C I RICH 2 AC 4413(1) RICHMOND BOROUGH OF RIGHMOND (SURREY). ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH 1933. richmond : j. h. broad and co., ltd., printers, 8, king street. BOROUGH OF RICHMOND (SURREY). ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH 1933. richmond: j. h. broad and co., ltd., printers, 8, king street. Public Health Staff. Medical Officer of Health and School Medical Officer— *Charles Stuart Brebner, D.S.O., M.D., D.P.H., Barrister-at-Law. Medical Officer for Ante-Natal Clinic and Child Welfare Centre, Petersham and Ham— Margaret E. Cryer, M.D. (Glas.). Chief Sanitary Inspector— *George Laws, M.R. San. Inst., F.S.I.A. Certified Inspector of Meat and other Foods. Inspector under Shop Hours Acts. Assistant Sanitary Inspectors— Bernard Aisthorpe (Certificate Royal Sanitary Institute and Meat and Food Inspectors' Certificate). Victor Edward Baughan (Certificate Royal Sanitary Institute, Meat and Food Inspectors' Certificate and Smoke Inspectors' Certificate). School Nurses and Health Visitors— Mrs. L. K. Dunford, C.M.B. Miss C. G. Hay, S.R.N., C.M.B., New Health Visitors' Certificate, R.S.I. Miss J. D. Law, R.R.C., S.R.N., C.M.B., Health Visitors' Certificate, Univ. Edin. Clerks- Miss, D. K. Jemmett. Miss M. J. Bird. Miss O. W. Ponsford. Drain Tester and Disinfector— J. Davis (part time). Veterinary Inspector— W. J. Hatton, M.R.C.V.S. (part time). Contribution is made to Salaries of Officers marked thus* 3 Public Health Department, Parkshot, Richmond, Surrey. June, 1934. To the Mayor, Aldermen and Councillors of the Borough of Richmond (Surrey). Ladies and Getlemen, I have the honour to submit my Annual Report on the health and sanitary condition of the Borough during the year ended December 31st, 1933. The Report is drawn up according to the directions contained in Circular 1346 issued by the Ministry of Health in October, 1933 and is what is known as an Ordinary Report. On April 1st of the year under review a considerable part of the Urban District of Ham was transferred to Richmond. This extended the Borough by 1,644 acres. During the year considerable progress was made in the Slum Clearance Programme under the Housing Act of 1930. A local Enquiry by the Ministry of Health was held on the appeal of the owners of 41 houses which had been represented as unhealthy and unfit for human habitation. This will be dealt with at length in the Section headed "Housing." The Birth rate throughout England and Wales for 1933 is 14.4, while the rate in Richmond is only 10.9 per 1,000 of the population. The Death rate for the Borough is 11.0 per 1,000 of the population, while this year's rate for England and Wales is 12.3, 4 The Infantile Mortality rate is 38 per 1,000 births, which compares very favourably with the Infant Mortality rate of England and Wales, viz., 64 per 1,000 births. I take this opportunity to express my thanks to the Chief Sanitary Inspector and the staff of the Department for their work during the year. I am, Ladies and Gentlemen, Your obedient Servant, C. S. BREBNER. 5 Natural and Social Conditions of the Area. Area (in acres) 4,243 Population (census 1931) 37,791 „ (estimated 1933) 38,776 Number of inhabited houses (1933) 8,967 Rateable Value £519,299 Sum represented by a penny rate £2,067 Physical features and general character of the area. The Borough of Richmond lies on the south bank of the Thames. Incorporated in 1890, its boundaries were in 1892 enlarged by the inclusion of the parishes of Kew, Petersham and a part of Mortlake. On April 1st, 1933, the Borough was'further enlarged by the inclusion of a large part of the Ham Urban District. During the year also the boundaries of the various wards of the Borough were revised. The wards were increased in number from six to ten. The height above ordnance datum varies, being 16 feet at the bottom of Water Lane, 31 feet opposite the General Post Office, 152 feet at the Park Gates, and 180 feet inside Richmond Park. The subsoil is chiefly gravel and sand interspersed with patches of clay on the Hill. Social Conditions. The Borough is chiefly a residential district. There are one or two small factories in addition to the usual trades carried on in any town, while a certain number of the inhabitants are engaged in those industries and occupations connected with boating. 6 Poor Law Relief. The Clerk of the Public Assistance Committee informs me the approximate number of cases afforded Outdoor Relief in the Richmond district during the year was 490. The Philanthropic Society has assisted the needy to the following extent:— £ s. d. To Monetary Grants, on petition, for surgical appliances, convalescent treatment, etc. 170 0 0 Boots and Clothing 50 0 0 Relief in other forms 270 0 0 Convalescent Home, Hospital and Surgical Aid Letters purchased 30 0 0 Richmond Royal Hospital. The Secretary, Mr. Richard Allen, has kindly supplied the following information:— 1,415 In-Patients and 5,232 Out-Patients were treated at the Hospital during 1933. Those received from the Borough of Richmond were 468 In-Patients and 1,234 Out Patients. Extracts from Vital Statistics of the Year. TOTAL. M. F. Births (Legitimate) 390 193 197 „ (Illegitimate) 28 17 11 Stillbirths (Legitimate) 14 8 6 „ (Illegitimate) — — — Deaths 500 221 279 Birth Rate (R.G.) 10.9 Death Rate (R.G.) 11.0 7 Death Rate of Infants under 1 year of age. Deaths of all children under 1 year per 1,000 Births 38 Deaths of Legitimate Infants per 1,000 Legitimate live Births 28 Deaths of Illegitimate Infants per 1,000 Illegitimate live Births 178 Deaths from Measles (all ages) — Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) — 8 BIRTH RATE, DEATH RATE, AND ANALYSIS OF MORTALITY DURING THE YEAR 1933. (Provisional figures). (The mortality rates for England and Wales refer to the whole population but for London and the towns to civilians only). Rate per 1,000 total population. Annual Death Rate per 1,000 Population. Rate per 1,000 Live Births. Percentage of Total Deaths. Live Births. Stillbirths. All Causes. Typhoid and Paratyphoid Fevers. Small-pox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under two years). Total Deaths under one year. Certified by Registered Medical Practitioners. Inquest Cases. Certified by Coroner after P.M. No Inquest. Uncertified Causes of Death. England and Wales 118 County Boroughs and 14.4 0.62 12.3 0.01 0.00 0.05 0.02 0.05 0.06 0.57 0 54 7.1 64 90 9 6.3 1.9 0.9 Great Towns, including London 14.4 0.67 12.2 0.00 0.00 0.06 0.62 0.06 0.08 0.55 0.49 9.4 67 91.0 6.0 2.5 0.5 132 Smaller Towns (Estimated Resident Populations 25,000 to 50,000) at 14.5 0.63 11.0 0.00 0.00 0.04 0.02 0.04 0.04 0.53 0.44 4.9 56 91.7 5.8 1.5 1.0 London 13 2 0.45 12.2 0.00 0.00 0.02 0.02 0.08 0.08 0.51 0.58 11.6 59 88 3 6.3 5.4 0.0 RICHMOND 10.9 0.39 11.0 0.00 0.00 0.00 0.03 0.03 0.23 0.62 0.57 0.00 38 86.1 9.4 4.5 0.0 Puerperal Sepsis. Others. Total. The maternal mortality rates for England and Wales are as follows per 1,000 Live Births 1.79 2.63 4.42 ,, ,, Total Births 1.71 2 52 4.23 The maternal mortality rates for Richmond are as follows per 1,000 Live Births 0.00 0.00 0.00 ,, ,, Total Births 0.00 0.00 0.00 9 Population. At the Census of 1931 the population of the Borough was 37,791 while the Registrar General's estimate of the population at the middle of 1932 was 37,640. On the addition of part of Ham on April 1st, 1933, the added population was given as 1,479 and I should estimate the population of the combined district at the middle of the year to be not less than 40,000. The Registrar General's estimate for the whole Borough at the middle of 1933 is 38,776 but he states "adjustment requires to be made in the above-mentioned population to make allowance for the change of area and the following adjusted figure should accordingly be used for the calculation of Birth and Death Rates for the year 1933:—38,380."This is, in my opinion, a low figure and consequently the Birth and Death rates will be shown higher than they actually are. Births. There were 418 births during the year(210 males and 208 females). This gives a birth rate of 10.9 per 1,000 of the population as compared with a rate of 14.4 in England and Wales and 13.2 in London. There were 14 still births registered giving a rate of 0.39 per 1,000 of the population, as compared with 0'62 in England and Wales and 0.45 in London. Deaths. The number of deaths registered during the year was 500 (221 males and 279 females). In the list of deaths supplied weekly by the local Registrar there were 191 deaths of persons usually residing outside the Borough. These are not included in my statistics but are dealt with in the districts concerned. On the other hand 95 persons who normally resided in the Borough died elsewhere and are included in the total deaths. 10 The number of deaths which occurred in Institutions in the Borough was 370, and the number of inquests held was 77, though all of these were not concerned with Richmond residents. The crude death rate is therefore 13.02 per 1,000 of the population, as compared with 12.3 in England and Wales and 12.2 in London. The total number of deaths received weekly from the local Registrar does not always tally with the number received at the end of the year from the Registrar-General. This is due to the fact that the statistical year of the Registrar-General may not begin at the first day of the week. The number of deaths, therefore, in the following table, is as near to the Registrar-General's figure as I am able to make it. The deaths occurred in persons of the following ages:— 16 under 1 year of age. 5 between 1 and 5 years of age. 16 5 ,, 15 ,, 19 15 „ 25 ,, 43 25 „ 45 ,, 122 45 „ 65 „ 186 65 „ 80 ,, 84 over 80 years of age. It will be noticed that no fewer than 270 persons died over the age of 65, i.e., more than half the total deaths, while 84 were deaths of people over 80 years of age. 11 Causes of death under 1 year of age. Cause of Death Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks Total under 4 weeks 4 weeks and under 3 months 3 months and under 6 months 6 months and under 9 months 9 months and under 12 months Total deaths under 1 year 1. Other Tuberculous Diseases. ... ... ... ... ... ... ... ... ... ... 2. Bronchitis ... ... ... ... ... ... ... ... ... ... 3. Pneumonia ... ... ... ... ... ... ... ... ... ... 4. Congenital Debility and Malformation including Premature Birth 4 1 2 ... 7 1 2 ... ... 10 5. Other defined diseases 2 1 3 1 1 1 ... 6 6 1 3 ... 10 2 3 1 ... 16 Infantile Mortality. This rate is calculated on the number of deaths of children under one year of age per 1,000 births. During 1933 there were 16 deaths of children under one year of age and 418 births. This gives an Infantile Mortality rate of 38 per 1,000 births, as compared with 64 in England and Wales, and 59 in London. This is the lowest Infantile Mortality rate ever recorded in the Borough, the previous lowest rate being 42 in 1924. This is all the more gratifying as the summer of 1933 was hot and dry. Not many years ago a hot summer was invariably marked by an increase in the Infantile Mortality. In 1911, 1914 and 1921 (all hot summers) the Infantile Mortality figures were 116, 86 and 58 per 1,000 births. It will be seen from the table that out of the 16 deaths, six occurred in the first week of life. The neonatal deaths, i.e., deaths occurring in the first four weeks numbered 10 out of the total 16. This gives a neonatal mortality of 23 per 1,000 births. Seven of these deaths were due to Congenital Debility and Premature Birth. There were five deaths of illegitimate infants under one year of age out of 28 illegitimate births. This gives an Infantile Mortality rate of illegitimate children of 178 per 1,000 births. 12 Causes of Death. M. F. All Causes 221 279 1. Typhoid and Paratyphoid Fevers — — 2. Measles — — 3. Scarlet Fever 1 — 4. Whooping Cough — 1 5. Diphtheria 6 3 6. Influenza 11 13 7. Encephalitis Lethargica 1 1 8. Cerebro-Spinal Fever — 1 9. Tuberculosis of respiratory system 9 16 10. Other tuberculous diseases 1 3 11. Syphilis — — 12. General paralysis of the insane, tabes dorsalis 1 — 13. Cancer, malignant disease 23 51 14. Diabetes 2 4 15. Cerebral haemorrhage, etc. 10 10 16. Heart disease 51 57 17. Aneurysm — 1 18. Other circulatory diseases 17 23 19. Bronchitis 8 16 20. Pneumonia (all forms) 11 9 21. Other respiratory diseases — 6 22. Peptic Ulcer 2 1 23. Diarrhoea, etc. (under 2 years) — — 24. Appendicitis 2 3 25. Cirrhosis of Liver 3 2 26. Other diseases of liver, etc. 1 1 27. Other digestive diseases 6 8 28. Acute and chronic nephritis 4 16 29. Puerperal sepsis — — 30. Other puerperal causes — — 31. Congential debility, premature birth, malformations, etc. 5 3 32. Senility 3 7 33. Suicide 4 — 34. Other violence 8 10 35. Other defined diseases 31 13 36. Causes ill-defined or unknown — — Special Causes (included in No. 35 above). Small-pox — — Poliomyelitis — — Polioencephalitis — — 13 General Provision of Health Services in the Area. (1) Public Health Officers of the Authority. (a) Medical:— C. S. Brebner, D.S.O., M.D., Medical Officer of Health, School Medical Officer and Medical Officer for Maternity and Child Welfare. Margaret E. Cryer, M.D. (Glas.), Medical Officer, Ante-Natal Clinic and Child Welfare Centre, Petersham and Ham. J. W. Bell, M.D., L.R.C.P., L.R.C.S., for cases of Puerperal Fever, etc. Miss E. Russell, L.D.S., Dental Surgeon for Maternity and Child Welfare. (b) Others: George Laws, M.R., San. Inst., F.S.I.A., Chief Sanitary Inspector, Certified Inspector of Meat and other Foods, Inspector under Shop Hours Acts. Bernard Aisthorpe, Assistant Sanitary Inspector, Certificate of Royal Sanitary Institute and Meat and Food Inspectors' Certificate. Victor Edward Baughan, Assistant Sanitary Inspector, Certificate of Royal Sanitary Institute, Meat and Food Inspectors' Certificate and Smoke Inspectors' Certificate. Mrs. L. K. Dunford, C.M.B., Health Visitor. Miss C. G. Hay, S.R.N., C.M.B., New Health Visitors' Certificate, R.S.I. Miss J. D. Law, R.R.C., S.R.N., C.M.B., Health Visitors' Certificate, Univ., Edin. W. J. Hatton, M.R.C.V.S. (part time), Veterinary Inspector, 14 (2) (a) Laboratory Facilities. The Pathologist at the Royal Hospital, Richmond, undertakes the Bacteriological examinations required by the Council. During the year 479 examinations were made and a detailed list is shown on page G4. Samples of Certified Milk are taken on instructions from the Ministry of Health and are examined at the National Institute for Dairying Research, Reading. Chemical and Bacteriological examinations are also made frequently of samples of water taken from the various supplies in the Borough. Local and General Adoptive Acts, Bye-Laws and Regulations. The following is a list of the Adoptive Acts in force in the district:— Infectious Disease Notification Act 1889 Infectious Disease Prevention Act 1890 Public Health Acts Amendment Act 1890 Private Street Works Act 1892 Public Libraries Act 1893 Local Government Act 1894 Public Health Acts Amendment Act (part of) 1907 Notification of Births Act 1914 The following is a list of the Bye-laws or Regulations in force in the district:— 1. Bye-laws as to keeping water closet supplied with sufficient water for flushing. 