CI ACC39(1) WILLSEDEN millesden arban Distict Council. 1920. THE 45th ANNUAL HEALTH REPORT. GEORGE F. BUCHAN, M.D., D.P.H., Medical Officer of Health London: WIGHTMAN & CO., LTD., Regency Street, Westminster, S.W. 1. 1921. WIL 20 millesden arban District Council. 1920. THE 5th ANNUAL HEALTH REPORT. GEORGE F. BUCHAN, M.D., D.P.H., Medical Officer of Health. London: WIGHTMAN & CO., LTD., Regency Street, Westminster, S.W. 1. 1921. 3 INDEX. page Abnormal Children 9 After-care of Physically and Mentally Defective Children 11 Anthrax 34 Attendances at Clinics 38, 113 Bacteriological Examinations 32 Births Notification of 37 „ Rates 19, 101 Canal Boats Acts 22 Cerebro-Spinal Meningitis 31 Children's Care Committee—Members of 5 Children under 5 years of age 8, 88, 95 Common Lodging Houses 23 Continued Fever 31 Co-operation of Parents, Teachers and Attendance Officers 9 Council—Members of 5 Deaths 102 „ Rates 19, 34, 36, 101 Dental Defects—Treatment of 49, 73 Dental Work 12 ,71 ,, ,, Report of Dentist 71 Diphtheria 31,87,91, 148 Disinfection 21, 33 Dysentery 32 Economic Circumstances Scale 115 Education Committee—Members of 5 Employment of Children in Entertainments—Rules, 1920 64 Enteric Fever 31 Exceptional Children 9, 48 Expenditure—Contemplated for 4 years 144 Factory and Workshop Act, 1901—Administration of 42 Flies 140 Food 24, 26 Grants in Aid 153, 154, 155 Health Committee—Members of 5 Health Sub-Committee—Members of 5 Health Visitors—Training of 39 Health Visitors'Work 117 Health Work 13 Home Nursing 12, 81 Hospital Report 85 Hospital Treatment of School Children—Tables 59 House Refuse—Removal of 19,21 Houses Let in Lodgings 20, 23 Housing 41 Infant Death Enquiries 37 Infant Mortality 36. 110 Rate 36, 110 Infectious Disease—Death Rates 27, 34 ,, ,, Notifications 7,27, 111 Influenza 34 Juvenile Employment 11 4 page Malaria 32 Marriages 19 Maternity and Child Welfare 36 Measles 33 Meat Inspection 25 Medical and Dental Treatment 49 Medical Inspection Centre-—Utilisation of for Clinic Purposes 138 Medical Inspection—Tables 45-57 Medical Treatment 9 Medical Treatment—Table of work done 58 Mentally Defective Children—After-care of 54 Milk—Free issues—Comparative Table of Cost 152 Milk—Amount expended in Willesden compared with neighbouring Local Authorities 152 Milk, Mothers and Children Order, 1919 24 Milk Supply 24 Mothers and Children under 5 years 8 Motor Ambulance Service 8 ,, Report 141 Municipal Hospital 13, 85 ,, ,, Nursing and Domestic Staff 90,121,137 Natural and Social Conditions of the District 17 Nuisance—Burning Rubber 23 Offensive Trades 21,23 Open-air School 123 „ „ Reports on Visits 124 Ophthalmia Neonatorum 36 Pneumonia 32 Population 17, 18, 101 Premises and Occupations controlled by Bye-laws or Regulations 23 Provision of Meals 12, 75 Provision of Meals—Grant in aid 155 Physically Defective Children—After-care of 54 Puerperal Fever 36 Rabies 34 Sale of Food and Drugs Act 26 Sanitary Administration 40 Sanitary Circumstances 19 Sanitary Inspections 20 Sanitary Work 8 Scarlet Fever 27, 87, 93, 148 ,, „ Return Cases 28 School—Absence from 61 School Children —Medical Treatment of 9 Schools—Cleanliness in 9 School Medical Officer—Report of 45 School Medical Service—Grant in Aid 154 Schools—Sanitary Condition of 24 Secondary School Children—Medical Inspection 12 „ „ „ ,, ,, Tables of 65-69 Slaughter Houses Small Pox Hospital Accommodation 91, 138 Special Cases Referred - Special Schools; 9, 54, 123 Special Schools Children—Numbers of 54 Surgical Appliances—Mothers and Children under 5 38 ,, „ School Children 63 Teachers—Medical Examination of 11 Trench Fever 32 Tuberculosis 34 „ Notifications 34 Vaccination 33 Venereal Diseases 34 Vital Statistics 7, 101 X-Ray Outfit for Municipal Hospital 147 5 WILLESDEN URBAN DISTRICT COUNCIL, 1920-21. †*MR. Councillor W. M. BOLTON, J.P. (Chairman). Mr. Councillor BRIGGENSHAW (Elected, 14th Dec., 1920). Mr. Councillor W. L. TRANT BROWN. Mr. Councillor T. CHELLEW. †*mr. Councillor j. comber. Mr. Councillor J. E. CONLON (Seat declared Vacant, 9th Nov., 1920). Mr. Councillor A. E. DORAN. Mr. Councillor A. GARDNER. *Mr. Councillor P. GARDNER. †*Councillor Dr. J. D. GRANGER-EVANS. Mr. Councillor H. G. GREENER. *Mr. Councillor W. A. HILL (Vice-Chairman). *Mr. Councillor W. J. HILL. Mr. Councillor G. H. HISCOCKS. *Mr. Councillor C. W. HOGG. *Mr. Councillor E. W. B. HUTT. †*Mrs. Councillor E. J. KENT. †*Mr. Councillor E. J. LANE (Chairman of Health and Health Snb-Committee). *Mr. Councillor H. LATHAM. Mr. Councillor T. G. MATTHEWS (Seat declared Vacant 6th Aug., 1920). Mr. Councillor G. C. MINTER. †*Mrs. Councillor R. MOORE. *Mr. Councillor J. MORSE. Mr. Councillor NODES-LELLO (Elected, 28th Aug., 1920). *Mr. Councillor W. J. PYKE. Mr. Councillor C. REED. †*Mr. Councillor W. RILEY, J.P. Mr. Councillor I. M. ROSENBAUM. *Miss Councillor M. E. ROYLE. Mr. Councillor H. J. SAVORY. *Mr. Councillor H. E. SCOTT. Mr. Councillor G. A. SEXTON. Mr. Councillor A. SMITH, J.P. Mr. Councillor J. M. SMITH. *Mr. Councillor S. P. VIANT. *Member of Health Committee. † Member of Health Sub-Committee. WILLESDEN EDUCATION COMMITTEE, 1920-21. Mr. Councillor W. M. BOLTON, J.P. *Mr. Councillor T. CHELLEW. Mr. Councillor A. GARDNER. Mr. Councillor W. A. HILL. Mr. Councillor W. J. HILL. Mr. Councillor G. H. HISCOCKS. Mr. Councillor C. W. HOGG. Mr. Councillor E. W. B. HUTT. *Mr. Councillor H. LATHAM. *Mrs. Councillor R. MOORE. *Mr. Councillor J. MORSE. *Mr. Councillor W. J. PYKE. Mr. Councillor C. REED. *Miss Councillor M. E. ROYLE. *Mr. Councillor H. J. SAVORY. *Mr. Councillor H. E. SCOTT (Vice-Chairman). Mr. Councillor J. M. SMITH. Mr. Councillor S. P. VIANT. Mr. E. B. C. ARROWSMITH *Mr. A. R. CLARK. Mr. W. J. DOWDELL. *The Rev. E. R. FORD, M.A. (Chairman of Children's Care Committee.) *Miss M. A. LUPTON. *The Rev. G. MARTIN, M.A. *Mr. G. H. PLYMEN, B.Sc. *The Rev. H. MARTIN THORPE, M.A. (Chairman). *Mr. D. T. WILLIAMS. * Member of the Children's Care Committee. 7 Municipal Offices, Dyne Road, Kilburn, N.W. 6. 30th April, 1921. To the Willesden Urban District Council— The Local Sanitary Authority, and the Local Education Authority. I beg to submit herewith the Annual Health Report for Willesden for the year 1920. This report includes:— (i.) the 45th Annual Report on the health and sanitary condition of the district; (ii.) the 13th Annual Report on the health of children attending the public elementary schools; (iii.) the 1st Annual Report on the Health of children attending Secondary Schools; (iv.) the 3rd Annual Report on Dental Work in connection with children attending the Public Elementary Schools, expectant and nursing mothers and children under 5 years; (v.) the 1st Annual Report on Home Nursing; (vi.) the 6th Annual Report on the provision of meals to children attending the public elementary schools, expectant and nursing mothers, and children under 5 years; and (vii.) the 29th Annual Report on the Municipal Hospital. The Annual Health Report for a district is written by the Medical Officer of Health under instructions received from the Ministry of Health and the Board of Education. The Annual Health Report for 1919 followed these instructions closely, and this year, where the conditions have not changed, reference is made to the Annual Health Report for last year. Vital Statistics. The year 1920 has been a record year in the health annals of Willesden. The population is the highest on record, while the death rate and the infant mortality rate are the lowest ever recorded. Population.—At the Census of 1911 each inhabited room in Willesden was occupied on the average by 1 -007 persons. Assuming that the average number of occupants per occupied room is the same in 1920 as 1911 the population of Willesden is 170,892. Birth Rate.—The number of births in Willesden, after falling to 2,651 in 1918, the lowest during the war period, has risen to 4,232 in 1920, a greater number than in any year since 1907. The birth rate of 24 -8 per 1,000 of the population for the year 1920 exceeds the rate for the two pre war years 1913 and 1914, when it was 24-7. Death Rate.—During the year 1920, 1,672 deaths occurred in Willesden, giving a death rate of 9-78 per thousand, which is the lowest on record. Infant Mortality Rate.—274 infants under one year died during 1920, giving an Infant Mortality Rate of 65 per 1,000 births, which is the lowest ever recorded. The Infant Mortality Rate amongst legitimate births was 59, and illegitimate births 223, which facts alone indicate that the proper care and nurture of the child is an important item in determining longevity. Infectious Diseases. During the year 2,281 notifications of compulsorily notifiable Infectious Diseases were received. Of this number 705 were cases of Scarlet Fever, and 699 cases of Diphtheria. The number of cases of Scarlet Fever is the third highest number ever recorded in Willesden, and the figure for Diphtheria the highest on record. The concurrent prevalence of epidemics of Diphtheria and Scarlet Fever in 1920 have greatly taxed the hospital accommodation for these diseases, which was already insufficient, and for which no additional provision had been made since 1902. Fortunately the type of disease was on the whole mild, the fatality rate amongst Scarlet Fever cases being 11 per thousand, and Diphtheria cases 62 per thousand. It is not, of course, practical to have a hospital of sufficient dimensions to take all cases of Diphtheria and Scarlet Fever and possibly other Infectious Diseases which may from time to time appear in epidemic form ; nevertheless there is urgent need for additional hospital accommodation. I do not advocate additional hospital accommodation for Infectious Diseases with the view of the prevention of the disease, for the Isolation Hospital as a means of prevention has failed, but I am satisfied from an analysis of the records that hospital provision is a means of reducing the mortality from Infectious Diseases, and is one of the factors to which the saving of lives and the consequent low death rate in Willesden may be properly attributed. The difficulty in stamping out Infectious Diseases arises from the fact that many cases are infectious for prolonged periods, others are intermittently infectious over long periods, while others 8 again may "carry" the specific germ of an infectious disease and be infectious to others without suffering themselves. An outbreak of Diphtheria which occurred in one of the Schools of the district provides typical examples of these occurrences. In February, 1920, an undue prevalence of diphtheria was noted in one of the Schools, 25 cases having occurred in the neighbourhood, 18 of which attended the School. The school was visited by one of the Medical Staff. Children in the classes where a case had been reported were carefully examined for any signs suggestive of Diphtheria, particular attention being paid to the examination of children from a family in which a case of Diphtheria was known to have occurred. Nasal and throat swabs were taken for bacteriological examination from all cases considered suspicious. As a result of this examination, one girl who appeared healthy was found to be a "carrier"— an example of a "carrier" where the individual carrying the germ had not herself been a sufferer, although her sister had been notified as a case of Diphtheria 116 days previously. A second source of infection was traced to a boy in another class who infected two cases at home, and two cases in his own class. This boy was the first of the 25 cases under review to be notified, and it was found that he had been attending school with a "running" nose, the discharge from which was found, on swabbing and bacteriological examination, to contain Diphtheria bacilli 110 days after his original discharge from hospital—an example of a "carrier" where the individual carrying the germ had himself been a sufferer and was intermittently infectious over a long period, the bov having been free from Diphtheria on discharge from the Hospital. No further cases were reported from the school after these two "carrier" cases were excluded for treatment. Sanitary Work. The passing of new Acts of Parliament relating to Housing has had its reflection in the work of the Sanitary Department. The total number of complaints received during the year from householders as to the insanitary condition of property was 3,164, or a greater number than has ever before been received by the Department in any year. The number of notices served on owners as a result of these complaints has similarly been the greatest on record. Since the passing of the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920, it has been somewhat easier for the Health Department to get the work of sanitary repairs carried out, but the large arrears of sanitary work which increased during the war period have yet to be dealt with, and it will probably be some years before the housing of Willesden is all that could be desired by the Council. When the building of a sufficient number of new houses has been completed it is hoped that labour and materi>'? will be freed for dealing with the necessary repairs to the old, and that, in consequence, good housing conditions will again prevail in Willesden. Motor Ambulance Service. This service was first instituted in 1913, when seven motor vehicles were purchased by the Council in connection with Hospital work, the conveyance of Physically and Mentally Defective Children to School, Disinfection, and Health work generally. The service has been much appreciated by the public, and the number of calls upon the Ambulance Station has increased year by year. During the year ended 31st March, 1920, the total number of calls in connection with Infectious Diseases and Disinfection'and Sickness and Accident was 3,886, as compared with 2,185 in the preceding year, while the total number of miles run by the service was 61,306 as compared with 54,174 during the year ended 31st March, 1919. An all-night service has now been established, but this is only partial, as there is only one man on duty, and any calls coming when he is out cannot be dealt with at once. The vehicles are now in their eighth year of service, when the amount of repair work required naturally increases. In these circumstances, and in view of the increased calls upon the Ambulance Station, it becomes a matter of increasing difficulty to meet all demands. Mothers and Children under Five Years. No extension of the Council's work in connection with Maternity and Child Welfare has taken place during the year, but the public demand for attention at the Council's Clinics has increased. In 1920,53,291 attendances were made at the Clinics by Mothers and Children under 5 years for medical or dental treatment and advice, as compared with 33,748 attendances in the year 1919, or an increase of 58 per cent. The School for Mothers has similarly shewn a growth in attendances from 1,089 in 1919 to 2,354 in 1920, or an increase of 116 per cent. It is difficult to estimate the value of the continuous medical supervision of the mother and child, but it is pleasing to note that the Infant Mortality rate for the year 1920 has fallen to 65 per thousand births as compared with 83 in the previous year, and is the lowest figure yet recorded in Willesden. The Infant Mortality rate for the 96 great towns in England and Wales, including Willesden for 1920, was 85 per thousand births. 9 35 per cent, of all the births occurring in Willesden attended the Council's Clinics and the Infant Mortality rate amongst the babies attending the Clinics in 1920 was 43 as against 76 amongst the babies not attending the Council's Clinics. It is not suggested that continuous medical supervision of the mother and child is the only factor which contributes to the low Infant Mortality rate amongst the babies attending the Council's Clinics, but the experience of the past three years shews that it is a dominating factor, the development of which is likely to improve the public health to the greatest possible extent. Public Elementary School Children. Medical Inspection.—During the year 1920 the average number of Scholars on the School Rolls in Willesden was 24,997. Article 58 (b) of the Code of Regulations for Public Elementary Schools requires annually the medical inspection of the following groups of children to be undertaken :— (1) All children admitted to the schools. (2) All children between 8 and 9 years of age; and (3) All children between 12 and 13 years of age, together with children over 13 years of age who have not been examined on reaching the age of 12. The total number of children in these age groups is approximately 8,332. The work of medical inspection of children in the schools has been in abeyance in Willesden since 3rd December, 1915. The authority has since that date directed attention to ailing children and the provision of remedial measures for the conditions found. Medical Treatment.—During the year 1920, school children came under the notice of the Medical Officer on account of 16,417 medical defects and 5,089 dental defects. Treatment was obtained for 19,906 of the defects which came under notice and were found to require treatment. 97.1 per cent, of the medical defects were treated and 84.2 per cent, of the dental defects. Of the total medical defects treated, 88.7 per cent., and of the total dental defects treated, 97.7 per cent, were dealt with by the Education Committee through the Clinics, Municipal Hospital or Home Visitation. The remainder or 11.3 per cent, of the Medical defects and 2.3 per cent, of the dental defects treated were dealt with by private practitioners, voluntary Hospitals or other charitable institutions or the Poor Law. In connection with the defects treated, the children concerned made 75,258 attendances at the school clinics in 1920 as compared with 57,203 or an increase of 31.5 per cent., and spent a total of approximately 6,000 days in hospital in 1920 as compared with 7,500 days in 1919, or a diminution of approximately 20 per cent., due to lack of hospital accommodation. Cleanliness in the Schools.—Cleanliness inspections were carried out in the schools by the Health Visitors on 527 occasions during the year and 31,759 examinations were made at the schools. Approximately 21,724 individual children were examined and 2,748 individual children were found unclean, or 12.6 per cent. The total number of individual children found unclean during the year, whether at the school cleanliness inspections or otherwise, was 2,920. As the total number of children on the rolls of the schools is 24,997, it will be seen that 12 per cent, came under the notice of the Health Department on account of nitty or verminous conditions. If regular routine cleanliness inspections can be maintained, a considerable reduction of this percentage will be effected. It is, however, very difficult for the Health Visitors to find time for this work owing to the pressure of other duties. Co-operation of Parents, Teachers and Attendance Officers.—When medical inspection first began in 1908, there were parents who considered that medical inspection was an interference with their liberty of action and that they had a perfect right to deal with their own children as they liked. The number of such parents to-day is practically nil and all are only too desirous of co-operating as far as they can with the Medical Officer for the benefit of the child. Parents too, are better educated in respect of the importance of attending at once to abnormal conditions which they may notice in their children. In 1920, 40 per cent, of the conditions referred to the School Medical Officer were so referred by parents as against 3 per cent, in 1914. In the same way, teachers and school attendance officers co-operate to make use of the special advantages which the School Medical Service offers in connection with their work relative to the school child. As far as possible Health Visitors visit the schools and Departments in their area once a week and have the advantage of an interchange of views with the teacher respecting individual children under their care. The Health Visitor also visits at the home in connection with the treatment of defects which have come under notice. She is invariably well received and the parents talk freely with her as to the condition and as to the best means of having the defect remedied. Such visits are valuable in assisting the parent to understand the nature of the defect and its influence on the future health and earning capacity of the child. Abnormal Children.—All children thought to be abnormal either as regards their mental or physical condition, and who appear unsuitable to attend an ordinary elementary school, are referred to the School Medical Officer for special consideration. Information regarding these children is received from Head Teachers, Parents, Health Nurses, Attendance Officers, Private Medical Practitioners, Voluntary Societies, other Local Authorities and Hospitals. Cases so referred are submitted to a special examination and recommendations are made to the Education Committee as to the best method of dealing with each case, according to the abnormality found. Instruction in a special day school or residential institution may be considered advisable or surgical appliances 10 or treatment in a special hospital may be necessary. During the year 1920, 162 children were referred as unsuitable for attendance at an ordinary elementary school and 103 of them were examined. 41 were found to be physically defective, 28 mentally defective, 11 dull and backward, 9 epileptic, 6 blind, 6 deaf and 2 normal. 59 were awaiting examination at the end of the year. Leinster Road Mentally Defective Day School.-—This is the only day school provided in Willesden for mentally defective children since Leopold Road M.D. School was closed in 1917. The certified accommodation is for 100 children, the average number on the roll being 87. The Staff consists of one Head Teacher, three Assistant Teachers, and one Blind Teacher, who gives special instruction in blind methods. The progress made by the children during the year has, with few exceptions, been satisfactory. During the year 1920, four children were notified to the Middlesex County Council as being incapable of benefiting by further instruction in a special day school and were excluded from further attendance to await transfer to a special institution, and two cases due to leave on reaching 16 years of age were also referred for institutional care. Instruction is given by the Blind Teacher in Braille methods and special manual work to certain children with progressive eye disease and a few exceptional cases. Three cases of letter blindness are showing definite improvement after Braille instruction. Many of the children attending this school reach a certain mental age in school attainments, but show no further progress with prolonged teaching. These children are still capable of benefiting by practical instruction and becoming more skilful in occupational work. It is therefore satisfactory to note that the scope of the manual work done here, which during the war was very restricted, has been extended during 1920. More specialised work in manual and occupational trades, however, should be undertaken so that the boys and girls unable to compete mentally with normal children, may be given a better opportunity oj: becoming proficient in some trade or work likely to be of use to them, and so enable them to become self-supporting citizens after leaving school. The school is visited each week by one of the Medical Officers for the re-examination of selected cases, each child in the school being examined once during the year and a report made as to its progress. During the year 1920, 84 mentally defective children were re-examined. Furness Road Physically Defective Day School.—This was the only school in Willesden for cripple children until 13th December, 1920, when Leopold Road Physically Defective Day School was opened. Furness Road is certified for 60 children. The work and health of the children during the year has been satisfactory, but under improved conditions, better results could be obtained both physically and educationally. The accommodation at this school, which would not be considered good for normal children, is poor for physically defective children who, in the majority of cases, have been semi-invalids up to the time of admission to school, and who are consequently of inferior physique and have less stamina than the average normal child. Games, exercises and outdoor occupations likely to be beneficial to them cannot be undertaken owing to lack of suitable recreation ground. The best results, both mentally and physically, can only be expected from these children when they are suitably fed and educated under open-air conditions in surroundings which will give them all the requirements essential for a healthy life. Better facilities are urgently required foi the teaching of handicraft work to both boys and girls whose choice of employment on leaving school is limited owing to their physical defect. The school is visited every fortnight by one of the Medical Officers for the re-examination of selected cases, each child being examined at least once during the year. 105 children were re-examined during 1920, and the parents notified in all cases where defects were found requiring attention. Leopold Road Physically Defective Day School.—Owing to the number of physically defective children in Willesden for whom no accommodation could be found at the Furness Road Physically Defective School, the Education Committee decided to utilise the Leopold Road Special School which had been in disuse since 1917 as a second school for physically defective children. Consent was given to the repairs and alterations required to make the building suitable for cripple children. The school consists of two large classrooms, and is certified to accommodate 40 children, but arrangements could only be made to admit 20 children when the school was opened on 13th December, 1920, owing to lack of available ambulance transport to convey the children to school. In order to convey these children to Leopold Road Physically Defective School, an extra journey is made by one of the school ambulances after the children have been carried to Furness Road Physically Defective School. This of necessity means that the school is unable to commence the morning session until 10.45 a.m. and the afternoon session does not close until 4.30 p.m. As there is only one teacher attached to the school, it has been necessary for teaching purposes to admit only children up to 7 or 8 years of age, older children with a prior claim being passed over to await a vacancy at Furness Road Physically Defective School. The appointment of a second teacher is dependent upon an improved ambulance service, and until this is provided, no further use can be made of the accommodation available. A trained nurse, who is also a certified masseuse, has been appointed as nurse ambulance attendant, and is responsible for the physical care of the children during school hours. When specially ordered by the Medical Officer who visits the school every fortnight, massage is given regularly to certain cases, and absence from school to attend Hospitals for this form of treatment is thus avoided. Open-Air Education.—A Sub-Committee was appointed by the Children's Care Committee during the year to visit various Open Air Schools. This Sub-Committee issued an exhaustive report, which appears in appendix G of this report. The education of the Physically Defective child is now a compulsory duty of the Education Authority, and the recommendations of the Children's Care Committee were as follows :— (a) That a day open air school to accommodate 240 physically defective children be established in Willesden. 11 (b) That steps be taken for the purchase of about six acres of land for the open air school. (e) That, having regard to accessibility, acreage, aspect and the nature of the buildings to be erected, Dudden Hill allotments be approved as the best site for the school and that the necessary acreage be acquired there. (d) That sanction be given to the capital expenditure involved, estimated at £48,000, details of which are found in the report of the Sub-Committee. (e) That the children in attendance at the Committee's Physically Defective Schools be transferred to the open air school when ready. (/) That the provision of a residential open air school be deferred. These recommendations duly came before the Education Committee, which has taken the following action from time to time:— 7th July, 1920.—That, subject to the approval of the Council, negotiations be commenced for the acquisition of a site suitable for the erection of an open air school, and that the question of building be further considered at the expiration of six months. 3rd November, 1920. -That, subject to the matter being postponed until February, 1921, to enable the necessary expenditure to be included in the estimates for the financial year 1921-22, sanction be given to the expenditure of the sum of £5,600, including costs, in respect of the purchase of 7-3 acres of land in Denzil Road for the purposes of a site for the proposed open air school ; and that the Council be asked to raise the necessary loan. 5th January, 1921.—Letter received from Board of Education stating that schemes involving expenditure not yet in operation are to remain in abeyance. 5th January, 1921.—Question of the building of an open air school deferred until site acquired. 23rd March, 1921.—Estimates passed. No provision made for open air school in year 1921-22. After-Care.—The After-Care of defective children in Willesden is carried on by a special voluntary Committee who formerly dealt with mentally defective cases only, but in December, 1920, agreed to supervise physically defective children referred to them by the Health Department. Particulars of each child leaving Furness Road Physically Defective School during 1920 were forwarded to the Secretary of the Society, together with the names of other children, who had previously left and were known to require after-care. These cases are to be visited periodically, and the nature of the enquiries were agreed upon by the Secretary of the After-Care Committee and the Medical Officer of Health. Mentally defective children are notified to the committee mainly by the Head Teacher of Leinster Road M.D. School, who, as a routine, sends in the name and particulars of each child leaving her school. Certain other cases are reported from outside societies, parents, etc. These cases are visited 2 or 3 times during the year, and more frequently, if the reports are unsatisfactory, and a continuous record is kept of each child under observation. Unsatisfactory cases requiring more than after-care are reported to the Middlesex County Council. A certain number of the mentally defectives in Willesden referred for after-care are low grade and unemployable, and are sometimes awaiting a vacancy in an Institution. Arrangements are in contemplation by the After-Care Committee to open an occupation centre in Willesden, which will provide some form of physical exercise, games or simple manual training 2 or 3 times a week for these defectives. After-care work on account of the home influence is not always successful. Juvenile Employment.—A Juvenile Employment Committee has been set up by the Education Committee consisting of 21 members representing Education, Employers of Labour and Workpeople. The Managers of the Council Schools have formed After-Care Committees composed of Managers with others added. These After-Care Committees have formed School Committees for each school in the group of schools for which the Managers are responsible. It is desirable that the records of medical inspection of children concerned should be available in connection with the nature of the work children propose to adopt as a career, but owing to the suspension of medical inspection it has not been possible for a completely co-ordinated scheme as between the work of the School Medical Service and the Juvenile Employment Committee to become operative. It is equally unfortunate that owing to the multiplicity of authorities engaged on health work the Certifying Factory Surgeon has got to do again, on admission to the factory, what has or should have been done at the time of leaving school by the School Medical Officer. During the year a new duty was cast on the School Medical Officer of reporting on the fitness of children and young persons engaged in entertainment under the Employment of Children in Entertainments Rules, 1920, dated January 12th, 1920, made by the Board of Education under Section 3 of the Prevention of Cruelty to Children Act, 1904, as amended by Section 13 (2) of the Education Act, 1918. These Rules became operative on the 1st day of April, 1920, and provide, inter alia, that every application for a licence must be accompanied by a certificate from the School Medical Officer of the Local Education Authority that the child may be employed in the manner proposed without prejudice to his or her health or physical development and that the employment will not render the child unfit to obtain proper benefit from his or her education. 19 applications for licences and 3 for renewals were received up to 31st December, 1920, making a total of 22, of which 19 were granted. Examination of Teachers.—33 teachers were examined during the year by the School Medical Service, and all were found fit to perform the duties of a teacher. 12 Secondary School Children. There are two Secondary Schools in Willesden, namely, the Kilburn Grammar School with 301, and the Polytechnic Day Trade School with 84 pupils on the rolls at September, 1920. Section 18 of the Education Act, 1918, requires that the Medical Inspection of pupils attending these schools shall be undertaken annually as from the 1st April, 1920. By an arrangement with the Middlesex County Council, this school inspection of the pupils attending the two Secondary Schools in Willesden has been carried out by the Medical Staff of the Willesden School Medical Service under Section 18 of the Education Act, 1918, the Board of Education (Higher Education, Medical Inspection and Treatment) Regulations, dated 19th March, 1920, and Circular 1,153 of the Board, relating to Medical Inspection and Treatment of Pupils in Secondary Schools and Continuation Schools, dated 31st March, 1920. Particulars of these examinations and the results have been forwarded to the Middlesex County Council in Tabular form as required by the Board of Education for the 9 months ended December, 1920. During this period, 283 pupils were examined and 326 defective conditions noted, 168 of which were referred for treatment and 158 for further observation. The attention of the parents was called to the defects verbally, if the parents attended the examination, and otherwise, by letter. A review of the action taken by parents to deal with the defective conditions brought to their notice is not included in the information sent to the Middlesex County Council for the 9 months under review and will not be available until the pupils concerned automatically come under review in the following year as required by the Code of Inspection. Dental Work. During the year the two dentists employed by the Council have had their hands full. 3,500 School Children, 706 Mothers and Children under 5 years made 12,493 attendances at the Dental Clinics. 4,050 fillings were done, 13,002 extractions and 1,381 other operations performed. Anaesthetics were given 4,133 times. A feature of the year's dental work has been the large number of cases referred to the clinic on account of gross decay of the teeth, or septic conditions of the gums. The proper function of the dentist relative to oral hygiene, as of the doctor relative to personal hygiene generally, is to keep the patient's mouth healthy, and this can only be done by regular inspection and immediate treatment from youth upwards. The number of patients that a dentist can keep well is generally accepted as 3,000. The moment a mouth becomes mutilated by disease or even by the extraction of a tooth, its defences are weakened and pyorrhoea and other conditions of the mouth leading to affections of the general health arise. Conservative dentistry is one of the most important adjuncts to good health. Home Nursing. Home Nursing was begun on January 19th, 1920, the scheme of the Council having been approved by the Ministry of Health, who agreed to the proposed apportionment of the cost of the Nursing Services between Maternity and Child Welfare and other purposes in the proportion of half and half. During 9 months of the year, 4 Home Nurses were on duty and for the remaining 3 months, 8 Home Nurses. 681 cases have been nursed by the Home Nursing Service of the Council, 11,531 visits having been paid, an average of 10 visits being made per day per nurse. Of the 681 cases, 468 were referred by the Health Department, 115 by Private Medical Practitioners and 98 by Voluntary Hospitals and others. The cases referred by Voluntary Hospitals have largely been cases of minor operations where after operation at the hospital they were sent home, and also accident cases treated in the out-patient departments, such as fractures, burns, scalds, cuts and the like. The cases referred have come from every part of the Willesden district and have included such conditions as, Ophthalmia 59 cases, Measles and its complications 54 cases, Bronchitis 44 cases, Scarlet Fever 43 cases, Threadworms 42 cases, Pneumonia 36 cases, Maternity 26 cases and Influenza 24 cases. Of the total number of 681 cases referred, 525 recovered, 78 entered a hospital or other institution, 20 died, and 58 were still being nursed at the end of the year. Of the cases which recovered, a certain proportion were in need of further treatment at a Convalescent Home. In many cases nursed, and especially in such cases as Pneumonia and Influenza, where a fluid diet is ordered, there seems to have been difficulty in obtaining the milk prescribed on account of the cost. Of the 11,531 visits, 6,037 referred to mothers and children under 5 and 5,494 referred to others, shewing that the original apportionment of half and half was approximately correct. The services of the Home Nurses of the Council have been greatly appreciated by every class of the community and many expressions of thanks and gratitude have been received from residents. Provision of Meals. Mid-day meals have been provided during the year to mothers and children under 5 years of age and school children where the economic circumstances of the family come below the scale fixed by the Council and the Education Committee. The Education Committee also provide breakfasts to school children where the economic circumstances of the family are less than half the scale fixed. These meals are provided at three centres provided by the Education Committee and one by a Voluntary Agency in Willesden. During the year 1920, 135,300 meals were provided, 16,951 to mothers and children under 5 and 118,349 to school children. The total number exceeds by 19,213 the number of meals supplied in 1919 on account of the unemployment which was prevailing during the last quarter of 1920 and on account of. the provision of breakfasts which appear in the returns for a full year for the first time. 13 Municipal Hospital. The report on the Municipal Hospital, written by the Medical Superintendent, discloses how great has been the volume of work carried out at the Municipal Hospital during 1920, under great pressure and conditions unfavourable to the staff. During the year, 2,608 patients were admitted, 1,113 being Infectious diseases, 551 women, 815 children and 129 other conditions, the numbers being higher than ever before recorded in the history of the Hospital. The Hospital has been well and economically conducted, and with the public demand for hospital treatment continuing, the Council will require to give careful consideration as to what restrictions, if any, should be placed upon the admission of ratepayers who desire admission to Hospital. The Value of Health Work. The foregoing statement is but a brief summary of the work done by the Health Department during the year for the maintenance and improvement of the public health. Probably at no period in our history was attention to health more needed than it is to-day. The' report of the Medical Department of the Ministry of National Service, issued in 1920, shews that only 35-36 per cent, of the men examined for the Army, or approximately 1 in every 3, were placed in grade 1, that is, were capable of enduring physical exertion suitable to their age. The records of the defects noted show that it was mainly the neglect of preventable conditions that gave rise in large measure to the physical inefficiency of men who had not yet reached the prime of life. Insanitary conditions in the home, improper feeding, unhygienic conditions in the workshop, unsuitable work, prolonged hours of labour, too little rest and sleep, unsuitable or insufficient recreation, and above all too little attention to the beginnings of disease, had all made their contribution to the general lack of good health amongst the manhood of the nation. No one interested in the prosperity of his country can read the report without being animated by a desire to do all that in him lies to improve the conditions of national health. The lay reader must not suppose that a C3 population will be converted into an A1 population in one day by the discovery of some elixir of life ,but must understand that the process will be gradual and be accomplished only by hard work and the development and co-ordination of the various health services rendered in part to the individual by the private practitioner, to the locality by the Local Authority, and to the nation by the Government. The loss to the community created by sickness and ill-health is incalculable. Some idea of it may be obtained from the report on the administration of National Health Insurance during the years 1914-17, which shews that in these three years no less a sum than £18,168,354 was paid out by way of sickness benefit (maximum rate, 10s. per week for men and 7s. 6d. for women), and disablement benefit (maximum rate, 5s. per week) to insured persons. This sum includes nothing for the cost of medical care and treatment while off sick, nor does it give any idea of the cost of the dislocation of industry brought about by ill-health and sickness among the workers. Some idea of this latter figure may be obtained from the fact that having regard to the rates of benefit paid the figures given mean that the work of at least 270,000 insured persons is lost every year owing to conditions of ill-health. During the year 1920, the nature, if not the magnitude, of the problem of National Health has been realised by the Consultative Council on Medical and Allied Services established under the Ministry of Health Act, 1919, and various suggestions have been made by them in their First or Interim Report for the improvement of Health Services and the National Health. The report indicates the way in which the Medical and Allied Services of an area should be utilised in connection with the maintenance and improvement of health and shews the need for the co-ordination of medical services. When and to what extent it may become practical to act along the lines indicated by this report is a problem which only the future will solve. It is satisfactory to note, however, that two years prior to the issue of this report in May, 1920, the Willesden Urban District Council had established, for the better carrying out of the health work which they have undertaken, Municipal Clinics and a Municipal Hospital much on the lines indicated in the report. These clinics and hospital are concerned mainly with the control and treatment of Infectious diseases and the care and treatment of mothers and children up to 5 years of age and of children attending the Public Elementary Schools. For purposes of this section of health organisation, Willesden is divided into 4 areas of approximately equal size, each of which is in charge of an Assistant Medical Officer, who is the pivot of the public medical work of his area and controls within his district Infectious diseases, Maternity and Child Welfare work and School Medical work. He has at hand for the elucidation of cases of difficulty, the services of part-time Consultants appointed by the Council, and a Hospital with beds for the observation or treatment of cases, when necessary. In this way it is assured that there is at hand for patients attending the Council's clinics the best possible medical skill for diagnosis and treatment. Neither the clinics nor the hospital are as yet fully equipped, but when this is done the mothers and children attending will be in a position to know that the local authority has left nothing to chance in their endeavour to secure healthy child life. The advantage of the medical arrangements that I have mentioned is that under the control of one medical officer is placed the care of the child before birth, after birth up to 5 years of age and during school life so that preventive measures may be studied and applied in the early years and a minimum amount of work consequently be required later. This ideal has not yet_been attained 14 because owing to the mass of defects discovered amongst children and the urgent need for treatment, time is not available for the study and application of measures for prevention which should proceed parri passu with treatment. The preservation and improvement of health represents a new field for medicine Present day doctors have all been educated in respect of the treatment of disease, in fact their whole training has been in respect of the diagnosis and treatment of pathological or diseased conditions rather than the maintenance of normal physiological functions. A large field for inquiry in Preventive Medicine is thus open and the Ministry of Health and Board of Education urge that inquiries into the causation of disease should be undertaken. The need for inquiries of this kind is evident, if only a few examples be taken from this report. Table No. 44 shews that 1,338 or 9.96 per cent, of the special cases referred to the School Medical Officer during the year, were suffering from defective ear conditions and defective conditions of the upper respiratory passages. Defective hearing is a definite handicap in industry, "running" ears are usually associated with defective hearing and are a danger to life, while defective conditions of the upper respiratory tract, mean constant ill-health. The need for increasing attention, therefore, to this subject, with the view of elucidation of the causes of these conditions and their eradication, will not only help the individual sufferer but the nation generally, in respect of better health and greater working capacity. Again, it will be observed in the same Table, that 503 children or 3-7 per cent, of the special cases referred to the School Medical Officer, were referred on account of visual defects. In 53 per cent, of these cases, vision was brought up to normal at the Municipal Clinics by the provision of Spectacles. This of course, is merely palliative treatment, and enquiry needs to be conducted to ascertain to what extent the production of visual defect is attributable to the hygienic conditions of the school or conditions of work or play or home surroundings or otherwise. Table No. 61, in connection with an enquiry as to absences from school, conducted in certain Willesden Schools during 4 months in 1920, shews that 69.5 per cent, of the absences were due to actual or alleged illness of the child, and that 23.7 per cent, were unconnected with illness of the child, as far as ascertained. Nearly half of the 23.7 per cent, of absences were caused by children being sent to the country for a holiday, and some of such absences were therefore very likely connected with ill-health or debility in the child. The principal illnesses causing absences from school were: Infectious diseases, accounting for 13.2 per cent, of the total attendances lost, diseases of the Lungs and Upper Respiratory Passages, 21.7 per cent; Skin diseases, 6.6 per cent.; andDebility, 8.2 per cent. The need for an intensive study of the physical condition of the child, in relation to school and home, with the view of prevention of illness amongst scholars and consequent loss of schooling, is again work waiting to be undertaken. Table No. 25 also shews that, out of 17,491 children from 0-14, who came under the observation of the Medical Officers of the Willesden Council during the year 1920, 8 or 0-045 per cent, were found shewing signs of congenital or acquired syphillis. This number is not large, but the disease is of a kind which transmits itself to others or reproduces itself in the offspring, frequently with mental and physical disabilities, and is therefore one of national importance. These items which I have noted will, I trust, shew the need for scientific enquiry in the development of the work of preventive medicine. With every member of the Medical Staff of the Authority having more routine work than he or she can reasonably perform, it is impossible to give the necessary attention to subjects of the kind I have mentioned. They are, nevertheless, of firstrate importance. It is only by such enquiries, scientifically conducted, that truth is reached and progress attained. The importance of scientific research is accepted in industry. Scientific research has enabled operative surgery to be undertaken to-day with little, if any, risk to the patient, and so again scientific research will enable investigator after investigator gradually to build up the principles on which the maintenance and improvement of individual and national health may be achieved. While much work remains to be done, I do not wish it to be thought that much has not already been accomplished. Fifty years ago the expectation of life at birth in males in England and Wales was 41 -35 years. To-day it is 51 -50 years. Taking Willesden, and going back 40 years, we find that the death rate in Willesden in 1880 was 18-7 per thousand of the population,and the Infant Mortality rate 173 per thousand births. Twenty years ago the death rate in Willesden was 13-6 per thousand of the population and the Infant Mortality rate 139 per thousand births. Last year, in 1920, the death rate in Willesden was 9 -78 per thousand of the population and the Infant Mortality rate 65 per thousand births. The difference in the death rates between 1880 and 1920 represents a saving of 1,520 lives in Willesden per annum. It is not easy to put down the value of this Health work in terms of money, but Dr. Farr, in 1876, in the 39th Annual Report of the Registrar General, reckoned that the mean net value of each male person in the community was £150, as estimated by the standard of the agricultural labourer of that day. For the whole population, including females, he thought the value might be lowered to £110. Willesden is an urban community, and having regard to the lower value of money to-day, it is not unfair on Dr. Farr's estimate to put the value of each life in Willesden at £250* in 1920, as * Since this was written Mr. Edgar Crammond, in his address to the Institute of Bankers, on 28th June, 1921, estimated the national wealth at £16,400,000,000 in 1913. Sir Josiah Stamp estimates the national wealth in 1913 at £14,319,000,000. On the lower figure the value per head of the population in 1913 was £313, from which it will be seen that my estimate of £250 in 1920 considerably understates the case.