TWI 047 Twickenham Urban District Council. ANNUAL REPORT OF THE Medical Officer of Health WITH THE ANNUAL REPORT OF THE School Medical Officer FOR THE YEAR 1917. Twickenham: Printed by H. & C. Franklin, King Street, 19 18. Twickenham Urban District Council. Annual Report OF THE MEDICAL OFFICER OF HEALTH For the Year 1917. 3 Public Health Department, Radnor House, Twickenham, August 1st, 1918. To the Chairman and Members of the Urban District Council. Gentlemen, I have the honour to submit my Annual Report on the health and sanitary condition of the district and the treatment of patients at the Isolation Hospital during the year 1917. With a view to economy, the report has been largely reduced, tables have been almost entirely eliminated, but the most important statistics have been retained for purposes of comparison with previous years. Maternal and Infant Welfare has been the only question referred to at any length, the present importance of this subject rendering more detailed reference necessary. The work of the year may be summed up as "carrying on under increasing difficulties," With the exception of the Medical Officer of Health and School Nurse, all the permanent staff of the department have been called up for military service, and I desire to acknowledge the valuable and willing assistance rendered by all those who have taken their place. I am, Gentlemen, Your obedient Servant, George H. Dupont. Medical Officer of Health. 4 VITAL STATISTICS. The Registrar General has again furnished two estimates of the civilian population, (a) that for the calculation of the death rate, 35,764, and (b) that for the calculation of the birth rate, 39,867. It is impossible to estimate the total population with any degree of assurance. The population on the Sugar Card Register was 38,000 It is probable that this has since been exceeded, owing to a number of persons coming out of London to reside temporarily in this district, and the figure towards the end of the year was probably in the neighbourhood of 40,000 No great movement of persons either into or out of the district occurred during the year. Some of the Belgian refugees left, and. I am informed, returned to certain fishing villages on the French coast, but the numbers were not such as to affect the total materially. The police estimate the Belgian population at between five and six thousand persons. Births.—The nett births numbered 559, being 164 less than the preceding year, and 167 less than the average for the previous five years, in spite of the increasing population. The birth rate was 14.27 per thousand, as compared with 20.5 per thousand the previous year and an average of 23 per thousand during the previous five years. Of the total births, 291 were males and 268 females A few instances ot inter-marriage between Belgian men and English women have come under notice. Illegitimate births numbered 43, as compared with 49 and 40 during the preceding years. Deaths.—The nett number of deaths was 370. Calculated on the figure supplied by the Registrar General, the death-rate per thousand of the population was 10 34. The number of deaths was 53 less than during 1916, and the death rate was 2.35 per thousand less than in that year. The births during the year 1917 exceeded the deaths by only 189. During the preceding five years the births on the average have exceeded the deaths by 341. 5 To sum up, therefore, we again have a marked diminution in the birth rate, but counterbalanced to some extent by a diminution in the death rate. The deaths from tuberculosis were 3 less than last year, while those resulting from zymotic diseases were 5 less. Only 2deaths were certified as directly due to alcohol, this being the lowest lor any previous year of which I have a record, the average number of deaths from these causes for ten years prior to 1916 was 7.3 per year. The connection between the restrictions imposed by the regulations of the Liquor Control Board and the diminution of deaths from this cause furnishes interesting food for thought. SANITARY INSPECTION. Staff.- Mr. Marsden, the Inspector of Nuisances, was called up for duty in the Royal Naval Air Force, on February 5th, the Council appeals to the local and county tribunals being dismissed. The decision to call up the chief inspector of a district with a population of nearly 40,000 was a most unusual one, and the wisdom of the decision most distinctly open to question. It is some satisfaction to know, however, that Mr. Marsden is carrying out valuable duties of a sanitary character in the important service to which he is attached. From then the work was carried out by the Medical Officer and Mr. J. P. Clarke, the temporary Assistant Inspector, who was appointed temporary Inspector of Nuisances. Attention was largely concentrated on meat and food inspection and enquiry into and disinfection after infectious disease. Although routine housing inspection had perforce to be abandoned, a surprisingly large number of insanitary conditions have been remedied at the instance of the department during the year. The total number of inspections and re-inspections made was 4,055; 292 intimations were sent and 69 statutory notices were served by direction of the Council. Proceedings were taken in respect of three of these and convictions were obtained. Cowsheds, Dairies and Milkshops.