2. Bye-laws with respect to nuisances (limiting the time for removal of offensive matter through the streets). 3. Regulations as to Glanders or Farcy. 4. ,, ,, Dairies, Cowsheds and Milkshops. 15 5. Bye-laws as to Slaughterhouses. 6. ,, „ New Streets and Buildings. 7. „ „ Pleasure Grounds. 8. ,, „ Allotments. 9. ,, ,, Locomotive Act, 1898. 10. Bye-laws under Good Rule and Government of the Borough. 11. Bye-laws with respect to occupation of basement sleeping rooms, Section 18 (7) H. & T.P. Act, 1925. 12. Bye-laws as to Fish Frying, 1920. 13. Bye-laws as to Tents, Vans, Sheds, etc., 1920. 14. Bye-laws as to Houses Let in Lodgings. (b) Ambulance Facilities. The Joint Isolation Hospital Committee have two ambulances which remove infectious cases to the Hospital. The Richmond Council has a motor ambulance kept at the Fire Station, for use in accidents and private cases. During the year this ambulance was used 793 times and the mileage covered was 2,839. (c) Nursing in the Home. The local Queen's District Nursing Association through its two nurses performs excellent work in nursing patients in their own homes. The Kew and Kew Gardens District Nursing Association (with one nurse) performs a similar service in Kew and St. Luke's parishes. The Richmond Council makes grants towards the Queen's District and the Kew Nursing Associations and in return cases of illness in children under five years of age receive nursing assistance. During the year the total number of patients attended by the District Nurses was 75 and the number of visits paid was 1,175. The Nurse employed by the Kew,and Kew Gardens Association attended 187 cases (Medical 137, Surgical 44, Maternity 6) and paid 5,501 visits, 16 Infectious Disease. The District Nurses referred to above will also attend cases of minor infectious illness such as Measles if the necessity arises. Clinics and Treatment Centres. Address. By whom provided. Minor Ailments Clinic Windham Road, Richmond. For Elementary School Children Education Committee. Dental Clinic Ditto Ditto. (10 half-davs per fortnight). Ditto. Do. do Eye Clinic Ante-Natal Clinic Ditto Ditto Ditto 1 hour weekly. (1 session per fortnight). (1 session per fortnight). M. and C. W Committee. Education Committee. M. and C.W. Committee. Tonsils and Adenoids Ringworm (X-rays) Richmond Royal Hospital. Mr. G. G. Blake, 10, Onslow Rd., Richmond. When required. By arrangement with Education Committee. Education Committee. Maternity and Child Welfare Treatment Tuberculosis Treatment.. Richmond Royal Hospital. Surbiton Hill. Once weekly. Twice weekly. By arrangement with M. & C. W. Committee. Countv Council. School Clinics. The School Clinics include Minor Ailments Clinic, Eye Clinic and Dental Clinic, while Tonsils and Adenoids are dealt with at the Richmond Royal Hospital, and Ringworm (by means of the X-rays) by Mr. G. G. Blake, M.I.E.E., F.Inst.P. The Minor Ailment Clinic is held every morning, and during the year 952 children have made 4,201 attendances. 17 The Eye Clinic is held once a fortnight by Mr, Blair. who prescribes glasses for those children requiring them. The glasses are obtained from a Richmond optician at a contract price; 139 children were treated during the year. The School Dental Clinic is held 10 times a fortnight, and 1,297 children were treated during the year. Hospitals. 1. Isolation Hospital. Richmond sends its Infectious cases to the Mogden Isolation Hospital, which is managed by a Joint Hospital Committee, comprised of members of the Richmond and Heston and Isleworth Councils. The Hospital is in the Borough of Isleworth (Middlesex). There is accommodation for 45 patients mainly Scarlet Fever and Diphtheria cases, but provision can usually be made for cases of Enteric Fever. Toward the end of the year arrangements were made whereby the four Isolation Hospitals. viz., Twickenham, Hampton, Mogden and Staines, were to be available for cases anywhere in the proposed combined district. Consequently some of the cases of Infectious Disease in this Borough were sent to the Twickenham and Staines Isolation Hospitals. During the year under review many conferences have taken place between representatives of Boroughs and Districts in South West Middlesex with a view to the establishment of a Joint Hospital Board for the whole area. As Richmond had been for so many years a partner with Heston and Isleworth in the Mogden Hospital it was decided to become if possible, one of the constituent authorities of the Joint Board. Application has been made for the formation of the Board and it is hoped that by 1935 it will be functioning. The areas in the proposed Board are the Boroughs of Twickenham, Heston and Isleworth and Richmond, and the Districts of Hampton, Hampton Wick, Sunbury and Teddington. 18 2. Smallpox. Arrangements have been made with the Surrey County Council whereby cases of Smallpox occurring in the Borough will be admitted to the Smallpox Hospital at Clandon. 3. Tuberculosis. Patients seen by the County Tuberculosis Officer and found to be suitable for Hospital treatment are sent to Hospitals and Sanatoria. The Surrey County Council have a Sanatorium at Milford, near Godalming, for the reception of Tubercular cases from all parts of the County. 4. Children. The Richmond Royal Hospital has a special Children's Department one day a week. Children can be sent from the Council's Maternity and Child Welfare Centres, and are treated as In or Out Patients according to condition. The Richmond Council make a grant towards this Department. 5. Other Hospitals. The Royal Hospital, Richmond, is a General Hospital and provides for Medical, Surgical, Ophthalmic and Dental cases from Richmond and the neighbouring towns and districts in the Thames Valley. The Grove Road Infirmary, formerly under the Guardians, is now under the control of the Surrey County Council. 19 MOGDEN HOSPITAL. ADMISSIONS CLASSIFIED. Richmond. Richmond Union. Heston and Isleworth. Hounslow Carrison. Brentford Union. Hospital Staff. TOTALS. Scarlet Lever Diphtheria Enteric Fever Other Diseases Total Scarlet Fever Diphtheria Enteric Fever Other Diseases Total Scarlet Fever | Diphtheria Enteric Fever Other Diseases Total. Scarlet Fever Diphtheria Enteric Fever Other Diseases Total. Scarlet Fever Diphtheria Enteric Fever Other Diseases Total. Scarlet Fever Diphtheria Enteric Fever Other Diseases Total. Scarlet Fever Diphtheria Enteric Fever Other Diseases Total. 1933 109 58 ... 5 172 1 ... ... ... 1 253 46 1 20 320 1 ... ... ... 1 10 ... ... 1 11 1 ... ... ... 1 375 104 1 26 506 20 3. (i) Midwifery and Maternity Service. The only development in these services during the year was occasioned by the inclusion of part of Ham in the Borough. Previous to April 1st, 1933, the Maternity and Child Welfare work in Ham was controlled by the Surrey County Council. A Maternity Centre was held at Petersham twice monthly. This was staffed by a Medical Officer and Health Visitor from the County who had the help of several voluntary workers. For some years there has been an arrangement whereby Petersham mothers and children could attend this Welfare Centre and one of the Richmond Health Visitors attended at each session. When the amalgamation took place Richmond became the Maternity and Child Welfare authority for that part of Ham taken over and arrangements were made to carry on the Centre as before in the same building. Dr. Margaret Cryer, who had been appointed Medical Officer for the Ante-Natal Clinic was appointed as Medical Officer for the Ham and Petersham Clinic. The ladies who attended as voluntary workers have kindly remained to assist and 1 am indebted to Mrs. Field, Mrs. Daniels, Mrs. Soimenow, and Mrs. Hughes for their valuable assistance. The Richmond Welfare Centre at Windham Road continues to be held on three afternoons a week. I have again to express my thanks to the voluntary workers who render valuable assistance week by week. They include Mrs. Johnstone and Mrs. Govett (who are co-opted members on the Maternity and Child Welfare Committee), Mrs. Wheeler, Mrs. Brebner, Miss Reid, Mrs. Hammond, Mrs. Coleman, Mrs. Smith and Mrs. Bishop. During the year the attendances at the Centre were:— Mothers 6,324 Children 8,465 Average per session 42.7 „ „ 57.2 The Medical Officer of Health held 2,748 consultations during the year. 21 The Health Visitors visit at the homes, and during the year under review, 377 first visits were made, and 2,675 re-visits. From April 1st to the end of the year the number of mothers and children who attended the Ham and Petersham Clinic were as follows:— Mothers 302 Average per session 16.8 Children 445 „ ,, 24.6 Number of Consultations held by the Medical Officer 263. Ante-Natal Work. An Ante-Natal Clinic is held twice a month (2nd and 4th Wednesday afternoons) at which expectant mothers can attend and receive advice. The figures for the year 1933 are:— Number attended,101. Total attendances, 351. Midwives and doctors have been advised of any abnormalities and the mothers also advised re diet, etc. Many have received Dental treatment as a result of attending the Ante-Natal Clinic. Dental Clinic. Arrangements have been made for Dental work in connection with the Maternity and Child Welfare Centre. A Dental Clinic is held once a week and Miss E. Russell, L.D.S. (Eng.), the School Dental Surgeon, attends for the treatment of nursing and expectant mothers and of children under 5 years of age. Anæsthetics are given by the Medical Officer of Health and artificial dentures supplied at prices similar to those charged in connection with the National Health Insurance Scheme. During the year 1933, 35 sessions have been held, including 16 for the administration of anaesthetics. One hundred and fifty-eight patients were treated and made 289 attendances. 22 The work done was as follows:— Extractions of permanent teeth 317 ,, temporary ,, 308 Filling of permanent teeth 13 „ „ temporary „ 4 Other operations chiefly in connection with provision of dentures 27 Dentures supplied 12 Number of anæthetics given 150 (ii) Institutional Provision for Mothers or Children. There is a Home (supported by voluntary effort) for unmarried mothers and illegitimate children. No arrangements are made for confinements to take place there. By arrangements with the Surrey County Council unmarried mothers and their children can be sent to a Home at Epsom if beds are available. (iii) Health Visitors. There are three Health Visitors employed as such half-time. The rest of their work is as School Nurses. With the enlargement of the Borough some re-arrangement of districts was required, and the Health Visitor who takes the southern portion of the Borough (including Ham and Petersham) attends the Welfare Centre at Petersham twice monthly. (iv) Infant Life Protection (under part 1 of the Children Act, 1908, as amended by the Children and Young Persons Act, 1932). The Maternity and Child Welfare Work also includes the supervision of Foster Children, a work formerly in the hands of the Guardians. All persons taking children for gain require to be registered and their homes are visited by the Health Visitors 23 The children come under this Act until they are nine years of age, and of course, the Nurses pay more frequent visits when the children are below school age. 249 visits were paid to Foster Children by the Nurses in 1933. 4. Nursing Homes Registration Act, 1927. The Surrey County Council are the supervising Authority for Registration of these Homes. After registration is completed the delegation of all other powers (inspection, etc.) are carried out by the Medical Officer of Health of the Borough. The County Medical Officer consults me with regard to premises when registration is asked for. The County Council have issued Bye-laws with regard to Nursing Homes. The number of Homes in the Borough during the year was 10 of which 8 take Maternity cases. Inspections have been made and no contraventions of the Bye-laws have been found. Sanitary Circumstances of Area. Water. The Borough receives its water from two sources (1) from Wells situated in the area and (2) from the Metropolitan Water Board. The local wells are of two kinds (1) a deep well in the chalk and (2) five wells near the river. The water from these latter wells is chlorinated by an automatic process. Even before chlorination analysis shows that the water is a good one, but after chlorination the analyst's report invariably shows a practically sterile water, and one excellent for the purpose of a public supply. Drainage and. Sewerage. Practically all houses in the Borough are drained into the sewers. The construction of drains for new buildings is supervised 24 by the Borough Surveyor and his staff, after plans for the erection of the new buildings have been approved by the Highways Committee and the Council. The reconstruction or repair of drains is supervised by the Public Health Department, and details of the house drainage work supervised by the Sanitary Inspector will be found below. Sewerage. The Richmond Main Sewerage Board formed in 1887, of which the constituent Authorities are the Richmond and Barnes Corporations, deals with the sewage from the Boroughs of Richmond and Barnes. The Board's works are situated alongside the River Thames in the Parish of Mortlake. The sewage of the Borough is conveyed by numerous collecting sewers into a main outfall sewer. The town was partially re-sewered in 1898. The separate system was introduced many years ago and surface water sewers are now laid along most of the streets within the Borough. Treatment of Sewage. The method of sewage disposal at the Works is that of precipitation, and through bacterial filter beds, the effluent passing nto the Thames. Closet Accommodation. Water closet accommodation is general throughout the Borough. 