—G.F.B. 15 compared with £110 in 1876 on the basis of the agricultural labourer standard of that period. It will therefore be seen that the maintenance of the health activities of the Council represents a return translated in terms of cash to the inhabitants of Willesden on the low standard indicated of £380,000 per annum, which represents a handsome profit on the total gross expenditure of the Health Department of approximately £92,000 in 1920-21. The rise in the Willesden Rates for the financial year ending 31st March, 1922, by 4s. in the £ from 15s. 3d. or 26-2 per cent., is to be regretted at a time of trade depression in the country. It is no part of the duty of the Medical Officer of Health to examine the general causes of increase, but he is interested in the proportion of the increase which is caused by the Health Department. For the financial year, ending 1920-21, the estimates of the Health Department, including all Services, were responsible for 1s. 2d. of the 15s. 3d. rate,or 7.6 per cent, of the total rate of the district. For the financial year 1921-22, the estimates of the Health Department, including all Services, are responsible for Is. 4½d. of the 19s. 3d. rate or 7.1 per cent, of the total rate of the district. It will therefore be seen, that while the rate for 1921-22 has increased by 4s. over the rate for 1920-21, only 2½d. of this increase is due to the increased cost of the various services rendered by the Health Department. The result of the Health work of the Council has been to reduce the Willesden death rate and infant mortality rate of 1920 to less than one-half of what it was 50 years ago, and to give to each citizen on the average a life longer by 10 years. There is no reason why this improvement should not continue, and 50 years hence my successor in office be able to record even better results. But this will depend on a policy of action. At every period in our history there have been good honest men and women opposed to health action, but the results of the past years should encourage the Council to seek and secure the health of the citizens along the lines which lie to their hand and which are indicated in this Report. Your obedient Servant, GEORGE F. BUCHAN, Medical Officer of Health. 17 THE FORTY-FIFTH ANNUAL REPORT For the Year ending 31st December, 1920 on the HEALTH and SANITARY CONDITION of the URBAN DISTRICT OF WILLESDEN. 1. NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. Population (Census 1911, and estimated 1920).—The following Table No. 1. shews the population estimated by the method in vogue in Willesden, at Midsummer of each year since 1901, together with the estimated annual increase and the natural increase as indicated by the excess of births over deaths:— Table No. 1. Year. Estimated Midsummer population. Estimated annual increase of population. Natural increase of population, i.e. excess of births over deaths. 1901 116,089 — 2,141 1902 122,211 6,122 2,120 1903 129,315 7,104 2,477 1904 134,539 5,224 2,776 1905 140,758 6,219 2,457 1906 142,871 2,113 2,600 1907 146,107 3,236 2,543 1908 149,035 2,928 2,472 1909 150,145 1,110 2,494 1910 153,253 3,108 2,417 1911 154,344 Census Population — 1911 156,572 3,319 2,151 1912 159,868 3,296 2,472 1913 163,644 3,776 2,360 1914 166,634 2,990 2,363 1915 166,840 206 1.745 1916 167,810 970 1,958 1917 169,344 1,534 998 1918 169,358 14 373 1919 170,625 1,267 1,158 1920 170,892 267 2,560 The following Table, No. 2, gives certain particulars as to the estimated population oi 170,892 at Midsummer, 1920:— 18 TABLE NO. 2.—POPULATION ESTIMATED AT MIDSUMMER, 1920. WARD. Population estimated on the number of rooms in occupation in each Ward as ascertained by enumeration. Occupiable Houses, including houses recently erected but-not yet occupied. Occupiable rooms, including those of houses recently erected. Houses recently erected but unoccupied. Houses in course of erection. Houses demolished or unoccupiable Percentage of empty houses exclusive of houses recently erected Percentage of empty rooms inclusive of those of houses recently erected. Total. Empty Houses. Wholly unoccupied. Partly Empty. No. having one or more empty tenements. Empty tenements, exclusive of those houses wholly unoccupied. Total No. occupied. No. empty. 1 room. 2 rooms. 3 rooms. over 3 rooms. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) Met. Drain Area. A 1. South Kilburn 15,195 1,307 4 3 — 3 — — 10,337 10,316 21 — — - .30 .20 2. Mid Kilburn 15,071 1,762 17 3 — — — 3 13,635 13,517 118 — — — .96 .86 3. North Kilburn 12,948 2,047 13 2 — — — 2 17,068 16,947 121 — 2 — .63 .70 4. Brondesbury Pk. 10,048 1,422 2 2 - — — 2 11,470 11,444 26 - — — .14 .22 5. Kensal Rise 14,418 1,895 2 3 — — 2 1 12,514 12,494 20 - 2 — .10 .15 6. Harlesden ... 17,647 2,592 3 5 — — — 5 18,182 18,137 45 — 4 .11 .24 TotalMet. Drain Area 85,327 11,025 41 18 — 3 2 13 83,206 82,855 351 -- 5 — .37 .42 Brent Drain Area. A 7. Stoncbridge 17,972 2,089 11 4 — — 2 2 13,881 13,814 67 1 1 .47 .48 8. Roundwood 15,883 2,196 7 2 — — 1 1 15,631 15,572 59 — — .31 .37 9. Church End 14,436 1,981 4 - - - - - 12,385 12,360 25 — 34 — .20 .20 10. Willesden Gn. 17,207 2,486 7 4 — 1 2 1 16,618 16,561 57 — 1 — .28 .34 11. Cricklewood 20,067 3,777 16 9 — — 3 6 29,370 29,209 161 3 16 — .34 .54 TotalBrentDrain Ar. 85,565 12,529 45 19 — 1 8 10 87,885 87,516 369 4 51 1 .32 .41 Total 170,892 23,554 86 37 — 4 10 23 171,091 170,371 720 4 59 1 .34 .42 19 Physical Features and General Character of the District.—Vide Annual Health Report, 1919, p. 13. Social Conditions, including the Chief Occupations of the Inhabitants; the Influence of any Particular Occupation on Public Health.—Vide Annual Health Report, 1919, pp. 13 and 14. Vital Statistics- The population of Willesden estimated at Midsummer, 1920, was 170,892. Marriages.—Table No. 3. Total number of marriages in Willesden 1,609 Marriage Rate in Willesden per 1,000 of population 18.83 Marriage Rate in England and Wales per 1,000 of population 20.1 Births.—Table No. 4. Total number of births in Willesden 4,232 Birth Rate in Willesden per 1,000 of population 24.76 Birth Rate in England and Wales per 1,000 of population 25.4 Illegitimate Births.—Table No. 5. Number of Illegitimate Births 148 Illegitimate Births per 1,000 total births 34.97 Deaths.—Table No. 6. Total number of deaths in Willesden 1,672 Death Rate in Willesden per 1,000 of population 9.78 Death Rate in England and Wales per 1,000 of population ... 12.4 274 deaths of infants under one year of age occurred during 1920, giving an Infant Mortality Rate of 64.74 per 1,000, which is the lowest on record. The Amount of Poor Law Relief.—The following Table, No. 7, shewing the proportion of persons in receipt of relief to the population on or about January 1st, 1921, has been kindly supplied by Mr. J. Hutton Havlor, Clerk to the Willesden Board of Guardians:— Table No. 7. Ratio per 1,000 of estimated population. Indoor Poor. Outdoor Poor. Total chargeable (excluding lunatics). England and Wales 5.3 9.7 15.9 County of London 10.7 11.3 22.1 County of Middlesex 4.3 8.5 12.9 Willesden Urban District 6.0 5.9 11.9 The Extent to which Hospital and other Forms of Gratuitous Medical Relief are Utilised.—The extent to which Hospitals are utilised may be gauged from the following Table No. 8, which shews the total deaths of Willesden residents and the number and proportion of deaths occurring at home, Workhouse, or Hospitals. No. Per cent, of Total Deaths. Total Deaths 1,672 Deaths of persons dying in their own homes 940 56.2 Deaths of persons dying in Workhouses 306 18.3 Deaths of persons dying in Municipal Hospital 140 8.4 Deaths of persons dying in other Hospitals 286 17.1 A list of voluntary and other charitable agencies within the district established in the interests of sick persons, or public health, will be found in the Annual Health Report, 1919, pp. 15-20. 2.—SANITARY CIRCUMSTANCES OF THE DISTRICT, Water.—Vide Annual Health Report, 1919, p. 20. Rivers and Streams.—Vide Annual Health Report, 1919, p. 20. Drainage and Sewerage.—Vide Annual Health Report, 1919, p. 20. Closet Accommodation.—Vide Annual Health Report, 1919, p. 20 Scavenging.—This is carried out by direct labour and electric vehicles owned by the Council under the joint control of the Surveyor's and Electricity Departments. During 1920 this method proved adequate and satisfactory. 20 Sanitary Inspection of District. Table No. 9. Inspections: Number of premises inspected on complaint 3,164 Number of premises inspected in connection with infectious diseases 66 Number of premises under periodical inspection ... 695 Houses inspected from House to House (Housing Acts, 1890 to 1919) 0 Total number of inspections and re-inspections made 14,602 Action Taken (other than under Housing Acts, 1890 to 1919) : Cautionary or Intimation Notices Issued 2,546 Number complied with 1,908 Statutory Orders issued 1,132 Number complied with 686 Summonses served 38 Number of convictions obtained 35 Summonses withdrawn 3 dismissed 0 Notices under Section 36 of the Housing, Town Planning, etc., Act, 1909, issued... 73 Dwelling Houses and action under Housing Acts, 1890 to 1919: Number of houses dealt with under Section 15 (Housing, Town Planning, &c., Act, 1909) 0 Number of houses dealt with under Section 28 (Housing, Town Planning, &c., Act, 1919) 24 Number of houses closed under Section 28 (Housing, Town Planning, &c., Act, 1919) 2 Number of houses found to be in a state dangerous or injurious to health, Section 17 (Housing, Town Planning, &c., Act, 1909) 3 Number of representations made by Medical Officer of Health, Section 17 (Housing, Town Planning, &c., Act, 1909) 3 Number of houses made habitable without closing orders 16 Number of closing orders made by Local Authority, Section 17 (Housing, Town Planning, &c., Act, 1909) 3 Number of closing orders determined after repairs, Section 17 (Housing, Town Planning, &c., Act, 1909) 2 Number of houses demolished— (a) by order of Local Authority, Section 17 (Housing, Town Planning, &c., Act, 1909) 0 (b) voluntarily 0 Illegal Underground Rooms vacated 0 Houses Let in Lodgings (Tenement Houses): Number registered under Bye-laws 0 Number of contraventions 0 Common Lodging Houses: Number registered under Bye-laws 1 Number of Inspections made 10 Number of contraventions 5 Canal Boats used as Dwellings: Number of contraventions of Regulations 3 Movable Dwellings, Caravans, Tents, &c. : Number observed during the year 35 Number of nuisances therefrom abated 2 Number removed from district 34 Bakehouses: Number in district 63 Contraventions of Factory Acts 27 Slaughter-houses: Number on register 9 Inspections of carcases, etc. 228 Contraventions of Bye-laws 1 Cowsheds: Number on register 3 Number of inspections made 29 Contraventions of regulations 2 Number of milch cows in district 45 Dairies and Milkshops: Number on register 129 Number of inspections made 146 Frequency of inspection yearly Contraventions of regulations 17 21 Unsound Food: Meat (including organs) seized and surrendered 442 lbs. Poultry and game surrendered 5 lbs. Fish surrendered 751 lbs. Fruit and vegetables surrendered 198 lbs. Bacon surrendered 265 lbs. Flour surrendered 6,920 lbs. Cheese surrendered 10 lbs. Butter surrendered 2 lbs. Jam and Marmalade surrendered 0 lbs. Eggs surrendered 1,453 Rabbits ... 84 lbs. Bread 1,278 lbs. Tinned Vegetables 3 lbs. Tinned Fish 2 lbs. Tinned Fruit 6 lbs. Tinned Meat 12 lbs. Method of disposal Part sent fat extractors, part for fowl and pig feeding, partmanure, rest destroyed. A dultercited Food : Samples taken (See Table No. 12) 0 Found adulterated 0 Offensive Trades: Number of premises in district (Rag and Bone Dealers) 16 Number of inspections made 19 Contravention of Bye-laws 3 Water Supply and Water Service: Wells:— New sunk 0 Cleansed, repaired, etc. 0 Closed as polluted 0 Percentage of houses supplied from public water service 100 Cisterns:— New provided 16 Cleansed, repaired, covered, etc 136 Draw-taps placed on mains 47 Percentage of houses supplied on constant system 100 Number of samples obtained for analysis from:— (a) Local Wells 1 (b) Public supply 0 Drainage and Sewerage of existing Buildings : Water Closets:— Number of water closets substituted for dry receptacles 0 Repaired, supplied with water or otherwise improved 349 Percentage of houses provided with water closets 100 Drains:— Examined, tested, exposed, etc. 112 Unstopped, repaired, trapped, etc. 231 Waste pipes, rain-water pipes, disconnected, repaired, etc. 184 New soil pipes or ventilating shafts fixed 49 Existing soil pipes or ventilating shafts repaired 89 Disconnecting traps or chambers inserted 64 Re-constructed 22 Cesspools:— Rendered impervious, emptied, cleansed, etc 0 Abolished and drain connected to sewer 0 Percentage of houses draining into sewers 100 Disinfection: Rooms disinfected :— (a) Ordinary infectious diseases 1365 (b) Phthisis 17 Articles disinfected or destroyed :— (a) Ordinary infectious diseases 6,062 (b) Phthisis 108 Dust: New bins provided 977 Periodical frequency of dust removal weekly Number of complaints of non-removal received 305 Method of disposal By tipping and barging Sundry Nuisances abated : Overcrowding 6 Smoke 4 Accummulations of refuse 41 Foul ditches, ponds, etc., and stagnant water 7 Fowls, pigs, and other animals 48 Dampness 174 Yards and forecourts paved, repaved or repaired 255 Walls and ceilings cleansed 1971 Leaky roofs made watertight 335 Additional ventilation provided under floors 128 Dilapidated plaster repaired 502 Flooring and other woodwork repaired 177 Damp-proof courses inserted 80 Water supply reinstated 21 Washhouse floors repaved 137 Fireplaces and stoves repaired 123 Decayed brickwork repaired and repointed ... 145 Additional sinks provided 13 Additional light and ventilation to staircases 13 Larders or food cupboards provided 9 Gutters and rainwater pipes repaired 396 Smoke observations 8 Additional water closets constructed 4 Miscellaneous 159 Inspection of Premises where Food is prepared: Butchers' shops 69 Fish shops 43 Eating houses 28 Greengrocers' shops 53 Ice-cream premises 10 Canal Boats Acts, 1877 and 1884.—Table No. 10. Return shewing the contraventions observed and remedied during the year:— Infringement of the Acts and Regulations with respect to:— Carried forward from 1919. Found during 1920. Remedied during 1920. Carried forward from 1920. (a) Registration — — — (b) Notification of change of Master — — - — (c) Certificates - 1 1 — (d) Marking - 1 1 — (e) Overcrowding - — - — (f) Separation of Sexes — — — (g) Cleanliness — — — — (h) Ventilation — — — (i) Painting — — — — (j) Provision of water cask - — — — (k) Removal of Bilge Water - — - — (I) Notification of Infectious Disease - — - — (m) Admittance of Inspector - — — — (n) Habitable condition ... - 1 1 — Totals - 3 3 — During the year 32 visits were made to the Canal, and 16 boats were inspected. Two were found to be contravening the regulations. 23 Premises and Occupations which can be Controlled by Bye-Laws or Regulations. (1) Houses Let in Lodgings.—Reference to this subject is made later in the report. (2) Offensive Trades.—Vide Annual Health Report, 1919, pp. 26 and 27. Effluvium Nuisance—Burning Rubber.—Early in February, 1920, and on subsequent dates, letters were received by the Health Department from residents, particularly in the Harlesden district, complaining of suffocating fumes and the nauseating stench of burning rubber, occurring usually between two and three o'clock in the morning. After many efforts, the source of this nuisance was ultimately traced to a factory in Acton, where old worn out motor tyres were used for kindling ten furnaces. A letter was sent to the owners of the factory calling upon them to abate the nuisance by ceasing to burn this rubber product at their works. The owners failed to comply, and the Council, acting upon the advice of their Solicitor, applied to the High Court of Justice for an Injunction to restrain the defendants from permitting or suffering to be kindled at their factory, fires with rubber or with rubber products causing effluvia therefrom, so as to be a nuisance or injury to the public. As a result of this action, the defendants gave a perpetual undertaking not to use rubber or rubber products for their furnaces, each party paying their own costs. (3) Common Lodging Houses.—Vide Annual Health Report, 1919, p. 27. (4) Underground Sleeping Rooms.—Regulations governing underground sleeping rooms were made by the Council in 1913. The Annual Report of that year contains a full reprint of the same. Work under these regulations has been in suspense during the year owing to the insufficient staff of inspectors employed and the lack of housing accommodation for families displaced while the necessary alterations to the basement rooms are being carried out. (5) Prevention of Nuisances.— The Council at its meeting on 28th December, 1920, approved new Bye-Laws for the Prevention of Nuisances, including nuisances caused by the keeping of pigs and other animals, to replace their original Bye-laws, dated 1876. These bye-laws now await the confirmation of the Ministry of Health. (6) Slaughter Houses.—During 1920 the Council revised its Slaughter House Bye-Laws, incorporating therein the model clauses of the Ministry of Health relating to the "Humane killing of Animals in Slaughter Houses." Before the Health Committee definitely adopted these special clauses, they asked the trade in Willesden for their observations. The Trade was in agreement with the use of mechanically operated instruments for the killing of beasts, but was of opinion that the use of such instruments was not successful in the killing of small animals, such as sheep, pigs,— etc. The " Humane Clauses " were accordingly amended in order to apply only to the slaughtering of cattle with a mechanically operated instrument. The Bye-laws in their final form were approved by the Council on December 28th, 1920, and are now awaiting the confirmation of the Ministry of Health. (7) Public Decency.—A Memorial signed by residents of Priory Park Road, nearest to, or adjoining the High Road, Kilburn, was received by the Council, complaining of the use of the passage way known as Glengall Passage and of the entrance lobbies of their private residences, as public conveniences. The matter was considered by the Health Committee, who instructed that the Commissioner of Police be communicated with on the subject, with a view of the Police taking steps against any person whom they might find committing a nuisance. The Commissioner of Police replied, that owing to the absence of any Bye-law in Willesden dealing with this class of offence, the efforts of the Police were necessarily hampered, and pointing out that the London County Council have in operation a Bye-law dealing with Public Decency under which the Metropolitan Police are able to take action in the Metropolis. The Home Office have issued the following Model Bye-law:— " No person shall in any street or public place, to the annoyance of residents or passengers, commit any nuisance contrary to public decency or propriety." The Council at its meeting on the 28th December, 1920, passed a resolution, asking the Middlesex County Council to take steps to make the above Bye-law applicable to Willesden. (8) Houses Let-in-Lodgings.—During the year 1920, draft Bye-laws relating to houses letin-lodgings in pursuance of Section 26, Housing and Town Planning, etc., Act, 1919, based on the Model Bye-laws of the Ministry of Health, were prepared and submitted to the Health Committee. The draft Bye-laws were also considered by the Legal, Parliamentary and Bye-la\vs Committee, and the Solicitor of the Council was instructed to obtain from the Ministry of Health an interpretation of their definition of the term Lodging House in the Model Series. The reply of the Ministry to the Solicitor's enquiry was not deemed by the Legal, Parliamentary and Bye-laws Committee to be satisfactory, and on their recommendation, the Council at its meeting on 28th December, 1920, passed the following resolution:— That the proposed Bye-laws relating to houses let-in-lodgings be not adopted by the Council, pending the issue of further Model Bye-laws by the Ministry of Health, containing a more specific definition as to the premises to which it is intended such Bye-laws shall apply. 24 Other Sanitary Conditions requiring Notice.—Note should be made of any important matters of Sanitary environment which have received attention during the year 1920. or demand special consideration now, and are not included in the above headings. No matter falls to be reported under the above heading. Schools.—The Sanitary condition and water supply of schools, especially public- elementary schools, should be reported on. The total number of public elementary schools in the district is 32, of which 20 are Council schools and 12 Non-provided schools. In addition, there are 2 Physically Defective schools and 1 Mentally Defective school. 18 of the Council schools are permanent and 2 temporary buildings. They are all of modern construction. The sanitary arrangements are satisfactory and in accordance with the regulations of the Board of Education relating to Public Elementary Schools. The Non-provided schools are not of modern construction, but the sanitary arrangements have, as far as practicable, been amended in accordance with modern principles. Water is supplied to all the schools from the main of the Metropolitan Water Board, and adequate facilities are provided in the playgrounds for supplying drinking water for the scholars Certain details of construction with regard to the Public Elementary schools in Willesden are to be found in the Annual Health Report for 1909, pages 38-95. Since this report was written, Lower Place and Disraeli Road Temporary Schools have been discontinued and the following new Schools opened:— Lower Place School (permanent)—Junior and Senior. Mixed. Bridge Road School (permanent)—Boys, Girls. Infants. Carlton Vale (permanent)—Girls and Infants. Percy Road Boys' School (permanent)—Boys. Gladstone Park School (temporary)—Mixed and Infants. College Road School (temporary)—Mixed and Infants. Schools.—The action taken in relation to the health of the scholars and for preventing the spread of infectious disease. During the year, 360 cases of Scarlet Fever, 411 Diphtheria, 1,025 Measles and German Measles, 337 Whooping Cough and 373 cases of Chicken Pox were reported amongst Willesden scholars and dealt with according to the principles and regulations set out in my Annual Health Report. 1919, pp. 27-29. 3. FOOD. (a) Milk Supply.—The wholesomeness of the milk produced within or imported into the district and the general adequacy of the arrangements for the supply and distribution of milk of pure and wholesome character should be reported upon ; also the administration of the Dairies, Cowsheds, and Milkshops Orders ; and any action taken as to tuberculous milk, whether under local Acts or under Articles 13 and 15 of the Dairies, Cowsheds, and Milkshops Order of 1885, and Article 11 of the Dairies, Cowsheds, and Milkshops Order of 1899. The amount of milk produced in Willesden is rapidly decreasing year by year. At the end of the year 1919 there were 51 milch cows in 3 farms in the district. At the end of the year 1920, the keeping of cows at one of the three farms had been discontinued and the number of cows reduced in the others to 33 and 4 respectively. The amount of milk produced by 37 cows is a negligible quantity, when considering the total milk supply of Willesden, and Willesden therefore, like London, is dependent on outside sources for its milk supply. It is a recognised fact, that generally the conditions under which Milk is produced and distributed in this country are unsatisfactory. The Milk and Dairies Consolidation Act, 1915, which is at present suspended, makes provision for securing more adequate supervision of the conditions under which milk is produced and distributed. A Bill is at present before Parliament to amend the Act to secure improvements in the quality of the milk supply. The date, however, of the passing of the Bill, is indefinite. No action was taken by the Council under the Dairies, Cowsheds, and Milkshops Order, or the Tuberculosis clauses of the Willesden District Council Act, 1903, for the detection of Tuberculosis of the udder in cows ; the continued suspension throughout the country of the Tuberculosis Order of 1914 rendering such local action valueless. The 129 milkshops in the district were all visited and the conditions under which milk is handled, together with the appliances and methods of cleansing of cans and utensils, inspected and examined. 17 contraventions of the Regulations were observed and remedied after the service of notices. Milk (Mothers and Children) Order, 1919.—A review of the action taken by the Local A uthority tinder this Order should also be included. The Annual Health Report, 1919, pp. 30 and 31, states the conditions under which milk, dried milk, or meals were supplied to expectant and nursing mothers and children under 5 years, 25 during the year 1919. The alteration in the conditions of supply subsequent to the Milk (Mothers and Children) Order, 1919, is described in page 31 of the Annual Health Report, 1919. These later conditions of supply continued until 25th May, 1920, when the Council decided to abolish, on account of its cost to the Local Authority, the part-payment system and supply milk, dried milk or meals free to expectant mothers and children under 5 years of age, where the income per head of the family per week comes below the following scale:— No. in Family. Net income per head of the family per week. S. d. 2 12 0 3 11 0 4 10 0 5 or over 9 0 The method of calculating the net income per head of the family is given in the Annual Health Report, 1919, pp. 30 and 31. All statements made at the Clinics as to income, when these incomes come below the above scale, are verified by letter to the employers and by personal enquiries at the home. The following statement shows the amount of milk and dried milk distributed during the year. Dried Milk. Supplied without cost to Council. (Parents pay full cost.) Supplied at quarter cost to Council. Supplied at half cost to Council. Supplied at three-quarter cost to Council. Supplied at full cost to Council. (Parents receive free.) 19,896 lbs. 126 lbs. 176 lbs. 241 lbs. 6,962 lbs. Milk (Liquid). No. of pints supplied Free. No. of pints supplied at quarter cost to Council. No. of pints supplied at half cost to Council. No. of pints supplied at three-quarter cost to Council. 6,272 pts. 112 pts. 364 pts. 224 pts. 5,143 meals were supplied free or at part cost to mothers and children under 5 years. Appendix P. of this report shews that the expenditure on milk and dried milk in Willesden is at the rate of l½d. per birth per week, and that, with the exception of Westminster, where the conditions are not comparable, Willesden spends relatively less in this direction than 19 neighbouring districts where the expenditure was verified. This fact is a tribute to the excellence of the methods employed in distribution. (b) Meat—The report should include references to the following matters, considered particularly in relation to the recent de-control of the sale of meat:— (i.) Meat inspection, disease in meat, and condition of slaughter-houses. (ii.) It should be stated whether a public abattoir has been established in the district, and if not, what are the existing arrangements for inspecting meat at the time of slaughter. (iii.) Action under Section 117 of the Public Health Act, 1875, or Section 47 of the Public Health (London) Act, 1891. (iv.) Number of carcases and parts of carcases condemned for tuberculosis. (v.) Statement in tabular form of number of slaughter-houses in district in 1914, January, 1920, and December, 1920. . Seven of the eight sanitary inspectors are qualified meat inspectors and examine meat exposed for sale in the various shops of the district from time to time. In addition, on Saturday nights, two inspectors are on duty for the purpose of inspecting meat in shops and markets in the area. During 1920 no diseased meat was detected in this way. There are nine slaughter-houses in the district, five being licensed and four registered. One of the licensed premises is used only for the killing of horses. The sanitary condition of these slaughterhouses is satisfactory. A public abattoir has not been established in the district. Visits to the nine private slaughterhouses in Willesden, are paid by the Inspectors as often as possible when slaughtering is in operation for the purpose of examining the carcases and internal organs of the slaughtered animals. In five instances, bullocks livers, shewing abscess formation, were seized at the slaughter-houses and destroyed as unfit for food. 26 Table No. 11. Shewing the Slaughter-houses in Willesden. 1914. January, 1920. December, 1920. Registered 4 4 4 Licensed 5 5 5 Total 9 9 9 (c) Other Foods.—The following items should receive special attention:—Unsound food and food inspection; sanitary condition of bakehouses and premises where foods are manufactured, prepared, stored, or exposed for sale, indicating any important respects in which existing powers have been found inadequate for dealing with insanitary conditions in such places. The year 1920, like 1919, has been again remarkable on account of the large quantities of damaged and unsound foodstuffs voluntarily surrendered by shop-keepers, particulars of which are given in this report under the heading, "Sanitary Inspection of District." (d) A reference should be made to any cases of food poisoning in the district. No case of food poisoning occurred in Willesden in 1920. (e) Sale of Food and Drugs Acts.— A report on the work done by the local authority tinder these Acts should be included, with observations on special questions which have received or require attention. The administration of these Acts is in the hands of the Middlesex County Council, and the following information relating to the work done in Willesden, has been kindly supplied me by Mr. Robinson, Chief Officer, Public Control Department. Table No. 12. Samples taken during the year ended 31st December, 1920:— Article. Formal. Informal. Taken. Adulterated. Taken. Adulterated. Milk 236 24 260 22 Separated Milk 12 — 1 — Butter — — 28 — Margarine — — 1 — Preserved Cream 3 — 1 — Self-raising Flour — — 4 1 Ale — — 1 — Carbonate of Soda — 1 — Lime Juice — — 1 — Baking Powder — — 2 — Cream of Tartar — — 2 — Egg Powder — — 1 — Custard Powder — — 8 — Coffee — — 2 — Lard — — 1 — Dripping — — 3 — Cream 2 1 2 1 Egg Substitute Powder — — 6 — Fish Paste 1 — 3 — Lard Compound — — 1 — Pepper — — 3 — Sugar — — 1 — Whiskey — — 1 — Total 254 25 334 24 One milk-seller was prosecuted for refusing to sell milk to an Inspector, and was fined £10 and Five guineas costs. Another milk-seller was prosecuted for obstructing an Inspector, and was fined £10 and 10s. costs. Public Health Milk and Cream Regulations, 1912-1917.—Milk: No preservative was found in any of the samples of milk analysed. Cream: In one case, preserved cream was sold without being so labelled, and the vendor was cautioned. 27 4. PREVALENCE OF AND CONTROL OVER INFECTIOUS DISEASES. Infectious Diseases Generally.—The prevalence of notifiable infectious diseases during the year should be reviewed, and noteworthy facts as to the source of spread of infection should be recorded. Such matters as the supply and prompt use of diphtheria anti-toxin, the occurrence of cases of encephalitis lethargica, or the discovery of "return" cases of scarlet fever should be noted, as well as the experience of the district in regard to the diseases notifiable under the regulations of 1th January, 1919, i.e., pneumonia, malaria, dysentery, and trench fever. Notifications.—Tabu-: No. 13. No. of Notifications of:— Diphtheria 699 Erysipelas 91 Scarlet Fever 705 Enteric Fever 22 Continued Fever 3 Puerperal Fever 20 Cerebro-Spinal Fever 4 Poliomyelitis 0 Ophthalmia Neonatorum 49 Measles and German Measles — Pulmonary Tuberculosis 296 Other forms of Tuberculosis 47 Whooping Cough 193 Pneumonia 107 Malaria 41 Dysentery 4 Encephalitis Lethargica 0 Acute Polio-encephalitis 0 Total 2,281 Scarlet Fever.—Table No. 14. Shewing the number of cases notified, the number and percentage removed to Hospital, and the Incidence and Fatality rates each year since 1892. Year. No. of Cases notified. No. of Cases removed to Hospital. Percentage removed to Hospital. Incidence Rate. Cases per 1,000 population. Fatality Rate. Deaths per 1,000 cases. 1892 366 49 13.3 5.5 22 1893 589 107 18.1 8.5 25 1894 268 83 30.9 3.6 26 1895 392 243 61.9 4.9 43 1896 475 282 59.3 5.5 35 1897 510 320 62.7 5.4 21 1898 361 209 57.8 3.6 28 1899 414 220 53.1 3.9 38 1900 335 188 56.1 2.9 35 1901 553 265 47.9 4.9 21 1902 466 282 60.5 3.8 27 1903 502 393 78.2 3.8 22 1904 326 242 74.2 2.4 6 1905 397 328 82.6 2.8 13 1906 637 543 85.2 4.5 17 1907 641 547 85.3 4.4 30 1908 737 651 88.3 5.0 19 1909 638 556 87.1 4.4 25 1910 314 265 84.3 2.0 0 1911 326 226 69.3 2.1 15 1912 430 373 86.7 2.7 2 1913 504 446 88.5 3.1 14 1914 765 682 89.1 4.6 7 1915 453 406 89.6 2.7 33 1916 387 350 90.4 2.3 3 1917 166 141 84.9 0.98 12 1918 131 111 84.7 0.77 23 1919 418 274 65.5 2.44 10 1920 705 435 61.7 4.12 11 28 It will be seen that a larger number of cases of Scarlet Fever were notified than has been the case since 1914, the incidence rate likewise being greater than it has been since 1914. This increase in incidence was associated with a fatality rate of 11, which is relatively low. The prevalence of the disease was general throughout the country, and not confined to Willesden or any particular area. Owing to the tax on the Hospital accommodation in all directions, it has been again impossible to admit to Hospital all cases of Scarlet Fever desiring removal. Hospital removal for Scarlet Fever had to be curtailed in October, 1920, after which time only the most urgent cases were removed. From then to the end of the year, cases of Scarlet Fever were nursed at home wherever practicable. In such cases and in cases where removal was delayed, when application has been made, proper expenses incurred whilst nursing the cases at home have been allowed by the Council. Since the 2nd October, 1920, out of 339 cases notified, 153, or 45 per cent., were removed to hospital. These were not all removed as soon as notified, but as and when beds were available. A count was taken from time to time of the number of cases of Scarlet Fever being nursed at home in the district. The greatest number being nursed at home at any one time was 74 on December 7th, 1920. During the 1919-20 prevalence of Scarlet Fever, 9 cases were granted expenses at a cost of £2 5s. 6d. per case. During the 1920-21 prevalence, up till 22nd April, 1921, 93 cases had been allowed expenses amounting to £214 7s. 9d. or £2 6s. Id. per case. It is unsatisfactory that all cases needing or desiring removal to Hospital should not be admitted— (1) for the welfare of the patient; (2) on account in most cases of the inconvenience and expense of nursing the cases at home; (3) on account of employers, in some instances, being unwilling for other members of the family to continue, work ; and (4) on account of the additional length of time scholars have to remain away from School. A Special Report on the 1920 Epidemics of Scarlet Fever and Diphtheria in Willesden appears in Appendix O. Table No. 15. Giving Particulars of Infecting and Return Cases of Scarlet Fever during 1920. Initials of Infecting Cases. No. of days isolated. Initials of Return Cases. No. of days elapsing between release from isolation of infecting case and onset of illness of return case. Notes on Infecting Cases. J.R.C. Mixed case of Scarlet Fever and Nasal Diphtheria 107 C.C. Scarlet Fever and Diphtheria 20 Persistent rhinorrhœa for protracted period in hospital. Had nasal catarrh after return home. W.C. Scarlet Fever and Diphtheria 40 T.F.J. 81 J.F.J. 10 Rhinorrhœa during convalescence and after return home. Sub-maxillary cervical glands enlarged. H.E.J. 14 H.C. 73 E.C. 10 Nasal discharge during convalescence and after return home. F.D. 60 W.D. 12 L.B. 52 IB. 6 Slight nasal discharge, sore at base of nostril and behind ear after return home. Had tonsils enlarged and nasal moisture and injection of mucous membrane during convalescence in hospital. A.B. 7 D.C. 48 M.C. 5 Nasal discharge. 29 Initials of Infecting Cases. No. of days isolated. Initials of Return Cases. No. of days elapsing between release from isolation of infecting case and onset of illness of return case. Notes on Infecting Cases. F.M. 46 R.M. 37 Adenoids. P.S. or J.s. 45 C.S. 13 Adenoids. 37 20 Ear discharge after return home. Ear discharge and tendency to nasal discharge in hospital. F.P. 43 E.P. 110 F.T. 43 R.T. 125 Had morbilli during convalescence. W.F. 43 D.F. 13 Aural and post-nasal discharge after return home, throat inflamed. adenoids present. G.L. 42 home case F.D. 2 E.S. 3 between date of first contact and onset of illness F.L. 16 between date of first contact and onset of illness. W.E. 41 home case A.M.E. 8 Ear discharge and suppurating cervical gland during isolation and after release. S.S. 41 K.S. 8 Nasal discharge, post-nasal sepsis after return home. Had rhinorrhoea in hospital. V.F. 39 JF. / 6 History of cough and nasal discharge after return home. Suffers from enlarged tonsils and adenoids. C.D. 39 JD. 11 Rhinorrhoea during acute stages in hospital. Septic thumb, dry, on discharge. D.W. 38 J.D. 55 C.L. 37 V.L. 5 Nasal discharge and sore throat for one day after return home. I.B. 36 L.N. 28 K.J. or A.J. 36 A.M.J. 17 Enlarged tonsils. 30 52 W.S. 35 C.S. 3 Sore nostril and swollen cervical glands after return home. G.M.W. 35 G.R.W. 28 Interior of nostrils sore and cervical glands enlarged after return home. Child is the subject of adenoids and very large and obstructive tonsils. G.W. 33 N.C. 14 M.C. or C.B. 33 H.F. 154 31 154 30 Initials of Infecting Cases. No. of days isolated. Initials of Return Cases. No. of days elapsing between release from isolation of infecting case and onset of illness of return case. Notes on Infecting Cases. L.A. 32 G.A. 2 Slight rhinitis after release. M.M.A. 32 J.L.A. 18 Thickened mucous membrane in naso-pharynx. D.L.C. 32 M.C, 38 Slight excoriation left nostril, very slightly moist after return home. C.C. 39 N.C. 41 R.C. 42 C.P. 32 R. P. Scarlet Fever and Diphtheria 5 Had co-existent Scarlet Fever and nasal Diphtheria. Nasal discharge and soreness of inside of nostrils, and cervical adenitis after return home. E.P. 6 C.B. 31 D.B. 12 Slight nasal discharge and small septic sore left nostril after return home. E.B. 12 L.F. 28 P.F. 27 Rhinitis after return home. M.J. or A J. 27 F.J. 12 Felt tired and run down after return home. 27 A.G. 26 W.G. 14 Severe cold in head after return home. D.W. 22 A.E.W. 8 I.M. 21 P.M. 249 Some lymphoid thickening in naso-pharynx on return home. Return Cases of Scarlet Fever.—Table No. 16. 1919. 1920. Number of infecting cases 12 34 Number of infecting cases per cent. of cases notified 2.9 4.8 Number of return cases 27 44 Number of return cases per cent. of cases notified 6.5 6.2 Table No. 17. Giving particulars of multiple cases of Scarlet Fever occurring in houses in 1920. No. of Houses. Per cent. of Houses. No. of Cases. Per cent. of Cases. Houses in which 1 case occurred 444 80.7 444 63.0 2 „ „ 69 12.5 138 19.6 3 „ „ 29 5.3 87 12.3 4 „ „ 5 0.9 20 2.8 5 „ „ 2 0.4 10 1.4 6 „ „ 1 0.2 6 0.9 Totals 550 100.0 705 100.0 Diphtheria.—The following Table, No. 18, shews the number of notifications of Diphtheria received year by year since 1892, together with other particulars. 31 Diphtheria and Membranous Croup.—Table No. 18. Shewing the number of cases notified, and number and percentage removed to hospital, and the incidence and fatality rates each year since 1892. Year. No. of Cases notified. No. of Cases removed to Hospital. Percentage of Cases removed to Hospital. Incidence Rate. Cases per 1,000 population. Fatality Rate. Deaths per 1,000 Cases. 1892 145 14 9.6 2.1 127 1893 229 0 0.0 3.1 199 1894 129 8 6.2 1.7 126 1895 186 66 35.4 2.2 190 1896 173 51 29.4 2.1 169 1897 275 132 480 2.9 250 1898 335 217 64.7 3.3 204 1899 319 183 57.3 2.9 148 1900 226 120 53.1 1.9 124 1901 404 190 47.0 3.4 138 1902 440 222 50.4 3.5 122 1903 221 122 55.2 1.6 46 1904 353 290 82.1 2.6 54 1905 275 227 82.5 1.9 51 1906 286 222 77.6 2.0 57 1907 254 186 73.2 1.7 71 1908 215 175 81.3 1.4 65 1909 207 171 82.6 1.4 48 1910 166 142 85.5 1.1 66 1911 192 130 67.7 1.2 57 1912 222 191 86.0 1.4 45 1913 233 215 92.3 1.4 34 1914 303 258 85.2 1.8 79 1915 231 213 92.2 1.4 130 1916 225 213 94.7 1.3 76 1917 254 234 92.1 1.5 79 1918 271 223 82.3 1.6 92 1919 494 461 93.3 2.9 55 1920 699 652 93.3 4.0 62 This is the greatest number of cases notified since the above records were kept in 1892, and the highest incidence rate. It is satisfactory to note that the fatality rate of 62, although higher than last year, was not a high one. The disease was not confined to Willesden or any particular area, but was general throughout the country. The notifications were high throughout the year, and increased in October to the end of the year, the increase being co-incident with the increase in Scarlet Fever notifications. With respect to the supply and use of Diphtheria anti-toxin, vide Annual Health Report, 1919, pp. 36-37. A special report on the epidemics of Scarlet Fever and Diphtheria in Willesden in 1920 appears in Appendix O. Enteric Fiver.