WAL 88 Malthamstow Urban District Council. REPORT of THE MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER, FOR THE YEAR 1921. Waltbamstow Printed by J. C. Phelp & Son (T.U.), 62-64, Beulah Road. TO THE CHAIRMAN AND MEMBERS of the Walthamstow Urban District Council. Mrs. McEntee and Gentlemen, The Ministry of Health issued in December, 1921, a Circular as to the contents and arrangement of the Annual Reports of Medical Officers of Health. Inter alia, these are in future to be known as "Survey" and "Ordinary" Reports. The former are to be issued every fifth year, the latter for the intervening years. That issued for 1920 is reckoned as a Survey Report, and those for 1921 and three following years are to be of a simple character, giving certain information as outlined in an appendix to the Circular. By the deletion of a large quantity of matter fully dealt with in 1921, a considerable saving in time and money will be effected. Certain tables to preserve the continuity of the Reports, though not asked for, are given in this year's Report, as they will be useful when the next Survey Report has to be made. The outstanding feature of Public Health interest during the year 1921 for this District, was the epidemic prevalence of Scarlet Fever, which commenced in July and continued during the remaining months and on into February, 1922. Although 983 persons suffered from the disease, only five deaths occurred, giving a death-rate about half that of London and less than that prevailing in the 96 Great Towns. In June the National Census was taken, but no detailed figures for the Area have yet been published. Our enumerated population was 127,441—less than 3,000 in excess of that for 1911. It is difficult to realise the accuracy of these figures in view of "the overcrowding" repeatedly brought to notice, and remembering that in 1911 there were 3,000 "empties," and now not a single empty house to be found. The Registrar-General gives for the mid-year an estimated population of 129,800, upon which our Birth and Death rates are calculated. Birth-rate.—This was 2T7 for the year, compared with 24.7 for 1920, and an average of 19 for the preceding five years. 2 Our birth-rate is less than that for the Country as a whole and for the Great Towns, but only 0 6 per 1,000 less than that prevailing in London. Death-rate.—This has been a very favourable one—9.5 per 1,000 as compared with 12.1 for England and Wales, 12.3 for the Great Towns and 12 4 for London. Our death-rate for 1920 was 9 7 and the average for the five years 1916-20, 11.4. Our total deaths were 1,237 as against 1,293 in 1920, and the diminution was largely due to the fewer deaths caused by Influenza and lung diseases. There were seven fewer deaths from Diphtheria than in 1920, but the total deaths from Scarlet Fever and Diphtheria were only three less. The Zymotic Death-rate, or that resulting from deaths caused by Diphtheria, Scarlet Fever, Erysipelas, Measles, Whooping Cough and Diarrhœa was 0.52, as compared with 0.45 in 1920, 0.59 in 1919, 0.8 in 1918, 1.58 in 1911, and 2 82 in 1901. The increased rate of 1921 compared with 1920 was due to deaths from Diarrhoea and Enteritis and Scarlet Fever. Diarrhœal deaths were 45 and Scarlatinal 5, against 24, and 1 in 1920. Deaths from all these diseases are theoretically preventable, and no one should die except from senile decay, but we have not yet attained to that ideal. None of the diseases mentioned caused a death-rate here in excess of that elsewhere. The table on page 4 shows this. Infantile Mortality Rate.—This was slightly in excess of that of the previous year— 61.4, as against 59.9. Under this heading come the deaths of children under 1 year of age, and the number as compared with the births determines the rate. There is no assumption about the rate and it is not liable to error as the general birth-rate and Wards' rates are, which are determined on an estimated population. In the period 1901-10 this rate averaged 112, and only in the two latter years of the decade was it below 100. Between 1910 and 1920 the rate averaged 78.6, and practically every intervening year showed an improvement. The rate for 1920 was the lowest on record, a rate sought for but not believed to be obtainable some 25 years ago. Considering the character of our population, our infant mortality is most favourable. The rate is 22 per 1,000 less than that of the Country as a whole, and 26 per 1,000 less than that of the 96 Great Towns. 3 The following are the birth, death, and infantile mortality rates for this and similar districts in the outer zone of London:— Town. Population. Birth-rate. Death-rate. Infantile mortality rate. Croydon 190,877 194 . 10.6 77.6 Willesden 165,669 20.7 . 10.0 75.8 Hornsey 87,691 15.3 10.8 52.8 Tottenham 146,695 21.1 10.4 74.8 Edmonton 66,809 28.1 10.2 59.0 West Ham 300,905 28.4 12.1 71.5 East Ham 143,304 20.6 10.1 66.5 Leyton 128,432 18.9 9.8 74.2 Walthamstow 127,441 21.2 9.5 63.6 Ilford 85,191 . .. 173 . 8.7 50.9 The position of Ilford and Hornsey may depend largely on their low birth rates and the social conditions prevailing in the areas ; that of Edmonton shows that a considerable diminution of the infant mortality rate here is still possible. The following table shows our relative position compared with the Country and the Great and Smaller Towns as regards general death and infant mortality rates and those from the principal infectious diseases:— Birth-rate, Death-rate, and Analysis of Mortality during the Year 1921. (Provisional figures. Provisional populations estimated to the middle of 1920 have been used for the purposes of this Table. The mortality rates refer to the whole population as regards England and Wales, but only to civilians as regards Loiidon and the groups of towns.) Birthrate per 1,000 Total Population. Annual Death-rate per 1,000 Population. Rate per 1,000 Births Percentage of Total Deaths. All Causes. Enteric Fever. Small-Pox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Violence. Diarrhoea and Enteritis (under 2 years). Total Deaths under 1 year. Deaths in Public Institutions. Certified Causes of Death. Inquest Cases. Uncertified Causes of Death. England and Wales 22.4 121 0.02 0.00 0.06 0.03 0.12 0.12 0.23 0.44 15.5 83 25.5 92.5 6.4 1.1 96 Great Towns, including Lond. (Census Populations exceeding 50,000). 23.3 12.3 0.01 0.00 0.08 0.04 0.13 0.15 0.23 0.40 19.3 87 33.2 92.5 6.8 0.7 148 Smaller Towns (Census Populations 20,000—50,000). 22.7 11.3 0.01 0.00 0.05 0.03 0.11 0.11 0.26 0.35 15.6 84 17.7 93.5 51 1.4 London 22.3 12.4 0.01 0.00 0.05 0.06 0.12 0.25 0.23 0.42 21.3 80 49.2 91.6 8.2 0.2 Walthamstow 21.7 9.5 0.00 0.00 0.02 0.03 0.06 0.09 0.22 0.41 12.7 61.4 35.1 99.6 4.9 0.4 4 5 Comparing the figures for 1920 with those for 1921, the year 1921 may be regarded as a good one from the view of Public Health; under every heading there was a diminished mortality except from Scarlatina and Diarrhoea & Enteritis. The administration of the Maternity and Child Welfare Act, 1918, Milk (Mothers' and Children) Order, and the account keeping necessary in connection with the Welfare Centre, placed an amount of work on the clerical staff which is difficult to realise. The Lady Members of the Maternity and Child Welfare Committee have helped considerably by their dealing with all the applications for milk, and no complaints or grumblings have followed their decisions. The Council, no doubt, appreciate their work. I beg to remain, Mrs. McEntee and Gentlemen, Your obedient servant, J. J. CLARKE. 6 GENERAL STATISTICS Area 4,343 acres. Population 127,441 No. of inhabited houses (1911) 26,399 „ „ „ (1921) not yet given by Registrar-General. Rateable value £511,535 Sum represented by a penny rate... £1,917 M. F. Births Legitimate 1,384 1,369 Birth rate 21.7 Illegitimate 31 30 M. F. Deaths registered within District 801 397 404 No. registered of non-residents 25 7 18 No. of residents dying without the District 461 231 230 Death rate 1921 95 No. of women dying in, or in consequence of, child-birth From Sepsis 3 „ other causes, 10 Deaths of infants under one year of age, per 1,000 births— Legitimate, 160; Illegitimate, 13; Total,173 Deaths from Measles (all ages) 3 „ „ Whooping Cough (all ages) 8 „ „ Diarrhoea (under two years of age) 36 NOTIFIABLE DISEASES DURING THE YEAR. Disease. Total cases notified. Cases admitted to hospital. Total deaths. Diphtheria 380 259 12 Scarlet Fever 983 517 5 Enteric Fever (including Paratyphoid) 8 3 Puerperal Fever 5 3 8 Pneumonia 49 35 88 Tuberculosis— Pulmonary Males 109 53 64 Females 101 54 53 Non-pulmonary Males 26 4 14 Females 20 5 13 Thirty per cent. of those dying from Tuberculosis have not been notified as suffering from the disease during their life time, and death followed within three months of notification of 11 per cent. 7 Attention has been drawn to this, and failure to notify must be largely attributed to the fact that the doctors know well that little in the way of institutional treatment or after-care will be carried out for their patients. The Public Health administration as applied to Tuberculosis is lame and halting and unsatisfactory. The Medical Officer of Health receives the notification, a sanitary survey of the home is made, then copies of both are sent to the County Council, and practically here the local Medical Officer of Health finishes with the case until death occurs. Some years ago I made an effort to have the homes disinfected when vacated by Phthisical patients, and to do this I had to ask the co-operation of the landlords, which was readily given. Such a procedure was declared by the Local Government Board as ultra vires, and a breach of faith as to the secrecy which was supposed to be attached to every notification. Is it surprising that notification of Tuberculosis is inefficient? OPHTHALMIA NEONATORUM. These cases are classified as follows:— Cases notified. Cases treated. Vision unimpaired. Vision impaired. Total blindness. Deaths. At home. In hospital. 34 34 — 33 1 — 1 Twenty-one cases were very slightly and 13 seriously affected in one or both eyes. The latter had treatment at the Public Health Offices, and were visited at their homes by the Nurses. 4. CAUSES OF SICKNESS Apart from the epidemic prevalence of Scarlet Fever there were no outstanding features calling for special comment. During the first five months of the year Influenza was fairly prevalent, and 29 deaths have been attributed to this cause. 5. HOSPITAL PROVISION AND NURSING ARRANGEMENTS. Nursing.—There is no provision for home nursing by the County or the Local Authority. The local branch of the Essex Cottage Nursing Association employs 12 nurses who are largely occupied in Midwifery practice. They also do a considerable amount of nursing among the poor, but they do not attend, as a rule, on cases of Fever, Measles or Whooping Cough. Midwives.—There are 15 practising in the District. 8 Of these 4 reside at the local Branch of the Essex Nursing Association, and they are all under the supervision of the Medical Officer of Health. They are visited regularly and reported upon to the County Medical Officer of Health, through whom payments are made in accordance with the Provisions of the Midwives' Act, 1918. The work of all the Midwives has been satisfactory, and each and all showed a keen desire to comply with the regulations of the Midwives' Board. Clinics and Treatment Centres.