25 Scavenging. The house refuse is collected at least once weekly, but in most districts a bi-weekly collection is maintained. The refuse is taken to the destructor at Barnes and there destroyed by burning. Recently the destructor has been much improved and consequently the plant is able to deal more efficiently with larger quantities of refuse. Schools. The premises of all schools, elementary and secondary, are regularly inspected. The Medical Officer of Health is also School Medical Officer, so that there is no difficulty in dealing with matters relating to the health of the scholars, nor in dealing with infectious disease. No schools were closed during the year. 26 SANITARY INSPECTION OF THE AREA. Report of Chief Sanitary Inspector. In compliance with Article 19 of the Sanitary Officers Order, 1926, made by the Minister of Health, I have the honour to submit the following tabulated particulars upon the work carried out by the Sanitary Staff during the year 1933 in connection with the administration of the numerous Acts of Parliament and Bye-Laws in force within the district. Whilst the functions and duties of the Sanitary Staff are numerous as shown by the work set out in the following tabular statements, it can be said that all the demands made upon it closely affect and concern the well being of the community in the application of those social reforms which make for the common good. The work accomplished during the year in the inspection and condemnation of the first batch of slums consisting of 106 houses and the consequent labours involved in the numerous functions and duties in the preparations made for the re-housing of the displaced tenants—nearly 400 in number —have entailed much extra work upon the whole staff. In addition to the work involved in slum clearance, good progress has been made in the inspection of many unsatisfactory premises found to be let out into tenements and which were the cause of many complaints arising from unsuitable sanitary conditions, etc., also the inspection of basement properties occupied as cellar dwellings and underground rooms used as sleeping rooms in contravention of the Statutes. The new byelaws and regulations governing the use of such premises and giving greater power to control such premises came into force in May. 20 premises were the subject of special reports to the Health Committee followed by closure. The work done is set out more fully in the section of this report dealing with Housing. 27 The continued shortage of housing accommodation emphasises the need for maintaining existing houses in an efficient state of repair. 942 houses were inspected for housing defects either under the Public Health or the Housing Acts. Details of the inspections made and improvements effected as a result of such surveys are set out in the following summary. Inspections. The total number of inspections made during the year was 6,229. On 545 of the premises visited nuisances to the number of 2,863 were discovered, and in dealing with the sanitary defects from which they arose 330 "intimation" or "preliminary" notices and 37 statutory notices were served. The number of letters written with regard to the abatement of nuisances, etc., was 186. At the end of the year 1,550 of the defects discovered had been abated, the work of remedying 1,209 was in hand, and the remaining 104 were outstanding. In order to ascertain that the sanitary defects were being properly remedied 1,404 visits were paid to the respective premises. The number of inspections made under the Housing and Town Planning Act and particulars recorded was 381, and the number of sanitary defects remedied and improvements made under this heading was 1,880. The following list shows the number of routine inspections and visits made:— Inspections During 1933. Houses inspected and particulars recorded (H.T.P. Acts) 381 Houses visited (P.H. Acts) 586 Re-visits to houses and other premises 698 Miscellaneous visits 1,322 Visits to works in progress 706 „ factories 20 „ workshops, bakehouses, etc. 151 28 Visits to outworkers' premises 6 „ workplaces, tearooms, etc. 122 „ dairies, cowsheds and milltshops 81 „ ice cream vendors 9 „ food stores 72 „ slaughter house 73 ,, fried fish shops 22 „ greengrocers' premises 77 ,, stables 110 „ piggeries 1 „ public conveniences 159 ,, petrol stores 169 „ employment agencies 10 ,, school premises 14 ,, re infectious diseases 171 Inspections after infectious diseases 174 Smoke observations 58 Special visits re Shops Acts 212 Visits re Destructive Insects and Pests Acts 10 Visits under Rats and Mice Destruction Act 244 Visits to Corporation dwellings 492 Samples of "Certified Milk" sent for Analysis 19 Interviews re abatement of nuisances, &c. 60 Total visits made 6,229 Rent Restriction Act. Number of certificates issued certifying premises not in a reasonable state of repair 2 Shop Hours Acts. Number of shops on register at end of year 980 „ new additions to register 4 „ changes of occupancy notified 4 Contraventions:— Half-holiday notices not exhibited 2 Serving of customers after closing hours (warned) 2 29 SANITARY IMPROVEMENTS. Water Supply. Drinking-water cisterns repaired, cleansed or covered 50 Water fittings repaired or renewed 10 Taps provided direct from rising main 5 Water Closets. New pans fixed 48 Pans cleansed or repaired 26 Walls, roofs, &c., repaired 93 Flushing cisterns repaired and renewed 43 Water supply re-instated or provided 9 Foul woodwork around closets removed 4 W.C.'s lighted and ventilated 14 Brickwork repaired and re-pointed 21 Seats repaired and renewed 25 Soil Pipes and Ventilating Pipes. Repaired, renewed or ventilated 35 Drainage. System re-constructed 19 Repaired or cleansed 91 Manholes repaired or new provided 28 Ventilating pipes repaired or renewed 35 Drains intercepted from sewer 12 Want of drainage 55 Sub-soil drainage renewed — Gullies renewed or provided 65 Gratings, dishing or curbing renewed 9 Fresh air inlets renewed 24 Dustbins. New provided 65 Yard Paving. Repaired 72 Newly paved 12 30 Sinks, &c. New provided 32 New waste pipes provided 46 Waste pipes repaired, trapped or ventilated 38 Insanitary wall surfaces around sinks cemented — Dampness. Roofs repaired 74 Gutters and downspouts repaired and renewed 105 Damp course fixed 56 External walls repaired and pointed 44 Pointing to reveals renewed 48 Floor cavities ventilated 4 Site of house concreted 24 Wall ventilators to floor cavities renewed 39 General Repairs. Walls and ceilings repaired 262 Floors repaired 61 Doors, windows, sills, &c., repaired 193 Window fastenings renewed 62 Windows made to open 3 Stoves repaired and renewed 100 Coppers repaired or renewed 36 Rooms cleansed and re-decorated 174 Verminous rooms cleansed 48 Passages, staircases cleansed 29 Sash cords renewed 91 Larders repaired 15 Outbuildings repaired or renewed 10 Coal cupboards repaired 10 Obstructive buildings removed 15 Staircases repaired 18 Accumulations of refuse removed 54 Rooms ventilated 50 Defective and smoky flues remedied 17 31 Dirty floors and bedding cleansed 27 Basement sleeping rooms unfit for use, closed 8 Rat infested premises (remedied) 35 Nuisances from the keeping of fowls, &c., remedied 2 Overcrowding abated 3 Miscellaneous. Nuisances remedied 200 Stables. Manure accumulations removed 15 Manure receptacles provided or repaired 2 Stables repaired, cleansed, &c. 3 Yards repaved, cleansed, &c. 2 Urinals. Reconstructed, and flushing apparatus provided — Repaired, &c. 23 Flushing tanks repaired 5 Dairies. Accumulations removed — Premises repaired — Premises cleansed — Gullies cleansed — Other defects 1 Greengrocers' Premises. Accumulations removed 10 Nuisance from fowls or other animals — Yards repaved — Yards cleaned 5 Other defects 14 Testing of Drains and Sanitary Fittings. Application of smoke test 82 „ water test (new work) 76 „ chemical test 3 32 Drainage systems opened out for examination, on written complaint 14 Sewers relaid by Corporation on private property — Service of Notices. The following table shows the particulars of the notices served:— Informal Notices 330 Statutory or Formal Notices:— Sec. 94, Public Health Act, 1875 (To abate nuisances 7 Sec. 49, Public Health Act, 1875 (To remove filth) 5 Sec. 41, Public Health Act, 1875 (To redrain premises) 2 Sec. 17, Housing Act, 1930 (To repair houses) 12 Sec. 36, Public Health Act, 1875 (To provide dustbin) 9 Sec. 36, Public Health Act, 1875 (To provide sufficient water closet) 2 367 Number of interviews with owners of Property, Builders, etc.. re Sanitary Improvements 247 Defective Drainage. 19 drainage systems were completely reconstructed and 91 repaired under the supervision of this department. 14 drainage systems were opened out and examined under Section 41 of the Public Heath Act, 1875. The statutory notices served upon four owners of a block of houses to reconstruct the defective combined and branch drains and sanitary fittings were not complied with. As the various owners could not agree as to the execution of the work, the Health Committee instructed me to invite estimates from local builders for the execution of the works in default, The lowest tender was 33 accepted, viz., £122 5s. 0d., and the works duly carried out. The costs were subsequently apportioned between the respective owners and recovered from them in a summary manner as provided by the Public Health Acts. Disinfection of Premises. Reason. Houses. Rooms. Number of Houses Bedding removed. Infectious Fevers 181 197 183 Tuberculosis 33 48 31 Other Diseases 34 44 36 Vermin, &c. 70 109 31 318 398 281 Costs recovered for the disinfection of rooms reported to be in a verminous condition amounted to £21 19s. 0d. Meat and Food Inspection. The operation of the Public Health (Meat) Regulations, which came into force in April, 1925, has necessitated considerably increased activity by the staff in the inspection and supervision of meat and food supplies throughout the district. Slaughterhouses. There is one "registered" slaughterhouse only and this is situated at Ham. 73 visits of inspections were made during the year. The number of animals inspected after slaughter were as follows:— 1 calf, 22 beasts, 132 sheep, 41 pigs. All carcases found to be in a sound condition, 34 Seven livers and lungs principally affected with "fluke" disease and cirrhosis were surrendered for destruction. Four hundred and thirty visits have been made to the Meat Shops or Stores and other premises where food is prepared or exposed for sale. Inspection of Meat and other Foods. The following is a list of the articles of unsound food surrendered and condemned:— 4 ox livers, 1 sheep liver, 1 pig's liver, 1 pair of lungs, 43 lbs. English mutton. Bakehouses. The number of bakehouses on the register at the end of the year was 15, five of these being underground. Frequent inspection of the bakehouses have been made during the year. Dairies, Cowsheds and Milkshops. There are two cow-keepers and 28 dairymen and purveyors of milk registered under the Dairies, Cowsheds and Milkshops Orders within the Borough. The dairies, cowsheds and milkshops have been kept under supervision during the year and were generally found to be kept in a satisfactory condition. Monthly inspections are made of all the milch cows in the Borough by the Veterinary Surgeon, Mr. J. H. Hatton, M.R.C.V.S. who reports to the Executive Committee monthly. Inspections of all milch cows are also periodically made by the Veterinary Inspectors of the Surrey County Council, 35 Factory and Workshops Acts, 1901 and 1907. The total number of Factories, Workshops and Workplaces on the register is 142. The businesses carried on at the respective premises are as follows:— Bakehouses 15 Dressmakers and Milliners 16 Tailors 6 Bootmakers 5 Laundries 4 Builders' workshops 4 Restaurant kitchens 67 Motor engineers 2 Shoeing forges 2 Wig making 1 Coach building 1 Furriers 2 Other trades 17 142 These premises have been visited, and as a result of action taken by the department, the following defective conditions have been remedied:— Want of cleanliness 8 Walls, floors, gutters and roofs repaired 3 Sanitary accommodation Insufficient — Not separate for sexes - Unsuitable or defective 5 Foul sanitary coveniences 6 Accumulations removed 3 Other nuisances and defects remedied 13 Defective dustbins 2 40 36 Stable Premises. There are 36 premises on the register, and these have all been systematically inspected during the year, strict attention being given to the provision of efficient receptacles for the storage of manure, and the prompt and frequent removal of all manure from the premises in order to minimise the risk of nuisance from flies. Rats and Mice Destruction Act. The provisions of this Act have been enforced during the year. Forty complaints were received, and in thirty-five instances ''preliminary" intimations have been served upon the owners and occupiers of premisess to eradicate "rodents," and render the premises rat proof. PETROLEUM ACTS, 1871-1926. All premises under licence have been systematically inspected to see that the special conditions embodied in the respective licences were being complied with. Total number of visits made during the year 169 Number of applications for licences during the year 58 Number of new licences granted and issued during the year 2 Number of persons on the register licensed to keep Petroleum 53 The licences cover two different methods of storage, namely Bulk storage in underground tanks with pumps (39) Storage capacity, 62,150 gallons Stores for 2-gallon metal cans either in brick or metal bins (20) Storage capacity, 2,218 gallons. Amount of fees collected in respect of the licences issued during the year:—£37 7s. 0d. The quantity of carbide of calcium which may be kept in licensed stores is 380 pounds. 37 Rag Flock Acts, 1911-1928. There are no premises in the Borough on which rag flock is manufactured, used or sold. Housing Statistics for the Year. 1932. Number of New Houses erected during the year:— (a) Total (including numbers given separately) under (b) houses, 44 flats, 125 (1) By the Local Authority Nil (2) By other Local Authorities Nil (3) By other bodies and persons houses, 44 flats, 125 (b) With State Assistance under the Housing Acts:— (1) By the Local Authority:— (a) For the purpose of Part 2 of the Act of 1925 Nil (b) For the purpose of Part 3 of the Act of 1925 Nil (c) For other purposes Nil (2) By other bodies or persons Nil 1. Inspection of Dwelling-houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 942 (b) Number of Inspections made for the purpose 942 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulation, 1925 381 (b) Number of Inspections made for the purpose 381 38 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 106 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 702 2. Remedy of Defects during the year without service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 665 3. Action under Statutory Powers during the year:— A.