of Bed Bugs. Complaints regarding infestation by Bed Bugs are followed up by the Sanitary Inspectors who advise generally as to the best means of eradication. The disinfestation of Council Houses thus affected is undertaken by the Surveyor's Department. 49 (a) During 1937 premises infested with vermin were inspected as under: Council Houses 15 Others 34 (b) In the case of Council Houses each of the premises found to be infested were disinfested by the Local Authority by using Solution 'B' or Cimex Fumigating Blocks. Where complaints are received regarding other houses infested, an inspection is made by the Inspector who afterwards communicates with, or interviews the owner, and advises the removal of the woodwork, wallpaper, etc., and spraying, or fumigation, as may be indicated. (c) Where the belongings of tenants for removal to Council Houses are suspected of being infested, Cyanide Fumigation of furniture and effects is undertaken under the supervision of this Department—by contractors—before rehousing takes place. (d) In all cases where treatment for the eradication of bed bugs has been undertaken, and bearing in mind that the complete banishment of such vermin from the infected house can only be successfully undertaken with the co-operation of the tenant, follow up visits are made with a view to the giving of advice, if same appears necessary. 50 G(6). Factories, Workshops and Workplaces. 1.—INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises Number of Inspections Written Notices Occupiers Prosecuted 1 2 3 4 Factories (including Factory Laundries) 14 – – Workshops (including Workshop Laundries) 10 – – Workplaces (other than Outworkers premises) 11 – – Total 35 – – 2.—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES Particulars Number of Defects Number of Prosecutions Found Remedied Referred to H.M. Inspector 1 2 3 4 5 Nuisances under the Public Health Acts:— Want of Cleanliness – – – – Want of Ventilation – – – – Overcrowding – – – – Want of drainage of floors – – – – Other Nuisances 3 3 – – Sanitary accomodation: Insufficient – – – – Unsuitable or Defective 6 6 – – Not separate for sexes – – – – Offences under the Factory and Workshop Acts:— Illegal Occupation of underground bakehouse – – – – Other offences – – – – Total 9 9 – – 51 H(5). Legislation in Force. List of Bye-Laws, Adoptive Acts, and Regulations in force in this district, with date of adoption:— Prevention of Nuisances Sept., 1887. Keeping of Animals Sept., 1887. Removal of Offensive Matter Sept., 1887. Public Mortuaries Sept., 1888. Pleasure Ground June, 1897. Sewerage Regulations July, 1898. Cleansing and Removal of Refuse Oct., 1898. Public Baths and Wash-houses Sept., 1907. Filth and Rubbish May, 1912. Offensive Trades Dec., 1912. Employment of Children Dec., 1912. New Streets and Buildings Oct., 1927. Tents, Vans and Sheds Feb., 1928. Houses Let in Lodgings Jan., 1930. Slaughter-houses Jan., 1932. Nursing Homes July, 1934. New Streets and Buildings Oct., 1935. Pleasure Grounds Jan., 1936. Erith Tramways and Improvement Act. 1903. Erith Improvement Act, 1920. Infectious Disease (Prevention) Act, 1890 1891. Public Health Acts Amendment Act, 1890 1891. Public Health Acts Amendment Act, 1907, Sections 19, 21, 22, 23, 25, 31, 33 and 51 1912. Section 95 1928. Public Health Act, 1925, Sections 14—19, 21—28, 30—35, 38—44, 48—55 1927. URBAN DISTRICT OF ERITH. ANNUAL REPORT OF THE School Medical Officer FOR THE YEAR 1937. 3 EDUCATION COMMITTEE. Chairman:—Councillor Bates. Vice-Chairman:—Councillor Ebben. Councillor Brierley. ,, Dunkley. ,, Mrs. Corsan. Councillor Wilkinson. ,, Whinnerah. ,, Woodcock. Councillor Mrs. Nichols. Co-opted Members: T. W. Fudger, Esq. Rev. H. Darvill. Miss Murphy. F. J. Millard, Esq. G. W. Luck, Esq. Rev. A. S. Harryman. SCHOOL MEDICAL STAFF. School Medical Officer: A. Wallace Johns, m.r.c.s., l.r.c.p., d.p.h. Assistant School Medical Officer: David S. Clark, m.b., b.s. (Resigned August, 1937.) Helen M. Evans, m.r.c.s., l.r.c.p., d.p.h. (Appointed September, 1937.) Ophthalmic Surgeon: N. Howard Allen, m.r.c.s., etc. Dental Surgeon : R. A. Presslie, l.d.s., Edin. Dental Attendant: Miss M. L. Buckley. School Nurses: Mrs. Lange, s.r.n., Miss Briggs, s.r.n. Clerk: Miss M. Smith. 