—These embrace the following Situation. Accommodation. By whom provided. Description. Brookscroft, Forest Road Waiting rooms, weighing room, consult ing room, class rooms Voluntary Association Infant consultations, wards for observation and treatment. Truro Hall, High Street Waiting, weighing and consulting rooms Urban District Council Infant consultations, Ante-Natal Clinic. Lloyd Park, Walthamstow Waiting, consulting and treatment rooms Walthamstow Education Committee Minor ailments, Dental Clinic, Eye Clinic. Hoe Street, Walthamstow Do. Voluntary X-ray treatment for school children by arrangement. Do. Do. Essex County Council Tuberculosis Dispensary. Venereal Diseases are treated at the London Hospitals by arrangement made by the Essex County Council. The Council's Centre has been moved from High Street to Truro Road, a distance of some few hundred yards. Its present location is more favourable and suitable, and the premises, though not by any means ideal, are more roomy and convenient than those vacated. The consultations are still held twice weekly, and the number of names in the register at the end of the year was 2,648. The following are the quarterly attendances of children during the year:— New cases. Old cases. 1st quarter 287 1,751 2nd „ 239 2,259 3rd „ 252 2,649 4th „ 199 2,837 927 9,496 9 Brookscroft Voluntary Centre.— No change in the work or its character has taken place during the year. There are 4,415 names on the register, and the following are the quarterly attendances of children during the year:— New Cases Old Cases. 1st quarter 180 2,768 2nd „ 164 2,414 3rd „ 125 2,301 4th „ 116 2,115 Total 585 9,598 For 1920 the totals were 769 7,971 The Voluntary Nurses paid 2,646 visits to the homes of children brought to the Infant Consultations; 4,403 attendances were made by the mothers at the lectures delivered on Mothercraft and Infant Care, and 818 mothers attended the Needlework Classes. In addition, 321 massages were administered to children for varying causes. On the poorest estimates a very great deal of good is done for child welfare at the Centre, and much excellent work is carried out by educated, well-to-do voluntary workers, under the supervison and guidance of the Honorary Physician, Dr. Ellitott. The Ministry of Health has shown its appreciation by seeking information from the Hon. Secretary rather than the Medical Officer of Health as to Summer Diarrhœal Sickness in the Area. The number of cases admitted to the Observation Wards during the year was thirty. The children were suffering mainly from Malnutrition or the effects of improper feeding. Of the seven children who died, three were premature and rather hopeless from the start; one had Congenital Syphilis, one died from Meningitis, one from Zymotic Enteritis and one from Marasmus. HOSPITALS. The Local General Hospital contains 50 beds. It was originally established for the treatment of diseases of children, but now serves all the purposes of a general hospital. It is not subsidised by the Local Authority, except to the extent that two beds are retained for typhoid patients at a fixed fee, with a definite charge for those sent in by the Medical Officer of Health. There is no Institutional provision for Maternity. 10 The Fever Hospital—recognised accommodation 84 beds, for Scarlet Fever and Diphtheria patients—is situated without the area, and Brookfield, within the area, provides 22 additional beds for convalescent Scarlet Fever patients. Though taxed to their utmost capacity, they were unable in 1921 to deal with all the cases of Scarlet Fever needing removal from their homes. No recommendation to provide additional beds was made by me, nor was the enlargement of the Hospital considered by the Council. The present time is considered inopportune for any expenditure of money for such a purpose, and there is no unanimity among Public Health Officials that such an expenditure would be justified by results. The arrangements for dealing with Infectious Diseases in the district was fully set out in last year's report. At present there is no provision for the hospital treatment of Small Pox, and if cases of this disease arose in the area the situation would be an embarrassing one. There is no institution in the district for unmarried mothers, illegitimate infants or homeless children. Ambulance Facilities.—Two Motor Ambulances for Infectious Diseases are maintained by the Local Authority, and the St. John's Ambulance Association hires its motor ambulance for the removal to hospital of cases of serious illness, and deals with accidents without payment. 6. LABORATORY WORK. The Municipal Laboratory is mainly used for the Bacteriological diagnosis of Diphtheria. During the year 2,482 examinations were made as follows:— No. Examined. Result. Positive. Negative. Diphtheria 2,467 522 1,945 Hairs for Ringworm 10 9 1 Sputum for T.B. 5 1 4 The County Council of Essex provide, free of charge, at the County Laboratories in London, for the examinations of all kinds of pathological specimens sent by any practitioner in the district. The local laboratory is found so convenient that, during the year, the local doctors sent 643 specimens of suspected Diphtheria. Cases of Infectious Disease notified during the Year 1921. The following table shows the numbers and the Infectious Diseases notified for the whole District and for the Wards, and the number removed to Hospital:— Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in Each Locality. Total Cases Removed to Hospital. All Ages At Ages—Years. St. James Street. High Street. Hoe Street. Wood Street. Hale End. Higham Hill. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 65 and upwards. Small Pox — — - - - - - - - - - - - - - Cholera - - - - - - - - - - - - - - - Plague — - - - - - - - - - - - - - - Diphtheria (including Membranous Croup 380 6 78 224 42 23 6 1 99 68 43 30 46 94 259 Erysipelas 58 1 — 3 8 19 20 7 8 7 12 13 10 8 5 Scarlet Fever 983 5 131 685 126 33 3 - 170 137 124 106 198 248 517 Typhus Fever - - - - - - - - - - - - - - - Enteric Fever 3 — — 1 — 2 — — — — 1 1 1 — 3 Relapsing Fever — - — — — — — — — — — — — — — Continued Fever - - - - - - - - - - — — — — — Puerperal Fever 5 — — — 1 4 — - 1 — 1 1 — 2 3 Cerebro - spinal Meningitis - - - - - - - - - - - - - — — Poliomyelitis 2 — 1 1 - - - - - — 2 — — — 1 Ophthalmia Neonatorum 34 34 - - - - - - 6 3 6 4 3 12 — Pulmonary Tuberculosis 210 — 3 16 58 107 25 1 42 42 37 21 29 39 — Other forms of Tuberculosis 46 — 10 12 9 11 4 — 8 12 5 10 5 6 — Encephalitis Lethargica 6 — 1 — 1 3 1 — 1 1 2 1 — 1 4 Malaria (Imported) 1 — — — — 1 — — — 1 — — — — — Dysentery „ — — — — — — — - — — — — — — — Pneumonia 49 - 2 9 7 18 12 1 8 12 8 2 7 12 35 Trench Fever 1 — — — — 1 — — — — — — 1 — — Totals 1778 46 226 951 252 222 71 10 343 283 241 189 300 422 827 Causes of and Ages at Death during the year 1921. Whole District and Wards. Causes of Death. Nett Deaths at the subjoined ages of "Residents" whether occurring within or without the district. Total Deat hs whether of "Residents" or "NonResidents" in Institutions in the District. Wards. All Ages Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 45 years. 45 and under 65 years. 65 and upwards. St. James Street High Street Hoe Street Wood Street Hale End. Higham Hill. No. 1 2 3 4 5 6 7 8 9 10 11 1 Enteric Fever - - - - - - - - - - - - - - - - 2 Small-Pox - - - - - - - - - - - - - - - - 3 Measles 3 2 1 — — — — — — — 3 - — — — — 4 Scarlet Fever 5 — 1 2 2 — — — — — — 4 — — — 1 5 Whooping Cough 8 3 4 1 — — — ;— — — 4 — 2 1 — 1 6 Diphtheria and Croup 12 — 1 4 7 — — — — — 5 3 — 1 1 1 7 Influenza 29 2 — 1 4 5 3 9 5 — 7 4 6 5 4 3 8 Erysipelas 2 — - — — — — 1 1 — — 1 1 — — 9 Phthisis (Pulmonary Tuberculosis) 117 — — — 3 29 56 27 2 — 25 18 29 15 11 19 10 Tuberculous Meningitis 12 1 4 3 3 1 — — — — 2 2 3 2 — 3 11 Other Tuberculous Diseases 15 — 1 — — 2 5 7 - - 3 3 1 2 3 3 12 Cancer, malignant disease 111 — — — 1 — 11 50 49 — 19 25 27 12 15 13 13 Rheumatic Fever 3 - - - - 1 2 — — — — 1 — 1 — 1 14 Meningitis 7 3 — - 1 2 1 — — — 2 1 2 — 2 — 14a Cerebro - spinal Meningitis - — - - - — - - - - - — — — — — 15 Organic Heart Disease 118 - - - 3 7 20 33 55 1 20 19 28 21 16 14 16 Bronchitis 96 12 1 - - - 5 22 56 - 26 19 19 14 9 9 17 Pneumonia (all forms) 88 15 9 4 7 5 17 18 13 1 24 8 18 12 9 17 18 Other Diseases of Respiratory Organs 16 — 1 — 1 — 2 7 5 — 4 2 6 1 1 2 19 Diarrhœa and Enteritis 45 30 6 — 2 — 2 1 4 — 14 11 1 8 5 6 20 Appendicitis and Typhlitis - - - - - - - - - - - - - - - - 21 Cirrhosis of Liver 10 — — — — — 1 6 3 — 2 2 3 2 — 1 21a Alcoholism 1 - - - - - - 1 — — 1 — — — — - 22 Nephritis and Bright's Disease 27 — — — 2 — 3 14 8 — 3 5 6 5 4 4 23 Puerperal Fever 3 — — — — — 3 - — — 1 — — 1 — 1 24 Other Accidents and Diseases of Pregnancy and Parturition 10 - - - - 2 8 - - - 1 3 1 - 2 3 25 Congenital Debility and Malformation, including Premature Birth 83 83 - - - - - - - - 17 15 20 11 6 14 26 Violent Deaths, excluding Suicide 54 3 3 2 4 5 17 9 11 6 14 5 6 8 6 15 27 Suicide 6 — — — — — 2 3 1 — — — 2 — 2 2 Poliomyelitis and Encephalitis 2 — — 2 — — — — — — — — 1 1 — — Old Age 94 - - - - - - - 94 - 16 12 24 14 9 19 28 Other Defined Diseases 260 19 3 4 10 9 41 75 99 2 50 39 58 34 34 45 29 Diseases ill-defined or unknown - - - - - - - - - - - - - - - - Totals 1237 173 35 23 50 68 199 283 406 10 263 202 264 171 139 197 SUMMARY, 1921. Causes of Death of Children 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 Mths. 3 Months and under 6 Mths. 6 Months and under 9 Mths. 9 Months and under 12 Mths. Total Deaths under One Year. Wards. St. James Street. High Street. Hoe Street. Wood Street. Hale End. Higham Hill. All Causes Certified 53 19 8 10 90 27 24 18 14 173 Uncertified - - - - - - - - - - Influenza 1 - - - 1 - - - - 1 - - - - 1 - Small-Pox — - - - - - - - - - - - - - - - Chicken-Pox — - - - - - - - - - - - - - - - Measles - - - - - - - 1 1 2 2 - - - - - Scarlet Fever - - - - - - - - - - - - - - - - Whooping Cough — — — 1 1 1 - - 1 3 — - 2 - - 1 Diphtheria and Croup - - - - - - - - - - - - - - - - Erysipelas - - - - - - - - - - - - - - - - Tuberculous Meningitis — — — — — — - 1 — 1 — - — - - 1 Abdominal Tuberculosis (b) — - - - - - - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - - - - - - - Phthisis - - - - - - - - - - - - - - - - Meningitis (not Tuberculous) — — — — — — 2 1 1 4 — — 2 - 2 — Convulsions — 2 — 1 3 — 1 - 1 5 1 2 — - — 2 Laryngitis — — — — — — — - — — - — — - — — Bronchitis 1 1 — 2 4 3 3 2 — 12 4 4 — 2 1 1 Influenzal Bronchitis 1 — — — 1 — — — — 1 1 - — — — — Pneumonia (all forms) — — — — — 3 4 4 5 16 6 4 1 3 1 1 Diarrhœa — 1 — 1 2 2 5 3 2 14 7 2 — 3 1 1 Enteritis — — 1 — 1 3 5 4 3 16 4 4 1 3 2 2 Gastritis — — 1 — 1 — — 1 — 2 — — — — — 2 Syphilis — — — — — — — 1 — 1 — — — 1 — — Rickets — - - - - - - - - - - - - - - - Inattention at Birth, wilful neglect 4 — — — 4 — — — — 4 — — — 3 1 — Suffocation, overlying 2 — — — 2 1 — — — 3 1 — — 1 — 1 Injury at Birth - - - - - - - - - - - - - - - - Atelectasis 3 2 — 1 6 — — — — 6 1 2 1 — — 2 Congenital Malformations 6 1 1 1 9 3 1 — — 13 2 1 3 4 2 1 Premature Birth 32 7 2 1 42 5 — — — 47 10 7 14 5 4 7 Atrophy, Debility and Marasmus 2 5 3 1 11 3 — — — 14 3 3 3 1 — 4 Other Causes 1 — — 1 2 3 3 — — 8 1 3 - 1 1 2 53 19 8 10 90 27 24 18 14 173 43 32 27 27 16 28 11 Birth, Death, and Other Rates since 1891. Year. Births. Deaths. B. Rate. D. Rate. Zymotic D. R. Infantile Mortality Rate. Natural Increase of Population. 1891 1756 694 37.3 14.7 1.9 120.0 1062 1892 1717 915 34.75 18.0 3.9 145.6 802 1893 1809 809 34.78 15.55 2.43 133.2 1000 1894 1813 717 32.0 12.6 1.8 129.6 1096 1895 2021 965 33.2 15.8 3.5 153.3 1056 Average for 5 years. 