ERI 19 BOROUGH OF ERITH ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE YEAR ENDED 1938 BY a. wallace johns, m.r.c.s., l.r.c.p., d.p.h. BOROUGH OF ERITH. With the Compliments of the Medical Officer of Health. Council Offices, Erith. BOROUGH OF ERITH. ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE YEAR ENDED 1938 BY a. wallace johns, M.R.C.S., L.R.C.P., D.P.H. Arrangement of Report. Section Page A Statistics and Social Conditions 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 Condition of the Area 13 8. Unemployment Figures and Comments 14 B Maternity and Child Welfare Services. 1. Maternity and Child Welfare Scheme 14 2. Notification of Births 16 3. Child Welfare Centres 17 4. Home Visits by Health Visitors 19 5. Maternity Services 19 (a) Maternity Home—Hainault 19 (b) Ante-natal Clinic 19 (c) Ante-natal Inpatient Accommodation 20 (d) Abnormal Cases 20 6. Infant Life Protection 20 7. Midwives 21 8. Maternity and Nursing Homes 21 9. Dental Clinic 21 10. Nursing in the Home 22 (a) General 22 (b) Infectious Disease 22 (c) Home Help 22 11. National Society for the Prevention of Cruelty to Children 22 C Prevalence of and Control over Notifiable Infectious Diseases. 1. Infectious Diseases Hospital 23 2. Tables 23 (a) Notifications 23 (b) Age Distribution 24 i Section C (continued). Page 3. School Incidence of Infectious Disease 25 4. Diphtheria Immunisation 25 5. Comments on: (a) Diphtheria 26 (b) Scarlet Fever 27 (c) Enteric Fever 27 (d) Measles 27 (e) Provision of Serum for Cases of Measles 27 (f) Puerperal Pyrexia 28 (g) Ophthalmia Neonatorum 28 (h) Smallpox 28 6. Disinfection of Premises after Infectious Disease 28 7. Laboratory Facilities 28 8. Tuberculosis 29 (a) Treatment and Hospital Accommodation 29 (b) Table (i) Particulars of New Cases and Deaths 29 (ii) Quarterly Statements 30 9. Consultations with Local Medical titioners 31 10. Ear, Nose and Throat 31 11. Clinics and Treatment Centres 32 D Hospital Facilities. 1. General 34 2. Venereal Diseases 34 3. Children 34 4. Ambulance Facilities 34 E Sanitary Circumstances of the Area. 1. General 34 2. Refuse Collection and Disposal 35 (a) Details of Refuse Vehicles and Staff 35 (b) Details of Tonnage 36 3. Trade Refuse 36 4. Water Supply 36 5. Drainage and Sewerage 37 6. Closet Accommodation and Cesspools 37 7. Sanitary Inspection of the Area 37 (a) Routine Visiting 37 (b) Summary of Nuisances and Defects Remedied during the Year 38 (c) Number of New Houses Erected during the year 38 ii Section E (continued). Page (d) Shops and Offices 88 (e) Camping Sites 39 (f) Hop Pickers 39 (g) Rag Flock Act 39 (h) Smoke Abatement 39 (i) Health Education—Rat Week 40 (j) Eradication of Bed Bugs 40 (k) Cleansing of Verminous Persons 41 (1) Swimming Baths and Pools 41 (m) Schools 41 8. Housing 41 (a) Inspection of Dwelling houses during the year 41 (b) Remedy of Defects during the year without service of Formal Notices 42 (c) Action under Statutory Powers during the year 42 (d) Housing Act 1936—Part IV crowding 43 (e) Fitness of Houses 43 (f) Clearance Areas 43 9. Factories 43 F Inspection and Supervision of Food. 1. Milk Supply 44 2. Slaughter of Animals Act, 1933 45 3. Inspection and Supervision of Meat and Other Foods 45 4. Other Foods 47 5. Food and Drugs Act 47 6. Shellfish 47 7. Offensive Trades 47 H General. 1. Letter by Medical Officer of Health 2 2. Members of Committees 4 3. Staff of Public Health Department 5 4. Legislation in Force 48 iii 2 H (1). Public Health Department, Council Offices, Erith. The Mayor, Aldermen and Councillors of the Borough of Erith. Mr. Mayor, 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 1938. I have to apologise for the late appearance of this report but it is due to circumstances outside my control. The report of course is a review of the work of the department up to the end of the year 1938, but it is bound to be viewed in the atmosphere of 1939, and what has happened in 1939 must affect the recording of the work and events of 1938 in scope and in tone. It is impossible therefore to avoid making mention at least of A.R.P., these duties that have thrust themselves into every aspect of our lives, and have forced us to struggle to maintain the scope and efficiency of our Public Health work with this additional burden placed upon us. Expansion of the work of the department has gone on in all its executive aspects. The most urgent needs of its constructional or architectural expansion can best find expression in the provision of more and modern lying-in accommodation for our expectant mothers, and centralisation of our School Clinic arrangements and co-ordination in one building with other health services. Vital Statistics. The vital statistics of the year show a Death Rate of 9.799 (11.6), a Birth Rate of 15.87 (15.1) and an Infantile Mortality Rate of 53.62 (53.0), the figures in parenthesis being the corresponding figures for England and Wales. 8 I am particularly appreciative of the willing help of my staff on whose loyalty and co-operation the success of the department must always very largely depend. It is to their credit that a Public Health outlook has been maintained, in the atmosphere of the past year, and it is to them that what success the department has achieved is due. I am, Your obedient Servant, A. WALLACE JOHNS, Medical Officer of Health. October, 1939. 4 H (2). MEMBERS OF COMMITTEES. Health and Buildings Committee. Chairman—Councillor Grant. Councillor Bates. Councillor Sejlfe. ,, Firmin. ,, Wilson, J.P. ,, Munns. Maternity and Child Welfare Committee. Chairman—Councillor Munns. Councillor Corsan. Councillor Morling. ,, Dunkley. ,, Nichols. ,, Firmin. . ,, 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— H. M. Evans, M.R.C.S., L.R.C.P., D.P.H. Senior Sanitary Inspector— L. E. King, Cert. R.S.I., Cert. S.I.E.B., Meat Inspector's Certificate, M.I.H. (1) Sanitary Inspector— W. E. Moses, Cert. S.I.E.B., Meat Inspector's Certificate, C.A.G.S. (1) 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) Miss G. Woodward, 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 L. M. Barclay, S.R.N., S.C.M. Clerks— Chief Clerk—H. M. Coles, L.A.G.C. General Clerks— Public Health—R. Durey. Maternity and Child Welfare—Miss O. R. Reeves. School Medical Service—Miss M. Smith. Shorthand Typist—Miss B. L. Kell. Junior Clerks— Public Health— G. S. Hallett. School Medical Service—Miss J. Redgrave. 2. Part-time. Consulting Surgeon for Aural Diseases— T. P. Gill, F.R.C.S. Consulting Obstetrician— 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. Ad). SUMMARY OF STATISTICS. A(1)a. General. Area.—4,607 acres. Population.—39,800 (Estimated 1938). Density of population, i.e., number of persons per acre.—8.638. Number of inhabited houses.—10,937 (as per Rate Book). Rateable value, 1938.—£303,052. Sum produced by a penny rate, 1938.—<£1,196. A (1 )b. Births. TOTAL. Male. Female. Live Births. Legitimate 621 306 315 Illegitimate 13 9 4 634 315 319 Live birth rate per 1,000 of population (1938 estimated). —15.87. Corresponding rate for 1937—15.82. Still Births. TOTAL. Male. Female. Legitimate 20 8 12 Illegitimate 2 1 1 22 9 13 Still Birth rate per 1,000 total births.—28.81. A(1)c. Deaths. Males 206. Females 184. Total 390. Death rate per 1,000 of population (estimated 1938).— 9.799. Corresponding rate for 1937.—10.852. Number of women dying in, or in consequence of, childbirth—3. Maternal Mortality per 1,000 total registered births—4.57. 7 A(1)d. Infantile Mortality. Deaths of infants under one year of age. TOTAL. Male. Female. Legitimate 34 23 11 Illegitimate — — — 34 23 11 Death rate of infants under one year of age per 1,000 live births.—53.62. Total number of deaths from : 1937 1938 Measles (all ages) — — Whooping Cough (all ages) — — Diarrhoea (under 2 years) 8 — 8 — 8 A(1 )e. Vital Statistics of Whole District during 1938 and previous years. Year Population estimated to middle of each year Births 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 16 161 45 82.44 419 12.53 1930 33,420 45^ 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 1933 34,950 5H 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 5io 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 1938 39.800 668 656 16.48 273 6.83 17 134 34 5362 390 9.799 9 A (1 ) f. Table showing Summary of Causes of Death during the year ended 31st December, 1938. Cause of Death Males Females Total 1 Typhoid Fever, etc. — — — 2 Measles — 1 1 3 Scarlet Fever — — — i Whooping Cough — — — 5 Diphtheria 3 2 5 6 Influenza 1 2 3 7 Encephalitis Lethargic — — — 8 Cerebral-spinal fever — — — 9 Respiratory Tuberculosis 7 17 24 10 Other Tuberculosis 1 2 3 11 Syphilis — — 12 General paralysis of insane, etc. — 1 1 13 Cancer 23 28 51 14 Diabetes 2 3 5 15 Cerebral haemorrhage 7 4 11 16 Heart disease 57 51 108 17 Aneurysm 1 1 2 18 Other circulatory diseases 14 8 22 19 Bronchitis — 3 3 20 Pneumonia 23 11 34 21 Other respiratory diseases 5 2 7 22 Peptic ulcer 2 — 2 23 Diarrhoea, etc. (under 2 years) 5 1 6 24 Appendicitis 3 2 5 25 Cirrhosis of liver 1 — 1 26 Other liver diseases — 2 2 27 Other digestive diseases 3 4 7 28 Nephritis 4 3 7 29 Puerperal sepsis — 2 2 30 Other puerperal causes — 1 1 31 Congenital causes, etc. 11 7 18 32 Senility -— 2 2 33 Suicide 2 2 4 34 Other violence 10 6 16 35 Other defined causes 21 16 37 36 Ill-defined causes — — — Total All Causes 206 184 390 10 A(l)g. Table showing Birth-rate, Death-rate, and Analysis of Mortality during the year 1938. Provisional figures. The mortality rates for England and Wales refer to the whole population, but for London and the towns to civi ians only Rate 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 Small-pox 1 Measles Scarlet Fever Whooping Cough Diphtheria Influenza Diarrhoea & Enteritis (under Two years) Total Deaths under one year England and Wales 15.1 0.60 11.6 0.00 0.00 0.04 0.01 0.03 0.07 0.11 5.5 53 125 County Boroughs and Great Towns, including London 15.0 0.65 11.7 0.00 0.00 0.0 5 0.01 0.03 0.07 0.10 7.8 57 148 smaller towns (1931) adjusted populations 25,000—50,000 15.4 0.60 11.0 0.00 0.00 0.03 0.01 0.02 0.06 0.11 3.6 51 London 13.4 O.48 11.4 0.00 0.00 0.06 0.00 0.03 0.05 0.06 57 53.62 Erith (Estimated population 39,800) 16.23 0.552 9.798 0.00 0.00 0.025 0.00 0.00 0.125 O.O75 9.287 11 A (2). Population. The Registrar General's estimate of 39,800 as the population for the year ending mid-year, 1938, is an increase of 1,560 over last year's figure. This increased figure is likely to be maintained for the next few years. Building operations during the year have shown no sign of abating—the rate is still approximately 80 per month— and it would seem that this activity will continue until all available building land has been used. A (3). Births. During 1938, the number of births under the Notification of Births Act, was 668, approximately 10 per cent, more than those for the preceding year. Twenty-two stillbirths were also registered, giving a stillbirth rate of 32.93 per 1,000 live births. It is quite reasonable to presume that whilst our population continues to grow in the manner in which it has done during the past two or three years this increase will be reflected in the number of births. A (4). Deaths. The total number of deaths was 390, 206 being males and 184 females. This is after allowing for inward and outward transfers. The death rate for 1938 is 9.799. Compared with 193? the number of deaths shows a decrease of 25. This is rather interesting when it is noted that the number of deaths from Influenza in 1937 was 15 whilst during 1938 the number was 3; and the number of deaths from Bronchitis 12 and 3 respectively. A (5). Maternal Mortality. Three deaths were recorded during 1938 under this heading. 