—At the end of the year 7 cowkeepers and 42 purveyors of milk were on the register. One 6 hundred and fourteen visits of inspection were paid to these during the year. There were on an average 116 cows in the district, and these were examined quarterly by the Council's Veterinary Inspector and reported to be in healthy condition. Inspection of Meat and other Foods.—Slaughterhouses and butchers' shops were visited on 539 occasions. The amount of diseased and unsound meat voluntarily surrendered was 884lbs; unsound fish, 143lbs.; unsound fruits, 43cwts. ; unsound oats, 61bs and unsound milk, 3 gallons. Nine chicken carcases, 49 herrings and 2 bushels of unsound fruit were seized. Proceedings were instituted in reference to seizures of unsound poultry, fish and fruit, and convictions were obtained in all three instances Owing to the shortage of supplies there was less local slaughtering towards the end of the year, and for the same reason there was little likelihood of butchers keeping meat long enough for it to become unsound. Horseflesh is sold now at five shops in the town. Pig Keeping.—To encourage food production, licences have been granted in 11 cases to keep pigs under conditions which do not comply with the bye-laws, and approximately 62 pigs were thus kept. Closer supervision is obviously necessary under these conditions. On account of the difficulty of obtaining foodstuffs the number of pigs kept by what may be termed the regular pig keepers is considerably less than in normal times. Factories and Workshops.—As far as possible, these have been kept under observation, and several nuisances and cases of deficient water closet accommodation have been dealt with. In one instance, smoke observations were taken over a prolonged period in reference to a factory chimney from which black smoke was emitted. Proceedings were taken, and a fine of £5 and £10 10s. costs was inflicted. Housing.—The deficiency of houses of all classes mentioned in the last report has been even more pronounced during the year under 7 review. Practically every house is occupied, hundreds of houses originally let to one family are let to two or three families, and the number of families occupying only one room has largely increased. Overcrowding is universal, and measures taken to check crowding in one house merely result in the overcrowding of another similar dwelling. In one of the smaller streets a house to house inspection showed that, out of 66 houses visited, overcrowding on the basis of more than two to a room, existed in 16 case and this is probably somewhat below the actual figure. In several instances in the large basement houses, especially in the east end of the district 30 and 40 persons are living in each house, but on account of the large and lofty character of the rooms overcrowding in the legal sense does not exist, and action cannot be taken. These are in short tenement dwellings, with this drawback, that they were never intended as such when built, and no bye-laws have been adopted in this district for the regulation of such dwellings, while the moral aspect of the conditions under which such families exist are such as to afford considerable fcod for reflection. Several of these houses are rented by one person as a speculation, and the profits realised must be very considerable. No representation has been made with reference to the closing of any dwelling which was considered unfit for human habitation, as this would merely accentuate the existing shortage. Six cottages with reference to which closing orders were made during the previous year remained closed during 1917. If any further increase in the number of munition works in the district is contemplated by the Ministry of Munitions, it is imperative that special housing arrangements should be made before more workers are introduced. PREVALENCE AND CONTROL OF INFECTIOUS DISEASE. Following is a list of the notifications received during the year, the numbers in brackets being the figures for the year 1916:— ,8 These are the net figures after deducting those cases in which, after observation, the original diagnosis proved inaccurate. Scarlet Fever 26 (42) Diphtheria 32 (43) Puerperal Fever 2 (-) Erysipelas 3 (10) Ophthalmia Neonatorum 8 (-) Measles 323 (429) German Measles 544 (79) Cerebro-Spinal Fever 5 (-) Pulmonary