WalthamstowUrban District Council' REPORT of THE MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER, FOB THE YEAR 1924. LonOon: Metcalfe & Cooper, Ltd., Printers, 41/42, Wool Exchange, Coleman Street, and 18 24, Scrutton Street, E.C. 2. Telephone Noa. 4419 London Wall & 1580 Central. 715 ' TO THE CHAIRMAN AND MEMBERS of the Walthamstow Urban District Council Mr. Chairman, Ladies and Gentlemen, I beg to submit my Twenty-seventh Annual Report on the Vital Statistics and Sanitary Administration of the District for the year 1924. The Report is compiled in accordance with the instructions issued by the Ministry of Health in 1921. The year under review, apart from the number of cases of Encephalitis Lethargica arising from March until September, presented no special features of importance. Compared with 1923, there was a considerable drop in the birth-rate—17.4 against 19.4—and an increase in the death-rate— 10.01 compared with 8.96. There were 183 more deaths in 1924 compared with 1923 and the increase was distributed over nearly all the principal diseases which bulk largely in Mortality Statistics. Deaths from Influenza were greater by 23; those from Heart Disease and Arterio Sclerosis by 61; Tuberculosis by 14; and there were 92 more deaths from other diseases of the Respiratory Organs—Bronchitis and Pneumonia. There was no increase in deaths from Cancer, but strangely we had 30 more deaths in children under one year of age, although the number of births was 238 less than in 1923. Twenty of these deaths were due to Pneumonia; 5 to Whooping Cough ; 2 to Measles; and 4 children were lost by want of attention at birth. The increased number of deaths must not be interpreted as a reflection on the work of our Child Welfare Centres or Health Visitors, nor could they be prevented by any Welfare System of visiting and advice short of provision for specialised Hospital treatment. The Registrar-General estimates that our 1924 Mid-year population was 131,100, or 137 more than our excess of births over deaths would account for, compared with 1923. 2 It is probably quite correct that only a few persons have migrated into this Area during 1924 owing to the acute shortgage of housing accommodation experienced by those already living in the District. During 1924 there were 96 houses erected by private enterprise and 16 by your Council as compared with 15 and 309 in 1922 and 70 and 26 in 1923, or a total of 532 since the census enumeration. Approximately 600 more houses are required to meet the needs of our people, in other words to produce the same ratio of houses to population as existed before the War. The anomaly of the situation is that there are at all times a considerable number of vacant houses, and at the same time a, greater number of parents with two, three or more children forced to live in one room. With the best intentions in the world on the part of such people the children have no real opportunity to grow into decent healthy citizens. The money spent on Child Welfare and the School Medical Services is no compensatory balance for this drawback and cannot make good what is primarily lost to the children. The home conditions of many of our people are, to put it mildly, inimical to decency and health, and if not quickly remedied must become a danger to family life and the State. The birth, death and infantile mortality rates given in the Tables following are based on the figures given by the RegistrarGeneral. The number of births and deaths exceed those coming to my knowledge during the year and account for some apparent discrepancies. The Birth-rate for 1924 was 17.4 per 1,000 for the year, compared with 19-4 in 1923, 19-6 in 1922 and 21-7 in 1921. With the exception of the years 1917, 1918 and 1919, it is the lowest recorded and lower than that of the Country as a whole, or of those of the Great and Smaller Towns of the Registrar-General's Tables. The total births registered within the Area was 2,138. Of these, 34 were excluded, being children of parents domiciled elsewhere, making the nett number 2,104. The Registrar-General gives in his four quarterly summaries the births as 2,134, and in March, 1925, having made the necessary corrections, the number given was 2,291. 3 Births distributed in Wards—with populations (1921), and Birth-rates for 1924. St. James Street. High Street. Hoe Street. Wood Street. Hale End. Higham Hill. Totals. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1st quarter 63 50 46 48 45 39 38 39 37 32 65 60 294 268 2nd quarter 65 61 40 36 40 49 32 39 36 47 54 54 267 286 3rd quarter 63 59 35 .39 44 42 33 46 29 29 52 41 256 256 4th quarter 53 58 33 37 41 43 37 19 44 31 40 41 248 229 244 228 154 160 170 173 140 143 146 139 211 196 1065 1039 Totals 472 314 343 283 285 407 2104 Number of Births as given by R.G. - - - - - - 1161 1130 2291 Population (enumerated, 1921) 25000 20000 24000 17500 18500 25000 130000 Population (assumed, 1924) - - - - - - - Birth-rate 1924 18.8 15.7 14.3 16.2 15.4 16.2 17.4 Infantile Mortality Rate 1924 61.4 79.6 75.8 77.7 56.1 68.8 64.1 4 The foregoing Table shows the births as distributed in the various Wards of the District, also the Birth-rate and Infantile Mortality-rate for each area. The populations assumed are practically as enumerated at the Census, and very little error is possible in the rates given. The birth-rates of High Street and Higham Hill Wards are less by nearly 3 per 1,000 than in 1923; those of St. James' Street, Hoe Street and Wood Street by over 1 per 1,000; and that of Hale End shows a slight increase. The highest birth-rate is that for St. James' Street and the lowest was that in Hoe Street. Death-rate.—The Table on page 9 shows the Birth and Death rates for the Country and for this District. The Death-rate for England and Wales for 1924 was 12-2; the Great Towns, 12-3; and Walthamstow, 10-01. Compared with the average for the previous five years our Mortality was slightly greater in 1924 but yet well under the Country as a whole. The increase of 1-05 compared with 1923 is accounted for by the greater number of deaths from Measles, Whooping Cough, Heart and respiratory diseases. The Death-rate for the Wards varied from 11-6 in Hoe Street to 8-9 in Higham Hill. A rate of 10 per 1,000 for the whole Area can be looked on as favourable. The Zymotic Death-rate was slightly over -19 per 1,000 as compared with -3 in 1923, 1-07 in 1922, -52 in 1921, and 2-8 in 1901. The deaths taken into account in forming this rate are the so-called preventable ones arising from Diphtheria, Scarlet Fever, Measles, Whooping Cough, Diarrhoea, Erysipelas and Typhoid. Measles in an epidemic form started in January and lasted until June. Isolated cases of Whooping Cough were reported in these months also, but the disease in an epidemic form started in August and continued throughout the remaining months of the year. Seventeen children died from the latter disease and eleven from the former. All the children dying from Measles were under 5 years of age, as were 15 of the 17 dying from Whooping Cough. 5 The Mortality from these diseases in 1923 was negligible whereas in 1922, Measles caused 40 and Whooping Cough 39 deaths. Probably very few deaths will occur in 1925 or in the two subsequent years. Only one death occurred from Scarlet Fever and 4 from Diphtheria. There were 6 deaths from Diphtheria in 1923 although the actual number of cases was 45 less than in 1924. There was no death from Enteric, and Diarrhoea as a cause of death in children under 2 years of age has become a very unimportant factor, in spite of the overcrowding and the want of air and light in many of the homes (so-called) of these children. Infantile Mortality-rate.—This rate is based on the deaths of children under 1 year of age as compared with the births taking place within the year, and was 64-1 per 1,000 as compared with 45-8 in 1923—the most favourable year on record. The increased mortality from Measles, Whooping Cough and Pneumonia (27 deaths) explains the big jump for 1924. Our rate is 11 per 1,000 less than the Country as a whole and 16 less than that of the Great Towns. Compared with the average for the previous 5 years the rate is 4-2 per 1,000 in excess, but taking the five-yearly periods since 1891—136-3; 151-5 ; 123-3; 101-4; 87-4 and 69-9—the mortality for 1924 is less than any of the averages up to and including 1920. Most Authorities, and all interested in Infant Welfare Work, like a pat on the back for the lowered infant mortality of children under 1 year of age shown in recent years, and attribute the improvement to Health Visiting and Infant Welfare Work. Could four-fifths of this work be dropped and the Community no worse off ? In the period 1896-1900, 151 out of every thousand born died in the first year of life. The birth-rate then was 32-3 per 1,000. Assuming the same birth-rate for 1924, we should have had 4,234 births, or 1,943 more than actually took place, so that even with an Infantile Mortality-rate of 151 per 1,000 the State would be the richer by 1,450 children than under present conditions. As pointed out previously the work carried out at the Ante and Post-Natal Clinics and by Child Welfare Workers appears to be a 6 great success, but once our Mothers grasp the real value of breast feeding, and, in its absence, that of clean Milk—natural or dried— cleanliness in the home and the paramount importance of fresh air and sunlight, Child Welfare Centres will disappear and the money now spent will be more usefully diverted to the teaching of our senior girls these essential truths for their future guidance. Infant deaths, apart from intelligence and knowledge on the part of the Mothers, largely depend on the economic conditions of the home. The children born in the Hale End Ward have a greater chance of survival than those in the other Wards, and the Mortality of unwanted children is no less than before the advent of Child Welfare Centres ; their chances of surviving to the second year of life are less than half those born in wedlock, and the comparative mortality figures of both are 139-5 and 62-7 for the Whole Area. Scarlet Fever.