—During the year, 22 cases were notified; 16 of these were removed to the Willesden Municipal Hospital, 1 to St. Thomas's Hospital, 1 to St. Mary's Hospital and 1 to the Willesden Infirmary, whilst 3 were nursed at home. The incidence rate per 1,000 of the population is 013. Five of the 16 cases removed to the Willesden Municipal Hospital proved not to be Enteric Fever. The diagnosis in these cases was as follows:— Ptomaine Poisoning 1 Appendicular Colic 1 Debilitated 1 Pyonephrosis 1 (proved fatal) Tubercular Meningitis 1 (proved fatal) There were no deaths from Enteric Fever. Continued Fever.—Three cases were notified. Two were removed to the Municipal Hospital, one being diagnosed as Cephalgia and one as Bronchitis. Both recovered. The third case was removed to the Willesden Infirmary, and was diagnosed as Puerperal Fever and recovered. Cerebro-Spinal Meningitis.—Four cases were notified during the year. Two were treated in the Municipal Hospital, one in Great Ormond Street Homeopathic Hospital, and one in St. Mary's Hospital. 32 Of the two cases removed to the Municipal Hospital, one occurring in a man of 50 years, was diagnosed in hospital as Cephalgia and recovered. The other case, occurring in a woman of 23 years, was diagnosed in hospital as Tubercular Meningitis and died. The case removed to Great Ormond Street Homeopathic Hospital, a child of 5 years, proved fatal. The case removed to St. Mary's Hospital, a man of 51, also died, the death being certified as Otitis Media. Pneumonia, Malaria, Dysentery and Trench Fever became notifiable on March 1st, 1919. Pneumonia.—One Hundred and seven cases were notified, the greatest number, 29, occurring between the ages of 25 and 45, and 27 between the ages of 45 and 65. The wards with the greatest number of notifications were South Kilburn and Mid-Kilburn, with 20 and 23 respectively as against an average of 7 in the other wards. The notifications were highest during the 4 weeks ended 24th January, 20th March, 17th April and 15th May, 1920, being 13, 14, 24 and 15 respectively. With these exceptions, the notifications did not rise above 9 in any of the 4 weekly periods. Fourteen of the 107 cases notified were removed to the Municipal Hospital. Of the 107 cases notified, 37 died. Out of 101 of the notified cases in which information is available, 57 were nursed at home and 44 were removed to hospitals—14 to the Municipal Hospital, 11 to other Hospitals and 19 to the Willesden Infirmary. Of the 57 nursed at home, 22 died, or 38.6 per cent. Of the 44 removed to hospitals, 15 died, or 34.1 per cent., 4 deaths occurring in the Municipal Hospital, 5 in other Hospitals, and 6 in the Willesden Infirmary. Malaria.—Forty-one cases were notified. In 35 instances the original attack occurred whilst the patient was abroad. In one instance the first attack occurred shortly after the patient had returned from abroad. In two other instances the patients had been abroad during the war but had not had Malaria. In one of these, there was a history of gnat bites two days previous to onset. In three instances details could not be obtained. No deaths were recorded from Malaria. Dysentery.—Four cases were notified, 2 occurring in children. In 1 instance the disease was contracted abroad, in 1 no details were available. In the case of the children, 1 was removed to the Municipal Hospital and proved not to be Dysentery. The other was removed to Paddington Green Hospital and discharged well. The only death from Dysentery recorded was not a notified case. The patient had been suffering from Amcebic Dysentery for 5 years, and death occurred in a Hospital outside Willesden. The annual report should state whether and to what extent bacteriological aids to diagnosis have been utilised, action to discover "contacts," arrangements for isolation and disinfection, as well as any action taken to deal with special difficulties, e.g., return cases, carrier cases, etc. Vide Annual Health Report, 1919, pp. 38, 39 and 40. Table No. 19. Table shewing Chemical and Bacteriological Examinations made during the year 1920. Nature of Specimens examined. Positive Result. Negative Result. Total. 1. Swabs for Diphtheria Bacilli 566 1,608 2,174 2. Sputum for Tubercle Bacilli 33 153 186 3. Blood for Widal Reaction 9 17 26 4. Urine 1 6 7 5. Spinal Fluid — 3 3 6. Pleuritic Fluid for Tuberculosis — 1 1 7. Synovial Fluid — 1 1 8. Fluid from Cavity in Thigh — 1 1 9. Testicle Histologically 1 — 1 10. Staphylococcus 3 — 3 11. Streptococci 1 1 2 12. Swabs for Meningococci — 15 15 13. Swabs for Gonococci — 1 1 14. Swab for Salpingitis — 1 1 15. Pus from Pelvic Abscess 1 — 1 16. Pus from Antinomycosis — 1 1 17. Blood for Organisms — 5 5 18. Blood Films for Malaria — 1 1 19. Faeces for Bacillus Typhosus — 10 10 20. Faecal Specimen of Entamveba Histolytica — 1 1 615 1,826 2,441 Two specimens were sent for Histological Examination, both proving to be malignant — — 2 Total 615 1,826 2,443 33 Table No. 20.—Sources of Specimens Examined. From Municipal Hospital, 1,330 From private practitioners 499 From clinics, and health visitors 524 From Willesden Infirmary 50 From other Hospitals or Institutions 40 Total 2,443 Action to Discover "Contacts."—Vide Annual Health Report, 1919, p. 39. Isolation.—Isolation Wards are available at the Municipal Hospital. Beds are set aside for Diphtheria and Scarlet Fever, and other infectious diseases are taken in, as and when accommodation is available. In cases where removal to hospital is not desired, and isolation can be satisfactorily carried out at home, this is permitted, the Health Visitors paying subsequent visits to ascertain that isolation is being maintained. 62 per cent. of Scarlet Fever cases, 93 per cent. of Diphtheria cases, 73 per cent. of Enteric Fever cases, and 50 per cent. of Cerebro-Spinal Meningitis cases were isolated in the Municipal Hospital during 1920. Disinfection.—Vide Annual Health Report, 1919, p. 39. A statement of the number of (a) primary vaccinations, and (b) re-vaccinations performed by the Medical Officer of Health under the Public Health (Small-Pox Prevention) Regulations, 1917, should also be included in the Annual Report. No vaccinations or re-vaccinations were performed under these regulations during the year. Non-notifiable acute infectious diseases should be similarly reported upon, so far as the less complete information enables this to be done. The extent to which school intimations of disease are utilised should be stated. The mortality from influenza should be stated and a note made of the results of any special inquiry made in connection with this epidemic and of action taken in the district in regard to it. Sources from which Notifications of Measles and German Measles were received during the Year 1920.—Table No. 21:— From Private Doctors 46 Head Teachers 656 Clinic Doctors and other members of Health Department 112 Parents 370 School Attendance Officers 220 Sources outside Willesden 7 Total 1.411 Measles.—Table No. 22 Shewing the number of cases coming under the notice of the Health Department each year since 1907, and the number of deaths occurring among these cases; the number of deaths occurring among unknown cases, and the probable number of these cases, assuming the fatality rate to have been the same in each class:— Year. Total No. of Cases known before death. Cases unknown prior to death. Percentage of all probable Cases coming to knowledge. Total. Cases. Deaths. Fatality Rate per cent. Deaths. Estimated No. of Cases. 1907 1,442 25 1.75 20 1,153 55 2,595 1908 1,678 23 1.55 23 1,871 47 3,549 1909 1,445 17 1.17 24 2,040 41 3,485 1910 1,757 13 0.74 17 2,297 43 4,054 1911 1,845 26 1.40 25 1,774 51 3,619 1912 1,665 17 1.02 18 1,763 48 3,428 1913 1,656 21 1.26 48 3,785 30 5,441 1914 539 0 0.00 8 *664 *45 1,203 1915 1,947 20 1.03 54 5,257 27 7,204 1916 871 7 0.80 0 0 100 871 1917 2,979 36 1.21 12 993 75 3,972 1918 1,257 10 0.79 10 1,257 50 2,514 1919 1,375 20 1.45 3 206 87 1,581 1920 1,387 8 0.58 9 1,560 47 2947 Totals 21,843 246 1.13 277 24,620 47 46,463 *These figures are based on the average for the years 1907-1914. 34 Of the 17 measles deaths, 1 occurred in the Willesden Infirmary, and 16 at home. Influenza.—Twenty-seven deaths from influenza were recorded in 1920 as against 114 in the previous year. These deaths occurred as follows, throughout the year:— Month. No. of Deaths. January 1 February 3 March 5 April 7 May 3 June 0 July 0 August 1 September 1 October 0 November 5 December 1 Anti-influenza vaccine is supplied to Medical Practitioners on application at the Health Department. The followiilg Table No. 23 gives the death rates per 100,000 of the population from certain infectious diseases in 1920:— Table No. 23.—Death Rates from certain Infectious Diseases. Scarlet Fever 5 per 100,000 of the population. Diphtheria 25 „ „ „ Enteric Fever - „ „ „ Measles 10 „ „ „ Whooping Cough ... 8 „ „ „ Other diseases which have received special attention during the year should be referred to, e.g., locally contracted Anthrax or Rabies. No case of Anthrax or Rabies was notified to the Medical Officer of Health. Particulars should be given as to the facilities available in the district for the cleansing and disinfection of verminous persons and their belongings. Facilities for the cleansing of verminous expectant and nursing mothers and children up to 14 years of age exist at the two Municipal Clinics, at each of which a properly equipped cleansing room has been established with a nurse attendant. The Health Visitors visit and inspect and make arrangements for the disinfection or destruction of belongings as may be necessary. The Ministry would also be glad to have information as to the extent to which the requirements as to notification of tuberculosis are observed by medical practitioners, and of any action taken to enforce the regulations and, secure prompt notification. Tuberculosis Notifications, etc.—Table No. 24. Notifications received—Pulmonary 709 Other forms 61 New cases to which notifications refer—Pulmonary 296 Other forms 47 1,120 of the total of 4,030 cases of Tuberculosis notified in Willesden since 1909, when notification began, were living in the area at the end of the year 1920. It has not been necessary to take any action to enforce the regulations and secure prompt notification. Tuberculosis.—The treatment of Tuberculosis is the responsibility of the Middlesex County Council, therefore this paragraph of the Ministry of Health's memorandum as to contents and arrangement of the Annual Reports of Medical Officers of Health for 1920 is not dealt with. Venereal Diseases. The above work is under the Middlesex County Council, therefore this paragraph of the Ministry of Health's memorandum as to contents and arrangement of the Annual Reports of Medical Officers of Health for 1920 is not dealt with. 17,491 children from birth up to 14 years of age came under the observation of the Medical Officers of the Willesden Council during the year 1920. Of this number, 8 children or .045 per cent. of cases coming under observation were found showing signs of congenital or acquired syphilis. In no case under review could a previous history of syphilis on the mother or father's side be obtained. Ihe following Table, No. 25, gives details of the 8 cases: 35 Table No. 25.—Particulars of 8 Cases of Children from 0—14 Years of Age coming under Observation of Willesden Health Department in 1920 and Shewing Syphilitic Manifestations. Total No. of Children coming under Notice = 17,491. Case. Age. Onset. Rash. Snuffles. Teeth. Eyes. Ears. Bones. Wasserman Family History. Mother's History. Case still under Treatment. Case 1 (Girl) yrs. 13 May, 1919 - - - - - Periostitis Rt. Tibia Positive 8 Still births at 7 months. 2 births (full term). Mother under treatment at St. Mary's Hospital V.D. Dept. St. Mary's Hospital V.D. Dept. Case 2 (Girl) 10 1920 - - Hutchinson's Teeth. Typical Interstitial Keratitis (Rt. & Lt.) - Periostitis Lt. Tibia Negative 3 children (Healthy) 3 births full term. 1 miscarriage For eye condition Municipal Clinic Willesden. Case 3 (Girl) 10 1919 Primary Sore Yes. 1919 Nasal discharge. 2nd Svph. 1919 2nd Syph. (1919). Ulceration of tongue 2nd Syphilis (1919). Abscess left eye. Suppuration of Lachrymal duct - - Positive 3 children (Healthy) 4 births full term. Miscarriage = 0 Still births = 0 St. Mary's Hospital V.D. Dept. *Case 4 (Girl) 8 7 wks. of age 1913 7 wks. of age 1913 7 wks. of age 1913 Hutchinson's Teeth. Typical Partially blind Vision: Right Eye = Nil Left = Impaired - - Positive 2 children, both attending Maida Vale Hosp. Mentally instable 2 births full term. 1 still birth. 2 miscarriages. No treatment. Case 5 (Boy) 1 5 wks. of age 5 wks. of age 5 wks. of age - - - - - 6 children (Healthy) Miscarriage = 0 Still births = 0 Municipal Clinic, Willesden. Case 6 (Girl) 1 2 wks. of age 2 wks. of age 6 wks. of age - - - - - 1st child Miscarriage = 0 Municipal Clinic, Willesden. Case 7 (Boy) 1 4 wks. of age 4 wks. of age - - - - - - 1st child (Premature) Miscarriage = 0 Municipal Clinic, Willesden. Case 8 (Boy) 1 6 wks. of age 6 wks. of age - - - - - - 1st child (Premature) Miscarriage = 0 Municipal Clinic, Willesden. *This child is not in attendance at the Willesden Municipal Clinic, formerly attended Western Ophthalmic Eye Hospital, no treatment recommended, but mother informed that child had a Pathological condition of both eyes. In infancy child apparently received a short course of mercury treatment. 36 5. MATERNITY AND CHILD WELFARE. (1) Information on the inspection of midwives and the other activities of the supervising authority under the Midwives Acts. 1902 and 1918. This work is in the hands of the Middlesex County Council. (2) Information on the general arrangements made for attending to the health of expectant and nursing mothers and children under five years of age, including the work of Health Visitors, midwives and nurses, consultation and treatment centres, and maternity homes and hospitals and other institutions for the reception of expectant and nursing mothers and young children as in-patients. Special reference should be made to investigations of stillbirths and infant deaths. The development of ante-natal work at centres and in connection with the midwifery service where this has proved practicable, methods of dealing with unmarried mothers and illegitimate children and with children permanently or temporarily deprived of a home with their own parents, and the arrangements for the supply of food and milk. The work of voluntary societies in the district in connection with maternity and child welfare and the place occupied by each in the local authority's scheme should be briefly described, as also the co-ordination of all the work under this sub-section with the school medical service. Vide Annual Report, 1919, pp. 42-44, and the sections of this Report on the Milk (Mother and Children) Order, 1919, and Provision of Meals, Mothers and Children, for the arrangements for the supply of food and milk. At the Municipal Clinics, expectant mothers attended the medical consultations on 2,812 occasions; nursing mothers, 16,476 and children under 5 years, 32,180 times; making a grand total of 51,468. 35.2 per cent. of all births registered in Willesden during the year 1920 attended the Municipal Clinics. In all, 4,232 births were registered in Willesden during the year 1920. Of these, 1,490 subsequently attended the clinics. During the year 1920, 274 children under 1 year died in Willesden. Of this number, 65 attended the clinics, and 209 did not, giving an infant mortality rate of 43.6 per thousand births amongst babies attending the clinics, and 76-2 per thousand births amongst those who were not in attendance. The infant mortality rate for all babies was 64.74 per thousand births, the lowest on record. (3) Information on the incidence of puerperal fever, ophthalmia neonatorum, measles, whooping cough, epidemic diarrhoea, poliomyelitis and other infectious diseases of parturient women, infants and young children, and the methods adopted to diminish the mortality and permanent injury to health caused by these diseases, and the results achieved by these methods. In particular, details should be given of each case of ophthalmia neonatorum notified, showing whether one or both of the eyes suffered permanent injury, and, if so, to what extent. Puerperal Fever.—During the year, 20 cases of puerperal fever were investigated; 10 cases were removed to the Municipal Hospital, 4 of these cases died and 6 recovered; 5 cases were removed to other hospitals, 2 of these cases died and 3 recovered; and 5 cases were treated at home, 1 had a private doctor but inadequate nursing attendance and died, while the remaining four, with adequate medical and nursing attendance, all recovered. This gives a case mortality of 35 per 100 cases. Ophthalmia Neonatorum.—Forty-nine cases of this disease were investigated during the year. 18 of these cases were attended by a doctor at the confinement, and 31 by a midwife. In one of these cases, no particulars are obtainable as to result of treatment; in 44 cases, the length of treatment varied from six days to seventy-nine days and the eyesight was unimpaired, while in the 4 remaining cases, one eye was permanently injured, in 1 case, one eye was blind, while the other eye had a definite corneal ulcer and was still under treatment after 153 days; while in the 2 remaining cases both eyes were permanently injured and were receiving treatment in other hospitals at the end of the year. j^Other Infectious Diseases.—These are referred to in the section dealing with Infectious Diseases generally. Infant Mortality.—Table No. 26. Number of deaths of infants under 1 year from all causes 274 Number of deaths of infants under 1 year from diarrhoea and enteritis 30 Infant Mortality Rate per 1,000 births 65 Infant Mortality in Wards. Births and Birth Rates in Wards. Table No. 27. Table No. 28. No. of Births. Birth rate per 1,000 of population. South Kilburn 82 513 33.76 Mid Kilburn 56 443 29.39 North Kilburn 79 240 18.53 Brondesbury Park 34 177 17.61 Kensal Rise 60 319 22.12 Harlesden 48 433 24.70 Stonebridge 74 514 28.60 Roundwood 59 461 29.02 Church End 86 348 24.10 Willesden Green 62 416 24.17 Cricklewood 58 365 18.18 37 Infant Mortality of Legitimate Infants. Table No. 29. Number of deaths of legitimate infants under 1 year 241 Infant Mortality per 1,000 legitimate births 59 Infant Mortality of Illegitimate Infants. Table No. 30. Number of deaths of illegitimate infants under 1 year 33 Infant Mortality per 1,000 illegitimate births 223 Notification of Births Acts, 1907 and 1915. Table No. 31. Notified births attended by doctors 2,571 Notified births attended by midwives 1,550 Total 4,121 Number of still births notified 99 Number of births registered 4,232 Table No. 32. Table shewing the number of visits, re-visits, and still-births inquiries under the Notification ol Births Acts, 1907 and 1915, and otherwise since 1912:— Year. No. of first visits to children under 1 year of age. No. of re-visits to children under 1 year of age. No. of visits and revisits to children between 1 and 5 years of age. No. of still-birth inquiries. 1912 ... 180 ... ... 1913 ... 976 ... ... 1914 ... 1,052 ... ... 1915 2,464 926 ... ... 1916 2,590 2,492 ... ... 1917 2,218 6,835 1,399 33 1918 2,080 5,756 6,140 56 1919 2,509 7,648 5,946 69 1920 4,020 14,981 9,839 91 Table No. 33. Table shewing the number of visits and re-visits to Expectant and Nursing Mothers:— Year. No. of first visits to Expectant Mothers. No. of re-visits to Expectant Mothers. No. of first visits to Nursing Mothers. No. of re-visits to Nursing Mothers. 1918 195 149 1,099 2,313 1919 371 580 2,233 6,198 1920 1,077 768 4,324 12,757 Infant Death Inquiries.—Table No. 34. Year. No. of deaths of Infants under 1 year No. of Infant Death Inquiries No. of deaths of Children 1 year and under 5 years No. of Death inquiries for Children 1 year and under 5 years 1913 325 300 - - 1914 337 231 - - 1915 344 266 - - 1916 283 189 - - 1917 309 230 - - 1918 258 212 192 100 1919 242 182 98 77 1920 274 277 77 72 38 Table No. 35. Method of Feeding of 2,276 Children attaining 1 year of age during 1920. No. of children solely breast fed for:— Less than 1 month 167 1 month and less than 2 months 126 2 months and less than 3 months 181 3 „ „ 4 „ 128 4 „ „5 „ 112 5 „ „ 6 „ 114 6 „ „ 7 „ 162 7 „ „ 8 „ 174 8 „ „ 9 „ 276 9 „ „ 10 „ 342 10 „ „ 11 „ 160 11 „ „ 12 „ 97 12 or over 46 No. of children solely hand fed 135 No. of children breast and hand fed (this does not include children who were first breast fed and subsequently breast and hand fed) 56 No. of children breast and hand fed while under 6 months of age who were originally solely breast fed 324 No. of children solely hand fed while under 6 months of age who were originally solely breast fed 439 No. of children for whom no report available who were originally solely breast fed 65 No. of cases in which breast and hand feeding was continued when the child was over 9 months of age 597 Table No. 36. Shewing the number of Mothers and Children under 5 years in attendance at the Clinics and under supervision during the year. Under observation by Health Visitors during 1920. Attending Clinic during 1920. % of Cases under observation during 1920 attending Clinic. Under observation at end of 1920. Attending Clinic at end of 1920. % of Cases under observation at end of 1920 attending Clinic. Expectant mothers 1,412 995 70 318 221 69 Nursing mothers 6,371 2,731 43 3,743 1,539 41 Children under 5 12,212 6,308 52 10,164 5,303 52 Total 19,995 10,034 50 14,225 7,063 50 For attendances of Mothers and Children under 5 years and School Children registered at Clinics during 1920, vide Table No. 55. Provision of Surgical Appliances to Mothers and Children under 5 Years. Surgical appliances are provided by the Council to Mothers and Children under 5 years under certain conditions. The cases are referred by the Clinic Medical Officers to the Council's Surgeon at the Municipal Hospital, who recommends the appliance required. On the 27th July, 1920, the Council adopted the following Report and recommendation of the Health Committee. (Minutes, page 331, par. 50.):— "We have had under consideration the question of the general procedure now in force for the provision of surgical appliances in orthopaedic cases. We are of opinion that such procedure, which involved the sanctions of the Health Committee, the Finance Committee, the Council and the Ministry being obtained before instruments can be purchased, is cumbrous and causes unnecessary suffering and delay. We therefore recommend that a general sanction be obtained from the Ministry and the Council 39 for the supply of instruments ordered by the Surgeon, subject to the cost being defrayed by the parents in such cases as are above the economic scale of the Council; the cost in other cases to be defrayed by the Council, not exceeding the sum to be provided in the annual estimates." Application was made to the Ministry of Health on the 29th July, and again on the 3rd December for his sanction to the arrangements proposed, and on the 16th December a reply was received as follows:— "I am directed by the Minister of Health to refer to your letters of the 29th July and 3rd inst., in regard to the provision of surgical instruments by the Willesden Urban District Council, and to say that the Council's proposal is still under consideration in connection with other general questions with a view to grants-in-aid, and the Ministry regret that they are unable to send a definite reply at present." The system at present in operation, therefore, is that outlined in the preamble to the resolution above set out. During the year, 3 surgical instruments were supplied to Mothers; 1 being paid for by the Council, 1 by the recipient, and 1 partly by the Council and partly by the recipient. Four surgical instruments were supplied to children under 5 years; 2 being paid for by the Council and 2 by the parents. Where application for assistance is made to the Council, the family economic circumstances are inquired into, and each case reported to the Council for their decision. Training of Health Visitors. At its meeting on 22nd July, 1919, the Council agreed to afford facilities for students of the Household and Social Science Department of King's College for Women to receive instruction in practical work at the Municipal Clinics at a fee of £5 5s. per student for daily attendance for a period of 6 months. The first student took up her course on 1st October, 1919, and between that date and May, 1920, 18 students attended. The following is the Students' syllabus of practical work Students' Syllabus, 1919-20. Students attending the Willesden Municipal Clinics will receive instruction in the following departments:— Office.—Notification forms, enquiry forms, clinic cards, the filing and keeping of records, following-up system and bookings in connection with Maternity work, etc. Cleansing.—Attendances at Cleansing Departments to see the various conditions where treatment is considered necessary—Heads, Scabies, Impetigo, etc. The giving of baths and the method of carrying out the treatment ordered, also the improvement resulting from such treatment which can only be seen by consecutive attendances. Observation of cases which do not respond readily to treatment—re-infection in Impetigo, Scabies, etc., or where treatment has lapsed through non-attendance. Children under 5 Years.—Attendance in the weighing room, where they would be taught to observe the normal baby and child under 5 years and the abnormal child. How to handle and dress a baby, how to weigh a baby. Points to observe between breast and bottle fed babies. Average standard weights at various ages, minor ailments and their treatment. Observation as to the suitability of clothing worn by children. Asepsis and surgical dressings and bandaging and the treatment for various eye conditions. Medical Consultations under direction of Clinical Medical Officer.— To be present at medical consultations where instruction would be given in the common diseases of children, also the causes of such conditions. Also common ailments due to neglect or bad feeding. Correct method of feeding infants either breast or bottle fed, suitable diets for children up to five years. Advantages and disadvantages of the various proprietary foods. Normal and abnormal conditions in the nursing and expectant mother. School for Mothers.—Instruction in the correct method of clothing a child and the making of various garments. How to dress and change a baby with least possible disturbance. Various hints on the care of the baby. Minor Ailments.—Instruction in common minor ailments, their cause and treatment. Eyes.—Normal and abnormal refraction, testing eyes, common eye diseases and the method of treatment. 40 Throat, Nose, Ear Conditions.—Instruction in common throat, nose and ear conditions, and their treatment. Dental Work.—Preparing patients for fillings and extractions, sterilising instruments, inspection of school children, recording and clerical work. District Work.—The work of the District Health Visitor, visiting in the home and at the Schools, reporting, office work and record keeping. The training of the Students is under the general supervision of the Clinic Matron. In May, 1920, the Council's Health Visitors represented to the Health Committee that the teaching of untrained women took up too much of their time and in addition was inimical to their profession and the public interests. The Medical Officer of Health was instructed to confer with the Health Visitors. The following is a minute of the conference:— The Medical Officer of Health had a conference with the Health Visitors at Municipal Clinic (1), on May 18th, 1920. Present.—The Chief Health Visitor, two Matrons and 14 Health Visitors. The Health Visitors agreed that they were prepared to accept "bona fide students in training as Health Visitors" for three months practical instruction in the work of a Health Visitor, provided the students had had previous training as follows:— (1) Three years nursing training at— (a) A General Hospital, or (b) A Women's and Children's Hospital, or (c) A Children's Hospital, and (2) A Central Midwives' Board qualification. The Health Visitors further stated that they were of opinion that during their three months practical course in the work of a Health Visitor, these students should attend during the full working day and that they should be recognised as Probationer Health Visitors and be paid by the Council at the rate of £1 per week plus bonus in force at the time. A "Bona fide student in training as Health Visitor" is deemed to be one who is studying for a recognised certificate as Health Visitor or Sanitary Inspector from a recognised examining body or board, such as the Royal Sanitary Institute, King's College for Women, Battersea Polytechnic, and the like. In connection therewith, the Council at its meeting on the 27th July, 1920, passed the following report and resolution of the Health Committee:— "The Medical Officer of Health submitted letter from the Household and Social Science Department, King's College for Women, University of London, stating that probably a certain number of women students would be prepared to undertake a three months' course of practical training in Health Visiting. We recommend that two students, each of whom shall have had three years' training at a General Hospital, a Women's and Children's Hospital, or a Children's Hospital, and who hold a Central Midwives Board qualification, be engaged at each Clinic at a salary of £1 per week, plus bonus. The students will attend during the full working day and will be recognised as Probationer Health Visitors. These engagements will be subject to the concurrent report of the Finance Committee, to the sanction of the Ministry of Health being obtained and to their paying half of the cost." The Ministry of Health approved the above arrangement, but the provision made by the Health Committee in the 1921-22 estimates was not passed by the Council. 6. SANITARY ADMINISTRATION. 1. Staff:—Work of Sanitary Inspectors, Inspectors of Nuisances and other Officers engaged in Sanitary Work.—Vide Annual Health Report, 1919, p. 47. The work done by the Sanitary Inspectors during the year 1920 is fully set out in this report under the heading Sanitary Inspection of District. 2. Hospital Accommodation Available for Infectious Diseases, Including Smallpox; its Character, Sufficiency and use During the Year; Hospital Administration. This subject is dealt with in the Annual Hospital Report included in this report and in Appendix N. 3. Local Acts, Special Local Orders, or General Adoptive Acts in Force in the District (of both of which a list should be included in the report) and their Administration.—Vide Annual Health Report, 1919, pp. 47 and 48. 41 4. Arrangements for Chemical and Bacteriological Work During the Year 1920, and Their Results (Including Examinations of Material for Detection of Tubercle Bacilli). Any Report by the Public Analyst which it may be considered desirable to append. This is dealt with in the section relating to Infectious Diseases generally. The work of the public analyst is controlled by the Middlesex County Council. 7. OTHER SERVICES. Information should be given of any important points in which the work of the Council is related to or is in Co-operation with the Medical and Ancillary Services of National Health Insurance, or of the Voluntary Hospitals, or of the Poor Law, or of other Agencies. No information is available on this heading. 8. HOUSING. (I.) General Housing Conditions in the District.—Vide Annual Health Report, 1919, p. 48. The total number of empty houses in Willesden at Midsummer, 1920, as shown in Table No. 2, was 86. In no instances were these houses billed, "To be let," all being "For Sale" or " Sold." At Midsummer, 1920, there were 26 tenements unoccupied, 4 being tenements of 2 rooms, 10 of 3 rooms and 12 with over three rooms. In no instances were these empty tenements billed "To Let," all being re-let before, or, as soon as, they were vacated by the late tenant. (II .) Overcrowding.—Vide Annual Health Report, 1919, p. 49. (III.) Fitness of Houses.—Vide Annual Health Report, 1919, p. 49. (IV.) Unhealthy Areas.—Vide Annual Health Report, 1919, p. 51. (V.) By-laws Relating to Houses, to Houses Let in Lodgings, and to Tents, Vans, Sheds, etc. (1)As to working of existing by-laws, and (2) As to need for new by-laws or revision of existing by-laws. This is dealt with in this report under "Premises and Occupations which can be controlled by Bye-laws or Regulations." (VI.) General and Miscellaneous.—Vide Annual Health Report, 1919, p. 51. (VII.) Appendices, Statistics, Year Ended 31st December, 1920. Table No. 37. 1.—General. (1) Estimated population 170,892 (2) General death rate 9.78 (3) Death rate from tuberculosis 0.85 (4) (5) Infantile mortality 65.0 Number of dwelling-houses of all classes 23,554 (6) Number of working-class dwelling-houses 20,258 (7) Number of new working-class houses erected 97 2.—Unfit Dwelling-Houses. I.—Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 3,189 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 0 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 3 (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 22 II.—Remedy of Defects without Service of Formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 2 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 22 42 (2) Number of dwelling-houses which were rendered fit— (a) by owners 16 (b) by Local Authority in default of owners 0 (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close 2 B. Proceedings under Public Health Acts. (1) Number of dwelling-houses in respect of which notices were served quiring defects to be remedied 3,164 (2) Number of dwelling-houses in which defects were remedied— (a) by owners 2,546 (b)by Local Authority in default of owners 0 C. Proceedings under sections 17 and IS of the Housing, Town Planning, &c., Act, 190V. (1) Number of representations made with a view to the making of Closing Orders 3 (2) Number of dwelling-houses in respect of which Closing Orders were made 3 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit *2 (4) Number of dwelling-houses in respect of which Demolition Orders were made †5 (5) Number of dwelling-houses demolished in pursuance of Demolition Orders 0 *Closed in 1919. †Appeal made to Minister of Health. 3.—Unhealthy Areas. Areas represented to the Local Authority with a view to Improvement Schemes under (a), Part I., or (b), Part II., of the Act of 1890:— (1) Name of area 1 No (2) Acreage action (3) Number of working-class houses in area taken or (4) Number of working-class persons to be displaced needed. 4.—Number of houses not complying with the building bye-laws erected with consent of Local Authority under section 25 of the Housing, Town Planning, &c., Act, 1919 85 5.—Staff engaged on housing work with, briefly, the duties of each officer.— The Staff of the Health Department engaged in connection with housing, consists of 1 Chief and 7 District Sanitary Inspectors and 2 Clerks. Each Sanitary Inspector carries out in his district all the duties prescribed under the Housing (Inspection of District) Regulations, 1910. Administration of Factory and Workshop Act, 1901. The following tables shew the number of premises visited in pursuance of the provisions of the Factory and Workshop Act and the action taken in connection therewith. Table No. 38. Factories, Workshops, Laundries, Workplaces and Homework. Inspection—Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Primary Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) Factories (including Factory laundries) 143 18 - Workshops (including Workshop laundries) 169 4 - Workplaces (other than Outworkers' premises included in Part 3 of this Report) 12 3 - Total 324 25 - 43 Table No. 39.—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 14 13 — — Want of Ventilation — — — — Overcrowding — — — — Want of drainage of floors 2 2 — — Other Nuisances 11 11 — — Sanitary accommodation— Insufficient 1 1 — — Unsuitable or defective 14 14 — — Not separate for Sexes 1 1 — — Unscreened for Sexes 2 2 — — Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouses (S. 101) — — — — Breach of special sanitary requirements for bakehouses SS. 97 to 100) 19 18 — — Other offences — — — — (Excluding offences relating to outwork which are included in Part 3 of this Report.) Total 64 62 — — Table No. 40.—Registered Workshops. Workshops on the Register (s. 131) at the end of the year. Number. (1) (2) Factories 104 Factories, Laundries 59 Workshops, Laundries 27 Domestic Laundries 12 Bakehouses 63 Dressmakers 57 Outworkers 178 Blouse Makers 24 Tailors 47 Bootmakers 85 Metal Workers 11 Wood Workers 22 Seamstresses — Motor and Cycle Makers 32 Upholsterers 10 Milliners 22* Miscellaneous 53 Total number of Workshops on Register 806 Table No. 41.—Other Matters. Class. Number. (1) (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Act (s. 133) — Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (s. 5)— Notified by H.M. Inspector 2 Reports (of action taken) sent to H.M. Inspector 2 Other — Underground Bakehouses (s. 101):— Certificates granted during the year — In use at the end of the year 17 44 Table No. 42. Home Work. Nature of Work. Outworkers' Lists, Section 107. Notices served on Occupiers as to keeping or sending lists. Prosecutions. Outwork in Unwholesome Premises. Section 108. Outwork in Infected Premises. Section 109, 110. Lists received from Employers. Sending twice in the Year. Sending once in the Year. Failing to keep or permit inspection of lists. Failing to send lists. Instances Notices served. Prosecutions. Instances Orders made S. 110. Prose cutions. Section 109,110 Lists. Outworkers. Lists. Outworkers. Contractors. Workmen. Contractors. Workmen. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Wearing Apparel— Making, &c. 14 15 14 3 1 2 1 1 Cleaning and Washing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Household linen ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lace, lace curtains, and nets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Furniture and upholstery 4 1 4 ... ... ... ... ... ... ... ... ... ... ... ... Umbrellas, &c. ... ... ... 1 1 ... ... ... ... ... ... ... ... ... ... Total 18 16 18 4 2 2 ... ... ... 1 1 ... ... ... ... 45 THE THIRTEENTH ANNUAL REPORT FOR THE Year Ending 31st December, 1920, ON THE HEALTH OF CHILDREN ATTENDING THE PUBLIC ELEMENTARY SCHOOLS IN WILLESDEN. Giving the Tables required by the Board of Education. TABLE No. 43.—CORRESPONDING TO TABLE 1. OF APPENDIX G OF ANNUAL REPORT OF CHIEF MEDICAL OFFICER OF BOARD OF EDUCATION FOR 1919. Number of Children inspected 1st January, 1920, to 31st December, 1920. A.—Routine Medical Inspection.* Age. Entrants. , 3 4 5 6 Other Ages. Total. Boys — — — — — — Girls — — — — — — Totals — — — — — — Age. Intermediate Group. Leavers. Grand Total. 8 12 13 14 Other Ages. Total. Boys — — — — — — — Girls — — — — — — — Totals — — — — — — — *Routine Medical Inspection is medical inspection carried out on the lines of the approved Schedule at the time when routine medical inspection is due and made on the School premises or other place sanctioned by the Board of Education under the Code 46 B.—Special Inspections. Special Cases,† Re-examinations (i.e., No. of Children Re-examined). Boys 6,302 817 Girls 7,128 949 Totals 13,430 1,766 †"Special Cases" are those children specifically referred to the Medical Officer and not due for routine medical inspection under the Code at the time when specially referred. Such children may or may not be of Code-group age and may be referred to the Medical Officer at the School or the Clinic by the Committee, Medical Officers, School Nurses, Teachers, Attendance Officers, Parents or otherwise. In this area, where routine inspections have been suspended and the "ailing children" basis adopted, the number of children dealt with has been entered here. 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). Number of Individual Children Inspected 11,183 Table No. 44.—Corresponding to Table II. of Appendix G of Annual Report of Chief Medical Officer of Board of Education for 1919. Return of Defects Found in the Course of Medical Inspection in 1920. Defect or Disease. Routine Inspections. Specials. N umber referred for treatment. N umber requiring to be kept under observation but not referred for treatment. Number referred for treatment. N umber requiring to be kept under observation but not referred for treatment. (1) (2) (3) (4) (5) Malnutrition — — 47 — Uncleanliness:— Head — — 2,061 — Body — — 39 — Skin 'Ringworm:— Head — — 255 — Body Scabies — — 356 — Impetigo — — 1,337 — Other Diseases (non- tubercular) — — 594 — Eye 'Blepharitis — — 174 — Conjunctivitis — — 246 — Keratitis — — 1 — Corneal Ulcer — — 11 — Corneal Opacities — — 17 — Defective Vision — — 503 — Squint — — 52 — Other Conditions — — 27 — Spectacles broken — — 288 — Spectacles lost — — 22 — 47 Defect or Disease. Routine Inspections. Specials. Number referred for treatment. Number requiring to be kept under observation but not referred for treatment. Number referred for treatment. Number requiring to be kept under observation but not referred for treatment. (1) (2) (3) (4) (5) Defective Hearing — — 53 — Ear Otitis Media — — 305 — Other Ear Diseases — — 51 — Nose and Throat Enlarged Tonsils — — 153 — Adenoids — — 62 — Enlarged Tonsils and — — — — Adenoids — — 346 — Other Conditions — — 368 — Enlarged Cervical Glands (non-tubercular) — — 151 — Defective Speech — — 13 — Teeth Dental Diseases (see Dental Statements) — — — — Heart and Circulation Heart Disease:— Organic — — 20 — Functional — — 12 — Anaemia — — 69 — Lungs 'Bronchitis — — 301 — Other Non-Tubercular — — — — Diseases — — 56 — Tuberculosis 'Pulmonary:— Definite — — 4 — Suspected — — 50 — Non-Pulmonary:— Definite:— Glands — — 4 — Spine — — 0 — Hip — — 0 — Other Bones and Joints — — 0 — Skin — — 0 — Other forms — — 2 — Suspected:— Glands — — 6 — Bones and Joints — — 5 — Other forms — — 16 — Nervous System Epilepsy — — 13 — Chorea — — 36 — Other Conditions — — 24 — Deformities 'Rickets — — 8 — Spinal Curvature — — 31 — Other forms Other Defects and Diseases — — 5,593 — Total — — 13,782 — Notes.—(1) In this area the routine medical inspection of the groups of children prescribed by the Code is temporarily suspended, and the examination of ailing children of all ages is undertaken instead. (2) Under the heading "Specials" (see columns 4 and 5 above), are included all special cases which were medically inspected during the year, whether the inspection took place in the Schools or at the Clinics, and from whatever source the cases were derived. Number of Individual Children having Defects which required Treatment or to be kept under observation 10,875 48 Table No. 45.—Corresponding to Table III. of Appendix G of Annual Report of Chief Medical Officer of Board of Education for 1919. Numerical Return of all Exceptional Children in the area in 1920. Boys. Girls. Total. Blind (including partially blind). Attending Public Elementary Schools 1 1 2 Attending Certified Schools for the Blind 9 2 11 Not at School 1 1 2 Deaf and Dumb (including partially deaf). Attending Public Elementary Schools 1 0 1 Attending Certified Schools for the Deaf 12 8 20 Not at School 0 1 1 Mentally Deficient. Feeble Minded. Attending Public Elementary Schools 10 8 18 Attending Certified Schools for Mentally Defective Children †* 47 57 104 Notified to the Local (Control) Authority during year 3 3 Not at School † 7 3 10 Imbeciles. At School 2 0 2 Not at School 22 6 28 Notified to the Local (Control) Authority during year 10 3 ††13 Idiots. 0 0 0 Epileptics. Attending Public Elementary Schools 9 3 12 Attending Certified Schools for Epileptics 5 4 9 Not at School ** 1 1 2 Physically Defective. Pulmonary Tuberculosis Attending Public Elementary Schools 30 33 63 Attending Certified Schools for Physically Defective Children 0 1 1 Not at School 19 11 30 Other Forms of Tuberculosis Attending Public Elementary Schools 39 28 67 Attending Certified Schools for Physically Defective Children 19 8 27 Not at School 11 15 26 Cripples Other Than Tubercular. Attending Public Elementary Schools 10 4 14 Attending Certified Schools for Physically Defective Children 28 19 47 Not at School 5 3 8 Physically Defective Other Than Tubercular and Other Than Cripples Attending Public Elementary Schools 7 5 12 Attending Certified Schools for Physically Defective Children 12 15 27 Not at School 1 0 1 § Dull or Backward. Retarded 1 year 5 3 8 Retarded 2 years 2 5 7 Retarded 3 years 0 2 2 §Judged according to age and standard, †One boy is also Epileptic. ††One girl and two boys are also Epileptic. *One of these boys is also partially blind. **This boy is also mentally defective. 49 Table No. 46.—Corresponding to Table IV. of Appendix G of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Treatment of Defects of Children during 1920. A.—Treatment of Minor Ailments. Defect or Disease. Number of Children. Referred for Treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Total. Skin :— Ringworm—Head 307 271 32 303 Ringworm—Body Scabies 413 369 44 413 Impetigo 1,482 1,393 85 1,478 Minor Injuries 655 597 52 649 Other Skin Disease Ear Disease 588 504 58 562 Eye Disease (external and other) 562 523 35 558 Miscellaneous 6,100 5,120 872 5,992 B.—Treatment of Visual Defects. Number of Children. Referred for Refraction. Submitted to Refraction. For whom Glasses were Prescribed. For whom Glasses were Provided. 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. 735 715 - - 715 643 621 4 3 68 C.—Treatment of Defects of. Nose and Throat. Number of Children. Referred for Treatment. Received Operative Treatment. Received other forms of Treatment. Under Local Education Authority's Scheme—Clinic or Hospital. By Private Practitioner or Hospital. Total. 1,350 274 145 419 876 D.—Treatment of Dental Defects. (1) Number of Children dealt with. (2) Particulars of time given and of operations undertaken. Vide 3rd Annual Report on Dental Work in connection with children attending the public elementary schools, expectant and nursing mothers and children under 5 years, herewith. Table No. 72. 