4 Report of the School Medical Officer. In accordance with the suggestions contained in Form 6M issued by the Board of Education, much of the subject matter of this Report, having been included in previous reports, is not repeated; reference is made to items which have in previous years received full consideration. Co-ordination. Achievement of this is sufficiently important to repeat that as your Medical Officer of Health is also School Medical Officer, it is ensured that there is no overlapping between the two Departments. All information as to the incidence of infectious diseases is immediately available for the use of the Assistant School Medical Officer and the School Nurses, and vice versa, infectious diseases discovered through absences from school, and which are not notifiable, are transmitted to the Health Department for following up, thereby ensuring that such outbreaks are controlled. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. Under the Authority of the Erith Education Committee there are 8 provided schools with 19 departments, and one non-provided school with one department. At the end of 1937, there were 4,982 children on the roll of the elementary schools, distributed as follows:— Infant Schools 1411 Junior Mixed and Infant Schools 41 Junior Schools 1711 Mixed with Infants 155 Senior Schools 1664 Special Schools (Outside the District) 19 Some change has taken place since my last report, in the dispensation of the schools and departments at Belvedere. The All Saints' School has now been entirely closed. At Bedonwell Hill, two departments, a Junior Mixed for 292, and an Infants department for 240 children have been opened but extensions are already necessary and four additional class rooms are in course of erection. 5 The old Belvedere Boys' School has been entirely remodelled and modernised, and now houses a small school of about 120 infants, and children in Standard I. The modernising of old school buildings has continued and Northumberland Heath Junior and Infants' Schools have been remodelled, provided with new and modernised cloakrooms, nursery classrooms, central heating and hot water; electric light has also been installed. A nursery classroom has been provided at the Crescent Road Infant School, by the adaptation of an existing one, and the Junior Boys' and Junior Girls' Departments here have been combined to form the Crescent Road Junior Mixed School, the premises being improved and adapted for the purpose. Medical Inspection. The general routine medical inspection work has been carried out as in former years. Whenever possible, arrangements are made for both the Head Teacher and Parent to be present at these inspections. The practice of examining three routine age groups has again been followed. FINDINGS AT MEDICAL INSPECTIONS. Malnutrition. The year 1937 is the third year in which the new clinical assessment laid down in Administrative Memorandum No. 124, has been in operation, and it is interesting to compare the figures obtained this year with last year's, and to compare our figures with those for England and Wales. It is, perhaps, fair to say that the main importance of these figures is still to decide from them whether we have yet a reliable method of assessing nutrition and when the method has proved itself the state of nutrition of the school child, as revealed by it, can be discussed with more confidence. The Chief Medical Officer to the Board of Education, in his Annual Report, has pointed out that some very unexpected figures have been obtained due probably to the personal factor. It is interesting to note therefore, how closely our own figures approximate to the average figures for England and Wales. Taking the percentages, the following table will show this:— Age Groups A Excellent B Normal c Slightly subnor'l D Bad E & W E E & W E E & w E E &w E Entrants 13.2 13 75.8 65 10.3 18 0.7 .55 Second Age Grp. 12.9 12 74.1 64 12.2 22 0.8 .67 Third „ „ 17.1 7.31 72.8 76 9.6 15 0.6 .37 6 A comparison of the 1937 figures with those for 1936 shows a considerable reduction in the percentage total of the bad group, a slight reduction in the percentage total in the slightly sub-normal group, and a slight increase in the normal and excellent groups. The variation in these figures is, I think, to be explained in two ways. There is first, the personal factor in assessment, and secondly the nutrition of our school children is generally good, and there is a gradual improvement in nutrition in the two sub-normal groups. This is confirmed by examinations and contacts other than those routine ones. Arrangements for supplying milk during the school term continue generally to work satisfactorily. The arrangements for supplying during