12 Since 1920 there have been 10,103 births with 28 maternal deaths, as shown below, giving a Maternal Mortality rate of 2.78. 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 1 658 547 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 1938 3 656 634 Tota 28 10259 10103 Maternal deaths are investigated by the Medical Officer of Health in collaboration with the medical practitioner and midwife concerned. A(6). Infant Mortality. 34 infants died before reaching one year of age, giving an infant mortality of 53.62. The comparable figure for the whole country is 53. 13 Analysis of the causes of death of this age group reveals the following figures : — Deaths from 1937 1938 Pneumonia 7 6 Whooping Cough — — Bronchitis — 2 Neo-Natal 3 9 Other causes 14 13 Gastro-Enteritis 4 4 28 34 I have included a table showing the Infant Mortality at 5 year intervals for the past 25 years and for 1038. Erith England and Whiles 1910 70.91 130 1915 73.17 91 1920 61.5 83 1925 56.48 75 1930 61.05 66 1935 40.0 59 1938 53.62 53 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 District of Cray ford on the East, and the Borough of 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 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 unemployment has occurred mainly in the adult groups. Whilst these figures are rather disconcerting, I am informed that there was a constant increase in unemployment through out the year. Although there has been no slackening in building operations in Erith itself, the easing of all building operations in the adjoining areas, has affected us, owing to people living here being employed outside the Borough. With regard to the unemployment figures for the female group, the increase can be explained, I am advised, by the reduction of staff at a local factory employing a large proportion of female labour. Year ending 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 December, 1938 934 160 40 16 1150 SECTION B.—MATERNITY AND CHILD WELFARE SERVICES. B(l). Maternity and Child Welfare Scheme. The Maternity and Child Welfare Scheme 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. 15 3. Hospital provision for cases of Puerperal Pyrexia and Ophthalmia Neonatorum. 4. The facilities for the provision of Free Milk for expectant, and nursing mothers. 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. During the period under review the School Medical Service was extended to allow for all its facilities to be made available to children under five years of age. This extension has enabled infants and toddlers with eye defects to be seen by the School Ophthalmic Surgeon; with orthopaedic defects to be seen by the Orthopaedic Surgeon, and certain cases with minor ailments in need of regular treatment to secure this at the School Minor Ailment Clinic. Month Births Sex Legitimacy Notified by B(2). Notification of Births. During 1938, 646 live births and 22 stillbirths, giving i total of 668 were notified to me, as shown in the following table : Live S'born M F Leg. Illeg. Midwives Hosp. etc. Doctors M F M F January 50 2 — 32 20 52 — — 30 21 1 February 54 — 2 30 26 56 — — 19 34 3 March 41 1 1 19 24 42 1 — 24 18 1 April 59 — — 28 31 59 — — 31 27 1 May 51 — 1 33 19 52 — — 15 35 2 June 68 1 2 28 43 70 1 — 37 32 2 July 52 2 2 25 31 55 — 1 24 30 2 August 60 — — 36 24 60 — — 28 31 1 September 51 1 1 25 28 53 — — 25 24 4 October 48 — 1 29 20 48 1 — 26 21 2 November 56 1 1 26 32 58 — — 26 31 1 December 56 1 2 31 28 59 — — 23 34 2 Total 646 9 13 342 326 664 3 1 308 338 22 16 17 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 Borough is a system of 3 clinics held on one half-day a week, and one clinic held on one half-day a fortnight, in various parts of the town. Each Infant Welfare Clinic is attended by a Medical Officer, three 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 18. 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 and other auxiliary foods, i.e., Cod Liver Oil and Malt, Glucose, Farex, &c., 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. 18 Infant Welfare Centres. Month Belvedere Erith 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 217 128 69 229 80 43 45 34 23 161 88 63 February 200 112 47 252 91 37 55 45 20 140 89 45 March 287 190 78 258 67 48 67 52 28 171 73 40 April 122 83 24 307 97 60 76 42 18 139 52 35 May 226 134 49 294 90 58 70 35 18 227 100 43 June 178 123 46 286 88 48 74 38 20 132 63 28 July 178 118 51 339 103 62 78 52 26 196 82 52 August 226 165 38 281 80 49 74 41 19 216 87 40 September 191 123 40 408 130 69 60 38 17 232 77 38 October 185 116 41 3<U 99 61 45 38 18 290 130 58 November 271 183 60 294 91 52 68 45 22 241 100 35 December 123 92 23 235 63 36 32 33 7 132 55 26 Totals 2410 1567 566 3484 1079 613 724 493 236 2277 996 503 3977 4563 1217 3273 Grand Total—Infants Weighed 13,030 Consultations 1,918 Under 1 year 8,895. 1—5 years 4,135 19 B(4). Home Visits by Health Visitors. 1938 Children Special Visits Expectant Mothers Infant Life Protection Total Visits 1st Visits ReVisits StillBirths Others January 51 592 1 9 17 9 679 February 59 585 2 11 21 3 681 March 34 499 — 15 21 3 572 April 57 719 1 10 20 5 812 May 57 613 1 11 22 7 711 June 43 750 2 14 17 3 829 July 136 1327 8 28 21 7 1527 August September 50 557 1 14 15 2 639 October 42 597 2 9 18 4 672 November 56 632 1 9 18 6 722 December 40 426 3 15 5 4 493 Total Visits 625 7297 22 145 195 53 8337 B(5). Maternity Services. B(5)a. Maternity Home—Hainault. The Council provides a maternity home of 7 beds, including one isolation bed. The staff consists of a Sister-in-Charge, a Junior Sister, and two mid wives. Institutional treatment for normal cases is provided, and during the period under review 116 maternity cases were admitted. Of these 95 cases were delivered by mid wives and 21 by doctors. The average duration of stay of these cases in the home was 13.00 days. B (5)b. Ante-natal. The ante-natal sessions which are held on one half-day each week at the Hainault and Bedonwell Clinics, continue to function, and as will be seen from the following table, the attendance figures are most gratifying. 20 1938 Ante-natal patients seen by Doctor Erith Jan. Feb. Mr. Apr. May June July Aug Sep. Oct. Nov Dec. To t al 1445 85 66 79 87 75 60 62 62 97 62 56 89 880 Bedonwell 35 33 37 33 27 44 34 35 58 50 94 85 565 B(5)c. Ante-natal In-patient Accommodation. The need for increased institutional accommodation, for maternity cases within the area, has again been under consideration during the year, and serious attention is being given to the provision of a new Maternity Home with increased accommodation. 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. Eight cases were admitted under this arrangement during the year. The conditions for which they were admitted were as follows : Condition No. Toxaemia 1 Trial Labour 2 Extended Breeeh 3 Ante partum haemorrhage 2 Total 8 B(6). Infant Life Protection. The Health Visitors are responsible for the execution of Infant Life Protection work. As a general rule they undertake routine visiting in their own districts. 21 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 foster mothers on register at end of year 22 Number of children on register at 31st December, 1938 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 is one registered Nursing Home in the district. No applications for registration were received during the year. B (9). Dental Clinic. The Maternity and Child Welfare Dental Clinic which is held fortnightly for Dental Treatment for mothers and preschool children, was well attended during the year, attendances being as follows: Hainault 139 Bedonwell 115 Total 254 22 B(10). NURSING IN THE HOME. B(10)a. General. Three voluntary Nursing Associations provide nurses for work in the district. These are not directly subsidised by the Local Authority, but are supported by weekly contributions by Members of the Associations, and subscriptions from others. The services of these nurses are also available to nonmembers of the Associations for a small fee per visit. B(10)b. Infectious Disease. 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)c. Home Help. A Scheme has been formulated for supplying Home Helps to households during the mother's confinement either at home, or in a Maternity Ward, or Nursing Home, and during any non-infectious illness of a nursing mother, or whilst she is away in a hospital. A full-time Home Help is employed by the Council and she will attend daily at the homes of patients for a period of two weeks, as directed by the Medical Officer of Health, or to suit the convenience of the patient. A scale of charges is in operation and is based on incomes and sizes of families. This service is 011 trial and the present small demand is surprising and disappointing. Strenuous efforts have been made to ensure that this apparent absence of the need for this service is not due to ignorance of its existence. The press have generously co-operated to secure this end, and I am pleased to state that signs are beginning to be evident that these efforts are meeting with success. B (11). 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. 23 SECTION C.—PREVALENCE OF AND CONTROL OVER NOTIFIABLE INFECTIOUS DISEASES. C(1). Infectious Diseases' Hospital. The Erith Borough Council provides its own Isolation Hospital. A large portion of admissions are cases of Scarlet Fever and Diphtheria, but any notifiable infectious disease may be admitted, with the exception of smallpox and puerperal infections, special arrangements for which are described elsewhere in this report. Cases of Measles and Whooping Cough are admitted during epidemic times. C (2). TABLES. C(2)a. Notifications. The following table shows the total notifications received during the year 1938:— Disease Total cases notified Cases admitted to infectious diseases hospital Total Deaths Diphtheria 35 34 5 Scarlet Fever 150 139 — Erysipelas 12 — — Pneumonia 34 — 34 Puerperal P 5 — 3 Oph. Neon. 1 — — Paratyphoid 1 - - 24 C(2)b. Age Distribution. This second table shows, in detail, the age distribution of the notified infectious diseases mentioned above:— Disease Age Groups under 1 1 2 3 4 5 10 15 20 35 45 65 over 65 Totals Diphtheria 1 1 3 1 3 2 8 6 2 7 — 1 - 35 Scarlet Fever 3 2 4 8 13 18 75 15 1 6 4 — - 149 Erysipelas - - - - - - - - - - 1 6 5 12 Pneumonia 2 2 3 2 4 4 3 2 1 3 4 3 2 35 Puerperal P. - - - - - - - - - 3 2 — — 5 Oph. Neon. 1 — — — — — — — — — — — — 1 Poliomye'is Acute - - - - - - - - - - - - - — Paratyphoid 'B' — — — — — — — 1 — — — — — 1 Dysentery - - - - - - - - - - - - - Totals 7 5 10 11 21 24 86 24 4 19 11 10 7 239 25 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 Boys. North. Heath 560 — — — — Picardy 480 — 3 — 3 Central Girls. North. Heath 560 1 5 — 6 Picardy 480 2 2 — 4 Junior Boys. North Heath 200 — 2 — 2 St. Augustine's Road 350 - 1 1 2 West Street 300 — 13 — 13 Junior Girls. North. Heath 200 - 2 2 St. Augustine's Road 350 - - - - West Street 300 1 6 - 7 Junior Mixed. Bedonwell Hill 490 1 — 1 Crescent Road 330 1 5 — 6 Juniors Mixed and Infants. Crossness 150 - 1 - 1 Mixed and Infants Infants. St Fidelis R.C 150 1 1 — 2 Bedonwell Hill 240 3 9 — 12 Belvedere 150 - 7 - 7 Crescent Road 200 — 4 — 4 North. Heath 340 1 5 — 6 St. Augustines Road 350 3 9 - 12 West Street 350 — 27 — 27 Totals 6530 13 103 1 117 Private and other Schools. Males _ 1 - 1 Females 1 1 — 2 Schools out of Town Males — — — — Females — 2 — 2 Under School Age Males 7 14 — 21 Females 2 16 — 18 Over School Age Males 3 7 — 10 Females 9 6 — 15 Totals 22 47 - 69 Grand Totals 35 150 