—Proceedings under sections 17, 18 and 23 of the Housing Act, 1930:— (l) Number of dwelling houses in respect of which notices were served requiring repairs 12 (2) Number of dwelling-houses which were rendered fit after service of formal notice:— (a) By owners 12 (b) By Local Authority in default of owners Nil B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 427 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 25 (b) By Local Authority in default of owners Nil 39 C.—Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which demolition orders were made. 20 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil D.— Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 9 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been made fit 4 Three, hundred and seventy-four complaints were received with reference to the following matters, viz.: — Defective drains and sanitary fittings 58 Defective water storage tanks and fittings 11 Absence of, or defective dustbins ... 34 Insanitary condition of houses 2 Insanitary condition of passage-v/ays, etc. - Nuisance from dampness 14 Nuisance from general defects, etc. 50 Nuisance from keeping of animals... 2 Nuisance from rats and mice 40 Smoke nuisances 13 Nuisances from overcrowding 7 Verminous premises ... 34 Accumulation of refuse or manure... 30 Miscellaneous 79 Prompt investigations of complaints were made and suitable action taken where it was found necessary. (Signed) George Laws, m.r.san.i., f.s.i.a., Chief Sanitary Inspector. 40 HOUSING. Slum Clearance. Of the many and varied duties which a Local Authority is called upon to perform for the protection and maintenance of the health of the community, the proper housing of the working classes is one of the most important. The general provisions of the Housing (1930) Act are now too well known to need reiteration. Its object is to end the slum and prevent future slums. The measures to be applied are "curative " and "preventive." There is no legal definition of what constitutes a slum, but a good definition of a slum would be "an area which contains a whole set of circumstances comprising conditions which are injurious to health, or a cluster of houses, or a house in which it is not possible to live a healthy life under proper sanitary conditions." Two of the most important factors in the creation of slums are "bad housing" and "overcrowding." The Act provides for three lines of attack:— (1) by Clearance Areas, (2) Improvement Areas and (3) Individual defective houses. Experience has shown that concentration on "Slum Clearance" is the most sound method, it is less costly, gives more satisfaction and provides for better housing accommodation for the largest number of people. The first provisional five years' programme was submitted to the Ministry of Health in December, 1930 and consisted of a Schedule of 104 dwellings, occupied by 415 persons of the working classes, for action under "Slum Clearance," or demolition if individual unfit houses. 41 Following upon the acceptance of the schedule of unfit properties, a detailed inspection was made. The making of a careful and detailed survey by the Sanitary and Housing Officer is a matter of the first importance as it is largely on his report that the Medical Officer of Health must frame his decision. The properties inspected were as follows:— l/l0, Long's Cottages Dealt with as a Clearance Area. 1/4, Castle Row 11/16, West Sheen Vale l/l8, Botten's Place 6/12, Worple Way 11 11 11 1/22, Benn's Cottages 11 11 11 1/8, Union Court 11 11 11 These properties were the subject of official representations in pursuance of section 51 (2) of the Housing Act, 1930, as unfit for human habitation. The Health Committee considered that the most satisfactory way of dealing with the properties in the four areas was to demolish them and the Council decided to declare the areas as clearance areas. Objections were lodged by the owners of 1/10, Long's Cottages and 2/18, Botten's Place, and on January 30th and 31st, 1933, Mr. H. A. Chapman, F.R.I.B.A., Inspector of the Ministry of Health, attended at the Town Hall to hear the objections of the owners of the properties concerned. Some of the owners engaged Counsel and called other expert evidence on their behalf. After a very full two days' enquiry the properties were inspected by the Ministry of Health Inspector, accompanied by one representative of each owner and the Chief Sanitary Inspector. Subsequently each of the Orders were "confirmed." 42 The following 12 properties were also inspected and fully reported upon, viz.:- Ormond Cottage, These premises consisting of 12 dwellings all occupied by persons of the working classes, were found to be unfit for human habitation and not capable at reasonable expense of being rendered so fit. After notification had been made by the Chief Sanitary Inspector to each of the owners concerned the premises were voluntarily demolished without the necessity of demolition orders being made by the Council. These displaced tenants found other accommodation on their own initiative. 107, Mortlake Road, l/9, Caroline Place, and 19, Parkshot. The remainder of the houses included in the first quinquennial programme were also inspected and reported upon as follows:— 18/l 8a, Parkshot. 1/2, Chapel Cottages. l/7, Sandpits Cottages. 18/22, Worple Way. 17, 19, 21, Worple Way. 15, 16, 17, 18, 19, The Square. 1, 2, 3, Day's Cottages. All these premises which were dwellings suitable for occupation by persons of the working classes were found to be unfit for human habitation and not capable of being rendered so fit at reasonable expense. The Corporation were owners of Nos. 17, Worple Way 15/19, The Square and l/3, Day's Cottages, having purchased these properties several years ago for private street improvement purposes. 43 The owners of the other properties herein mentioned were invited to attend the Meeting of the Health Committee, but accepted the decision of the Council to demolish as provided by the Act. All the condemned properties were not dealt with at the same time. "Representations" were made with regard to the Botten's Place and VVorple Way Clearance Areas as the first part of the whole scheme. In May, the Benn's Cottages and Union Court properties were represented and in the Autumn the representations regarding the individual unfit houses were made. As land was available at Ham the first of the new buildings were erected there, followed by others in Braddon Road (Richmond). As these are completed, the houses in the Botten's Place and Worple Way Areas will be cleared and the tenants removed to the new dwellings by easy stages. Good progress has been made during the year in the erection of 102 new houses to replace those demolished under Clearance Area Schemes and demolition of individual unfit houses. The following gives particulars of the houses already erected and occupied in connection with the first slum clearance scheme and those about to be erected and which it is expected will be finished during 1934. Particulars of Houses now erected to replace those demolished under First Slum Clearance Scheme. Types. Al. A2. A3. A4. Braddon Road, Richmond. 6 Flats @ 5/- per week — — 10 Houses @ 9/8 per week. Mead Road. Ham. — — 28 Houses @ 7/2 per week. — Cleves Road, Ham. — 6 Houses @ 5/10 per wk. 20 Houses @ 7/2 per week. — Back Lane. Ham. - 4 Houses @ 5/10 per wk. — - Total (68 Housses and 6 Flats). 6 10 48 10 These 74 Houses and Flats are now completed with the exception of six which will be finished by the middle of June. 44 To be constructed. Al. A2. A3. A4. Lovell Road, Richmond. — — 12 Houses @ 7/2 per week. — Botten's Place, Richmond, — 12 Flats @ 6/9 per wk. 4 Flats @ 8/4 per week. - Total (12 Houses and 16 Flats). — 12 16 — The Contract for the building of the 12 houses in Lovell Road has already been settled and tenders for the erection of the 16 Flats in Botten's Place have been invited. For the first time in the history of "housing of the working classes" the new Housing Act of 1930, though not free from ambiguity and pit falls, opens out the way to a higher and better standard of living by the provision of decent houses at rents which, the poorer section of the community can afford to pay. It puts into effect the past teachings of experience and the ideal of "every family a home—every child a chance." The human factor has been considered before "bricks and mortar" by the shape of grants for the number of persons "dehoused" instead of as hitherto on the number of houses built. It imposes the first duty of getting actual displaced tenants re-housed under better conditions thus giving a real chance to those families who have been victims of circumstance. Conditions creating New Slums. Whilst the work of abolishing the real slum is in progress, strong and energetic measures have been taken regarding the slums that are being manufactured from day to day. 45 Since the war, Local Authorities have had to concentrate upon the building of houses to meet shortage, but no effective measures have been taken to counteract the many evils that have arisen which were daily accentuating the growth of new slums. The evils I refer to are those caused by:— (a) Sub-letting—or the occupation by several families of one dwelling house—frequently causing acute overcrowding—sanitary defects and disrepair ; and (b) The use of underground sleeping rooms and cellar dwellings—frequently found to be dark, damp and unfit for habitation. Owing to the lack of good housing accommodation and the rents charged for decontrolled houses, many working class families have been compelled to live and sleep in one or two rooms, having to pay exorbitant rent for such inadequate accommodation. Overcrowding became rife and owing to the lack of provision of additional water supply, sinks, sanitary accommodation and facilities for the proper cooking and storage of food, harmonious relations between the respective families can rarely be preserved, quarrels frequently arise between tenants and sub-tenants, making life a burden, particularly for those unfortunate women who are endeavouring to rear young children and who have nothing more than one room at their disposal. A very careful and detailed survey was undertaken by the Chief Sanitary Inspector of several streets in the Richmond Hill Area, consisting of old basement houses. In almost every road, in the best residential part of the district, some of such houses had been sub-let, particularly those where the lease had only a few more years to run and which had been acquired for a small sum by persons residing outside the district. These properties had without any alteration or adaption been let off into tenements, the basement rooms frequently found to be dark and damp and to be illegally occupied as cellar dwellings. 46 In one of the best residential areas a 10 roomed house where the lease had only a few years to run, was acquired by a female property speculator from outside the Borough. Each of the 10 rooms was let out to 10 separate families, with an income of £6/10/0 per week. Suitable action was taken to stop their conditions and the house reverted to the original leaseholder. Up to the passing of the Housing Act the powers of a Local Authority to deal with these problems were very limited. This Act not only brought the powers to deal with Slum Clearance but encouraged Local Authorities to build further houses for the working classes at rents they could afford to pay, thus helping to solve the difficulties herein referred to. Following upon the reports of the Chief Sanitary Inspector, the Health Committee applied to the Ministry of Health for powers to make and enforce bye-laws to cope with the sub-letting problem and Section 6 of the principal Housing Act was put into operation for the establishment of bye-laws in the case of houses intended or used for occupation by the working classes. The principal powers contained in those bye-laws are as follows:— (1) The power of making and enforcing bye-laws under the Public Health Act, 1875, and the Public Health (London) Act, 1891, shall include the making and enforcing by local authorities of bye-laws in the case of houses intended or used for occupation by the working classes (a) for fixing and from time to time varying the number of persons who may occupy a house which is let in lodgings or occupied by members of more than one family, and for separation of the sexes therein; (b) for the registration and inspection of such houses; (c) for enforcing drainage and promoting cleanliness and ventilation of such houses; 47 (d) for requiring provision adequate for the use of and readily accessible to each family of— (i.) closet accommodation; (ii) water supply and washing accommodation; (iii) accommodation for the storage, preparation and cooking of food; and, where necessary, for securing separate accommodation as aforesaid for every part of such house which is occupied as a separate dwelling; (e) for the keeping in repair and adequate lighting if any common staircase in such houses; (f) for securing stability, and the prevention of and safety from fire; (g) for the cleansing and redecoration of the premises at stated times, and for the paving of the courts and courtyards; (h) for the provision of handrails, where necessary, for all staircases of such houses; (i) for securing the adequate lighting of every room in such houses; (j) as respects houses situate in the administrative county of London, for the taking of precautions in the case of infectious disease ; and any such byelaws. in addition to any other penalty, may prohibit the letting for occupation by members of more than one family of any such house unless the same are complied with, subject in the case of houses so let or occupied at the time when such byelaws come into force to the allowance of a reasonable time for the execution of any works necessary to comply therewith. These byelaws came into force in May last. 48 In addition, new and improved Regulations were asked for under Section 18 (1) of the Principal Housing Act, which provides for the making of a "Closing Order" in respect of any Underground Room which contravenes the Regulations made under this Section. The new Regulations were made and came into force on the 8th May, 1933. Section 18 (l) is as follows:— (1) A room habitually used as a sleeping place, the surface of the floor of which is more than three feet below the surface of the part of the street adjoining or nearest to the room, or more than three feet below the surface of any ground within nine feet of the room, shall for the purposes of this Part of this Act be deemed to be A HOUSE SO DANGEROUS OR INJURIOUS TO HEALTH AS TO BE unfit for human habitation, if the room either— (a) is not on an average at least seven feet in height from floor to ceiling; or (b) does not comply with such regulations as the local authority with the consent of the Minister may prescribe for securing the proper ventilation and lighting of such rooms, and the protection thereof against dampness, effluvia or exhalation. Provided that, if the local authority, after being required to do so by the Minister, fail to make such regulations, or such regulations as the Minister approves, the Minister may himself make them, and the regulations so made shall have effect as if they had been made by the local authority with the consent of the Minister. Prior to the operation of the 1930 Housing Act, Local Authorities have had no powers to close part of a house let off as a separate tenement and deemed to be unfit for human habitation, but under Section 20 of this Act a Local Authority may now deal with "part of a building" by the application of a "Closing Order" until such "part of a building" has been rendered fit for human habitation. 