school holidays are, however, not so satisfactory. Many children fail to attend to obtain the milk. The milk supplied under the Milk in Schools Scheme to schools in the area coming within the scope of the scheme, is required to be milk designated as Pasteurised, and treated in accordance with the provision of the Milk (Special Designations) Order, 1936. Provision of Meals, Milk and Malt and Oil. Milk has been issued on the School Medical Officer's certificate to 119 children during the year, the issue being two 1/3 pint bottles per day. In the case of children suffering from a greater degree of malnourishment, meals have also been provided, particularly at the Northumberland Heath School Canteen and to a lesser degree at the Picardy Central School Domestic Subjects Centre. Below is set out a table showing the quantities of Malt and Oil distributed:— Total amount issued 1642 lbs. Amount issued free 1564 lbs. No. of children receiving free issues 159 Amount sold at cost price 78 lbs. At the end of the year a total of 245 children were receiving free milk at school. Extension of provision of facilities for having meals at school would be of undoubted benefit, and would simplify the attempts in certain cases, of the School Medical Service to supplement the feeding of ill-nourished children who come under observation. 7 Uncleanliness. During 1937, 208 children were found to be verminous, at inspections made in the schools by the School Nurses. This figure again shows a slight improvement over the previous year's figure, but, in fairness to the large proportion of parents whose children are invariably clean, I must repeat, as has been observed before, that the persistence of this figure is due to a small group of chronic offenders. Nose and Throat Defects. The number of individual defects are set out in Table II. As pointed out last year, a growing section of medical opinion is leaning to the view that if tonsils are not giving rise to secondary conditions they do not call for removal. Moreover the part that enlarged adenoids alone plays in producing the conditions attributed jointly to enlarged tonsils and adenoids has not been assessed precisely. It sometimes happens that children, on leaving school, have been advised and in some cases required to have their tonsils removed. The personal element in assessing the need for this operation will always result in differing opinions, but, it has been the practice for some years, in this School Medical Service, to advise operation only in cases where secondary conditions such as enlarged glands, or recurrent attacks of throat infection exist. I have repeated the following table, which shows the comparison year by year of the number of operations for the removal of Tonsils and Adenoids. Operations were performed on 120 children, 105 being under the Authority's Scheme, whilst 15 done by private practitioners, were on the advice given at School Medical Inspection. Year Operation in Hospital under Authority's Scheme By Private Practitioners Total 1932 131 30 161 1933 132 17 149 1934 87 14 101 1935 68 12 80 1936 57 4 61 1937 105 15 120 I am pleased once more to record the happy relations existing between the staff of the Royal Waterloo Hospital far Children and Women and ourselves, with regard to operative treatment. 8 Ear Diseases and Defective Hearing. Reference to Table IV will show that 43 defects were treated during the year. Dental Defects. The year 1937 has seen another year's operation of the extended dental scheme, introduced in September, 1935. The extent of increase of dental work over previous years is well shown by repeating the table introduced last year, and brought up to date to show the figure for 1937. Year. No. of fillings. 1931 215 1932 195 1933 178 1934 226 1935 (extended service in operation during last quarter of year) 394 1936 (first full year of extended service) 791 1937 770 The present scheme is not capable of providing treatment for all children found on inspection to require treatment and consequently an attempt has been made to concentrate on the lower age groups and reference to Group V page 21 will show to what extent the increase in inspection of the earlier age groups has been carried out. There is still an obstinate belief among some parents that the school dental service is anxious to fill milk teeth, in spite of the most careful and constantly repeated advice that this is not so. This at any rate is the excuse frequently put forward for refusing to have fillings done. Reference to page 22, Group V, paragraph 4, will show that no fillings of temporary teeth were carried out. Visual Defects and External Eye Disease. The following notes have been supplied by the Ophthalmic Surgeon—Dr. N. Howard Allen, M.R.C.S., L.R.C.P. "Since my last report I have resumed charge of the Ophthalmic Department—Minor Ailments having reverted to the School Medical Officer. This is, from my point of view, a more satisfactory arrangement." 