1891-95 1823 820 34.4 15.33 2.7 136.3 1003 1896 2101 817 32.3 12.5 2.4 127.5 1284 1897 2246 832 32.08 11.88 2.8 132.0 1414 1898 2294 1034 29.8 13.4 3.67 169.5 1260 1899 2835 1282 34.14 15.44 2.94 170.0 1553 1900 3037 1254 33.37 13.78 2.8 158.7 1783 Average for 5 years 1896-00 2502 1043 32.33 13.4 2.92 151. 5 1458 1901 3210 1296 33.1 13.35 2.2 147.6 1914 1902 3426 1154 34.82 11.73 1.3 115.0 2272 1903 3535 1178 34.97 11.65 1.9 113.7 2357 1904 3649 1330 35.14 12.81 3.1 135.9 2319 1905 3389 1249 31.76 11.71 1.8 104.4 2140 Average for 5 years 1901-05 3341 1241 33.94 12.25 2.18 123.3 2200 1906 3594 1447 32.79 13.20 2.9 129.7 2147 1907 3629 1376 32.23 12.22 2.0 104.7 2253 1908 3482 1258 30.10 10.87 1.0 100.8 2224 1909 3369 1205 28.35 10.14 1.0 83.4 2164 1910 3197 1186 26.18 9.71 0.8 88.5 2011 Average for 5 years. 1906-10. 3454 1294 29.93 11.22 1.5 101.4 2159 1911 3182 1456 25.36 11.70 1.58 108.4 1726 1912 3150 1267 24.40 9.80 0.87 78.9 1883 1913 3261 1334 24.76 10.13 0.84 79.5 1926 1914 3134 1428 23.24 10.50 0.98 77.5 1706 1915 2826 1573 21.7 11.9 1.06 93.1 1253 Average for 5 years. 1911-15. 3110 1411 23.89 10.8 1.06 87.4 1698 1916 2854 1376 20.5 10.7 0.72 69.3 1478 1917 2228 1330 16.7 11.1 0.75 70.0 898 1918 2034 1792 15.9 15.7 0.79 81.1 252 1919 2215 1273 17.2 9.9 0.61 69.5 1028 1920 3286 1293 24.7 9.7 0.45 59.9 1993 1921 2673 1237 21.7 9.5 0.52 61.4 1436 Average for 6 years. 1916-21 2548 1383 19.4 11.1 0.64 68.5 1181 12 ADOPTIVE ACTS, BYE-LAWS AND REGULATIONS Relating to Public Health in force in the District. Adopted Acts. The Infectious Disease (Notification) Act, 1889. The Public Health Acts (Amendment) Act, 1890. Parts II., III. and V. The Infectious Disease (Prevention) Act, 1890. The Public Libraries Act, 1892. Baths and Wash houses Act, 1846, and the Acts amending the same. The Burials Acts, 1852 to 1885. The Public Health Acts (Amendment) Act, 1907. Parts II., III., IV., V., VI. and X. Bye-Laws. Bye-Laws with respect to Common Lodging-houses. Bye-Laws with respect to Slaughter-houses. Bye-Laws with respect to Nuisances. Bye-Laws with respect to Houses let in Lodgings or occupied by members of more than one family. Bye.Laws as to Nuisances in connection with the Removal of Offensive or Noxious Matters. Bye-Laws as to the Decent Conduct of Persons using Sanitary Conveniences provided and maintained by the Local Authority for Public Accommodation. Bye-Laws for Imposing on the Occupier of any Premises duties in connection with the Removal of House Refuse so as to facilitate the work of collection. Bye-Laws for the Prevention of Nuisances arising from Filth, Ashes and Rubbish. Bye-Laws with respect to New Streets and Buildings and the Alteration of Buildings. Bye-Laws with respect to the Provision of Means of Escape in case of Fire in certain Factories and Workshops. Bye-Laws for the Regulation of Offensive Trades. Bye-Laws re Employment of Children. Regulations. Regulations to be observed by Occupiers of Bakehouses. Regulations with respect to the Management of Sanitary Conveniences provided and maintained by the Local Authority. Regulations with respect to Dairies, Cow-sheds and Milk Shops. 18 7. SANITARY ADMINISTRATION. The following is a summary of the work carried out during the year by the Sanitary Inspectors:— 1921. 1920. Number of Inspections made 6145 6425 Number of nuisances detected 2742 2260 Number of complaints received 2188 1847 Informal Notices served 2617 2532 ,, „ complied with 2418 1870 Statutory Notices served 33 42 The nature and variety of the work is shown in the following tables:— Drains tested 260 „ reconstructed or repaired 260 „ obstructions removed 196 ,, means of access provided 38 „ ventilation provided 35 „ ,, repaired 134 Soil pipes repaired 26 ,, new provided 5 Rainwater pipes, renewed 180 „ ,, disconnected from drains 6 Roofs repaired or renewed 448 Gutterings repaired or renewed 335 W.c. pans or traps provided 127 Gully traps provided 67 W.c. flush cisterns provided 46 „ „ repaired 256 „ reinstated 49 W.c. floors concreted 49 W.c.'s repaired and cleansed 257 W.c.'s, light and ventilation improved 1 Waste-pipes renewed or trapped 225 New sinks provided 12 Water supply reinstated 11 Cisterns cleansed and covered 106 Drinking-water cisterns abolished 0 Urinals, improved flushes provided 1 „ cleansed or repaired 9 ,, paved 1 „ provided new 1 Sculleries paved 29 Yards and forecourts paved and repaired 341 Dirty houses cleansed 99 „ rooms cleansed 4,567 Floors repaired 234 14 Ventilations under floors provided 228 New damp-proof courses provided 38 Sites concreted 5 Rooms ventilated 4 Offensive accumulations removed 59 Animals improperly kept removed 6 Manure receptacles provided 4 Stables closed — „ cleansed 29 ,, paved and drained 5 Manholes repaired or resealed 39 Bell traps abolished — Other cases of dampness remedied 159 Miscellaneous repairs 722 Infectious Diseases. Visits to premises 1,359 Premises disinfected 1,435 Articles disinfected at Low Hall 12,820 Articles destroyed at Low Hall 55 Dampness in Houses. Sites concreted 5 Damp-proof courses provided 38 Yards and forecourts paved and drained 341 Roofs made watertight 448 Rainwater pipes made good 186 Guttering repaired or renewed 335 Dampness remedied 159 Ventilation under floors provided 228 House-to-House Inspections 110 Special Premises. Number. Visits paid. Slaughter-houses 15 147 Butchers' shops 72 276 Bakehouses 44 64 Fishmongers (fish frying and curing) 38 229 Eating-houses 34 27 Ice cream vendors 70 70 Cowsheds 12 40 Milkshops 66 146 Laundries 29 52 Rag and bone dealers 12 36 Elementary Schools 27 14 Private Schools 13 6 Piggeries 10 46 Street Stalls Numerous 158 Greengrocers „ 47 15 As a result of the regular periodical visiting of the Special Premises the following works were carried out:— Butchers' Shops and Slaughter-Houses. Special cleansings, 42; Smoke Nuisance abated, 1; Paving repaired, 3; Floors repaired, 5; Accumulations removed, 1 ; New Safes provided, 2; New Galvanised Bins provided, 4. Bakehouses. Special cleansings, 51; Roofs repaired or improved, 1; Paving repaired, 6; Rain-Water Pipe provided, 1; Gutters repaired, 4; New Sink-waste provided, 1 ; New Ceiling provided, 2. Fishmongers' Shops. Premises cleansed, 21; Smoke-holes repaired, 5; Paving repaired, 10; Flushes to w.c.'s repaired, 2 ; Drains cleared, 1; Drains repaired, 3; New w.c. pans and traps provided, 2; Floors repaired, 2; Accumulations removed, 6; New Sinkwaste provided, 1. Coffee and Eating Houses. Special cleansings, 3; Choked drains cleared, 1; Dust-bins provided, 1; Gutters repaired, 1; New Man-hole cover provided, 1; New Sink-waste provided, 1; Yard Paving repaired, 4. Ice-Cream Vendors. Special cleansings, 6. Cowsheds and Milkshops. Special cleansings, 12; Offensive accumulations removed, 4; Drainage improved, 2; Roofs repaired, 1; Yard paving repaired, 2; VV.c's. cleansed, 2. Stable Premises. Cleansings, 29; Accumulations removed, 39; Gutterings repaired, 6; Paved and drained, 5. Laundries. Special cleansings, 13; Pavings repaired, 1; D.W. Cistern cleansed and covered, 3. Rag and Bone Dealers. Accumulations removed, 1; Cleansings, 14; Floors repaired, 1; Roofs repaired, 3. Private Schools. Cleansings, 2; Obstruction in drains removed, 2; Piggeries cleaned, 12; Paved and drained, 2; Paving relaid, 2. 16 Unsound Food. 80 bags of potatoes 30 trunks of haddocks 7 stones of mutton 6 stones of herrings 4 stones 6 lbs. of beef 1 case of dates 11 boxes of kippers 4 cases of rabbits 8 stones of skate 62 cases of rabbits 26 stones 6 lbs. of bacon 29 cases of rabbits 2 boxes of kippers 50 cases of rabbits 1 trunk of haddocks 20 cases of rabbits 1 ox liver 22 cases of rabbits 5 sheep carcases and all organs 1 box of dabs 3 lbs. of beef pieces 120 boxes of apples 94 rolls of bacon (4½ cwts.) 60 bags of potatoes 1 sack of winkles The following were condemned and affected with T.B.:— 5 pigs heads. 1 sow pig and all organs. Sale of Food and Drugs Act. Number of samples taken 6 Number of samples found genuine 6 Unsound Food. 1 pig and all organs seized, T.B. Penalty on butcher, £10 and costs. HOUSING. Number of new houses erected during the year— (а) Total 161 (b) As part of Municipal Housing scheme 159 I.—Unfit Dwelling Houses. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health and Housing Acts) 6,145 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 110 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation nil (4) Number of dwelling-houses (exclusiveof those referred to under the preceding sub-heading)found not to be in all respects reasonably fit for human habitation 108 17 II.— Remedy of Defects with Service of Formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 2,418 III.— Action under Statutory Powers. A. Proceedings under section 28 of the Housing, Town Planning, &.c, Act, 1919. (1) Number of dwelling-houses in respect of which notices were served requiring repairs 28 (2) Number of dwelling-houses which were dered fit— (a) by owners 19 (b) by Local Authority in default of owners 6 (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close nil B. Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 5 (2) Number of dwelling-houses in which defects were remedied— (a) by owners 5 (b) by Local Authority in default of owners nil C. Proceedings under sections 17 and 18 of the Housing, Town Planing, &c., Act, 1909. (1) Number of representations made with a view to the making of Closing Orders nil (2) Number of dwelling-houses in respect of which Closing Orders were made nil (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouse having been rendered fit nil (4) Number of dwelling-houses in respect of which Demolition Orders were made nil (5) Number of dwelling-houses demolished in suance of Demolition Orders nil rs 18 SANATORIUM REPORT, 1921, As submitted by Dr. Daly, Resident Medical Officer. ADMISSIONS, DISCHARGES, AND DEATHS. Scarlet Fever. Diphtheria. Tuberculosis. S. F. & Diph. S. F. & C. P. Diph. & C. P. Total. Remaining on Dec. 31,1920 90 30 14 — — — 134 Admitted during 1921 545 263 — 6 2 1 872 Total 635 293 69 6 2 1 1006 Discharged during 1921 550 229 50 6 2 1 838 Died during 1921 1 12 4 — — — 17 Remaining on Dec. 31,1921 84 52 15 — — — 151 Total 635 293 69 6 2 1 1006 SEX AND AGES OF PATIENTS ADMITTED. Disease. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years and upwards. Total of Total. M f M f M f M f M F Scarlet Fever 39 43 93 124 60 101 33 52 225 320 545 Diphtheria 30 27 51 63 30 34 4 24 115 148 263 S.F. & Dipli. — 2 1 1 1 1 — — 2 4 6 S. F. & C. P. — — — 2 — — — — 2 2 Diph. & C.P. - - 1 - - - - - 1 - 1 Tuberculosis - - - - - - - 55 - 55 55 Totals 69 72 146 190 91 136 37 131 343 529 872 141 336 227 168 872 872 Scarlet Fever.—Five hundred and forty-five cases were admitted during the year, compared with 228 in 1920, 205 in 1919 and 100 in 1918. MONTHLY ADMISSION OF SCARLET FEVER CASES. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years and upwards. Total. M F M F M F M F January 2 5 11 13 12 5 1 2 51 February 4 3 2 6 1 7 1 3 27 March 1 — 5 5 7 3 2 6 29 April 2 3 2 6 1 6 5 2 27 May 2 1 8 11 1 2 1 3 29 June 6 4 6 12 2 5 2 4 41 July — 3 11 10 8 22 2 3 59 August 3 6 11 4 3 11 7 6 51 September 2 6 8 15 4 10 4 8 57 October 4 4 14 12 10 11 1 8 64 November 4 5 6 16 4 11 4 4 54 December 9 3 9 14 8 7 3 3 56 Totals 39 43 93 124 60 101 33 52 545 19 There was one death during the year, with a case mortality of 0.18 per cent. The chief complications were Otorrhœa, 20; Heart trouble, 11; Nephritis, 8; Transient Albuminuria, 12; Glandular involvement, both simple and septic, 15; Rheumatism (Muscular), 4; Arthritis (simple), 3; Mastoiditis, 3 ; Bronchitis, 3. One case proved to be incubating Chicken 1'ox. Diphtheria.