1 186 C (4). DIPHTHERIA IMMUNISATION. During the year under review, details of a scheme for immunisation of children against diphtheria were prepared and placed before the Council, with the result that on 27th June. 1938, the first session under this scheme was held. 26 The method used is three injections of T.A.M., at fortnightly intervals. The sessions are held on Saturday mornings at the Hainault and Bedonwell Clinics alternately and are attended by a Medical Officer, a School Nurse, a Health Visitor and a Clerk. Children of school age and pre-school age attend the same sessions, thus enabling mothers whose family includes children of both groups to take them at the one time. The attention of all Medical men was called to the scheme and the material is supplied free upon request for the treatment of their private patients. The scheme has been working admirably, and no case in which a reaction has occurred has been brought to the notice of the Department. In the beginning the response in applying for treatment was gratifying, some 940 being received within the first two or three months. The present rate at which applications are coming in, despite the activities of the School Medical Officer, School Nurses and the Health Visitors, however, is disappointing. Another disappointing feature is the fact that whereas approximately 200 children are invited to attend each session, the actual number attending in one session has never exceeded 120, thus requiring subsequent appointments being made, and the duplication of clerical work, which in any case in schemes such as this must necessarily be extensive in order to keep adequate records. The system of records in Erith is a card index, each card containing a pocket into which are filled the injection slips, which are completed at each injection. White being the first injection, blue the second, and pink the third—this scheme of coloured slips proves very useful in conveying to the doctor which injection is being given. I give below some figures regarding the Scheme: No. of applications received during the year 1024 No. of First Injections given 375 No. of Second Injections given 371 No. of Third Injections given 367 C(5). Comments on:— (a) Diphtheria. The number of notifications of Diphtheria show a slight decrease on last year. The type of Diphtheria was not unduly severe, and the incidence closely followed that of previous years. 27 Anti-toxin is always available as provided by the Antitoxin Order, 1915, and the Council's Medical Officers are always willing to give a second opinion 011 doubtful cases. There was 110 special incidence in any school. (b) Scarlet Fever. There were 150 cases of Scarlet Fever, as compared with 61 for the previous year, notified during the year. The incidence of these cases was fairly uniformly spread throughout the year; the weekly totals maintaining a fairly constant level which was slightly higher than the previous year and not a greatly increased number over a short period. As will be seen from the Table facing page 24 only one weekly return during the ytar reached a higher level than 7 cases and in only 5 returns was the figure in excess of 5. Of the 150 cases notified 139 were admitted to hospital for treatment. (c) Enteric Fever. There was no change in the number of cases occurring under this heading one case being notified as Paratyphoid B. (d) Measles. This condition is not notifiable in this district but a system of notification by Head-teachers of schools of the absences of scholars, due to such conditions has revealed that the mild epidemic of Measles which occurred during November and December of 1937 faded during January, 1938, but a rise in number of cases occurred in February, reached its peak during April and faded away again during July. One death occurred during the year through Measles. % (e) Provision of Serum for Cases of Measles. During 1937 the Committee agreed to co-operate with the Kent County Council, in a Scheme for the provision of such serum, as follows: ''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 '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." 28 (f) Puerperal Pyrexia. Five cases of Puerperal Pyrexia were notified during the year. 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 Pyrexia) Regulations 1939, a Consulting Obstetrician, Mr. A. Galletly, is available for assistance to Medical Practitioners within the area. (g) Ophthalmia Neonatorum. One case of Ophthalmia Neonatorum was notified, and was treated at Hospital. There was no impairment of vision as a sequel. (h) Smallpox. An arrangement exists between the London County Council and the Erith Borough Council for accommodation for cases of smallpox occurring within the District. C (6). Disinfection of Premises after Infectious Disease. The Sanitary Foreman acts also as Infectious Disease Enquiry Officer and Disinfecting Officer. Following the removal of cases of infectious disease, tuberculosis, etc., 73 premises were disinfected, whilst enquiries to obtain particulars regarding 57 cases of tuberculosis were undertaken. In the 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. The Council have a steam disinfector at the Isolation Hospital, at which clothing, bedding, etc., are disinfected, in addition to the disinfections carried out for the hospital itself. C(7). Laboratory Facilities. Examination of pathological specimens, and other laboratory work for the District, are undertaken by the Kent County Laboratory, Sessions House, Maidstone. 29 During 1938, 299 specimens were sent, as shown below:— Nature of Specimen sent Result Total Positive Negative Swabs for Diphtheria 7 97 104 Sputum for suspected Tuberculosis 49 114 163 Various 7 25 32 Total 63 236 299 C (8). TUBERCULOSIS. C (8 )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. In the tables which follow, particulars of new cases of Tuberculosis and of all deaths from the disease in the area, during 1938, 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, 1938. C(8)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 — _ — 1 — — 1 — - —— 5 — 1 1 — —— 1 _ 10 — — 1 1 — - 15 1 3 — 1 - 2 - — 20 5 4 — — 1 3 1 — 25 9 9 1 1 3 6 — — 35 6 4 — — 2 2 — — 45 2 1 1 — — 1 — — 55 — — — 2 1 — 65& upwards — — — I 1 1 — — Totals 23 22 5 6 8 16 1 — 30 Table (ii). Quarterly Statements. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter M F T M F T M F T M F T Pulmonary T.B. Number on register 185 188 373 190 185 375 195 193 388 191 191 382 New notifications during year 7 3 10 6 9 15 3 5 8 7 5 12 Cases removed, which have been restored - - _ - - - - - - - - - Cases added to register other than by notification 2 1 3 2 3 5 - 2 2 - 2 2 Cages removed from register 4 7 11 3 4 7 7 9 16 4 7 11 Cases remaining on register 190 185 375 195 193 388 191 191 382 194 191 385 Non-Pulmonary T.B. Number on register 86 65 151 85 65 150 85 67 152 84 68 152 New notifications during year 1 — 1 1 2 3 1 1 2 2 3 5 Cases removed, which have been restored - - - - - - - - - - - - Cases added to register other than by notification - - - - - - - 1 1 - - - Cases removed from register 2 — 2 1 — 1 2 1 3 1 2 3 Cases remaining on register 85 65 150 85 67 152 84 68 152 85 69 154 Total Pulmonary and Non-Pulmonary cases on Register at end of year 539 31 C (9). Consultations with local Medical Practitioners. It is pleasing to again record the happy relationship which exists between officers of the Health Department and private practitioners. Practioners 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. CUO). 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 appointed Mr. T. P. Gill, F.R.C.S., as Consulting Aural Surgeon in place of Mr. F. C. Capps who resigned from the appointment. This appointment is renewable annually and a retaining fee is paid. The services of Mr. Gill are available for his opinion, and for operations on patients in the Sanatorium, as required. 32 C (11 ). Clinics and Treatment Centres. Clinics and Treatment Centres. Address. Attend ed by. Day and Time. Provided by the Erith Borough Council. Ante Natal Clinics I. Hainault. Lesney Park Road Assistant M.O.H. Thursdays, 2—4 2. Bedonvvell Clinic Assistant M.O.H. Thursday 9.30—12 Infant Welfare Centres 1. Hainault, Lesney Park Road Assistant M.O.H. Fridays 2—4 2 Belvedere Public Hall Assistant M.O.H. Tuesdays 2—4 3. Primitive Methodist Church, Belvedere M.O.H. 1st and 3rd Wednesday 2—4. 1. Bedonwell Clinic Assistant M.O.H. Mondays 2—4 Maternity and Child Welfare Dental Clinic I. Hainault, Lesney Park Road M.O.H. and 4th Wednesday 2.0 2. Bedonwell Clinic Mr. R. A. Presslie, L.D.S. 2nd Wednesday 2.0 School Clinics (Minor Ailment) 1. Hainault, Lesney Park Road A.S.M.O. and School Nurse Daily at 9.15 2. Bedonwell Clinic Tuesdays 9.30 Ophthalmic Clinic Hainault, Lesney Park Road Dr. N. Howard Allen, M.R.C.S., L.R.C.P. Alternate Wednesdays 9.30 (by appointment) School Dental Clinic (Conservation) Hainault, Lesney Park Road Bedonwell Clinic Mr. Presslie Tuesdays 2.0 Mr. Stone-Wigg Fridays 9.30 ,, Wednesdays 9.30 ,, 1st & 3rd Wednesdays 2.0 ,, 1st, 2nd and 4th Thursdays 2.0 ,, Fridays 2.0 33 (Extractions) Hainault, Lesney Park Road Mr. Presslie Thursdays 9.30 ( ,, and Fillings) Bedonwell Clinic Mr. Stone-Wigg Tuesdays 9.30 (Dental Inspections) Schools ,, 3rd Thursdays 2.0 Orthopaedic Clinic: (Consultation) Bedonwell Clinic \V. Eldon Tucker, Esq., F.R.C.S. 3rd Thursdays 2.0 (Treatment) Krith Hospital Orthopaedic Sister By arrangement (Remedial Exercises) Bedonwell Clinic Orthopaedic Sister Monday and Friday 10.0 Foot Clinic Bedonwell Clinic Miss N. Heddle, M.I.S.Ch. Tuesdays. Alternating 2—4- and ?—9. Diphtheria Immunisation Clinic Bedonwell Clinic Hainault, Lesney Park Road Assistant M.O.H. Alternate Saturday mornings at 10.0 (by appointment) Assistant M.O.H. Provided by the Kent County Council. Tuberculosis Dispensary ().") Bexley Road, Erith Dr. S. Roy C. Price Mondays 5—6. Thursdays 10.30—12.30 Venereal Diseases Clinic County Hospital, West Hill, Dart ford. Drs. Renton and Ockwell Men. Mondays 4.30—6.30 Wednesdays 5—6. Women. Mondays, Tuesdays, Thursdays and Fridays 2—4 34 SECTION D.—HOSPITAL FACILITIES. D (1). General. Situated within the area is a hospital of 43 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 Council. 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 Chief Officer 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. Ed). General. In April of 1938 a reorganisation of the Sanitary Section of the Health Department was effected since which time every effort has been made to dispose of work which had accrued during the past year or so, whilst at the same time it has been necessary to cope with the ever-increasing legislation. The Services of the two Sanitary Inspectors have therefore been utilised to the fullest capacity throughout the year in essential matters pertaining to Housing, Water supply, Food supply, Factory administration, Drainage, Nuisances, etc. In September, 1938, Inspector W. E. Moses attended the Civilian Anti-Gas School at Falfield, Gloucester and qualified for a 1st Class Certificate for instruction in Anti-Gas Precautions. 35 E(2). 