9 "The treatment carried out is for the correction of Errors of Refraction, treatment of diseases involving the eyes or eyelids, such as Blepharitis, Conjunctivitis, Corneal Ulceration, etc.; advice to parents regarding the care of children having defective sight, especially in relation to Myopia—and advice and arrangements for such operative measures which cannot suitably be carried out at the Treatment Centre." Orthopaedic and Postural Defects. Our orthopaedic scheme commenced to function with the first diagnosis clinic held by the Orthopaedic Surgeon, Mr. W. Eldon Tucker, on 23rd September, 1937. It was decided to bring all orthopaedic cases among the school population under review, so that continuity of supervision by Mr. Eldon Tucker could be achieved at the outset. Two sessions for remedial exercise classes are held each week by the Orthopaedic Nurse at the Bedonwell Clinic. The waiting hall as described in the Annual Report is fitted up with the necessary apparatus. Average attendance at these sessions has been 13. While it is not the primary concern of the School Report, it is worth recording that an arrangement was made as recommended in Circulars 1550 and 1621, whereby the facilities of the new orthopaedic scheme were made available to the preschool child. The value of this to everybody concerned including the Education Committee is obvious. The following is a list of cases which have attended the clinic:— Condition requiring treatment. No. of cases. Congenital Talipes 2 Congenital Dislocation of Hip 3 Hallux Valgus 2 Scoliosis and Kyphosis 4 Ostemyelitis 1 Flat feet 4 Infantile Paralysis 8 Hemiplegia 1 Syringomyelia 1 Congenital Deformities—arms and hands 2 Spastic Paraplegia 1 Shortening of leg 2 Deformity of leg following burns 1 Others 10 10 Heart Disease and Rheumatism. Table II shows that 16 cases of organic heart disease were observed, whilst the number of cases of functional heart disease was 193. Tuberculosis. The Kent County Council is responsible for the Tuberculosis Scheme, and a Dispensary is maintained at 65 Bexley Road, where the Tuberculosis Officer attends twice weekly. Sanatorium treatment is also provided by that Council. It will be seen by reference to Table III, Subsections 1 and 2 that 4 cases of Pulmonary Tuberculosis and 6 cases of Non-Pulmonary Tuberculosis are included in the records for this district. The closest co-operation is maintained between the Dispensary Staff and the Staff of the School Medical Service and as your School Medical Officer is a member of the Tuberculosis Care Committee which is a voluntary committee organised by the Kent Council for Social Service, the opportunities for mutual help in this work are thereby extended. Following up and Summary Work by the School Nurses. Following up work by the School Nurses is summarised in the following table:— Visits paid to the schools 1021 Children examined 14856 Children found with vermin 208 Visits to homes 797 Attendances at Ophthalmic Clinic 25 ,, ,, Orthopaedic ,, 4 Minor Ailments are treated at the school clinic, but in all cases where practicable children suffering from defects, other than Minor Ailments, are referred to general medical practitioners or to Hospitals. Apart from the use of the clinic as a treatment centre, it performs the function of re-examining certain children who were discovered at previous inspections to require observation; also children are presented for examination on the advice of teachers or parents. It will be seen that the number of visits paid to the schools has again increased this year. Attendances at the Minor Ailments Clinic have increased by 3,026, and the actual number of children who made use of the clinic during the year has increased by 274. 