—Two hundred and sixty-three cases admitted during the year, compared with 220 in 1920, 273 in 1919, 180 in 1918. MONTHLY ADMISSION OF DIPHTHERIA CASES. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years and upwards. Total. m f m f m f m f January 3 3 8 9 5 4 — 3 35 February 4 3 4 7 1 4 1 2 26 March 2 2 5 4 4 1 — 2 20 April — 4 1 3 2 2 1 2 15 May 1 1 2 2 1 — — 1 8 June 2 4 2 1 2 3 — — 14 July 2 — 7 7 2 2 — — 20 August 4 1 2 3 4 3 1 18 September 2 1 5 4 2 9 1 6 30 October 5 6 6 9 1 2 — 2 31 November 2 2 6 8 4 1 1 — 24 December 3 — 3 6 2 3 — 5 22 Totals 30 27 51 63 30 34 4 24 263 There were 12 deaths during the year, equal to a case mortality of 4'5 per cent. The chief complications were Otorrhcea, 11; Cardiac syncopal attacks, 20; Palatal Paralysis, 10; Strabismus, 6; Albuminuria, 7; Nephritis, 3; Adenitis, 2. Of the cases admitted 16 had urgent Laryngeal involvement. Two cases were so urgent that Tracheotomy had to be performed at once. Both cases recovered. The fatal cases were mainly those who failed to have early medical attendance and consequent very late administration of Antitoxin Serum. Three cases were found on admittance to have Scarlet Fever as a concurrent infection. Staff.—One nurse contracted Diphtheria, and a nurse and one maid suffered from Scarlet Fever. One of the nurses contracted Erysipelas; a maid and a nurse Tonsilitis; and one of the maids developed Mastoiditis. Swabs.—One thousand seven hundred swabs were taken and examined during the year. SCHOOL MEDICAL SERVICE. 23 TO THE CHAIRMAN AND MEMBERS of the Walthamstow Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit the Annual Report on the work of the School Medical Service as carried out in your District in 1921, under the Education (Administrative Provisions) Act, 1907. In December, 1920, the Board of Education issued a Memorandum with suggestions as to the headings under which the Annual Reports of School Medical Officers should be made. These instructions were very fully carried out in the Report submitted for 1920. There has been no change in the routine medical work at the Schools or the Clinics, and no new service has been initiated in 1921, so that much of the information asked for by the Board of Education and given in last year's Report holds good for this and will not be reproduced. With this reservation the present Report follows the lines laid down by the Central Authority. From the perusal of the Official Statistical tables given at the end of the Report, all the Members can get a fairly correct appreciation of the work done here and the results of " following up." Dr. Harding left your service in October, and fortunately Dr. Broderick, his successor, was able to commence duty a fortnight later, so that the requirements of the Code as to Medical Inspection were fully carried out. The activities of the Clinics were not at any time interfered with. The keeping of complete records of work done at the inspections and treatment Clinics for individual children, entails an amount of clerical work which cannot be justified as far as results are concerned. The.thing that matters is that every child needing treatment should have it, and not that the details of it should be recorded on a card. For statistical purposes a complete medical record for each child during school life is no doubt of value, but unless the present clerical 24 staff is increased one cannot guarantee that all minor treatment given to each child will be recorded, and that full records for all children examined and found without defects are equally kept. When a child leaves school his "Dossier" or half a dozen cards must either be stored away or later passed on to his panel doctor, to whom they would be neither useful nor helpful. In nine cases out of ten he could base no judgment on the facts disclosed. If there were less routine inspections, indexing and tabulations of our school children, more time would be available for advice and treatment, and the money saved could be usefully employed in other directions. It is a matter of great regret that on the grounds of "economy" the Board of Education refused sanction for the Physically Defective Centre, and have given instructions that the usefulness of the Myope Centre as it exists must be curtailed, while maintaining and insisting on services which could be very well scrapped. I am pleased to acknowledge the valuable help given me throughout the year by the Head Teachers and their Staffs. Their hearty co-operation in the work of Medical Inspection and in safeguarding the health of our school children was invaluable. The Head Teachers show great discrimination in sending ailing and other children to the School Clinic, and thus helped to strengthen my views that under the control of the Teachers our school children maintain a better standard of health and more freedom from Infectious Diseases than when supervised only by the parents. Mr. Longman, the Superintendent of Attendance Officers, has also been most helpful. Gifted with an instinctive liking for children, he appreciates the objects of the School Medical Service, and he has freely and willingly entered into the spirit of the work and given all the co-operation and help which one could wish. The School Medical Staff has served your Committee intelligently and faithfully, and has always willingly rendered me every assistance that could be reasonably asked for. I beg to remain, Ladies and Gentlemen, Your obedient servant, J. J. CLARKE. 25 GENERAL INFORMATION- REPORT FOR 1921 Number of Schools and Accommodation. Boys Girls Infants Mixed Seating Accommodation Boys Girls Infants Mixed Provided 17 17 16 7 7491 7233 6834 2715 Non-provided 1 2 2 1 244 472 437 314 Special Schools— Mentally Defective 1 1 — — 65 65 — — Deaf and Dumb — — — 1 — — — 20 Myope Centre — — — 1 - — — 120 Totals 19 20 18 10 7960 7890 7271 3169 1921 1920 Number of children on Register, December 31st 23,510 23,861 Average attendance 20,229 19,599 Percentage attendance 86.0 82.1 Census June population 127,441 132,771 Percentage of school children to population 18.3 18.0 26 FINANCIAL STATEMENT. 1920. 1921. £ s. d. £ s. d. Rateable value of District 505,182 0 0 511,535 0 0 The average cost of education per child:— (1) In the ordinary school 9 0 6 10 19 2¾ (2) Mentally Defective centre 30 17 0 37 13 1 (3) Deaf and Dumb centre 24 14 11 31 10 6¼ (4) In the Myope centre 21 8 6¾ 32 3 10½ The education rate tor— The half year ending March 31st 0 1 3¾ 0 2 5¼ „ „ „ Sept. 30th 0 2 1¼ 0 2 4 „ „ „ March 31st, 1922 ... 2s. . 5¼d. Total cost of medical inspection for the year 4,641 15 2 4,907 0 0 Grant towards the above for the year ending March, from Board of Education 1,707 17 8 2,297 0 0 Other receipts:— Medical treatment 123 14 1 104 2 7 Spectacles 53 10 3 50 1 8 Amount spent on repairs, improvements, etc., to schools for the year 8,554 11 1 8,370 0 0 27 REPORT OF THE WORK OF THE SCHOOL MEDICAL SERVICE. Arranged According to the Suggestions made by the Board of Education, December, 1920. 1. STAFF. The Staff consists of the School Medical Officer, who is also Medical Officer of Health, two Assistant School Doctors, a wholetime Dentist, a part-time Ophthalmic Surgeon, five School Nurses and a Dentist's Assistant. 2. CO-ORDINATION. Co-ordination of the work of the School Medical Service with that of other health services is quite satisfactory. The offices of School Medical Officer and Medical Officer of Health are held by the same person; the services of the School Nurses and Health Visitors are interchangeable, and when necessity arises the services of both staffs are utilised wholly for Public Health or School work. The services of the School Dentist and the Ophthalmic Surgeon are made use of for the treatment of children under 5 years of age and for Expectant or Nursing Mothers. The Assistant School Medical Officers carry out Bacteriological Examinations for Public Health or School purposes, and make enquiries at the schools when epidemics affecting school children arise. The School Medical Officer is Chairman of the Executive Committee of the Voluntary Child Welfare Association. The work of this Society is carried out in close association with that undertaken by the District Council whose members form a majority of the Education Committee. One of the Assistant School Medical Officers has acted as Physician to the Municipal Child Welfare Centre, and arrangements have been made for the appointment of an Assistant Medical Officer whose duties will embrace School Medical, Public Health and Child Welfare work. There are no Nursery Schools in the Area. The parents of Debilitated Children are advised by the Health Visitors and School Nurses to seek advice from their family doctors. Failing this they are advised to attend one or other of the Child Welfare Centres, or to call on the Medical Officer of Health who deals with them under the Milk (Mothers and Children) Order, 1918, or procures for them letters for the Dispensary or Hospital. 28 3. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene.—The information asked for under this heading was given fully in last year's Report. The School Buildings are under the constant supervision of the Education Committee's Architect, and are invariably well maintained. A Sanitary Survey of all the buildings was carried out by the Public Health Authority, and the sanitary defects found were brought to the notice of the Education Committee. These defects are generally remedied at once. During the year over £8,000 were spent on the schools in general repairs, cleansing, etc. Medical Inspection.—No change under this heading has taken place during 1921, and the information given in the previous year's Report holds good with the exception that Dr. Broderick (Dr. Harding's successor) practically devotes the whole of his time to School Work. Upon a few occasions he has been called upon to take the Infant Consultations at the Child Welfare Centre, but not sufficiently often to disturb the routine work of Medical Inspection at the Schools. The Education Committee has in contemplation the employment of the part-time services of another Medical Officer, and if this proposal meet with the approval of the Board of Education, a more satisfactory and efficient School Medical Service will be made possible, and greater control can be exercised over the children suffering from Defective Vision and Otorrhœa, without adding any additional expense to that already incurred. Arising out of the School Medical Inspections 90 children were excluded under Article 53B for varying periods for the following causes:— Sore Throat 19 Rhinitis 6 Tonsilitis 3 Pediculosis 2 Bronchitis 15 Ringworm 6 Heart Disease 1 Chorea 4 Pulmonary Disease 3 Mumps 1 Impetigo 3 Scarlatina 3 Debility 4 Chicken Pox 1 Blepharitis 1 Various 18 The general health conditions and cleanliness of our school children may be judged from the foregoing table. The number found suffering from conditions likely to spread disease among other children is comparatively small, although greater than in 1920. 