50 E.—Treatment of Uncleanliness. (a) The average number of visits per annum made by the School Nurses to each School 16 (b) The total number of examinations made of children by School Nurses in the year in the Schools 31,759 (c) The number of individual children found unclean 2,748 (d) The arrangements made by the Authority for cleansing, and the number of children cleansed 318 The Authority has established a cleansing room at each of its two Municipal Clinics. Children excluded from School for nitty and verminous conditions are given the opportunity of being cleansed at these Clinics. The mothers are encouraged to attend with the children so that they may see how the cleansing should be carried out. Baths are also given for scabies and other skin conditions as necessary. (e) A record of legal proceedings taken under the Children Act, 1908, or the School dance Bye-laws. Under the School Attendance Bye-laws, 13 Summonses were issued, 3 were adjourned or withdrawn, and 10 Fines were inflicted, the amounts ranging from 3s. 6d. to 10s. (f) No. of school sessions at which inspections were conducted 527 (g) (i) Original Inspections:— Children examined 23,080 Children excluded on account of uncleanliness 473 (ii.) Re-inspections:— Children examined 8,679 Children excluded on account of uncleanliness 285 (iii.) Total:— Examinations 31,759 Exclusions on account of uncleanliness 758 51—52 Table No. 47.—In this Table is embodied the information required in Table IV. F. of Appendix G. of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Return showing the nature and number of medical defects referred for treatment, the number of visits and medical examinations made in connection therewith, and the extent to which remedial measures were carried out during 1920. CONDITION. No. of defects found for which treatment was considered necessary. No. of visits made on account of these defects. No. of Medical Examinations made on account of these defects. No. of times attended by Clinic Nurse only on account of these defccts. No. of defects for which no report is available. No. of defects not needing treatment. No. of defects treated. Total. Results of Treatment. Percentage of defects treated. No. of defects not treated. No. of defects under observation at end of year and carried forward to succeeding year. Remedied. Improved. Unchanged. Under observation at end of year (result of treatment not known at end of vear. School Clinic. Municipal Hospital. Home (under super- of Council Staff). Voluntary Hospital or other charitable Institution. Infirmary or Poor Law. Private Practitioner. Removed from tion. Still under observation at end of year. Total. Brought forward from previous year. †New. Total. l 2 3 4 5 6 7 8 9 10 11 12 13 14 I5 16 17 18 19 20 21 22 23 24 25 Clothing— Unsatisfactory 1 19 20 72 7 0 0 2 0 18 0 0 0 20 11 3 0 6 100.0 0 0 0 6 Footgear— Unsatisfactory 0 7 7 18 0 0 0 0 0 0 7 0 0 0 7 5 0 0 2 100.0 0 0 0 2 Cleanliness of Head— Nits 47 1464 1511 2141 197 750 0 0 151 0 1,349 0 0 0 1,500 1,383 5 0 112 99.3 4 7 11 119 Pediculi 18 606 o24 1071 250 827 2 0 171 0 443 0 0 0 614 592 0 0 22 98.7 5 3 8 25 Other dirty conditions 1 3 4 12 1 0 0 0 2 0 2 0 0 0 4 4 0 0 0 100.0 0 0 0 U Cleanliness of Body- Dirty 1 14 15 62 4 12 0 0 3 0 12 0 0 0 15 14 0 0 1 100.0 0 0 0 1 Pediculi 0 15 15 29 11 6 0 0 6 0 9 0 0 0 15 12 0 0 3 100.0 0 0 0 3 Fleabitten 0 10 10 21 9 0 0 0 2 0 8 0 0 0 10 7 0 0 3 100.0 0 0 0 3 Nutrition— ,J Below Normal 10 51 61 81 237 0 0 0 51 0 1 3 0 I 56 15 3 0 38 91.8 1 4 5 42 Bad 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0 0 0 0 Nose and Throat- Enlarged Tonsils 125 188 313 811 881 56 1 10 121 63 5 37 0 23 249 160 20 2 67 82.5 29 14 53 91 Adenoids 81 69 150 339 338 40 0 6 77 20 4 24 0 10 135 91 8 1 35 93.7 8 1 9 36 Enlarged Tonsils and Adenoids 158 371 529 1261 1757 80 0 9 212 174 8 68 0 27 489 239 14 4 232 94.0 15 16 31 248 Other conditions 57 382 439 960 1210 106 1 6 340 17 27 10 0 28 422 288 20 1 113 97.7 3 7 10 120 Cervical or Neck Glands— Enlarged 57 157 214 403 425 15 0 0 104 7 43 17 0 34 205 167 9 1 28 95.8 3 6 9 34 External Eye Disease— Blepharitis 43 174 217 424 720 605 0 0 195 0 12 6 0 2 215 158 6 0 51 99.1 2 0 2 51 Conjunctivitis 34 248 282 414 938 884 0 0 239 3 19 11 0 7 279 221 6 0 52 98.9 1 2 3 54 Corneal Opacities 4 17 21 83 193 117 0 0 13 2 0 6 0 0 21 7 2 2 10 100.0 0 0 0 10 Other Disease 5 41 46 83 147 38 0 1 32 3 5 2 0 1 43 35 0 0 8 95.6 1 1 2 9 Ear Disease Chronic Suppuration of Middle Ear 150 265 415 1,120 2,300 1,638 1 0 329 10 10 32 0 12 393 235 11 0 147 94.9 17 4 21 151 Chronic Catarrh of Middle Ear 1 48 49 137 168 48 3 0 32 1 3 3 0 4 43 29 3 0 11 93.5 3 0 3 11 Wax 8 52 60 62 182 42 0 0 59 0 0 0 0 0 59 47 1 0 11 98.3 0 1 9 12 Other Disease 20 56 76 137 196 48 0 0 46 3 11 2 0 5 67 50 1 0 16 88.2 6 3 9 19 Teeth—See Dental Returns Heart and Circulation- Organic Disease 8 20 28 140 56 0 0 0 5 1 0 5 1 10 22 0 3 2 17 78. 0 6 0 6 17 Functional Disease 4 12 16 58 25 01 0 0 7 0 4 0 1 4 16 12 2 0 2 100.0 0 0 0 2 Anaemia 37 73 110 267 298 0 0 1 81 0 3 3 0 14 101 57 2 0 42 92.7 5 6 8 45 Other defects 0 8 8 9 8 0 0 0 6 0 0 1 0 0 7 1 0 0 6 87.5 1 0 2 6 Lungs— Chronic Bronchitis and Bronchial Catarrh 94 310 404 799 1070 0 1 0 284 0 41 11 2 54 392 233 8 1 150 97.3 3 8 11 158 Tuberculosis - - - - - - - - - - - - - - - - - - - - - - - - T.B. Suspected 31 50 81 323 228 9 0 0 40 0 0 27 1 6 74 15 14 12 33 91. 4 7 0 7 33 Other disease 6 58 64 161 129 0 0 0 37 4 7 1 2 10 61 38 3 0 20 95.3 1 2 3 22 Nervous System— Epilepsy 9 13 22 99 54 0 0 0 7 0 0 7 0 4 18 2 8 2 6 81.8 4 0 4 6 Chorea 26 36 62 285 180 0 0 0 25 3 0 20 0 14 62 35 5 0 22 100.0 0 0 0 22 Other disease 12 24 36 147 83 0 0 0 17 0 4 6 0 8 35 16 5 0 14 97.2 0 1 14 Skin- Ringworm Body 52 256 308 665 1,075 82 0 0 252 0 19 12 3 17 303 226 0 0 77 98.4 4 1 5 78 Head Impetigo 145 1,341 1,486 2.687 2,692 7,987 0 0 1,134 6 253 24 0 61 1,478 1,396 2 3 77 99.5 4 4 8 81 Scabies 57 356 413 855 1,175 2,650 0 0 323 5 41 20 1 23 413 383 0 0 30 100.0 0 0 0 30 Other disease 61 607 668 1,191 1,664 2,322 0 0 524 5 68 12 1 39 649 568 9 3 69 97.2 6 13 19 82 Rickets- Slight 2 0 2 2 0 0 0 0 2 0 0 0 0 0 2 1 1 0 0 100.0 0 0 0 0 Marked 3 8 11 40 21 0 0 0 7 2 0 1 0 1 11 1 4 0 6 100.0 0 0 0 6 Deformities- Deformity present 17 32 49 160 74 0 0 0 23 0 1 16 2 3 45 3 7 10 25 91.8 3 l 4 26 Tuberculosis (Non-Pulmonary) - †Glandular - - - - - - - - - - - - - - - - - - - - - - - - Bones or Joints - - - - - - - - - - - - - - - - - - - - - - - - ‡Other forms - - - - - - - - - - - - - - - - - - - - - - - - Suspected—Glandular 7 7 14 51 32 0 1 0 6 1 0 3 0 1 11 3 3 0 5 84.6 2 0 2 5 ,, Boneg and joints 8 5 13 27 28 0 0 0 8 0 1 3 0 0 12 7 1 2 92.3 1 0 1 2 ,, Other forms 4 16 20 6S 38 0 0 0 5 0 0 7 0 3 15 0 3 3 9 75.0 5 0 5 9 Speech— Defective Articulation 0 13 13 13 12 0 0 0 10 0 3 0 0 0 13 1 1 6 100.0 0 0 0 5 Squint— Squint present 12 59 71 172 178 0 1 2 55 3 0 2 0 1 61 15 28 3 15 89.7 3 4 7 19 Vision- Defect not ascertained 23 23 46 123 48 0 3 2 12 0 6 11 0 1 30 12 3 4 11 73.2 7 4 11 15 One eye normal 11 58 69 85 219 8 0 9 57 0 0 2 0 0 59 21 19 4 15 98.3 1 0 1 15 Both eyes 6/6 18 119 137 130 290 3 0 41 84 0 4 0 0 0 88 28 33 13 14 191.7 6 2 8 16 6/9 16 64 80 82 243 5 0 7 66 0 0 3 0 1 70 35 20 6 9 195.9 1 2 3 11 One eye 6/9 other 6/12 13 63 76 61 242 7 0 0 72 0 0 2 0 1 75 55 7 6 7 98.7 1 0 1 7 Both eyes 6/12 or less 43 252 295 377 976 23 2 3 277 0 0 1 0 0 279 107 108 9 55 96.2 10 1 11 56 Spectacles broken 21 295 316 162 619 0 0 5 30C 0 0 0 0 0 300 274 0 0 26 96.5 9 2 11 28 lost 1 25 26 19 46 0 0 3 22 0 1 0 0 1 23 17 0 0 6 100.0 0 0 0 6 Debility 147 883 1030 2,763 1 2,898 3 0 10 663 13 141 53 2 119 991 552 72 2 365 97.2 19 10 29 375 Miscellaneous 433 4,932 5,365 9,551 8,663 8,107 15 193 2,96C 77 1,287 174 10 534 5,045 4,42 126 12 477 97.7 87 28 115 505 Grand Totals 2,142 14,275 16,417 31,313 33,535 I 26,518 31 308 9,558 423 3,87S 649 26 1,084 15,619 12,311 609 114 2,585 97.1 295 164 459 2,749 Mental Condition—Dull or Backward and Mentally Defective (all grades)— No. of new Cases examined during 1920 40 Found on examination to be dull or backward 10 Found on examination to be mentally defective 30 Re-examinations in respect of Defective Vision other than Lost and Broken Spectacles— No. of Visits 2,215 No. of Medical Examinations 2,879 † 4 Cases were notified by the Assistant School Medical Officers during the year and were dealt with as notifiable infectious diseases, ‡2 Cases ,, „ „ „ ,, ,, ,, ,, ,, ,, 53 Table No. 48.—Corresponding to Table V. of Appendix G of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Summary of Treatment of Defects as shown in Tables 46 and 47 (A, B, C, D and F, but excluding E.). Disease or Defect. Referred for Treatment. Number of Children. Total. Treated. Under Local Education Authority's Scheme. Otherwise. Minor ailments 10,107 8,777 1,178 9,955 Visual defects 647 624 — 624 Defects of Nose and Throat 1,350 1,068 227 1,295 Dental defects 5,089 4,188 99 4,287 Other defects 1,643 1,233 354 1,587 Total 18,836 15,890 1,858 17,748 Table No. 49.—Corresponding to Table VI. of Appendix G. of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Summary Relating to Children Medically Inspected at the Routine Inspections during the Year 1920. (1) The total number of children medically inspected at the routine inspections* — (2) The number of children in (1) suffering from Malnutrition — Skin Disease — Defective Vision (including squint) — Eye Disease — Defective Hearing — Ear Disease — Nose and Throat Disease — Enlarged Cervical Glands (non-tubercular) — Defective Speech — Dental Disease — Heart Disease — Organic — Functional — Anaemia — Lung Disease (non-tubercular) — Tuberculosis:— Pulmonary:— Definite — Suspected — Non-pulmonary — Disease of the Nervous System — Deformities — Other Defects and Diseases — (3) 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) — (4) The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) — (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, &c.) — *"Specials" are not included in this Table. 54 Table No. 50.—Certain Statistical Data. No. of Public Elementary Schools at December, 1920 32 No. of School Departments at December, 1920 77 Average Public Elementary School Roll, year ended 31st December, 1920 24,997 Total No. of Children medically inspected 11,183 Total No. of Children dentally inspected 5,086 Total No. of Defects of every description "followed up" during 1920 21,506 Total No. of Defects of every description for which treatment was obtained during 1920 19,906 Total No. of Attendances at the School Clinics during 1920 75,258 Table No. 51.—Special Schools. No. of Physically Defective Schools 2 (1 school formerly for mentally defective children was closed on 25/7/17 and re-opened on 13/12/20 for physically defective children). No. of Mentally Defective Schools 1 No. of children attending Special Schools during 1920:— In Willesden. Outside Willesden. Total. Blind and Partially Blind — 11 11 Deaf — 20 20 Mentally Defective 102 2 104 Epileptic — 9 9 Physically Defective 89 13 102 Total 191 55 246 Table No. 52.—Corresponding to Appendix E of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Form of Annual Return of the After-Careers of Children Formerly Attending Special Schools. Local Education Authority Willesden. Name of School Furness Road Physically Defective School. Boys. Girls. 1. Number of children who have left the school since 1910, or since the date of certification, if later 91 95 2. Number who:— (a) have since died 9 6 (b) are known to be incapable by reason of mental or physical defect of undertaking employment 5 8 (c) are in attendance at an Institution for further education (give details) 19 26 and ††(d) are in any other Institution (specify Asylum, Workhouse, Colony for Epileptics, etc.) 1 3 3. Number who are employed in:— (a) Industrial or manual occupations 19 7 (b) Agricultural or rural occupations 3 — (c) Domestic occupations, including those who are helping in the domestic work at home — 8 (d) Commercial, professional or clerical work 2 4 (e) Blind alley or other precarious occupations 6 4 4. Number who have left the neighbourhood or whose after-careers have not been traced 27 29 55 †2(c).—Details of Children who are in Attendance at an Institution for Further Education. [ Ordinary Elementary School. Private School. Technical or Secondary School. Home for Cripples. Institution for Deaf. Sanatorium School. Girls 17 1 5 1 1 1 Boys 12 1 2 1 — 3 ††(2d).—Details of Children who are in any other Institution. Epileptic Institution. Home—Willesden Board of Guardians Barnardo's Home. Home for Cripples. Girls 1 — 1 1 Boys — 1 — — Table No. 53.—Corresponding to Appendix E of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Form of Annual Return of the After-Careers of Children Formerly Attending Special Schools. Local Education Authority Willesden. Name of School Leinster Road School for Mentally Defectives. Boys. Girls. 1. Number of children who have left the school since 1910, or since the date of certification, if later 87 72 2. Number who:— (a) have since died 7 3 (b) are known to be incapable by reason of mental or physical defect of undertaking employment 10 7 *(c) are in attendance at an Institution for further education (give details) 7 9 and **(d) are in any other Institution (specify Asylum, Workhouse, Colony for Epileptics, &c.) 12 7 3. Number who are employed in:— (a) Industrial or manualoccupations 12 3 (b) Agricultural or rural occupations — — (c) Domestic occupations, including those who are helping in the domestic work at home 13 (d) Commercial, professional or clerical work 3 1 (e) Blind alley or other precarious occupations 6 6 4. Number who have left the neighbourhood or whose after-careers have not been traced 30 23 *2(c).—Details of Children who are in Attendance at an Institution for Further Education. Ordinary Elementary School. Private School. Deaf and Dumb Institution. Residential M.D. Institution. Girls 7 1 — 1 Boys 4 1 1 1 56 **2(d).—Details of Children who are in any other Institution. Home—Willesden Board of Guardians. Asylum, Middlesex County Council. Epileptic Institution Private Home. Roman Catholic Home. Girls — 4 — 2 1 Boys 4 7 1 — — Table No. 54. Return showing No. of Special Cases referred in 1920 and previous years with the view of Medical Treatment being obtained, Remedial Measures carried out, or other action taken. Year. Referred by Total. Medical Inspection and Officers of Health Department. Head Teachers. Attendance Officers. Others. 1920 2,949 4,774 353 5,354 13,430 1919 1,796 4,167 451 3,538 9,952 1918 1,674 4,163 395 1,150 7,382 1917 1,227 3,372 441 427 5,467 1916 1,436 3,264 313 394 5,407 1915 1.308 3,429 109 298 5,144 1914 2,322 2,401 108 140 4,971 1913 1,092 1912 1,102 1911 1,030 1910 941 Table No. 55. Medical and Dental Treatment—Attendances at Clinics, 1920. Condition. Mothers and Children under 5. School Children. Grand Total. Expectant Mothers. Nursing Mothers. Children under five. Total. 1. Cleansing 39 31 1,106 1,176 7,495 8,671 2. Throat, Nose, and Ear Diseases 0 2 300 302 6,314 6,616 3. Minor Ailments 24 432 2,972 3,428 42,835 46,263 4. Eye Diseases 0 0 126 126 7,059 7,185 5. Medical Consultations 2,749 16,011 27,524 46,284 0 46,284 6. Total 1—5 2,812 16,476 32,028 51,316 63,703 115,019 7. Dental Consultations 279 674 870 1,823 10,670 12,493 8. Total 6—7 3,091 17,150 32,898 53,139 74,373 127,512 9. Ringworm Attendances 0 0 152 152 885 1,037 10. Grand Total 3,091 17,150 33,050 53,291 75,258 128,549 57  Clinic (I.). Clinic (II.). Grand Total. Mothers and Children under five. School Children Total. Mothers and Children under Five. School Children. Total. 11. Medical Attendances 24,817 30,279 55,096 26,499 33,424 59,923 115,019 12. Dental Attendances 692 4,771 5,463 1,131 5,899 7,030 12,493 13. Total 25,509 35,050 60,559 27,630 39,323 66,953 127,512 Table No. 56. Shewing attendances at the Municipal Clinics each year since 1913. Year. Mothers and Children under 5 years. School children. Total. School for Mothers. Nursery. Grand Total. Medical. Dental. Total. Medical. Dental. Total. 1913 0 0 0 299 0 299 299 0 0 299 1914 0 0 0 2,517 0 2,517 2,517 0 0 2,517 1915 0 0 0 5,674 0 5,674 5,674 0 0 5,674 1916 389 0 389 9,593 0 9,593 9,982 0 0 9,982 1917 8,641 0 8,641 9,448 0 9,448 18,089 0 0 18,089 1918 32,169 1,165 33,334 15,811 2,403 18,214 51,548 44 220 51,812 1919 32,870 878 33,748 46,179 11,024 57,203 90,951 1,089 2,814 94,854 1920 51,468 1,823 53,291 64,588 10,670 75,258 128,549 2,354 3,452 134,355 58 Table RETURN OF WORK DONE AT THE MEDICAL Ringworm and Special Skin Clinic. Eve Clinic. Expt. Mothers. Nursing Mothers. Children under 5. School Children. Total. Expt. Mothers. nursing mothers. Children under 5. School Children. Total. No. under treatment at 27th December, 1919 0 0 18 67 85 0 0 8 169 177 No. coming under treatment 0 0 31 196 227 0 0 16 848 864 Total No. under treatment 0 0 49 263 312 0 0 24 1,017 1,041 No. cured or relieved:— (a) By X Rays 0 0 12 77 89 — — — — — (b) By provision of Spectacles — — — — — 0 0 9 439 448 (c) By baths — — — — — — — — — — (d) By other means 0 0 19 109 128 0 0 8 283 29J No. referred to Municipal Hospital — — — — — 0 0 0 7 7 No. previously attending Clinic cured by other than Municipal agencies or removed 0 0 0 10 10 0 0 0 11 11 No. not requiring treatment 0 0 1 13 14 0 0 4 79 83 Total No. remaining under treatment at 25th December, 1920 0 0 17 54 71 0 0 3 198 201 Re-examinations including further treatment, where necessary, of cases previously treated at Clinics ... — — — — — 0 0 4 1,732 1,736 Note.—Minor ailments referred to Municipal Hospital include such conditions as bronchitis where the children were brought to the Clinic to see the Doctor and referred on to Hospital. Table No. 58. Return respecting the Provision of Spectacles during 1920. No. of pairs of Spectacles provided 1,105 Cost of Spectacles provided £380 13 0 Average cost per pair £0 6 11 No. of pairs wholly paid for by parents 68 No. of pairs partly paid for by parents 329 Total amount received as above £58 17 4 Cost of repairs £16 2 0 Total amount received for repairs £6 19 0 59 No. 57. TREATMENT CLINICS DURING 1920. Throat. Nose and Ear Clinic. Minor Ailment Clinic. , Cleansing Clinic. Grand Total. Expt. Mothers. Nursing Mothers. Children under 5. School Children. Total. Expt. Mothers. Nursing Mothers. Children under 5. School Children. Total. Expt. Mothers. Nursing Mothers. Children under 5. School Children. Total. Expt. Mothers. Nursing Mothers. Children under 5. School Children. Total. 0 0 2 277 279 0 2 29 801 832 0 0 4 53 57 0 2 61 1,367 1,430 0 0 26 925 951 23 70 179 4,679 4,951 4 6 96 698 804 27 76 348 7,346 7,797 0 0 28 1,202 1,230 23 72 208 5.480 5,783 4 6 100 751 861 27 78 409 8,713 9,227 — — — — — — — — — — — — — — — 0 0 12 77 89 — — — — — — — — — — — — — — — 0 0 9 439 448 — — — — — — — — — — 3 3 47 295 348 3 3 47 295 34S 0 0 6 562 568 23 66 103 3,884 4,076 1 3 45 371 420 24 69 181 5,209 5,483 0 0 12 312 324 0 6 53 162 221 0 0 2 6 8 0 6 67 487 560 0 0 0 5 5 0 0 9 93 102 0 0 2 16 18 0 0 11 135 146 0 0 0 28 28 0 0 0 304 304 0 0 0 0 6 0 0 5 424 429 0 0 10 295 305 0 0 43 1,037 1,080 0 0 4 63 67 0 0 77 1,647 1,724 0 0 0 15 15 0 0 3 146 149 — — — — — 0 0 7 1,893 1,900 I i Table 59. HOSPITAL TREATMENT OF SCHOOL CHILDREN DURING 1920. (Excluding Infectious Diseases.) No. of School Children in Hospital at 31st December, 1919 27 ,, „ ,, „ admitted to Hospital during 1920 570 ,, „ ,, discharged from Hospital during 1920 580 ,, „ ,, ,, died in Hospital during 1920 6 ,, „ ,, ,, remaining in Hospital at 31st December, 1920 11 60 TABLE NO. 60.—HOSPITAL TREATMENT OF SCHOOL CHILDREN DURING 1920. Defects. Admitted from Total. Forms of Treatment. Results of Treatment. School. Clinics General Practitioner Operative. General. Other forms specify, e.g., massage, electricity, etc. Remedied. Improved . . Unchanged Died. In Hospital at end of year. Acute Rheumatism 5 3 8 — 8 — 8 — — — — Tonsillitis 5 26 31 — 31 — 26 — — — 5 Influenza — 1 1 — 1 — 1 — — — — Chorea 3 2 5 — 5 — 5 — — — — Rickets 2 — 2 1 1 — 1 1 — — — Debility 5 1 6 — 6 — 6 — — — — Ptomaine Poisoning — 1 1 — 1 — 1 — — — — Cephalgia 2 1 3 — 3 — 3 — — — — Concussion 1 1 2 — 2 — 2 — — — — Tubercular Meningitis — 2 2 — 2 — — — — 2 — Ac. Ascending Paralysis — 1 1 — 1 — — — — 1 — Otitis Media 7 1 8 — 8 — 7 — — — 1 Stomatitis — 1 1 — 1 — 1 — — — — Acute Gastritis — 1 1 — 1 — 1 — — — — ,, Enteritis — 1 1 — 1 — 1 — — — — Colic 2 — 2 — 2 — 2 — — — — Jaundice 2 — 2 — 2 — 2 — — — — Laryngitis 1 — 1 — 1 — 1 — — — — Pleurisy — 1 1 — 1 — 1 — — — — Bronchitis 4 — 4 — 4 — 4 — — — — Broncho-Pneumonia 5 7 12 — 12 — 11 — — — 1 Pulmonary Tuberculosis 1 — 1 — 1 — — — — — 1 Pericarditis 1 — 1 — 1 — 1 — — — — Morbus Cordis 2 1 3 — 3 — — 1 — 1 1 Acute Nephritis 2 2 4 — 4 — 3 — — 1 — Eneuresis 1 1 — 1 — 1 — — — — Cystitis 1 1 — — 2 — 2 — — — — Tonsillectomy 315 1 316 316 — — 316 — — — — Antrum Disease 3 — 3 3 — — 3 — — — — Deflected Septum 5 — 5 5 — — 5 — — — — Mastoiditis 8 1 9 7 2 — 8 — — — 1 Postoperative Septic Throat — 1 1 — 1 — 1 — — — — Hernia 5 — 5 5 — — 5 — — — — Hydrocele 1 — 1 1 — — 1 — — — Phimosis 3 — 3 2 1 — 3 — — — — Implantation Cyst 1 — 1 — — — 1 — — — — Thyroglossal Cyst 1 — 1 — — — 1 — — — — Sebaceous Cyst 2 — 2 2 — — 2 — — — — Ganglion 2 — 2 2 — — 2 — — — — Ranula 1 — 1 1 — — 1 — — — — Talipes Eguino-Varus 3 — 3 3 — — 3 — — — — Fracture (various) 7 — 7 2 5 — 5 2 — — — Mal-united Fracture 1 — 1 1 — — 1 — — — — Prepatellas'Bursitis 1 — 1 — 1 — 1 — — — — Appendicitis 6 2 8 7 1 — 7 — — 1 — Rectal Polypus 1 — 1 1 — — 1 — — — — Adenitis 2 1 3 1 2 — 3 — — — — Suppurative Adenitis 3 1 4 4 — — 3 — — — 1 Tubercular Adenitis 4 1 5 2 3 — 2 3 — — — Abscess (various) 15 5 20 20 — — 20 — — — — Necrosis of Jaw 1 — 1 1 — — 1 — — — — Impetigo 2 — 2 — 2 — 2 — — — — Septic Rash 2 1 3 — 3 — 3 — — — — Septic Wound ... 7 3 10 1 9 — 10 — — — — Dermatitis 2 — 2 — 2 — 2 — — — — Urticaria 1 — 1 — 1 — 1 — — — — Cellulitis 2 2 4 2 2 — 4 — — — — Scabies 9 — 9 — 9 — 9 — — — — Chronic Eczema 2 — 2 — 2 — 2 — — — — Onychia Gryposis 1 — 1 1 — — 1 — — — — Paronychia 2 — 2 2 — — 2 — — — — 61 Table No. 60.—Hospital Treatment of School Children during 1920.—continued. Defects. Admitted from Total. Forms of Treatment. Results of Treatment. In Hospital at end of year. School. Clinics General Practitioners Operative. General. Other forms specify, e.g., massage, electricity, etc. Remedied. Improved. Unchanged Died. Contusions (face) 2 — 2 — 2 — 2 — — — — Contusion of Abdomen 1 — 1 — 1 — 1 — — — — Strabismus 7 — 7 7 — — 7 — — — — Corneal Ulcer 4 — 4 — . 4 — 4 — — — — Occlusion of Lachrymal Duct 2 — 2 1 1 — 1 1 — — — Keratitis 1 — 1 — 1 — — 1 — — — Injury to Eye 1 — — — 1 — 1 — — — — Punctured Cornea 1 — 1 1 — — 1 — — — — Conjunctivitis 1 — 1 — 1 — 1 — — — — Nil — 3 3 — 3 — — — 3 — — Total 493 77 570 404 166 — 541 9 3 6 11 Table No. 61. Absence from School. Term commencing August 23rd, 1920, and ending December 23rd, 1920. Causes of Absence. P.F.B. P.F.G. P.F.I. F.R.S.M. F.R.J.M. F.R.I. D.H.I. Total. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. 1. Illness, actual and alleged, of the Child. Infectious diseases 874 828 1,903 473 262 1,234 578 6,152 Otorrhcea 40 70 10 — 72 24 8 224 Other ear diseases 21 21 — 21 — 65 42 170 Sore throat 362 368 106 — 322 193 55 1,406 Other diseases of the nose and throat 0 92 267 339 240 372 85 1,395 teeth (toothache, etc.) 53 90 24 36 147 218 60 628 External eye diseases 81 249 181 84 26 30 91 742 Diseases of the heart and circulation, including anaemia 51 — — 187 211 — — 449 Lungs:— Bronchitis 87 23 502 22 136 — 341 1,111 Pneumonia — 52 — — 146 — 30 228 Pleurisy, etc. — Coughs and Colds 201 721 673 1,040 454 1,478 1,183 5,750 Phthisis — — — — 125 — 119 244 Tuberculosis, nonpulmonary — 166 — — 168 — 95 429 Debility — 199 285 — 116 40 555 1,195 Enlarged glands 136 76 12 93 83 60 88 548 Skin diseases:— Ringworm — 10 226 140 26 208 — 610 Scabies — 120 — 38 255 — 21 434 Impetigo 1ll 145 549 — 89 381 91 1,366 Sores, etc. 153 54 331 — — 117 15 670 Rheumatism 158 420 — 60 122 63 43 866 62 Causes of Absence. P.F.B. P.F.G. P.F.I. F.R.S.M. F.R.J.M. F.R.I. D.H.I. Total No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. Chorea and other diseases of the nervous system 229 177 45 — 179 — 73 703 Accidents and injuries 191 11 123 230 88 302 194 1,139 Convalescent homes, etc. 87 100 36 170 — — 135 528 Other illness:— Rash 17 — — — — 10 — 27 Internal pains and appendicitis 178 32 — — — — — 210 Hernia, appendicitis kidney, etc. — — — — 255 — — 255 Abscess 47 — — — — 164 — 211 Delicate — — — — — 952 — 952 Headache — 56 — — — 13 — 69 Peritonitis — 124 — — — — — 124 Poisoned thumb and knee — 55 — — — — — 55 Bilious attacks — 26 — — — — 73 99 Diarrhœa — 8 — — — — — 8 Leg — 62 — — — — — 62 Feet, chilblains, etc. Phlebitis — 87 81 — — — — 87 81 Vaccination — — — — — 10 — 10 "Not well," (mostly days & half-days) 498 191 — 273 68 664 — 1,694 Attendances at Hospitals (disease not stated) 74 74 25 — 20 183 1 377 Attendances at Clinics (diseases not stated) — 18 — — 176 — — 194 Uncleanliness —' 330 — 140 170 91 131 862 Total 3,649 5,055 5,379 3,346 3,956 6,872 4,107 32,364 2. Illness in the Home. Compulsorily under regulations (e.g. as contact with scarlet fever or diphtheria 182 419 273 306 214 323 104 1,821 Not under regulations (needed at home owing to illness, mother ill, etc.) 143 341 504 28 274 66 1,356 Total 325 760 273 810 242 597 170 3,177 3. Unconnected with Illness (as far as ascertained). Country holidays, etc. 494 485 446 1,684 82 1,354 789 5,334 Religious holidays, Jewish, Mass, etc. — 4 — — — 26 — 30 To give evidence in police court — 4 — — — — — 4 Weather — — — — — 571 10 581 No boots 101 112 — — 28 76 11 328 Visiting Zoo — — — — — 67 — 67 Visiting Cenotaph — — — — — 260 — 260 Weddings — — — — — 4 — 4 Out with mother — — — — — 23 52 75 Helping mother (not due to illness) — 625 — — — — — 625 63 Causes of Absence. P.F.B. P.F.G. P.F.I. F.R.S.M. F.R.J.M. F.R.I. D.H.I. Total. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. No. of attendances lost. Getting up late, Out with mother, no boots, minding baby, too late for mark — — 536 — — — — 536 Too late for mark — 60 — — — — — 60 Truant — — — — — — 5 5 Indifference of parents, neglect, etc. 183 220 164 — — — 103 670 Reason not recorded 322 283 — 513 759 500 91 2,468 Total 1,100 1,793 1,146 2,197 869 2,881 1,061 11,047 Grand Total of Attendances lost 5,074 7,608 6,798 6,353 5,067 10,350 5,338 46,588 Total No. of possible attendances 56,918 54,799 44,688 68,197 62,625 65,172 54,355 406,754 % of attendances lost from (1) 6.4 9.2 12.0 4.9 6.3 10.6 7.6 8.0 % „ „ „ (2) 0.6 1.4 0.6 1.2 0.4 0.9 0.3 0.8 % „ „ „ (3) 1.9 3.3 2.6 3.2 1.4 4.4 1.9 2.7 % of attendances lost from all causes 8.9 13.9 15.2 9.3 8.1 15.9 9.8 11.5 Note.—The Medical Officer of Health is indebted to the Head Teachers of the Princess Frederick Boys', Girls' and Infants, and Furness Road, Senior and Junior Mixed and Infants, and Dudden Hill Infants Schools, for the figures given in this table. Provision of Surgical Appliances to School Children. The Board of Education, in a letter, dated 3rd September, 1920, sanctioned the provision of Surgical appliances to School Children by Education Committee, under the following conditions:— (a) Free, if family income is below the Education Committee's Economic Circumstances Scale. (b) On payment of full cost if the family income is above the Education Committee's Economic Circumstances Scale. (c) That treatment is recommended by the School Medical Officer. (d) That the appliances are necessary in order to enable the child to attend or continue to attend a Public Elementary School. (e) That the Authority are satisfied that the parents are unable to defray the whole or part of the cost. (f) That the cost is reasonable. (g) That a full account of the working of the arrangements, including the results of the treatment in each case, be included in the School Medical Officer's Annual Report. (h) That particulars of all cases of an unusual nature or in which the expenditure is heavy must be submitted to the Board of Education for previous approval. School children are recommended for Surgical Instruments by (a) the Council's Surgeon at the Municipal Hospital, (b) Special Schools Medical Officer, (c) Clinic Medical Officers, (d) Surgeons of London Hospitals. Investigation is made into the economic circumstances of the family, and if found to be below scale, an estimate is obtained of the cost of the instrument, and if reasonable, an order is given and the parent is requested to take the child to the surgical instrument makers to be measured for the instrument. The instrument is passed by the Council's Surgeon, Hospital Surgeon or Special Schools Medical Officer before being accepted. Where the economic circumstances are above the scale the parent is informed that the Education Committee are unable to supply the instrument, but if the parent agrees, the case is referred, together with particulars of the instruments required, to the Invalid Children's Aid Association. 64 During the year 22 cases have been dealt with. Of this number, 9 have been supplied with instruments free; in 4 cases, the parents have paid full cost, and in 4 cases, the parents have paid part cost. 4 cases have been referred to the Invalid Children's Aid Association and one case to the Willesden Board of Guardians. Table No. 62.—Employment of Children in Entertainments Rules, 1920. Particulars as to applications received in 1920 for certificates from the School Medical Officer. No. of Applications, 1st April to 31st December, 1920. No. Granted. Boys. Girls. Total. Boys. Girls. Total. Original applications — 19 19 — 17 17 Applications for renewals — 3 3 — 2 2 — 22 22 — 19 19 65 THE FIRST ANNUAL REPORT for the Year ending 31st December, 1920, on the HEALTH OF CHILDREN ATTENDING THE SECONDARY SCHOOLS IN WILLESDEN. Giving the Tables required by the Board of Education. Table No. 63.—Corresponding to Table 1 of Appendix G. of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Number of Children Inspected 1st January, 1920, to 31st December, 1920. A.—Routine Medical Inspection.* (i.) Cases in which a full examination has been made (see para. 4, Circular 1,153, Board o: Education). Age. 10 11 12 13 14 15 16 17 18 Admitted during preceding term and not included in foregoing or admitted during term. Leaving during term. Total. Boys — — 14 20 30 15 11 2 1 75 24 192 Girls — — — 3 10 8 — — — 36 33 90 Total — — 14 23 40 23 11 2 1 111 57 282 (ii.) Cases in which only partial examination has been made (see para. 4, Circular 1,153, Board of Education). Age. 10 11 12 13 14 15 16 17 18 Total. Boys — — — — — — — — — — Girl — — — — — — — — — — Total — — — — — — — — — — *Routine Medical Inspection is medical inspection carried out on the lines of the approved Schedule at the time when routine medical inspection is due and made on the School premises or other place sanctioned by the Board of Education under the Code. B.—Special Inspections. Special Cases.† Re-Examinations (i.e., No. ol Children Re-examined). Boys 1 25 Girls — 5 Totals 1 30 †"Special Cases" are those children specifically referred to the Medical Officer and not due for routine medical inspection under the Code at the time when specially referred. Such children may or may not be of Code-group age and may be referred to the Medical Officer at the School or the Clinic by the Committee, Medical Officers, School Nurses, Teachers, Attendance Officers, Parents or otherwise. 66 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). Number of Individual Children Inspected 283 Table No. 64.—Corresponding to Table II. of Appendix G of the Annual Report of Chief Medical Officer of Board of Education for 1919. Return of Defects Found in the Course of Medical Inspection in 1920. Defect or Disease. Routine Inspections. Specials. No. referred for treatment. No. requiring to be kept under observation but not referred for treatment. No. referred for treatment. No. requiring to be kept under observation but not referred for treatment. (1) (2) (3) (4) (5) Malnutrition 5 Uncleanliness:— Head — — — — Body — — — — Skin Ringworm Head — — — — Body Scabies — — — — Impetigo — — — — Other Diseases (nontubercular) 9 3 — — Eye Blepharitis 3 — — — Conjunctivitis — 1 — — Keratitis — — — — Corneal Ulcer — — — — Corneal Opacities — — — — Defective Vision 33 39 1 — Squint — 1 — — Other Conditions — 3 — — Spectacles broken — — — — Spectacles lost — — — — Ear Defective hearing 1 1 — — Otitis Media 2 6 — — Other Ear diseases — — — — Nose and Throat Enlarged Tonsils 4 10 — — Adenoids 4 — — — Enlarged Tonsils and Adenoids — — — — Other Conditions — 2 — — Enlarged Cervical Glands (non-tubercular) — 12 — — Defective Speech 1 I — — Teeth—Dental Diseases 101 15 — — Heart and Circulation Heart disease:— Organic — 9 — — Functional — 1 — — Anaemia 5 6 — — Lungs Bronchitis — 1 — — Other non-tubercular diseases — — — — 67 Defect or Disease. Routine Inspections. Specials. No. referred for treatment. No. requiring to be kept under observation but not referred for treatment. No. referred for treatment. No. requiring to be kept under observation. but not referred for treatment. (1) (2) (3) (4) (5) Tuberculosis Pulmonary:- Definite — — — — Suspected — — — — Non-Pulmonary:- Definite:- Glands — 1 — — Spine — — — — Hip — — — — Other Bones and Joints — — — — Skin — — — — Other forms — — — — Suspected:- Glands — — — — Bones and Joints — — — — Other forms — — — — Nervous System Epilepsy — — — — Chorea — — — — Other conditions — — — — Deformities Rickets — 1 — — Spinal Curvature — 15 — — Other forms 3 15 — — Other Defects and Diseases 1 10 — — Total 167 158 1 — Number of Individual Children having Defects which required treatment or to be kept under observation 188 Table no. 65.—Corresponding to Table IV. of Appendix G of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Treatment of Defects of Children during 1920. A.—Treatment of Minor Ailments. Defect or Disease. Number of Children. Referred for Treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Total. Skin:— Ringworm:— Head — — — — Body Scabies — — — — Impetigo — — — — Minor Injuries — — — — Other Skin Disease 9 — — — Ear Disease 3 — — — Eve Disease (external and other) 3 — — — Miscellaneous — — — — 68 B.—Treatment of Visual Defect. Number of Children. Referred for Refraction. Submitted to Refraction, For whom Glasses were Prescribed. For whom Glasses were Provided. Recommended for Treatment other than by Glasses. Received other Forms of Treatment. For whom no Treatment was considered necessary. TJnder Local Education Authority's Scheme Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 33 — — — — — — — — — C.—Treatment of Defects of Nose and Throat. Referred for Treatment. Number of Children. Received Operative Treatment. Under Local Education Authority's Scheme—Clinic or Hospital. By Private Practitioner or Hospital. Total. Received other forms of Treatment. 8 — — — — D.—Treatment of Dental Defects. (1) Number of Children dealt with. (2) Particulars of the time given and Operations undertaken. Dental Work is not done in connection with the Secondary Schools in Willesden. E.—Treatment of Uncleanliness. Inspection and treatment of uncleanliness has not been undertaken by the School Nurses in the Secondary Schools in 1920. F.—Treatment of all other Defects. (a) The number of cases referred for treatment:— Defective speech 1 Heart and Circulation. Anaemia 5 Deformities 3 Other Defects and Diseases 1 10 (b) The measures adopted for securing improvement. Notices were sent to parents informing them of the condition requiring treatment and the pupils concerned have been noted for special re-examination of the condition on the next occasion" of inspection under the Code. (c) The effect of the measures taken. Not available for 1920. 69 Table No. 66.—Corresponding to Table V. of Appendix G of the Annual Report of the Chief Medical Officer of the Board of Education, 1919. Summary of Treatment of Defects as shown in Table IV. (A, B, C, Dand F, but Excluding E.). Disease or Defect. Number of Children. Referred for Treatment. Treated. Total. Under Local Education Authority's Scheme. Otherwise. Minor Ailments 15 - - - Visual Defects 33 - - - Defects of Nose and Throat 8 - - - Dental Defects 101 - - - Other Defects 10 - - - Total 167 - - - Table No. 67.—Corresponding to Table VI. of Appendix G of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Summary Relating to Children Medically Inspected at the Routine Inspections During the Year 1920. (1) The total number of children medically inspected at the routine inspections* 282 (2) The number of children in (1) suffering from:— Malnutrition 5 Skin Disease 12 Defective Vision (including squint) 73 Eye Disease 7 Defective Hearing 2 Ear Disease 8 Nose and Throat Disease 20 Enlarged Cervical Glands (non-tubercular) 12 Defective Speech 2 Dental Disease 116 Heart Disease:— Organic 9 Functional 1 Anæmia 11 Lung Disease (non-tubercular) 1 Tuberculosis:— Pulmonary:— Definite — Suspected — Non-pulmonary 1 Disease of the Nervous System — Deformities 34 Other defects and Diseases 11 (3) 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) 52 (4) The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) 135 (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) — *" Specials " are not included in this Table. 71 THE THIRD ANNUAL REPORT FOR THE Year Ending 31st December, 1920, ON DENTAL WORK in connection with SCHOOL CHILDREN, EXPECTANT AND NURSING MOTHERS, AND CHILDREN under 5 years. By E. A. JENNINGS, L.D.S., R.C.S. Eng. School Children.—The third annual report on the working of the dental clinics covers the year 1920, during which 3,500 elementary school children from 5 years of age and upwards were examined by the dentists. The number brought forward from 1919 was 1,248, and the number still under observation at the end of 1920 was 1,270. 3,237 children were referred for and 2,926 actually received treatment, 681 of these 2,926 being re-treated as a result of periodical re-examination. The total number of cases completed during the year was 2,877. 435 did not return to be completed, and in 408 cases it was not permitted to carry out the treatment required. 2,364 fillings were done on permanent teeth, and 1,292 on temporary teeth; 1,394 permanent teeth and 10,017 temporary were removed; making a total of 3,656 fillings and 11,411 extractions during the year. In addition to these, 1,077 other operations were performed on the temporary and permanent teeth and soft tissues of the mouth. 10,670 attendances were recorded by all school children. There were 182 anaesthetic sessions, during which nitrous oxide was administered 3,262 times. Table No. 68 gives the results of the examination of the teeth of the 3,500 children examined, and demonstrates the amount of work involved. Table No. 68. Age. Number of Children Examined. Number of Temporary Teeth. Number of Permanent Teeth. Total No. of Teeth Decayed. Decayed Savable. Decayed Unsavable. Decayed Savable. Decayed Unsavable. 5 years 238 269 578 9 856 6 „ 523 401 1,629 124 3 2,157 7 „ 566 275 1,972 270 20 2,537 8 „ 323 115 1,232 191 23 1,561 9 „ 4 21 33 10 1 65 Specials 1,846 524 7,100 1,936 1,386 10,946 Total 3,500 1,605 12,544 2,540 1,433 18,122 The outstanding feature of the year's work is the large number of special cases, which have been referred to the Clinics on account of gross defects of the teeth and gums. It is not the object of the school dental clinic to treat large numbers of cases of gross neglect; the ideal to be aimed at is rather the ultimate diminution of such treatment. The treatment of children with gross defects is in many cases urgently necessary, but the amount of work to be done when mouths are allowed to get into such a condition is enormous. 72 To prevent gross lesions and the gross dental decay and oral sepsis from which so much illhealth springs, it is necessary to deal with dental disease at the commencement by treatment at an early age. All children entering the infant departments should be inspected as soon as possible and the necessary treatment given at once. The dental scheme should also provide for re-examination of all children in the age groups previously inspected and for immediate treatment, if necessary, so that a health}' condition of the teeth and gums may be secured and maintained. In this way the whole of the children of elementary school age would eventually be brought under adequate dental inspection and treatment and leave school with healthy dentures. The annual re-inspection of children is as important as the inspection and treatment of new cases; if this work is allowed to get seriously into arrears the benefit of conservative work already done will be largely nullified. This will be appreciated by glancing at the following Table, No. 69, which was prepared from a series of test re-examinations of school children where treatment had been completed at the clinic from 6 months to 2 years previously. Table No. 69. No. of Children. Interval. No. of Fresh Caries. Average per Child. 31 6—12 months 52 1.6 15 12—18 ,, 30 2.0 30 18—24 ,, 92 3.06 It will be noticed that the three groups, with intervals of 6—12 months, 12—18 months, 18—24 months have respectively 1.6, 2.0, 3.06 teeth with fresh caries, proving the necessity for re-treatment at least once a year. It is not possible for the two Dentists employed to carry out a complete scheme for all the children of the schools. One dentist can keep the mouths of 3,000 children fit and free from caries. Table No. 70. Return Showing No. of Cases Referred in 1920 with the View of Dental Treatment being Obtained. Year. Referred by Total. Dental Inspection and Officers of Health Dept. Head Teachers. Attendance Officers. Others. 1920 1,386 466 6 1,379 3,237 1919 2,833 654 17 1,371 4,875 Table No. 71. Return showing the number of dental defects referred for treatment, the number of visits and dental examinations made in connection therewith, and the extent to which remedial measures were carried out during 1920. No. coming under observation during 1920 'Brought forward from 1919 1,248 From the 1920 inspections 3,237 From the 1920 re-examinations 604 - Total 5,089 No. of visits made by Health Visitors 8,024 No. of dental examinations made 10,670 No. Treated Clinic 4,188 Private Practitioner or Dentist 55 Voluntary Hospital or other Charitable institution 44 Total 4,287 No. treatment completed 2,976 No. improved—completion refused or patient removed 435 No. still under treatment at end of year 876 Percentage treated 84-2 No. Not Treated Refused treatment 408 Still under observation at end of year 394 Total 802 Total No. under observation at end of vear and carried forward to ceeding year 1,270 73 Table No. 72.—Corresponding to Table IV. D. of Appendix G. of the Annual Report of the Chief Medical Officer of the Board of Education for 1919. Treatment of Dextal Defects. (1) Number of children dealt with. Age Groups. Specials. Total. 5 6 7 8 9 10 11 12 13 14 (a) Inspected by Dentist 210 369 422 195 4 — - 2,300 3,500 (b) Referred for treatment 941 2.296 3,237 (c) Actually treated 548 2,378 2,926 (d) Re-treated* (result of periodical reexamination) 273 408 681 *It is understood that cases under this head are also included under C. above. (2) Particulars of the time given and of operations undertaken. Number of half-days devoted to inspection. Number of half-days devoted to treatment. Total number of Attendances made by children at the Clinic. Number of Permanent Teeth. Number of Temporary Teeth. Total number of fillings. Number of administrations of General Anaesthetic in 4 & 6 Number of other operations. Extracted Filled Extracted Filled Permanent Teeth Temporary Teeth. 1 2 3 4 5 6 7 8 9 10 #] 27 1,014 10,670 1,394 2,364 10,017 1,292 3,656 3,262 799 278 Expectant and Nursing Mothers and Children under 5 Years.—The report on this section of the work shows that 706 patients attended the Dental Clinic during 1920; of this number, 168 were brought forward from 1919 and 538 were new patients. 1,823 Attendances were recorded. Of the number of new patients, 255 were mothers and 283 were children. 1,591 Teeth were extracted, 394 fillings done, and 304 other forms of dental treatment carried out during the year. In addition 29 children were re-examined and re-treated and 477 patients received general anaesthetics. Comparing the work with that of the previous year, it will be seen that the attendances have increased by 945. The number of fillings done exceeds previous figures by 226 and the number of extractions by 765, or nearly double. This satisfactory progress no doubt is due to the growing appreciation of the dental work and to the decision of the Council on the 24th February, 1920, to undertake the provision of dentures to expectant and nursing mothers under the following conditions:— (a) That the cost should not exceed £3 per upper or lower denture. (b) That the supply of dentures be distributed among the local registered dentists who were prepared to accept this rate. (c) That dentures be supplied free to those applicants whose economic circumstances come within the economic circumstances scale, fixed by the Council in connection with the scheme for the Provision of Milk and Meals. (d) That cases above the economic circumstances scale be supplied with dentures at cost to the Council and that payment be accepted by minimum instalments of 5s. per week, to commence from the time of the first extractions and subject to the patient having paid a minimum sum of £1 before the dentures are supplied. Mothers much more readily submit to treatment when they know that their mastication will to a large extent be restored and that they are not going to be left toothless. 74 The following Table No. 73 shews the number of orders that were given for dentures und this scheme up to 31st December, 1920 :— Table No. 73. At Cost to Council At Cost to Applicant. Total. Municipal Clinic (1). 8 8 16 Municipal Clinic (2) 4 9 13 Total 12 17 29 Many patients requiring dentures did not receive treatment because they were unable or unwilling to pay the cost price or feared they would not be able to keep the payments by instalments up-to-date. The scheme, however, can only be complete and economical when the Council has its own work-rooms and mechanics. The measures to be taken to secure a clean and healthy mouth, represent a very important branch of public health and it is extremely necessary that all mothers have healthy and efficient dentures both for their own sakes and that of their children. When this is done we shall be a step nearer towards overcoming that, at present, formidable task, " The Systematic Dental Treatment of Elementary School Children." Anœthetics. The use of Nitrous Oxide gas as a general anœsthetic is not altogether satisfactory for dental operations, the anaesthesia is very short and it is impossible to clear the mouth of septic teeth at one sitting. It is trying both for mothers and children to have to attend on several occasions for administration of nitrous oxide, and this adds to the number of cases not completed. Ethyl Chloride is an anœthetic specially applicable to dental work, and when properly administered gives complete relaxation. It requires, however, a specialist anaesthetist or it may prove dangerous. 