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 900 on the like figure for the previous year, reflects due credit on the administration of this section of the Department. During the year reorganisation of the days of collection was rendered necessary, due to the increase in the number of houses in certain defined districts, and as the service is now working at full pressure, the Council have authorised the purchase of a new vehicle during 1939. The method of storage is by means of sanitary dust-bins, and some 11,500 are emptied weekly. The dust-bins are provided and maintained by the owners of the properties concerned, the Council securing this bv a local act—The Erith Improvement Act, 1920. Disposal is effected by barging under contract, and these arrangements are still working very satisfactorily. It is perhaps justifiable here to draw attention to the costs of this service for the year, to further emphasise how economical as well as efficient our present arrangements are. Costs. The cost per ton of collecting refuse is 7s. 4d. (previous year was 7/10) The cost per ton of disposing refuse 3s. l0d. Net cost per 1,000 of population £132 The following tables show : 1. Details of the refuse collection vehicles and staff, 2. Details of the tonnage dealt with during the year. E (2) a. Table 1. Vehicle Capacity I Dennis Lorry 12 cubic vards 2 Easvloaders 4 ,, ,, 2 S. D. Freighters 7 ,, ,, These are operated by— 1 Foreman, 5 Drivers and 9 Loaders. 36 E(2)b. Table 2. Month Tonnage Tons Cwt January, 1938 778 6 February 714 3 March 842 19 April 783 3 May 810 17 June 653 2 July 665 4 August 700 3 September 741 19 October 777 19 November 849 11 December 844 12 Total 9161 18 The total tonnage dealt with during the year, as shown above was 9,161 tons 18 cwts., this is an increase of 820 tons 1 cwt. over that of last year. E(3). 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. The growth of this section of the refuse disposal services has been rapid, when it is remembered that 8 years ago approx. 116 tons were disposed of while in 1938 the amount reached approx. 383 tons. E (4). 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 examinations of such supplies have been undertaken throughout the year with completely satisfactory results, and arrangements are in existence with the Kent County Laboratory for 2 samples of this supply to be taken monthly for bacteriological examination from various points in the district. On 5th March, public water supply was laid on to the encampment at Belvedere Marshes, and a water meter reading of this supply recorded that 41,700 galls, were consumed during a period of 9 weeks, this amount being indicative of .89 gallons per person per day. 37 Extensive sampling of water from the abysinian wells on the Belvedere Marshes has resulted in warning letters regarding the unsuitability for drinking purposes of water from certain wells being issued to owners and occupiers of the sites. Statutory action under Section 140 Public Health Act, 1936, was taken in the case of four wells on the Marshes, water from which was reported as unsatisfactory. Summonses were issued, but in each instance, the pumps and fittings were dismantled before the hearing, thus obviating Police Court proceedings. E(5). Drainage and Sewerage. Extensions to the existing drainage systems were made during the year by the completion of 9,000 yards of new sewer to estates being developed in the District, and, in addition, there have been many extensions of house drains and connections. E(6). Closet Accommodation and Cesspools. The whole of the closet accommodation in both the older parts of the town and the newly built up areas is on the main drainage system, there being only 18 known premises which are drained into cesspools. Cesspools are emptied once a month by mechanical plant of 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. During the year 1938, cesspools were emptied on 81 occasions. E (7). SANITARY INSPECTION OF THE AREA. In the following tables, the work of the Sanitary Inspectors, during the year is summarised:— E(7)a. Routine Visiting. rremises visited ancl recorded results or sucn visits: — Premises No. in District No. of visits in 1938 No. of faults and defects found No. of Faults and defects remedied Bakehouses 10 34 3 3 Cowsheds 3 14 1 1 Dairies 11 62 6 6 Factories 95 138 31 31 Slaughter Houses (licensed) 4 453 4 4 Other Food preparing premises 58 176 9 9 Offensive Trades 13 51 5 5 38 E(7)b. Summary of Nuisances and Defects Remedied during the year. Other than those enumerated in the above tabulation: Drains repaired 23 Drains cleared 48 W.C. pans renewed 22 New W.C. cisterns 19 Roofs and eaves gutters repaired 186 Plasters renewed 140 New cooking stoves 17 New coppers 7 Houses cleansed 54 Accumulations removed 24 Yard pavings repaired 19 Windows made to open 65 Damp walls remedied 76 Floors repaired 51 New sinks fixed 23 W.C.'s cleansed 39 Additional closets provided 3 Privy closets demolished 1 New doors provided 8 Keeping of animals 2 Dustbins provided 87 Cesspools abolished 3 Vermin eradicated 25 The total number of visits of all kinds made by Inspectors during the year was 4,709. Notices served:—Statutory 5 ; Informal 446. Number of houses and other premises disinfected 283 Batches of bedding, etc., disinfected 214 E(7)c. Number of new Houses erected during the year. (1) By the Local Authority — (2) By other Local Authorities — (3) By other bodies or persons 880 E(7)d. Shops and Offices. A total of 108 shops were inspected by the Sanitary Inspectors during the year, the results of such inspections being duly recorded on inspection cards. 39 Non-compliance with Section 10 of the Shops Act, 1934, relating to health and comfort was located in the following instances, and Notices were consequently served to effect the necessary improvement:— Notices served. Insufficient closet accommodation 4 Absence of washing accommodation 1 Lack of heating facilities 2 With regard to the Notices served, adequate heating facilities were subsequently installed in two shops, and though the Notices respecting additional washing and closet accommodation were not complied with by the end of the year, the necessary work was in hand. No action has been taken during the year under Section 46, Public Health Act, 193G, in respect to sanitary accommodation at offices within the Borough. In no case has it been located that insufficient sanitary conveniences exist at such premises. E(7)e. Camping Sites. 1'here are no summer camping sites within the District. There are however 4 sites within the Borough which have been constantly occupied by van dwellings for a number of years. Frequent inspections have been made by the Sanitary Inspectors during the year when the Borough Bye-laws have been stringently enforced. No licenses have been granted by the Local Authority during the year under Section '269 of the Public Health Act, 1936. E (7) f. Hop Pickers. There are no hop fields within the district. E(7)g. Rag Flock Act. There are no premises in the district in which rag flock is manufactured, used or sold. E (7) h. Smoke Abatement. Twelve smoke observations were carried out at various factory shafts in the District, but no statutory action was taken during the year with regard to the abatement of nuisances from smoke. The closest co-operation exists between the various factories, and the officers of the Local Authority, and informal action in one instance resulted in the increasing of a laundry steel shaft by 8 feet. 40 E (7) i. Health Education. Rat Week. Rat Week was observed in Erith during the week commencing 7th November. Large posters were displayed on the Council's advertising boards, affixed to various Council vehicles and announcements were inserted in the local Press inviting the co-operation of the public with the Local Authority's Officers in destroying rats and mice. Literature as prescribed by the Ministry of Agriculture was supplied to the public on request at the office of the Health Department. Special visits and inspections were carried out at factories, food preparing premises, slaughterhouses and open spaces, etc., where the Rat Officers acted in an advisory capacity. 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(7)j. Eradication of Bed Bugs. During 1938, 34 dwellinghouses were found to be infested with vermin and subsequently disinfested as under:— Private dwellinghouses 25 Council houses 9 Infestation of dwellinghouses by the bed bug is invariably located by the Sanitary Inspectors whilst carrying out Housing Inspections. The elimination process includes immediate communication with the owner who is requested to arrange for the removal of wallpaper, picture rails, etc. and proceed forthwith with disinfestation by means of spraying, fumigation or by use of a blow lamp. It is insisted that the work proceeds under the direction of a Sanitary Inspector, and that all infested household effects be surrendered with a view to destruction. To avoid a repetition of such verminous conditions, the Inspectors indicate to the tenants suitable remedial measures which may be employed by them, and the necessary re-visits are made to determine that improvement is effected. The disinfestation of Council houses is carried out by the Borough Surveyor's Department. The disinfestation methods utilised include the use of Solution 'B' or alternatively Cimex Fumigating Blocks. Where the effects of a tenant due for removal to a Council house is found to be infested, furniture and other articles are subjected to Cyanide Fumigation by Contractors, who work under the supervision of the Health Department, prior to rehousing of such tenant. 41 All prospective and selected tenants for Council houses are visited by the Sanitary Inspectors who subsequently report to the Housing Committee upon the condition of the applicant's household contents. E (7) k. 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 (7) I. Swimming Baths and Pools. An open air swimming bath is provided by the Council. The water is mechanically filtered and regularly sampled. During 1988, 12 samples were taken for bacteriological examination, all of which proved to be satisfactory. E (7) m. Schools. All schools in the District have been visited at least twice during the year by a member of my Staff. Any defects located are reported to the Education Committee. All Schools within the District are supplied with the Metropolitan Water Board's water supply. Further details with regard to the schools are given in my Report as School Medical Officer. E (8). HOUSING. E(8)a. 1. Inspection of Dwellinghouses during the year. (1) (a) Total number of dwellinghouses inspected for housing defects (under Public Health or Housing Acts) 980 (b) Number of inspections made for the purpose 2618 (2) (a) Number of dwellinghouses (included under subhead (1) above) which were inspected and recorded under the Consolidated Housing Regulations 1925 and 1932 217 (b) No. of inspections made for the purpose 518 (3) Number of dwellinghouses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwellinghouses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 523 42 E(8)b. 2. Remedy of Defects during the year without service of formal Notices:— Number of defective dwellinghouses rendered fit in consequence of informal action by the Local Authority or their officers 501 E(8)c. 3. Action under Statutory Powers during the year:— (a) Proceedings under Section 9, 10, and 16 of the Housing Act, 1936: (1) Number of dwellinghouses in respect of which Notices were served requiring repairs 4 (2) Number of dwellinghouses which were rendered fit after service of formal Notices: — (a) By Owners 4 (b) By Local Authority in default of owners 0 (b) Proceedings under Public Health Acts: (1) Number of dwellinghouses in respect of which Notices were served requiring defects to be remedied 1 (2) Number of dwellinghouses in which defects were remedied after service of formal Notices : — (a) By Owners 1 (b) By Local Authority in default of owners 0 (c) Proceedings under sections 11, and 13 of the Housing Act, 1936:— (1) Number of dwellinghouses in respect of which demolition Orders were made 1 (2) Number of dwellinghouses demolished in pursuance of Demolition Orders 0 (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 0 0 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined the tenement or room having been made fit 0 43 E (8) d. 4. Housing Act 1936. Part IV.