49 New Powers in Operation. A good deal of useful and effective work has been accomplished during the year in the operation of the Housing Statutes with the Regulations and Byelaws pertaining thereto. The following is a list of the premises reported upon in which the basements or cellars were let separately as dwellings and which were deemed to be unfit for human habitation :— Premises. Action Taken. 34, Cambrian Road. Closing Order made. Premises made fit 54, The Vineyard. ,, ,, ,, Still operative. 11, Church Road. „ „ ,, „ „ 37, Evelyn Road. ,, „ ,, ,, ,, work proceeding. 68, Friar's Stile Road. ,, ,, ,, Still operative. 2, Park Hill. „ „ „ „ „ At the undermentioned premises, the owners appeared before the Committee and gave an undertaking to carry out such works within a specified period as would render the premises fit for human habitation. The occupiers meanwhile vacated the premises. 63, Queen's Road. Reconditioned and made fit. 53, Church Road. „ ,, „ ,, 58, Friar's Stile Road. „ „ ,, ,. As a result of the action taken, permanent improvement in the letting and usage of the premises was established by the re-occupation of most of the basement in conjunction with rooms on the ground floor of the dwelling. Underground Rooms used as sleeping places found to contravene the Regulations and deemed to be unfit for human habitation were reported as follows :— 22, The Hermitage. (2 rooms). Closing Order still operative. 12, Pyrland Road. „ „ „ „ 28, Grosvenor Road. „ ,, ,, „ 50 At the undermentioned premises the owners gave an undertaking to carry out the necessary works within a specified period to render the rooms fit for human habitation, or to close same until rendered fit. 65, Queen's Road. Reconditioned and made fit. 23, Friars Stile Road ,, „ „ „ 7, Warrington Road ,, „ „ ,, 38, Jocelyn Road „ „ ,, „ 3, Warrington Road. ,, „ „ „ 7, Church Road ,, ,, ,, ,, 266, Kew Road. Room closed. This section of the Housing work which is being carried out systematically and effectively cannot help but have a beneficial effect, not only upon the health of the people occupying such premises, but also in improving the amenities of the district. Housing Inspections—Power of Local Anthority to require repair of insanitary houses. Systematic house to house inspections have been carried out during the year in accordance with the Housing Act and all dwellings occupied by the working classes, or of a type suitable for accupation by the working classes, found in any respect unfit for human habitation, have been subject of notice to repair or recondition same, when reported upon as being capable of repair at reasonable expense. 942 dwelling houses were inspected for housing defects (under the Public Health or Housing Acts) and 381 of such dwellings were examined and particulars recorded under the Housing Consolidated Regulations, 1925. Details of those properties dealt with for demolition under " Slum Clearance" and " individual unfit houses" have been given in the earlier part of this report. 51 Those premises found capable of repair at reasonable expense were dealt with by the service of a detailed specification of works of repair upon owners. This practice which has been systematically carried out for many years has been proved to be beneficial as the owners are in a position to obtain estimatess for the necessary repairs without delay. In addition, they know the full demands of the Local Authority and the standard of work required to render the house fit for human habitation. In very few instances only was it necessary to serve statutory or formal notices to get the work done. The Chief Sanitary Inspector when forwarding the preliminary notice and specification of works invites the owners to meet him on the property and settle any matter upon which the owner may require advice or guidance. Reasonable time is given for the execution of the work and in those cases where additional time is required by the owner owing to financial or other difficulties, the matter is reported to the Health Committee for a reasonable extension of time. Second Slum Clearance Programme and Housing Survey. In spite of the fact that the Local Authority submitted the first five years Housing Programme and Slum Clearance Scheme in December, 1930, we had hardly got to grips with the work when the Government decided to launch a further programme and Local Authorities instead of being allowed to carry out their first scheme, were compelled to amend their plans and housing programme by submitting a further slum clearance scheme in October, 1933. A further survey was called for and in addition to the 104 houses previously scheduled a second schedule consisting of 83 dwellings were included for survey and report under slum clearance or individual unfit houses. Pressure is being brought upon Local Authorities to carry out all works of slum clearance within the next five years and it is likely that the second schedule will be extended to include further properties. 52 PARTICULARS OF DWELLINGS ERECTED BY THE COUNCIL. Situation of Dwellings. Description. No. of house Weekly rent inclusive of rates. Manor Grove (built 1895-6). Housing Act, 1890. Part 3. (No Subsidy). Type A. Parlour, living room, scullery and four bedrooms 62 25 @ 11/7 27 (a), 11 /3 10 @ 10/10 Type D. Parlour, living room, scullery and 18 12 @ 10/11 three bedrooms 6 @ 10/6 Type B. Parlour, living room, scullery and two bedrooms 42 16 @ 9/8 16 @ 9/4 10 @ 8/11 Addition to rent if bathroom is provided— Types A. and D., 2/4. Type B. 3/-. Flats:—First Floor:— Type C. Living room, scullery and two bedrooms 6 7/5 Flats :—Ground Floor :— Type C. Living room, scullery and one bedroom 6 6/2 House and Shop Premises (No. 80) :— Shop, living room and scullery, parlour and three bedrooms — 21/7 per week. Tenant pays rates. North Sheen (built 1907-8). Housing Acts, 1890-1923. (No Subsidy). Living room, kitchenette (with bath) and three bedrooms 40 11/8 53 Situation of Dwellings. Description. No. of bouses. Weekly rent inclusive of rates. Victoria Place (built 1908-9). Housing Act, 1906. (No Subsidy). Flats—First Floor :— Type—. Living room (with lobby), scullery and two bedrooms ... 10 8/7 Flats— Ground Floor:— Type—. Living room (with lobby), scullery and two bedrooms ... 10 9/7 King's Farm Estate (built 1927-9). Housing Act, 1924 (with Special Conditions Subsidy). Type A. Parlour, living room, scullery and three bedrooms (with bathroom) 35 16/7 Type B. Living room, scullery and three bedrooms (with bathroom) 54 13/10 North Sheen (built 1924-5). Housing Acts, 1890-1923. (No Subsidy). Type B3. Parlour, living room, scullery and three bedrooms (with bathroom) 7 20/1 Type E. Living room, kitchenette and three bedrooms (with bathroom) 3 16/5 Selwvn Estate (built 1922). Housing Act, 1919 (with Treasury and Council Subsidy). Type B4. Parlour, living room, scullery and four bedrooms (with bathroom) 20 22/11 54 Situation of Dwellings. Description. No. No. of houses Weekly rent . inclusive of rates. Type B3. Parlour, living room, scullery and three bedrooms (with bathroom) 62 20/1 Type B3. * Ditto 4 20/1 Type A. Living room, scullery and three bedrooms (with bathroom) 10 16/10 Flats—First Floor :— Living room, scullery and two bedrooms (with bathroom) 38 13/1 Flats—Ground Floor :— Living room, scullery and two bedrooms (with bathroom) 38 13/1 *These four houses are £6 Subsidy Houses (Housing Act, 1923) built 1926. The remainder on the Selwyn Estate are Addison Scheme. 55 INSPECTION AND SUPERVISION OF FOOD. (A) Milk Supply. Most of the milk supplied in the district is brought in from country districts. There are, however, two dairy farmers who keep their own cows in the Borough. The Veterinary Inspector appointed by the Corporation inspects all cattle regularly and reports to the Executive Committee monthly. All Dairies and Cowsheds are frequently inspected. In 1923 the Milk (Special Designation) Order came into force by which milk is graded into four special classes :— (a) Certified Milk. (b) Grade A Tuberculin tested. (c) Grade A. (d) Pasteurised. Producers of Certified Milk receive their licenses direct from the Ministry of Health. County Councils and County Borough Councils are authorised to grant licences to producers to sell Milk as Grade A, and District Councils are authorised to grant licences to any person other than a producer to sell milk as Certified, Grade A and Pasteurised. The Ministry of Health have granted a licence to one firm in the Borough for the production of Certi'ied Milk. Other firms purchase this grade of milk and retail it under licence. The Ministry of Health have asked the Richmond Council to take samples of the Certified Milk sold in the Borough and have these analysed. Last year 20 such samples were taken and on analysis 13 were found to he up to the required standard. The Analysts employed (The National Institute of Research in Dairying, Reading) report direct to the Ministry on every analysis, 56 The Borough Council have granted licences to sell Certified Milk to 5 firms in the Borough (comprising 10 premises), Grade A Tuberculin Tested Milk to 4 firms (comprising 5 premises), Pasteurised Milk to 4 firms (comprising 1 1 premises), and Grade A Pasteurised Milk to one firm. They have also granted a Pasteurising Licence to one firm. (B) Meat. Meat has always been very thoroughly inspected in this Borough, so that very little change was necessary when the Public Health (Meat) Regulations, 1924, came into force on the first of April, 1925. By these Regulations notice of killing must be sent to the Medical Officer of Health. Up t<> April, 1933 there had been no slaughterhouse in the Borough for some time, but with the amalgamation of Ham there is now one slaughterhouse to come under supervision. Any meat surrendered or condemned is destroyed. If a large quantity, such as a whole carcass is to be dealt with, arrangements are made for it to be sent to a firm to boil it down. Smaller quantities are burnt at the destructor. During the nine months from April to December, 1933, the slaughterhouse was visited on 67 occasions and 196 carcases inspected. The following articles were surrendered :— 4 Ox livers. 1 Sheep liver. 1 Pig Liver. 1 Paii- Pig's lungs. Sale of Food and Drugs Acts (1875 to 1907). (C) The duties in connection with these Acts have been carried out in the Borough by the inspector acting under the County Council. The County Medical Officer of Health has kindly furnished the following particulars for 1933, 57 SURREY COUNTY COUNCIL. SALE OF FOOD AND DRUGS ACTS. Particulars of samples taken in the Borough of Richmond during the year ended December 31st, 1933 :— Articles- Analysed Adulterated or Deteriorated Prosecutions Convictions. Formal Informal Total Formal Informal Total Milk 44 44 ... ... ... ... ... Cream 1 1 2 ... ... ... ... ... Butter 2 ... 2 ... ... ... ... ... Meat 5 ... 5 ... ... ... ... ... Confectionery and Jam 1 4 5 ... 1 1 ... ... Sausages 1 ... 1 ... ... ... ... ... Whiskv 5 ... 5 1 ... 1 ... ... Other Articles 9 1 10 ... ... ... ... Totals 68 6 74 1 1 2 ... ... 58 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASES. Notifiable Diseases during the year. Disease Total Cases Notified. Cases Admitted to Hospital. Total Deaths. Cerebrospinal Meningitis 3 3 1 Diphtheria 64 64 9 Scarlet Fever 138 130 1 Puerperal Pyrexia 5 5 — Pneumonia (Primary) 22 17 3 Influenzal Pneumonia 8 5 2 Erysipelas 18 9 2 Chicken Pox 16 1 — Ophthalmia Neonatorum 1 — — Tuberculosis : (a) Respiratory (M). 25 19 10 (F.) 26 15 17 Total 51 34 27 (b) Non-Respiratory (M.) 6 4 1 (F) 8 5 2 Total 14 9 3 Diphtheria. During the year 64 cases of Diphtheria were notified as compared with 8 in 1932, 33 in 1931 and 155 in 1930. The cases occurred particularly in the months of May, October, November and December. Many of the cases were Nasal Diphtherias found by swabbing contacts when a previous case had been notified. These cases were usually not ill but had they not been discovered and isolated, they would probably have given rise to further cases of the disease. There were unfortunately nine deaths from the disease during the year. Two of these deaths occurred in the case of Richmond residents who contracted the disease in London Hospitals. In some of the other cases where death occured, there seems to have been delay in calling in a Medical Man. It cannot 59 be too well known that patients with this disease, if treated properly within the first twenty-four hours will almost certainly recover. Every hour of delay beyond this means increased danger to the life of the patient. Antitoxin for the treatment of the disease is kept by various chemists in the Borough and is immediately available for any medical practitioner. The cost of serum so supplied during the year was £4 12s. 6d. In view of the prevalence of this disease during the year and the high mortality it will be opportune to mention that it is possible to test people as to whether they are immune to Diphtheria or not and (what is and perhaps more important) it is possible by a series of injections of a Toxoid to immunise those susceptible against the disease. I have reported to the Health Committee on this matter and append a copy of the Report. THE SCHICK TEST AND IMMUNISATION AGAINST DIPHTHERIA. The Schick test depends on the local irritant action of Diphtheria Toxin if it is injected into the skin of a susceptible person. Some people are naturally immune to Diphtheria, i.e., they will not contract the disease. The Schick test is therefore used to determine the immunity of a child or adult, a negative reaction indicating that the person is adequately protected against Dipheheria and does not require any prophylactic immunisation. Also when immunisation has been practised the Schick test affords a means of estimating its success. The injection is made into the skin of the forearm and if the rtaction is positive an area of redness will appear in from 24— 48 hours. To obtain reliable data however, the test should be 60 done by one with much experience of it and it takes some time to acquire the necessary experience both in the injection and in the estimation of the result. The number of immune persons varies according to age. Children under 6 months of age are generally immune. As the child grows this immunity is lost and it is found that a large proportion of children are susceptible. As the person gets towards adult life the immunity increases. It may be interesting to give a summary of a series of Schick tests at various ages. Age. No. tested. Positive Negative No. Percentage. No. Percentage. Under 5 years 781 744 95% 37 5% Up to 6 years 1263 1180 93% 83 7% From 6 to 10 years 2054 1646 80.2% 408 19.8% From 11 years to adult life 507 33!) 