Tuberculosis 43 (52) Non-pulmonary 18 09) Continued Fever 1 (-) Total notifications 1005. The number of cases of Scarlet Fever and Diphtheria was less than half the average number during the past five years and less than any year since 1903. Every case of Ophthalmia Neonatorum was visited by the Health Visitors and assistance in nursing given where necessary. Four of the cases were treated at hospitals, and in every instance recovery took place. The number of cases of Measles was considerably less than during the preceding year, but there was a large increase in the number of notifications of German Measles, these cases occurring especially during March, April and May, As only four deaths were certified as due to measles during the year the disease was evidently of a mild type, but where a child has died from pneumonia following measles it is not uncommon to find that pneumonia only is mentioned in the death certificate and the original infectious disease omitted. It is probable, therefore, that the mortality rate was somewhat higher. On the whole, notification both of first and subsequent cases of measles was satisfactory, but 61 cases were discovered which had not been notified. In the majority of these the parents pleaded ignorance of the regulations, but in several instances parents had sent notices to the school teachers, under the impression that this was a sufficient notification. In one case a medical practitioner was warned for having omitted to notify. Out of the total of 867 cases, 442 were first notified by doctors and 238 by parents, the remaining 87 being discovered through the school teachers, school nurse or health visitors. First visits were paid by the 9 health visitors or school nurse to 507 cases, a total of 530 visits and revisits being paid. Notification of casts of Tuberculosis by medical practitioners were usually prompt. A certain proportion of the notifications referred to persons in whom the disease was advanced, but it must be remem bered that in many cases the disease takes a rapid course and is often well developed before the patient comes under medical treatment. In fifteen instances the first intimation of a case was the notice of admission to a sanatorium or other institution. These were principally men who were soldiers discharged from the service on account of tubercular disease and sent to sanatoria soon after they had received their discharge from the army. In some instances the previous residential connection with Twickenham was of a very slender character. The Medical Officer of Health has again continued to act as Deputy Tuberculosis Officer for this area of the County of Middlesex during the year, and in consequence the co-operation between the County Council as the Tuberculosis Authority and the Local Health Authority has been complete. The School Medical Officer has examined a considerable number of the contacts who were of school age. Visits of enquiry and disinfections after death or removal have been continued as usual. Cerebro-Spinal Fever.—Four cases of cerebro-spinal Meningitis came under notice in the district during the year, and all proved fatal. Three of these were removed to the hospital for observation and treatment. One was a naval case home on leave. The home contacts examined were found free from the organism causing the disease, which presumably was contracted in the service. The second case was that of a young woman in one of the large temporary Government departments. In this case, one of the contacts, a Canadian soldier was found to be a carrier of the disease. In the third case, removal to hospital was not requested and the diagnosis was not confirmed baeteriologically. In the fourth case, two of the contacts were found to be carriers of the disease, and examination was repeated during six to eight weeks before the absence of causative organism could be reported. No further case erose from this source. 10 HOSPITAL ACCOMMODATION and ADMINISTRATION. The admissions to the hospital numbered in all 71. Scarlet fever 24, diphtheria 35, cerebro-spinal fever 3. epidemic diarrhoea 2. In seven cases the original diagnosis was not confirmed. Seven deaths occurred, four being due to diphtheria and 3 to cerebrospinal meningitis. In June, two chalets were provided in the hospital grounds for outdoor treatment of cases of infectious disease, and have proved of the greatest value. Under the arrangements made to receive cases of epidemic diarrhæa among infants, should such occur during the hot weather, two cases were admitted, and both recovered. At the end of the year the Council decided to admit severe or complicated cases of measles to the hospital. The widening scope of hospital administration which is taking place calls for some remark. The hospital, with its two main wards and convalescent block, was intended