75 THE SIXTH ANNUAL REPORT for the Year ending 31st December, 1920, on the PROVISION OF MEALS TO SCHOOL CHILDREN AND TO MOTHERS AND CHILDREN UNDER FIVE YEARS IN WILLESDEN. PROVISION OF MEALS—SCHOOL CHILDREN. Feeding Centres.—Meals have been supplied at three Feeding Centres under the control of the Education Committee. At Furness Road Centre there is adequate accommodation for the number of children being served. The children attending the physically defective school are served at 12 noon, the second dinner being served at 12.30 p.m., thus allowing time for the arrival of children from more distant schools. At Gibbons Road Centre, owing to the large increase in numbers during the year, the rooms have been more than comfortably crowded for the first dinner, and a relay dinner has been served to the children, who, by reason of coming from a distance, arrive late. The seating arrangements here are not very satisfactory, desks serving for tables, and the cooking stoves, coppers and sink being closer to the children than is desirable. A large number of the applicants for free meals are drawn from the Stonebridge area and it would be advisable in the near future to consider the establishment of a feeding centre that would be more conveniently located for the district to be served, and more suitably equipped for the service. At Strode Road Feeding Centre during the early part of the year, the numbers dropped to less than 50 children per day, but since the autumn this number has considerably increased. In the table given below the number of individuals attending the Education Committee's Centres is shewn, together with the number of meals supplied. Table No. 74.—Education* Committee's Centres. Four Weeks Ended. No. of Individuals Fed Average per week. No. of Meals Supplied. Dinners. Breakfasts (including Kilburn). Special Meals. Total. (1) (2) (3) (4) (5) (6) 24/1/1920 266 4,526 39 19 4,584 21/2/1920 315 5,459 59 35 5,553 20/3/1920 327 5,657 1,109 27 6,793 17/4/1920 275 4,440 981 48 5,469 15/5/1920 325 5,760 1,021 52 6,833 12/6/1920 317 5,196 896 51 6,143 10/7/1920 313 5,235 810 52 6,097 7/8/1920 252 4,105 632 30 4,767 4/9/1920 234 4,056 600 18 4,674 2/10/1920 330 5,811 733 20 6,564 30/10'1920 346 5,788 1,199 44 7,031 27/11/1920 396 7,052 1,902 79 9,033 25/12/1920 459 7,978 2,025 36 10,039 4,155 71,063 12,006 511 83,580 Av. per week 320 76 In April, 1920, the Education Committee purchased the premises at 84, Strode Road. Meals.—There has been no change in the kind of food given since last year. The same three weeks' menu is followed, which provides 2 meat meals, 2 meatless meals and 1 fish meal in each week with a pudding or stewed fruit for the second course. A dietary which provides the same meals whether winter or summer is open to criticism, but it should be remembered that the variable climate of this country renders a division into seasons according to calendar impracticable. The itinerant ice-cream vendor may cry his delicacies in the month of May in brilliant sunshine under azure skies, but his trade might be equally brisk with roasted chestnuts while a cold sleet is falling. To him a weekly change of stock-in-trade is easily accomplished, but where orders must be given a week in advance, where hundreds are catered for, failing a reliable weather forecast, the difficulties are less satisfactorily overcome. A substantial dinner of soup and dumplings rarely comes amiss to a hungry child whatever the weather, and a spell of hot weather early or late in the season is generally ,of too short duration to make a modification of the dietary worth while. The Feeding Centre Superintendents report that there is no marked falling off of the appetites of the children in warm weather. It may be supposed that in necessitous cases one good meal per day is so much needed, that to reduce its caloric value in anyway would be detrimental to the child. Only by much increasing the cost of the meals could a summer dietary equal in food value be arranged. All authorities are agreed that the most economical method of preparing meat is in some form of stew and that roasting or baking is the most extravagant. Hence it is readily understood that it is not practicable, having regard to the high cost of living, to arrange for cold meals in summer time, nor to dispense with the nourishing element supplied by dumplings and suet puddings without much increasing the cost of the meals. Where children's meals are under consideration, a claim for the value of milk puddings is strongly urged, but the physiological value of the suet pudding is higher while the cost is little more than half, and there is no doubt as to the greater popularity of jam roly-poly over baked rice, even if a helping of jam is added to the attractions of the latter. Breakfasts.— In December, 1919, the Education Committee approved the provision of breakfasts for a few children whose parents' circumstances were unusually poor, and in March, 1920, authority was given permitting children whose parent's economic circumstances do not exceed half the Education Committee's Scale to attend the feeding centre for breakfasts as well as dinners. The extent of the need for this extra provision is evidenced by the rapidity with which the Numbers increased as shewn in Table 74, Column 4. The meal is served at 8.15 a.m. and is extremely simple, consisting of cocoa made with dried milk and sugar, and bread and margarine. It may be urged that porridge provides a more nourishing meal for the cost than that given at the Centres, but if the cost of fuel (in this case, gas) is added, porridge as a meal has no longer the advantage of cheapness usually claimed for it. In addition to this, the meals must be ready not later than 8.15 a.m., in order that the children may have ample time to continue their way to school, so that 15 minutes is the time available for the preparation of the breakfast by the Feeding Centre Staff. Dried milk is used in preference to fresh for the cocoa, so that any number of new attendants for breakfast may be supplied without shortage. Special Meals.—Extra milk meals have been given in a few cases where specially recommended on medical grounds by the Medical Staff. These meals are given at the morning school interval, either free or at a charge of one penny, according to the circumstances of the parents. Difficulties have arisen, however, as to the service of these meals, the teachers finding themselves already too fully occupied by their scholastic duties to be able to devote the time to the preparation of the milk for these individual cases. The caretakers of the particular schools concerned were approached, in order that other possibilities of service might be considered, but the duties of these, particularly that of furnace stoking, rendered such an arrangement out of the question. The wives of the caretakers are not always on the premises and in some cases the caretaker has no wife, so that this suggested solution of the difficulty was unavailing. No other provision for the service of these meals has at present been made. The total number of special meals given throughout the year was 511. Staffing.—The number of assistants employed at the Feeding Centres varies directly with the number of individuals attending, reductions and increases being made as soon as a change in numbers renders such a course justifiable. A general rule is followed allowing 1 assistant per 50 persons attending. This proportion appears to be adequate within certain limits, but however large the number attending, a certain part of the work remains constant in amount; for example, the floor area, and the number of sinks and stoves to be cleaned. The variable part of the work, which becomes noticeably heavier with increasing numbers, is the washing up and the preparation of vegetables. Therefore, though 1 assistant per 50 persons attending is a fair average up to the first 4 assistants, one additional assistant should suffice per 75 additional diners for increases above that number. Table No. 75 shews the number of assistants employed and the number of individuals attending at different periods during the year. 77 Table No. 75.—Table to Shew Proportion of Staff to No. of Individuals Fed. Feeding Centre. Week ending. No. of Staff employed. No. of Individuals fed. Gibbons Road 17.1.20 2 full time 118 17.7.20 3 full time 152 20.11.20 4 full time 205 Furness Road 17.1.20 2 full time 1 part time 131 17.7.20 2 full time 121 1 part time 20.11.20 2 full time 127 1 part time Strode Road 17.1.20 1 full time 58 1 part time 17.7.20 1 full time 72 20.11.20 1 part time 1 full time 95 1 part time The following Table, No. 76, shews the cost per meal for the 4 weekly periods of 1920 for food only and the total cost per meal. Table No. 76. Four Weeks Ended. Cost for Food only per meal in pence. Total Cost per meal in pence. (1) (2) (3) 24/1/1920 3.49 6.51 21/2/1920 3.71 6.43 20/3/1920 3.42 5.69 17/4/1920 3.54 7.26 15/5/1920 3.66 5.80 12/6/1920 3.69 6.65 10/7/1920 3.74 6.46 7/8/1920 3.59 7.89 4/9/1920 3.65 7.62 2/10/1920 4.34 7.31 30/10/1920 3.42 6.15 27/11/1920 3.23 6.14 25/12/1920 3.80 6.23 It should be noted that these costs do not include capital charges when paid out of revenue, as, e.g., the purchase of Strode Road or the allocation of costs of other departments to school meals. Selection of Children.— No change has been made in this respect. Recommendations for free meals are accepted from school teachers and health visitors as well as from the medical staff at the clinics, and parents are free to make application at any time, directly to the Feeding Centies. A large number of applications, more particularly in the Kilburn area, are from the children themselves, driven by need to overcome natural shyness and to present themselves at the Feeding Centre, saying, "Please may I join." The total number of new application forms presented at the Education Committee Centres throughout the year was 1,088. 78 Increase in unemployment was most marked as the year drew to a close, and the number of necessitous cases rose in proportion. The following Table, No. 77, shews the weekly minimum, weekly maximum, and weekly average number of individual school children fed in 1920. Table No. 77. Week Ending. No. of Individuals Fed. No. of Meals Supplied. 14 8/1920 189 778 Minimum. 18/12/1920 704 3,567 Maximum. For 52 weeks ending, 25/12/1920 Average per week. 467 2,212 Average for Year. Below is given an occupational percentage list of the parents whose children were fed during December, 1920, with a comparative column for December, 1919. Table No. 78. No. of Children Fed. No. of Families Involved. Percentage. 1920. 1919. 1920. 1919. 1920. Unemployed 470 48 189 36 64.3 Widows 114 39 52 29.3 17.7 Deserted Wives 38 12 17 9 5.8 Orphans 10 2 9 1.5 3.0 Labourers 8 10 2 7.5 .6 Raihvaymen 6 3 2 2 .6 Hawkers 11 3 3 2 1.0 Others ... 61 16 20 12.7 7.0 Kilburn Feeding Centre.— As before, the children from South Kilburn are fed at the Presbyterian Mission Hall, Granville Road. As the school doors open at 12 noon, a stream of from two to three hundred children pours down Granville Road, and disappears into the cellarlike basement of the Mission Hall. Each child is eager to be first and to escape the wearisome ordeal of the long queue waiting admission. The meal supplied is served on enamelled plates with the minimum of table appointments, one spoon. The children sit packed closely together on narrow high forms and scramble out before the last mouthful is swallowed. The Mission Authorities increased the charge from 3½d. to 4d. per meal from week-ending November 22nd, 1920, on the grounds of higher administrative costs, but' agreed, on request, to introduce certain improvements, namely, a more varied dietary. Some meat is now given and occasionally fish, while the puddings are generally improved. Suet with treacle or raisins varies the monotony of the watery, unsweetened rice that appeared two or three times a week before, these changes were made. The service has been expedited by the voluntary assistance of several ladies, two of whom attend daily from 12.0 till 1 p.m. The educational and social aspect of the meal is still entirely lacking. The Mission Hall authorities were asked to arrange for the provision of breakfasts for the most necessitous, but they were unwilling to make the necessary changes in staffing arrangements to admit of this being done. The children are therefore given breakfasts at the Carlton Vale School House, the arrangements being undertaken by the caretaker. The food provided is the same as that given at the Feeding Centres. The children assemble outside the school gates and are admitted through the playground at 8.15 a.m. The meals are partaken of quietly, and in good order; the quantity of food consumed is not limited. Owing to the large demand and need for the breakfasts in South Kilburn, there is insufficient accommodation at the caretaker's house for the numbers fed, and the children are top crowded for comfort. The need for a large, well equipped Feeding Centre in this district, that can be properly controlled, is a most pressing one. 79 The following Table, No. 79, shews the number of school children fed at the Kilburn Centre and the number of meals supplied. Table No. 79. Four Weeks Ended. Average No. of Individuals Fed per week. No. of Meals Supplied. Dinners. 24/1/1920 120 1,954 21/2/1920 142 2,469 20/3/1920 159 2,779 17/4/1920 155 2,448 15/5/1920 167 3,022 12/6/1920 159 2,689 10/7/1920 147 2,516 7/8/1920 120 1,938 4/9/1920 102 1,714 2/10/1920 143 2,365 30/10/1920 170 3,010 27/11/1920 217 3,846 25/12/1920 228 4,019 34,769 The total number of application forms received from South Kilburn for the year was 460 for dinners. The total number of individuals supplied with breakfasts in South Kilburn was 93, and the total number of breakfasts in South Kilburn was 4,693, this number being from week ending 28/2/1920, the earliest time by which the arrangements could be made. Provision of Meals—Mothers and Children under 5 Years.—The number of individuals fed and the number of meals supplied at the Education Committee Centres is shewn in Table No. 80. The attendance of the mothers is irregular, there being continuous requests for the meals to be sent home. This is due in some cases to a disinclination to attend at the Feeding Centres, in other cases the distance is great, while in other cases, again, the mother has a home meal to prepare for the husband and those members of the family not eligible for attendance at the Feeding Centres, and in this way is prevented from attending. Table No. 81 shews the number of meals supplied to mothers and children under 5 at the Kilburn Centre. The attendance here is more regular, a large number of the necessitous cases of the district being drawn from the immediate neighbourhood. Notwithstanding this, the requests for meals to be sent home are many, the reasons given being varied, but predominating is the claim made on the mother by other members of the family. A meal sent home is probably a meal shared. Generally the requests are not acceded to except in cases of illness. Table No. 80.—Education Committee's Centres. Four Weeks Ended. Individuals Fed. Total. No. of Meals Supplied. Total. Mothers. Children under 5. Mothers. Children under 5. Average per week. 24/1/1920 5 13 18 91 206 297 21/2/1920 9 12 21 140 193 333 20/3/1920 8 11 19 136 176 312 17/4/1920 10 10 20 157 176 333 15/5/1920 11 10 21 179 178 357 12/6/1920 9 12 21 141 194 335 10/7/1920 8 15 23 137 241 378 7/8/1920 11 25 36 181 396 577 4/9/1920 12 21 33 181 337 518 2/10/1920 10 18 28 143 302 445 30/10/1920 8 15 23 123 260 383 27/11/1920 8 16 24 105 275 380 25/12/1920 12 21 33 137 358 495 — — — 1,851 3,292 5,143 80 Table No. 81.—Kilburn Voluntary Centre. Four Weeks Ended. Individuals Fed. Average No. per week. No. of Meals Supplied. Mothers. Children under 5. Total. Mothers. Children under 5. Total. 24/1/1920 8 29 37 125 441 566 21/2/1920 10 30 40 156 508 664 20/3/1920 11 33 44 194 582 776 17/4/1920 15 38 53 232 599 83 15/5/1920 18 41 59 307 704 1,011 12/6/1920 18 37 55 289 615 904 10/7/1920 19 36 55 331 620 951 7/8/1920 *15 30 45 260 522 782 4/9/1920 *15 29 44 243 510 753 2/10/1920 21 33 54 340 588 928 30/10/1920 25 41 66 422 671 1,093 27/11/1920 26 49 75 453 816 1,269 25/12/1920 27 51 78 473 807 1,280 — — — 3,825 7,983 11,808 * Closed one week. A new scale was adopted in Way, 1920, based on a re-investigation into the cost of the upkeep of a child in this district. Previous to that date, the Council had adopted a scheme of part payment according to the Economic Circumstances of the. applicant, for meals, milk, dried milk, etc., but in practice this was found to be costly and was discarded after 3 months' trial. The present scale is :— No. in Familv. Net income per head of the family per week. 2 12s. 3 11s. 4 10s. 5 or over 9s. 81 THE FIRST ANNUAL REPORT FOR THE Year Ending 31st December, 1920, ON HOME NURSING. 82 Table No. 82.—Showing Cases dealt with during 1920 and Results. Disease. Removed from Observation during 1920—Results of Treatment. Still being Home Nursed at end of 1920. Number of Visits Paid during 1920. New Cases during 1920. ' Died. Removed to Hospital or other Institutions. Recovered. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Nursing Mothers. Children under Five. School Children. Others. Total. Expectant Mothers. Aursmg Mothers. Children under Five. School Children. Others. Total. Expectant Mothers Nursing Mothers Children under Five School Children Others Total Bronchitis — 3 36 2 3 44 — — †3 — — 3 — — 3 — 1 4 — 3 26 2 2 33 — — 4 — — 4 — 37 321 21 17 396 Cardiac cases — — — 2 1 3 — — — 2 — 2 — — — — — — — — — — 1 1 — — — — — — — — — 116 5 121 Chicken pox — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 4 — — 4 Diarrhoea — — — — — — — ——— — — — — — — — — — — — — — — — 2 — — — — — — — — 20 — — 20 Epidemic diarrhoea — — 17 2 — 19 — — 1 — — 1 — — 2 — — 2 — — 14 2 — 16 — — — — — — — — 124 12 — 136 Influenza 9 1 2 10 9 24 — — — — — — 1 — 1 — — 9 1 1 1 10 9 22 — — — — — — 4 10 9 116 82 221 Maternity nursing 3 23 — — — 26 — — — — — — — — — — — — 3 23 — — — 26 — — — — — — 29 316 — — — 345 Measles and its complications — — 37 17 — 54 — — — — — — — — 9 1 — 3 — — 30 14 — 44 — — 5 2 — 7 — — 502 226 — 728 Miscellaneous 1 6 37 37 48 129 — — — 1 ‡10 11 — — 4 3 5 12 1 6 32 33 23 96 — — 1 — 10 11 14 107 497 622 1,395 2,635 Ophthalmia — 1 20 7 3 31 — — — — — — — — — — 1 1 — 1 17 7 1 26 — — 3 — 1 4 — 37 866 142 47 1,092 Ophthalmia neonatorum — — 28 — — 28 — — — — — — — — 3 — — 3 — — 24 — — 24 — — 1 — —. 1 — — 892 — — 892 Otitis media — — 15 5 — 20 — — — — — — — — — — — — — — 13 4 — 17 — — 2 1 — 3 — — 528 226 — 754 Pleurisy — — — 1 — 1 — — — — — — — — — — — — — — 1 — 1 — — — — — — — — — 6 — 6 Pneumonia (acute primary) — — 15 8 12 35 — — *1 — — 1 — — — 2 1 3 — — 13 3 11 27 — — 1 3 — 4 — — 216 73 116 405 Pneumonia (acute influenzal) — — — — 1 1 — — — — — — — — — — — — — — — — 1 1 — — — — — — — — — — 15 15 Rheumatism — 1 1 6 3 11 — — — — — — — — — 1 — 1 — 1 — 5 2 8 — — 1 — 1 — — 16 72 — 101 296 Scalds and burns — — 1 1 — 2 — — — — — — — — — — — — — — 1 1 — 2 — — — — — — — — 17 — 19 Scarlet fever — 1 12 21 9 43 — — — — — — — — 8 16 6 30 — — 2 — 1 3 — 1 2 5 2 10 — 1 159 208 34 402 Septic conditions 3 5 40 44 16 108 — — — — — — — 1 2 4 4 11 3 4 36 37 10 90 — — 2 3 2 7 82 88 481 574 677 1,902 Threadworms — 1 19 22 — 42 — — — — — — — — — — — — — 1 18 22 — 41 — — 1 — — 1 — 11 213 235 — 459 Throat conditions — 1 6 11 4 22 — — — — — — — — — — 1 1 — 1 6 9 3 19 — — — 2 — o — 4 46 80 62 192 Tuberculosis — 2 — 3 2 7 — 1 — — 1 2 — 1 — 2 — 3 — — — 1 1 2 — — — — — — — 9 — 49 20 78 Uterine disorders — — — — 7 7 — — — — — — — — — — 1 1 — — — — 6 6 — — — — — — — — — — 83 83 Whooping cough (& its complications) — — 19 2 — 21 — — — — — — — — 1 — — 1 — — 16 2 — 18 — — 2 — — 2 — — 320 10 — 330 Total 9 45 308 201 118 681 — 1 5 3 11 20 1 2 26 29 20 78 8 41 252 153 71 525 — 1 25 16 16 58 129 636 5,272 2,840 2,654 11,531 † 1 of these had died before Nurse visited, ‡ 2 of these had died before Nurse visited. 1 of these was dying when Nurse first visited. * Had died before Nurse visited. The 10 Miscellaneous Deaths of others were 1 Colotomy case. 3 Cancer cases. 1 Hemiplegia case. 4 Senile cases. 1 Tuberculosis. 83 Table No. 83. Shewing Sources from which cases were referred for Home Nursing during the Year 1920. Referred by Number. Health Department 468 Private Doctors 115 Others 98 Total 681 Table No. 84. Shewing cases referred for Home Nursing in Wards during 1920. Ward. No. of Cases dealt with. No. of Visits paid. 1. South Kilburn 82 1,331 2. Mid-Kilburn 119 1,401 3. North Kilburn 92 1,317 4. Brondesbury Park 35 782 5. Kensal Rise 103 1,543 6. Harlesden 70 1,409 7. Stonebridge 37 914 8. Roundwood 38 410 9. Church End 34 539 10. Willesden Green 58 1,118 11. Cricklewood 13 767 Total 681 11,531 * . 85 THE TWENTY-NINTH ANNUAL REPORT FOR THE Year ending 31st December, 1920, ON THE MUNICIPAL HOSPITAL, BY W. J. J. STEWART, M.D., D.P.H. To the Chairman and Members of the Willesden Urban District Council. Ladies and Gentlemen, I beg to submit the Annual Hospital Report for 1920, the Twenty-ninth of the Series. The Report must necessarily take the form of last year's to a great extent, for there is little fresh matter to be introduced. Except for fresh statistical figures, it is rather an exact repetition, for I have again to refer to those matters I particularly drew your attention to a year ago. I refer to the want of proper ward accommodation for patients, and especially small ward accommodation, to the inadequate bedroom, mess room and recreation room accommodation for Staff, to the small number of Nurses you employ relative to the number of patients treated and similarly to the insufficient number of resident medical officers. All of these matters remain as a year ago, it is therefore my duty to bring them again to your notice for such consideration as you think they now require. During the year just completed, 2,608 patients were admitted. Never in the history of the hospital has it been called upon to deal with such a number of cases. Moreover, it is very questionable if any hospital of its character, limited as it is in respect to accommodation and to staff, has accomplished or even attempted such a task. When a hospital of this size (199 beds) is called on to deal with 2,608 cases, of all kinds of disease, in the year, a figure equal to if not in excess of the number of cases customarily admitted to a hospital double its size, some idea of the enormous strain on its limited resources can be realised. When I say the hospital has limited resources, I do not think I am overstating the case. Instead of the hospital accommodation increasing along with the size of the district, it has certainly for the last 9 years very decidedly decreased. It is just 9 years ago since Kingsbury Hospital, used as an overflow hospital, was burned down. That building contained 32 beds, which to this day have not been made good. Again in 1912, W. Block (12 beds) had to be given up temporarily to accommodate staff, and though it reverted to its original use late in 1913, it finally was converted into staff quarters in 1918, since when it has not been available. The loss of these two buildings means a reduction of 44 beds. This is a very important point to bear in mind when the question of the hospital extensions is under consideration at any time. If it should be necessary to further accentuate the decrease as regards accommodation that has taken place, I would mention that in 1903, when first I took charge of the hospital, it then consisted of 8 ward pavilions and Kingsbury Hospital. Today it is minus two of these ward pavilions or blocks (S. ward and W. ward) given over to Staff, and Kingsbury Hospital, and therefore consists of 6 ward blocks only. The hospital really has never had adequate accommodation since I entered your service, even during the years it remained an isolation hospital purely. In 1908 for instance there was actually insufficient room for Scarlet Fever cases, a small number of cases of that disease being transferred to a Convalescent Fever hospital at Stanmore. These facts, I think, clearly show how the accommodation has not only not been maintained, but has actually been reduced. A year ago in my report for 1919, a year in which 1,703 cases were admitted, I pointed out that the nursing staff was insufficient and it was not possible for the required amount of treatment to be carried out without imposing great hardship on your nurses. Abundant evidence of the truth of that statement has been forthcoming during the twelve months now under review. The sickness rate amongst nurses has been very high, and a clean bill of health at any time has been unknown. On more than one occasion, 6 nurses have been laid up at one time with ailments, most of which in my opinion were the result of overwork. It is true that private nurses have been engaged to fill their places, but inasmuch as there is not sufficient accommodation for the permanent staff even, it has never been possible to engage the required number to fill the gaps, with the result that even 86 greater hardship is imposed on those nurses who are still on duty. I trust the Council will bear these facts in mind and further that this hospital is always working short-handed and without the full complement of nurses (58) that the Council some time ago decided was the number required. Only 51 nurses can be housed at one time. There is therefore a permanent shortage of 7 nurses and a proportionate overworking of the remaining 51, always supposing it was possible, which it never has been, to have them all fit and on duty at one and the same time. I have therefore again to draw your attention to the necessity for more staff accommodation so that the proper complement of nurses can be engaged. So far I have referred only to the shortage of nursing staff. Equally well might my statements in that connection be applied to the case of the medical staff. Only two resident medical officers as you are aware hold office, a medical superintendent and one assistant. In other words, although the hospital itself has increased in size, although its scope of work has enormously increased in extent and importance, and although the admissions have more than trebled in the last 3 years, the number of medical officers remains the same. No hospital that I can learn of can show such a record as this, where with only 199 beds, 2,608 patients (be it noted infectious and non-infectious cases) are admitted, and yet with only two resident medical officers. In order to be sure of this fact, I have been at some pains to obtain figures from provincial fever hospitals comparable with this as to the medical staff they employ. In one hospital with 250 beds, I learn that 2,152 cases were admitted last year and that three medical officers are constantly in residence, whilst a fourth is engaged in the stress of winter. In another of similar size, 2,132 patients were admitted and here three medical officers are employed. In a third, in an extra-metropolitan district where the average admissions for the last 10 years is 1,050, and where 1,732 cases were admitted last year, the local authority consider that three medical officers are required. In addition to the fact that the admissions to this hospital are nearly 500 in excess of the first mentioned hospital and nearly 1,000 more than in the third, there is the fact that in this hospital half of the total number are non-infectious cases. Now these cases are admitted for urgent treatment and because they are of such a nature that the treatment cannot be carried out at home. A very different matter as compared with infectious cases, a verv large proportion of which are of such a nature that they require very little medical treatment at all. These figures I feel sure the Council will consider convincing and amply justifying the appointment of another medical officer. With two medical officers as at present and having regard to the number of urgent cases that are being admitted it is not possible for them to get adequate relief. In order to accomplish the work the Council expects them to perform they necessarily must be on duty seven days a week. Should they be absent for a few hours, they must still keep in touch with the hospital. There is no break from year end to year end save for annual leave. Were a third medical officer appointed, reasonable off-duty time could be arranged which could not possibly fail to have a beneficial effect on their health as well as to favourably affect the exacting work it is their constant duty to perform. At the present moment there is some rumour of the estimates for the current year being reduced by 20 per cent. It is to be hoped that this will not deter any member of the Council from approving of the appointment of an assistant. A reduction to that extent may mean a reduction in the aggregate admissions for the year, say from 2,600 to 2,000; it may mean that the wards instead of being overfull as at present will only be fully occupied; it will mean, however, the selected cases (non-infectious) requiring urgent treatment will only be admitted, the less serious remaining at home; but, it certainly will not mean any reduction in the amount of medical treatment or of the possibility of closing any of the wards. I will now deal with the figures set out in the Statistical tables appended to this report. The grand total of admissions as will be seen reaches the high figure of 2,608. Of these, 1,113 are of an infectious and 1,495 of a non-infectious character. It is to be particularly noted that the infectious cases are unusually high, nothing approximating the figure has ever been reached before. The highest previously was 979 in 1914. In 1919, the number was 723. There is therefore an increase of just 400 cases in 1920. The actual increase takes place amongst Scarlet fever and Diphtheria cases, there being an unusual prevalence of these two diseases in the latter part of the year. During the war years the incidence of these diseases was providentially low. It was well recognised, however, that the comparatively empty state of the hospitals during that period would not continue long, as it is common knowledge that the incidence of Scarlet Fever and of Diphtheria is subject to quinquennial fluctuations and that a low incidence spread over a number of years is followed almost invariably by years of increased prevalence. At the present time of writing, Scarlet Fever, judging by the number of cases in hospital, is as prevalent as it was in mid-winter, though Diphtheria cases show more definitely the seasonal drop in the incidence that is customary to expect at this period of the year. Of the 1,113 infectious cases, 445 suffered from Scarlet Fever. In 1919 there were 238. ,, ,, ,, 605 ,, Diphtheria. „ ,, 431. ,, „ ,, 63* ,, Other Infections. „ ,, 54.† (* Including 8 Enteric Fever cases). († Including 2 Enteric Fever cases). 87 Scarlet Fever. The remarkable thing in connection with this disease is not only the great increase in number, but also the invariable mildness of the attacks which occurred during the period of greatest prevalence. A regrettable circumstance, however, has to be noted, that in spite of the mildness, the infectiousness of the patient seemed to persist during convalescence for an unusually long period and in a larger number of cases than it is usual to expect. It is to be assumed that the increased incidence of the disease is to be attributed to a particularly active infection, and possibly that very fact accounts to some extent for the undue persistence of the infectiousness in the patient. In my opinion, however, a much more potent factor was the circumstance that in order to accommodate all the cases overcrowding of the wards constantly prevailed. The floor space per patient being approximately 50 per cent. of what is generally considered adequate. As the result of a fairly long experience, I have no hesitation in saying that if the floor or cubic space, of Scarlet Fever patients especially, is diminished below the recognised standard, that will at once aggravate the infectiousness of your patient. A large proportion of patients, once this happens, do not convalesce so readily, their throats, nose and ear conditions do not heal, purulent discharges from all these sites become frequent and persistent, they interchange their infections, and generally the patients remain in a quite unsuitable state for discharge to their homes. It is not my intention to try to prove that persistence of infectiousness is solely attributable to overcrowding; there are other factors at work, but I am anxious the Council should realise that when you diminish the floor space or cubic space per patient below the standard, that you defeat the very end for which the hospital exists. By so doing, instead of rendering the infection in the patient harmless, you foster and intensify it. There is ample proof that free ventilation and adequate space per patient renders Scarlet Fever infection quickly inert, just as there is proof that the reverse aggravates it. It is false economy to provide insufficient accommodation for your infectious patients To refrain from building may effect a saving in that particular direction but it invariably means, and experience teaches it here, that extra expenditure is incurred by reason of the fact that your, patients remain longer under treatment. Diphtheria. The 605 cases of this disease is the highest yet reached. Diphtheria seemingly is as prevalent as ever, and clinical experience shows that there is no diminution in its virulence. Were it not for the beneficial effect of anti-toxin treatment there can be no doubt that it would be the most fatal of all the infectious ailments now existent in this country. Throughout the year the type of attack for the most part was severe, and there is the added fact that, even in cases which came early under treatment, the diseases seem to have progressed with unusual rapidity. Many cases of great malignity were admitted, and several exceeded anything in that respect I have ever seen before. Attention might be drawn to the unusual number of cases of nasal diphtheria admitted. Many of these cases had no throat affection, but a condition entirely limited to the nasal passages. These pure nasal cases are never fatal. They are, however, intensely infectious. There is great danger of the condition spreading to others and of the condition continuing long after the patients return home in spite of that fact that a negative bacterial examination was obtained at the time of leaving the hospital. This is the explanation, at any rate in part, in my opinion of the rather large number of return cases of diphtheria that occurred during the year, though here, also, the crowded state of the wards may have played its part. In any case it has been the experience that return cases of diphtheria are extremely rare, but there is no doubt that for the last two years, since when patients suffering from this disease have had to be treated under crowded conditions, that return cases have greatly increased. Considerable discussion is at present being carried on in the medical journals with regard to the advisability of discharging diphtheria convalescents who are still harbouring the specific germ. The invariable custom here is to discharge the patient only when the bacteriological examination has proved that he or she is free from infection. It is an interesting fact, however, that experience here shows that no harm accrues in the case of a patient discharged after a faucial or throat attack, and who possibly, in spite of a negative bacteriological examination, harbours the specific organism on his return home, but that a second or return case frequently results on the return home of the patient recovered from a nasal attack in whom apparently the infection had similarly persisted. I would again draw your attention to the fact that all bacteriological examinations connected with diphtheria and other infectious diseases are still being made in London, and that delay is caused thereby. This, in many instances of diphtheria, I believe, has militated against the chances of recovery of the patient. Other Infectious Diseases. The total admitted under this heading was 63, and these include:— 8 cases of Enteric Fever. 2 „ Whooping Cough. 9 ,, Measles. 16 „ Infantile Diarrhoea. 8 ,, Erysipelas. 88 5 cases of Ophthalmia Neonatorum. 6 ,, Pneumonia. 1 ,, Varicella. 8 „ Influenza.' Most of the above diseases require to be isolated from the other patients and in special wards. The lack of small ward accommodation made it a matter of great difficulty to provide adequate isolation, especially during the winter months. Coexistent Disease. Under this heading a total of 54 cases were admitted :— In 35 patients Scarlet Fever and Diphtheria coexisted at the tim,e of admission. 7 „ „ „ Chicken Pox „ „ „ ,, 7 „ ,, ,, Measles ,, ,, ,, „ 4 „ Diphtheria and Chicken Pox ,, „ ,, ,, 1 „ „ „ German Measles ,, ,, ,, „ The number is a considerable increase on previous years, and is due to the fact that a more systematic bacteriological examination of the throats and noses of Scarlet Fever patients during the acute stages of the attack have been carried out Amongst the 35 coexistent Scarlet Fever and Diphtheria patients, 19 had developed Diphtheria in an ordinary faucial or throat form, the balance exhibiting the intensely infectious nasal type I have already referred to in an earlier part of this report. I specially allude to these Coexistent Scarlet Fever and Nasal Diphtheria cases for the reason that a large proportion of them have very clearly, I might add very unpleasantly, brought home to me the very close relationship there is between Coexistent Scarlet Fever and Diphtheria, and Return cases of the former disease. So much so, that I have now the greatest diffidence in discharging those cases of Scarlet Fever in which I know this second infection to have existed. During the eighteen years I have been in this hospital I have had a very intimate knowledge of every case of Scarlet Fever that has passed in and out of the hospital, for all of them have been under my own particular care in the wards. I have in consequence a very clear idea of the class of patient which gives rise to a Return Case of Scarlet Fever on its return home and I have no hesitation in saying that a very large number of these return cases of Scarlet Fever are set up by patients discharged from hospital in whom Coexistence of Scarlet Fever and Nasal Diphtheria has existed. So repeatedly has this occurred on the discharge home of these Co-existent cases during previous years that it only required the convincing experience of last year to remove all vestige of doubt. It is in consequence of this fact that I have drawn special attention to it. It has long been recognised that convalescent cases of Scarlet Fever with mucous discharges from the nose are above all others the most likely to give rise to return cases, but I do not think it has been noted that the infecting cases are mixed infections or that the mucous discharges are in many instances of diphtheritic origin. The interesting fact to note in connection with the whole question is that these cases of Scarlet Fever or Nasal Diphtheria on their return home seldom give rise to Coexistent Scarlet Fever and Diphtheria return cases, and still more seldom to pure Diphtheria cases; in the great majority of cases the return case suffers from Scarlet Fever alone. In other words the Coexistence of the two infections intensifies the power to infect of the Scarlet Fever element almost to the exclusion of the other. Non-Infectious Cases. Reference to Table No. 1 shows that 1,495 cases of this category were admitted. This is an addition of 515 patients as compared with 1919, the increase actually taking place in the case of children of school age and in maternity. There was also a slight increase amongst Gynaecological cases and adults. Children under 5 Years of Age. I here is nothing to state under this heading, except that the number of cases as compared with the previous year shows a decrease of 79. Children of School Age. Tables Nos. 59 and 60, which deal with the above, appear in the School Medical Officer's Report and are specially dealt with by him. I would, however, draw special attention to the large number of cases in which enlarged tonsils and adenoids were removed, also to the fact that although one morning a week is given up entirely to operating on these particular patients the number on the waiting list does not diminish and at present, approximates over two hundred. It is obviously a very prevalent condition, and even if the hospital admitted nothing but infectious cases, I am of opinion that the systematic removal of these enlarged tonsils and adenoids would be well advised. J here is a close relationship between the conditions just mentioned and the onset of infectious ailments, and it is well recognised that not only are these cases more prone to catch infection than others, but also that they suffer from that infection more severely, and above all harbour it for a protracted period of time. It is these tonsil and adenoid cases which carry infection home in a large proportion of cases, and it is these cases that are so difficult to prepare and get ready for discharge and remain so long in hospital. 89 Altogether it seems that it would be a wise policy to arrange for the operations on these cases on an even greater scale than at present, with the double object of improving the health of the patient and of diminishing the incidence of infectious ailments amongst them. That surely would come under the heading of preventive medicine. Maternity Cases. Very great pressure was maintained without intermission during the year on this department. Sixteen beds and 1 labour bed are provided, but as many as twenty-three patients in hospital at one time was by no means infrequent. A total of 470 cases as compared with 239 in 1919 was admitted, and as seen in Table No. 97, the complications or ailment associated with the confinement are set out. Of the 470, 30 proved "not to be in labour. Of the number confined, 429 infants were born alive and 11 dead. Amongst the former born alive, 26 subsequently died within a few days from general feebleness and immaturity. Of the infants born alive 223 were males and 217 females. The following table gives the number of the pregnancy:— Table No. 85. Pregnancy. No.] 1st 299 2nd 83 3rd 43 4th 28 5th 21 6th 14 7th 10 8th 10 9th 4 10th 7 11th 2 12th 3 13th 1 14 th — 15th 1 16th 1 Five mothers were delivered by Caesarean Section, all of them recovering, whilst 31 required --Torceps delivery. By referring to Table No. 100 under the heading of Obstetrics, other conditions , calling for operative interference at the time of confinement are tabulated. Seven mothers died :— 3 from Septicaemia. 1 „ Pelvic Peritonitis. 1 „ Eclampsia. 1 „ Antepartum Hemorrhage. 