11 This increase will be appreciated better perhaps when these figures are expressed as percentages, in other words, attendances at the Clinic have gone up by 38 per cent. and the actual number of children who attended has increased by 20 per cent. The average number of children attending, per session, has gone up by an approximate average of 14. One result of this increased attendance has been to throw a great deal of extra work on the staff, and this has fallen particularly on the Clerk to the School Medical Service. Set out below is a table giving the number of children examined, together with the total attendances, at the various clinics:— 1937 1936 Children Attendances Children Attendances Minor Ailments Clinic 1614 10739 1392 9086 Dental Clinic 1116 1759 1331 1867 Ophthalmic Clinic 309 776 463 1156 Special Examinations 3430 6368 2792 5321 Operations for Tonsils and Adenoids 105 – 57 – Orthopaedic Clinic 37 53 – – 6611 19695 6035 17430 Infectious Diseases. As mentioned last year, the scheme adopted for detecting outbreaks of infectious diseases is fully described on page 11 of the report to the Committee for the year 1932. During 1937, 54 swabs were examined for Diphtheria, 9 of these proving positive. Open Air Schools. There is no open-air school provided by this Authority, but as will be seen from Table III a number of delicate children attend certified day schools and residential open air schools maintained by other Education Authorities, this Authority being responsible for the fees and in most cases the parents contribute towards the cost. 12 The number of children for whom special school, convalescent or hospital school treatment was provided during the year for periods of varying length was 19. Physical Training. On the recommendation of the School Medical Officer, children are given remedial physical training in the schools by teachers who have been trained in this subject. Orthopaedic cases attend the remedial clinics held at Bedonwell Hill. Facilities are given by the Education Committee to teachers to attend courses of instruction in physical training, and the Education Committee have also voted additional expenditure in respect of Physical Training equipment and apparatus. They have provided gym shoes for the more necessitous of the children. Mr. G. H. Atkinson still acts as organiser for Physical Training, but Mrs. McLennon has resigned and Miss Bailey is to take her place. The influence of the organisers upon the physical training, games and swimming in the schools is already to be seen, and an improved scheme for swimming has been carried out by the teachers acting jointly with the organisers. Both the organisers are well qualified and experienced. As in previous years, students from the Bergman Osterberg Physical Training College, Dartford Heath, have attended some of our Central Schools for teaching practice under the supervision of the Head Teachers and tutors of the College. Physical Education Clubs continue to function in association with the schools, and old pupils' associations also have these sports organisations. Already Erith has seven flourishing 'Keep Fit' Classes held mainly in the Schools during the evenings. Co-operation of Parents, Teachers, &c. I have mentioned previously that parents continue to show keen interest in the medical examination of their children. At Routine Medical Inspections the parents attend in 91 per cent. of inspections in the case of infants, 82 per cent. in the case of intermediates, and 58 per cent. in the case of leavers. 13 Blind, Deaf and Epileptic Children. An analysis of children falling under this head is given in Table III, in which is fully set out the type of education and treatment received. The condition of affairs shown is that existing approximately at the last day of the year. It will once again be noticed that we have no blind children, but 8 who are partially blind are attending public elementary schools, and 1 is at a Certified Special School. There are no deaf children in our area, but 2 children who are partially deaf attend elementary schools. Every possible care is taken in classifying those concerned, when Routine Medical Inspection has been completed. No epileptic children came under our notice during 1937. Nursery Schools. There are no nursery schools provided by this Authority, but there are four infant schools where nursery classrooms are now provided, to which, at present, children of 4 years are admitted. Direct access to the open air, kitchen facilities, sandpits, separate sanitation and cloakrooms are features of these nursery class units. They have been provided at the St. Augustine's Road, Bedonwell, Crescent Road and Northumberland Heath Infant Schools. Parents' Payments. There is a scale of charges drawn up for the recovery of the cost of treatment at the minor ailments clinic from those who are able to contribute. In practice, however, it is impossible generally to put into effect. There is also a scale of charges for those in receipt of treatment at the dental and ophthalmic clinics. A fee has been fixed also for Secondary School Children who attend our Dental and Ophthalmic Clinics, for which the Higher Education Authority is responsible. 