—This disease was much less prevalent than in 1923—the notified cases were 185 compared with 351—and only one death was recorded. This happy result could hardly be anticipated in view of the existing housing conditions. The serious view taken, by most parents, of the disease, the intelligent supervision of our children by their Teachers and by way of the School Clinics, and the removal to Hospital of nearly 80 per cent, of the sufferers, may account largely for this. The type of disease as met with during the year was milder than usual and contacts seemed less vulnerable than heretofore. This may be due to two causes. Children now, although their parents are out of work, are well fed, and as the result of medical inspection, unhealthy conditions of throat and nose are remedied and in consequence the children have greater resisting power. Diphtheria.—Of the 257 cases notified 120 of them were discovered by the Medical Officer of Health or the doctors on his Staff. Two hundred and twenty-eight, or over 88 per cent, of the total, were treated in Hospital. There were 4 deaths, or a case mortality of 1-5 per 100. Although our Mortality for the disease was only half that of the Country as a whole, it might have been less. Mistakes were made' in many cases ; the parents assuming that the patients were suffering from headache or cold, or both, failed to have medical advice until the period had passed when modern treatment could have prevented a fatal issue. 7 The facilities for diagnosis of doubtful cases by way of bacteriological examination are ample, but many first or primary cases in a family were only discovered by me when examining them as "contacts." There is no charge made for examinations of swabs nor for Anti-toxin serum if injected gratuitously by the doctor in attendance. During the year, in a considerable number of the children under treatment for Otorrhoea, Diphtheria bacilli were found, and these children with carrier cases (80 in all) were a source of great anxiety. They were kept under constant observation and had treatment daily at the School Clinic. A few of the cases were believed to have caused Diphtheria in others—and these, and those where no proper isolation could be effected in the homes, were removed to the Isolation Hospital. Encephalitis Lethargica (Sleepy Sickness). Sporadic cases of this disease occurred throughout the Country in January. In February 2 cases arose here, followed by 4 in March, 8 in April, 7 in May, declining to 2 in September and 1 in October. Altogether 28 cases were notified and 6 deaths were registered. All the cases were visited and the usual precautions taken. There was no spreading by contact as far as I could make out except in two instances—a teacher contracted the disease in a mild form from one of the scholars who was in attendance during the early stages of her illness, and a nursing sister contracted the disease in a severe form from a pupil patient. Two cases occurred in one road in almost adjoining houses. The illness of both started on the same date and no casual relationship between them could be traced. The ages of the patients were:— 5-10 10-15 15-20 20-30 30-40 40 years years. years. years. years. years, and upwards. 4 4 2 6 5 7 All the cases were re-visited towards the end of the year. Seventeen of the cases were removed to Hospital, and of these 4 died. Of the sufferers of School age, 1 died ; 3 apparently have completely recovered ; 3 are, I fear, hopeless wrecks, and 1 suffers . from irritability and insomnia at night, is dull and slow in all his movements and suffers from a complete change in his moral outlook. 8 Of the adults, 3 have well marked Parkinsonian symptoms and are unable to work, and the remainder, while suffering from slight to severe after.effects, have resumed their usual employment The following are the birth, death, and infantile mortality rates for this and similar districts in the outer zone of London during 1924, as taken from the four quarterly Returns of the Registrar. General:. Town Population Birthrate Deathrate Infantile mortality rate Croydon 193,400 18.3 11.6 54.8 Willesden 168,700 15.7 10.2 75.6 Hornsey 87,430 12.0 10.4 48.9 Tottenham 151,700 16.0 10.2 73.7 Edmonton 69,590 26.6 9.9 40.4 West Ham 314,400 25.4 11.5 69.2 East Ham 146,200 15.8 9.6 65.0 Leyton 132,800 130 10.0 65.4 Walthamstow 130,000 161 100 68.9 Ilford 89,020 15.5 9.6 44.2 Corrections have been made at the end of the year at Somerset House for all these Districts but as these are not within my knowledge, by retaining the above figures, the relative positions will not be much altered The true infantile mortality rate for Walthamstow is 64.1 and probably those for the other Areas are also lower than shown Six of the 10 Large Towns have a smaller birth.rate, 5 have a greater death.rate and only 3 have a higher infantile mortality rate Ilford and Hornsey occupy yearly enviable positions in these tables and this may be accounted for by the character of their populations and their low birth.rates; but there is no such explanation for Edmonton Here is a poor Area with the highest birthrate, the lowest infantile mortality rate; and a general death. rate equal to the best One does not expect very favourable rates at West Ham from the character of its population and its location, but Tottenham and Willesden, districts with advantages, natural and economic, two of the best administered Areas with Public Health Services second to none in the Country, apparently have no better results than those of Walthamstow By such a comparison our District's record is good but Edmonton shows that a considerable improvement is 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:- 9 Birth.rate, Death.rate, and Analysis of Mortality during the Year 1924. (Provisional figures. The rates for England and, Wales have been calculated on a population estimated to the middle of 1924, ithile those iot the towns have been calculated on populations estimated to the middle'of 1923. The mortality rates refer to the whole population as regards England and Wales, but only to civilians as regards London and the groups of towns.) Birthrate per 1,000 Total Population. Annual Death.rate per 1,000 Population. Rate Per 1,(00 Births Percentage of Total Deaths All Causes. Enteric Fever. Small.Pox. Measles. Scarlet Fever. Whooping Cough Diphtheria. I Influenza. 1 Violence. Diarrhoea and Enteritis (under 2 years). Total Deaths under 1 year. Causes of Death Certified by Registered Medical Practitioners. Inquest Cases. Uncertified Causes of Death. England and Wales 18.8 12 2 0.01 0.00 0.12 0.02 010 0.06 0.49 0.44 7.3 75 92.3 6.6 1.1 105 County Boroughs and Great Towns, including London 157 Smaller Towns (1921 Adjusted Populations 20,000—50,000) 194 18.9 12.3 112 0.01 001 0.00 0.00 0.18 0.08 003 002 0.12 0.09 0.08 0.06 0.45 0.50 0.40 0.36 9.2 6.2 80 71 92.5 93.3 6.9 5.5 0.6 1.2 London 18.7 12.1 0.01 - 0.29 0.03 0.11 0.12 0.36 0.44 8.4 69 91.3 8.6 01 Walthamstow 17 4 1001 0.00 000 0.08 0007 001 0.03 0.32 0.23 40 641 90.9 91 0.0 10 Under all the headings the Public Health in Walthamstow attained a satisfactory standard. I beg to remain, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, J J. CLARKE. 11 GENERAL STATISTICS. Area 4,343 acres. Population 131,100 No. of inhabited houses (1921) 25,526 Rateable value £520,754 Sum represented by a penny rate £1,955 m. f. Birth Legitimate 1,143 1,105 Iiiegtimate 18 25 birth rate 17.4 m f Deaths registered within District 786 382 404 No. registered of non-residents 39 25 14 No. of residents dying without the District 554 296 258 Death-rate 1924 10.01 No. of women dying in, or in consequence of, From Sepsis 4 child-birth other causes 8 Deaths of infants under one year of age, per 1,000 births— Legitimate, 627 ; Illegitimate, 1395 ; Total, 64-1. Deaths from Measles (all ages) 11 „ Whooping Cough (all ages) 17 „ „ Diarrhcea (under two years of age) 12 NOTIFIABLE DISEASES DURING THE YEAR. Disease Total cases notified. Cases admitted to hospital. Total deaths. Diphtheria 257 228 4 Scarlet Fever 185 144 1 Enteric Fever (including Paratyphoid) 6 3 - Puerperal Fever 3 3 4 Pneumonia 170 48 128 Tuberculosis— Pulmonary Males 101 88 69 Females 101 88 53 Non-pulmonary Males 24 24 6 Females 32 25 15 Those failing with Scarlet Fever were less by about half the number, and those with Diphtheria 45 greater than in 1923. 12 There was no death from Typhoid Fever. The RegistrarGeneral's Returns show 4 deaths from Puerperal Sepsis, although I received only 3 Notifications of Puerperal Fever. Over 19 per cent, of those dying from Tuberculosis have not been notified as suffering from the disease during their life-time; 5 were notified subsequent to death. Twenty-eight of the 143 deaths followed within three months of Notification, 12 within six months, 13 within nine months, and the remainder were notified for a year or over. The number of Tubercular patients who received Hospital treatment was 225 as compared with 34 in 1923. The following table shows the number of new cases of Tuberculosis notified during the year according to ages and the deaths occurring among those notified:- Age-Periods. New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M F M F M F M F Under 1 yr - 1 3 - 1 - 1—5 yrs. - 5 4 3 - 2 2 - 5—15 yrs 1 14 9 17 - - 1 2 15—25 yrs 25 31 7 5 6 7 - - 25—45 yrs 46 36 3 2 8 4 1 1 45—65 yrs 27 13 2 7 4 65 yrs. & upwards 2 2 - - 1 - - - Totals « 101 101 24 32 22 17 5 3 OPHTHALMIA NEONATORUM. These cases are classified as follows :—• Cases Cases Vision Vision Total n , notified. treated. unimpaired, impaired, blindness. Deaths' At home. In hospital. 16 11 5 16 - - All the patients except one who died in Hospital—the cause of death given being Prematurity—did well and no defect in vision resulted, 13 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 10 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 18 practising in the District. Of these 7 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 generally satisfactory. Clinics and Treatment Centres.—These embrace the following :— Situation. Accommodation. By whom provided. Description. Brookscroft, Waiting rooms, Voluntary Infant consultations, Forest Road weighing Association wards for observa- room, consult- tion and ing room, ment. class rooms Truro Hall, Waiting, weigh- Urban Dist. Infant consultations, High Street ing and con- Council Ante-Natal Clinic, suiting rooms Lloyd Park Waiting, con- Walthamstow Minor ailments, DenWalthamstow suiting and Education tal Clinic, Eye treatment Committee Clinic rooms Hoe Street, Do. Voluntary X-ray treatment for Walthamstow school children by arrangement. Do. Do. Essex County Tuberculosis Dis- Council pensary. Venereal Diseases are treated at the London Hospitals by arrangement made by the Essex County Council. The Council's Centre, situated in a turning off a main street, is fairly well placed as regards accessibility for those who attend and for those for whom the Centre was primarily established. 