—Overcrowding. (a) (1) Number of dwellings overcrowded 1937 1938 at the end of year 32 26 (2) Number of families dwelling therein 28 (3) Number of persons dwelling therein 205½ (b) Number of new cases of overcrowding reported and relieved during year 6 (c) (1) Number of cases of overcrowding relieved during year 12 (2) Number of persons concerned in such cases 62 (d) Number of dwellinghouses which again became overcroweded after the Local Authority had taken action for abatement of overcrowding Nil E(8) e. Fitness of Houses. During the year, in connection with the inspection of existing houses under the Housing Consolidated Regulations, 1925, 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, 217 records were made of houses necessitating 518 inspections. In addition to these, 523 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 (8) f. Clearance Areas. No action has been taken during the year under the provisions of Part III of the Housing Act, 1936, relating to Clearance Areas. E(9). Factories. Administration of the Factory and Workshop Act 1901 and the Factories Act 1937 (which superseded the Act of 1901 on 1st July, 1938). 44 1. INSPECTIONS for the purposes of provisions as to health including inspections made by Sanitary Inspectors. Premises Number of Inspections Written Notices Occupiers Prosecuted Factories with mechanical power 91 14 — Factories without mechanical power 47 3 — Other premises under the Act (including works of building and engineering construction bat not including outworkers premises) 17 — — Total 155 17 — 2. DEFECTS FOUND. Particulars Number of Defects Number of defects in respect of which prosecutions were instituted Found R emedied Referred to H M. Inspector Want of Cleanliness 3 3 — — Overcrowding — — — — Unreasonable Temperature — — — — Inadequate Ventilation — — — — Ineffective drainage of Floors — — — — Sanitary Conveniences: Insufficient 14 14 — — Unsuitable or Defective 9 9 — — Not separate for sexes — — — — Other offences 5 5 — — Total 31 31 — — SECTION F.—INSPECTION AND SUPERVISION OF FOOD, F (1 ). Milk Supply. Regular inspections were made at the 3 cowsheds, and 11 dairies within the Borough. 45 19 samples of milk from various sources were obtained and submitted to the County Bacteriologist for bacteriological examination. Generally speaking, the results have proved very satisfactory. In one case only was an adverse report received, when the Sanitary Inspector visited the premises and advised with a view to the effecting of an improvement in the method of production and distribution by the dealer concerned. The following table indicates the number of licenses issued by the Authority under the Milk (Special Designations) Order, 1936:— Designation No. Tuberculin Tested 4 B ' (Dealers) licence 1 Pasteurised ' B ' (Dealers) licence 1 Pasteuriser's ' C licence 1 Supplementary licences Pasteurised 7 Tuberculin Tested 2 Tuberculin Tested (Pasteurised) 4 13 F(2). Slaughter of Animals Act, 1933. The Slaughter of Animals Act, 1933, made the use of a mechanically operated instrument in certain circumstances a statutory obligation. On 23rd May, 1938, the Council resolved that Section 1 of the Act should on, and from 1st June apply to sheep, and all slaughtermen were thereupon acquainted with this provision. It is therefore the practice now for sheep to be stunned by a mechanically operated instrument of approved pattern. During the year, no persons made application for a licence to slaughter or stun animals in compliance with the requirements of the above Act. No. of licensed slaughtermen on register at 31st December, 1937 10 No. of licensed slaughtermen on register at 31st December, 1938 10 F(3). Inspection and Supervision of Meat and Other Foods. The inspection of food supplies again received the large amount of attention which this important branch of the Public Health Service demands, and 629 visits were made to food premises including the 4 licensed slaughterhouses, during the 46 year. A total weight of 1 ton 11 cwts. 0 qrs. 11½ lbs. of meat was confiscated at the private slaughterhouses during the year. The Requirements of the Public Health (Meat Regulations) 1924, continue to be observed by members of the meat trade regarding slaughtering, storing, transport, and handling. The supervision and inspection of meat in the slaughterhouses within the Borough entails visits by the Sanitary Inspectors at very irregular hours especially during the evenings and week ends, to accommodate the requirements of the trade. One of the principal features in this branch of Public Health administration has been the large increase in the establishment of restaurent and cafe premises which cater for the needs of persons employed at the various factories in the district. On many occasions, the Sanitary Inspectors have assisted in the reconditioning of premises with a view to maintaining a standard provided for by Section 72 of the Public Health Act, 1925. Regular visits and inspections have been made in cafe kitchens where the food is prepared, and if found so necessary, improvements have been requested, and ultimately effected. SUMMARY OF CARCASES INSPECTED AND CONDEMNED. Cattle excluding Cows Cows Calves Sheep & Lambs Pigs Number killed (if known) 24 — 24 528 2471 Number inspected 24 — 24 528 2471 All diseases except Tuberculosis Whole Carcases condemned — — — — 3 Carcases of which some part or organ was condemned 1 — — — 35 Percentage of the number inspected affected with disease other than tuberculosis 4.1% — — — 1.5% Tuberculosis only Whole Carcases condemned — — — — 8 Carcases of which some part or organ was condemned — — — — 71 Percentage of the number inspected affected with tuberculosis — — — — 3.1% 47 No system of meat marking under Part III of the Public Health (Meat) Regulations, 1924, is operative in the District. No legal action was taken by the Authority with regard to unsound meat and other foods during the year. F(4). Other Foods. In addition to the meat insj>ected in the slaughterhouses, the Sanitary Inspectors dealt with the following foodstuffs which upon examination was found to be unfit for human consumption, duly surrendered and destroyed: — Beef 153 lbs. Liver 10 lbs. Chickens 4 Fish 13 stones Potatoes 3 tons Onions 3 cwt. Apples 17½ cwt. Vinegar 1 bottle Chocolates 1 lb. F(5). Food and Drugs Act. The Sale of Food & Drugs Act 1928 is administered by the Kent County Council within the Borough, and routine sampling is undertaken by that Authority. The County Sampling Officer is also employed in the capacity of Inspector of Weights and Measures. It has not been found necessary for the Borough Sanitary Inspectors to submit any article of food to the County Laboratory for the purpose of examination. Two complaints regarding suspected food supplies were received during the year, each of which were investigated in detail, but not confirmed by the Sanitary Inspector. F (6). Shellfish. There are no shell-fish beds or layings within the administrative district of the Borough of Frith. F(7). Offensive Trades. In addition to the statutory Offensive Trades enumerated under Section 107 Public Health Act, 1936, Fish Frying was, in 1912, declared by Order to be an Offensive Trade within the District, and Bye-laws were made accordingly. 48 The only Offensive Trade operated in this District is that of Fish Frying, of which there are 13 businesses. Regular visits have been made at these premises throughout the year in order to ensure that the standard of cleanliness is maintained on all occasions. Within the area of the Council's Town Planning Scheme, Offensive Trades may be carried on only within certain prescribed zones, and subject to obtaining consent of the Council. H(4). 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. Employment of Children Dec., 1920. New Streets and Buildings Oct., 1927. Tents, Vans and Sheds Feb., 1928. Houses let in Lodgings Jan., 1930. Slaughterhouses Jan., 1932. Nursing Homes July, 1934. New Streets and Buildings Oct., 1935. Pleasure grounds Jan., 1936. Erith Tranvwavs & Improvement Act, 1903. Erith Improvement Act, 1920. Infectious Disease (Prevention) Act, 1890. Part 1891. Public Health Acts (Amendment) Act, 1890. Part 1891. Public Health Acts (Amendment) Act, 1907. Part 1912 & 1928 Public Health Act, 1925. Part 1927. Erith Planning Scheme 1938. Dogs fouling footways 1939. Regulation of Offensive Trades Mar., 1939, BOROUGH OF ERITH. ANNUAL REPORT OF THE School Medical Officer FOR THE YEAR 1938. MEMBERS OF THE EDUCATION COMMITTEE DURING THE YEAR 1938. His Worship the Mayor, Councillor .J. W. WILKINSON, M.A., J.P., CX. Alderman: Mrs. C. Lenney. Councillors: W. A. D. Bailey. G. W. H. Luck. J. M. Bates. S. G. A. Mantle. J. R. Brierley. Mrs. S. G. Nichols. Mrs. M. I. Corsan. T. C. Pannell. J. P. Dunkley. J. N. Powrie. W. ,T. Ebben. Miss H. A. Tyrer. G. R. N. Farquhar. C. Whinner ah. C. C. Firmin. H. C. F. Woodcock. H. Fletcher. Co-opted Me tubers: A. Affleck, Esq. F. H. Hunt, Esq. Dr. J. T. Barr. Dr. MacDonald. Rev. Darvill. F. J. Millard, Esq. T. W. Fudger, Esq. Miss K. Murphy. Rev. Harryman. Mrs. Pannell. The above members constituted the Education Committee which functioned during 1938. The list of members given on the opposite page show the Education Committee as at the beginning of 1938. 3 EDUCATION COMMITTEE. Chairman:—Councillor Bates. Vice-Chairman:—Councillor Ebben. Councillor Brierley. Councillor Wilkinson. „ Dunkley. „ Whinner ah. Mrs. Cor san. „ Woodcock. Councillor Mrs. Nichols. Co-opted Members: T. W. Fudger, Esq. F. J. Millard, Esq. Rev. H. Darvill. G. W. Luck, Esq. Dr. J. T. Barr. 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: Helen M. Evans, M.R.C.S., L.R.C.P., D.P.H. Orthopaedic Surgeon: W. Eldon Tucker, F.R.C.S. Ophthalmic Surgeon: N. Howard Allen, M.R.C.S., etc. Dental Surgeon: R. A. Presslie, L.D.S., Edin. Dental A ttendant: Miss M. L. Buckley. School Nurses: Mrs. Lange, S.R.N., C.M.B., Miss Bhiggs, S.R.N. Clerks: Miss M. Smith. Miss J. Redgrave. 4 Report of the School Medical Officer. It will he appreciated that a good deal of the subject matter of these Reports is repeated from year to year. This is due to a variety of reasons—one being the fact that the report has to conform to a prescribed form, in accordance with the requirements of central Departments. Another important reason is my aim to make the Annual Reports of my Department a reference as well as a Report, thus reference is made to items which have in previous years received full consideration, whilst in other cases a detailed description of the arrangements available is included. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. Under the Authority of the Erith Education Committee there are 9 provided schools with 19 departments, and one nonprovided school with one department. At the end of 1938, there were 5,125 children on the ro of the elementary schools, distributed as follows:— Infants Schools 1,390 Junior Mixed and Infant Schools 150 Junior Schools 1,840 Senior Schools 1,745 In addition there were in Special Schools (Outside the District) 17 Medical Inspection. Routine Medical Inspections have been carried out during the year as required by the Board of Education. The age groups examined are entrants, 8 year olds and leavers. It will be observed from a perusal of the Tables that 1,689 children were examined of whom 356 were found to require treatment. It is generally admitted that the introduction of the routine medical inspection at schools was a pioneer step in the development of the Health Service for the School 5 Child, but it is questionable whether some more economical method of discovering the relatively small number of children with defects, and the still much smaller proportion of children with serious defects could not be found. In this area 84 sessions per year are devoted to Routine Medical Inspection or nearly a quarter of the Assistant Medical Officer's time. Everybody who has carried out these examinations over any length of time will agree that the constant examination of normals tends to blunt clinical enthusiasm, and there appears to be a real risk that minor variations from the normal may achieve undue importance in consequence. The disadvantages of conveying the impression to parents, teachers and even the child itself, that he or she is not in all respects normal are obvious. Malnutrition. On referring to table B, and comparing these figures with last year's, the following fat ts emerge. In the first age group, Entrants, there were 9 per cent, in A (excellent), an increase of (5 per cent.; 67 per cent. were in B (normal), an increase of 2 per cent.; 22 per cent. in C (slightly sub-normal), an increase of 4 per cent.; and there were .5 per cent, in 1) (bad), which shows little change. In the second age group, 8 year olds, there were 17 per cent, in A, an increase of 4 per cent.; 60 per cent. in B, a decrease of 4 per cent.; 22 per cent. in C, no change; and 0.3 per cent, in D, a decrease of 50 per cent. In the third age group, leavers, 15 per cent, were A, an increase of 8 per cent.; 58 per cent. were B, a decrease of 18 per cent.; 25 per cent. were C, an increase of 10 per cent.; and 0.4 per cent. were in D, a decrease of 1 per cent. Comparing totals of children examined with last year's figures, there are 249 children in A Group, an actual increase in number of 47. There are 1033 in B Group, a decrease of 27. There are 400 in the C Group, an increase of 90, and there are 7 in the D Group, a decrease of 2. It will be appreciated that the numbers involved do not justify any startling conclusions. These figures are of far more value in assessing the nutritional state of the school children in England and Wales than they are of measuring the possible change from any one year to another in the nutritional state of the school children of a Borough with a school population of 5,000. There is nothing to suggest any significant change in the nutritional condition of the school children from last year. 6 Provision of Meals, Milk and Malt and Oil. Milk has been issued 011 the School Medical Officer's certificate to 71 children during the year, the issue being twothird pint bottles per day. In the case of children suffering from a greater degree of malnourishment, meals have also been provided. Below is set out a table showing the quantities of Malt and Oil distributed:— Total amount issued during the year: Erith 1275 lbs. Bed on we 11 156 lbs. — 1431 lbs. Amount issued free: Erith 1222 lbs. Bedonwell 150 lbs. — 1372 lbs. No. of children receiving free issues: Erith 127 Bedonwell 10 — 137 Amount sold at cost price: Erith 53 lbs. Bedonwell 6 lbs. — 59 lbs. At the end of the year a total of 31(5 children were receiving free milk at school. Nine recommendations were made for free meals during the year, bringing the total number of children receiving free meals to 24. Uncleanliness. During 1938, 140 children were found to be verminous, at inspections made in the schools by the School Nurses. This figure again shows an improvement over the previous year's figure, but, in fairness to the large proportion of parents whose children are invariably clean, I must again repeat that the persistence of this figure is due to a small group of chronic offenders. 7 Nose and Throat Defects. Reference to Table II will show individual defects under this heading. In view of the attention now being paid to this question, it is of interest to recall that for some years a conservative outlook has been adopted regarding the importance of removal of tonsils and adenoids. Those of us actively engaged in clinical work among preschool children, must often have wondered why, if tonsil removal was of importance, greater attention is not paid to this condition in the under five's before many of the damaging effects attributed to unhealthy tonsils and adenoids are already in evidence, some of them to be permanent. It always seems to me that by the time the child reaches school age, he has already been exposed for a considerable proportion of the most dangerous period of his exposure to risk period," and by the time he has been kept under observation this period is still further increased. The indications for tonsil and adenoid removal in our School Medical Service remain as before, that is, if the tonsils are not giving rise to secondary conditions or repeated sore throats, they do not call for removal. It should perhaps be noted that a considerable proportion of our Tonsillectomies have already been advised by their own private practitioner to have the operation and they are consequently referred to the clinic for convenience of arrangements in securing the operation. 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 10.5 children, 83 being under the Authority's Scheme, whilst 22 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 1938 8. I am pleased once more to record the happy relations existing between the staff of the Royal Waterloo Hospital for Children and Women and ourselves, with regard to operative treatment. Ear Diseases and Defective Hearing. Reference to Table IV will show that 144 defects were treated during the year. Dental Defects. The Dental Scheme was again extended during the year, to 8 sessions per week. Reference to Table V will show among various other interesting facts that there was a considerable increase in the number of fillings done during the year. It will be seen also that 2,135 received dental inspection during the year, and of this number 1,525 children or approximately 70 per cent. were found to require treatment. Taking our school population as five thousand—actually there are 5,125 children on the rolls of the Elementary Schools—this means that three thousand children did not receive dental inspection and 70 per cent. of this figure in need of dental treatment did not receive it. The following table has again been brought up to date: 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 1938 1097 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. 9 "During the last year Ophthalmic Treatment has been carried out on similar lines to the previous year. This consists oi checking the condition and progress of old patients, the treatment of eye diseases such as Blepharitis, Corneal Ulceration, etc., and advice to parents in cases of Squint and Myopia; in addition, ten cases are refracted at each session, suitable spectacles being prescribed when necessary." "It has been found necessary to include some extra sessions as the waiting-list was becoming unwieldy, so that I have been attending each week instead of once a fortnight, but this was only for a limited period." Orthopaedic and Postural Defects. The Orthopaedic Scheme has entered on its second year. All pre-existing orthopaedic cases known to the department, as well as new cases during the year have now been examined by the Orthopaedic Surgeon. Some of these made periodic attendances at the Orthopaedic Out-patient Department of London Hospitals. In these cases the opportunity has been given of regular supervision at the Clinic thus relieving them of the fatiguing journey to London; in other cases desirous of maintaining contact with particular hospitals or particular surgeons, reducing the frequency of such visits; in all cases affording the facility of readily accessible and frequent treatment. Many parents of these patients have expressed their appreciation of the improved facilities this clinic offers. Cases requiring electrical therapeutic measures are referred to the radiological department at the Erith Hospital; as will be seen 353 attendances were made for this purpose by 32 children during the year under review. Two sessions for remedial exercises are held each week by the Orthopaedic Nurse at the Bedonwell School Clinic. As will be remembered, the waiting hall, which for this purpose was made larger than is usual in such clinics, is fitted up with the necessary apparatus. The Orthopaedic services are of special benefit in cases left with such disabilities as result from muscular wasting following prolonged confinement to bed, as in certain infectious diseases, particularly Diphtheria. Their relative accessibility compared to similar facilities provided by London General Hospitals is a very valuable feature of these arrangements. The following is a list of cases which have attended the clinic: 10 CASES SEEN BY Mr. TUCKER—1938. Defects. Infant Welfare. School Children. Congen. Absence patella 1 Infantile Paralysis 1 1 Talipes 1 1 lalipes Equino Varus 1 „ Varus 3 „ Valgus 4 2 Genu Valgum 4 4 „ Varum 4 „ Recurv 1 Painful feet and ankles 1 Bowed Tibia 1 Congen. Dislocation of Hip 1 SI. Spastic Paralysis 1 3 SI. Metatarsal Varus 1 Rickets—Chest 1 3 Exercises—Chest (Asthma) 1 Sternomastoid Tumour 1 Webbed Toes 1 Inturning Toes 1 Hammer Toes 2 Clawed Toes 1 Congen. deformity 1 Deform it}' leg—burn 1 Hallux Valgus 25 Chondritis R. Hip 1 Scoliosis and Kyphosis 16 Amputation of Leg 1 SI. Pes Cavus 1 Dorso lumbar cur v. 1 Raised or dropped shoulders 2 Pain and swelling arches of feet 1 Shortening of leg 8 Wasting of muscles 1 Sp. Bifida 1 Dislocated Hip 1 Osteomyelitis 1 During the year the Council resolved to make all facilities of the School Medical Service available to children up to School Age, to include provision of institutional treatment under the scheme for orthopaedic cases. 11 The wisdom of this action becomes apparent if one considers in addition to the desire for efficiency of the scheme and humanitarian motives the possibility of its justification on purely economic grounds. It would be poor economy to burden the Education Committee with the high cost of special education for a physically defective child whose defect might have beer remedied in earlier years. I have much pleasure in setting out below some notes on the work of the Orthopaedic Clinic contributed by W. Eldon Tucker, Esq., F.R.C.S., the Orthopaedic Surgeon. This Clinic has now been functioning for over sixteen months and it is now possible to indicate the benefits derived from it. The Clinic keeps in touch with all cases that require orthopaedic treatment in the district, and makes certain that cases are not being left to their own devices, or to become chronic from lack of supervision. Many different types of orthopaedic conditions have been treated, but the commoner ones are flat feet, and back deformities giving rise to scoliosis and kyphosis. It has been noted that both the children and the parents co-operate extremely well in performing at home the remedial exercises which have been taught in two Remedial Exercise Classes under the excellent supervision of Miss Whitworth." Heart Disease and Rheumatism. Table 11 shows that 49 cases of organic heart disease were observed, whilst the number of cases of functional heart disease was 166. Tuberculosis. The responsibility for the Tuberculosis Scheme for this area, rests with the County C ouncil and under their Tuberculosis Scheme they provide a Dispensary at Erith where a 'Tuberculosis Officer attends twice weekly. The School Clinic is of course an important adjunct of the Tuberculosis Scheme and close co-operation is maintained between the Dispensary and the School Medical Service. It is at the School Clinic that the preliminary clinical observations necessary to justify further and perhaps extensive investigation can be carried out. The Orthopaedic Clinic is another link in the chain of Tuberculosis supervision where every care is maintained over recovered cases who suffer from permanent disabilities as a result of the disease. 