66.9% 168 33.1% Out of these, 4,605 tested 3,909 were found to be susceptible or 84%. In Richmond there will be roughly 5,000 children under school-leaving age. With the same percentage as in the group mentioned 4,200 of these children would be susceptible and could be immunised. Immunisation. It has been found that immunity can be given to persons who are found by the Schick test to be susceptible. There are two methods of immunisation possible (1) the injection of Antitoxin Serum (the same serum as is used in the actual treatment of the disease) and (2) inoculation with a toxoid-antitoxin mixture. The first of these confers merely a passive immunity of short duration, whereas the latter will give an active immunity which is likely to last for some years—if not for life. But this latter method takes time both in its application and in its working so that it is not suitable for dealing with contacts, with the idea of preventing them getting the disease. It is, however, suitable for the purpose of immunising all susceptibles, just in the same 61 way as vaccination is suitable for protection against Smallpox. Statistics show that where immunisation is done on a large scale the death rate and case rate of Diphtheria have dropped in a striking manner. Immunisation is being carried on in many cities and towns in this country but it is not yet general. In some American and Canadian districts very striking results are shown but there are many difficulties arising with regard to statistical figures and how we interpret them. Diphtheria is a disease which is periodic and it might be that a decrease in the number of cases following an immunisation campaign, was due to natural causes. Richmond has been fortunately free from the disease except in periodic years. In districts is which the disease is more or less endemic there is a certain natural immunity developed and the cases seen are not so serious as those which occur in a district which is comparatively free from the disease for a few years. Methods Employed. Immunisation is obtained by the injection under the skin of various toxoid-antitoxin mixtures. The injections are three in number at intervals of a week or ten days. After an interval of three or more months the persons immunised as above should have a further Schick test in order to see that they are completely immune. If not, a further injection of toxoid-antitoxin mixture is required. (Probably about ten per cent, will require further injections). In some districts, in order to save time and probably also money, the initial and final Schick tests have not been carried out. Only the immunisation injections have been given to all without finding out whether they were immune or not. The Ministry of Health is of opinion that both the initial and the final Schick tests should be carried out. 62 It will be seen therefore that a susceptibie child would have:- (1) Preliminary Schick tests ; (2) Three or more injections for immunisation at intervals of a week; (3) Posterior Schick test; (4) Further injections, again followed by Schicking if not immunised. I have mentioned that children show considerable immunity in the first six months of life and then remain very susceptible for some years, slowly developing immunity as age advances. There is much to be said, then, for tiding them over the susceptible age, even if the protection conferred by the injections is not permanent. Zingher suggests that not only is an active immunity—such as follows other forms of vaccination — produced, but that there is also an earlier development of the natural immunity which would otherwise have manifested itself more gradually. The presence of this latter factor would justify the hope that the immunity is likely to be more or less permanent. The cost of immunising on a large scale is difficult to estimate as of course it cannot be made compulsory and therefore it is impossible to say how many parents will take advantage of the facilities offered. One thing, however, is definite. For the amount paid to treat one case of Diphtheria in Hospital, material to immunise 200 children can be obtained. In districts where immunisation is carried out the cost of the scheme varies considerably. This depends on (1) whether Schick tests are omitted and only immuniastion injections given, and (2) whether an existing staff is able to deal with the whole of the work, including the interpretation of the Schick tests. It seems to me that in a matter of this kind, only those who are, by experience, skilled both in technique and in the 63 interpretation of results should be employed. It is only by having such experts that one could give confidence to the general public in what, to them, is something new. 1 should like to mention that in 1924 there was an epidemic of Diphtheria particularly in part of the North Sheen Ward. I took the opportunity then, of immunising 104 children living in the neighbourhood so that I was one of the first in this area to use immunisation methods. None of the children mentioned has since contracted Diphtheria. No Schick tests were done at that time as I wished to get the greatest possible number of children done in the least possible time. Even then some children were not brought for their third injection. At that time I also got permission from this Committee to immunise any children whose parents asked for it. I gave several talks to mothers at the Welfare Centre on the subject but there has been little response. The Health Committee instructed me to report on how a scheme of immunisation could be worked in the Borough and I am at present considering the matter and getting the information necessary. 64 During the year the number of specimens, etc., sent up for examination was as follows :— Disease Suspected. Nature of Specimen. Result. Total. Positive. Negative. Diphtheria Swabs from Throat and Nose 44 337 381 Tuberculosis Sputum 23 72 95 Enteric Fever Blood — 3 3 67 412 479 Scarlet Fever. During 1933, 138 cases of this disease were notified and 130 were treated in hospital. The rate per 1,000 living was 3.59 as compared with a case rate of 3-21 in England and Wales. In 1932 there were 102 cases. There was one death from this disease, but this occurred in a child who contracted the disease and died outside the district. Puerperal Fever and Puerperal Pyrexia. During 1933 five cases of Puerperal Pyrexia were notified. There were no deaths from Puerperal Sepsis. The Council has made arrangements whereby a medical practitioner in attendance on one of these cases can have a consultation with an Obstetric Specialist if he desires. 65 Total Cases Notified. Total Deaths. Under 1 year 1-2 2-3 3—4 4—5 5-10 10—15 15-20 20—35 35—45 45—65 65 and over. Under 1 year 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20-35 35-45 45—65 65 and over. Cerebro-spinal Meningitis 1 ... ... ... 1 ... ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... ... ... ... Diphtheria ... ... 3 1 3 30 16 3 5 1 2 ... i ... 1 1 ... 4 1 ... ... ... 1 ... Scarlet Fever 1 1 5 2 5 64 30 8 18 3 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... Chicken Pox ... 2 ... ... 2 10 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia (Primary) ) ... 2 2 ... 1 5 1 1 2 2 6 ... ... ... ... ... ... ... ... ... ... ... 3 ... Influenzal Pneumonia ... ... ... ... ... ... ... ... 1 1 4 2 ... ... ... ... ... ... ... ... 1 ... ... 1 Erysipelas 1 1 ... ... ... 1 ... ... 5 4 3 1 1 ... ... ... ... ... ... ... ... ... ... 1 Puerperal Pyrexia ... ... ... ... ... ... ... ... 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculosis :— {a) Kespiratory ... ... ... ... ... ... 1 5 24 12 6 3 ... ... ... ... ... ... ... 3 11 9 4 ... (6) Non Respiratory ... 1 ... ... ... 1 2 ... 5 ... 3 2 ... ... ... ... ... 1 ... ... ... ... 1 1 66 Public Health (Prevention of Tuberculosis) Regulations, 1925. No action was taken under this Act. Public Health Act, 1925. Section 62. No action was taken under these Regulations. Respiratory Tuberculosis (Phthisis). Fifty-one cases of this disease were notified during the year (25 males and 26 females). Of these 34 (19 males and 15 females) were removed to Hospital or Sanatorium. There were 53 cases notified in 1932. There were 27 deaths from this disease during the year. Non-Respiratory Tuberculosis was responsible for 3 deaths, while 14 cases were notified during the year. Tuberculosis. Age Periods New Cases. Deaths. Respirator-y. NonRespiratory. Respiratory. NonRespiratory. M F M F M F M F 0 ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... ... ... ... 5 ... 1 1 2 ... ... ... 1 15 7 9 ... 1 ... 6 ... ... 25 5 8 3 1 4 4 ... ... 85 8 4 ... ... 5 4 ... ... 45 3 2 1 1 1 3 ... ... 55 1 ... 1 ... ... ... ... 65 and upwards 2 1 ... 2 ... ... 1 1 Totals 25 26 6 8 10 17 1 2 67 Ophthalmia Neonatorum. This is an inflammation of the eyes in newborn children (up to three weeks old), and is a very serious disease if not immediately treated. Total blindness may be caused by neglect. One case was notified during the year. Ophthalmia Neonatorum Cases Vision Unimpaired Vision Impaired Total Mindness Deaths Notified Treated At Home In Hospital l l — — — — l Death due to Marasmus BOROUGH OF RICHMOND (SURREY). (Education (Konunitto. ANNUAL REPORT OF THE School Medical Officer. 19 3 3 RICHMOND I J. H. Broad & Co., Ltd., 8, King Street. BOROUGH OF RICHMOND (SURREY). Report on the Medical Inspection and Treatment of Elementary School Children for the year ended December 31st, 1933. To the Chairman and Members of the Education Committee. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Report on the work of the School Medical Department during the year 1933. This is my thirteenth report as your School Medical Officer. The Board of Education, in a circular regarding the arrangement of Annual Reports, suggests that where matters have been described in previous reports and remain unaltered, it is unnecessary that the information should be repeated annually. This Report, therefore, although on the same lines as in former years, will omit much of what has already been reported and in which there has been no change. The average number of children on the school registers for the year was 3,381. On April 1st, 1933, the Borough was enlarged by the addition of part of the Urban District of Ham. The added portion included the school (Church of England) with its 195 scholars. All the cards relating to school medical and dental work were forwarded to me by the Surrey County Council, 4 A summary of the year's work in all the schools is appended. 1,167 children medically inspected. 4,201 attendances at the Minor Ailment Clinic. 124 children suffering from Defective Vision obtained glasses after examination by an Eye Specialist, either at Clinic or privately. 74 children underwent operations for Throat and Nose disease. 1,750 attendances were made at the Dental Clinic. 431 children were given general anaesthetics (i.e., Gas or Ethyl Chloride). I wish to express my thanks to the staff of the Department for their loyal work during the year, and to the Teachers for their co-operation. 1 am, Ladies and Gentlemen, Your obedient Servant, C. S. BREBNER. 5 1. Staff. School Medical Officer : C. S. Brebner, D.S.O., M.D., D.P.H., Barrister-at-Law. Ophthalmic Surgeon (part time) : C. Longworth Blair, M.R.C.S., L.R.C.P. Dental Surgeon : Miss Evelyn Russell, L.D.S.. R.C.S. (Eng.) (half-time). School Nurses : Mrs. L. K. Dunford, C.M.B. Miss C. G. Hay (S.R.N., C.M.B.) (New Health Visitors' Cert.) Miss J. D. Law, R.R.C. (S.R.N., C.M.B.) (Health Visitors' Cert.) Dental Assistant (part-time): Miss M. D. Banks. Clerks : Miss E. M. Oakes (part time) (resigned August). Miss M. J. Bird (part time). Miss O. W. Ponsford (part time) (appointed August). 2. Co-ordination with other Health Services. The three School Nurses act also as Health Visitors in the Maternity and Child Welfare work. The School Medical Officer is also Medical Officer of Health and Medical Officer to the Maternity and Child Welfare Centre. There is thus close cooperation between these departments, and this is particularly useful in connection with the occurrence of Infectious Diseases in the Schools and in the Borough generally. 6 3. School Hygiene. There are thirteen schools in the Borough, four being Council Schools (one Special School), the remainder being Church of England 7, Roman Catholic 1, and Undenominational 1. Many of the School Buildings are old, but some have been altered and brought to a fairly satisfactory condition. The sanitary conveniences in five of the schools are not satisfactory. They are of the old "trough" type and should be replaced by more modern fittings. 4. Medical Inspection (Table 1, page 19). Medical Inspections were carried out during the year as follows:— 1. Routine Inspections required by the Board of Education. (a) Entrants; (b) Intermediates; (c) Leavers; 2. Other Inspections : (a) Special children not in the above groups but who are examined, usually at the request of the Head Teacher. (b) Children seen at the Clinic, sent by Parents, Head Teachers or the School Nurses. (c) Re-inspections of children previously found with a defect of some kind. There were 324 entrants examined at the Routine Inspections and 196 parents or guardians attended. 364 children of the intermediate age were inspected and 417 leavers, i.e., children aged 12 years. There were 62 other Routine Inspections made during the year, so that the total number of children examined was 1,167. 