14 Complaints have been made by the workers from time to time of the unsuitability of the premises, and the provision of an up-todate Centre has been discussed by the Maternity and Child Welfare Committee on several occasions. The greatest difficulty is the provision of a suitable site and probably during the coming year this will be obtained. The consultations are still held twice weekly, and the number of names on the register at the end of the year was 5,582. The following are the quarterly attendances of children during the year:— New Cases. Old Cases. 1st quarter 207 2,578 2nd „ 209 2,755 3rd „ 210 2,917 4th „ 157 2,437 783 10,687 Brookscroft Voluntary Centre.—No change in the work or its character has taken place during the year. There are 5,984 names on the register, and the following are the quarterly attendances of children during the year :— New Cases. Old Cases. 1st quarter 129 2,181 2nd „ 139 2,359 3rd 128 1,868 4 th 96 1,884 Total 492 8,292 For 1923 the totals were 548 8,836 The Visiting Nurse paid 2,454 visits to the homes of children brought to the Infant Consultations; 3,600 attendances were made by the mothers at the lectures delivered on Mothercraft and Infant Care, and 98 mothers attended the Needlework Classes. In addition, 265 massages were administered to children for varying causes. This Centre continues to do much excellent work, and the Honorary Physician, Dr. Elliott, and his Staff, voluntary and paid, are most enthusiastic workers. The number of cases admitted to the Observation Wards during the year was thirty-one and of these one was sent by your Authority. 15 Arc Lamps were installed towards the end of the year and children suffering from Marasmus and Rickets have apparently been much benefitted by the "Sunlight treatment " given. 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. The Governors of the Hospital are putting forth great exertions for the extension of the present buildings and probably in the near future 40 more beds will be provided. The work carried out meets with approval from the general public and is of a character leaving little to desire as far as the existing accommodation will permit. Hopes are entertained that under the new conditions, closer co-operation with the Municipal Authority and greater co-ordination of all Medical and Surgical work within the District will eventuate. The Fever Hospital—recognised accommodation 84 beds, for Scarlet Fever and Diphtheria patients—-is situated without the area, and provided ample accommodation for all the patients needing removal from their homes. At present we have no provision for the hospital treatment of Small Pox Cases, and if the disease arose in the area the situation would be an embarrassing one. The matter has occupied the attention of the Council but no satisfactory solution of our difficulty has been found. In view of the number of cases of Small Pox occurring throughout the Country for the past two years, the Council should make some arrangement and be in a position to deal with any case that might arise in this District. The position would be a very serious one if for want of proper isolation, the disease, once introduced, could spread indefinitely. There is no institution in the district for unmarried mothers, illegitimate infants or homeless children. 16 Ambulance Facilities.—Two Motor Ambulances for Infectious Diseases are maintained by the Local Authority, and the St. John Ambulance Association hires its motor ambulance for the removal to hospital of cases of serious illness, and deals with accidents without payment. The Council in response to a request from the Police Authorities has had under consideration the provision of an ambulance to be kept at the Fire Station for cases of accident occurring within the Area. LABORATORY WORK The Municipal Laboratory is mainly used for the Bacteriological diagnosis of Diphtheria. During the year 2,171 examinations were made. These were mainly in connection with the School Clinics and for contacts. No. examined. Positive. Negative. Diphtheria 2,171 339 1,832 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, however, is found so convenient that, during the year, the local doctors sent 568 specimens of suspected Diphtheria. Cases of Infectious Disease notified during the Year 1924. 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) 257 1 61 176 10 8 1 - 86 40 42 16 24 49 228 Erysipelas 53 1 - 10 7 10 20 5 11 13 9 4 10 6 13 Scarlet Fever 185 - 51 110 20 4 - - 26 45 41 21 15 37 144 Typhus Fever - - - - - - - - - - - - - - - Enteric Fever 6 - - 5 - 1 - - - 3 - 1 - 2 3 Relapsing Fever - - - - - - - - - - - - - - - Continued Fever - - - - - - - - - - - - - - - Puerperal Fever 3 - - - - 2 1 - - 1 1 1 - - 3 Cerebro-spinal Meningitis 2 - 1 - - 1 - - 1 - 1 - - - 1 Poliomyelitis 6 1 5 - - - - 1 - 2 3 - - 6 Polio-encephalitis i - 1 ' - - - - - - - - - - 1 1 Ophthalmia Neonatorum 16 16 - - - - - - 3 1 3 2 4 3 - Pulmonary Tuberculosis 202 - 5 15 56 82 40 4 40 36 35 24 18 49 - Other forms of Tuberculosis 56 4 7 26 12 5 2 - 13 6 9 9 9 10 - Encephalitis Lethargica 29 - - 9 5 10 3 2 7 7 2 4 4 5 18 Malaria (Imported) - - - - - - - - - - - - - - - Dysentery (Imported) - - - - - - - - - - - - - - - Pneumonia 170 4 21 22 27 37 41 18 47 28 24 20 22 29 48 Trench Fever - - - - - - - - - - - - - - - Totals 986 27 152 373 137 160 108 29 235 180 169 105 106 191 465 Causes of and Ages at Death during the year 1924. Whole District and Wards. Causes of Death Nett Deaths at the subjoined ages of "Residents" whether occurring within or without 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 1 Enteric Fever - - - - - - - - - - - - - - - 2 Small Pox - - - - - - - - - - - - - - - 3 Measles 11 2 6 3 - - - - - 3 3 1 1 2 1 4 Scarlet Fever 1 - - 1 - - - - - - 1 - - - - 5 Whooping Cough 17 5 6 4 1 1 - - - 5 8 1 2 1 - 6 Diphtheria 4 - 1 1 1 - - 1 - 1 1 1 - - 1 7 Influenza 42 - - 1 2 1 2 23 13 5 6 9 7 7 8 8 Encephalitis Lethargica 6 - - - 1 2 1 1 1 2 2 - - 2 - 9 Meningococcal Meningitis 3 - 1 - - - 1 1 - 1 - 1 1 - - 10 Tuberculosis of Respiratory System 122 1 3 - 2 31 52 29 4 20 18 21 24 14 25 11 Other Tuberculous Diseases 18 3 - 5 6 3 1 - - 4 - 1 7 3 3 12 Cancer, malignant disease 153 - - - 3 - 13 77 60 37 25 32 10 21 28 13 Rheumatic Fever 2 - - - - 1 1 - - - 1 1 - - - 14 Diabetes 12 - - - 1 1 - 3 7 1 2 3 1 3 2 15 Cerebral Haemorrhage, etc. 67 1 - - - - 2 25 39 17 9 11 12 8 10 16 Heart Disease 171 - - - 2 4 17 55 93 33 26 42 27 23 20 17 Arterio-sclerosis 16 - - - - - - 2 14 7 2 2 4 1 - 18 Bronchitis 159 8 3 - - 3 6 33 106 31 30 39 18 13 28 19 Pneumonia (all forms) 128 33 19 6 3 2 16 22 27 25 21 30 23 12 17 20 Other Respiratory Diseases 17 1 1 2 - 1 2 4 6 2 5 5 2 2 1 21 Ulcer of Stomach or Duodenum 9 - - - - - 2 7 - - - 1 2 3 3 22 Diarrhoea, etc. (under 2 years) 9 9 - - - - - - - 4 - 2 2 1 - 23 Appendicitis and Typhlitis 15 - - 1 3 3 1 6 1 3 2 1 3 4 2 24 Cirrhosis of Liver 6 - - - - - - 2 4 - - 3 2 1 25 Acute and Chronic Nephritis 40 - - - 1 4 10 14 11 7 6 7 5 7 - 26 Puerperal Sepsis 2 - - - - - 2 - - - 1 1 - - - 27 Other accidents and diseases of Pregnancy and Parturition 7 - - - - 3 4 - - - 2 - 1 3 1 28 Congenital Debility and Malformation, Premature Birth 55 55 - - - - - - - 9 10 11 4 7 14 29 Suicide 15 - - - - - 5 8 2 4 2 2 2 2 3 30 Other Deaths from Violence 31 2 1 2 4 5 2 9 6 5 4 5 4 6 7 31 Other Defined Diseases 200 26 3 1 7 9 20 46 88 27 28 46 37 23 39 32 Causes ill-defined or unknown 2 - - - - - 1 1 - - - - 1 1 - Special Causes (included above) - - - - - - - - - - - - - - - Poliomyelitis - - - - - - - - - - - - - - - Polioencephalitis - - - - - - - - - - - - - - - Totals 1340 146 44 27 37 74 161 369 482 253 215 279 202 169 222 SUMMARY, 1924. 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 40 9 13 6 68 28 22 11 17 146 Uncertified - - - - - - - - - - Influenza - - - - - - - - - - - - - - - Small-Pox - - - - - - - - - - - - - - - - Chicken-Pox - - - - - - - - - - - - - - - - Measles - - - - - - - 2 - 2 - 1 1 - - - Scarlet Fever - - - - - - - - - - - - - - - - Whooping Cough - - 1 - 1 1 1 1 1 5 1 2 - 1 1 - Diphtheria and Croup - - - - - - - - - - - - - - - Erysipelas - - - - - - - - - - - - - - - - Tuberculous Meningitis - - - - - - 1 - 2 3 - - - 3 - - Abdominal Tuberculosis (b) - - - - - - - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - - - - - - - Phthisis - - - - - - - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - - - - - - - - - - - Convulsions 1 - 1 - 2 - - 1 - 3 - - - 1 2 - Laryngitis - - - - - - - - - - - - - - - - Bronchitis - 1 1 2 4 2 - - 1 7 3 2 - - - 2 Pneumonia (all forms) - 1 1 2 4 11 5 5 8 33 6 6 5 7 4 5 Diarrhœa - - - - - 1 2 - - 3 2 - - 1 - - Enteritis - - 1 1 1 2 - 1 5 2 - 2 1 - - Gastritis - - - - - - - - - - - - - - - - Syphilis - - - - - - - - - - - - - - - - Rickets - - - - - - - - - - - - - - - - Inattention at Birth, wilful neglect 4 - - - 4 - - - - 4 1 1 1 1 - - Suffocation, overlying - - - - - 1 1 - - 2 1 - 1 - - - Injury at Birth 2 1 - - 3 - - - - 3 - 1 1 - - 1 Atelectasis 6 1 - - 7 - - - - 7 - 1 1 1 1 3 Congenital Malformations 3 1 1 - 5 - - - - 5 - 2 - 1 2 - Premature Birth 20 3 4 1 28 5 - 1 - 34 7 1 10 2 4 10 Atrophy, Debility and Marasmus 3 1 3 - 7 2 6 - - 15 3 6 2 - 1 3 Cerebro-Spinal Meningitis - - - - - - 1 - 1 2 22 - - - - Encephalitis - - - - - - - 1 - 1 - - - - - - Other Causes 1 - 1 - 2 4 3 - 3 12 1 2 2 2 1 4 40 9 13 6 68 28 22 11 17 146 29 25 26 22 16 28 17 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 2.82 147.6 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 10 100.8 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 1915 3134 2826 1428 1573 23.24 21 .7 10.50 11.9 0.98 106 77.5 93.1 1706 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 16.7 111 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 Average , for 5 years, 1916.20. 2523 1413 19.0 11.4 0.66 69.9 1130 1921 2673 1237 21 .7 9.5 0.52 61.4 1436 1922 2479 1402 19.6 10.8 1.07 62.8 1077 1923 2529 1165 19.4 8.96 0.30 45.8 1364 1924 2291 1328 174 10.01 0.19 64.1 963 Average for 4 years. 1921.24. 2493 1283 19.5 9.82 0.52 58.5 1210 18 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 Washhouses 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. 