for scarlet fever only, and it was no uncommon experience in the past for all the beds to be empty during part of the summer. This not only made the cost per occupied bed work out at a higher figure, but also left the staff without nursing duties at these times. The admission during recent years of diphtheria, and now of cerebro-spinal fever and epidemic diarrhoea, has not only kept the beds more closely occupied but has added much to the interest of the work of the nursing staff, and, although of course the duties have been more onerous they have been cheerfully performed. At times it has been a matter of considerable difficulty to arrange separate accommodation for the varied cases, but on account of the small number of scarlet fever cases admitted during the year such arrangement has hitherto been possible. The gain to the community, and especially the increased comfort and improved prospects of recovery in the patients themselves have been very obvious, and one of the most important undertakings when building again becomes possible must be to provide sufficient and separate accommodation for the expanding list of diseases which require hospital treatment, and for which hitherto no provision has been made, either by voluntary or municipal efforts. 11 Bacteriological Work—During the year 157 throat swabs were taken for suspected diphtheria, 59 by private medical practitioners, 30 by the Medical Officer or School Nurse, and the remainder at the hospital. In addition, three specimens of sputum were examined for the tubercle bacillus, one blood for the typhoid fever reaction, and 11 throat swabs from contacts for the organism of cerebro-spinal fever. Disinfection was carried out as usual. INFANT MORTALITY AND MEASURES TAKEN FOR ITS PREVENTION. Infant Mortality. Net deaths under 1 year of age 46 Rate per thousand births 82.28 Average rate for preceding 5 years 82.8 Death rate per thousand births of legitimate infants 72.2 Death rates per thousand births of illegitimate infants 149.5 The time for uttering platitudes as to the diminishing birth rate and the necessity for conserving infant life has surely passed and the day has dawned when the community has begun to realise the responsibility which is placed upon it for saving the lives of its infants which, for various preventible reasons have been allowed to be lost in the past. It will be remembered that a Health Visitor was appointed in 1914, after the adoption of the Notification of Births Act, and that the present permanent Health Visitor left to undertake military nursing duty in May, 1915. Since that time the duties have been carried out by five part-time Health Visitors, who have not had the advantage of being trained, but who have willingly and to the best of their ability undertaken the work as far as their other duties permitted. In March, 1917, on receipt of a letter from the Local Government Board, again drawing attention to the question, and on a report from the Medical Officer of Health, the Health Committee gave careful attention to the subject of the most suitahle measures to be taken to 12 deal with Maternity and Child Welfare in this district. The report by the Medical Officer drew attention to the number of deaths of infants arising from diseases which are more or less preventible by administrative control, and also dealt with the features of a complete scheme of Maternity and Child Welfare and the portions of it considered most immediately suitable for the district. On account of the large number of mothers who are engaged in occupations outside their homes, the question of the establishment of a creche was included. The Health Committee decided to recommend the Council to adopt the following scheme: — (a) Continuation of Health Visiting; (b) establishment of an Infant Welfare Centre; (c) the establishment of a Creche (day); and (d) the provision of hospital beds for treatment of certain conditions among infants, especially severe digestive disorders. The recommendations were unfortunately rejected by the Council by a narrow majority, but on a further report by the Medical Officer in September the question was again considered, and this time the Council decided to open an Infant Consultation Centre in the Heath Road. The scheme for this was duly approved by the Local Government Board, and the Centre was ready for opening at the end of the year to which this report refers. The measures adopted are being attended with satisfactory results as far as their limited scope permits, but it cannot be doubted that further measures will be taken in the near future. Nothing at present is being done to deal with or assist the expectant mother, firstly to enable her to ascertain if her pregnancy is pursuing a normal course and is likely to come to a satisfactory conclusion. Secondly, no provision exists in