7 Other inspections include children seen as "Specials." These are generally children brought forward by the Head Teachers, or they may be seen by one of the School Nurses and deemed suitable cases for a special examination. 39 of these cases were examined during the year. Included in the Special Inspections in Table I. are the cases seen at the Inspection and Minor Ailment Clinic, so that there is a total of 952 special inspections. From the table on page 19 it will be seen that re-inspections totalled 1,090. Re-inspections are made of children actually found with defects which have not been treated, and also of children who have been placed "under observation." The routine inspections and special examinations take up a considerable time, and it is not possible to re-examine as often as one would wish. "Following up" at home by the School Nurses is thoroughly carried out and the figures in the tables at the end of this report show that a very small percentage of the defects go untreated. Parents are also asked to bring children to the Inspection Clinic and advice is given there. Age Groups Inspected. The Board of Education requires Local Authorities to make provision for the Medical Inspection of all children admitted to school during the year ending March 31st, and of all children between 12 and 13 years of age, together with children over 13 who have not been inspected after reaching the age of 12. An intermediate group, children between 8 and 9 years of age, must also be examined. The 324 entrants comprised 179 boys and 145 girls. ,, 364 intermediates „ 192 „ „ 172 „ ,, 417 leavers ,, 213 ,, 204 ,, The number inspected and re-inspected under the heading "Other Inspections" is 2,042 as compared with 1,774 last year, 8 5- Findings at Medical Inspections. (a) Malnutrition. — I have no evidence that there is any malnutrition owing to lack of food. 1 have not seen any cases in the number of children seen at Routine and other Inspections and have not had any reports from Head Teachers as to ill-nourished children. Children are found occasionally under-nourished more as a result of unsuitable diet than of shortage of food. Advice is given to the parents in these cases. (b) Uncleanliness. The degree of cleanliness of both head and body is noted at the inspections. 12 children were referred for treatment owing to verminous or "nitty" heads. During the year the average number of visits per school by the Nurses for Cleanliness Inspections was 8. The total number of examinations during these inspections was 8,284, as compared with 9,861 in 1932. 327 individual children were found either to be verminous or to have so many nits in their hair that notices had to be sent to the parents. The verminous cases are, of course, at once excluded from school. When children have to be excluded, the Education Secretary is at once advised and a letter is sent by him to the parent with the information that if the child's head is not cleansed in one week, prosecution will follow. This I find has the desired effect and no proceedings have had to be taken during the year. No cleansing of heads is done at the Clinic, but occasionally hair has been cut short after permission in writing has been obtained from a parent. (c) Minor Ailments and Diseases of the Skin. (Table IV., page 25). During the year 604 minor ailments were referred for treatment as compared with 643 in 1932. 9 Children suffering from these minor ailments were either seen at the Routine Inspections or were sent to the Clinic by parents or teachers. The diseases consist mainly of skin diseases, such as Ringworm, Impetigo, Ear diseases and External Eye Diseases. The methods of dealing with these are referred to later. During 1933, 2 cases of Ringworm of the scalp were in attendance at the Clinic, as compared with one in each of the four preceding years. Two cases of Body Ringworm were seen and treated at the Clinic. Six cases of Scabies were seen during the year as compared with 5 last year. (d) Visual defects and External eye disease.—37 cases of External Eye disease were referred for treatment during the year 33 of these being treated at the Clinic and 4 elsewhere. 146 children were referred for treatment for Defective Vision and Squint. 141 children received treatment during the year, 22 of these being cases referred from inspection in 1932. 45 cases were discovered at the Routine Inspections, and the remaining 101 were sent to the Clinic by parents or teachers owing to evidence of eye strain. All children who cannot read 6/12 line of Snellen's test type are referred for treatment, and also any who complain of difficulty in reading at a short distance. 31 cases of Squint were seen during the year and found to require treatment. Usually these cases are seen for the first time when children are admitted to school. The correction and cure of the trouble is then more difficult and it should be known that a squint should be treated as early as possible. (e) Nose and Throat Defects.—(Table IV., page 26). 76 children were found to be suffering from enlarged Tonsils, Adenoids, or both defects. 74 received operative treatment, 58 Hospital Vouchers were actually given. Of the 76 children 10 referred for treatment, 59 were operated on (44 at Richmond Royal Hospital and 15 privately). 13 cases are awaiting operations, making the percentage of cases treated or under treatment during the year 94.7. No case is recommended for operation unless it is obvious that the condition is causing general physical disability, or a special defect, such as deafness. Actually 74 children were operated on during the year (56 at Richmond Royal Hospital and 18 privately) 15 of these being cases referred from 1932. All cases sent to Richmond Royal Hospital are seen by the Nose and Throat Specialist before operation is finally decided upon. (/) Ear Disease and Defective Hearing.—25 cases were referred for treatment. Most of these were cases of discharging ears and they were treated at the Clinic. 4 cases were sent to the Royal Hospital—1 being a case of Defective Hearing which was operated on for Tonsils and Adenoids. (g) Dental Defects.—Table IV., page 27). During the Routine Medical Inspection the teeth are examined, but not as thoroughly as they are examined by the Dental Surgeon, i.e., with probe and mirror. Only the obvious carious teeth are therefore seen and noted by the School Medical Officer. During 1933, children of all age groups, i.e., 5—15, were examined by the School Dentist. Miss E. Russell, L.D.S., the School Dental Surgeon, examined 2,289 children of all age groups and found 1,291 to require treatment. This is 56.40 per cent., a higher percentage than in the previous year. This may seem to be a large proportion, but it must be remembered that the treatment in many cases is very small in amount and is conservative, that is, the preservation of the permanent teeth. (h) Orthopcedic and Postural Defects.—The former may be caused by (1) Infantile Paralysis, (2) Rickets, (3) Tuberculosis, (4) Brain or Nerve Lesions, (5) Congenital Defects, 11 The Postural Defects occur in otherwise healthy children who develop the condition by faulty positions while standing or sitting. They are corrected by remedial exercises. Four cases are under observation at the present time. Orthopaedic defects under observation at present include:— Infantile Paralysis 5 Tuberculosis 1 Congenital Defects 6 There is no special Orthopædic treatment scheme, but cases are referred to Hospitals dealing specially with these defects. When parents are able to pay moderate fees for advice, the cases have been sent to the Red Cross Curative Post at Kingston, where Orthopaedic Specialists can be seen and treatment obtained. (i) Heart Disease and Rheumatism.— Three cases of Heart Disease are under observation, one a congenital case and the others the result of illness. Six cases of Rheumatism were seen at the Clinic, and were referred elsewhere for treatment. All these cases, together with one other, are under observation. (j) Tuberculosis.— The one case of suspected pulmonary tuberculosis and 2 cases of non-pulmonary tuberculosis were seen at the Clinic and referred to the County Tuberculosis Officer. 6. Following up. After each Routine Inspection at theSchools a list of defective children and the defects found is made out and copies are given to the School Nurse and the Head Teacher concerned. The list also states the treatment necessary for each defective and in many cases the teachers can assist in getting treatment carried out. Further notice is sent to the parents of those found untreated, and if necessary the School Nurses call at the homes, or the parents are asked to attend at the Clinic and talk over the matter with the School Medical Officer. 12 62 visits were paid to the homes by Miss Banks re Dental treatment. The number of attendances at the Clinic in 1933 was 4,201 as compared with 3,804 in 1932. 7. Arrangements for Treatment. Arrangements have been made for the treatment of:— (a) Minor Ailments. (b) Enlarged tonsils and adenoids. (c) Defective Vision. (d) Dental Defects. (e) Ringworm. (a) Minor Ailments.—The treatment of these diseases is carried out each morning at the Health Centre. The School Medical Officer is present four mornings per week (including Saturdays) to see new cases and cases requiring supervision. The dressing of the various cases is carried out by one or other of the School Nurses. The number of individual children who attended the Clinic for actual treatment during the year was 317, and the total number of defects treated was 540. Also 635 children attended for inspection only, i.e., dirty heads, sore throats, &c. The total number of attendances was 4,201. (b) Tonsils and A denoids.—Arrangements have been made with the Richmond Royal Hospital authorities to undertake the operative treatment of these conditions. The Education Committee pay an agreed sum per operation. Some parents prefer to have treatment by their own doctor, or to go to a London Hospital. In every case the parents are advised to bring the child to the Clinic as soon as possible after the operation, so that they may be advised * as to the necessary after-treatment by means of breathing exercises etc. 13 During the year 76 children were referred for treatment after inspections. 58 Vouchers were given for the Hospital. Actually, 74 operations were performed (56 at the Richmond Royal Hospital and 18 elsewhere). 15 of these were cases referred from 1932, and there are 13 children awaiting operation, so that the percentage of children actually treated or under treatment as a result of examinations during the year was 94.7. (c) Tuberculosis. — Any child suspected of being tubercular is referred to the County Tuberculosis Officer at Surbiton (Dr. A. Cameron Renwick), who deals with the treatment of all Tubercular cases in this area of the County. He is always willing to see any suspicious case and let me have his opinion. The Health Committee of the Borough has agreed to pay the fares of patients proceeding to Surbiton for advice. 3 children were referred to him during the year. (d) Skitt Diseases. —Most of these are classed under minor ailments, and include Impetigo and Scabies, both of which are treated at the Clinic. The Education Committee has arranged to pay for the treatment of ringworm of the scalp by means of the X-rays in suitable cases. This is done by Mr. G. G. Blake, under the supervision of the School Medical Officer. 2 cases were treated by X-ray during 1933. Ringworm of the body is treated at the Clinic. (e) External Eye Diseases.—37 cases were seen during the year. (f) Defective Vision.—These cases are treated at a special Eye Clinic which is held at the Health Centre, once a fortnight. Mr. Blair attends on these occasions, and prescribes glasses when necessary. The Committee pay a fee per case seen and Mr. Blair sees all cases twice and sometimes three times. During the year under review, 146 cases were referred for treatment. In all, 141 cases were treated (22 of these being cases 14 referred from the previous year), and in 126 cases glasses were prescribed. Actually 126 children obtained glasses. Arrangements have been made whereby the glasses can be purchased by the parents from a local optician at a contract rate. The Education Committee pays the whole or part of the cost of glasses in necessitous cases. (g) Ear Cases—Most of these cases are treated at the Minor Ailment Clinic. In some special cases the parents have been advised to have a specialist's opinion and have been referred to the Royal Hospital, Richmond. (h) Dental Treatment.—During the year 2,289 children were inspected by the Dental Surgeon, and 1,291 were referred for treatment. In addition. 558 were referred for treatment from the inspections of the School Medical Officer, or were sent up to the Clinic by Head Teachers, making a total of 2,847 as compared with 2,040 in 1932. 1,297 were actually treated at the Clinic, some of these being cases referred from 1932. 1,374 children were re-treated as a result of periodical examination. These figures and those given in Table IV., Group 4, are a very good record for the year's work. Miss Russell does the whole of the Dental work and attends five half-days a week. 12 half-days were devoted to inspection of the teeth *t the Schools and 185 half-days were given up to treatment. It is now possible to inspect all age groups of children attending school every year and provide treatment when necessary. On reference to the table above-mentioned, it will be seen that during the year 1,043 permanent teeth were filled and 100 temporary teeth. 15 383 permanent teeth had to be extracted. This is because parents do not realise that a child's first permanent molars come in at six years of age. It is quite common to find these molars decayed so much that nothing but extraction is possible. These teeth were considered to be first teeth and were neglected with the above result. When it is found necessary to extract several teeth, a general anaesthetic is given, either Nitrous Oxide Gas or Ethyl Chloride. A special Dental Clinic is held once a fortnight for this purpose, and the School Medical Officer administers the anaesthetics. During 1933 1 administered anaesthetics to 431 children, as compared with 503 in 1932. During the year the following amounts were received as fees at the Clinic:— £ s. d. Dental fees 59 4 0 Tonsil and Adenoid Fees 1 8 6 £60 12 6 In addition to the above fees paid by parents grants to the Education Committee to the value of £7 13s. 0d. were made in respect of operations for enlarged tonsils and adenoids in cases where the parents were contributors to the Hospital Saturday Fund or Hospital Savings Association, so that the total amount received as fees was £68 5s. 6d. 8. Infectious Diseases. It was not found necessary to close any of the schools for infectious disease during 1933. 