29 The Head Teachers generally exercise very careful supervision of the children as may be seen from the numbers sent by them to the Clinic (Table VII), more particularly those suspected of Sore Throat, Ringworm and Impetigo, conditions that might be the cause of serious illness to others or extended exclusions from schools 5 REVIEW OF THE FACTS DISCLOSED BY MEDICAL INSPECTION Heights and Weights of Children Inspected A Age Average Height (inches) Average Weight (pouuds) Anthropometric Height Standard Weight Girls 5-6 yrs 42 39 4044 3774 8-9 yrs 495 53 4694 4995 12-13 yrs 56 76 5548 7386 B 5-6 yrs 4125 38 4044 3774 8-9 yrs 47 485 4694 4995 12-18 yrs 5475 66 5548 7386 A Boys 5-6 yrs 4225 41 4068 3668 8-9 yrs 485 52 4739 5205 12-13 yrs 58 72 5488 7266 B 5-6 yrs 41 39 4068 3668 8-9 yrs 47 49 4739 5205 12-13 yrs 55 75 5488 7266 A—represents a school serving a good clean area B—one whose children are largely drawn from poor homes in mean streets Clothing, Footgear and Nutrition ENTRANTS Clothing Footgear Nutrition Satisfactory percent Unsatisfactory percent Satisfactory percent Unsatisfactory percent Excellent percent Normal percent A—Girls 100 — 100 — 25 75 B—Girls 90 10 87 13 21 79 A—Boys 93 7 100 — 13 87 B—Boys 94 6 90 10 11 89 INTERMEDIATE A—Girls 94 6 94 6 15 85 B—Girls 94 6 76 24 8 97 A—Boys 98 2 98 2 25 75 B—Boys 80 20 66 34 17 83 LEAVERS A—Girls 100 — 100 - 38 62 B—Girls 83 17 88 12 4 96 A—Boys 100 — 98 2 21 91 B—Boys 76 24 75 25 6 94 80 The conditions found under these headings varied according to the location of the schools. Taking two extremes—the very good and the very bad—the above were the findings. It will be noticed that the Nutrition of a very large percentage of the children was excellent, and none below normal. Uncleanliness.—Physical uncleanliness of head or body, or both, is met with in all schools. The returns under this heading largely depend on the examiner's views. The presence of nits in children's hair is evidence of prior infestation with Pediculi, and although greater than one would wish, this condition is becoming less than in former years. The children suffering from uncleanliness are generally those of very poor or feckless parents. The causes are mainly due to economic conditions, which preclude the mothers from giving their children that constant care and attention which the well-to-do can afford. Less than .4 percent. of the children inspected were found to have lice, and only 2 percent. with nits in hair. Taking the results of the systematic examinations of the School Nurses—these are carried out without previous notice to the child or the parent— it would appear that the presence of head lice varies from 6.7 percent. in the worst school to '7 in the best, and nits from 25 percent. in the worst school to 14 in the best school. Strange to say, one of the very cleanest schools, Girls and Infants, is in a very poor neighbourhood, but for general cleanliness Maynard Road School shows the best record for its Infants' Department—only .7 percent. were found with Pediculi and T4 with Nits. On page 36 a summary of the work of the School Nurses in this direction will be found. It will be noticed that some improvement has been effected as compared with 1920. Minor Ailments.—The number of children found suffering with Minor Ailments on medical inspection is small as seen by the exclusions under Article 53 B shown on page 28. This is what might be expected, as the teachers send all such children to the Clinic. The findings on Table II. also indicate the keenness of the teachers in presenting this class of child for Special Examination. 81 The contrast between the numbers found suffering with Skin affections and External Eye Diseases at the Routine Medical Inspections, compared with those specially presented by the Teachers, shows that only a very few children are missed. Tonsils and Adenoids.—Enlarged tonsils and adenoids were found in 8.7 percent. of those examined. Of these 4.5 suffered to an extent that operation was advised; the others were kept under observation, and were dealt with subsequently as found necessary. Of the 570 children so classified, and the 108 others found by Special Examinations, 413 were operated upon—401 under the Local Education Authority's Scheme and 12 elsewhere. The Surgeons' classifications of these children were 326 operated on for Tonsils and Adenoids, 74 for Adenoids, and one for Enlarged Tonsils only. Young children with Enlarged Tonsils have usually Adenoid tissue so enlarged that removal is advisable, but this is not always apparent at Medical Inspection. There is a good deal of divergence of medical opinion as to the necessity for the removal of Tonsils of school children, and many parents consult me on this point before accepting the advice given them. In some cases postponement of the proposed operation is sufficient to show that the parents' doubts are well founded, and unless there is good and obvious reason I seldom advise the removal of Tonsils. The improvement in general health which follows the operation in the cases really needing it is so marked that some parents are anxious to have their children so dealt with without the slightest reason. Other parents, on the contrary, have such strong prejudices against the operation that they require a good deal of persuasion to have it carried out. On the whole, I think very few children here suffering from pathologically Enlarged Tonsils and Adenoid growths fail to have them removed. Tuberculosis.—Seldom are children found attending school with definite well marked signs of Phthisis. During the year four with no apparent symptoms, such as cough and expectoration, were discovered, and 14 others were gravely suspect and sent on to the Tuberculosis Officer. Fifty-four other children had some suspicious signs of the disease, and were kept under observation and re-examined by the School Doctors at their subsequent visits. 32 Those not progressing satisfactorily were referred to Dr. Sorley. The results of his examinations of the children between 5 and 14 years of age sent to him in 1921 were as follows:— Boys. Girls. Tuberculosis of Lungs 4 5 Probable suspected — — No definite signs 29 17 Tubercular Glands 1 — „ Spine 1 — Skin Diseases.—Only a very small number of these were found on medical inspection. Ten children had slight Impetiginous Sores and three Ringworm of the Head. This is what one would expect since the Teachers have by experience become quite as familiar with these diseases and quite as keen in their cure as the School Nurses. Impetiginous or Contagious Sores in children seem perennial. They cause discomfort and are unsightly, and account for a good deal of loss of school attendance. All such children are sent to the Clinic for treatment. It is not uncommon to find these Impetiginous Sores infected with Diphtheria Baccilli, and children so suffering have been known to cause virulent Diphtheria in others. Were it not for the Teachers "diagnosing" these and similar diseases—a reprehensible practice as viewed by the Medical Officer to the Board in 1912—all the children in some of our schools would in turn suffer from them. The number of children seen and treated for Ringworm was greater than in the previous year, but the condition in individual children was much milder and generally of shorter duration. Those requiring X Ray treatment numbered 29 as against 48 in 1920. External Eye Diseases.—These were of a minor character and generally yielded to treatment administered at the Clinic. The diseases and the numbers of children so suffering are given on Table II. Children with Corneal Ulcer are invariably sent by the Teachers to the Clinic upon the first appearance of symptoms, and this accounts for the few found at Medical Inspection. The treatment of this and other conditions of a serious nature is directed by Dr. Corbett. Defects of Vision.—Table IV shows that 370 children or 9 percent. of the total, excluding the infants, were found at the Routine Medical Inspection to be suffering from Defective Vision. Most of these chiidren, together with 350 others, were subsequently seen at the School Clinic, and appointments were made for them to see the Ophthalmic Surgeon. 33 The total number treated for defective vision, 523—equal to 11 per cent of those examined, excluding those under 7 years of age—shows that probably all our school children with defective vision had suitable glasses prescribed for them. Deafness and Ear Disease.—A greater number suffering from deafness was found during the year than in 1920, but for the more serious condition—Middle Ear Disease—the number was less. These numbered 70, and received treatment at the Dispensary under the Education Authority's Scheme. The total number of these children under treatment during the year was 147. The results are not as satisfactory as one would wish, and the consequence is that a number leave school with permanent damage to their hearing powers. Dental Defects.—The results of inspection by the Doctors and Dentists show that the dentures of the school children were better in 1921 than in 1920. Among entrants examined, over 46 percent. of the boys and 43 percent. of the girls, as compared with 17 and 26 for 1920, were free from dental caries. Among the leavers the figures were 43 and 45 as against 27 and 32 in 1920. From the Dentist's Report on 3,140 children only 24 per cent, of boys and girls, aged 6 to 8 years, examined by her have sound healthy teeth. The discrepancy between the views of the Doctors and Dentist shows the necessity for reserve in drawing conclusions from statistical data supplied by different observers. To make parents realise the importance of early dental treatment for their children is very difficult. As long as a child does not complain of severe toothache, although the mouth may be half full of septic teeth with roots ulcerating the gums, tonsils and throat inflamed, the child obviously suffering from general bad health due to pus absorbtion, yet it is difficult to get some parents to keep the appointments made for their children's treatment at the Clinic. Much of the Dentist's time is in this way wasted. No dentist can deal efficiently with more than 3,500 to 4,000 children a year, so the amount of necessary work left undone among our 24,000 school children can be appreciated. Crippling Defects.—There were few found, and these are recorded on Table II. c 84 Rickets is a disease seldom met with here, and only one case of Spinal Curvature was noted. The number of children found with Organic Heart Disease was small, those with functional murmur numbered 101. These were kept under observation and the parents advised. Many children of the latter group were found to have enlarged tonsils and septic teeth, and were of the rheumatic type. With the removal of these obvious defects the children generally improve very quickly and reach normal conditions. 