19 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. SANITARY ADMINISTRATION. The following is a summary of the work carried out during the year by the Sanitary Inspectors:— Number of Inspections made 9,451 Number of nuisances detected 8,025 Number of complaints received 1,794 Informal Notices served 2,265 „ „ complied with 2,254 Statutory Notices served 66 Total number of visits from all causes 18,444 The nature and variety of the work is shown in the following tables:— Drains tested 280 „ reconstructed or repaired 233 „ obstructions removed 137 „ means of access provided 28 „ ventilation provided 72 „ „ repaired 195 Soil pipes repaired 19 „ new provided 18 Rainwater pipes, renewed 284 „ „ disconnected from drains 6 Roofs repaired or renewed 719 Gutterings repaired or renewed 521 W.c. pans or traps provided 240 Gully traps provided 128 W.c. flush cisterns provided 164 „ „ repaired 208 „ reinstated 211 W.c. floors concreted 46 W.c.'s repaired and cleansed 399 20 W.c.'s, light and ventilation improved 14 Waste-pipes renewed or trapped 289 New sinks provided 27 Water supply reinstated 21 Cisterns cleanscd and covered 114 Drinking-water cisterns abolished 2 Urinals, improved flushes provided - „ cleansed or repaired 31 „ paved - „ provided new - Sculleries paved 80 Yards and forecourts paved and repaired 480 Dirty houses cleansed 132 „ rooms cleansed 4,097 Floors repaired 253 Ventilations under floors provided 189 New damp-proof courses provided 21 Sites concreted - Rooms ventilated - Offensive accumulations removed 88 Animals improperly kept removed 16 Manure receptacles provided 6 Stables closed 1 „ cleansed 80 „ paved and drained 4 Manholes repaired or resealed 58 Bell traps abolished - Other cases of dampness remedied 336 Separate Sanitary Conveniences provided to shops where both sexes are employed 2 Miscellaneous repairs 1,297 Infectious Diseases. Visits to premises 1,084 Re-visits to premises 232 Premises disinfected 692 Articles disinfected at Low Hall 6,503 Articles destroyed at Low Hall 66 21 Dampness in Houses. Sites concreted Damp-proof courses provided 21 Yards and forecourts paved and drained 480 Roofs made watertight 719 Rainwater pipes made good 284 Guttering repaired or renewed 521 Dampness remedied 336 Ventilation under floors provided 189 House-to-House Inspections 660 Special Premises. Number. Visits paid Slaughter-houses 14 346 Butchers' shops 77 618 Bakehouses 48 137 Fishmongers (fish frying and curing), etc 61 478 Eating-houses and Coffee Stalls 46 79 Ice cream vendors 53 85 Cowsheds 4 32 Milkshops 120 293 Laundries 18 35 Rag and bone dealers 12 35 Elementary Schools 27 68 Private Schools 13 Piggeries 12 75 Street Stalls Numerous 163 Greengrocers „ 183 Factories ... 320 Workshops ... 359 Outworkers ... 232 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, 52; Paving repaired, 7; Floors repaired, 5; Accumulations removed, 1; New Galvanised Bins provided, 1; Drains repaired, 3; W.C.'s repaired and cleansed, 1; Roofs repaired, 5. 22 Bakehouses. Special cleansings, 53; Roofs repaired or improved, 4; Paving repaired, 5; Gutters repaired, 2; W.C.'s repaired, 5; Drains repaired, 9; New W.C. provided, 1; New Sink provided, 1; Light and Ventilation improved, 1. Fishmongers' Shops. Premises cleansed, 36; Smoke-holes repaired, 1; Paving repaired, 8; Drains repaired, 2; Roofs repaired, 2; Yards re-drained, 2; Furnaces fitted with Hygienic Covers and Condensers, 2; Other improvements, 2; Floors repaired, 3; Yards re-paved, 6. Coffee and Eating Houses. Special cleansings, 14; Drains cleared and repaired, 4; Yard Paving repaired, 1; Drinking water cisterns cleansed and covered, 1; W.C.'s repaired, 1; New Galvanised Iron Bins provided, 2; Drains repaired, 1; Floors repaired, 2; New W.C. Cisterns provided, 4; New V.P. to Drain, 1. Ice Cream Vendors. Special cleansings, 16; Floors repaired, 3; Yards paved, 3; Drains repaired, 1; Special cleansing of Utensils, 4. Cowsheds and Milkshops. Special cleansings, 37; Roofs repaired, 2; Yard paving repaired, 5; New Copper provided, 1; Accumulation removed, 1; New Sink fixed, 1; Drains repaired, 2. Stable Premises. Cleansings, 47; Accumulations removed, 20; Gutterings repaired, 3; Paved and drained, 8; Roofs repaired, 3; Manure receptacles provided, 2; Obstruction from Drains removed, 3. Laundries. Special cleansings, 28; Pavings repaired, 6; Roofs repaired, 1; Drain repaired, 1; W.C. Flush reinstated, 3; Fouling of Surface Water, 1. Rag and Bone Dealers. Cleansings, 11; Floors repaired, 1; Roofs repaired, 1; Accumulation removed, 1; Paving repaired, 2. Private Schools. Cleansings, 1; W.C.'s repaired and cleansed, 2. Piggeries. Cleaned, 9; Paving relaid, 2. 23 Unsound Food. The following was condemned and destroyed:— 240 lbs. eels. 10 stones of haddocks. 1 set of ox lungs* 2 pigs' heads* 2 boxes of cods' roe. 1 set of ox lungs.* 1 trunk of skate300 eggs. 1½ sacks of potatoes. 1 set of ox lungs.* 1 ox head and heart.* 35 stones of beef.* 6 stones of hake. 2 boxes of skate. 1 barrel of crabs. 3 boxes of cod. 62 tins of haddock. 56 tins of parsnip. 124 tins of beetroot. 4 fowls. 7 rabbits. 1 ox head and tongue and set of lungs.* 1 brisket of beef.* 1 forequarter of beef.* 1 trunk of haddocks 2 pig carcases. 3 pigs' heads.* 1 trunk of haddocks. 4 pieces of beef. 5 pigs' heads. *These were affected with T.B. Sale of Food and Drugs Act. Number of samples taken 87 Number of samples found genuine 77 Three Summonses were issued against one Vendor. Defendant did not appear and a warrant for his arrest was issued. HOUSING. No. of Houses erected (private enterprise) 96 No. of Houses erected (building scheme) 16 Total 112 I.—Unfit Dwelling Houses. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health and Housing Acts) 9,451 24 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 660 (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 (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 437 II.—Remedy or 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 2,254 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 66 (2) Number of dwelling-houses which were rendered fit— (a) by owners 49 (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 tinder Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 10 (2) Number of dwelling-houses in which defects were remedied— (a) by owners 6 (b) by Local Authority in default of owners 4 25 C. Proceedings under sections 17 and 18 of the Housing, Town Planning, &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 dwelling-house 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 pursuance of Demolition Orders nil FACTORY AND WORKSHOP ACT, 1901. The following Table filled in for your district gives the information as required by the Home Office:— Factories, Workshops, Laundries, Workplaces and Homework. 1.—INSPECTION. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) Factories (Including Factory Laundries.) 332 - - Workshops (Including Workshop Laundries.) 382 — — Workplaces (Other than Outworkers' premises) 258 - - Total 972 — — 26 2.—DEFECTS FOUND. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) (4) (5) Nuisances under the Public Health Acts:-* Want of cleanliness 68 68 - - Want of ventilation 4 4 — - Overcrowding — — — - Want of drainage of floors — - — — Other nuisances 50 50 — — Sanitary accommodations insufficient 2 2 — — unsuitable or defective not separate for sexes 1 1 - - 2 2 — — Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouse (s. 101) - - - - Breach of special sanitary requirements for bakehouses (ss. 97 to 100) - - - - Other offences (Excluding offences relating to outwork.) - - - — Total 127 127 — — * Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act as remediable under the Public Health Acts. 27 SANATORIUM REPORT, 1924. As submitted by the Resident Medical Officer. ADMISSIONS, DISCHARGES, AND DEATHS. Scarlet Fever. Diphtheria. Whooping Cough Measles Tuberculosis. Other Diseases Total. Remaining on Dec. 31, 1923 28 33 - — 12 2 75 Admitted during 1924 151 232 25 14 53 7 482 Total 179 265 25 14 65 9 557 Discharged during 1924 157 204 12 12 51 7 443 Died during 1924 1 5 2 2 1 — 11 Remaining on Dec. 31, 1924 21 56 11 — 13 2 103 Total 179 265 25 14 65 9 557 SEX AND AGES OF PATIENTS ADMITTED. Disease. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years & upwards. Total of Total. M F M F M F M F M F Scarlet Fever 17 24 30 28 17 14 12 9 76 75 151 Diphtheria 35 22 38 52 27 43 5 10 105 127 232 S.F. & Diph. — —- — 1 — 1 — — — 2 2 S.F.& Measles - - - 1 - - - - - 1 1 Diph. & Meas. 2 — — — — — — — 2 — 2 Whooping C. 6 19 - - - - - - 6 19 25 Measles 5 3 3 2 — — — 1 8 6 14 EpidemicEncp. - - - - - - - 2 — 2 2 Tuberculosis — — — — — 4 — 49 — 53 53 Totals 65 68 71 84 44 62 17 71 197 285 482 133 155 106 88 482 SEX AND AGE AT DEATH. Disease. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years & upwards. Total. M F M F M F M F Scarlet Fever — 1 - - - - - - 1 Diphtheria 1 1 - 1 - — 1 1 5 Whooping Cough l 1 - - - - - - 2 Measles 1 1 - - - - - - 2 Tuberculosis - - - - - - - 1 1 Totals 3 4 1 — — 1 2 11 Scarlet Fever.—One hundred and fifty-one cases were admitted during the year, compared with 277 in 1923, 444 in 1922, 545 in 1921 and 228 in 1920. 28 MONTHLY ADMISSION OF SCARLET FEVER CASES. Under 5 years. from 5 to 10 years. from 10 to 15 years. 15 years & upwards. Total. M. F. M. F. M. F. M. F. January — 2 4 2 3 1 4 - 16 February — 4 1 4 — 1 1 1 12 March 1 1 - 1 1 - 1 - 5 April l — 3 1 1 2 1 2 11 May 1 2 3 3 3 — 1 — 13 June 1 3 2 3 2 — - - 11 July 1 — 3 5 — — - — 9 August 1 3 2 1 1 2 - 1 11 September 1 4 4 2 1 — - — 12 October 6 2 1 1 — 2 1 2 15 November 3 1 4 2 2 3 2 2 19 December 1 2 3 3 3 3 1 1 17 Totals 17 24 30 28 17 14 12 9 151 In addition to the cases of Scarlet Fever complicated by Diphtheria and Measles included in the group "Other Diseases," two cases were suffering from Chicken Pox and Scarlet Fever. Two cases were incubating Measles and one developed Mumps shortly after admission. One death occurred as a result of Scarlet Fever, giving a case Mortality of 0.66 per cent. The chief complications were as follows:—Otorrhœa, 7; Simple Arthritis, 4; Endocarditis, 2; Nephritis, 1; Chorea, 1. Diphtheria.—Two hundred and thirty-two cases were admitted, compared with 170 during 1923, 222 in 1922, 263 in 1921, and 220 in 1920. MONTHLY ADMISSION OF DIPHTHERIA CASES. Under 5 years. From 5 to 10 years. From 10 to 15 years. 