9. Open-Air Schools. There is no open-air school in the Borough. At all Medical Inspections, however, a note is made of those children who would benefit by attendance at an open-air school. 16 10. Physical Training. This is carried out in all the Schools, although there is no organiser of physical training. Organised games also appear in the time tables, and the older children attend the swimming baths in the summer months for instruction in swimming. Baths are not provided at any school, but arrangements are made so that the older children attend the Public Baths in the summer months. They are taught to swim as part of their physical training. 11. Provision of Meals. No free meals have been provided, but at the Special School for mentally and physically defective children a mid-day meal is prepared for all the children attending. The parents pay 1s. 6d. per week towards the cost of these meals. 12. Co-operation of Parents, Teachers, School Attendance Officer and Voluntary Bodies. Before a Routine Inspection a card is sent to the parents of the children concerned, informing them of the day and hour, and inviting their attendance. They are also asked to state what illness the child has had. The largest number of parents attend when infants are being examined. Their presence is helpful, as defects discovered at the inspection can be explained, and the necessary treatment advised at first hand. Where parents do not attend, the notice of any defect has to be sent by letter. In special cases parents are asked to see the School Medical Officer at the Clinic. The Head Teachers give a great deal of valuable assistance in connection with medical inspections. They provide me with monthly lists of admissions and leavers and these help to keep the office records up to date. As previously mentioned, they assist in seeing that glasses are worn regularly and often are very helpful in persuading parents to adopt the line of treatment indicated by the School Medical Officer. 17 The School Attendance Officer attends frequently at the School Clinic and gives and receives information regarding absent children. Medical Certificates for school children are sent to the Attendance Officer daily. The names of children excluded from School are sent to the Head Teachers and to the School Attendance Officer. The only Voluntary Body now co-operating with the School Medical Service is the Richmond Philanthropic Society, whose Secretary is Mr. R. Smith, the School Attendance Officer. During the year under review the Philanthropic Society has supplied 150 pairs of boots. 500 children were provided with clothing other than boots. 25 children were sent to Convalescent Homes and 70 children were given extra nourishment while ill. 13. Mentally Defective Children. The School for Mental Defectives has accommodation for 30 children. The Mistress (Miss Rowling) has special qualifications for the work and takes a very deep interest in the children at the School. As stated previously the children have their mid-day meal at school, and most of them assist in the purchase of the food and in its preparation. The Committee have made an agreement with the County Council whereby children from Barnes and Mortlake can attend so long as there is accommodation for them. At present 3 children attend from Barnes and Mortlake, and 18 from Richmond. Miscellaneous. Employment of Children.—Bye-laws under the Employment of Children Act, 1903, have been adopted by the Education Committee, and children attending school who wish to obtain employment (part-time) must be examined as to their fitness by the School Medical Officer. 18 Before the examination the Head Teachers concerned are asked to give their views as to the prejudicial effect of the proposed employment on the children's education. During the year 51 boys have been examined in connection with the medical certification as to their fitness for employment. 51 certificates were granted. Of the 51 children granted certificates, 48 were employed in the delivery of newspapers and 3 in the delivery of milk. Medical Examination of Teachers and Caretakers.—The Education Committee require that Teachers appointed to schools in the Borough should pass a Medical Examination. During the year, I examined 8 such teachers and certified them as fit to carry out their duties. One caretaker also was examined before being admitted to the Superannuation Scheme. 19 Table I.—Return of Medical Inspections. A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants 324 Intermediates 364 Leavers 417 Total 1,105 Number of other Routine Inspections 62 B.—Other Inspections. Number of Special Inspections 952 Number of Re-Inspections 1,090 Total 2,042 Table II.—A. Return of Defects found by Medical Inspection in the year ended 31st December, 1933. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring Treatment. Requiring to be kept under observation but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. (1) (2) (3) (4) (5) Malnutrition 1 9 6 – Un-cleanliness (See Table IV. Group V.) Skin Ringworm— Scalp – – 2 – Body – – 2 – Scabies – – 6 – Impetigo 1 – 46 – Other Diseases (NonTuberculous) 1 1 11 – Eye Blepharitis 5 1 6 – Conjunctivitis – – 19 – Keratitis – – – – Corneal Opacities – – – – Defective Vision (excluding Squint) 37 15 78 4 Squint 8 1 23 – Other Conditions – – 12 1 20 Table II.— continued. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No of Defects. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation, but not requiring Treatment. (1) (2) (3) (4) (5) Ear Defective Hearing – 2 – – Otitis Media 1 – 11 – Other Ear Diseases – – 9 – Nose & Throat Enlarged Tonsils only 13 64 6 – Adenoids only 1 4 – – Enlarged Tonsils and Adenoids 10 11 46 1 Other Conditions 5 4 5 2 Enlarged Cervical Glands (NonTuberculous) – 1 3 – Defective Speech – – 7 1 Teeth—Dental Diseases (See Table IV, Group 4). 355 – – – Heart & Circulation Heart Disease:— Organic – 1 – – Functional – 1 – – Anæmia – – – – Lungs Bronchitis – – – – Other Non-Tuberculous Diseases – – – – Pulmonary:— Tuberculosis' Definite – – – – Suspected – – – 1 Non- Pulmonary:— Glands – – 1 – Spine – – – – Hip – – 1 – Other Bones and Joints – – – – Skin – – – – Other Forms – – – – Nervous System Epilepsy – – – 2 Chorea – 1 5 – Other Conditions – – – – Deformities Rickets – 1 – – Spinal Curvature – – – – Other Forms – 5 – – Other Defects and Diseases 7 6 471 4 21 Table II.—continued. B. Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). Group. Number of Children. Percentage of Children found to require treatment. Inspected. Found to require Treatment. (1) (2) (3) (4) Code Groups: Entrants 324 27 8.33 Intermediates 364 34 9.34 Leavers 417 21 5.04 Total (Code Groups) 1105 82 7.42 Other Routine Inspections 62 6 9.68 Table III.— Return of all Exceptional Children in the Area. CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Blindness (NOT Partial Blindness). Deafness (NOT Partial Deafness). Mental Defect. Epilepsy. Active Tuberculosis. Crippling (as defined in the penultimate category of the Table). Heart Disease. Number of children suffering from any combination of the above defects 2 BLIND CHILDREN. A blind child is a child who is too blind to be able to read the ordinary school books used by children. Only children who are so blind that they can only be appropriately taught jn a school for blind children are included in this table. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. – – – – – 22 Table III.— continued. PARTIALLY BLIND CHILDREN. Children who, though they cannot read ordinary school books or cannot read them without injury to their eyesight, have such power of vision that they can appropriately be taught in a school for the partially blind. Children who are able by means of suitable glasses to read the ordinary school books used by children without fatigue or injury to their vision are not included in this Table. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. – – – – – – DEAF CHILDREN. A deaf child is a child who is too deaf to be taught in a class of hearing children in an elementary school. Only children who are so deaf that they can only be appropriately taught in a school for the deaf are included in this Table. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. – – – – – PARTIALLY DEAF CHILDREN. Only children who can appropriately be taught in a school for the partially deaf. 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. – – – – – – 23 Table III.—continued. MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. Mentally Defective children are children who, not being imbecile and not being merely dull and backward, are incapable by reason of mental defect of receiving proper benefit from the instruction in the ordinary Public Elementary Schools but are not incapable by reason of that delect of receiving benefit from instruction in Special Schools for mentally defective children. This category includes only those children for whose education and maintenance the Local Education Authority are responsible, and excludes all children who have been notified to the Local Authority under the Mental Deficiency Act. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 14 – – – 14 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. In this part of the Table only those children are included who are epileptic within the meaning of the Act, i.e., children who, not being idiots or imbeciles, are unfit by reason of severe epilepsy to attend the ordinary Public Elementary Schools. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 – – – 1 PHYSICALLY DEFECTIVE CHILDREN. Physically defective children are children who, by reason of physical defect, are incapable of receiving proper benefit from the instruction in the ordinary Public Elementary Schools, but are not incapable by reason of that defect of receiving benefit from instruction in Special Schools for physically defective children. A. Tuberculous Children. Cases diagnosed as tuberculous and requiring treatment for tuberculosis at a sanatorium, a dispensary, or elsewhere. Children suffering from crippling due to tuberculosis which is regarded as being no longer in need of treatment should be recorded as crippled children, provided that the degree of crippling is such as to interfere materially with a child's normal mode of life. All other cases of tuberculosis regarded as being no longer in need of treatment should be recorded as delicate children. 24 Table III.—continued. 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. – 1 – – 1 II.—Children Suffering from Non-Pulmonary Tuberculosis. (This category includes tuberculosis of all sites other than those shown in (I) above). At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. – 4 1 – 5 B. Delicate Children. This Section is confined to children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an Open Air School. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 12 – – 13 C. Crippled Children. This Section is confined to children (other than those diagnosed as tuberculous and in need of treatment for that disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life, i.e., children who generally speaking are unable to take part, in any complete sense, in physical exercise or games or such activities of the School curriculum as gardening or forms of handwork usually engaged in by other children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 9 – 1 11 25 Table III.—continued. D. Children with Heart Disease. This Section is confined to children whose defect is so severe as to necessitate the provision of educational facilities other than those of the Public ElementarySchool. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. – 1 – – 1 Table IV.—Return of Defects Treated during the year ended 31st December, 1933. TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness). Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. Skin- Ringworm—Scalp 2 – 2 Ringworm—Body 2 – 2 Scabies 6 – 6 Impetigo 45 1 46 Other Skin Disease 10 1 11 Minor Eye Defects— (external and other) 33 4 37 Minor Ear Defects 19 4 23 Miscellaneous— (e.g., minor injuries, bruises, sores, chilblains, &c.) 423 54 477 Total 540 64 604 26 Table IV.—Group 2. Defective Vision and squint. Defect or Disease. Number of Defects dealt with. Under the Authority's Scheme. Submitted to Refraction by Private Practitioner or at Hospital. Otherwise. Total. (1) (2) (3) (4) (5) Errors of Refraction (including squint) 139 2 – 141 Other Defect or Disease of the Eyes – – – – Total 139 2 – 141 Total number of children for whom spectacles were prescribed. (а) Under the Authority's Scheme 124 (b) Otherwise 2 Total number of children who obtained or received spectacles. (a) Under the Authority's Scheme 124 (b) Otherwise 2 Table IV.—Group 3. Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Received other forms of Treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from Authority's Scheme. Total (1) (2) (3) (4) (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) — 74 1 — 55 — 4 — 14 — 5 — 69 — (i) Tonsils only. (ii) Adenoids only. (iii) Tonsils and Adenoids, (iv) Other defects of the nose and throat, 27 Table IV.—Group 4. Dental Defects. (1) Number of Children who were:— (a) Inspected by the Dentist: Routine Age Groups Aged 5 years 87 „ 6 „ 189 „ 7 „ 213 „ 8 „ 224 „ 9 „ 224 „ 10 „ 252 Total 2,289 „ 11 „ 248 „ 12 „ 256 „ 13 „ 333 „ 14 „ 219 „ 15 „ 44 „ 16 „ – Specials 558 Grand Total 2,847 (b) Found to require treatment1,291 (c) Actually treated 1,297 (d) Re-treated during the year as the result of periodical ination 1,374 (2) Half-days devoted to Inspection 12 [Treatment 185 Total 197 (3) Attendances made by children for treatment 1,750 (4) Fillings Permanent Teeth 1,043 Temporary 100 Total 1,143 (5) Extractions Permanent Teeth 383 (Temporary „ 2,431 Total 2,814 (6) Administrations of general anaesthetics for extractions 431 (7) Other Operations Permanent Teeth 86 Temporary „ 11 Total 97 Table IV.—Group 5. Uncleanliness and Verminous Conditions. Average number of visits per school made during the year by the School Nurses 8 Total number of examinations of children in the Schools by School Nurses 8,284 Number of individual children found unclean 327 Number of children cleansed under arrangements made by the Local Education Authority Nil Number of cases in which legal proceedings were taken— (a) Under the Education Act, 1921 Nil (b) Under School Attendance Byelaws Nil