6. INFECTIOUS DISEASES. The arrangements made for the detection and prevention of the spreading of these were given fully in the report for 1920. No action was taken under Article 57, and none was necessary under 45 B. The number of children excluded for varying periods under Article 53 B was 88. Of these only 14 were suspects or sufferers from Infectious Diseases. The small number found at medical inspection is due to the supervision exercised by the Head Teachers and their promptness in sending all suspected cases to the School Doctor. Arising from their action in this respect, 773 boys and 942 girls were excluded for varying periods for the conditions noted on Table VII. Scarlet Fever prevalence continued from 1920 until the end of January, 1921, and was again epidemic in the last four months of the year. The number of children suffering from Diphtheria, Clinical and Non-clinical, was considerably less than in 1920, and few cases of Measles and Whooping Cough arose. With regard to Scarlet Fever and Diphtheria, their incidence is invariably greater following the school holidays than before. This is due to the fact that a number of mild cases of these diseases occurring during the holidays fail to come to the knowledge of the Public Health Authority. These children on returning to school readily act as foci of infection and transmit the diseases to susceptible children. No children known to be sufferers from, or contacts with, Scarlet Fever and Diphtheria, are allowed to resume school attendance until seen by the School Medical Officer and certified as free from disease. 35 For this reason 727 children seen at the Clinic and 648 contacts, all of school age, were swabbed. Otorrhosa infected with Diphtheria Baccilli has been found to be the only source of many cases of Scarlet Fever and Diphtheria arising in school children, and directly this condition was discovered, and the children so suffering were isolated, no further cases arose in the homes. The following table gives the number of children suffering from the diseases named:— Scarlet Fever. Diphtheria. N.C.D. Measles Whooping Cough. January 46 27 6 9 10 February 16 17 8 1 6 March 21 14 6 — 5 April 22 6 5 9 20 May 28 7 1 4 1 June 31 14 3 — 19 July 59 14 — 9 3 August 33 12 7 9 1 September 65 18 17 3 5 October 86 24 9 2 — November 99 26 12 — — December 101 23 7 — — Totals 607 202 81 46 70 7. FOLLOWING UP. Children with defects have "After Care Cards" made out for them at the time of inspection. These are primarily filed under "schools." Some six or eight weeks subsequently the doctor, on re-visiting, examines these children, and, if the Defects have not been remedied, the "After Care Cards" are passed on to the School Nurses, who visit the homes and advise the parents. Failure is reported to the School Medical Officer, more particularly cases where the Defects are serious and likely to injure permanently the health of the children. These are dealt with by invitations from the School Medical Officer for interviews with the parents, and generally the treatment required is carried out. A few cases of persistent uncleanliness were dealt with by summons under the Attendance Bye Laws, and a very bad case of persistent neglect to keep children cleanly was dealt with in January, 1922, by the mother being sent to prison for two months. 86 During the year the Nurses paid 3,214 visits to the homes in connection with the following:— Uncleanliness 74 Mumps 635 Defective Vision, 266 Chicken-pox 127 Tonsils and Adenoids 199 Measles 47 Otorrhœa and Deafness 250 Scarlet Fever 363 Impetigo 12 Scabies 9 Defective Teeth 952 Ringworm 13 Whooping Cough 60 Various 207 The following is a summary of the School Nurses' work apart from home visits and routine medical inspection:— Total number of visits to schools 398 Average number of visits for the year to each school 9 Total number of examinations for uncleanliness (Section 122, Children's Act) 105,544 Number of children found unclean 3,055 Number of notices sent to parents under the above Act 259 At the close of the school year, there were 2,419 children on the School Nurses' "Head Lists.'' 8. MEDICAL TREATMENT. Minor Ailments are dealt with on four mornings and two afternoons weekly. They embrace a considerable number of conditions, the principal being Contagious and other Sores, External Eye Diseases, Ringworm, and slight injuries received in the playing field or yard. A small charge is made for Ointments given, but not for treatment. During the year 29 cases of Ringworm of the Head as compared with 47 in 1920 were treated by X Rays. Varying charges according to the economic circumstances of the parents are made for this form of treatment. The maximum period of exclusion from school of children so dealt with was 126 days and the minimum 28 days. The average time from treatment to resumption of school work, worked out for all the cases, was 51 days. From the view of School Attendance X Ray treatment has a good deal to recommend it—efficiency and quickness of result. Prejudice against it on the part of the parents is much less than formerly. 37 The results in all the cases treated were very good, and only one child had severe Dermatitis which took a considerable time to get well. Tonsils and Adenoids.—Four hundred and one children received treatment during 1921 for these conditions. Invariably the operation was satisfactory, and the results were very good. There are no beds at the Dispensary, and children are taken to their homes within a few hours of the operation. So far nothing untoward has taken place, but the arrangement cannot be said to be entirely satisfactory. The School Nurse remains, if necessary, for some hours with cases presenting any difficulties after operation and has the children removed by cab to their homes. The total cost for Operative Treatment to the Authority was— Tonsils and Adenoids, £385; Ringworm, £35; and the total receipts were £35 and £3 12s. respectively. Tuberculosis.—Children suspected of, or suffering from, this disease are advised to consult their own doctors and to have treatment. Failing this they are, if possible, placed under the Tuberculosis Officer. During the year 176 children, aged 5 to 14 years, were seen by Dr. Sorley at the County Council's Tuberculosis Dispensary. Of these, 35 boys and 22 girls were sent by the School Doctors, 32 children by the family doctors, and the remainder were contacts. Of the school children referred by the School Doctors to the Tuberculosis Officer, 46 failed to give definite signs of the disease, 9 suffered from Tuberculosis of Lungs, 1 from Tuberculosis of the Hip, and one from Tubercular Glands. The notifications of Tuberculosis received by the Medical Officer of Health for children between the ages of 5 and 14 were as follows:— Boys. Girls. Tuberculosis of the lungs 7 16 ,, ,, ,, glands 3 1 ,, ,, ,, hip — — ,, ,, other joints 1 1 „ „ the spine — 1 ,, „ other bones 1 — ,, „ meninges — 1 „ ,, peritoneum — — „ ,, abdomen l — Seventeen children of the Pulmonary type of the disease and 3 Non-pulmonary received treatment at the Sanatorium. 88 Vision—No change in the methods employed for dealing with defective vision was made in 1921 They were fully described in last year's report, and were found to be satisfactory Dr Corbett, the Ophthalmic Surgeon, supplied the following report on the work carried out by him at the Eye Clinic:— 523 "New Class " attended the Clinic during the year—boys, 268; girls, 255 510 children had impaired vision due to errors of refraction 13 children had bad sight due to disease, injury or congenital defects As in previous Reports, the cases will be considered under three groups Group A—External disease of the eye, including squint Group B—Defective vision due to " errors of refraction" Group C—Defective sight due to diseases, etc Reference to Table I will show the nature of these defects and the sex incidences GROUP A TABLE I External Diseases, including Squint Disease Boys Girls Total Blepharitis 4 4 8 Phlyctæna 2 4 6 Nebulae 6 6 12 Blepharospasm 3 1 4 Ptosis — 1 1 15 16 31 Squint Boys Girls Totals Convergent Squint R = 19 R = 10 29 ,, L = 21 L = 17 38 Divergent Squint R = 1 — 1 ,, L = 1 1 2 Occasional Squint R = 2 — 2 ,, L = — — — Alternating Squint 1 — 1 ,, 45 28 73 39 Seventytwo children or 14 percent of the total number examined had this deformity Boys show a higher percentage, 86 to girls 54 GROUP B Defective Vision due to Errors of Refraction TABLE II Totals Percent Hypermetropia 235 4608 Hyp Astigmatism 125 2451 Mixed Astigmatism 24 470 Myopia 69 1353 Myopic Astigmatism 29 568 Odd Eyes 28 550 510 10000 Grouping Hypermetropia and Hypermetropic Astigmatism under the heading "Hypermetropia," and the four latter as "Myopia," we find that 7052 percent come under the Hypermetropic Group and 2941 percent under the Myopic Group TABLE III Sex Incidence Boys Percent Girls Percent Totals Hypermetropia 123 4142 112 4571 235 Hyp Astigmatism 67 2528 58 2368 125 Mixed Astigmatism 13 490 11 449 24 Myopia 36 1358 33 1347 69 Myopic Astigmatism 16 6 04 13 531 29 Odd Eyes 10 378 18 734 28 265 95 00 245 10000 510 Contrary to previous reports boys are in the preponderance, accounting for 52 per cent, of all the cases The girls show a slightly higher percentage of Hypermetropia, 7239 per cent, to the boys 71.70 percent. The boys show a slightly higher percentage of Myopia, 2830, to girls 27.61 percent 40 The visual acuity returns obtained for girls are, as a rule, worse on the average than for boys. TABLE IV. Age Incidence. Age. Hypermetropia. HyperAstigmatism. Myopic Group. Totals. 5 11 6 1 18 6 20 5 — 25 7 22 11 3 36 8 41 30 27 98 9 28 17 15 60 10 21 11 10 42 11 31 6 11 48 12 34 33 49 116 13 27 7 33 67 235 126 149 510 The above table shows the variation of the refractive error with age. Considering first Hypermetropia, neglecting oscillations, we find a decrease of from 61 to 40 per cent, in the nine years under consideration. Hypermetropic Astigmatism shows a steady decline from 33 to 10 per cent, in the corresponding years. Myopia, on the contrary, shows a steady increase from 6 to 50 per cent, in the years under consideration. We are led to the conclusion that the diminution of the Hypermetropic Group has been due to their transference to the Myopic Group. The Incidence o£ Serious Cases of Errors of Refraction. This table deals with errors of refraction of five dioptres or more. With such errors of refraction, more particularly when associated with Astigmatism, visual acuity is much reduced, and with the most accurate correcting lenses vision is not brought up to the normal standard. Boys. Girls. Total. Hypermetropia 10 6 16 Hypermetropic Astigmatism 23 12 35 Myopia 2 1 3 Myopic Astigmatism 2 1 3 37 20 57 41 These 57 children, or 11T7 percent. of the whole number of refraction cases, had an error of refraction of five or more dioptres. Reference to the table shows their character and sex incidence. The boys show a higher percentage, 12.14, as compared with 8 percent. for girls. GROUP C. Defective Sight due to Disease, Congenital Defects or Injuries to the Eyes. TABLE V. Boys. Girls. Totals. Superficial Keratitis — 4 4 Corneal Scars — 2 2 Congenital Cataracts — 1 1 Traumatic Cataract — 1 1 Secondary Glaucoma — 1 1 Coloboma Macular Area 1 1 2 Nystagmus 1 — 1 Iritis 1 — 1 3 10 13 Most of these children were recommended for the Myopic Centre. Dental Defects.—Very little treatment other than that provided by the School Medical Service is obtained for these. A considerably greater amount could be done even with the present staff if the full co-operation of the parents were obtained. Upon the slightest excuse, or none, the parents fail to keep appointments made for their children's treatment by the Dentist, and thus much of her valuable time is wasted. The Scheme of the Authority follows the lines laid down by the Board of Education, and inspection and treatment of the 6 to 8 years of age group of children has been, as far as possible, carried out. Mrs. Thorne, L.D.S., in her report states, " It would be advisable to extend the school inspection age group to include the entrants, thereby eliminating Caries and preventing irregularities in the permanent Dentition." This view accounts for the inspection and treatment of 248 children under 6 years of age. Table IV. "D" gives details of the Dentist's work during the year. 42 Crippling Defects and Orthopædics.