the district, or even within reasonable easy reach for the treatment of cases of pregnancy or labour presenting complications and requiring special treatment other than that of a major surgical character. The supply of midwives is probably sufficient. During the year 13 ten were on the register as practising in the district, six being trained and 4 registered but untrained. For some years now, a considerable and increasing number of patients of the wealthier classes have gone to private nursing homes for their confinement. Expectant mothers of a less wealthy class are now showing a tendency in the same direction, and in many instances are being admitted to midwives' houses for the birth of their babies. No doubt the influence of the war in disturbing domestic arrangements has increased this tendency, but the advantages derived from the conduct of a confinement away from a contracted flat or small cottage, in which are perhaps several young children, and in suitable surroundings and under more or less constant expert supervision, are no doubt appealing to all classes of mothers and are likely to be taken advantage of to an increasing extent in the future. The axiom that every woman has a right to proper surroundings and attention at the time of the birth of her child will probably be accepted without demur. If that is granted, then it cannot be said that Twickenham is fulfilling its obligations in this respect, and the question as to whether, at any rate, some provision should not be made for those expectant mothers who, by reason of some defect, require special treatment, or who, by reason of unsatisfactory conditions in their own dwellings, are unable to obtain the care and attention which they require. Still greater is the want of hospital accommodation for babies who, from various causes, may be described as "wasting." It is an evident fact to those engaged in Infant Welfare Work that a number of babies who die, and a still greater number of infants who do not "get on," would recover, improve, and improve permanently, if they could be admitted to hospital for a reasonable period and carefully tended. The treatment that these children require is difficult under the most favourable circumstances, and becomes practically impossible under the condition under which many of them have to be brought up. A scheme for institutional treatment of these cases could be easily combined with the provision of beds for expectant mothers just referred to. 14 Notification of Births Act.—Passing to a record of work done, it may be noted that 497 births were notffied, being about 91 per cent, of the number registered. Of those notified, 22 referred to stillbirths, the proportion of these to the births registered being about one in twenty-five. The Health Visitors paid the following visits during the year. To expectant mothers—nil. To infants under one year of age, 363 first visits paid. Visits were continued at intervals in a considerable number of cas^s until the children reached two years of age. The total visits and revisits paid during the year numbered no less than 3,306. TABLE OF CAUSES OF DEATH AMONG CHILDREN UNDER 1 YEAR OF AGE. Under 1 month 2—12 mos. Total Whooping cough — 2 2 Meningitis (not tubercular) 1 — 1 Convulsions — 1 1 Pneumonia (all forms) 1 10 11 Diarrhœa — 3 3 Enteritis 1 4 5 Overlaying 1 — 1 Injury at birth 1 — 1 Congenital malformation 3 — 3 Premature birth 5 — 5 Atrophy, debility and marasmus 1 6 7 Other causes 5 1 6 19 27 46 15 CAUSES OF DEATH DURING THE YEAR 1917. Civilians only. Causes of Death. All Causes. (Civilians only). Males. Females. 178 192 1 Enteric Fever - 1 2 Small Pox — - 3 Measles 3 1 4 Scarlet Fever — — 5 Whooping Cough 3 — 6 Diphtheria and croup 1 4 7 Influenza 5 7 8 Erysipelas — 1 9 Pulmonary tuberculosis 23 8 10 Tubercular meningitis — 3 11 Other tuberculous diseases 2 2 12 Cancer, malignant disease 12 23 13 Rheumatic fever — 14 Meningitis 4 3 15 Organic heart disease 17 21 16 Bronchitis 7 15 17 Pneumonia (all forms) 15 25 18 Other respiratory diseases 5 2 19 Diarrhoea, &c. (under 2 years) 4 3 20 Appendicitis and typhlitis 2 1 21 Cirrhosis of liver - 1 21A Alcoholism - - 22 Nephritis and Blight's disease 6 7 23 Puerperal Fever — — 24 Parturition, apart from puerperal fever — 1 25 Congenital debility, &c 5 8 26 Violence, apart from suicide 10 2 27 Suicide 1 28 Other defined diseases 53 53 29 Causes ill-defined or unknown Special causes (included above)- — — Cerebro-spinal fever 3 2 Polyomielitis — - Deaths of infants under 1 year of age 24 22 Total Births 291 268 Legitimate 269 247 Illegitimate 22 21 Population (for birthrate) 39,867 ,, death rate 35,764 Twickenham Urban District Council Annual Report of the SCHOOL MEDICAL OFFICER, 1917. 17 Public Health Department, Radnor House, Twickenham, August 1st, 1918. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Annual Report on the medical inspection and treatment of children attending the Public Elementary Schools in Twickenham for the year 1917. The work of medical inspection has been carried out to almost the full extent. As will be easily understood, this has been a matter of considerable difficulty at times, but has been rendered possible by the willing co-operation of the staff, without which it could not have been accomplished. While the normal inspections have been made, the amount of treatment has been considerably larger, the number of attendances at the Inspection and Minor Ailment Clinic having increased by almost a thousand on the previously high figure, while the number of cases treated by the School Dentist was 150 in excess of those recorded in any year since the treatment was commenced. There were 4,700 children on the school registers at the end of the year. The three code groups have been inspected and re-inspections made where necessary. All the medical inspections have been carried out by the School Medical Officer. For reasons of economy in printing and time, the report which follows will be found to be largely statistical, and is chiefly a record of work done, for purposes of comparison with previous years. Analysis of the figures to any extent has not been possible. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, George H. Duponk School Medical Officer,. 18 MEDICAL INSPECTION. The number of children examined at routine medical inspection in the schools was 1,456 In addition, 61 children were specially seen at the schools, and of the new cases seen at the Inspection Clinic, 915 weree xamined at the request of the Head Teachers, making a total of 2,432 inspections. All the re-inspections were made at the Clinic, and numbered approximately 336. TABLE I. Children examined at routine inspection in school. (Code Groups). Entrants. Intermediate Groups. Leavers. Total. G. T. 5 6 Oth. Tot. 8 Oth Tot. 12 13 14 — — Boys 189 90 27 306 176 22 198 149 5 — 154 658 Girls 203 111 29 343 217 14 231 218 6 — 224 798 Total .. 392 201 56 649 393 36 429 367 11 — 378 1456 19 TABLE II. Return of Defects found in course of Medical Inspection, 1917. Defect or Disease. Code Groups. Specials, Number referred for treatment. Number referred for observation. Malnutrition 3 Included Included under the return of cases seen at Inspection Clinic and not kept seperately. Uncleanliness— in other Head 133 conditions Body 3 Skin Ringworm— Head Body 2 Scabies 11 Impetigo 1 Eve Def. vision and squint 14 8 Ext. eye disease 2 Ear Def. hearing 2 2 Ear disease 8 Nose and throat Enlarged tonsils 7 4 Adenoids 11 4 Enl. tons, and adenoids ... 11 5 Def. speech 1 Heart's Circulation Organic 3 Functional Anaemia 12 2 Lungs Tuberculosis— Definite Suspend 1 5 Chronic bronch.&bronch.cat. 4 3 Other disease 1 2 Non-pulmonary tuberculosis Glands 4 Bones 1 Rickets 1 Deformities 1 Other dis. or defects 5 4 Nutrition.—The general nutrition of the children was, on the whole, satisfactory, and the increase in the price of food did not appear to have adversely affected the nutrition of the children to any appreciable extent. As in previous years, a comparatively small number of children were found to be underfed and neglected, but the condition of these was nearly always attributable to the unsatisfactory 20 character of their individual domestic conditions, and not to causes connected with the War. Cleanliness.—As has been noted in previous reports, the number of children found verminous at routine medical inspection was comparatively small, but the systematic examination by the School Nurse of all the children in the girls' and infants' departments has been continued. For obvious reasons, the Nurse's visits were not paid at regnlar intervals, but every class in the departments mentioned was examined at least twice during the year. Seventy-eight classes in all were examined, a total of about 3,000 children, and 341 children were found to show sufficient evidence of living vermin or nits to require notices to the parents. In 62 instances formal exclusion by the School Medical Officer was necessary, and in eleven cases proceedings were taken and convictions obtained. The number of mothers who go out to work is cjnsiderable and increasing, and in consequence the time that they can devote to the cleansing of the children's heads is restricted. This is undoubtedly an important reason for the increase of verminous cases. Adenoids and Enlarged Tonsils.