1 ,, Pulmonary Embolism. Gynecological Cases. Eighty-one as compared with 41 of these cases in 1919 were admitted Two died, one from Suppurative Salpingitis and one from Pelvic Abscess following abortion. If there is one department in the Council's hospital more than another, I think it is this which calls for special support. Evidently there is a large field for helpful work on the part of the Council with a view to determining the extent to which cases coming under this category exist in the district, and if considered necessary carrying out the operative treatment already undertaken by the Council on an even larger scale. From the short experience of 2½ years, there appears to me no doubt but that there is a large number of women in the district who as the result of pregnancy, and particularly of the actual confinement itself, suffer from certain grave physical disabilities which must and does mean to them chronic ill-health. The very nature of the disability makes the patient very diffident about seeking advice. It is consequently very difficult to get in touch with these, but the increasing number admitted to the hospital suggests that the Clinic Medical Officers are at least searching some of these unfortunate cases out. Peculiarly enough, though the condition leads to ill-health, once operative treatment is carried out, a quick improvement in health is the almost invariable rule : the patient being once more able to carry out her ordinary household duties. Almost without exception, these cases are drawn from a class of the community who cannot pay for an operation such as is entailed. Moreover, the pressure in the. London general hospitals, and the fact too that these patients require at least 3 weeks or a month's hospital ward treatment, precludes their admission there in a considerable number of cases. The result of such a condition of affairs necessarily means that, failing the Council's endeavour, these sad cases will continue with no hope of alleviation. Operations. By reference to Table No. 100, it will be seen that 619 operations requiring an anaesthetic, and of a major or minor character, were performed during the year. This is an average of 50 per 90 month, or nearly more than 11 per day. I mention this figure specially, as it is desirable that it should be borne in mind when you are considering the question of the medical and nursing staff and the work they perform. In an ordinary fever hospital where it can be said the nursing and medical staff are considerably higher than here, a fair average number of operations is about 5 or 6 per month, or practically one-tenth the number of this hospital in the same time. Further, you will remember that not only do operations take up a large amount of time and quite half of the number mentioned are performed by your resident medical officers, but they also entail subsequently a great deal of responsible and often tedious after treatment. Duration of Stay in Hospital. No patient is discharged until he or she is fit enough to return safely home. At the same time some of them do return at an earlier date than would be the case if the wards were less full or if there was a convalescent home attached to the hospital as was the case 10 years ago, when* Kingsbury Hospital was in use. Nothing is to be gained by keeping a patient convalescent after a serious illness in a ward full of patients in the acute stages of their attacks. It is much better to send them to their homes, though it would be better still if they were sent to a convalescent home, there to reap the full benefit of the treatment which they receive whilst under the Council's care in this hospital. The figures below give the duration of the stay in hospital of all the cases treated, infectious and non-infectious alike. Table No. 86. Cases. Average duration of stay in Hospital. Maternity 15.0 days. Diseases of Women 23.1 „ Children under 5 Years 26.6 „ School Children 18.5 „ Adults 21.7 „ Scarlet Fever 35.7 „ Diphtheria 26.0 „ Enteric Fever 34.0 „ Other Infections 15.6 „ Visiting Medical Staff. No change has taken place in the number of Visiting Surgeons attached to the hospital. Each of the first three Surgeons on the subjoined list attends on one morning a week, and Mr. Oliver attends once a month for operations on patients he has previously selected when attending the Clinics. The names of the Visiting Surgeons are :— A. H. Bourne, F.R.C.S. R. H. Campbell, F.R.C.S. J. F. O'Malley, F.R.C.S. M. W. B. Oliver, F.R.C.S. Sick Staff. I have to report an even greater amount of sickness during this year than ever. It is doubly unfortunate too that it should occur at a time when the hospital was so severely taxed with work. There were no less than 283 occasions on which members of the staff reported sick, and out of that number there were 85 who were off duty for more than 24 hours at one time. The aggregate number of days these 85 people were off duty was 986 days, as compared with 922 days a year ago. Amongst the 85, 55 were nurses, and these were off duty for a total of 730 days, or the equivalent of two nurses practically, throughout the year. In 1920, 44 nurses were off duty for a total of 414 days only. There would therefore seem to be a direct connection between the amount of work and the amount of sickness amongst the nursing staff. As the hospital admissions increase, the proportion of nurses remaining at the low figure of 50, so the amount of sickness amongst them becomes more frequent. This lack of staff through illness is a very urgent matter, and it is one which calls for your very early attention. There can be no doubt that if you have not a sufficient number of nurses, the treatment of patients must suffer. The same degree of sickness did not occur amongst the Domestic Staff; these members of the staff work much shorter hours, besides they do not come into such close contact with the patients as nurses do. Hospital Accommodation. A better heading would perhaps be "Lack of accommodation." In various parts of the -report I have indicated the directions in which accommodation is wanting or is insufficient. In my opinion more large wards are wanted so as to bring the number of infectious beds at any rate up to 170 at least; that is, 1 bed for every 1,000 of the population, a standard number this hospital 91 has been without for certainly 18 years. More small wards are also required for observation purposes, Should it be that the Council deems it inexpedient to build these extensions, a remedy is to be found by giving up the S. and W. blocks used by the domestic staff at present, and renovating these for occupation by patients, the purpose for which they were originally built. Such an arrangement would relieve the congestion of the larger wards and the observation wards ; it would entail, however, the building of additional staff quarters. Passing now to the question of staff accommodation, here again a shortage exists. There never has been, as a matter of fact, anything but an insufficiency ever since the hospital was extended in 1903. In that year an annexe with 25 beds for nurses was built certainly, but a house then used for the accommodation of nurses in Bruce Road close at hand was given up, and it was in that year that S. Ward block was first used for their accommodation. In 1905 I reported that the nursing staff accommodation was inadequate and as a consequence the Council added another wing to the ward block just mentioned, which certainly improved matters, though it by no means relieved the situation. Since that date, even admitting that a further 16 beds in W. block have been added for the use of staff, at the expense of the ward accommodation for patients, and that a few beds for staff have also been made in odd corners of the hospital, the accommodation for nurses, just as it is for staff, is a long way short of actual requirements. As I have already mentioned, it is not possible to house all the nurses the hospital requires, and 51 out of 58 is all that there is accommodation for. Equally well does all that I have said apply to the question of mess room and recreation room accommodation for the nurses. The mess rooms and recreation rooms at the present time are quite inadequate. In extent they are just exactly what they were in 1894, when the staff was one-third of its present day number. The mess room measures 22 ft. by 17 ft. and the recreation 29 ft. by 16 ft. 6 in. ; both of them frequently called upon to accommodate over 30 nurses at one time. As regards the domestic staff accommodation, quite 50 per cent, of them live outside in their homes in the district, but for the remainder there is practically no real staff quarters of a recognised kind. They are housed in the iron and wood blocks already referred to, which are by design unfitted for the purpose of mess room and recreation rooms just as they are as bedrooms. Altogether, there is, I am afraid, no remedy but to build more accommodation for the staff, both nursing and domestic. It is unfortunate that the Council at such a time should have to meet this extra outlay; it is all because Councils in the past have refused to face the actual facts, that these force themselves to the front now and call for your earliest attention. Within two years the hospital admissions have trebled in size ; it is reasonable to expect that the number of staff and the accommodation for them to be provided shall be increased in proportion. Otherwise, I submit with all due respect, the Council will continue to impose the hardships to which I have already drawn attention. Small Pox Accommodation. During the year frequent reference has been made to the question of the Small Pox accommodation. Nothing in the shape of a Small Pox hospital exists, other than the burnt down remains of Kingsbury hospital, which previously was used for the purpose, but which I understand the Council no longer considers suitable for the purpose. Finally, I would take this opportunity of thanking my colleague, Dr. McKenzie, and the entire Nursing, Domestic and Hospital Staff generally, for their loyal support during a year of strenuous work under the most difficult conditions. I am, Ladies and Gentlemen, Your obedient servant, W. J. J. STEWART, June 8th, 1921. Medical Superintendent. 92 TABLE No. 87. Scarlet Fever. Diphtheria. Enteric Fever. Other Infectious Diseases. Total. Children under 5 years. Children of School Age. Obstetrical. Gynaecological. Diseases of Adults. Total. Grand Total. No. of cases admitted during 1920 445 605 8 55 1,113 245 570 470 81 129 1,495 2,608 No. under treatment Dec. 31st, 1919 38 61 0 3 102 19 27 13 0 6 65 167 Total No. under treatment during 1920 483 666 8 58 1,215 264 597 483 81 135 1,560 2,775 No. discharged during 1920 419 572 8 44 1,043 226 580 457 75 119 1,457 2,500 No. died during 1920 8 40 — 14 62 22 6 7 2 14 51 113 Mortality % 1.7 6.0 — 24.1 5.1 8.3 1.0 1.4 2.5 10 .4 3 .3 4.1 Remaining in hospital, Dec. 31st, 1920 56 54 0 0 110 16 11 19 4 2 52 162 TABLE No. 88. Month. Scarlet Fever. Diphtheria. Enteric Fever. Other Infect. Diseases. Total. Total. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. January 44 — 47 3 — — 4 1 95 4 February 42 — 58 2 — — 4 2 104 4 March 14 2 35 1 — — 8 — 57 3 April 14 — 31 2 — — 7 2 52 4 May 20 — 41 5 — — 5 1 66 6 June 15 2 45 4 2 — 2 — 64 6 July 31 — 36 4 — — 4 1 71 5 August 26 — 37 2 — — 8 3 71 5 September 51 1 59 5 2 — 8 2 120 8 October 73 — 72 4 3 — 4 2 152 6 November 65 1 78 3 1 — 1 — 145 6 December 50 2 66 3 — — — 116 5 Total 445 8 605 40 8 — 55 14 1,113 62 TABLE No. 89. Children under 5 years. Children of School age. Obstetrical. Gynaec ological. General Diseases of Adults. Total. Month Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Jan. 24 2 43 — 40 — 8 — 12 1 127 3 Feb. 29 3 59 2 33 2 4 — 11 2 136 9 Mar. 36 1 45 — 50 — 6 — 8 4 145 5 Apr. 14 1 64 1 39 — 5 — 10 1 132 3 May 19 — 44 1 33 4 1 8 1 108 3 June 16 1 55 1 39 1 12 — 12 1 134 4 July 17 1 51 — 41 .— 4 — 13 2 126 3 Aug. 9 1 11 — 35 1 6 — 12 — 73 o Sept. 21 2 55 — 39 — 13 — 11 — 139 2 Oct. 16 4 57 1 42 — 7 1 16 2 138 8 Nov. 17 1 48 — 39 2 9 — 8 — 121 3 Dec. 27 5 38 — 40 1 3 — 8 — 116 6 Total 245 22 570 6 470 7 81 2 129 14 1,495 51 93 TABLE No. 90. Scarlet Fever. Age. Males. Females. Total. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Under 1 1 — 1 — 2 — 1 to 2 3 — 3 — 6 — 2 „ 3 10 — 4 — 14 — 3 „ 4 9 — 14 — 23 — 4 „ 5 18 1 15 2 33 3 5 „ 10 77 2 96 2 173 4 10 „ 15 47 — 84 1 131 1 15 „ 20 11 — 10 — 21 — 20 „ 25 4 — 11 — 15 — 25 „ 30 2 — 5 — 7 — 30 „ 35 1 — 5 — 6 — 35 „ 40 3 — 7 — 10 — 40 „ 45 1 — 3 — 4 — 50 and over — — — — — — Total 187 3 258 5 445 8 TABLE No. 91. Diphtheria. Age. Males. Females. Total. Admissions. Deaths. Admissions. Deaths. Admissions. Deaths. Under 1 1 — 1 1 2 1 1 to 2 6 — 2 — 8 — 2 „ 3 9 1 13 1 22 2 3 „ 4 24 4 13 — 37 4 4 „ 5 18 4 18 1 36 5 5 „ 10 147 9 159 10 306 19 10 15 54 1 67 5 121 6 15 „ 20 14 1 10 — 24 1 20 „ 25 4 — 9 — 13 — 25 „ 30 — — 6 — 6 — 30 „ 35 5 — 9 — 14 — 35 „ 40 3 1 6 — 9 1 40 „ 45 4 1 3 — 7 1 50 and over — — — — — — Total 289 22 316 18 605 40 TABLE No. 92. Diphtheria. Day of Disease on Admission. Admissions. Deaths. Case Mortality. 1st 26 — % 2nd 131 6 4.6 3rd 145 9 6.2 4th 108 12 11.1 5th 73 9 12.3 6th and over 122 4 3.3 Total 605 40 6.6 94 Table No. 93. Chief Complications of Scarlet Fever. Number of Cases. Otitis Media 24 Mastoiditis 2 Adenitis 19 „ (Suppurative) 3 Relapse 2 Rheumatism 16 Nephritis 5 Albuminuria 15 Endocarditis 1 Septicaemia 1 Total 88 Table No. 94. Chief Complications of Diphtheria. Number of Cases Adenitis 16 Albuminuria 44 Paralysis 39 Toxaemia 16 Total 115 Table No. 95. Showing Cases wrongly Certified and the Diseases for which they were mistaken. Certified as suffering from Diagnosed as suffering from Total. Scarlet Fever. Diphtheria. Enteric Fever. 3 — — Pharyngitis 3 2 — — Stomatitis 2 17 26 — Tonsillitis 43 — — 1 Debility 1 — 1 — Secondary Syphilis 1 1 1 — Morbilli 2 — — 1 Bronchitis 1 1 — — Varicella 1 1 1 — Quinsy 2 — 5 — Scarlet Fever 5 — — 1 Cephalgia 1 — 3 — Rhinitis 3 2 — — Diphtheria 2 1 — — Septic Rash 1 2 — — Nil 2 30 37 3 Total 70 95 Table No. 96. Children under 5 Years admitted during 1920 (excluding Epidemic Diarrhoea, Measles, Whooping Cough and Ophthalmia Neonatorum, which are included with Infectious Diseases). Condition. Municipal Clinic. Private Medical practitioner. Total Treatment. Result. Remaining in Hospital, Dec. 31, 1920. Operation . General Other. Remedied. Improved. Unchanged Died. (i.) (ii.) Rickets 1 2 — 3 3 — — 2 — — — 1 Marasmus 7 5 3 15 — 15 — 8 — — 7 — Prematurity 3 1 — 4 — 4 — 1 — — 1 2 Debility 3 3 1 7 — 7 — 6 — — — 1 Acute Rheumatism — — 1 1 — 1 — 1 — — — Tonsillitis 2 — 12 14 — 14 — 14 — — — — Pyaemia — 1 — 1 — 1 — — — — 1 — Septicaemia 1 — 1 2 — 2 — — — — 2 — T.B. Meningitis — — 1 1 — 1 — — — — 1 — Post. Basal Meningitis — 2 — 2 — 2 — — — — 2 — Rhinitis — — 3 3 — 3 — 3 — — — — Bronchitis 19 2 12 33 — 33 — 28 — — — 5 Broncho Pneumonia 8 2 6 16 16 11 — — 5 — Stomatitis — 1 1 2 — 2 — 2 — — — — Pyloric Stenosis — 1 — — — 1 — 1 — — — — Constipation ,.. — — 1 — — 1 — 1 — — — — Appendicular Colic — — 2 — — 2 — 2 — — — — Colitis — — 1 — 1 — 1 — —. — — Morbus Cordis — 1 — — — 1 — — 1 — — Nephritis 1 — — — — 1 — — — — 1 — Phimosis 20 21 — 41 39 2 — 39 — — — 2 Paraphimosis 1 1 — 2 2 — — 2 — — — — Tonsillotomy 9 14 1 24 24 — — 24 — — — — Hernia (Ing.) 8 — 1 9 9 — — 8 — — — 1 Hydrocele 2 — — 2 2 — — 2 — — — — Vulvo-Vaginitis — — 1 1 — 1 — 1 — — — — Appendicitis 1 — — 1 1 — — — — 1 — Hare Lip — 1 _ 1 ' 1 — — 1 — — — — Cleit Palate 1 — — 1 1 — — 1 — — — — Tubercular Glands 3 — 1 4 1 3 — 4 — — — — Wart on Face — 1 — 1 1 — — — — — — 1 Nsevus 1 3 — 4 3 1 — 4 — — — — Sebaceous Cyst 1 1 — 2 2 — — 2 — — — — Dernoid Cyst — 1 — 1 — 1 — 1 — — — — Thyroglossal Cyst — 1 — 1 1 — — 1 — — — — Talipes EquinoVarus — 1 — 1 1 — — 1 — — — — Syndactly 1 — 1 1 — — — 1 Fracture (Limbs) 2 — — 2 1 1 — 1 — 1 — — Conjunctivitis — — 2 2 — 2 — 2 — — — — Burns — — 2 2 — 2 1 — — 1 — Ostes-Myelitis — 1 — I 1 — 1 — — — — Cellulitis 1 2 — 3 3 — 2 — — 1 Impetigo 2 2 — 4 — 4 — 4 — — — — Seborrhoric Dermatitis 1 — — 1 — 1 — — — — — 1 Abscess 5 5 1 11 11 11 — — — — Septic Wound 1 4 5 — 5 — 5 — — — — Septic Eruption — — 1 1 — 1 — 1 — — — — Furunculosis 1 1 — 1 1 — — — — Scabies 2 1 — 3 — 3 3 — — — Nil — — 1 1 — 1 — — — 1 — — Total 107 81 57 245 108 137 — 204 — 3 22 16 96 Table No. 97. Maternity Complications. Condition. Number. Placenta Previa 6 Contracted Pelvis 5 Puerperal Mania 1 Morbus Cordis 3 Phlebitis 2 Eclampsia... 2 Pelvic Cellulitis 3 Pelvic Peritonitis 2 Saprsemia 7 Septicaemia 3 Albuminuria 3 Pulmonary Embolism 1 Breech Presentations 7 Brow „ I Face „ 2 Prolapse of Cord 3 Contraction Ring 1 Persistant Occipito - Posterior Presentations 7 Twin Labour 2 Speno-Nedullary Leuchasmia 1 Retained Placenta 3 Suppurative Mastitis 2 Henoch's Purpura 1 Pneumonia 2 Bronchitis... 1 Chronic Nephritis 1 Total 72 Table No. 98. Gynaecological Cases. Condition. Number. Threatened Abortion 4 Inevitable Abortion 6 Incomplete Abortion 19 Prolapse of Uterus 9 Retroversion of Uterus 3 Menorrhagia 2 Cervical Polypus 3 Cervical Erosion 1 Ovaritis 1 Salpingitis 5 Chronic Endometritis 2 Pelvic Peritonitis 4 Pelvic Cellulitis 1 Parametritis 1 Puerperal Saprsemia 1 Puerperal Septicemia 3 Ovarian Cyst 2 Tubal Pregnancy 1 Retracted Nipples 1 Retained Placenta 1 Albuminuria of Pregnancy 2 Hyperemesis Gravidarum 1 Acute Mastitis 8 Total 81 97 Table No. 99. Diseases of Adults. Condition. Number. Recovered. Unchanged. Died. Laryngitis 1 1 — — Bronchitis 3 3 — — Asthma 1 1 — — Pleurisy 6 5 — 1 Empyema 1 — — 1 Morbus Cordis 4 — 1 3 Malignant Endocarditis 1 — — 1 Anaemia 2 2 — — Syphilis 1 — 4 — Gonorrhoral Rheumatism 1 1 — — Acute Rheumatism 4 4 — — Septic Arthritis 1 1 — — Chorea 1 1 — — Tonsilitis 23 23 — — Epilepsy 1 — 1 — Ptomaine Poisoning 1 1 — — Belladonna Poisoning 1 1 — — Gastro-Enteritis 4 4 — — T.B. Meningitis 1 — — 1 Cephalgia 3 3 — — T. B. Adenitis 1 1 — — Concussion 3 3 — — Cerebral Haemorrhage 1 1 — Fracture of Leg 3 3 — 7 Synovitis (Knee) 3 3 — — Epulis of Tongue 1 1 — — Tonsillotomy 2 2 — — Mastoiditis 2 2 — — F.B. in (Esophagus 1 1 — — Carcinoma of Face 1 — 1 — Cellulitis of Face 2 — — 2 Gastric Ulcer 2 1 — 1 Gastrostaxis 1 — — 1 Post-Operative Adhesions 1 1 — — Femoral Hernia (Strang.) 2 2 — — Ventral Hernia 1 1 — — Inguinal Hernia 1 1 — — Intestinal Obstruction 1 — — 1 Gall Stones 1 1 — — Pyonephrosis 1 — — 1 Renal Colic 1 1 — — Urethral Stricture 1 1 — — Enlarged Prostate 1 — 1 — Phlebitis 5 5 — — Varicose Veins 2 2 — — Septic Wound 3 3 — — Septic Rash 1 1 — — Abscess 8 8 — — Scabies 1 1 — — Colic 1 1 — — Appendicitis 12 11 — 1 Nil 1 — 1 — Total 129 109 6 14 98 Table No. 100. Anesthetics Administered for Operations during 1920. General Surgical Cases. Number. General Surgical Cases. Number. Operation. Operation. Appendicectomy 19 Mastoid (Antrotomy) 6 Fermoral Hernia (Strang.) 2 Removal of F.B. in Ear 1 Inguinal Hernia 13 Tonsillotomy 340 Umbilical Hernia 1 Tracheotomy 5 Ventral Hernia 1 Broken Cartilage of Nose 1 Hydrocele Deflected Septum 3 Perforated Gastric Ulcer Extirpation of Antrum of Highmore 1 Glands in Neck 2 Strabismus 9 Intestinal Obstruction 1 Rectal Polypus 1 Amputation 1 Sequestrotomy 1 Bone Grafting Ganglion 2 Bone Plating 1 Angioma 4 Semi-lunar Cartilage 1 Varicose Veins 1 Hare Lip 1 Sebaceous Cyst 3 Cleft Palate 1 Ranula 1 Osteotomy Epulis of Tongue 1 Haemorrhoids 1 Phimosis 44 Ischio-Rectal Abscess 1 Para-phimosis 2 Gastrotomy 1 Abscess 19 Empyema Incisions for Cellulitis 4 Liver Abscess 1 Prepatellar Bursa 1 Syndactly 1 Lumbar Punctum 3 Supra-pubic Cystotomy 1 Manipulation of Fracture 1 Thyroglossal Cyst 1 Application of Plaster 4 Mastoid (Radical) 2 Tenotomy 3 Total 524 Obstetrical Cases. Number. Gynaecological Cases. Number. Operation. Operation. Csesarean Section 5 Ventral Fixation 4 Craniotomy 1 Salpingectomy 6 Ectopic Gestation 1 Perineorraphy 7 Induction 4 Colporrhaphy 2 Contraction Ring 1 Fibrous Polypus 2 Adherent Placenta 3 Ovarian Cyst 2 Instrumental Delivery 31 Replacing Retroversion 1 Parametritis 1 Pelvic Peritonitis 1 Peri-Ovarian Abscess 1 Curettage 16 Acute Mastitis 6 Total 46 Total 49 99 APPENDICES. 100 APPENDIX A. VITAL STATISTICS. Explanatory Notes. Table I.— This Table is arranged to show the gross births and deaths in the District, and each ward, and the births and deaths properly belonging to them with the corresponding rates. The rates are calculated per 1,000 of the estimated gross population. In Column 6 are included the whole of the deaths registered during the year as having actually occurred within the district, but excluding the deaths of soldiers and sailors. In Column 12 is entered the number in Column 6, corrected by subtraction of the number in Column 8 and by addition of the number in Column 9. In Column 10 the deaths are similarly corrected by subtraction of the deaths under 1 year, included in the number given in Column 8, and by addition of the deaths under 1 year, included in the number given in Column 9. Column 4.—This number has been obtained by adding to the number shewn in Column 3 the number of births belonging to the district but occurring outside and subtracting the number occurring in the district but belonging to other districts. Column 8.—This number is the number of deaths excluded from the returns of the local Registrar as transferable deaths defined below. Column 9.—This number is the number of deaths transferred to the district by the RegistrarGeneral. "Transferable Deaths" are deaths of persons who, having a fixed or usual residence in England or Wales, die in a district other than that in which they resided. The deaths of persons without fixed or usual residence, e.g., casuals, are not included in Columns 8 or 9, except in certain instances under 3 (b) below. The following special cases arise as to Transferable Deaths :— (1) Persons dying in Institutions for the sick or infirm ; such as hospitals, lunatic asylums, workhouses, and nursing homes (but not almshouses) must be regarded as residents of the district in which they had a fixed or usual residence at the time of admission. If the person dying in an Institution had no fixed residence at the time of admission, the death is not transferable. If the patient has been directly transferred from one such institution to another, the death is transferable to the district of residence at the time of admission to the first Institution. (2) The deaths of infants born and dying within a year of birth in an Institution to which the mother was admitted for her confinement should be referred to the district of fixed or usual residence of the parent. (3) Deaths from Violence are to be referred (a) to the district of residence, under the general rule; (b) if this district is unknown, or the deceased had no fixed abode, to the district where the accident occurred, if known; (c) failing this, to the district where death occurred, if known; and (d) failing this, to the district where the body was found. Table II.—The classification of Causes of Death are those of the Detailed International List of Causes of Death as adapted for use in England and Wales. All "Transferable Deaths" of residents, i.e., of persons resident in the District who have died outside it, are included, and all transferable deaths of non-residents, i.e., persons resident in England and Wales who have died in the District excluded. All deaths occurring in Institutions for the sick and infirm situated within the district, whether of residents or non-residents, are entered in the last column of this Table. All deaths certified by registered Medical Practitioners and all Inquest cases are classed as " Certified "; all other deaths are regarded as " Uncertified." 101 Table I. VITAL STATISTICS OF WHOLE DISTRICT DURING 1920 AND PREVIOUS YEARS ; VITAL STATISTICS OF THE WARDS DURING 1920. Year. Population estimated to Middle of each Year. Whole District. Births. Total Deaths Registered in the District. Transferable Deaths. Nett Deaths belonging to the District. Uncor rected Number. Nett. Number. Rate. of nonresi dents registered in the District. of residents not registered in the District. Under 1 Year of Age. At all Ages. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) 1911 156,572 3,863 4,001 25.6 1,618 10.3 10 240 495 124 1,848 11.8 1912 159,868 3,912 4,075 25.5 1,307 8.7 27 233 328 80 1,603 10.02 1913 163,644 3,891 4,037 24.7 1,449 8.9 23 251 325 80 | 1,677 10.24 1914 166,634 3,971 4,115 24.7 1,501 9.0 32 283 337 82 1 1,752 10.51 1915 166,840 3,641 3,775 22.6 1,792 10.7 44 282 344 91 2,030 12.16 1916 167,810 3,557 3,668 21.9 1,436 8.55 34 308 283 77 1,710 10.19 1917 169,344 2,704 2,816 16.6 1,571 9.27 45 292 309 110 1,818 10.73 1918 169,358 2,520 2,651 15.65 1,975 11.66 35 338 258 97 2,278 13.45 1919 170,625 2,843 2.924 17.13 1,519 8.90 39 286 242 83 1,766 10.35 1920 170,892 4,203 4,232 24.76 1,427 8.35 50 295 274 65 1,672 9.78 WARDS. 1. S. Kilb'n 15,195 488 513 33.76 146 9.60 — 39 42 81.87 185 12.17 2. Mid K'b'n 15,071 457 443 29.39 148 9.82 4 43 25 56.43 187 12.40 3. N.Kilb'n 12,948 235 240 18.53 116 8.95 5 27 19 79.16 138 10.65 4. Brondsb'y Park 10,048 175 177 17.61 64 6.36 5 21 6 33.89 80 7.96 5. Kensal Rise 14,418 314 319 22.12 96 6.65 — 18 19 59.56 114 7.90 6. Harl'd'n 17,647 429 436 24.70 119 6.74 — 30 21 48.16 149 8.44 7. Stone. bridge 17,972 516 514 28.60 156 8.67 5 '26 38 73.92 177 9.84 8. Round. wood 15,883 448 461 29.02 148 9.31 10 12 27 58.56 150 9.44 9 Church End 14,436 353 348 24.10 119 8.24 1 16 30 86.20 134 9.28 10. Willesden Green 17,207 412 416 24.17 137 7.96 — 26 26 62.50 163 9.47 11. Cricklewood 20,067 376 365 18.18 178 8.87 20 37 21 57.53 195 9.71 Area of District in acres (land and inland water) 4,384 Total population at all ages 154,344 Total families or separate occupiers 35.478 at Census, 1911. 102 TABLE 11.—DEATHS OF WILLESDEN RESIDENTS DURING THE YEAR 1920. CAUSE OF DEATH. All Ages. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 to 75 75 to 85 85 Up. Total deaths, whether of " Residents" or Non-Resi dents," in Institutions in the District (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) All Causes Certified 1,672 274 77 55 38 34 49 92 165 156 213 223 234 62 519 Uncertified ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1.—General Diseases. Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Typhus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 17 7 7 3 ... ... ... ... ... ... ... ... ... ... 1 Scarlet Fever 8 3 4 ... ... ... ... ... ... ... ... ... ... 7 Whooping Cough 13 3 10 ... ... ... ... ... ... ... ... ... 5 Diphtheria 43 1 12 21 6 1 ... ... ... ... ... ... ... ... 40 Influenza 27 ... ... 1 1 ... 3 5 4 3 3 4 ... ... 5 Miliary Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Asiatic Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera Nostras ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Dysentery 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... 1 ... ... ... ... ... ... Yellow Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Leprosy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas 4 ... ... ... ... ... ... ... 1 1 ... ... 2 ... 4 Other Epidemic Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pyaemia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Septicaemia 2 ... ... ... ... ... ... ... ... ... 1 ... 1 ... 1 Vaccinia 1 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 Glanders ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Anthrax (Splenic Fever) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rabies ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tetanus ... ... .... ... ... ... ... ... ... ... ... ... ... ... Mycoses: Actinomycosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pellagra ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Beri-Beri ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pulmonary Tuberculosis (not acute) 117 1 2 ... 4 7 19 29 •31 13 10 1 ... ... 18 103 Phthisis (not acute and not defined as Tuberculosis) 7 ... ... ... ... ... ... 2 2 3 ... ... ... ... 1 Acute Phthisis ... 3 ... ... ... ... ... ... ... 1 ... ... ... ... ... Acute Miliary Tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous Meningitis 10 ... 3 ... ... 1 ... 1 1 ... ... ... ... ... 6 Tabes Mesenterica ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Peritoneal and Intestinal Tubercle 1 ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 Tuberculosis of Spinal Column 3 ... ... ... ... 2 ... 1 ... ... ... ... ... ... 1 Tuberculosis of Joints 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... Tuberculosis of other organs 2 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... Disseminated Tuberculosis 1 1 ... ... ... ... ... ... ... ... ... ... ... ... Rickets, Softening of Bones 2 ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... Syphilis 4 ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Other Venereal Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... Cancer of Buccal Cavity 15 ... ... ... ... ... ... ... 1 5 8 1 ... 3 Cancer of the Stomach, Liver, &c 37 ... ... ... ... ... ... ... 3 8 8 9 8 1 9 Cancer of Peritoneum, Intestines and Rectum 43 ... ... ... ... ... ... ... 3 3 13 19 3 1 13 Cancer of the Female Genital Organs 23 ... ... ... ... ... ... 1 4 10 5 1 2 ... 5 Cancer of the Breast 22 ... ... ... ... ... ... 1 4 10 4 1 1 1 7 Cancer of the Skin 2 ... ... ... ... ... ... ... ... 2 ... 1 Cancer of other or unspecified organs 33 ... ... ... ... ... ... 2 2 7 9 7 6 ... 8 Other Tumours (situation undefined) 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Rheumatic Fever 7 ... ... ... ... ... ... 3 ... ... ... ... ... ... 2 Chronic Rheumatism 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... Osteo-Arthritis 5 ... ... ... ... ... ... ... ... 1 1 ... 2 ... 4 Gout ... ... ... ... ... ... ... ... ... ... ... ... ... ... Scurvy ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diabetes 14 ... ... ... ... ... ... 2 1 3 2 ... ... ... 3 Exophthalmic Goitre 1 ... ... ... ... ... ... ... I ... ... ... ... ... ... Addisons Disease 2 ... ... ... ... ... ... ... 1 ... 1 ... ... ... 1 Leucocythoemia (Leuchoemia) ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lymphadenoma i ... ... ... ... ... ... ... ... ... ... ... ... ... ... Anaemia, Chlorosis 6 ... ... ... ... ... ... ... l 1 ... ... ... ... 1 Other General Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... Alcoholism (Acute or Chronic) ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chronic Lead Poisoning ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Chronic Occupational Poisoning 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Chronic Poisoning ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2.—Diseases of the Nervous System and of the Organs of Special Sense. Encephalitis 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... Cerebro-spinal Fever 1 ... ... 1 ... ... ... ... ... ... ... ... ... ... ... Posterior Basal Meningitis 2 2 ... ... ... ... ... ... ... ... ... ... ... ... 2 Meningitis, other forms 7 2 3 1 ... ... ... ... I ... ... ... ... ... 1 104 ( Table II.—DEATHS OF WILLESDEN RESIDENTS—continued. CAUSE OF DEATH. All Ages. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 65 to to 65 75 75 to 85 85 Up. Total deaths, whether of " Residents" oi " Ncm-Residents," in Institutions. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) in the District. (16) 2.—Diseases of the Nervous System and of the Organs of Special Sense.— Continued. • Locomotor Ataxy 4 ... ... ... ... ... ... ... 1 ... 2 ... 1 ... 1 Other Diseases of the Spinal Cord 9 ... ... ... 1 1 ... ... 1 ... 5 1 ... ... 4 Apoplexy 7 ... ... ... ... ... ... ... ... 2 ... 3 2 ... ...... Serous Apoplexy and Oedema of Brain 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... Cerebral Congestion 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ...... Cerebral Atheroma ... ... ... ... ... ... ... ... ... ... ... ... ... .... . . Cerebral Haemorrhage 72 1 ... ... ... ... ... ... 5 7 18 15 25 ... 39 Softening of Brain 1 ... ... ... ... ... ... ...... ' ... ... ...... 1 ... ... ... Hemiplegia 6 ... ... ... ... ... ... ... ... 2 ... 1 ... ... 1 Paraplegia ... ... ... ... ... ... ... ... ... ... ... ... ... ...... Other Forms of Paralysis 1 ... ... ... ... ... ... ... ... 5 ... ... ... ... ... General Paralysis of the Insane 11 ... ... ... ... ... ... ... ... 1 ... ... ... ... 2 Other Forms of Mental Alienation 2 ... ... ... ... ... ... 1 ... 2 ... ... ... ... 1 Epilepsy 9 ... ... ... ... ... ... 1 ... ... ... ... 2 ... 2 Convulsions (non-pucrperal; 5 years and over) 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 1 Infantile Convulsions under 5, with teething 3 3 ... ... ... ... ... ... ... ... ... ... ... ... ... Other Infantile Convulsions under 5 10 10 ... ... ... ... ... ... ... ... ... ... ... ... 1 Chorea ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Hysteria, Neuralgia, Neuritis ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Idiocy, Imbecility ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cretinism ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebral Tumour 4 ... ... ... ... ... ... ... ... ... ... ... ... ... l Other Diseases of the Nervous System 4 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Eye and Annexa ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Mastoid Disease ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Ears 3 1 ... ... 1 ... ... ... ... 1 ... ... ... ... l 3.—Diseases of the Circulatory System. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pericarditis 1 ... ... ... 1 ... ... ... ... ... ... ... ...... ... ...... Acute Myocarditis 2 ... ... ... ... ... ... ... 1 1 ...... ... ... ...... 2 Infective Endocarditis 10 ... ... ... ... ... 1 3 5 ... ... 1 ... ... 2 Other Acute Endocarditis 6 ... 1 2 2 ... 1 ... ... ... ... ... ... ... 2 Valvular Disease 70 ... ... 2 1 4 3 3 9 5 15 17 7 4 5 105 Fatty Degeneration of Heart 11 ... ... ... ... ... ... ... ... 2 4 2 2 1 1 Other Organic Disease of the Heart 114 1 ... ... ... 5 1 3 7 12 22 30 29 4 35 Angina Pectoris 4 ... ... ... ... ... ... ... ... ... 2 1 ... 1 ... Aneurysm 2 ... ... ... ... ... ... ... ... 1 1 ... ... ... ... Arterial Sclerosis 21 ... ... ... ... ... ... ... ... 2 2 6 8 ... 1 Other Diseases of Arteries ... ... ... ... ... ... ... ... ... ... ... ... 2 ... Cerebral Embolism and Thrombosis 8 ... ... ... ... ... ... ... ... 1 4 1 ... 2 ... Other Embolism and Thrombosis 2 ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... Diseases of the Veins (Varices, Hemorrhoids, ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Phlebitis, &c. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Status Lymphaticus ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Lymphatic System ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Haemorrhage; other Diseases of the Circulating ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... System 3 ... ... ... 1 ... ... ... ... ... ... 2 ... ... ... 4.—Diseases of the Respiratory System. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Nasal Fossæ ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Larynx 5 1 2 ... ... ... ... ... ... ... 1 ... 1 ... ... Diseases of the Thyroid Body ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis 133 21 3 1 ... ... ... 1 5 3 15 28 46 9 34 Broncho-Pneumonia 44 21 10 ... ... ... ... 2 1 4 2 2 2 ... 7 Lobar Pneumonia 17 3 3 l ... ... ... 3 ... 1 6 ... ... 2 Pneumonia (type not stated) 43 4 1 2 ... ... ... 1 8 7 12 2 ... 1 22 Empyema 2 ... ... ... ... ... ... ... 1 ... 1 ... ... 3 Other Pleurisy 4 ... ... ... ... ... ... 1 ... ... ... 3 ... ... 1 Pulmonary Apoplexy and Infarction 2 ... ... ... ... ... ... ... 1 ... ... ... ... 1 1 Pulmonary Oedema and Congestion 5 1 ... ... ... ... ... ... ... 1 ... 1 ... 1 ... Hypostatic Pneumonia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Collapse of Lung (3 months and over) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Gangrene of the Lung ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Asthma 9 ... ... ... ... ... ... ... ... ... 1 6 ... ... ... Pulmonary Emphysema 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 Fibroid Disease of Lung ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Disease of the Respiratory System 2 ... ... ... ... 1 ... ... ... 1 ... ... ... ... ... 5.—Diseases of the Digestive System. . Diseases of the Teeth and Gums ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Mouth and Annexa 2 1 ... ... ... ... ... ... ... ... ... ... ... ... 2 Diseases of Pharynx, Tonsillitis 2 ... ... ... 1 ... ... ... ... 1 ... ... ... ... Diseases of Oesophagus 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... Perforating Ulcer of Stomach 8 ... ... ... ... ... ... 2 4 ... 2 ... ... 3 Inflammation of Stomach 12 6 3 ... ... ... ... ... ... ... 1 ... 1 1 6 Other Diseases of the Stomach 3 1 ... ... ... ... ... ... 1 ... ... ... 1 ... 2 106 Table II.—DEATHS OF WILLESDEN RESIDENTS—continued. CAUSE OF DEATH. All Ages. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 to 75 75 to 85 85 Up. Total deaths whether of " Residents" or "Non-Residents," in Institutions in the District. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) 5.—Diseases of the Digestive System—Continued. Infective Enteritis 6 5 1 ... ... ... ... ... ... ... ... ... ... ... 6 Diarrhoea, not returned as infective 3 3 ... ... ... ... ... ... ... ... ... ... ... ... 1 Enteritis, not returned as infective 11 4 1 ... ... ... ... ... ... ... ... ... 1 ... 2 Gastro-Enteritis, not returned as infective 10 10 ... ... ... ... ... ... ... ... ... ... ... ... 2 Dyspepsia, under 2 years 3 3 ... ... ... ... ... ... ... ... ... ... ... ... ... Colic ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ulceration of Intestines 3 ... ... ... ... ... ... ... 1 ... ... ... 1 ... ... Duodenal Ulcer 6 ... ... ... ... ... ... ... 1 O 2 ... ... ... ... ... Ankylostomiasis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Intestinal Parasites ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Appendicitis 17 ... ... ... ... ... ... ... 2 ... ... ... 1 ... 10 Hernia ... 8 ... ... ... ... ... ... ... 1 ... ... ... ... 1 1 Intestinal Obstruction 11 ... ... ... ... ... ... ... ... ... ... 3 1 1 Other Diseases of the Intestines 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... ... Acute Yellow Atrophy of Liver ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Hydatid of Liver ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cirrhosis of Liver (not returned as alcoholic) 5 ... ... ... ... ... ... ... ... 1 4 ... ... ... ... Cirrhosis of Liver (returned as alcoholic) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases formerly classed to " Other Diseases of Liver ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... and Gall Bladder " 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Biliary Calculi i ... ... ... ... ... ... ... ... ... ... 1 ... ... ... Other Diseases of the Liver 6 ... ... ... ... ... ... ... ... ... ... 2 2 ... ... Diseases of the Spleen ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Peritonitis (cause unstated) 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... Other Diseases of the Digestive System 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 6.—Non-Venereal Diseases of the Genito-Urinary System and Annexa. Acute Nephritis 6 ... 2 3 ... ... ... ... ... ... ... 1 ... ... 3 Brights Disease 30 ... ... ... 1 ... ... 2 6 4 8 4 5 ... 10 Nephritis (unqualified), 10 years and over, uraemia 6 ... ... ... ... ... 1 ... 3 ... 1 1 ... ... 4 Chyluria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of Kidney and Annexa 3 1 ... ... ... ... ... ... ... ... 1 1 ... ... 2 107 Calculi of the Urinary Passages ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Bladder 4 ... ... ... ... ... ... ... ... 1 ... 1 2 ... 2 Diseases of the Urethra, Urinary Abscess, &c. 4 ... ... ... ... ... ... ... 1 ... ... ... ... 2 Diseases of the Prostate 3 ... ... ... ... ... ... ... ... ... ... 2 1 ... 2 Non-venereal Diseases of Male Genital Organs ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Uterine Haemorrhage (non-puerperal) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Uterine Tumour (non-cancerous) 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Uterus ... ... ...... ... ... ... ... ... ... ... ... ... ... ... ... Ovarian Cyst, Tumour (non-cancerous) 2 ... ...... ... ... ... ... ... ... ... ... ... 1 ... ... Other Diseases of the Female Genital Organs 2 ... ... ... ... ... ... 2 ... ... ... ... ... ... 2 Non-puerperal Diseases of the Breast (non-cancerous) ... ... ... ... ... ... ... ... ... ... ... ...... ...... ... ... 7.—The Puerperal State. Abortion 3 ... ... ... ... ... 1 ... 2 ... ... ... ... ... 2 Haemorrhage of Pregnancy .1 ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 Uncontrollable Vomiting .1 ... ...... ... ... ... ... ... 1 ... ... ... ... ... 1 Ectopic Gestation ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Accidents of Pregnancy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Haemorrhage 3 ... ... ... ... ... ... ... 3 ... ... ... ... ... 1 Other Accidents of Childbirth 5 ... ... ... ... ... ... 2 3 ... ... ... ... ... ... Puerperal Fever 7 ... ...... ... ... ... 2 4 1 ... ... ... ... ... 5 Puerperal Albuminuria and Convulsions 3 ... ... ... ... ... 1 1 1 ... ... ... ... ... 1 Puerperal Phlegmasia Alba Dolens and Phlebitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Embolism and Sudden Death 1 ... ... ...... ... ... ... 1 ... ... ... ... ... ... Puerperal Insanity ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Diseases of the Breast ... ... ...... ... ... ... ... ... ... ... ... ... ... ... ... 8.—Diseases of the Skin and of the Cellular Tissue. Senile Gangrene 4 ... ... ... ... ... ... ... ... 1 ... 1 2 2 Gangrene, other types 1 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 Carbuncle, Boil 2 ... ... ... ... ... ... 1 1 ... ... ... ... ... Phlegmon, Acute Abscess 7 3 ... ... ... ... ... ... ... ... ... 1 ... ... 7 Ulcer, Bedsore 1 ... ... ... ... ...... ... ... 1 ... ... ... ... ... Eczema 1 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 Pemphigus ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Integumentary System 2 1 ... ... ... ... ... ... ... ... ... 1 ... ... 1 •9.—Diseases of the Bones and of the Organs of Locomotion. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of the Bones 5 ... 1 ... 1 1 ... ... 1 1 ... ... ... ... ... Diseases of the Joints ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Amputations ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases of the Locomotor System ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 108 Table II.—DEATHS' OF WILLESDEN RESIDENTS—continued. CAUSE OF DEATH. All Ages. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 to 75 75 to 85 85 Up. Total deaths whether of "Residents " or "Non-Resi dents," in Institutions in the District. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) 10.—Malformations. Congenital Hydrocephalus 2 1 ... ... ... 1 ... ... ... ... ... ... ... ... 1 Phimosis ... ... ... ... ... ... ... ... ... ... ... ... ... Congenital Malformation of Heart 8 7 ... ... 1 ... ... ... ... ... ... ... ... ... 3 Other Congenital Malformations 8 8 ... ... ... ... ... ... ... ... ... ... ... ... 4 11.—Diseases of Early Infancy. Premature Birth 70 70 ... ... ... ... ... ... ... ... ... ... ... ... 16 Infantile Atrophy, Debility and Marasmus 29 29 ... ... ... ... ... ... ... ... ... ... ... ... 16 Icterus Neonatorum 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... Sclerema and Oedema Neonatorum ... ... ... ... ... ... ... ... ... ... ... ... ... Want of Breast Milk ... ... ... ... ... ... ... ... ... ... ... ... ... Diseases of Umbilicus, &c ... ... ... ... ... ... ... ... ... ... ... ... ... Atelectasis 11 11 ... ... ... ... ... ... ... ... ... ... ... ... 3 Injuries at Birth 4 4 ... ... ... ... ... ... ... ... ... ... ... ... ... Cyanosis Neonatorum ... ... ... ... ... ... ... ... ... ... ... ... ... Lack of Care 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... 12.—Old Age. Old Age 84 ... ... ... ... ... ... ... ... ... 2 11 48 23 47 13.—Affections produced by External Causes. Suicide by Poison 2 ... ... ... ... ... 1 ... 1 ... ... ... ... ... 2 Suicide by Asphyxia 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Suicide by Hanging or Strangulation 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... Suicide by Drowning 5 ... ... ... ... ... ... ... 1 3 ... ... ... ... ... Suicide by Firearms 1 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... Suicide by Cutting or Piercing Instruments 5 ... ... ... ... ... ... ... 3 ... ... ... ... ... ... Suicide by Jumping from High Place ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Suicide by Crushing 1 ... ... ... ... ... ... ... 1 ... ... ... ... ... ... Other Suicides ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Poisoning by Food ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Acute Poisonings ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Conflagration ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 109 Burns (conflagration excepted) 3 ... 3 ... ... ... ... ... ... ... ... ... ... ... 2 Absorption of Deleterious Gases (conflagration excepted) 9 6 ... ... ... 1 ... 2 ... ... ... ... ... ... ... Accidental Drowning 4 ... ... 1 ... ... ... ... 1 ... 1 ... ... ... ... Inj ury by Firearms 2 ... ... ... 1 ... ... 1* ... ... ... ... ... ... 2 Injury by Cutting or Piercing Instruments 2 ... ... ... ... ... ... ... ... ... ... ... ... ... ... Injury by Fall 6 ... ... ... ... ... ... ... 1 ... 3 ... ... ... 3 Injury in Mines and Quarries ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Injury by Machines ... ... ... ... ... ... ... ... ... ... ... ... ... 1 Injury by Other Crushing, Vehicles, Railways, Landslides, &c. 11 ... ... 4 2 ... 1 1 3 ... ... ... ... ... 4 Injury by Animals 2 ... ... ... ... ... ... ... 1 ... 1 ... ... ... 1 Starvation ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Excessive "Cold ... ... ... ... ... ... ... ... ... ... ... ... ... ... Effect of Heat ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lightning ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Electricity (lightning excepted) ... ... ... ... ... ... ... ... ... ... ... ... ... ... Homicide by Firearms ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Homicide by Cutting or Piercing Instruments ... ... ... ... ... ... ... ... ... ... ... ... Homicide by Other Means ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Fractures (cause not specified) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Violence ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 14.—Ill-defined Causes. Dropsy ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Syncope (aged 1 year and under 70) ... ... ... ... ... ... ... ... ... ... ... ... ... ... Sudden Death (not otherwise defined) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Heart Failure (aged 1 year and under 70) ... 5 1 ... ... ... ... ... ... 2 1 1 ... ... ... Atrophy, Debility, Marasmus (aged 1 year and under 70) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Teething ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Ill-defined Deaths ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cause not Specified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 1672 274 77 55 38 34 49 92 165 156 213 223 234 62 519 * Wounds received in battle. 110 Table III.—INFANT MORTALITY DURING 1920. Nett Deaths from Stated Causes at Various Ages under 1 Year of Age. Nett Deaths from all Causes under one year of age classified in Wardt- Cause of Death. Under 1 week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 4 Weeks. 4 Weeks and under 3 Months. 3 Months and under 6 Months. 6 Months and under 9 Months. 9 Months and under 12 Months. Total Deaths under One Year. South Kilburn. MidKilburn. WARDS. North Kilburn. Brondesbury Park. Kensal Rise. Harlesden. Stone bridge. Roundwood Church End. Willesden Green. Cricklewood. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) All Causes Certified 84 18 12 20 134 48 44 27 21 274 42 25 19 6 19 21 38 27 30 26 21 Uncertified — — — — — — — — — — — — — — — — — — — — — Small Pox — — — — — — — — — — — — — — — — — — — — — Chicken Pox — — — — — — — — — — — — — — — — — — — — — Measles — — — — — — — 2 5 7 2 1 — — 1 — 2 1 — — — Scarlet Fever — — — — — — — — — — — — — — — — — — — — — Whooping Cough — — — — — 1 2 — — 3 1 1 — — — — — — — 1 — — Diphtheria and Croup — — — — — — — — — — — — — — — — — — — — — 1 Erysipelas — — — — — — — — — — — — — — — — — — — — — Tuberculous Meningitis — — — — — — — — — — — — — — — — — — — — — Abdominal Tuberculosis (a) — — — — — — — — — — — — — — — — — — — — — Other Tuberculous Diseases — — — — — — — 1 2 1 — — — — — — — 1 — 1 1 Meningitis (not Tuberculous) — — — — — — — 2 2 4 — — — — — 1 1 — 1 1 — Convulsions 3 3 — — 6 1 1 4 1 13 1 2 2 3 1 2 1 1 Laryngitis — 1 — — — — — — — 1 1 — 1 — — — — — — — — — Bronchitis 1 1 1 | 2 5 6 6 2 2 21 2 — 2 1 2 4 — 3 4 1 2 | 1 Pneumonia (all forms) 2 1 — 3 6 7 9 2 4 28 10 — 1 — 1 3 5 1 2 4 1 Diarrhoea — — — — — — 1 — 2 3 1 — — — 1 1 — — — — Enteritis — — 1 1 2 5 9 3 — 19 1 — 3 — 2 — — 2 — 5 6 Gastritis — — — 1 1 1 2 3 — 7 — 2 1 — 1 — — — 3 — — Syphilis 1 — 1 2 — — — — 2 1 — — — 1 — — — — — — Rickets — — — — — — — — — — — — — — — — — — — — Suffocation, overlying 1 — — 1 2 1 1 2 — 6 1 2 — — — — 2 1 — — — Injury at birth 3 — — — 3 1 — — 4 — 1 — — — — 1 — 1 1 — Atelectasis 10 1 — — 11 — — — 11 3 3 1 — — — 1 — 1 1 1 Congenital Malformations (6) 3 1 1 2 7 4 3 1 1 16 2 1 1 2 — 2 1 2 1 1 3 Premature Birth 52 6 4 4 66 4 — — — 70 10 4 5 — 2 6 11 9 12 5 6 Atrophy, Debility and Marasmus 3 3 2 1 9 14 4 2 — 29 3 4 2 1 2 4 3 5 2 3 — Other Causes 5 2 3 4 14 3 6 2 1 26 5 2 1 1 2 3 5 1 4 2 — Total Deaths 84 18 12 20 134 48 44 27 21 274 42 25 19 6 19 21 38 27 30 26 21 Deaths—Legitimate 77 17 10 19 123 39 37 22 20 241 36 24 18 6 15 18 33 23 26 23 19 Illegitimate 7 1 2 1 11 9 7 5 1 33 6 j 1 1 4 3 5 4 4 3 2 Births—Legitimate — — — — — — — — — 4,084 488 426 226 175 308 422 494 446 333 408 358 Illegitimate — — — — — — — — — 148 25 17 14 2 11 14 20 15 15 8 7 Total Births — — — — — — — — — 4,232 513 1 443 240 177 319 436 514 461 348 416 1 365 Infant Mortality Rate— Legitimate — — — — — — — — — 59.00 73.77 56.33 79.64 34.28 48.70 42.65 66.80 51.56 78.07 56.37 53.07 Illegitimate — — — — — — — — — 222.97 240.0 | 58.82 71.42 - 363.63 214.28 250.00 266.66 266.66 1375.00 285.71 Infant Mortality Rate — — — — — — — — — 64.74 81.87 56.43 79.16 33.89 59.56 48.16 j73.92 58.56 86.20 62.50 57.53 Population — — — — — — — — — 170892 15,195 15,071 12,948 j 10,048 14,418 117,647 17,972 15,883 14,436 ! 