—The total number of children coming under this heading and attending our schools was 102, and those not attending number 60. "Crippling Defects'' embrace very varying conditions extending from slight lameness due to Tubercular Hip to cases brought to school in spinal carriages. The Local Invalid Childrens' Aid Society has a register of all crippled children in the district, and through its agency surgical boots and other instruments required by the children are obtained. The Society is very active, and cases involving much expense unable to be borne by the parents, are brought before the Education Committee who deals with them under Section 13 (1) 6, of the Act of 1907. Through the agency of the Society, 34 children had convalescent treatment. Two boys were away for one year and several children had stays of 2, 3 and 4 months at the seaside. Provision of surgical boots cost the Society over £45, the parents contributing £125 6s. 9d. In the Society's Annual Report, the Hon. Secretary pays a compliment to the parents who make great sacrifices on behalf of their children. The various surgical instruments needed for crippled children are, in the Secretary's words, " things always expensive, slow to procure and constantly needing repair.'' The disproportion in the amounts spent by the parents, the Society and the Education Committee is very marked. Five percent. of the cost is a very small portion of the burden shouldered by the Local Authority, and were it not for the difficulty in having to obtain sanction from the Board of Education for each individual child, for whom a surgical boot or other appliance is needed, the condition of many of these children would be much better than it is. Many of the children are found wearing boots that are much too small for them and dilapitated instruments that no longer serve the purposes for which they were obtained. Table III. shows the number of these children not attending School and I have referred in my foreword to the injustice done them in the name of " Economy." 9. OPEN AIR EDUCATION. There is no open-air school in the district. A number of schools lend themselves to open-air instruction and teachers are encouraged to carry out this as far as our climate will allow. A circular to this effect was issued by the Education Committee in April and a fair response was made, but its extension and universal adoption is a matter of time and education. In some of the schools neither the central halls or the cloak rooms are found efficiently ventilated and the air is stuffy. 43 The Head Teachers appreciate in general terms the value of fresh air, but many will tell you they cannot tolerate draughts, and the general feeling of discomfort arising from a free use of open windows in the central halls. Were the halls maintained as large reservoirs of fresh air and not places for working in by Head Teachers the "fresh air" condition of the class-rooms could be made to approximate that of the open. School Journeys.—Although the district is burdened with an Education rate ot 2s. 6d. in the £, permission was given to the Head Teacher of the Myope School for a school journey for the children under her charge. The children were taken to Hastings for a fortnight. With a like enthusiasm the Head Teachers of the other special schools could probably take their children for similar outings. The children were not seen (medically) before or after their journey, so I am unable to say what benefit they derived. Miss Balls, the Head Teacher, kindly furnished me with a report, in which she says :— "The benefits accruing from this expedition were threefold. "There is no doubt that the general health of the children was improved both by the change of air and good and regular food. "The educational value is enormous Powers of observation are trained as they could be in no other way. Information is gained which proves valuable throughout the school life of the child and rouses an interest which will lead him to seek for more knowledge at a later date. (Here I might say that in illustrating such a thing as a city wall and its uses in olden days, the wall round Hastings Castle has proved of inestimable value). This is only one of the countless instances that might be quoted. "The first-hand knowledge then, forms an excellent basis for further instruction. "The moral training afforded is enormous. Perhaps one of the greatest results from this is the development of the ' team spirit.' In such a large party each one must think of the rest, thus becoming thoughtful, unselfish and helpful. Then there are the habits of cleanliness, tidiness, quiet behaviour in the house and the proper use of knives and forks, etc., at meals. Quick children learn to be patient with the slow ones, and old ones with younger. Self-reliance and self-confidence are also possible to cultivate under such conditions. Last, but very important, each child realises that its teachers are its friends, and a relationship is established between pupil and teacher which will probably last a life time, and the child will realise that in joy or sorrow he will receive complete sympathy and, if necessary, advice. "The total cost of the school journey was just under £96. The hostel expenses came to £68, and the rest was spent on travelling and local expenditure." 44 10. PHYSICAL TRAINING. The School Medical Service is not associated with the work of physical training in the schools and there is no Area Organiser. From observation of the children at physical exercises and drill at many of the schools the impression is left that before any real value is obtained from these by the pupils, most of the teachers should undergo some training and acquire a knowledge of the movements which they desire the children to undertake. 11. PROVISION OF MEALS. Daily dinners are given to school children because of the poverty of the parents. Children apparently ill-nourished are sometimes referred by the Head Teachers to the School Medical Officer, and his recommendation is accepted by the Education Committee. Less than half a dozen children have in this way received half a pint of milk daily for varying periods. To this extent the School Medical Service is associated with that of the provision of meals. The School Medical Officer has visited the feeding centres at various times and was quite satisfied as to the amount, wholesomeness and suitability of the food provided for the children. Teachers occasionally assist in supervising the children at their meals, and members of the Ladies' Committee do likewise, but more attention should be given to the amenities of the table and to the use of simple decorations in order that the educational value of the meals may be properly realised. During the year 8,133/meals were given to our school children. 12. CO-OPERATION OF PARENTS. Some parents who fail to be present at the medical inspection of their children object, in the first instance, to treatment of defects of vision. They cannot realise that such exist, and a similar difficulty arises in connection with Enlarged Tonsils and Adenoids. If after two visits by the School Nurse treatment is not undertaken, the parents are invited by letter to see the School Medical Officer at his office. Upon his demonstrating to them that the children suffer from defective vision, or that the tonsils need removal, compliance usually follows. All parents are invited to be present at the medical inspection of their children. At the examinations of the infants, 27 per cent. of the parents attend, of the boys and girls 30.8 per cent. 45 The presence of the parent generally ensures the necessary subsequent treatment without much trouble. Occasionally some parents consult the family doctor—and they are encouraged in this—before _ accepting the advice given, but generally the parents place much confidence in the school doctors and act as advised. The great majority are keenly anxious to have obvious defects remedied. All cases of Ringworm have had appropriate treatment, and the prejudice against X Ray treatment for Ringworm diminishes yearly. Over 90 per cent. of the children found to have defective vision at the Routine and Special Examinations were seen by the Ophthalmic Surgeon and had appropriate glasses prescribed for them. Nearly 70 per cent. of those with Dental defects had treatment, and of the 514 children with enlarged tonsils and adenoids, or both, 432 or 83 per cent. were operated on. The co-operation of the Teachers and Attendance Officers, and their helpfulness in facilitating the work of Medical Inspection and treatment in 1921, in no way differed from that given in 1920. So far, no voluntary workers have been enlisted in the after-care or visiting of children suffering from defects. 13. BLIND, DEAF AND DEFECTIVE CHILDREN. There are three special day schools for these children. The methods adopted for ascertaining and dealing with these children were fully set out in last year's Report, and have not varied in 1921. The Mentally Defective Children attend Shernhall Special Schools. They have free passes on the tramcars from and to their homes. Attendance Officers supervise at various points on the tram route their coming and going to school. They are taught, in addition to the usual elementary subjects, handwork such as rug making and mat making, and the older boys go to a Carpentry Centre and the girls to Cookery and Laundry. A voluntary After-Care Society is in existence, but its operations are very limited. There were 32 boys and 30 girls on the Register at the end of the year. 46 The school for the Deaf and Dumb children is situated in the centre of the district, and has accommodation for 20 children. The number of pupils on the register at the end of the year was 14 boys and 8 girls. Speech and lip reading are soon acquired by most of the children, and many attain a fair standard of education. Their medical supervision is similar to that of the children in the ordinary schools. Myope Centre.—The present buildings—wood and corrugated iron—were formerly used as an ordinary day school with a capacity for 120 children. Its situation is convenient, the trams passing within a few hundred yards. The surroundings are also good, and a considerable amount of land for gardening is allotted to the school. During the year five boys and six girls were admitted, and three boys and one girl left. There are at present on the register the names of 53 children—boys 21 and girls 32. Five others have been refused admittance. Of those attending, 23 are "blind" within the meaning of the Elementary Education (D. and E. Ch. A.) 1899, and are taught Braille and suitable manual occupations such as chair caning, basket work, and the use of the knitting machine. The other children, apart from the special equipment supplied for them, learn to read and write in the ordinary way. "Their manual work includes printing, woodwork (strip), bent ironwork, cardboard modelling, knitting and drawing. In the summer of 1921 gardening was undertaken, and the results were good. In March, 1922, with the consent of your Committee, Miss Arthurton, a teacher from the " Guild of Blind Gardeners," commenced to give gardening lessons, and the Head Teacher tells me that the pupils are greatly benefiting by the instruction. The school journey of these children to Hastings has been reported upon by the Head Teacher, and there is little doubt she possesses all the qualifications which are so essential for a Head Teacher of a school of this kind. 47 14. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Bye-laws have been made by the Local Education Authority pursuant to the Provisions of the Employment of Children Act, 1903, as amended by the Education Act, 1918, regulating (a) the employment of children generally, and (6) street trading by persons under the age of 16 years. During the year 374 children between the ages of 12 and 14 years were examined, and certificates granted them. The children are employed in the delivery of milk, newspapers, parcels, and in assisting in shops. The Bye-laws prescribe that the children do not work for more than four hours on Saturday and two hours on other days. The views of the Assistant School Medical Officers are that such employment has no bad influence on the health of the children, and, like their class mates, show no particular signs of fatigue during school hours. No boy or girl under the age of 15 years is permitted to carry on street trading. No girl under 16 years shall be so employed unless in company with her parent or guardians, and no boy under 16 years shall be so employed unless he procures a badge for this purpose from the Education Authority. During the year 28 of these were issued, and three expired in virtue of age of recipients. 48 TABLE I. Number of Children Inspected, 1st January, 1921, to 31st December, 1921. "A"—Routine Medical Inspection. Age. Entrants. Intermed'te Group Leavers. Grand Total. 5 6 Other Ages. Total. 8 12 13 14 Other Ages. Total. Boys . 747 330 78 1155 1032 687 260 57 22 1026 3213 Girls . 697 360 81 1138 1073 823 206 56 24 1109 3320 Totals 1444 690 159 2293 2105 1510 466 113 46 2135 6533 “B”—Special Inspections. Special Cases. Re-examinations (i.e., No. of children re-examined). At Schools. At Clinic. At Schools. At Clinic. Boys 79 2334 3109 9855 Girls. 102 2306 3046 8111 Totals 181 4640 6155 17966 "C"—Total Number of Individual Children Inspected by the Medical Officer, whether as Routine or Special Cases (no Child being counted more than once in one year). No. of Individual Children Inspected. *11354 * The number 4,640 included in the figure 11,354 must not be accepted as for individual children. During the whole year the records at the School Clinic were not kept in such a way as to indicate "individual children" but rather "new cases." Among the latter, no doubt, were children who had been treated at different times for dissimilar defects and counted as new cases. Probably the figure 4,640 is from 5 to 10 per cent. in excess for individual children. This probable error will in future be eliminated as each school child is now provided with a continuous record card. TABLE II. Return of defects found in the course of Medical Inspection in 1921. Defects or Disease. 1 Routine Inspections. Specials. Number referred for treatment. 2 Number requiring to be kept under observation but not referred for treatment. 3 Number referred for treatment. 4 Number requiring to be kept under observation but not referred for treatment. 5 Malnutrition 6 8 1 - Uncleanliness, Head Pediculi 18 - - - ,, ,, Nits 67 67 21 - ,, Body 5 2 - - Skin. Ringworm, Head 3 - 121 - ,, Body - - 122 - Scabies 1 - 68 - Impetigo 10 - 592 - Other Diseases (Non-Tubercular) 6 3 9 - Eye. Blepharitis 17 - 50 - Conjunctivitis 3 - 145 - Keratitis - - - - Corneal Ulcer - - 12 - ,, Opacities 1 - - - Defective Vision 370 5 350 3 Squint 15 - 1 - Other Conditions 1 1 1 - Ear. Defective Hearing 208 45 4 - Otitis Media 70 - 68 - Other Ear Disease 12 - 7 - Nose and Throat. Enlarged Tonsils 214 237 98 - Adenoids 60 15 5 - Tonsils and Adenoids 32 12 5 - Other Conditions 9 9 110 - Enlarged Cervical Glands (Non-Tubercular) - 26 - 20 Defective Speech 2 7 - 3 Teeth-(see Table IV.) - - - - Heart and Circulation. Heart Disease, Organic - 14 - - ,, ,, Functional - 101 - 11 Angemia - 5 - - Lungs. Bronchitis and Bronchial Catarrh 8 71 20 3 Other Non-Tubercular Diseases 2 - - - T uberculosis. Pulmonary Definite 4 6 - - ,, Suspected 14 54 2 3 Non-Pulmonary Glands 2 16 - 1 „ Spine - - - ” Hip - - - ,, Other Bones & Joints 1 1 - - ,, Skin - - - - ,, Other Forms - - - - Nervous System. Epilepsy 3 3 - 1 Chorea 1 1 1 - Other Conditions 6 5 1 - Deformities. Rickets 1 - - 1 Spinal Curvature - 1 1 - Other Forms 2 7 - - Other Defecis or Diseases 21 31 308 7 Number of Individual Children having Defects which required Treatment or to be Kept Under Observation 5994 49 TABLE III. NumericalReturn of allExceptionalChildren in the Area in 1921. Boys. Girls. Totals. Blind (including partially blind), within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893 Attending Public Elementary Schools - - - Attending Certified Schools for Blind 2 1 3 Not at School - - - Myope Centre 21 32 53 Deaf and Dumb (including partially deaf;, within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893. Attending Public Elementary Schools Attending Certified Schools for Deaf 15 8 23 Not at School - - - Mentally Deficient Feeble Minded Attending Public Elementary Schools - - - Attending Certified Schools for Mentallv Defective Children ... 32 28 60 Notified to the Local Control Authority by Local Education Authority during the year :- Imbeciles 2 1 3 Idiots - - - Not at School - - - Imbeciles Not at School 5 1 6 At School - - - Idiots - - - Epileptics Attending Public Elementary Schools 17 19 36 Attending Certified Schools for Epileptics In Institutions other than Certified Schools - - - Not at Schools - - - Physically Defective Pulmonary Tuberculosis Attending Public Elementary Schools 15 9 24 Attending Certified Schools for Physically Defective - - - Schools 5 0 5 Not at School 5 4 9 Cripplingdue to Tuberculosis Attending Public Elementary Schools 39 20 59 Attending Certified Schools for Physically Defective Children In Institutions othei than Certified 1 1 2 Schools - - - Not at School 16 17 33 Crippling due to causes other than Tuberculosis, i.e., Paralysis, Rickets, Traumatism Attending Public Elementary Schools 25 18 43 Physically Defective Children In Institutions other than Certified - - - Schools - - - Not at School 17 10 27 Other Physical Defectives, e.g., delicate and other children suitable for admission to OpenAir Schools ; children sufferingfrom severe heart disease. Attending Public Elementary Schools 120 210 330 Attending Open-Air Schools - - Attending Certified Schools for Physically Defective Children other than Open-air Schools - - - Not at School - - - Dull or Backward Retarded 2 years 272 266 538 Retarded 3 years 63 60 123 50 TABLE IV. Treatment of Defects of Children during 1921. "A"—Treatment of Minor Ailments. Disease or Defect. Number of Children Referred for Treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Totals. Skin— Ringworm—Head 131 121 10 131 Ringworm—Body 122 122 - 122 Scabies 68 68 - 68 Impetigo 615 592 53 645 Minor Injuries 10 10 - 10 Other skin diseases 12 12 - 12 Ear Disease 395 284 35 319 Eye Disease (external and other) 244 207 37 244 Miscellaneous 80 66 14 80 "B"—Treatment of Visual Defect. Number of Children Referred for Refraction. Submitted to Refraction. For whom Glasses were prescribed. Number who obtained Glasses. Recommended for Treatment other than by Glasses. Received other Forms of Treatment. For whom no Treatment was considered necessary. Under Local Education Authority's Scheme— Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 720 592 7 — 599 672 660 12 10 62 "C"—Treatment of Defects of Nose and Throat. Referred Treatment. Number of Children Received Operative Treatment. Received other Forms of Treatment. Under Local Education Authority's Scheme— Clinic or Hospital. By Private Practitioner or Hospital. Total. 531 401 12 413 — 51 "D"—Treatment of Dental Defects. 1.—Number of Children dealt with. Age Groups. "Specials." Totals. (a) Inspected by Dentist: 5 6 7 8 9 10 11 12 13 14 Clinic 248 372 298 449 243 133 149 237 153 24 5 2311 Schools ... ... ... ... ... ... ... ... ... ... ... 3140 (b) Referred for treatment (b) 4752 (c) Actually treated (c) 3217 (d) Re-treated (result of periodical examination) (d) - 2.—Particulars of Time given and of Operations undertaken. No, of Half-Days devoted to Inspection. No. of Half-Days devoted to Treatment. Total No. of Attendances made by the Children at the Clinic. No. of Permanent Teeth. No. of Temporary Teeth. Total No. of Fillings. No. of Administrations of General Anaesthetics included in (4) and (6). No. of other Operations. Extracted. Filled. Extracted. Filled. Prohylatic Treatment. Dressings, etc. (i) (2) (3) (4) ( 5 (6) (7) (8) (9) (10) (11) 32 413 3422 919 549 6971 1514 2063 2439 53 312 TABLE V. Summary of Treatment of Defects as shown in Table IV (A, B, C, D and F, but excluding E). Disease or Defect. Number of Children Referred for Treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Totals. Minor Ailments 1707 1482 149 1631 Visual Defects 720 592 7 599 Defects of Nose and Throat 531 401 12 413 Dental Defects 4752 3217 48 3265 Other Defects 21 12 - 12 Totals 7731 5704 216 5920 52 TABLE VI. Summary Relating to Children Medically Inspected at the Routine Inspections during the year 1921. (l) The total number of children medically inspected at the routine inspections 6,533 (2) The number of children in (1) suffering from defects (other than uncleanliness or defective clothing or footgear) who require to be kept under observation (but not referred for treatment) 676 (3) The number of children in (1) suffering from— Malnutrition 14 Skin Disease 20 Defective Vision (including squint) 390 Eye Disease 23 Defective Hearing 253 Ear Disease 82 Nose and Throat Disease 588 Enlarged Cervical Glands (non-tubercular) 26 Defective Speech 9 Dental Disease 1,642 Heart Disease— Organic 14 Functional 101 Anaemia 5 Lung Disease (non-tubercular) 81 Tuberculosis— Pulmonary definite 10 suspected 68 Non-pulmonary 28 Disease of the Nervous System 19 Deformities 11 Other defects and diseases 52 (4) The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) 2,489 (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) 1,129 "Specials" should not be included in this Table. 53 TABLE VII. Statement of Defects for which attendances were made by Children at School Clinic during 1921. Conditions. First Inspection. Re-inspections. No. Excluded under Art. 53k. No. to Return to School. Boys. Girls. Boys. Girls. Boys. Girls. Ringworm 62 59 62 60 1587 1398 Scabies 18 38 3 9 192 462 Impetigo 5 4 18 20 26 21 Impetigo, Sores, etc., treated 98 68 249 130 2597 1092 Skin 5 6 60 74 275 245 Verminous Head, etc. — 11 4 17 10 292 Sore Throat 251 384 151 152 605 857 Discharging Ears and Deafness at Dispensary 7 12 126 88 2433 2084 Defective Vision 2 1 199 218 31 27 External Eye Diseases 27 30 81 69 1113 900 Tonsils and Adenoids 3 4 199 114 102 123 Mumps 72 81 7 12 24 34 Various 223 244 484 401 860 576 Totals 773 942 1561 1364 9855 8111 4640 17966 Number of children seen at first inspection 4640 „ „ sent by Attendance Officers and Attendance Committees 204 „ attendances made by children 22606 „ children sent by Head Teachers 4426 „ swabs taken 727 „ specimens of hair examined for Ringworm 10 „ operated on for Tonsils and Adenoids 432 „ children X-rayed 29 „ „ seen by Dr. Corbett—new cases 530 „ „ prescribed for 672 Total inspections 3121