14 Mentally Defective Children. I append the Annual Report of the Local Organiser of the Kent Voluntary Association for Mental Welfare. I mayadd that the work of this Association is very highly valued by the School Medical Department. Report of the Work of the Kent Voluntary Association for Mental Welfare for the Erith Education Committee for the year 1937. Enquiries have been made in the five cases of young people remaining under supervision at the end of the year. After Care. Two boys and three girls remain on the After Care list. One lad is in regular work and is believed to be getting on well. The other lad is less satisfactory partly on account of home circumstances. One girl is employed and is doing well. The two other girls are helping at home and it is doubtful if either of them will become self-supporting. As there may be need for some action in the future in respect of one of these, it is recommended that she be reported informally for friendly supervision. TABLE I. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups : — Entrants 722 Second Age Group 595 Third Age Group 264 Total 1581 B.—Other Inspections. Number of Special Inspections 8430 Number of Re-Inspections 2938 Total 6368 C.—Number of individual children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). 15  Number of Children GROUP Inspected Found to require Treatment 1 2 3 Prescribed Groups : — Entrants 722 114 Second Age Group 595 127 Third Age Group 264 45 Total (Prescribed Groups) 1581 280 TABLE II. A—Return of Defects found by Medical Inspection in the Year ended 31st December, 1937. Defect or Disease Routine Inspections Special Inspections No. of Defects No. of Defects Requiring Treatment Requiring to be kept under observation, but not requiring treatment Requiring Treatment Requiring to be kept under observation but not requiring treatment—— 1 2 3 4 5 Skin :— Ringworm: Scalp — — 3 — Body 1 — 8 — Scabies 1 — 10 2 Impetigo 12 — 111 1 Other Diseases (Non-Tuberculous) 25 12 134 14 Eye :— Blepharitis 2 1 36 2 Conjunctivitis — — 13 — Keratitis — — — — Corneal Opacities 1 — 1 — Defective Vision (excluding Squint) 80 57 6 — Squint 11 6 — — Other Conditions 2 8 63 7 Ear j— Defective Hearing 3 5 2 5 Otitis Media 9 2 44 — Other Ear Diseases 5 4 39 17 16 TABLE II—Continued. 1 2 3 4 5 Nose and Throat:— Chronic Tonsillitis only 29 127 25 37 Adenoids only ... 3 30 9 7 Chronic Tonsillitis and Adenoids 28 33 54 10 Other Conditions 9 78 159 137 Enlarged Cervical Glands (Non- Tuberculous) 236 11 84 Defective Speech — 2 — 3 Heart and Circulation :— Heart Disease : Organic 1 8 1 6 Functional — 160 — 33 Anaemia — 2 3 2 Lungs Bronchitis — 1 9 3 Other Non-Tuberculous Diseases 9 59 68 70 Tuberculosis :— Pulmonary : Definite — — — 1 Suspected ... — — — 1 Non-Pulmonary : Glands 1 2 — — Bones and Joints — — 1 — Skin — — — — Other Forms 1 1 — 1 Nervous System 2— Epilepsy 2 — — — Chorea 2 5 — 5 Other Conditions 1 9 6 7 Deformities:— Rickets — 14 1 4 Spinal Curvature 16 4 2 3 Other Forms 50 116 20 14 Other Defects and Diseases (excluding Incleanliness and Dental Diseases) 20 54 1264 178 Total 332 976 2103 655 17 B.—Classification of the Nutrition of Children Inspected during the year in the Routine Age Groups. (See Administrative Memorandum No. 124, dated 31st December, 1934. Age-Groups Number of Children Inspected A B C D Excellent Normal Slightly subnormal Bad No. % No. % No % No. % Entrants 722 107 3 476 65 135 18 4 .55 Second AgeGroup 595 77 12 381 64 133 22 4 .67 Third AgeGroup 264 13 7.31 203 76 42 15 1 .37 Other Routine Inspectios — — — — — — — — — Total 1581 202 12 1060 67 310 19 9 .56 TABLE III. Return of all Exceptional Children in the Area. Blind Children. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions At no School or Institution Total — — — — — Partially Sighted Children. At Certified Schools for the Blind At Certified Schools for the Partially Sighted At Public Elementary Schools At other Institution* At no School or Institution Total — 1 8 — — 9 18 TABLE III—Continued. Deaf Children. At Certified Schools for the Deaf At Public Elementary Schools At other Institutions At no School or Institution Total — — — — — Partially Deaf Children. At Certified Schools for the Deaf At Certified Schools for the Partially Deaf At Public Elementary Schools At other Institutions At no bchool or Institution Total — — 2 — — 2 Mentally Defective Children. FEEBLE-MINDED CHILDREN. At Certified Schools for Mentally Defective Children At Public Elementary Schools At other Institutions At no School or Institution Total 1 9 — 4 14 Epileptic Children. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total — — — — — 19 Physically Defective Children. A. TUBERCULOUS CHILDREN. I.—Children Suffering from Pulmonary Tuberculosis. (Including pleura and intra-thoracic glands.) At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total — 4 — — 4 II.—Children Suffering from Non-Pulmonary Tuberculosis. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 1 5 2 _ 8 B. DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 2 74 1 3 80 C. CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 9 12 1 2 24 D. CHILDREN WITH HEART DISEASE. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 3 — 1 2 6 20 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1937. TREATMENT TABLE. GROUP I—MINOR AILMENTS. (excluding Uncleanliness, for which see Group VI). Disease or Defect Number of Defects treated, or under treatment during the year Under the Authority's Scheme Otherwise Tota1 1 2 3 4 Skin— Ringworm—Scalp — — — (i) X-Ray Treatment. If none, indicate by dash. — — — (ii) Other Treatment 3 — 3 Ringworm—Body 7 2 9 Scabies 10 1 11 Impetigo 109 A 1 -A. JL 110 Other skin disease 92 9 101 Minor Eye Defects (External and other, but excluding cases falling in Group II). 97 4 101 Minor Ear Defects 64 8 72 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 1023 29 1052 Total 1405 54 1459 GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I). Defect or Disease Number of Defects dealt with Under the Authority's Scheme Otherwise Total 1 2 3 4 Errors of Refraction (including Squint) 309 28 337 Other Defect or Disease of the Eyes (excluding those recorded in Group I) — 4 4 Total 309 32 341 No. of children for whom spectacles were prescribed : (i) Under the Authority's Scheme 160 (ii) Otherwise 23 183 No. of children for whom spectacles were obtained : (i) Under the Authority's Scheme 130 (ii) Otherwise 23 153 21 GROUP III.—TREATMENT OF DEFECTS OF NOSE. AND THROAT. Number of Defects. Received Operative Treatment Received other forms of Treatment Total number treated Under the Authority's Scheme, in Clinic or Hospital (See Note B) By Private Practitioner or Hospital, apart from the Authority's Scheme Total 1 2 3 4 5 i. ii. iii. iv. i. ii. iii. iv. i. ii. iii. IV. 43 8 54 — 5 1 8 1 48 9 62 1 — 120 (i)Tonsils only, (ii) Adenoids only. (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat. GROUP V.—DENTAL DEFECTS. (1) Number of Children who were: — Routine Age Groups Total Special- Grand Total 5 6 7 8 9 10 11 12 13 14 (I) Inspected by Dentist 442 444 473 487 289 318 44 19 6 — 2522 887 3409 GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS. Under the Authority's Scheme Otherwise (1) (2) Residential treatment with education Residential treatment without education NonResidential treatment at an orthopaedic clinic Residential treatment with education Residential treatment without education NonResidential treatment at an orthopaedic Clinic Total number treated (i) (ii) (iii) (i) (ii) (iii) Number of children treated — — 22 — — 17 39 22 (ii) Found to require treatment 1936 (iii) Actually treated 1116 (2) Half-days devoted to :— Inspection 17 Treatment 168 185 (3) Attendances made by children for treatment ... 1759 (4) Fillings :— Permanent teeth 770 770 Temporary teeth — (5) Extractions :— Permanent teeth 272 Temporary teeth 1392 1664 (6) Administrations of general anaesthetics for extractions ... 808 (7) Other operations : Permanent teeth 115 Temporary teeth — 115 GROUP VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. (1) Average number of visits per school made during the year by the School Nurses 5 (2) Total number of examinations of children in the Schools by School Nurses 14,856 (3) Number of individual children found unclean 208 (4) Number of children cleansed under arrangements made by the Local Education Authority 0 (5) Number of cases in which legal proceedings were taken : — (a) Under the Education Act, 1921 0 (b) Under School Attendance Byelaws 0