17,207 20,067 (а) Under Abdominal Tuberculosis are included Deaths from Tuberculous Peritonitis and Enteritis and from Tabes Mesenterica. (b) Want of Breast Milk is included under Atrophy and Debility. 111 TABLE IV —CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1920. Notifiable Disease. Number of Cases Notified. Total Cases Notified in each Ward. At all ages. At Ages—Years. South Kilburn. Mid-Kilburn. North Kilburn. Brondesbury Park. Kensal Rise. Harlesden. Stonebridge. Round wood. Church End. Willesden Green, Cricklewood. Total Cases removed to Hospital. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 45. 45 and under 65. 65 and upwards. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) Small Pox — — — — — — — — — — — — — — — — — — — Cholera (C) Plague (P) — — — — — — — — — — — — — — — — — — — — Diphtheria (including Membranous Croup) 699 6 Ill 463 66 48 5 — 41 44 26 69 94 82 94 77 48 59 65 652 Erysipelas 91 3 1 10 10 27 28 12 15 9 7 4 6 10 9 8 12 8 3 13 Scarlet Fever 705 4 120 481 61 34 5 — 78 90 37 71 58 53 78 62 68 65 45 435 Typhus Fever — — — — — — — — — — — — — — — — — Enteric Fever 22 — 1 3 3 14 1 — 1 — 3 — 2 2 1 5 5 — 3 16 Relapsing Fever (R) Continued Fever (C) 3 — — (C) 1 (c) 2 — — — — — — — — (c)2 (C) 1 — — 2 Puerperal Fever 20 — — — 4 15 1 — 1 4 — — — 1 2 4 3 2 3 10 Cerebro-spinal Meningitis 4 — — 1 1 — 2 — — — — — 1 — 1 — — 2 2 Poliomyelitis — — — — — — — — — — — — — — — — — — — Ophthalmia Neonatorum 49 49 — — — — — — 3 5 2 2 10 3 6 5 6 2 5 7 Pulmonary Tuberculosis 296 — 2 35 74 132 50 3 27 31 19 11 14 27 32 31 26 54 24 — Other forms of Tuberculosis 47 — 4 20 6 13 4 — 8 4 2 2 6 3 7 6 3 2 4 — Whooping Cough 193 35 84 68 6 — — — 26 22 4 2 5 28 23 42 22 11 8 5 Pneumonia 107 3 12 20 13 29 27 3 20 23 9 13 3 13 14 2 4 4 2 14 Malaria 41* — — — 5 35 1 — 2 2 3 2 5 5 3 10 9 ' ~r — 1 Dysentery 4 — 1 1 — < 2 — — 1 — 1 1 — — — 1 — 1 Trench Fever — — — — — — — — — — — — — — — — — — — — Encephalitis Lethargica — — — — — — — — — — — — — — — — — — — Acute Polio Encephalitis — — — — — — — — — — — — — — — — — — — — Totals 2,281 100 336 1,103 249 351 124 18 223 234 112 176 204 229 269 255 207 208 164 1,158 The Willesden Municipal Hospital, Neasden, with 199 beds, provides accommodation for patients suffering with infectious diseases other than Small Pox. 113 APPENDIX B. Shewing Acts, Orders, Regulations, Circulars and Memoranda issued during the Year 1920 Relating to the Work of the Health Department. January 12th.—The Employment of Children in Entertainments Rules, 1920, made by the Board of Education under Section 3 of the Prevention of Cruelty to Children Act, 1904, as amended by Section 13(2) of the Education Act, 1918. March 15th.—Supervision of Children of Sailors, Soldiers and Airmen. Circular 72. April 1st.—Sections 18 and 20 of the Education Act, 1918, relating to Medical Inspection of Secondary Schools and Institutions and the Education of Physically Defective and Epileptic Children, become operative. April 23rd.—Employment of Discharged and Disabled Officers and Men as Sanitary Inspectors or Inspectors of Nuisances. Circular 84. May.—Interim Report of the Consultative Council on Medical and Allied Services on the Future Provision of Medical and Allied Services issued. June.—Supply of Sugar to Child Welfare Centres. Memo. 20, M.C.W. July 2nd.—Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. August 25th.—Sanitary Condition of Theatres, Music Halls, etc. Circular 120. September 15th.—Consolidated Regulations relating to the Special Services of Elementary Education (other than Nursery Schools) for promoting the Healthy Physical and Mental Development of Children. October 20th.—The Use of Milk. Circular 121. November 12th.—Maternity and Child Welfare. Circular 138. APPENDIX C. To the Health Committee. MUNICIPAL CLINICS Attendances. 1st March, 1920. During first 8 weeks of year. Total No. of Attendances at Clinics. Total No. of Births in Willesden. 1918 2,795 429 1919 13,635 339 1920 18,306 720 During the week ending 21st February, 1920, the total number of Medical Attendances were as follows :— Clinic 1. Dr. Borland (Kilburn) 735 Dr. Robertson (now Nicoll) Kensal Rise—Harlesden) 378 Total 1,113 Clinic 2. Dr. Wood (Stonebridge—Roundwood) 454 Dr. Butler (Church End—Willesden Green) 615 Total 1,069 Grand Total 2,182 The maximum number of patients that a doctor can see with efficiency at the Clinics is 60 per day or 330 per week according to present arrangements. (With School Medical and Dental Inspection in full operation this number will require to be reduced to allow for attendance at the schools and gas administration.) Having regard to the foregoing figures, it will be seen that it has now become impossible to carry out the work for which these Clinics were established without additional premises. Dr. Borland's district supplies enough work for both doctors at Clinic 1 and Dr. Butler's enough work for both 114 doctors at Clinic 2, and in the meantime therefore, it will be necessary to shut out Clinic work from the other areas, namely, the Kensal Rise— Harlesden area (Dr. Nicoll), and the Stonebridge— Roundwood area (Dr. Wood), and re-divide the Clinic work among the 4 doctors now employed. Future Clinics. In each area the Health Visitors have a number of cases under observation. The following table shows the percentage of these cases attending the Clinics at the 24th January table shows the percentage of these cases attending the Clinics at the 24th January, 1920, and the variations in percentage of Maternity and Child Welfare cases having regard to the accessibility of the Clinics. Maternity and Child Welfare. School Children Average % of cases attending Clinics. % of cases attending Clinics from neighbourhood. % of cases attending Clinics from most distant area. Average % of cases attending Clinics. Clinic (1). Dr. Borland, South KilburnMid-Kilburn-North Kilburn area 64% 71 % 42% 84% Dr. Nicoll, Brondesbury ParkKensal Rise-Harlesden area 30% - 24% 87% Clinic (2). Dr. Wood, — wood area 22% - 13% 75% Dr. Butler, Church End-Willesden Green-Cricklewood area 44% 63% 27% 89% From the foregoing statement it will be observed that the attendances at Clinics and consequently the provision to be made depend upon:— (1) The skill and personality of the Clinic Medical Officer. (2) The accessibility of the Clinic. (3) The total number of births in Willesden, and (4) The re-establishment of School Medical inspection. RECOMMENDATIONS RE CLINICS. The foregoing factors and circumstances have all been taken into account in submitting the following recommendations :— (1) That residents of the Stonebridge-Roundwood area and Kensal Rise-Harlesden area, as shown on the map, be not admitted to the Clinics at present. (2) That a Clinic be established in the Stonebridge area. (3) That a Clinic be established in the Kensal Rise-Harlesden area. (4) That sites be acquired for the establishment of Clinics in Roundwood and South Kilburn. MUNICIPAL HOSPITAL. During January and February of Year. Total No. of Cases Admitted. Total No. of Confinements, Total No. of Operations. No. of Major Operations. 1918 78 - - - 1919 205 35 25 3 1920 462 66 112 17 Maternity Cases. The Hospital has 16 Maternity Beds and each bed is on the average occupied for 3 weeks which means that 5-6 maternity cases per week can be dealt with on the average. During the first S weeks of this year 92 cases have been booked for confinement at the Hospital or more than double the number that can be accommodated. General. The Hospital is now constantly full and recently, during the prevalence of Scarlet Fever, a number of cases have had to be nursed at home. 115 RECOMMENDATIONS RE HOSPITAL. Having regard to all the foregoing facts, it is recommended— (1) That the same districts, namely, Kilburn, Church End, Willesden Green, be worked for Hospital purposes (other than Infectious Diseases, in respect of which, the hospital would deal with the Urban District), as for Clinic purposes, and (2) That every effort be made to expedite the provision of the necessary hospital dation. GEORGE F. BUCHAN, Medical Officer of Health. APPENDIX D. To the Health Committee. 4th May, 1920. I beg to report in accordance with the following minute :— " We have instructed the Medical Officer of Health to report on the Economic Scale of the Committee and the advisability of abolishing the quarter, half and three-quarter scale which has been adopted by the Council in reference to milk. On receipt of this report we shall report as to any additional Clinic Staff necessary to reduce overtime." (Council Minutes, March, 1920, page 987). Economic Circumstance Scale. The present Economic Scale of the Health Committee is as follows :— No. in Family. If income per head per week is not above the undermentioned amounts. Free. Pay ¼ Cost. Pay ¾ Cost. Pay ¾ Cost. s. d. s. d. s. d. s. d. 2 10 0 11 0 12 0 13 0 3 8 0 9 0 10 0 11 0 4 7 6 8 6 9 6 10 6 5 6 6 7 6 8 6 9 6 6 or over 6 0 7 0 8 0 9 0 Average Cost of Maintenance per head of Family. The minimum cost of the physiological upkeep of a child of ten years taken as the average unit of a family and excluding rent, insurances, fares to and from work and care of children, was last considered in April, 1919, in a report on the Feeding of School Children, presented to the Education Committee, and the figures then given were as follows April, 1919. s. d. Food 4 9 Lighting and Fuel 0 11 Sundries 0 5 Clothing 1 9 Tota l 7 10 The figure for clothing, namely 1s. 9d. was stated at that time to be too low, the investigation giving this figure having taken place in March, 1918. Revision of Scale, April, 1920. The following figures relative to the cost of living are based on enquiries into the weekly •expenditure of 15 families in receipt of or recently in receipt of benefits under the Council's Scheme relative to School Children or Maternity and Child Welfare. The families taken, therefore, are poor. The cost of clothing in the present revision is based on enquiry into the actual needs of thirteen children of these families. The following shows the average cost at the present time :— April, 1920. s. d. Food 5 0 Lighting & Fuel 1 0 Sundries 0 3¾ Clothing 4 5½ Total 10 5¼ 116 On the basis that 10s. 5d. is the minimum amount on which the average unit of a familv, taken as a child of ten years of age, can be maintained in physiological health, then the scale in operation for free benefits should be :— No. in family Net income per head of the family per week. 1 2 s. d. 2 12 0 3 11 0 4 10 0 5 or over 9 0 When the value of meals or dried milk is added to this scale, the total amount allowed per head of the family approximates the 10s. 5d. required as shewn in the following table : No. in family Probable No. fed Economic circumstances per head per week as per suggested scale Total. Relief from meals per week @ 4d. per meal per day Total including relief from meals Total economic circumstances per head per week. 1 2 3 4 5 6 7 s. d. £ s. d. s. d. £ s. d. s. d. 2 1 12 0 1 4 0 1 8 1 5 8 12 10 3 2 11 0 1 13 0 3 4 1 16 4 12 1 4 2 10 0 2 0 0 3 4 2 3 4 10 10 5 3 9 0 2 5 0 5 0 2 10 0 10 0 6 4 9 0 2 14 0 6 8 3 0 8 10 1 7 5 9 0 3 3 0 8 4 3 11 4 10 2 8 5 9 0 3 12 0 8 4 4 0 4 10 0 9 5 9 0 4 1 0 8 4 4 9 4 9 11 10 5 9 0 4 10 0 8 4 4 18 4 9 10 Effect of Part-Payment Scale. The part-payment scale came into operation on the 13th February, 1920. The following statement shows the relative costs for milk for about 12 weeks prior to the The part-payment scale came into operation on the 13th February, 1920. The following statement shows the relative costs for milk for about 12 weeks prior to the part-payment scale and for about 12 weeks subsequent to the operation of this scale :— 12 weeks ended 24/1/20. 12 weeks ended 17/4/20. (Part-payment System) £ s. d. £ s. d. Cost of Milk 554 19 10 685 17 5 Receipts 397 18 2 501 0 10 Cost to Council 157 1 8 184 16 7 Percentage of Receipts to Total Cost 71.7% 73.0% Clerical Staff Employed. Prior to the coming into operation of the part-payment scale, the dispenser received the money and issued the dried milk. At the annual audit, the Auditor expressed dissatisfaction with this system, as he was of opinion that one and the same person should not both receive monies and issue stores. The opportunity was taken in connection with the change to the part-payment system to meet the Auditor's views. The result is that a considerable proportion of the time of a third-class clerk at each Clinic is taken up with (1) Interviewing applicants for milk and dried milk. (2) Enquiring into economic circumstances both from the applicant and employer. (3) Informing applicants by letter of the result of their application. (4) Receiving money from applicants, giving receipts for same and issuing coupons for the milk or dried milk to be provided. (5) Keeping a continuous record of same; and (6) Keeping accounts of monies received. The remainder of these clerks' time is occupied in assisting in other work generally. Dried milk is issued to about 45 persons daily. 117 No additional clerical assistance has been provided for this work or for the work in connection with the provision of dentures to expectant and nursing mothers about to be undertaken as soon as the scale is revised and settled, or for the general increase of the Clinic work, the attendances being 9,873 for the 4 weeks ended 20th March, 1920, as compared with 6,997 for the 4 weeks ended 19th April, 1919 or an additional 41 per cent. It will be observed that during the month of April, 122J hours overtime were worked at the Clinics, which is in a large measure due to the operation of the new system as well as to the fact that the Clinic Medical Officers are kept late thus detaining the clerks. Recommendations. (1) Revision of the Scale. If the non part-payment scale above mentioned is adopted by the Committee the result will be that the estimated cost of milk would be as follows, in view of the above figures :— 12 weeks. Estimated expenditure 52 weeks. Estimated expenditure as provided in estimates, 1920-21. (1) (2) (3) (4) £ s d. £ s d. £ Cost of Milk 685 17 5 2,972 2 o 4,200 Total Receipts 397 18 2 1,724 5 5 1,371 Total Cost to Council 287 19 3 1,247 16 9 2,829 To the estimated expenditure shewn in Column (3) must be added a sum unknown representing the value of the milk which would be accepted by people free, who are not prepared or are unable to pay ¼,½ or ¾ cost on the present basis. (2) The appointment of two 4th class clerks, one at each Clinic, at a salary of £52—£80 per annum plus bonus. GEORGE F. BUCHAN, Medical Officer of Health. APPENDIX E. To the Health Committee. 4th May, 1920. HEALTH VISITORS' WORK. Work to be Done. The 16 District Health Visitors time is more than fully occupied. At 20/3/20 each had an average of approximately 700 Maternity and Child Welfare cases, 164 School cases and 69 Infectious Disease cases, or a total of'933 cases under observation. The total cases under observation increased by 1,407 between 24/1/20 and 20/3/20, i.e., in 8 weeks, and the average number of cases under observation by each Health Visitor increased by 88. During the past year the work has greatly increased. It was not until 1917 that children over 1 year of age were visited and kept under observation. When the 16 districts were arranged in 1918 there were only the children born in 1917 and 1918 under observation. Those born in 1917 will not reach 5 years of age till 1922 and until then these cases will continue to accumulate and additional staff will be needed if they are to be kept under supervision and dealt with as required. The birth rate is now increasing rapidly, there being 1,096 births in the first 3 four-weekly periods of 1920 as against 516 in the first 3 four-weekly periods of 1919, or more than double. This gives 4,749 births per annum which according to the Ministry of Health estimate of 400 births per annum per Health Visitor would require 12 Health Visitors. As only half the time of the present Health Visitors is occupied by Maternity and Child Welfare work, there are only 8 Health Visitors available for this work instead of 12. The number of visits to expectant and nursing mothers was practically nil until 1918, when 1,443 visits were paid, while in 1919, 9,382 visits were paid. 118 In 1919, 11,650 medical defects and 5,385 dental defects, or a total of 17,035 defects of School Children came under observation as against 7,231 medical defects and 1,011 dental defects or a total of 8,242 defects of School Children in 1918. Work not Done. From the above figures, it can be seen that the work has mofe than doubled. There has been no increase in staff to meet this increase in work beyond the appointment of 2 Dental Visiting Nurses to deal with the dental work. The Health Visitors have not sufficient time for regular periodical cleanliness Inspections at the Schools which requires to be undertaken. The following Tables show how the work of cleanliness inspection has been carried out this year. 4 weeks ended. No. of Districts in which no School Cleanliness Inspections were undertaken. No. of Districts in which systematic Inspections were undertaken. No. of Sessions. No. of Districts in which Inspection of children specially referred by H.T. to Health Visitor at School was undertaken. 24/1/20 11 1 2 4 21/2/20 8 5 11 3 20/3/20 4 10 33 2 In 5 districts no systematic cleanliness inspections have yet been undertaken this year. Systematic Cleanliness Inspections. Inspection of Children by Special request of H.T. when H.V. at the School. No. of Sessions 46 Original Inspections Children examined 2,902 69 Children excluded 67 14 Re-inspections Children examined 386 184 Children excluded 0 17 Actually a Health Visitor should be able to call in at her Schools daily. Cases of Verminous Heads have been coming to knowledge which should have been discovered long before and it is unsatisfactory that the Health Visitor should be unable to keep proper supervision over the cleanliness of the Scholars in her schools. There is much more teaching and educational work to be done but the Health Visitors have only time generally to go round as quickly as possible and deal with bare essentials—even then longer intervals elapse between revisitation than should. Considerably more work could be done among Expectant Mothers. It should be borne in mind that it is possible for a Health Visitor to go round and do 30,40 or 50 visits a day, but such work is of no value whatever. She becomes merely "a door knocker," excludes and re-admits children to school, records certain facts but makes no headway in the cause of health. The value of a Health Visitor depends on how far she secures the goodwill and confidence of her people so that they are ready to carry out her advice and teaching and all this takes time. 119 Health Visits—Time Required. The average time required per case to deal with it properly is as follows Case. 1st Visit, minutes. Re-visit, minutes. Maternity and Child Welfare Expectant Mother 30 10 Live-birth (including nursing mother) to 1 year 30 15 Still-birth 30 — Infant Death 20 — Children 1-5 years — 10 Nursing Mother only — 5 Infectious Diseases Tuberculosis 30 15 Scarlet Fever, Measles, Diphtheria, Whooping Cough, etc 30 10 Chicken Pox, Mumps 15 — Disinfection 10 — School Special Cases 15 — School Children 10 5 Cleanliness Inspection Session 90-120 variable according to No. needing reexamination '1 he time allocated to each Health Visitor for visiting is 4½ hours daily, 1½ on Saturdays or 24 hours per week. The number of cases visited per day varies according to : (1) Type of case dealt with—Maternity and Child Welfare, School, etc., original visit or re-visit. (2) Type of people dealt with. (3) No. of " No entries." (4) No. of times the Health Visitor gets stopped on her district by parents, relative to cases which require her attention. (5) Distance between cases and from Centre. Having regard to all circumstances the average number of visits per day should be 12. During the 4 weeks ending 20/3/20, the average number of visits, medical and dental per day per Health Visitor was 23. An excessive number of cases under observation gives rise to an excessive amount of clerical work and results in still further reducing the hours available for visiting. Absences of Health Visitors. Absences due to personal illness of the Nursing Staff are frequent. The following table shows the absences of the Nursing Staff other than holidays (excluding Home Nurses). 1919. No. of whole working days for each Nurse. No. of whole working days lost by all Nurses. Total days lost by all Nurses. Clinic 1. Clinic 2. 12 weeks ended 22/3/19 66 77 108 185 4 ,, ,, 19/4/19 20 ½ 33½ 10 43½ 17/5/19 21 25½ 11½ 37 ,, 14/6/19 20 4½ 24½ 29 ,, 12/7/19 22 2½ 33 35½ ,, 9/8/19 20 164 12 28½ 6/9/19 22 11 7 18 ,, 4/10/19 22 3½ 7½ 11 ,, 1/11/19 22 4 22 26 ,, 29/11/19 22 2½ 14½ 17 „ 27/12/19 19½ ½ 9½ 10 Total 1919 277 181 259½ 440½ 1920. 4 weeks ended 24/1 /20 22 5½ 26½ 32 ,, 21/2/20 22 4 39 43 „ 20/3/20 22 13 16½ 29½ Total 66 221 82 104½ It is thus seen that during 1919 there was an average of approximately 2 Health Nurses constantly off duty, excluding off duty time for holidays. Thus the effective Nursing Staff was two less than the actual. 120 The above table does not include holidays and does not include the intervals between an officer leaving and her successor taking up duty which are now considerable (e.g., Miss Cotton left 8/4/20. Successor not on duty till 21/4 20. Miss Anthony left 5/4/20. Successor not on duty till 23/4/20). It is therefore clear that a relief Health Nurse is needed at each Clinic. In order to lessen as far as possible the intervals between an officer leaving and her successor coming on duty, it would be an advantage if the Council would give authority for the issue of advertisements and appointment of Health Nurses immediately on the occurrence of vacancies as in the case of Hospital Sisters and Nurses. Causes and Results of Absences. It is not easy to understand why there should be so much illness amongst the Nursing Staff of the Council, but the conditions of work which appear to bring this excessive illness about are :— (a) Work at full pressure always and yet the work is never up-to-date. (b) The Health Visitors do a considerable amount of work at home in order to keep relatively abreast with their work, and (c) The annual holiday is the minimum practically allowed to any class of worker, and is less than the Health Visitors being fully trained nurses have ever had before— the standard holiday for trained nurses being 4 weeks. The results are :— (а) Over fatigue for the whole staff. (b) Additional work to be shared by the staff on duty owing to absences of other members. (c) Hopeless collection of over-due visits for a member returning from sick leave or holiday. (d) Lack of energy to keep properly up-to-date in the latest developments and aspects of Health work. (e) The natural dissatisfaction which results from the knowledge that they cannot possibly cope with the work that requires doing, and that the training and knowledge they possess might be of so much greater service and effectiveness had they only sufficient time at their disposal to do the work as it should be done. (f) Constant changes in the staff—some of the best workers have resigned because of the insufficient holiday and because the effort to keep up with the work was making them physically unfit (e.g., Miss Prickman and Miss Roberts). Dental Visiting. The arrangement of separate Dental Visiting Nurse is not altogether desirable, as it leads to overlapping in home visitation, duplication in cards, and to cases being overlooked for considerable periods. It is better that one Health Visitor only should be responsible for each family in her district, as she then has complete knowledge of all the facts affecting them and they have only the one person visiting them. Supervision. The Supervision of Health Visitors' work needs more care and time given to it. With a large staff as there now is, there are sure to be frequent changes, and it needs a person available at each Clinic to teach each new comer the various methods, etc., in operation, and the various facts which require to be looked out for and recorded. The filling in of forms and recording of salient facts needs supervision to see that it is carefully, systematically and uniformly done. At present it is only with difficulty and expenditure of considerable time that it is possible to get required information from the records. It also needs supervision to see that the various summaries and lists are kept uniformly, that the cases in each district are being properly worked off, that a reasonable number of new cases come under observation, and that cases are not marked off until duly completed. The Assistant Medical Officers have not time to carry out this work as it should be done, and further it is more particularly the medical aspect of the individual case that concerns them. A Senior Health Visitor is needed at each Clinic to carry out this portion of the work. She could then keep the balance as between the Medical and Dental work so that this could be done by the same district Health Visitor, and ensure that all the various branches of the work received their due attention. At present the above work is carried out as far as possible by the Clinic Doctors and Matrons, but it is not possible for them to keep proper supervision over the work, and the Matron's time is necessarily constantly interrupted by interviews with patients, etc., and looking after the general arrangement and well ordering and co-ordination of the various departments of the Clinic. Practically all additional and extra work and difficulties, etc., come on the Clinic Matrons. The difficulties of an ever changing staff (both medical, nursing, and cleaning) are constantly increasing the Matron's difficulties. At neither Clinic is there any person who could satisfactorily take the Matron's place in case of absence or resignation. 121 This is not a good or satisfactory arrangement. There should be at each Clinic someone conversant with the work and methods of the whole Clinic, in touch with the Matron and acting as her assistant who would be able to carry on her work without break of continuity or disturbance to the Clinic in the event of her absence. Clinic (2)—Need of Caretaker. At Clinic (2) the difficulties of the Clinic Matron are still further increased and the necessity of making some further arrangements made more urgent by the absence of a caretaker during the time the Clinic is opened. There should always be a resident caretaker in connection with a Clinic. A Caretaker is needed to be available throughout the day to keep some control over boys and others in the yard and round about the Clinic, to receive goods, to clean when children are sick, as not infrequently happens in the waiting and treatment rooms, etc. Further at Clinic (2), there is not anyone properly available to deal with the laundry. At Clinic (1) this is done by the Nurse Attendant. Recommendations. To meet the foregoing difficulties, the following action needs to be taken :— (1) Appointment of additional Health Visitors-at scale salaries. (2) Appointment of one Relief Health Visitor at each Clinic at scale salary. (3) Appointment of one Senior Health Visitor at each Clinic at salary of £160-£190 per annum with bonus in addition and uniform. (4) Sanction of Council to make appointments without delay when vacancies occur. (5) Appointment of Caretaker for Clinic (2). (6) Acquisition of 383, High Road, Willesden and extension of existing Clinics and ment of additional Clinics. NOTE.—Re Verminous Heads.—There is not sufficient cleansing room accommodation or staff to deal with all the verminous heads requiring cleansing. Cases cannot well be prosecuted until they have had an opportunity of being cleansed. They cannot be given an opportunity of being cleansed. They remain away from School for long periods. GEORGE F. BUCHAN, Medical Officer of Health. APPENDIX F. To the Health Committee. 28th May, 1920. MUNICIPAL HOSPITAL. Nursing and Domestic Staff. 48 Hours Week. I beg to report in accordance with the following Minute of the Council :— "Owing to the possibility of the provisions of the Hours of Employment Bill becoming law, which will affect the Nursing Staff at the Hospital to the extent of a 48 hour week, we have instructed the Medical Officer of Health to submit a report on possible alternatives which may be taken to meet the position." (Council Minutes, 23rd March, 1920, page 992). The Hospital has 199 beds or cots and 14 bassinettes. The hours of duty of the Nursing Staff vary from 48 hours per week in the case of a Sister to 58½ hours per week in the case of a Probationer Nurse on the average. The hours of duty of the Domestic Staff vary from 56½ hours in the case of a Laundress to 12¼ hours in the case of a Messroom Maid on the average. When the Hospital is fully occupied the following is the Nursing and Domestic Staff required. (a) On the basis of the existing hours of duty, and (b) On the basis of 48 hours duty per week. 122 Staff Required when Hospital Fully Occupied. On the basis of the existing hours of duty. On the basis of 48 hours duty per week. Day. Night. Total. Day. Night. Total. Nursing Staff. Sisters 8 1 9 8 1 9 Staff Nurses 7 2 9 7 3 10 Probationers 28 11 39 42 15 57 Ambulance Nurse 1 — 1 2 1 3 Relief for Sick Nurses — — — 4 1 5 Total 44 14 58 63 21 84 Domestic Staff. Cook 1 - 1 1 — 1 Assistant Cook 1 - 1 1 1 2 Kitchen Maids 2 - 2 4 1 5 Scullery Maids 1 - 1 3 — 3 Needle Woman 1 - 1 1 — 1 Needleroom Maid 2 - 9 2 - 2 Head Laundress 1 - 1 1 - 1 Assistant Laundress 1 - 1 1 - 1 Laundry Maids 5 - 5 7 - 7 Senior Pantry Maids 2 - 2 2 - 2 Junior Pantry Maids 2 - 2 4 - 4 Housemaids 2 - 2 3 1 4 Wardmaids 11 — 11 16 — 16 Dormitory Maids 4 - 4 9 — 9 Total 36 — 36 55 3 58 Grand Total 80 14 94 118 24 142 The existing sleeping accommodation at the Hospital, which is insufficient, provides 49 beds for Nursing Staff and 33 beds for Domestic Staff. It will therefore be seen that to make up for the present deficiency of bed accommodation at the Hospital and to allow for the additions to the Staff, consequent upon a 48 hours week. 60 additional beds will be required, 35 being provided for Nursing Staff and 25 for Domestic Staff. Nursing Staff. Thirty-five additional beds required. If a 48 hours week is adopted the necessary additional accommodation may be obtained. (1) By having the additional Nurses living out in rooms found by them, their wages being proportionately increased. (2) By having the additional Nursing Staff boarded out in houses obtained and maintained by the Council, or (3) By providing the necessary additional accommodation in the grounds at the Hospital. The first arrangement could be adopted in respect of Sisters and Staff Nurses—of whom, however, there would be only 19 employed—but such an arrangement would not be suitable in respect of Probationers who usually enter the Hospital from the country and require supervision during their training period. At the present time, however, it would seem a practical impossibility to consider the question of obtaining the necessary additional accommodation required in rooms or houses outside the Hospital on account of the scarcity of housing accommodation in Willesden. In these circumstances the alternative would appear to be to provide accommodation inside the Hospital. This may be provided by means of temporary or permanent buildings. Thirty of the Domestic Staff are at present housed in temporary corrugated iron buildings curtained off at the Hospital. This arrangement is not satisfactory and has already been reported on adversely by the Committee. It is possible to erect temporary buildings which would provide better accommodation for the Nurses, but it appears open to question if this is an economical or sound policy either from the building point of view or from the point of view that it is difficult to obtain and retain a staff which is not well housed. Domestic Staff. Twenty-five additional beds required. This additional number for Domestic Staff would not be required if the 9 Laundry Staff, 16 Ward Maids, 9 Dormitory Maids, 1 Needlewoman and 2 Needleroom Maids, or 37 in all, were made non-resident daily instead of resident staff as at present. 123 Summary of Accommodation Required. (1) Thirty-five beds for Nurses. (Note.—This might be reduced to 16 by having the 19 Sisters and Staff Nurses living out, if rooms or houses were obtainable. This is not recommended for Nursing Staff whose homes are generally far away and the majority of whom usually prefer to live in.) (2) Twenty-five beds for Domestic Staff. (Note.-These would not be required if 25 of the 37 Domestic Staff named lived out. This would probably be a practical arrangement in respect of a proportion of the 37 named who are not wanted very early in the morning and especially if their homes were in Willesden). (3) Thirty beds for Domestic Staff now housed in temporary corrugated iron buildings sidered unsuitable by the Council. (4) The kind of building to be erected. To be presented to the Visiting Committee, Friday, May 28th, 1920. GEORGE F. BUCHAN. Medical Officer of Health. APPENDIX G. To the Children's Care Committee. 28th May, 1920. "SPECIAL" SCHOOLS. OPEN AIR SCHOOL. We beg to report that in accordance with the Minute of the Education Committee dated 7th January, 1920, we have visited selected "Special" Schools. History of "Special" Schools Movement in Willesden. In order that the Committee may understand the present position we set out briefly below the main dates and facts relative to the "special" schools with which this report deals. 9th August, 1899.—The Elementary Education (Defective and Epileptic Children) Act, 1899, passed enabling Education Authorities to establish and maintain "special" schools for physically and mentally defective children. 4th December, 1899.—Granville Road mentally defective school established in Willesden. 24th February, 1903.—Leopold Road mentally defective school established in Willesden. 6th December, 1909. Furness Road physically defective school established in Willesden. 6th July, 1910.- Special Committee appointed to consider provision of school accommodation for mentally and physically defective children. 11th April, 1911-Board of Education indicated that Furness Road physically defective school could not be much longer recognised. 7th June, 1911.-Reference to Special Committee transferred to Children's Care Committee. 3rd July, 1911.-Special Sub-Committee of Children's Care Committee appointed to visit open air schools. This Committee did not report owing to resignation of Dr. Butler. 21st October, 1912.—Report on physically defective children and the open air recovery school by Dr. Buchan. 4th December, 1912.—Report of Dr. Buchan adopted by Education Committee. 24th February, 1913. -Leinster Road mentally defective school established in Willesden. 2nd July, 1913.—Education Committee resolved to purchase Denzil Road site for day openair school. 15th June, 1914.—Board of Education approved the purchase of Denzil Road site for day open-air school. 1st July, 1914.—Special Sub-Committee of the Children's Care Committee appointed to visit open-air schools and to report on plans for the proposed school. 17th July, 1914.—Report of Special Sub-Committee issued. 22nd July, 1914.—Report of Special Sub-Committee adopted by Education Committee. 10th August, 1914.—The Elementary Education (Defective and Epileptic Children) Act, 1914, passed, making the education of mentally defective children compulsory. 7th October, 1914.—Board of Education approved plans of the day open-air school buildings. 2nd June, 1915.—Education Committee deferred action re day open-air school on account of the War. 23rd July, 1917.—Education Committee determined on day open-air classes in King Edward VII. Park. 124 10th April, 1918.—Middlesex County Council refused to allow King Edward VII. Park to be used in connection with a day open-air school. 31st July, 1918.—Education Committee determined to rent Mapesbury House for use as a day open-air school. 4th December, 1918.—Ecclesiastical Commissioners refused use of Mapesbury House for purposes of a day open-air school. 8th August, 1918. -Education Act, 1918, passed making the education of physically defective and epileptic children compulsory. (Sec. 20—In operation 1st April, 1920.) 8th September, 1919.—Report of Medical Officer on "'Special' Schools—Open Air School" submitted under Circular 1119 of the Board of Education, dated 3rd July, 1919. 7th January, 1920.—Special Committee appointed to visit and report. Selected "Special" Schools Visited. A.—Day Opex Air Schools. 1. London—Birley House Day Open Air School—Forest Hill.—Visited 10th March, 1920. Deputation:—Councillors W. M. Bolton, Mrs. Moore, and Dr. Buchan. This school was established by the London County Council for 120 delicate children in 1908. The conditions treated include anæmia, mal-nutrition, debility, enlarged glands. Children are also sent here after operation for tonsils and adenoids and the like. The school is in charge of a head master and is open from 9 a.m. to 4 p.m. in the Winter, and 9 a.m. to 6 p.m. in the Summer on five days a week and from 9 a.m. to 1 p.m. on Saturdays. The children reach the school by public conveyance, the fares being paid by the Education Authority. The children receive three meals at the school, namely, breakfast, dinner and tea. The cost of these meals is in part recovered. The buildings consist of:— (1) The previously existing house which is used for administrative purposes including head master's room, Doctor's room and a kitchen; and (2) A number of sheds of wood and felt roofing or canvas and felt roofing erected as rooms and dining rooms and rest sheds. About ¾ of an acre of land are attached to the school but this is too little. The classes are mixed. Subjects are taught practically and as much teaching is done in the open air as possible. The average duration of stay of the children at this school is one year, and the head master reports that their health is greatly improved and that the educational methods in vogue enable them to take a wider outlook and to realise the practical value of education. 2. London—Shooter's Hill Day Open Air School.—Visited 10th March, 1920. Deputation:— Councillors W. M. Bolton, Mrs. Moore, and Dr. Buchan. This school has been established by the London County Council for 100 delicate children, and is in charge of a head master. The children reach the school on foot or by public conveyance, the fares being paid by the Local Education Authority. It is situate on six acres of land, 3½ of which are wooded. The buildings consist of a head teacher's room, a nurse's room, a tool shed, a clog room, and a large bungalow with canvas sides and wood floor facing south. As much teaching as possible is done in the open air, and the bungalow is only used in exceptional weather and for singing. The teaching of the children is mainly practical; in fact all subjects are taught practically, if this is at all possible. The bungalow is artificially heated only when the temperature falls below 40° Fah., additional clothing being advocated instead. Clogs and jerseys are supplied, but only children who are abundantly clothed and well shod are allowed to attend this school. The head teacher, who conducted us round the school, laid stress on the increased mental alertness of the children after a short attendance. The children receive three meals a day, prepared and served at Plum Lane school, close by, where the children go at the appointed time. A proportion of the cost of meals is recovered. 3. Kettering—Day Open Air Schools—Visited llth March, 1920. Deputation:—Councillors W. M. Bolton, Miss Royle, and Dr. Buchan. These schools were opened in December, 1913, by the Kettering Urban District Local Education Authority, which has a school population of about 5,000. The schools are for day scholars only and are in charge of a head mistress. The buildings are of brick and slate, and were originally erected for 20 tuberculous, 40 delicate, and 40 mentally defective children on about one acre of land. On the occasion of our visit on 11th March, 1920, 118 children were in attendance. Recently an additional acre of land adjoining the schools has been acquired, making two acres in all. In connection with the Kettering open air recovery schools, it was noted that the phthisical children were not kept apart from the delicate children, as there is no danger of infection in early cases under open air conditions. 125 The class-room for phthisical cases opens on three sides, the two end class-rooms for delicate and mentally defective children respectively open on two sides, but the class-rooms adjacent to and the drill and dining hall itself have practically only one side open to the air. The desks provided are movable but somewhat heavy. The seats are separate. The heating of the class-rooms is by means of low pressure hot water, with radiators at back and special floor plates around front of rooms. This arrangement was specially designed, but has little heating effect, as the sides of the class-rooms are always widely open, except in wet and stormy weather. The children and teachers are supplied with blankets and flannel coats during the cold season. The children are also supplied with felt-lined clogs. One large resting shed separate from the class-rooms is provided. This shed has a wooden floor raised on pillars about three feet from the ground. The back portion of the roof is boarded and fluted with galvanised iron, and the front portion is covered with patent glazing. The shed is too hot in Summer. The disadvantages of the single large resting shed are (a) the larger the shed, the greater is the tendency for the air therein to be stagnant; (b) the larger the number of children resting at once the more difficult is it to get them off to sleep; (c) the difficulty of the same shed being used by two or more different classes at once for different forms of rest or exercise. On the other hand, the advantage appears to be that a smaller number of the staff can look after all the children in the school while resting. The girls' cloak rooms are about twice the size of the boys' cloak rooms, and this seems to be the correct proportion. The kitchen is used for educational purposes—the teaching of cookery—but, as planned, it is too small. So also is the scullery. Cooking is carried out by electricity. There is no laundry where the towels, table linen, etc., can be washed and the children at the same time receive instruction in laundry. There is no manual centre for instructional purposes. There are 12 spray baths for 100 children, and a dressing room. These are mixed schools, the children ranging from 5 to 14 years. The children are asked to pay 4d. per day for their food—cost price. This is remitted in necessitous cases. The children receive instruction from the cook, but a laundry and cooking mistress should be on the staff. The staff employed at these schools is:—one head teacher, five class teachers, one nurse, one cook, one scullery maid and one caretaker. From the results of the work at Kettering we are of opinion that open air teaching is equally beneficial to the mentally defective. 4. Cambridge—Day Open Air School.—Visited 11th March, 1920. Deputation:—Councillors W. M. Bolton, Miss Royle and Dr. Buchan. This is a school for 30 boys and girls. It was established by the Cambridge Borough Education Committee in July, 1916, and a head mistress is in charge. The children attend from 9.30 a.m. till 4 p.m. in the Winter and 9.30 a.m. till 5.30 p.m. in the Summer. They receive breakfast, dinner and tea at the school, part of the cost of the meals being recovered. This school is opened five days a week, not on Saturday. The average duration of stay of a child is six to nine months. The buildings are two temporary structures, one of wood and felt and the other of asbestos sheeting and felt. The land attached to this school is about half an acre in extent. 5. Nottingham—Arboretum Day Open Air School.—Visited 12th April, 1920. Deputation:— Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a day open air school maintained by the Nottingham Education Authority. A head mistress is in charge. It consists of five open wooden sheds with fibro-cement roofing placed in a corner of one of the public parks of the city. There are 120 children on the roll. The cases admitted suffer from anaemia, mal-nutrition, non-tubercular lung disease, heart disease, oral sepsis and similar conditions. The school is open from 9 a.m. to 5 p.m. in the Winter and 9 a.m. to 6 p.m. in the Summer. The children receive three meals a day which are prepared by three workers in the kitchen. None of the children are employed in connection with the preparation of meals. The school itself is of a rudimentary character and no bathing is available for the children. The average stay at the school is seven months. 