15 years & upwards. Total. M F M F M F M F January 2 — 1 6 1 2 1 — 13 February 2 2 1 3 1 2 1 - 12 March 2 2 1 1 - — 1 — 7 April 3 1 — 4 1 2 — — 11 May 5 1 3 2 1 4 1 3 20 June 4 3 1 8 3 1 — 2 22 July 4 1 2 5 2 4 — — 18 August 2 — 1 2 3 2 — 1 11 September 4 2 7 4 2 6 — — 25 October 4 4 8 7 4 8 1 2 38 November 3 5 5 3 5 7 — 1 29 December — 1 8 7 4 5 — 1 26 Totals 35 22 38 52 27 43 5 10 232 29 Two cases were found on admission to be suffering from Measles, three cases proved to be incubating Whooping Cough, and two others Chicken Pox. Of the 232 cases treated during the year, 5 died. Of these, 2 cases—both adults—were proved to have died from causes other than Diphtheria. Consequently in calculating the case Mortality these 2 cases have been deducted, giving a case Mortality of 1.29 per cent. The chief complications were: Cardiac Paralysis, 9; Palatal Paralysis, 6; Albuminuria, 4; Strabismus, 2. Measles and Whooping Cough.—Of the 13 cases of Measles and 25 of Whooping Cough admitted during the year, 2 died from Measles and 2 from Whooping Cough. All the deaths occurred in children under 2 years of age. Epidemic Encephalitis.—Of the 2 cases treated in the Hospital, one—a woman aged 44—suffered from Chronic Nervous Disease simulating General Paralysis, and was transferred to a General Hospital; the other—a girl of 15 years of age—recovered with slight Parkinsonian Sequalae. Staff.—With the exception of one nurse, who contracted Diphtheria, and two who developed Tonsilitis, the health of the Staff was good. Swabs.—One thousand six hundred and forty-two swabs were taken and examined during the year. SCHOOL MEDICAL SERVICE 33 TO THE CHAIRMAN AND MEMBERS OF THE Walthamstow Education Committee Ladies and Gentlemen, I beg to submit the following report for the year 1924, upon the Schools and the Medical Inspection and treatment of the children under your control. With the exception of the Statistical Tables prepared under my supervision and the section dealing with defective vision by Dr. Sheppard, the report has been prepared by Dr. Broderick. The outstanding feature of the School year was the opening in February of the Cripple School with accommodation for 50 children, followed in June by the founding of Brookfield Orthopaedic Hospital with 25 beds. The initiation of the Hospital on a voluntary basis was made possible by the assistance rendered by your Committee and the generosity of the District Council. It is recognised by the Board of Education as a School and by the Ministry of Health for the treatment of cases of Surgical Tuberculosis. Within a few months of opening the accommodation provided at the School and Hospital was found to be inadequate, and already (March) another class room has been added to the School. All the beds at the Hospital, since its opening, have been occupied, and extension of buildings only awaits a favourable opportunity and the assistance of some generous donor! No change has taken place in the number of the School Medical Staff, and the Clinics, in operation throughout the year, have been made use of much more fully during the holidays than in previous years. This was especially noticeable at the Otorrhœal Clinic, 34 The number of children suffering from and under treatment for middle ear disease ("Running Ears") was slightly greater than in the previous year—152 against 145—but the number on the Register at the end of the year was less—157 compared with 200. My suggestion in last year's report, that the part time services of a Specialist would well repay the expense involved, was not considered, and I again draw your attention to the fact that our treatment of Otorrhœa is not so satisfactory or as efficient as is possible. The disease is a loathsome one in its manifestations, the source of a great amount of permanent deafness and consequent physical disability in after life; it is at all times dangerous—many of the sufferers die from a resulting septic Meningitis—and only under the best modern methods of treatment can its chronic course be cut short or really satisfactory results obtained. The ear discharges from a number of our children were found to contain Diphtheria Bacilli, and as a matter of precaution and owing to the home conditions six children were removed to the Isolation Hospital for varying periods. The Hospital expenses incurred for these children would have probably covered the cost of the part time services of an Aural Specialist. Enlarged Tonsils and Adenoids in children who contract Measles or Scarlatina are responsible for more cases of Otorrhœa than any other cause and the removal of these growths is very often followed by the cessation of the discharge. Under our existing arrangements with the Dispensary 173 children were operated on for the removal of Tonsils and Adenoids, 2 for Tonsils and 18 for Adenoids. A Sanitary survey of the home conditions of all these children was made prior to the operation, and the children were visited by a School Nurse subsequently. Four operations were carried out at Brookfield Hospital and 12 children have not yet been dealt with owing to overcrowding and unsuitable home conditions. By perusal of the official and other tables in the Report a good estimate can be obtained of the medical and other work carried out during the year and the changes taking place in our School population. 35 The number of School children on the Registers shows a yearly decline, but a general improvement in physique and general well being, as shewn on page 40, is apparent. You will probably notice that the numbers of children examined in the Code and other Groups were less than in 1923, but the obvious inference must not be drawn, for all the children due for Medical Inspection were seen by the doctors. To ensure this most of the Schools were re-visited to "pick-up" those absent at the routine inspections and to "survey" those who had previously objected to medical examination. The number medically examined was 6,138 or 891 less than apparently might have been expected. The smaller number is accounted for by the decreasing number of "Entrants" and "Intermediates" in our Schools during the past few years and the change of procedure in selecting those due for Medical Inspection as explained in the 1922 report. The defects found on Medical Inspection and their rate to children examined were very similar to those of previous years and on parallel lines with other Districts of like populations. Every effort was made by way of "following up" and, for the more serious defects of vision and unhealthy conditions of nose and throat, good results were obtained. Most of the Nurses' time spent in visiting parents to effect dental treatment for children over 8 years of age was wasted, and until a fuller and more adequate dental service is provided by your Authority no better results may be expected. During the year I examined 61 children reported to me as probably mentally deficient. Eleven of these were dull and backward from various causes, 16 were certified for the Special School, one was an imbecile, and the remainder were to be re-examined. The number of elementary School children deemed to be Mentally deficient varies from .8 to .5 per cent.—the latter figure is based on reports of School Medical Officers. Taking the smaller figure we should have in the Special School at least 110 children, and not 62 as we have at present. In this connection the following extract from a report of the Head Teacher of the Special School is of interest:— "In days gone by many of the Scholars were low grade M.D's. but happily now most of them are high grades and many only retarded." 36 Children from the Infants' Schools are seldom sent to the Special School and I invariably examine, more than once, all children presented to me as Mentally Deficient. It is quite a serious matter to a child to be labelled M.D. at any time of its life and I am fairly confident that few children remain in the ordinary Schools who are permanently incapable of receiving proper benefit from the instructions given therein. On Table II. may be seen how few children are found at Routine Medical Inspection to be suffering from minor ailments, as compared with the number sent to the Clinics. Only occasionally do the doctors now find at the Schools a child suffering from Ringworm or sores—a contrast to the early days and a change entirely due to the intelligent supervision exercised by the Teachers and Nurses. Measles were present in an epidemic form from February to May and Whooping Cough during November and December, causing a considerable loss of School attendances. Compared with 1923, the number of children failing with Scarlet Fever was less by half; the number found suffering with Diphtheria greater by 50 per cent. The maximum number of cases of Diphtheria in any month at one School was 5; in five Schools 3 cases occurred, and in 11 others 2 children contracted the disease. I think we can safely assume that very few children suffering from Diphtheria escape detection, and the part played by the School Medical Service in this respect may be judged from the fact that 120 cases, or 72 per cent. of the whole, were discovered at the Clinic or by way of examination of Contacts. The usual Sanitary surveys of the Schools were made during the year. Fifteen Schools—all Departments—were found to be quite satisfactory, and 9 had defects of a minor character. As in previous years, effective co-operation and the most cordial relations have existed between Teachers, Attendance Officers and Medical Staff. Mr. Longman has been specially helpful by his willing co-operation in everything undertaken for the betterment of the children's health. I beg to remain, Ladies and Gentlemen, Your obedient Servant, J. J. CLARKE, 37 Number of Schools and Accommodation. Boys Girls Infants Mixed Seating Accommodation Boys Girls Infants Mixed Provided 17 17 16 7 7,445 7,147 6,834 2,805 Non-provided 1 2 2 1 244 472 437 314 Special Schools— Mentally Defective — — — 1 — — — 130 Deaf and Dumb — — — 1 — — — 20 Blind and Myope Centre — — — 1 — — — 120 Physically Defective Centre — — — 1 — — — 50 Totals 18 19 18 12 7,689 7,619 7,271 3,439 GENERAL INFORMATION-REPORT, 1924. 1924 1923 1922 Number of children on Register, December 31st 21,087 21,325 22,526 Average Attendance 18,541.9 19,026.2 19,575 Percentage Attendance 87.9 90.6 86.9 Population (Registrar-General's estimate) 130,000 130,000 127,800 Percentage of school children to population 16.2 16.4 17.6 38 FINANCIAL STATEMENT. 1923. 