—Of all the children examined for various reasons, 135 were found to have adenoids or enlarged tonsils to such a degree as to require special treatment. Of these, 81 were operated upon, 68 being treated at the expense of the Committee under the arrangement with St. John's Hospital. This number was considerably in excess of that authorised under the approved scheme, The reason for thus exceeding the appointed number was that in so many cases the fathers were away on active service, and in others the mothers went to work daily, and had no time or opportunity to hunt about for letters of recommendation for local hospitals, while the expense of taking the child to a London hospital is prohibitive in most cases A considerable number of children for whom treatment, although recommended, was not obtained, were those of Belgian, and especially of Flemish, parents. Unfortunately, the School Medical Officer does not speak Flemish, and consequently his powers of persuasion are not attended with the same degree of success that might otherwise be the case- 21 Defective Vision and Squint.—From all sources 102 cases recommended for treatment, 71 being treated by the Council's Ophthalmic Surgeon, Mr. Charles Blair, F.R.C.S., and 2 at hospitals. In 64 cases glasses were prescribed and obtained in each case. Systematic supervision was kept over all children for whom glasses had been prescribed and lists of these furnished to head teachers at intervals. In 10 cases glasses were repaired or renewed where found to be lost or broken. Ringworm of the Scalp.—Twenty-one cases of ringworm of the scalp were discovered, of which 17 were treated effectually and successfully by the Committee's Radiographer, Mr. George Blake. This treatment by X-Rays continues, as usual, to produce most satisfactory and speedy cures, and was agreed to, almost without demur, by the parents. Dental Inspection and Treatment.—The School Dentist, Mr. George Wonlfoid, made as many inspections in the schools as was possible, but the greater part of his time was devoted to treatment at the Clinic. Towards the end of the year it was found necessary to discontinue special dental inspections, except in a few cases referred by the School Medical Officer for opinion. A commencement was, however, made of routine re-inspection of those children already treated two to three years ago, but the time, half day a week, at present devoted to dentaj inspection and treatment has been found quite inadequate to deal with more than a small part of the dental defects. It is obvious that as soon as conditions permit, the amount of time devoted to dental inspection and treatment must be considerably increased. When the medical inspection of the intermediate group of children aged eight to nine was made nothing was more striking than the improvement noted in the condition of the mouths of those who had been treated by the School Dentist between the ages of six and eight. As before, all extractions were made under nitrous oxide ("gas") anaesthesia. The School Medical Officer administered anaesthetics to 308 children, an increase of 100 cases over the figure for the previous year. 12 Number and ages of children examined by the School Dentist at his routine inspection in the schools TABLE III. Age at date of Inspection. Total Children inspected. Total children with teeth requiring attention Children with good teeth. 6 7 8 9 10 11 1 12 13 14 Boys. 41 50 9 44 40 16 2 1 1 204 182 22 Girls 33 42 12 35 26 9 1 — — 158 149 9 Totals 74 92 21 79 66 25 3 1 1 362 331 31 In addition, 70 re-inspections were made at the Dental Clinic chiefly among children of the nine to ten group; the figures for each age hare not been kept separately. TABLE IV. Table of work done at the Dental Clinic. Total No. of new cases. No. receiving treatment. Fillings. Extractions. Special Examinations. Treatment refused. Routine reinspections. Total No. of attendances Temp. Perm. Temp. Perm. 228 1 450 1934 64 37 1 70 699 Contributions towards Treatment.—The amount received from parents as contributions towards the cost of medical, including dental, treatment was £29 13s 8d. Inspection Clinic and Treatment of Minor Ailments. All previous increases in the number of children attending this 23 Clinic have been eclipsed by the figures for the past year, and the work done has assumed a position of unequalled importance in the public health work of Twickenham. The attendances for all purposes totalled 4,034, this being an increase of almost a thousand on any previous year. One thousand two hundred and eighty three new cases were seen, and of the total attendances 1707 were for the treatment of minor ailments. Treatment has been continued daily and during school holidays, except a portion of the summer holidays. A considerable amount of the added work was accounted for by the increase in the cases of infectious skin disease, especially scabies or itch. During the past year 45 cases of this disease were seen and treated, as well as the accommodation at the Clinic allowed. The number of cases of impetigo was almost double that treated during any previous year and the satisfactory results derived from regular treatment