12 These instances serve to emphasize the need and value of the association between these two departments. 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 839 Children examined 15830 Children found with vermin 140 Visits to homes 646 Attendances at Ophthalmic Clinic 23 „ „ Orthopaedic „ 11 Attendances at Dental Clinic: Bedonwell Hill 8 Erith 42 Attendances at the Minor Ailment Clinic have increased tremendously in the past few years, and the volume of work at these sessions has correspondingly increased. In my last year's report I drew attention to the need for extra clerical assistance as the proper recording of this work was becoming impossible. 1 am pleased to say that an Assistant Clerk was appointed for this purpose on 1st November, 1038. I have often felt some concern at the possibility of malingering in regard to attendances at this clinic, and it may be that the seriousness of some of the conditions for which some children present themselves to the clinic hardly warrant the time and journey and additional motives may be suspected. I am convinced however that although there may be one or two isolated cases who are regular "attenders" for a variety of causes and are regarded as suspect, this small number would not justify taking any measures to lessen the accessibility of this service in an attempt to exclude this possibility. It must be remembered that a considerable discretion in referring children to the clinic must remain in the hands of the head teachers, and I would like to take this opportunity of complimenting them on the conscientious and sagacious way in which they maintain this important liason between the parent, the child and the School Medical Service, 13 Set out below is a table giving the number of children examined, together with the total attendances, at the various clinics:— 1938 1937 Children Attendances Children Attendances Minor Ailments Clinic 1885 9567 1614 10739 Dental Clinic 1278 2196 1116 1759 Ophthalmic Clinic 256 696 309 776 Special Examinations 3307 5495 3430 6368 Operations for Tonsils and Adenoids 83 — 150 — Orthopaedic Clinic 92 254 37 53 Total 6901 18208 6656 19695 Infectious Diseases. Cases of the more common infectious diseases, measles, chickenpox, whooping cough, scarlet fever, &c., occurred throughout the year in the various Departments and Schools in small concentration and although these were in greater numbers than would warrant them being described as sporadic, they did not amount to epidemic proportions. There was no unusual grouping in any particular school. Immunisation against Diphtheria. As this scheme which was inaugurated in June, 1938, applies to all children up to 15 years of age. and not only to school children, it is fully described in my General Report for the year. Laboratory Facilities. Examination of pathological specimens, and other laboratory work for the District, are undertaken by the Kent County Laboratory, Sessions House, Maidstone. During 1938, 15 swabs were examined for Diphtheria, all of which proved to be negative; and 2 swabs for Haemolytic Streptococci, one of which was positive. Open Air Schools. There is no open-air school provided by this Authority, but as will be seen from Table Ilia 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. 14 The number of children for whom special school, convalescent or hospital school treatment was provided during the year for periods of varying length was 29. Physical Training. Miss F. W. Bentley and Mr. G. H. Atkinson, the Organisers of Physical Education for Erith, have kindly submitted the following notes on their work during the year. I have very much pleasure in including these in my Annual Report of the School Medical Service for the year 1938. ** The progress of the development of all branches of physical education in the Elementary Schools of this Borough during the past twelve months has been assisted in no small measure by the recent determined efforts of the Board of Education to secure the wider recognition of the subject's claims. That the physical welfare of the child is of fundamental importance to any scheme of child education is no new theory ; yet it is surprising how long it has taken to give practical effect to the principles involved and implied, namely:— (1) That a daily period of physical activity is required for all children. (2) That alternative indoor accommodation for physical cises is essential during inclement weather. (3) That a satisfactory scheme of exercises for older children necessitates the provision of fully-equipped gymnasia. (4) That the fullest benefits from physical exercises are obtainable only by pupils for whom suitable clothing and footwear are available. (5) That a sound scheme of physical education involves not only physical exercises, but games and athletics, swimming, dancing, rambling and camping; in fact, all activities which may justly claim to contribute to the child's physical welfare and development. 'The Board of Education, having clearly defined these principles and requirements, have done much to create satisfactory conditions for the subject's development in the elementary schools of this Authority. Physical Exercises. (a) Senior Schools. Interest and enjoyment in the Physical Training Lesson, the key-note of its modern interpretation, is secured in all Senior Schools. Advanced schemes of work, 15 carried out by specially trained teachers are generally adopted, and the resulting improved standard of classperformance has more than justified the provision of portable gymnastic apparatus. The empirical discovery during the past few years of unexpected potentialities for gymnastic skill possessed by the senior school child has established the subject s claim for increased facilities for gymnastic work. The provision of fully equipped gymnasia for Senior Schools is now an urgent prerequisite for the subject's further development and deserves the immediate and full consideration of the Committee. Given such facilities, the potential values of gymnastic work would not onlv be considerably increased, but the introduction of new and interesting activities would do much to create a desire amongst scholars to continue this form of recreation during post-school years. (b) Junior School. Satisfactory progress has been maintained, particularly in the management and practice of the Team System. The further development of the group-leadership method has been well featured, and the ability of children to handle their own group activities is greatly increasing. Although the general standard of class-teaching has shown some improvement, there are still a few teachers who are finding difficulty in appreciating the value of precision in the performance of the more formal type of exercise. As a rule with such teachers there is a general lack of class control which gives their lessons the appearance of looseness and confusion. There is also a hesitancy on the part of teachers to make the fullest demands upon the abilities of their pupils for strong and accurate work, a factor which results in the acceptance of standards of performance often far short of the pupils* real capacity. As the values of physical exercises depend so much on good teaching, the need for specialisation in certain Junior Schools is clearly indicated. (c) Infants' Schools. The character and scope of the activities employed in both the "Primary" and "Secondary" lessons for Infants' Classes calls for urgent re-consideration of the policy usually adopted in regard to the size of Infants' School Halls. Classes of fifty infants require at least as much room for their physical activities as is customarily provided for junior classes. 16 In spite, however, of the difficulties of restricted accommodation in certain schools there has been a general improvement in the quality of the instruction given. A more extensive use of music in application to the "Secondary" lesson, and the use of apparatus and a better appreciation of the training values of the "Primary" lesson have yet to be realised. The extraordinary growth of the Bedonwell Estate, in creating unforeseen demands upon school accommodation, has resulted in depriving the Junior and Infants' departments of the Bedonwell School of facilities for indoor work. As further classroom accommodation is at present being added, however, it is hoped that this handicap will soon be removed and the school halls will again become available for physical training during inclement weather. Shoes and Clothing. It is significant that in schools where there has been a really determined attempt on the part of the teaching staffs to secure the satisfactory equipment of children with shoes and clothing for physical exercieses, the resulting benefits to the work have more than justified the efforts employed. The present policy of the Education Committee is to encourage parents to provide these articles for their children, and, where occasion demands, to supplement this provision by limited supplies at Head Teachers' requests. In the case of Senior Schools this arrangement has worked satisfactorily, but much remains to be done before the problems and difficulties of this provision in the Junior and Infants' Schools are properly overcome. Arrangements for tiie storage of clothing and shoes at schools still present a major problem and until such arrangements are secured, the general practice of changing for physical exercises can never become really established. Equipment. In order to carry out the scheme of work suggested by the Board of Education Syllabus of Physical Training, a constant supply of small apparatus is essential. Arrangements have been made for a definite supply to be allocated to every department with a proportionate amount of renewals to be granted each year. 17 Organised Games. Facilities for weekly instruction in Organised Games are possessed by all Senior Departments. In certain cases, the walk to and from the playing fields causes considerable loss of time, and this problem, combined with the general lack of facilities for changing and showering, tends to restrict the full development of this branch of the work. Nevertheless, in spite of these difficulties, a keen interest is shown in all boys' games, and the standard of play amongst the girls is generally satisfactory. In all cases, the need for specific coaching in all games practices and for the more extensive use of the minor games such as Rugby Touch, Team Passing, and Long Rail, is much in evidence. The subject in the Junior Schools is at present undeveloped, owing to the fact that facilities for field practices are not generally possessed. Arrangements are needed to ensure that at least the upper standards of Junior Departments may have access to a playing field for weekly games. Swimming. Arrangements for organised class instruction at the Open Air Bath are necessarily limited—the demand for attendance being far in excess of the limits of accommodation. During the rather short season, instruction is given to six classes each morning, from 9.0 to 12.0; more or less equal opportunities being afforded to both Junior and Senior scholars. Suggested arrangements for the future have been designed to give preference to the needs of the Senior Schools, under a scheme which provides for the attendance of normal school classses as units of instruction and which overcomes the past difficulties of time-table disorganisation. This scheme ensures more effectively that every child on leaving school shall have been taught to swim. Dancing. In both Senior and Junior Schools throughout the Borough, English Folk Dancing is well taught and executed, facilities for instruction being generally satisfactory. There is still scope for the development of this branch of work along more interesting and varied lines, however, and encouragement will now be given to the introduction of National Dances, Folk Dances of Other Lands, and the Central European type of Natural Movement. 