1924. £ s. d. £ s. d. Rateable value of District 522,493 0 0 520,754 0 0 The average cost of Education per child:— (1) In the ordinary school 11 15 3¾ 12 1 0 (2) Mentally Defective Centic 34 6 2¼ 38 6 0¾ (3) Deaf and Dumb Centre 33 14 6¾ 28 19 l¼ (4) In the Myope Centre 25 4 3¾ 24 9 6½ The Education rate for— The half year ending March 31st 0 1 8¼ 0 1 9 „ „ „ Sept. 30th 0 1 11 0 2 1¼ „ March 31st, 1925 ... 2s. 0¾d. Total cost of medical inspection for year 4,618 10 11 4,624 3 0½ Grant towards the above for the year ending March, from Board of Education 2,308 2 1 2,170 12 9¼ Other receipts:— Medical treatment 44 2 6 24 3 9 Spectacles 50 0 7 46 14 0 Amount spent on repairs, improvements, etc., to schools for the year 5,790 2 4 3,954 19 0 39 REPORT OF THE WORK OF THE SCHOOL MEDICAL SERVICE. 1. STAFF. The Staff engaged in the medical care of the School children consists of the Medical Officer of Health, who is also the School Medical Officer, three assistant School Medical Officers, an Ophthalmic and an Orthopœdic Surgeon (part time), a whole time Dentist, six School Nurses, and two part-time Masseuses. 2. CO-ORDINATION. There is close co-operation between the School Medical Service and the other Medical Services in the Area. 3. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene and Accommodation.—The School premises are maintained in a satisfactory state of cleanliness. Ventilation and lighting are good and Warming is, in the main, efficient. A Sanitary Survey is made annually and wherever necessary by the Medical and Sanitary Staff—any defects arising are speedily attended to. The Education Committee spent during the year £3,954 19s. on repairs and improvements. 4. MEDICAL INSPECTION. A full description of the procedure at Medical Inspection was given in 1922 Report and as there have been no changes since it is not necessary to recapitulate. Arising out of Medical Inspection during the past year 95 children were excluded under Art. 53 b for varying periods for the following causes:— Influenza 11 Bronchitis and Bronchial Catarrh 23 Sore Throat 25 Styes 1 Stiff Neck 1 Vomiting 2 Impetigo 4 Worms 1 Cold 10 Rash 1 Sore Foot 1 Shingles 1 Feverish Cough 3 Febricular 1 Glands 1 Ringworm 2 Mumps 1 Chorea 1 Scabies 1 Malaise 1 Various 3 40 Malnutrition.—Taking into account the present deplorable state of unemployment as well as overcrowding, with its accompanying difficulties re baths, fresh air, etc., the general physique of our School Children is well maintained as shown by the following tables:— 5. REVIEW OF THE FACTS DISCLOSED BY MEDICAL INSPECTION. Heights and Weights of the Children Inspected. A Age. Average Height (inches). Average Weight (pounds). Anthropometric Height. Standard Weight. Boys. 5—6 42.5 39.5 40.44 37.74 8—9 48 55 46.94 49.95 12-13 56 73 55.48 73.86 B 5—6 41 40 40.44 37.74 8—9 46.5 52 46.94 49.95 12—13 57.75 76 55.48 73.86 Girls. A. 5—6 41.5 39.5 40.68 36.68 8—9 48.5 54 47.39 52.05 12—13 55.75 75 54.88 72.66 B 5—6 41 31 40.68 36.68 8—9 48 52.75 47.39 52.05 12—13 55.75 75.5 54.88 72.66 A—Represents a school serving clean area. B—One whose children are largely drawn from poor homes in mean streets. Clothing, Footgear, and Nutrition. ENTRANTS. Clothing. Footgear. Nutrition. Satisfactory. Unsatisfactory. Satisfactory. Unsatisfactory. Excellent. Normal. per cent. per cent. per cent. per cent. per cent. per cent. A Girls 100 — 100 — 10 90 B Girls 100 - 100 — 40 60 A Boys 89 11 94 6 21 79 B Boys 97 3 97 3 48 52 INTERMEDIATE. A Girls 100 — 100 — 17 83 B Girls 94 6 93 7 50 50 A Boys 100 — 100 — 27 73 B Boys 80 20 81 19 30 70 LEAVERS. A Girls 98 2 97 3 46 54 B Girls 95 5 96 4 66 34 A Boys 100 — 100 — 60 40 B Boys 86 14 85 15 68 32 41 Uncleanliness.—It was found necessary to take legal proceedings in only two cases of uncleanliness during the past year, these being taken under the School Attendance Bye-laws. We have no Cleansing Station. Our School Nurses paid 11 visits per School during the past year, making in all 115,135 examinations, and found 2,724 children unclean, or 12.9 per cent. of the total school population. Only 79 Notices were sent to parents under Section 87 of the Education Act, 1921, as compared with 219 last year. Minor Ailments.—Clinics are held three mornings weekly at Lloyd Park. During the past year 2,709 children, who made 14,709 attendances, were seen by the doctors making an average of 75 seen per session. A record of all cases is kept at the Clinic on special cards, the children having small cards on which their names, address, age, school and defect are recorded to enable the clerk to at once turn up their past history for the doctor's information, and on which the times of their arrival and departure, with a short note as to their condition and whether or not they are fit to attend school is noted for the information of the Head Teacher. Tonsils and Adenoids.—During 1924 there were 379 cases of Tonsils or Adenoids, or both, discovered at Routine Inspection, and of these 96 required treatment, i.e., 25 per cent. These, as well as 75 also found to require treatment at Special Inspections, were recommended for operation. Those requiring observation only, i.e., 281, were subjected to breathing exercises with considerable success in many cases. Tuberculosis.—Out of 5,749 children examined at routine inspection 14, or 2.5 per 1,000 were found to show definite signs of Tuberculosis; 6 of these were active and required treatment, while the remaining 8 were quiescent and only required observation. The District Tuberculosis Officer reserves one morning per week for the examination of children, and on this day all suspected cases are referred to him by the School Doctors, to whom he furnishes a report. If necessary he takes over complete control of the case, otherwise they are kept under observation by our Medical Stall. In Coppermill Road Junior Mixed School there are two open-air classrooms for Delicate or Tubercular children. The home conditions of all cases either doubtful or suspected are inquired into and advice and help (milk at School, etc.) is given where necessary. 42 Among our entire population of School Children (21,087) only 17 are suffering from Active Tuberculosis, and of these 4 are noninfectious and attend Public Elementary Schools. Skin Diseases.—(a) Ringworm. Owing to the considerable falling off of late years in the number of children suffering from this disease, only one afternoon per week is now devoted to its treatment. During 1924, 129 cases were found to require treatment as compared with 134 in the previous year. Only those suffering from Ringworm of the Scalp were excluded from School, 11 of the 51 so excluded last year being treated by X-ray with satisfactory results. (b) Impetigo, Scabies, etc., are treated at the Minor Ailment Clinic, Impetigo accounting for a good proportion of cases seen. The majority clear up quickly under treatment. Out of 483 cases of skin disease, excluding Ringworm, 401 were impetiginous, while only 17 were due to Scabies. Defects of Vision.—All children who are less than 6/12 with one or both eyes, or who suffer from Eye strain are referred for further examination to the Eye Clinic During 1924, 488 were submitted to refraction. Ninety-seven per cent. of this number suffered from defective sight due to "error of refraction," and 3 per cent. to disease, injury or congenital defects As in previous reports the cases will be considered under three groups. Group A. External Diseases of the Eye, including squint. Group B. Defective Vision due to " error of refraction." Group C. Defective Vision due to disease in infancy or congenital malformation of the eye. GROUP A. TABLE I. External Diseases of the Eye. Disease. Boys. Girls. s. Nebulae 3 3 6 Blepharitis 10 8 18 Hordeola 5 2 7 Conjunctivitis—Catarrhal 4 5 9 „ —Phlyctenular 8 7 15 Blepharospasm 1 2 3 Iritis 2 1 3 Corneal Ulcers 3 2 5 Totals 36 30 66 43 Squint. Boys. Girls. Totals. Convergent Squint R 8 9 17 ,, L 12 20 32 Divergent Squint R — — — ,, L 1 — 1 Occasional Squint 3 6 9 Alternating Squint 2 4 6 26 39 65 The above table shows the nature and sex incidence of this deformity. The left eye is more frequently involved than the right. GROUP B. Ninety-seven per cent, of the children submitted for treatment had defective sight due to "error of refraction," a condition in which the eye is slightly out of shape or has a difficulty in, or an insufficient power of, focussing. The optical conditions associated with defective sight are known as (1) Hypermetropia; (2) Astigmatism; (3) Myopia. Odd eyes is a condition in which one eye is Hypermetropic, the other Myopic. The following table shows the relative proportion of the various forms of "error of refraction." TABLE II. Totals. per cent. Hypermetropia 206 43.36 Hyp. Astigmatism 104 22.12 Mixed Astigmatism 19 4.10 Myopia 99 20.43 Myopic Astigmatism 28 5.89 Odd Eyes 19 4.10 475 100.00 Grouping the first two of these classes under the heading "Hypermetropia" and the four latter under the heading "Myopia," we find that 65.5 per cent, are Hypermetropic and 34.5 per cent. Mvones. TABLE III. Sex Incidence. Boys per cent. Girls. per cent. Totals. Hypermetropia 88 40.00 118 46.275 206 Hyp. Astigmatism 48 21.82 56 21.960 104 Mixed Astigmatism 7 3.18 12 4.706 19 Myopia 50 22.73 49 19.216 99 Myopic Astigmatism 12 5.45 16 6.274 28 Odd Eyes 15 6.82 4 1.569 19 220 100.00 255 100.000 475 44 In this report girls are in the preponderance, accounting for 53 per cent, of all cases. The girls show a higher percentage of Hypermetropia, 68 per cent, to the boys 62 per cent., while the boys show a higher percentage of Myopia, 38 per cent, to the girls' 32 per cent. TABLE IV. Age Incidence. Age. Hypermetropia. Hyp. Astigmatism. Myopic group. Totals. 5 14 2 — 16 6 22 7 1 30 7 15 9 7 31 8 37 20 23 80 9 27 18 21 66 10 26 16 18 60 11 26 10 22 58 12 25 15 35 75 13 14 7 38 59 206 104 165 475 The above table shows the variation of the refractive error with age. GROUP C. Disease. Boys. Girls. Totals. Primary Optic Atrophy 1 — 1 Posterior Costical Cataract — 1 1 Anterior Synechia old K.P. 1 — 1 Injury 3 1 4 Nystagmus 3 — 3 Leucoma 1 1 2 Ex ophthalmos — 1 1 9 4 13 The above table shows the nature and sex incidence of these diseases and defects. Fifteen children were admitted to the Myope Centre during the year and there are now 64 on the Register, of which 28 are "Blind within the Act." Discharging Ears and Deafness.