of this disease, even in severe cases, alone would justify the existence of school medical treatment, apart from its other advantages. The loss of school attendance from these two conditions alone was very considerable, and it was no uncommon experience to find that a child who had been kept away from school by the parents for some weeks before coming under observation recovered in a week 01 ten days sufficiently to be able to return to school, NEW CASES SEEN AT THE CLINIC AT RADNOR HOUSE. Ringworm of scalp 26 Bronchitis and Bron. Catarrh 41 ,, body 16 Enlarged Glands 25 Scabies 45 Accidental Injuries 15 Impetigo 103 Nervous Affections 20 Septic Bores 60 Heart Cases 4 Boils and Abscesses 14 Rheumatism 8 Other Skin Diseases 73 Anaemia and Debility 55 Tonsilitis and Sore Throat 75 Gastric cases 24 Enlarged Tonsili and Adenoids 72 Chicken Pox 8 Otorrhsea 37 Whooping Cough 26 Deafness 16 Mumps 5 External Eye Disease 32 Diphtheria 1 Defective Vision 48 Influenza 4 Preparation for Oph. Exam 66 German Measles 3 Tubercle Contacts 8 Verminous 58 Tuberculosis of lungs 3 Dental 55 Tuberculosis (non-pul.) 10 Convalescent Home Cases 2 Doubtful Lungs 20 Other Cases 207 1,283 24 Infectious Disease in the Schools. Of the cases of measles and German measles which came under observation during the year, 459 were children attending the schools in the district, and the majority of the cases occurred during February, March, April and May Among the 130 children attending the Nelson (Infants') School, 50 cases of measles were reported in November and December. Curiously, at this time measles was practically absent from the other schools,, and the Nelson School was not affected at the time when the other schools were attacked earlier in the year. Almost every case of measles was visited by the School Nurse or Health Visitors, and exclusion of the patients and contacts attending the Infants' departments arranged. Twenty notifications of scarlet fever and 26 of diphtheria referred to school children. In the latter disease daily inspection for 12 days of the throats of all the children in the classes where a case had occurred and swabbing of contacts were continued, as in previous years. Only 67 cases of school children suffering from whooping cough came under notice, and visits were paid in each case by the School Nurse The prevalence of infectious skin disease has been noted in reporting on the work of the Minor Ailment Treatment Clinic. In a large number of the cases of scabies a direct history of infection from soldier relatives or friends on leave could be traced. TABLE V. Defective conditions recommended for treatment during 1917. Conditions. Number of defects requiring treatment. No. of defects treated. Results of treatment. Treatment obtained. No. of defects not treated, Per centage ol defnct8 treated. Left dist. and given up. No. still requiring treatment. To carry frwd. to 1918. From prev. year. New Total. Rem Imp. Unch. Committee. Other. Exclusions—ver. minous condn. — 62 62 60 60 — — — 60 2 96.7 1 1 Nose and throat 6 93 99 81 79 2 — 68 13 18 81.8 10 8 Ear disease and hearing 1 7 8 4 1 3 — - 4 4 50.0 4 — External eye — — — — — — — — — — — — - Vision & squint 10 70 80 73 67 — 6 71 2 7 91.2 — 7 Nervous system 1 3 4 4 1 3 — — 4 — 100.0 — — Tuberculosis pul. 1 10 11 8 — 8 — — 8 3 72.7 — 3 ,, non.pul. 4 13 17 14 3 11 — — 14 3 82.3 — 3 Heart — — — — - — — — — — — — — Ringworm 1 20 21 19 19 — — 18 1 2 90.4 2 — Hernia — 2 2 2 2 — — — 2 — 100.0 — — Repairs or renewal of glasses 2 8 10 10 10 - - 10 - - 100.0 — — Con. home 1 12 13 11 2 9 — — 11 2 84.6 2 — Skin disease 4 4 3 1 2 — — 3 1 75.0 1 — Other 4 57 61 44 16 26 2 - 44 17 72.1 11 6 Totals 31 361 392 333 261 64 8 167 166 59 84.9 31 28 26 TABLE VI Exceptional children in the area- Boys. Girls. Total. Blind Attending Public Elementary Schools - - - Attending Certified Schools for the Blind 2 — 2 Not at School - - - Deaf and dumb Attending Public Elementary Schools - - - Attending Certified Schools — 2 2. Mentally Deficient Feeble minded Attending Public Elementary Schools 3 1 4 Attending Certified Schools 1 1 2 Notified to Local Control Authority 2 1 3 Not at School 2 — 2 Imbeciles No School — — — Notified to Local Control Authority — — — Idiots No School 1 - 1 Notified to Local Control Authority 1 - 1 In Institution 1 - 1 Epileptics (including minor epilepsy) Attending Public Elementary Schools 3 2 5 Attending Certified Schools - - - Not at School — 2 2 Physically Defective Pulmonary Tuberculosis Attending Public Elementary Schools 3 4 7 Attending Certified Schools - - — Not at School — 1 1 Other forms of Tuberculosis Attending Public Elementary Schools 4 4 8 Attending Certified Schools - - - Not at School 3 3 6 Cripples (nontubercular) Attending Public Elementary Schools 5 3 8 Attending Certified Schools - - - Not at School - - -