18 Further Training of Teachers. The following Courses for teachers in the service of the Erith and Gravesend Authorities have been conducted during the past year:— (1) A Course of Physical Training for Men Teachers in Junior Schools, held at the Dartford Technical College on two afternoons each week throughout the period January 24th—March 81st. (2) A similar Course for Women Teachers held in Krith on Saturday mornings throughout the Autumn Term. (3) Two Short Courses in Swimming Instruction for Men and Women Teachers held during May. In regard to Course (2) above, which was conducted on Saturday mornings as an experiment, experience has tended to establish the view that the most successful of teachers' classes are those which are conducted during school time. The problem of securing fully representative attendance by all schools is tremendously increased when such attendance depends upon the giving-up of so much of the teachers' leisure time. Conclusion. The continued interest and keenness of the teaching staff generally and their increasing appreciation of the value and importance of their work in Physical Education has resulted in a year of sound progress. Further development, however, depends to a considerable extent upon the provision of additional facilities for more advanced gymnastic work and organised games. The Organisers wish to acknowledge their indebtedness to the Education Committee for their continued confidence and support and also to the head and assistant teachers upon whose loyal co-operation the value of their work must always depend." Co-operation of Parents, Teachers, &c. The following figures will show the continued interest that parents take in the medical examination of their children. At Routine Medical Inspections the parents attended in 88 per cent. of inspections in the case of infants, 86 per cent. in the case of intermediates, and 64 per cent. in the case of leavers. 19 Blind, Deaf and Epileptic Children. Ail analysis of children falling under this head is given in Table 111, in which is fully set out the type of education and treatment received. One child conies within the blind children group this year. This child lost her sight following cerebro spinal meningitis. There are 8 partially sighted children at Public Elementary Schools and one at a Certified Special School for partially sighted children. There are no deaf children in our area, but 4 children who are partially deaf attend elementary schools. No epileptic children came under our notice during 1938. 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. Mentally Defective Children. The Annual Report of the Local Organiser of the Kent Voluntary Association for Mental Welfare is given below. Home visits have been paid in respect of five cases of the age of 19 years and under, and withdrawal from supervision has now been suggested in three of these for the following reasons : (a) The girl, aged 19 years 8 months, is useful in the home, is well cared for by her mother and further enquiries are resented. (b) This lad, born 20.2.20, has been in regular employment since 1934 and is now in the position of under-foreman. Further enquiries appear to be unnecessary. (c) This lad, now 19 years of age, has had irregular employment since 1934 and the mother appears to resent further enquiries. The two remaining on the list at the end of this year are both 18 years old. one lias been employed in the canteen of a local shop and the other is at home, said to be looking after her father's house. 20 It is a matter for regret that no cases of school age have been received from the Committee for the past five years. The possibility of carrying out effective after care is so much lessened when the children and their families only become known to the Association when school-leaving age is reached. The one case reported to the Association during the year as having been notified to the County Mental Deficiency Committee is now supervised on a Statutory basis for that Committee and is at present living at home. Two other cases, both under Statutory Supervision, are making a regular attendance at the Bexley Heath Occupation Centre and it is hoped that a similar arrangement will be made for another patient in the New Year. Valuable work continues to be done at the Occupation Centre where 24 children make a regular attendance. Owing to the increase in numbers and the need for more definite grading and grouping an Assistant was appointed in November, 1937. She also acts as Guide for the children from the Sidcup and Bexley districts. The thanks of the Association are due to the School Medical Officer and the Chief Education Officer for their willing; co-operation. TABLE 1. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups:— Entrants 363 Second Age Group 603 Third Age Group 723 Total 1689 B.—Other Inspections. Number of Special Inspections 3307 Number of Re-Inspections 2188 Total 5195 C.—Number of individual children found at Routine Medical Inspection to require Treatment (excluding Defects of Nutrition, Uncleanliness and Dental Diseases). 21 GROUP Number of Children Inspected Found to require Treatment 1 2 3 Prescribed Groups:— Entrants 363 77 Second Age Group 603 110 Third Age Group 723 169 Total (Prescribed Groups) 1689 356 TABLE II. A—Return of Defects found by Medical Inspection in the Year ended 31st December, 1938. Defect or Disease Routine Inspections Specia1 Inspections Mo. ot 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 1 - - - Body 2 _ 5 Scabies — _ 33 - Impetigo 7 - 103 - Other Diseases (Non-Tuberculous) 15 30 110 10 Eye :— Blepharitis - - 21 - Conjunctivitis 1 _ 18 -. Keratitis - - - - Corneal Opacities L - Defective Vision (excluding Squint) 134 48 4 - Squint 15 3 6 - Other Conditions 7 5 90 2 Ear :— Defective Hearing 1 2 3 9 Otitis Media 18 2 45 - Other Ear Diseases 2 12 86 12 22 TABLE II—Continued. 1 2 3 4 5 Nose and Throat:— Chronic Tonsillitis only 32 314 33 29 Adenoids only 3 5 2 7 Chronic Tonsillitis and Adenoids 31 13 76 10 Other Conditions 2 46 243 163 Enlarged Cervical (Hands (Non-Tuberculous) 3 467 16 54 Defective Speech — 4 3 9 Heart and Circulation:— Heart Disease: Organic 5 14 14 16 Functional — 103 — 63 Anaemia 2 15 4 6 Lungs:— Bronchitis 1 3 6 7 Other Non-Tuberculous Diseases 3 72 64 72 Tuberculosis:— Pulmonary: Definite 1 - - 1 Suspected 1 - - 1 Non-Pulmonary: Glands 2 1 1 5 Bones and Joints - - 1 - Skin - - - - Other Forms — — — — Nervous System:— Epilepsy 2 - 5 - Chorea 2 — 8 2 Other Conditions 2 1 4 3 Deformities:— Rickets 1 13 - 4 Spinal Curvature 3 21 2 3 Other Forms 74 102 29 10 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 27 69 1137 103 Total 400 1365 2172 601 23 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 Excellent B Normal C Slightly subnormal D Bad No. % No. % No % No. % Entrants 363 34 9 245 67 82 22 2 .5 Second AgeGroup 603 103 17 362 60 136 22 2 .3 Third AgeGroup 723 112 15 426 58 182 25 3 .4 Other Routine Inspections - - - - - - - - - Total 1689 249 14 1033 61 400 23 7 .4 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 — — — 1 1 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 24 TABLE III—Continued. Deaf Children. At Certified Schools for the Deaf At PublicElementary 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 School or Institution Total — — 4 — — 4 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 3 8 — 5 16 Epileptic Children. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total — — — — — . 25 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 — 3 — 1 4 II.—Children Suffering from Non-Pulmonary Tuberculosis At Certified Special Schools At Public Klementary Schools At other Institutions At no School or Institution Total — 5 1 — 6 B. DELICATE CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 3 26 — 3 32 C. CRIPPLED CHILDREN. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 6 15 1 1 23 D. CHILDREN WITH HEART DISEASE. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 1 1 2 2 6 26 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1938. TREATMENT TABLE. GROUP I.—MINOR AILMENTS. (excluding Uncleanliness, for which see Group VI). Disease or Defect Number of Delects treated, or under treatment during the year Under the Authority's Scheme Otherwise Total 1 2 3 4 Skin— Ringworm—Scalp - - - (i) X-Ray Treatment. If none, indicate by dash. - - - (ii) Other Treatment - - - Ringworm—Body 6 1 7 Scabies 33 4 37 Impetigo 103 2 105 Other skin disease 80 5 85 Minor Eye Defects (External and other, but excluding cases falling in Group II). 124 5 129 Minor Ear Defects 126 18 144 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.). 1153 19 1172 Total 1625 54 1679 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) 256 12 268 Other Defect or Disease of the Eyes (excluding those recorded in Group I) - 3 3 Total 256 15 271 27 No. of children for whom spectacles were prescribed : (i) Under the Authority's Scheme 154. (ii) Otherwise 11 165 No. of children for whom spectacles were obtained: (i) Under the Authority's Scheme 123 (ii) Otherwise 11 131 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. 35 2 45 1 11 1 10 — 46 3 55 1 — 105 (i)Tonsils only, (ii) Adenoids only. (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat. GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS. Under the Authority's Scheme Otherwise Total number treated (1) (2) Residential treatment with education Residential treatment without education NonResidential treatment at an orthopaedic clinic Residential treatment with education Residential treatment without education Non Residential treatment at an orthopaedic clinic (i) (ii) (iii) (i) (ii) (iii) Number of children treated — — 70 — — 11 77 GROUP V.—DENTAL DEFECTS. (1) Number of Children who were:— Routine Age Groups Total Specials Grand Total 5 6 7 8 9 10 11 12 13 14 (t) Inspected by Dentist 123 134 143 142 216 236 135 7 4 4 1144 991 2135 28 (ii) Found to require treatment 1525 (iii) Actually treated 1278 (2) Half-days devoted to:— Inspection 8 Treatment 184 192 (3) Attendances made by children for treatment 219f> (4«) Filling's:— Permanent teeth 1093 Temporary teeth 4 1097 (5) Extractions:— Permanent teeth 304 Temporary teeth 1638 1942 (6') Administrations of general anaesthetics for extractions 985 (?) Other operations: Permanent teeth 134 Temporary teeth 134 GROUP VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. (1) Average number of visits per school made during the year by the School Nurses 5.7 (2) Total number of examinations of children in the Schools by School Nurses 15,830 (3) Number of individual children found unclean 140 (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