—Discharge from the Ear may result from a variety of causes, some trivial, others serious, and as it constitutes one of the most dangerous of the "Minor Ailments" its effectual treatment is important. 45 During the past year there were 41 cases of Otitis Media brought to light at routine inspections and 110 at special inspections. In all 246 cases were treated under the Authority's Scheme by means of irrigation, etc.; an ineffectual method, I regret to say, for a number of the old standing cases, as owing to the intricate anatomy of the middle ear it is impossible to get at the seat of the trouble by this means. Diphtheritic inflammation of the ear is said to be rare, but, during 1924, out of the 246 cases treated, 36 or nearly 15 per cent, were found to contain Klebs Loffler Bacillus. These cases, instead of being seen only bi-weekly, are brought up daily for treatment by the Infectious Disease Nurse. A few cases developed Mastoid tenderness, the majority of which subsided rapidly with fomentations, it being found necessary only to refer one for operation, which was performed at the local Hospital. Deafness can arise in many ways and may be present in one or both ears, and may vary from slight deficiency to complete loss of hearing. Happily, of the 61 cases treated, 60 belonged to the former type, being due either to a plug of Cerumen, Polypus, foreign body or Eustachean Catarrh or obstruction, and were therefore remediable. Only one case of Labyrinthine deafness following Influenza was met with, and no case consequent to any other of the fevers or middle ear disease was detected. Infectious Diseases. The following table gives the notifications under the Infectious Diseases Notification Act, received in respect of the diseases named, occurring amongst children of school age :— Scarlet Fever. Diphtheria. N.C.D. Measles. Whooping Cough. January 6 10 — 49 1 February 3 6 5 105 4 March 3 3 1 199 1 April 7 7 2 185 2 May 9 12 3 163 3 June 9 14 6 34 23 July 8 14 5 10 3 August 3 5 3 — 21 September 9 21 4 4 40 October 7 28 8 16 14 November 10 24 6 5 123 December 14 23 8 9 163 Totals 88 167 51 779 426 The above table showing the outbreak of Measles and Whooping Cough—the former occurring in the first half of the year, the fatter 46 in the last—accounts for a rather low school attendance in the Infants' Departments. During 1924, 795 swabs from School Children were examined at the Public Health Laboratory at Lloyd Park. 6. CO-OPERATION. Our thanks are due to the Teachers and Voluntary Bodies in the area for their valuable assistance during the past year, and again we record a ready willingness on the part of the parents to attend at Medical Inspection as the following table shows :— Boys. Girls. Entrants 79.2 per cent. 79.5 per cent. Intermediate 56.6,, 66.2 Leavers 25.3 „ 45.4 7. FOLLOWING UP. If the parent is not present at medical- inspection, notice of defects requiring remedying is sent to them and if treatment is not being obtained within a reasonable time, steps are taken to enforce it, such as a visit by the School Nurse, etc. During the year the Nurses paid 2,727 visits to the homes in connection with the following:— Defective Vision 499 Pediculosis 13 External Eye Diseases 1 Otorrhcea and Deafness 28 Ringworm 26 Mumps 141 Scabies 1 Chicken Pox 109 Impetigo 56 Measles 554 Defective Teeth 370 Alopecia 1 Tonsils and Adenoids 446 Sore Throat 6 Whooping Cough 376 Various 108 Glands 2 The School Attendance Superintendent and his staff do excellent work. A schedule of all children in the Area is kept at the Attendance and Bye-laws Department. When children attain the age of five years and are found not to be attending school, the parents are visited by the Attendance Officers and the reason for non-attendance is ascertained. By this means cases of defective children are discovered and brought to the attention of the School Medical Staff. There has been an attendance of 87.4 per cent, in the schools during 1924, the prevalence of wet weather, Measles and Whooping Cough accounting for this somewhat low percentage. 47 8. EMPLOYMENT OF CHILDREN. During the year 199 boys seeking employment were examined, two being refused a certificate. They are principally engaged in milk and newspaper deliveries and general errands. If necessary they are periodically examined and no ill effects have been noticed from such occupations. 9. SCHOOL TEACHERS. The Medical Staff reported on 55 teachers and candidate teachers and paid 69 visits to teachers absent through illness. 10. PROVISION OF MEALS. Canteen Centres have been established at the Physically Defective, Mentally Deficient and Myope Schools. The dinners, excellently menued, tastefully cooked and served are supplied to all scholars attending these Centres, the parents contributing 3d. per meal towards the cost. The Centre in the M.D School was the first established and at the Autumn medical inspection only one scholar, a case of Tuberculosis and Septic poisoning, showed a loss in weight. All the rest had increased in weight and some of the most necessitous cases showed an increase of double that of previous years, a result which amply justifies the generous outlay made by the Education Committee. During 1924, 17,703 free meals were supplied to children attending the ordinary elementary schools, and a pint of milk per day at school being supplied to 42 children on medical grounds. The family income must not exceed a fixed sum per head to permit of the granting of free meals. Seven hundred and twenty-three pairs of boots were issued to children during the year from the Central Boot Fund. 11. PHYSICALLY DEFECTIVE CENTRE. On February 11th, 1924, a Physically Defective Centre was opened in Joseph Barrett School, a portion of the building devoted to the Infants being utilised for this purpose. The Central Hall is divided by a curtain, one end with classrooms being used by the Infants and the other with classrooms for the Physically Defectives. 48 There are two good classrooms, a combined rest and exercise room and a dining room where the cooking is also done. The Staff consists of a Head Teacher, Assistant Teacher, 2 parttime Masseuses, Assistant Masseuse, Nurse, Cook and Ambulance Driver. Since opening 70 children have been admitted, 11 re-admitted (i.e., after being away for treatment), 11 transferred to Hospital, 1 child left to go to work, 3 returned to ordinary elementary schools. On 31st December there were 55 on the Register. All the children are brought to school and returned home by Ambulance, 3 journeys being necessary each time, the conveyance holding about 20 children. A distance of about 30 miles is covered in the day. a maximum speed of 12 m.p.h. being fixed. The first load arrives at school about 8.45 a.m., the last leaving about 4.30 p.m. A nurse travels with the children in the Ambulance. The children are served with a good substantial meal on the premises. Mr. Whitchurch Howell, F.R.C.S., is in medical charge of the children, and a Masseuse and Assistant Masseuse attend daily and carry out the trestment. All the children have made great strides both mentally and physically since admission and all enjoy school, some of them never having been able to attend school previously. In addition to elementary school subjects handwork of various kinds is taught. Needlework for the girls and drawing and painting for the boys. The following table shows the conditions present in 60 children in the Physically Defective Centre at one time during the year Anterior Polio Myelitis 26 Hemiplegia 1 Tuberculosis 13 Pseudo Hypertrophic Paralysis 3 Spastic Paraplegia 5 Rickets 5 Kyphosis (due to injury) 1 Polio Encephalitis 1 Valvular Disease of Heart 4 Chorea 1 12. MENTALLY DEFECTIVE CHILDREN. During 1924 the two Departments of Shernhall Special School were merged into one, which permitted the re-grading of the children into three mixed classes more suited to their mental capabilities. 49 The Montessori system has been introduced for the Infants with good results. The older boys and girls, too, have progressed though perhaps to a less marked degree, and in fact never in the existence of the school have the children been so high a grade, more nearly approaching the retarded classes, as now. The school has capacity for 130 children. There are at present on the Register 27 boys and 28 girls, showing a percentage of 0-26 children attending the Mentally Defective School, and we have in all in this Area 0-36 per cent, mentally defective and ineducable. All these figures exclude Epileptics. There are voluntary after-care workers who keep in touch with these children after they leave school and when possible find them suitable employment, sometimes a very difficult matter, as the average employer is, very loth to take on a boy or girl whom he knows has come straight from the Mentally Defective Centre. For this reason, where practicable, such children are admitted to the ordinary elementary schools, if only for a short period, before their final discharge. The Essex County Council has in this town a continuation class for manual work for boys only—of course, our authority ceases at the age of 16. 13. DEAF CENTRE. This Centre was full to capacity on December 31st, there being 13 boys and 7 girls on the register. Of these, 16 are deaf, 3 hard of hearing and 2 aphasic. It is necessary to teach only 2 of the "Deaf" on the fingers. The classes are mixed and there is a Head and an Assistant Teacher. Two children were admitted and 3 discharged during the year. Of the latter, one being engaged in the building trade and 2 in carpentry. 14. BROOKFIELD. A Residential School for Physically Defective children was opened at Brookfield, Highams Park on June 3rd. There is accommodation for 26 children. The staff consists of Matron, Sister, Night Nurse, 2 Masseuses, Teacher, Visiting V.A.D.'s—one each day except Saturdays and Sundays—Cook, Housemaid and Porter, 50 The site is very healthy, being situated on the borders of Epping Forest, and the building is quite commodious and suitable, being built as a War Hospital and later used as a convalescent Annexe to our Isolation Hospital. Mr. Whitchurch Howell has Surgical care of the children. 15. SCHOOL JOURNEY. Last year 25 children from the Myope Centre spent an enjoyable and beneficial fortnight's holiday at Swanage at a total cost of £68 Is., or £2 14s. 5d. per child, which cost is entirely defrayed by the Education Committee. 16. PHYSICAL TRAINING. A full time instructor in physical training has been appointed during the year for the benefit of the boys in both Central Schools. There is also a part time instructress for the girls in the Central Schools. The teachers in the ordinary elementary schools carry out the physical training of the children. Lessons in swimming are under the supervision of an instructress for the girls, the male teachers undertaking the work for the boys. There is a swimming Committee on which teachers arc represented, and the annual Swimming Gala in September is one of the features of school life in the Area. N.S.P.C.C.—The Board of Education has sanctioned the giving by our Education Committee of £2 2s. per annum to the Nationa Society for the Prevention of Cruelty to Children. The following is an account of the work undertaken No. of Cases Nature of Offence How dealt with 20 Neglect 16 By warning and Ill-treatment 2 supervision Exposure 2 Number of children involved—Boys 23, Girls 33. Total 56. All these children were of school age, and in connection with the families visited there were many younger children some bordering on school age, and in addition to the neglect of the children themselves it was often found that the surroundings were dirty and insanitary, especially the sleeping apartments and beds, and were 51 not conducive to the health and well-being of the children, so that in addition to the warning of the parents, they were advised to take necessary steps to make a general improvement all round, and on subsequent visits it was found that the parents had acted on advice given. After the original visit and enquiry in connection with the above cases, 97 visits of supervision were paid by the Inspector to see that further and necessary improvements took place in connection with the children and surroundings, and in the majority of cases the warning and supervision had the desired effect, and the parents, far from resenting the visit of the Inspector, look upon him as their friend, and acting in the best interests of children and. parents, and should any difficulties arise they frequently call at the local Office of the Society and seek advice, often bringing the children to show the improvement which has taken place. Dental Defects.—An account of the work done at the Dental Clinic will be found on Table IV. Only children under 9 years of age are treated by the School Dentist except under exceptional circumstances. Stammering.—At present those children who stammer are dealt with as well as possible in the ordinary classes. There are 83 children so affected in the Area at the moment and a special class for them is under contemplation. 52 MEDICAL INSPECTION RETURNS, TABLE I. Return of Medical Inspections. " A."—Routine Medical Inspections. Number of Code Group Inspections— Entrants 1,576 Intermediates 1,762 Leavers 2,411 Total 5,749 Number of other Routine Inspections 389 " B."—Other Inspections. Number of Special Inspections 2,597 Number of Re-Inspections 24,448 Total 27,045 TABLE II. "A."—Return of Defects found by Medical Inspection in the Year ended 31st December, 1924. Defect or Disease. (1) Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring Treatment. (2) Requiring to Ije kept under observation, but not requiring Treatment. (3) Requiring Treatment. (4) Requiring to be kept under observation, but not requiring Treatment. (5) Malnutrition 1 - - - Uncleanliness (See Table IV., Group V.) - - - - Skin. Ringworm, Scalp 3 - 48 — ,, Body 1 - 77 - Scabies - - 17 - Impetigo 2 - 399 - Other Diseases (Non-Tuberculous) 21 3 141 — Eye. Blepharitis 31 2 48 — Conjunctivitis 1 - 59 - Keratitis — - - - Corneal Opacities 3 - 3 - Defective Vision (excluding Squint) 305 3 99 - Squint 25 5 - 1 Other Conditions 8 4 31 — Ear. Defective Hearing. 24 8 37 — Otitis Media 39 3 110 Other Ear Diseases 6 5 90 - Nose and Throat. Enlarged Tonsils only 48 254 1 — Adenoids only 14 13 6 - Enlarged Tonsils and Adenoids 26 10 68 - Other Conditions 8 4 — — Enlarged Cervical Glands (Non-Tuberculous) 7 21 - - Defective Speech. 4 9 - - Teeth—Dental Diseases (See Table IV., Group IV.) 1,358 - - - Heart and Circulation. Heart Disease, Organic 7 15 — — ,, „ Functional 8 251 - • — Anaemia 33 6 - - Lungs. Bronchitis 65 66 - - . Other Non-Tuberculous Diseases 4 6 — — Tuberculosis Pulmonary, Definite 4 — — — Suspected 11 32 - - Non-Pulmonary Glands — 6 - - Spine — — — — Hip - — - ,, Other Bones and Joints - - - - Skin 2 — - - „ Other Forms — 2 — — Nervous System. Epilepsy 3 2 - - Chorea 2 3 — - Other Conditions 8 11 1 — Deformities. Rickets - 2 - — Spinal Curvature — 1 - - Other Forms 3 4 — — Other Defects and Diseases 39 53 2 1 "B."—Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). Group. (1) Number of Children. Percentage of Children found to require Treatment. (4) Inspected. (2) Found to require Treatment. (3) Code Groups :— Entrants 1,576 583 36.9 Intermediates 1,762 612 34.7 Leavers 2,411 440 18.2 Total (Code Groups) 5,749 1,635 28.4 Other Routine Inspections 389 131 33.6 TABLE III. Return of all Exceptional Children in the Area. - — - Boys. Girls. Total. (i.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 13 16 29 Attending Public Elementary Schools — - — At other Institutions - — At no School or Institution - — — Blind (including partially blind) (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind 18 17 35 Attending Public Elementary Schools - - - At other Institutions - - - At no School or Institution — — - Deaf (including deaf and dumb and partially deaf) (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Ceitified Schools or Classes for the Deal 11 5 16 Attending Public Elementary Schools — — - At other Institutions — — - At no School or Institution — - - (ii.) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf 3 2 5 Attending Public Elementary Schools - - - At other Institutions — — — At no School or Institution - - — Mentally Defective Feebleminded (cases not notifiable to the Local Control Authority). Attending Certified Schools for Mentally Defective Children 27 28 55 Attending Public Elementary Schools - 1 1 At other Institutions 6 — 6 At no School or Institution 8 7 15 Notified to the Local Control Authority during the year. Feebleminded 1 — 1 Imbeciles 1 1 2 Idiots 2 - 2 Epileptics Suffering from severe epilepsy. Attending Certified Special Schools for Epileptics 3 1 4 In Institutions other than Certified Special Schools - - - Attending Public Elementary Schools 2 3 5 At no School or Institution 1 4 5 Suffering from epilepsy which is not severe. Attending Public Elementary Schools - - - At no School or Institution 1 5 6 Physically Defective Infectious pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 8 9 At other Institutions — — — At no School or Institution — 1 1 Non-infectious but active pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential Open Air Schools — — - At Certified Day Open Air Schools At Public Elementary Schools 3 1 4 At other Institutions — — - At no School or Institution — - — Delicate children (e.g., pre-or latent tuberculosis, malnutrition, debility, anaemia, etc.) At Certified Residential Open Air Schools — 2 2 At Certified Day Open Air Schools - - - At Public Elementary Schools — — — At other Institutions 3 2 5 At no School or Institution 2 4 6 Active non-pulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 2 1 3 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution . — - - Crippled Children (other than those with active tuberculous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease. At Certified Hospital Schools 10 10 20 At Certified Residential Cripple Schools 1 1 2 At Certified Day Cripple Schools 24 25 49 At Public Elementary Schools — - — At other Institutions — — — At no School or Institution 1 1 2 53 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1924. TREATMENT TABLE. Croup I.—Minor Ailments (excluding Uncleanliness, for which see Group V.) Disease or Defect. (1) Number of Defects treated, or under treatment during the year. Under the Authority's Scheme (2) Otherwise. (3) Total. (4) Skin— Ringworm—Scalp 39 9 48 Ringworm—Body 74 3 77 Scabies 15 2 17 Impetigo 382 17 399 Other skin disease 101 40 141 Minor Eye Defects (External and other, but excluding cases falling in Group II.) 125 15 140 Minor Ear Defects 246 13 259 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 118 45 163 Total 1,100 144 1,244 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease. (1) No. of Defects dealt with. Under the Authority's Scheme (2) Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. (3) Otherwise. (4) Total. (5) Errors of Refraction (including Squint) 475 31 - 506 Other Defect or Disease of the Eyes (excluding those recorded in Group I.) 13 - — 13 Total 488 31 — 519 Total number of children for whom spectacles were prescribed (а) Under the Authority's Scheme 717 (б) Otherwise . 31 Total number of children who obtained or received spectacles {a) Under the Authority's Scheme 710 (6) Otherwise 31 54 TABLE XV.—continued. Croup III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received Operative Treatment. Received other forms of Treatment. (4) Total number treated. (5) Under the Authority's Scheme in Clinic or Hospital. (i) By Private Practitioner or Hospital, apart from the Authority's Scheme. (2) Total. (3) 197 2 199 - 199 Croup IV.—Dental Defects. (1) Number of Children vvljo were:— (a) Inspected by the Dentist: Aged: Routine Age Groups 5 656 Total 2,487 6 804 7 803 8 224 9 - 10 - 11 - 12 - 13 - 14 - Specials 2,406 Grand Total 4,893 (b) Found to require treatment 3,417 (c) Actually treated 3,185 (d) Re-treated during the year as the result of periodical examination 785 (2) Half-days devoted to:— Inspection 34 Total 416 Treatment 382 (3) Attendances made by children for treatment 3,970 (4) Fillings:— Permanent teeth 435 Total 1,871 Temporary teeth 1,436 (5) Extractions:— Permanent teeth 856 Total 5,448 Temporary teeth 4,592 (6) Administrations of general anaesthetics for extractions 2,244 (7) Other operations:— Permanent teeth 19 Total 495 Temporary teeth 476 55 Group V.—Uncleanliness and Verminous Conditions (i.) Average number of visits per school made during the year by the School Nurses 11 (ii.) Total number of examinations of children in the Schools by School Nurses 115,135 (iii.) Number of individual children found unclean 2,724 (iv.) Number of children cleansed under arrangements made by the Local Education Authority — (v.) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 (b) Under School Attendance Bye-laws 2