120 6. Birmingham—Uffculme Day Open Air School—Visited 15th April, 1920. Deputation:— Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a permanent building of brick and tile, designed for 120 delicate children. The school is in charge of a head mistress. It is for day scholars only, and is easy of access by tram. It stands on 1½ acres, but in addition has the use of a park of 25 acres when not in use for Sunday school and other holiday treats. The school has been open nine years, and was presented to the City of Birmingham by Mr. and Mrs. Barrow Cadbury. The school has four classrooms, three of them are arranged corner to corner, thus allowing all four sides to be separate, but only three sides open. The fourth classroom is attached to the dining hall, and two sides open. The sides open right up to the ceiling, so as to prevent pockets of air forming. The desks provided are movable and the seats are separate. The kitchen is placed on the first floor, the idea being to prevent the smell of cooking entering the school proper. The girls' cloak room, which is the same size as the boys', is too small. There are ten spray baths and ten lavatory basins provided for 130 children in attendance. Ample cupboard accommodation is necessary for the clogs worn by the children out of doors, the blankets, jerseys, woollen mittens and caps provided by the Committee and used by the children in cold weather. The resting shed is separate from the class rooms. One large resting shed as shown at this school is not recommended, the head teacher thinking that two smaller sheds would be much better. Further, the sheds should not be too deep as free ventilation under these conditions is not practicable. This is a mixed school, the children ranging from 6 to 14 years. The average stay of a child at this school is about 1 year. The staff consists of one head teacher, four class teachers, one nurse, one cook, one kitchen maid, one additional maid and one caretaker. The school is open from 9 a.m. to 4.30 p.m. in the Winter and 8 a.m. to 5.30 p.m. in the Summer. The school is not closed during the holidays. All children are given three meals a day at the school, and in respect of the additional cost pay sums varying from nil to 4s. 6d. per week. B.—Day Schools for Cripple Children. 7. Manchester—Lancasterian Day School for Cripple Children.—Visited 13th April, 1920. Deputation:—Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a school of the same type as the Furness Road physically defective school, Willesden, although the accommodation is better. It is in charge of a head mistress; 150 children are taken to this school daily by bus or tram. The children admitted are those suffering from infantile paralysis and healed tubercular conditions of the bones and joints, such as hip joint disease and spinal disease. The classes are mixed and the number attending permits of sufficient classification for educational purposes. The training given is largely manual. There is a bath room attached to this school and all the children are bathed once a week. Great attention is paid to the condition of the teeth and the healthy condition of the mouth. A room is set aside for massage and remedial exercises and is under the supervision of a trained Masseuse. C.—Day Open Air Schools for Pulmonary Tuberculosis. 8. London—Kensal House Day Open Air School for Pulmonary Tuberculosis, Harrow Road, Paddington.—Visited 18th March, 1920. Deputation:— Councillors W. M. Bolton, Miss Royle, and Dr. Atkinson. This day school under the control of the London County Council and in charge of a head mistress, provides accommodation for 100 boys and girls, all children attending being notified cases of tuberculosis. The children travel to school by tram-car. The school consists of a large old fashioned house surrounded by ¾ acre of land and accommodation is provided for teaching, treatment, and domestic purposes. The classrooms are ordinary large rooms, doors and windows being open constantly, the room temperature being regulated by fires. A rest room for boys and one for girls is provided for compulsory rest twice daily, each child being provided with a stretcher bed. Unless the weather is very unfavourable the rest interval is always taken outside. 127 A nurse attends every morning to record temperatures and treat minor ailments. Single portable desks are provided, class instruction being given outside whenever possible, each child being wrapped in warm blankets. It was noticeable in the garden that, owing to the unprepared gravel ground and small foot rests attached to the desks in use, there was practically no protection against cold and damp feet, no extra provision in the way of lined clogs, etc., being made for the children. A large wooden platform screened round by canvas has been erected at a cost of £150. This affords useful protection for one class in rough weather but gives no protection or shade from the sun in hot weather. Dinners are cooked on the premises, each child paying 3½d. per dinner and 1½d. for extra milk. One cook is in charge with two kitchen women to assist. The kitchen women are also responsible for the carrying out of desks and stretcher beds to the garden. Each child is weighed every month and examined by the Tuberculosis Medical Officer three times during the year. D.—Residential Open Air Schools. 9. Seaford—Hamilton House Residential Open Air School.—Visited 22nd March, 1920. Deputation:—Councillors Mrs. Moore, the Rev. H. Martin Thorpe, and Dr. Buchan. This is actually a convalescent home for boys established and maintained by the Invalid Children's Aid Association. It is under the control of a matron. There are six acres of ground attached to the school. It has accommodation for 28 boys who are suffering from enlarged glands, chorea, or mal-nutrition. The house was not built primarily as an open air school, but the children going there derive benefit mainly from the change of air and the regime of the home. The stay in the home is about, on the average, three months, but in some cases it may be one year. There is a visiting Physician attached to the home, who, however, only calls as required. 10. Manchester—Bank Hall Residential Open Air School.—Visited 13th April, 1920. Deputation:—Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a residential school for 50 children who are in charge of a matron. The house in which the children sleep was a gift to the Corporation of Manchester for delicate children. An open air school consisting of a resting shed and two classrooms and teachers' rooms and offices has been built close to the mansion house. The children admitted come from the Manchester public elementary schools suffering from anaemia, debility, mal-nutrition and similar conditions. There are about 15 acres of land attached to this school. The children are resident and the average stay is about six months. 11. Cheshire—West Kirby Convalescent Home and Residential Open Air School—Visited 14th April, 1920. Deputation:—Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a residential home for 180 children sent by the Liverpool Education Committee, Boards of Guardians and other authorities. The children taken in are delicate children, pre-tubercular children, children suffering from infantile paralysis, and cripples. Some of the children are able to be up all day, others for only a portion of the day. The average stay of the children at this institution is one year. Classrooms are attached to the school and the teaching is largely manual. The institution is under the charge of a matron. 12. Cheshire—Heswall Residential Open Air School.—Visited 14th April, 1920. Deputation:— Councillor Mrs. Moore, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a residential institution for 56 boys and girls suffering from all forms of tuberculosis, anaemia, mal-nutrition, debility, etc., sent by Liverpool Boards of Guardians. A Matron is in charge. The residential part of the institution is beautifully situated overlooking the sea. Some additional accommodation is at present being provided by way of army huts which, however, do not permit of the ventilation usually associated with open air methods. A large open shed has been erected in connection with the school and is used as classrooms. Proficient teachers are not supplied by the Guardians but the children are under the care of a well educated man and his wife. Boys are admitted between the ages of 4 and 14 and girls up to 16. The average stay of the child at this institution is from 6 to 12 months. 128 13. Clacton—Ogilvie Residential Open Air School.—Visited 22nd April, 1920. Deputation:Councillor W. M. Bolton, the Rev. H. Martin Thorpe, and Dr. Atkinson. This home, endowed by the Ogilvie Trust, has accommodation at present for 22 boys and 22 girls, but an extension will shortly be completed whereby the accommodation will be increased to 100. The home is a two storey red brick building standing on eight acres of land, which, with the exception of a portion under cultivation, is used by the children for recreation. The dining room is a large airy room with oak fittings and parquet floor. Small dining tables to seat six are provided, the tables being covered with rough, white "Rexine," which has proved satisfactory. All cooking is done in the adjoining kitchens by steam. The school overlooking the garden consists of one large room divided by a movable partition into two classrooms. The rooms are large and airy with low casement windows, and each room has a large hot water radiator and a fireplace. Single adjustable desks are provided for the children and being light in structure are easily transferred. The classrooms although not opening direct on to the garden are satisfactory both in arrangement and equipment. Classes are also held in the garden and in wet or hot weather in the wide sheltered alcoves on either side of the main building. Sleeping accommodation is provided on the first storey in dormitories of 10 beds each and there are five beds out day and night on each open balcony. Ample bath and lavatory accommodation is provided for the children. The new extension when completed will give extra dormitory accommodation for children and maids, manual centre and a new school room and playroom. This institution is in charge of a matron. E.—Residential Schools for Cripple Children. 11. Middlesex—Halliwick Cripples Home, Winchmore Hill.-Visited 10th March, 1920. Deputation:—Councillor W. M. Bolton and Dr. Buchan. This school has been established by a Voluntary Committee for cripple girls, but the children sent to it are maintained by Boards of Guardians. It was certified by the Board of Education in February, 1919. There are 26 girls under 16, and 14 over 16. The girls are cripples as a result mainly of tuberculous disease of the joints or bones or infant paralysis. The children under 16 are taught in a classroom constructed of asbestos sheeting and corrugated iron roofing on the open air principle. The girls over 16 are mainly taught dressmaking and needlework for trade purposes. All pupils are resident in the institution and the dormitories and living arrangements that we saw were satisfactory. Eight acres of land are attached to the institution. This home is in charge of a matron. 15. Sussex—Residential School for Cripple Children, Chailey.—Visited 22nd March, 1920 Deputation:—Councillor Mrs. Moore, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a school established by voluntary effort and maintained in part by voluntary effort and in part by Boards of Guardians and Education Committees on account of payments in respect of children sent to the school. It is in charge of a lady superintendent. The boys' school is separate from the girls' and on the occasion of our visit the boys had been temporarily displaced from their quarters by disabled and wounded soldiers. The boys' school is in charge of a matron. The school has accommodation for 50 cripple girls and 60 cripple boys. These children have been crippled mainly on account of tuberculosis of the bone or the joints, infantile paralysis or injury. In addition, the school has accommodation for a few older girls who are taught domestic work such as laundry and household work. These girls are suffering from anaemia, debility, enlarged glands, mal-nutrition and the like. A small number of younger children of from two to five years are also admitted suffering from enlarged glands or early tuberculosis or infantile paralysis or the like. They are taught by the Montessori method, a trained Montessori teacher being attached to the institution. The girls' school stands on about eight acres of ground. The schools are under the charge of a hospital matron and a visiting Physician. A trained Masseuse (who is blind) lives on the premises and is employed in connection with the restoration of function as far as this may be possible to the paralysed muscles of the children. 129 The principle embodying the care of these children is that health is the primary consideration and so far as they are able to receive it, education is given during their residence in the institution. The institution differs from that of Kettering day open air school in that open air is not to the same extent in evidence but the children have the advantage of residential conditions and they live and work to the greatest possible extent in the open. The buildings in which the children reside, and in part work have all their windows open, but the whole sides of the building are not open as in Kettering. The temporary shelters which the boys used at the date of our visit were of the ordinary type used for sanatorium purposes. A feature of the work at this school is the practical training which both girls and boys receive —girls in needlework and domestic work and gardening and boys in wood-work and gardening. We were informed that these children were readily accepted, on reaching the age of 16, into practical workshops on account of the high standard of training they obtained at the schools. 10. Clacton- St. Michael's Convent of Mercy Residential School for Cripple Children.—Visited 22nd April, 1920. Deputation:—Councillor W. M. Bolton, the Rev. H. Martin Thorpe, and Dr. Atkinson. This school provides accommodation in three residential houses for 49 girls suffering from acute or chronic forms of surgical tuberculosis or cases of general debility, etc. The school is in charge of a Sister Superior and the cases are under the care of a Medical Practitioner who visits once per week. With the exception of a small open air shelter containing two beds all other sleeping accommodation is in the various bedrooms which contain five to eight beds. There was nothing worthy of note in the arrangement or equipment of the bedrooms or playroom ; the furniture and fittings of the home are old fashioned and depressing. A small brick building has been divided into classrooms, for purposes of a school, each classroom opening by glass doors on to a small court yard. Meals are served in two low sheds which have been erected in another part of the garden. The whole arrangements here are crude, the method of serving is unsatisfactory, rough and lacking in any attempt at daintiness. F. Residential Sanatorium Schools for Children Suffering from Pulmonary Tuberculosis. 17. Middlesex—Northern Hospital Sanatorium School, Winchmore Hill.—Visited 10th March, 1920. Deputation:—Councillor W. M. Bolton, and Dr. Buchan. This school was established in August, 1916, for boys under 7 and girls up to 16 years of age. The accommodation provided is for 60 pupils. The institution is maintained by the Metropolitan Asylums Board and the children sent to it are sent by the London County Council. The institution is in charge of a Medical Superintendent. Two pavilions at the Northern Hospital have been set apart for these children. These pavilions were originally built for convalescent fever cases and are not specially designed for purposes of a sanatorium school. There is much waste of space on account of the classrooms being too large. The children admitted are children suffering from early pulmonary tuberculosis. The average stay is from six to nine months. The children are under strict medical care and the matter of education is secondary to the matter of their health. On the slightest indication of active disease, as, for example, rise of temperature, the children are made to rest in bed or their school hours are reduced until their temperature becomes normal again. 18. Harpenden—National Children's Home and Residential Sanatorium School.- Visited 18th March, 1920. Deputation:—Councillors W. M. Bolton, Miss Royle, and Dr. Atkinson. This institution is a branch of the National Children's Homes and Orphanages, and was originally started to provide open air treatment and education for tuberculous children from their various branch homes over the country. The sanatorium is in charge of a matron. It is a two storey building built in red brick, rough cast and tile roof, having along the south aspect a verandah and a wide balcony overhead between the ground and first storey. On the ground floor separate dining rooms are provided for boys and girls and there are two large wards for bed cases in addition to recreation, treatment and staff rooms. On the first storey are small and large wards of two to eight beds, each ward opening by a French window on to the balcony, so that beds are very easily wheeled out, some of the children living outside day and night. When necessary, an overhead awning and side wind screens can be adjusted. 130 Children sufficiently well attend the open air school for two hours in the morning and oneand-a-half hours in the afternoon. The new open air school built in the grounds close to the sanatorium is a red brick building with tile roof, and consists of one large room divided by a folding partition into two classrooms, each classroom accommodating 25 children. The fourth side of the school facing South is completely open, but capable of being closed in inclement weather by a folding partition; on the opposite wall are large low windows opening outwards, so that both classrooms are light, airy rooms. Two nonresident teachers are in charge. A teachers' room and cloak room and lavatory accommodation for the children are provided in the annexe, and in each classroom there is a hot water radiator heated from a small boiler in the annexe basement. The single portable desks used by the children are easily transferred when lessons are given in the garden. The children have compulsorv rest in bed or out in the shelters three times a day. There are several revolving shelters in the grounds, each containing two beds, and these are in constant use by the children. A large play shelter is provided for wet weather, the children at other times playing in the garden or fields, the grounds surrounding the sanatorium being extensive. 19. Nottingham—Thurgarton Convalescent Home and Residential Sanatorium School.—Visited 12th April, 1920. Deputation:—Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This home admits the children of the Nottingham Education Authority who are suffering from phthisis and tubercular glands. It is a small residential home, under the charge of a matron, with accommodation for 10 children. Outside there is a wooden shed with one side open to the air where the children have lessons in wet weather. Thurgarton is about 15 miles from Nottingham City. 20. Oxford—Berks and Bucks Sanatorium and Residential Sanatorium School, Peppard Common.—Visited 21st April, 1920. Deputation:—Councillor Mrs. Moore, the Rev. H. Martin Thorpe, and Dr. Atkinson. This sanatorium is under the joint control of the Oxon, Berks and Bucks Joint Council, and provides accommodation for 34 males, 20 females and 40 children (boys and girls). A woman Medical Superintendent is in charge. The buildings are of the wooden hut type, well raised above the ground and with tiled roof, each hut being sub-divided into small and large wards, the wards opening on to a wide verandah and having a recreation room, nurses' duty room, etc., at the end of each pavilion. The small wards opening on to the verandah are fitted with carriage windows which drop to the level of the bed. The school is a similar hut divided into two classrooms, on each of three sides of the classroom there is a large French window opening outwards, and on either side large carriage windows so that each side can be partially thrown open according to weather conditions and each classroom is heated by an anthracite stove. As the buildings stand in 95 acres of land, ample recreation ground is available for the children. The sanatorium is being extended to provide accommodation for 60 males, 36 females, and 80 children, asbestos huts purchased from the Red Cross at a cost of £3,000, are in course of erection and when completed the transfer will cost £5,000. One hut divided by a moveable partition will give two extra classrooms. These classrooms will have three windows on each side opening inwards and at the end a medium sized French window and each room will be heated by a central stove. The window space appears to be inadequate for an open air school and the huts are liable to be very hot and stuffy in the summer and it seems unfortunate that with so much land available the two new huts for children should be placed so close together. Dormitory accommodation is provided in a similar hut and 12 small wards of two beds each are set aside for isolation purposes. In the new extension a large dining hall and playroom are provided in addition to duty rooms, bathrooms, lavatories, etc. The cooking for the sanatorium is to be done at a central kitchen and distributed from there to each pavilion. When the extension is completed extra children can be admitted, but the school conditions will not be ideal and for an open air school there is little to be said in favour of the conversion of army huts. 131 G.—Residential Sanatorium Schools for Children Suffering from Surgical Tuberculosis. 21. Alton—Lord Mayor Treloar's Cripples' Hospital and College for Surgical Tuberculosis.— Visited 17th March, 1920. Deputation:—Councillors W. M. Bolton and Mrs. Moore, and Dr. Buchan. This institution was established in 1907, by Lord Mayor Treloar. It now consists of three parts:— (1) The hospital, in which children up to 14 years receive treatment and education ; (2) The college, which has been established for the training of cripple boys from 14 to 18 years of age in trades suited to their capabilities and limitations ; and (3) St. Andrew's Home, Hayling Island, where patients are sent for a change of air. All are under the control of Sir Henry Gauvain, the Medical Superintendent. The deputation saw the hospital and the college, but did not see the convalescent home at Hayling Island. The hospital and college have accommodation for some 250 patients of which about 200 are in the hospital. The hospital exists for the alleviation of the sufferings, and the correction of deformities, of the crippled child. Attention is principally devoted to the care of cripples suffering from tuberculous disease of the bones and joints, because such patients are both the most numerous, the most needy, and, perhaps, the most neglected class of crippled children in this country. At the same time other crippled children are eligible for admission, but the demands of the tuberculous are so insistent and urgent that only rarely is it possible to admit others. It is probably no exaggeration to say that tuberculous disease causes more crippling than all other diseases combined. The ultimate direct mortality has been variously estimated as from 20 per cent. to 70 per cent. of the cases infected, and probably 50 per cent. would not be an unduly high estimate. A contributory factor to this high mortality is the lack of facilities afforded for systematic and adequate treatment. Few general hospitals are able to spare a bed sufficiently long to a serious case to ensure the patient's complete recovery, and indeed such hospitals cannot be rightly called upon to undertake the protracted treatment necessary for these patients. It was to remedy this defect that Lord Mayor Treloar's Cripples' Hospital was founded. With increased knowledge of the nature of the disease, it has been demonstrated, that surgical tuberculosis may be described as a general disease, in which the local lesion or lesions are special manifestations. This conception of surgical tuberculosis is of the most supreme importance, because on it is based the method of treatment adopted at this hospital. Conservative measures are adopted. By conservative treatment is meant the adoption of all measures which tend to improve the patient's general health, increase his powers of resistance, and preserve and restore the part attacked in contradistinction to radical treatment, which aims at the cure of the disease by the removal of the local lesion. This is really health work, and is a correct conception of medicine in its widest sense. The ideals of the hospital are set out in the first medical report under the following five headings, and if we avoid the particular application of these principles to the particular disease treated at Alton, we get what should really be the guiding features of all health work and medicine generally. These five points are as follows:— (1) To so increase the patient's powers of resistance that he himself may be made to come the disease by which he is attacked and render it innocuous; (2) To preserve and restore any particular bones or joints diseased; (3) To prevent deformity, or, if deformity already exists, to correct or reduce this deformity as much as is possible; (4) To educate the patient while he is being treated, if his condition permits; and (5) To exercise as far as possible, efficient after-care and guidance, when treatment in the hospital is completed, and the patient discharged. It will be observed that the Alton Authorities recognise that the separation of preventive from curative medicine or of either from education in the child is practically impossible. The children while under treatment in hospital receive education, there being a head mistress and five assistant teachers provided. Children receive three hours instruction daily, the teachers actually working in the wards six hours daily. In addition to various surgical apparatus, the children are as much as possible out in the open air and Heliotherapy or Sun treatment is always in evidence. The experience gained at Alton has shown:— (1) That tuberculous cripples should be treated conservatively, but energetically, and for a sufficiently long period, as soon as possible after the onset of the disease; (2) That during treatment their education should be, where possible, efficiently undertaken, with special regard to their limitations and requirements ; (3) That even the most advanced cases may, in the great majority of instances, be very materially benefited and their deformities either corrected or reduced; 132 (4) That tuberculous cripples should have after-care and guidance systematically given; and (5) That apart altogether from philanthropic considerations, the thorough treatment of these patients is not only logical and desirable, but economically sound. It is undoubtedly to the advantage, not only of the individual, but of the community, to cure and train the cripple, to convert him from a dependant to a wage-earner and producer. The deputation saw the cases at Alton at all stages and were particularly impressed with the boys at the college who were learning to become self-supporting citizens. The work of this college is a clear demonstration of the economic soundness of converting the helpless and dependent cripple into a self-supporting, independent wage-earner and producer, and in the opinion of the deputation such money is well spent and a sound financial investment. 22. Manchester—Swinton and Parkfield Residential Open Air School for Surgical Tuberculosis. —Visited 13th April, 1920. Deputation:—Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a school maintained by the Manchester Education Authority for 114 children suffering from surgical tuberculosis and rickets. The children are under complete medical supervision there being a visiting Surgeon and a matron in charge of the home. A considerable area of land is attached to the institution some of which is used for the grazing of nine cows which supply milk for the children. The institution is a few miles out of Manchester. One portion of it consists of an old manor house to which has been added an open air ward. The average stay here of children is two to three years, and during this time they receive education. Nine teachers are employed for this purpose as the instruction given requires largely to be individual as the children are in bed for long periods at a time. 23. Cheshire—Leasowe Hospital and School for Surgical Tuberculosis.—Visited 14th April, 1920. Deputation:- Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buchan. This is a hospital for 240 children suffering from tuberculosis of the bones and joints. It is situated on the sea coast at Leasowe in Cheshire and was originally started as a voluntary enterprise but now 80 per cent. of the beds are maintained by the City Corporation of Liverpool. A Medical Superintendent is in charge. The ages of the children range from 5 to 16 years, and the children are put into wards according to their educational attainments rather than their physical disabilities. This is done in order to make teaching easier. There are 28 acres of land attached to the institution. The average stay at this hospital is two to three years. 24. Birmingham—Woodlands Residential Sanatorium School.—Visited 15th April, 1920. Deputation:—Councillor Mrs. Moore, and the Rev. H. Martin Thorpe, and Dr. Buchan. This institution admits 100 children and is under the charge of a matron. The majority of the children are suffering from tuberculosis and remain in the institution in some cases as long as four years, but the average stay is one year. About 1 per cent. of the children come back to the Woodlands after returning to their home conditions. Six teachers are provided by the Birmingham Education Committee and visit the institution daily. Teaching is conducted on the verandah or quite out of doors in fine weather. The institution is a mansion which has been adapted for its present purpose. The children are nursed in three open air wards on the first floor, ranged round three sides of an open quadrangle. One of these wards is new, while the two others are converted lofts. The sides of the wards immediately surrounding the quadrangle are open except for the supporting pillars, and protection is afforded from the rain when necessary by canvas curtains. The other sides of the wards are solid, but amply supplied with windows, which may be opened widely. The sanitary annexes are of recent construction, and small handrails are found useful for the cripples who use the closets provided. Seven baths are provided. An operating theatre and anæsthetic room are attached to the institution. The Birmingham and District Cripples' Union which maintain this institution are considering the establishment of massage and plaster rooms at an early date. 133 H.—Residential Schools for Epileptic Children, Manchester. 26. Manchester—Soss Moss Council School.—Visited 13th April, 1920. Deputation:— Councillors W. M. Bolton, Mrs. Moore, Miss Royle, the Rev. H. Martin Thorpe, and Dr. Buehan. This school has accommodation for 100 children of both sexes. It deals with the educable type of epileptic. The boys and girls have separate living and sleeping pavilions, but the classes are mixed. The institution is in charge of a matron. Children are admitted between the ages of 5 and 16. There is a considerable area of land attached to this institution which is utilised to the greatest possible extent for the teaching of gardening. The boys are also taught cobbling and the girls dressmaking and knitting and the like. The instruction is largely manual. The institution is built on the pavilion system and is maintained by the Manchester Education Authority. We were much impressed by this institution. General Conclusions on Visits. From the foregoing statement of visits it will be noted that the following classes of schools have been seen:— A.—Day Open Air Schools—Six in number. B.—Day Schools for Cripple Children—One in number. C.—Day Open Air Schools for Children suffering from Pulmonary Tuberculosis—One in number. D.—Residential Open Air Schools—Five in number. E.—Residential Open Air Schools for Cripple Children—Three in number. F.—Residential Sanatorium Schools for Children suffering from Pulmonary Tuberculosis —Four in number. G.—Residential Sanatorium Schools for Children suffering from Surgical Tuberculosis— Four in number. H.—Residential School for Epileptic Children—One in number. The foregoing day schools and residential institutions have been established with a view of placing the children admitted under conditions likely to improve their health and educating them step by step with improvement in their physical condition. These schools have been established by various authorities in England and Wales, and everywhere we went there was agreement that the pupils attending improved mentally and physically owing to the regime at the schools, and leave in a condition which, with few exceptions, enables them to become self-supporting citizens. It was also borne in upon us that fresh air and sunlight are only adjuncts to the treatment of these cases and the improvement in their health, and that proper dieting, rest, cleanliness and physical exercises are equally important. Medical inspection requires to be frequent and supervision constant so that the health of the child may be permanently set up and its course of studies directed having regard to its physical disability and future career. Obligations of the Local Education Authority. The Local Education Authority is compelled to make suitable provision for the education of physically defective children whose age exceeds seven years. (Section 20, Education Act, 1918 —in operation, 1st April, 1920.) Having regard to the result of our visits, it would appear necessary for the local authority to establish:— (1) A Day Open Air School—for children suffering from anaemia, debility, mal-nutrition, paralysis and deformities, and for children showing pre-disposition to disease, i.e., pre-tubercular children; and, ultimately, (2) A Residential Open Air School—for children suffering from conditions too advanced for the day open air school, including tuberculosis of the lungs, bones, etc., where treatment is prolonged. Number of Physically Defective Children in Willesden. At the present time many of the Willesden children suffering from the conditions mentioned above are being inadequately or irregularly educated or are receiving no education at all owing to the want of the kind of school accommodation which will enable them to attend regularly without health deterioration. The School Medical Inspection records have been incomplete in Willesden since 1915, and there have been none at all since 1917, but having regard to such records as are 134 available and to experience elsewhere it may be stated that the number of children in Willesden suitable for admission to the above schools may be estimated on a conservative basis as 2.5 per cent. of the number on the roll that is to say that there are 600 such children in Willesden. This number may be divided thus:— Suitable for a Day Open Air School 480 „ ,, Residential Open Air School 120 Of the 480 children suitable for a day open air school 75 are now on the roll of Furness Road physically defective school and about 25 will be enrolled at Leopold Road "special" school when opened for physically defective children. The bulk of the remaining 380 children are weak and delicate children suffering from anæmia, debility and other ill-defined conditions, who attend irregularly at school and belong frequently to the backward type. It is proposed in the day open air school to be erected to incorporate existing physically defective schools and thus free again Furness Road "special" school for its original purpose. Of the 120 children suitable for a residential open air school it should be observed that the School Medical Records of 1915—the last year for which they are complete—shewed that 76 children of this type were not in attendance at any school. We are anxious that a residential school should be established to permit of the education of these" children. We are also anxious that the cost per head for maintenance should be reduced to a minimum and are of opinion that a residential school for 120 might not prove economical in this respect. In these circumstances we propose to defer the question of the establishment of a residential open air school and would suggest that favourable consideration be given to any proposal by which such an institution might be worked in conjunction with any other institution required in connection with the Health Department so as not to increase overhead charges and reduce the maintenance costs per head. In the meantime we are of opinion that a day open air school on the lines suggested by the Committee in 1914, should be proceeded with. Plan of Willesden Day Open Air School. We have duly considered the buildings of the open air schools that we visited. We have also reviewed the plan of the open air school which was approved by the Board of Education in October, 1914. We are of opinion that this plan should be adopted with certain slight modifications. Briefly the main points of this plan are as follows:— (1) Disposition of classrooms on site—The classrooms all face South. (2) Classrooms—In the Schools visited these were practically always open on the South and West sides. We are of opinion that instead of roller wooden shutters shewn on. the original plan there should be provided a small hollow parapet wall around the building with windows above which would lower into the hollow parapet wall, and above these lowering windows again a louvred or pivoted window similar to the arrangements that we saw at the Swinton and Parkfield residential open air school for children suffering from surgical tuberculosis, Manchester. We are of opinion that some form of heating should be provided for the classrooms and suggest that the pavilions should be heated by means of independent boilers and low pressure hot water. (3) Verandahs or resting sheds--Having regard to the disadvantages of having only one large resting shed, we have retained the arrangement in the original plan of having a small resting shed attached to each pair of classrooms. These sheds should be provided with ample ridge ventilation. (4) Kitchen—We are of opinion that this should only be large enough to cook for the children. The proposed provision for cookery instruction should be separate. (5) Laundry—We have retained this so that the laundry work necessary may be done on the premises and the children at the same time receive instruction. (6) Teaching of laundry and cookery—We are of opinion that the teaching of laundry and cookery will be of great service to the cripple children attending the Willesden open air school, while at the same time this form of instruction may be useful in "hardening" delicate children about to leave school and enter employment. The laundry and cookery centre should be planned on "open air" lines and would be available for other schools if required. (7) Baths—Twenty-eight shower and two slipper baths are provided. (8) Lavatory basins—Forty basins are provided. (9) Cloakroom and cupboard accommodation—This has been provided for the children's clogs, blankets, flannel coats, mittens, etc. (10) Playground—This has been provided on the North West corner so as not to interfere with possible future developments. A portion of the playground should be set aside for the cripple children. Ample space is left for the school gardens. (11) Massage and physical exercises room—This is an additional room not shewn on the original plan and having regard to the cripple children who will attend this school we consider its provision important. This room should be about 25 feet square. 135 (12) The proximity of the latrines to the kitchen and inaccessibility from the playground are points in the original plan which appear to require amendment. (13) The combination of dining room and assembly hall as one room appears impracticable having regard to the three meals per day to be served to 240 children. We are of opinion that two classrooms with the intervening verandah could be used as an assembly hall. (14) The nurse's room should be dispensed with and the doctor's room used by both. (15) Cloak room and W.C. accommodation for the domestic staff requires to be provided. (16) Greater accommodation for kitchen stores is required. Materials Proposed. In considering the materials to be used we have asked the Architect to have' every regard to durability and economy. (1) Dwarf walls and windows in lieu of roller shutters.—The sides and ends of classrooms, verandahs, work-shops, massage room and sides of dining hall and ends of cookery and laundry to have hollow parapet walls 3 feet high, with sash hung windows above which will lower into the hollow parapet and above these lowering windows glazed sashes hung on centres to be provided. The inner and outer faces of the lower framings forming the parapet wall to be faced with rough boarding and covered with asbestos sheeting. The roof of the above buildings to be supported on steel stanchions. The walls of administrative block, assistant teacher's room, offices and lodge to be brick. The external walls to be nine inches thick and rough cast on the outside. (2) Floors.—All floors to be formed with cement concrete four inches thick and covered with decolite composition, except the floors of washhouse and heating chambers, which are to be granolithic. (3) Roofs.—All roofs to be of wood construction, covered with felt and "poilite" gated sheeting. Note.—This sheeting will be cheaper and more weatherproof than poilite tiles and will admit of the pitch of the roof being reduced and effect a saving in timber and other materials. (4) Internal finishings.—The internal walls of administrative block to be faced with glazed bricks, except the nurse's and teacher's rooms, dining hall and heating chamber. The ceilings of verandahs or resting sheds to be open to apex of roof and to be formed with asbestos sheeting in lieu of matchboarding. The ceilings of classrooms, trades rooms, dining hall, massage, cookery and laundry rooms also to be similar sheeting in lieu of plaster. All other ceilings to be plastered. (5) Ventilation.—The verandahs or resting sheds and classrooms to have ventilating ridges. All other rooms to have ceiling outlets. (6) Heating.—The cloak rooms, dressing room and corridor of administrative block, dining hall and massage room to be heated with a hot water apparatus, the nurse's and teacher's rooms to have open fireplaces. The east and west ranges of pavilion blocks containing the workshops classrooms and rest sheds are each to be provided with a hot water apparatus. (7) Lighting to be by electricity. (8) Tar paving.-The paths surrounding the buildings and the playground to be tarpaved. ESTIMATED COSTS. The foregoing proposals involve the following estimated costs:— Estimated Capital Charges. £ (a) Land 8,000 (b) Buildings together with the provision of kitchen, larger stores, &c., massage and physical exercises room, revised and increased latrine accommodation, two additional heating chambers and hot water heating of the classrooms, verandahs, dining hall and massage room and the substitution of small, hollow parapet walls and windows in lieu of roller shutters 37,000 (c) Furniture and Equipment 4,000 £49,000 If the suggested modifications re materials, as per foregoing statement, is adopted the saving will be 1,000 Net estimate £48,000 136 ESTIMATED ANNUAL CHARGES. Expenditure. £ Meals 2,600 Salaries—Teaching staff and three instructors—Whole time for manual, cookery and laundry 3,215 Nurse 250 Doctor 400 Caretaker and cleaning 500 Cooks and helps 700 Lighting 100 Heating and gas for laundry and cookery 200 Consumable and renewable during year—Various stock 600 Interest and repayment on Loans—(£44,000, 30 years, 7%, and £4,000, 10 years, 7%) 4,090 Clerical expenses 300 Ambulance and travelling expenses 2,500 Total gross expenditure 615,455 Income. £ Meals—(say l/3rd of cost by parents), say 867 Sales 60 Board of Education Grant—50% of net Expenditure 7,264 Total Income £8,191 Net estimate £7,264 Recommendations. (1) That a day open air school for 240 physically defective children be established. (2) That the children in attendance at Furness Road and Leopold Road physically defective schools be transferred to the open air school when ready. (3) That about six acres of land be purchased for the open air school. (4) We have considered various sites but having regard to accessibility, acreage, aspect, and the nature of the buildings to be erected we are of opinion that the Dudden Hill allotments provide the best site and recommend purchase accordingly. (5) That the provision of a residential open air school be deferred. H. MARTIN THORPE, Chairman, Children's Care Committee. ROSALIND MOORE, Member, Children's Care Committee. MARGARET ROYLE, Member, Children's Care Committee. W. M. BOLTON, Chairman, School Accommodation Committee. GEORGE F. BUCHAN, Medical Officer. 137 APPENDIX H. To the Health Committee. 1st June, 1920. WILLESDEN MUNICIPAL HOSPITAL. Nursing and Domestic Staff. Wages.—As instructed, I beg to submit herewith a statement of the wages now payable to the Staff and the increase which would appear to be necessary to secure candidates:— Maximum No. Employed. Present Remuneration per annum. Salary. Nursing Staff. £ Theatre Sister 1 75 With, in addition, Bonus of £12 per annum granted on 11th October, 1919. Night Sister 1 60 Sisters 7 50-56 Staff Nurses 9 46-50 Probationers 39 22-26 57 Domestic Staff. Cook 1 46-50 Assistant Cook 1 30-34 Kitchen Maids 2 26—30 Scullery Maids 1 24—28 Needle Woman 1 42—46 Needleroom Maid 1 26—30 Head Laundress 1 42—46 Assistant Laundress 1 30—34 Laundry Maids 5 26—30 Senior Pantry Maids 2 28—32 Junior Pantry Maids 2 26—30 Housemaids 2 28—32 Wardmaids 11 26—30 Dormitory Maids 4 26—30 35 It is suggested that the Bonus be increased to £20 per annum as from June 1st, 1920, involving an estimated increased expenditure per annum of 92 by £8 = £736 in a full year or £613 6s. 8d. for the current financial year. Living Out.—Enquiries have been made of certain of the domestic staff who could suitably live out. Thirteen are prepared to do so. They all ask for £2 a week and meals on duty. It is suggested that they be paid the salary as above shown, plus meals on duty, plus 21s. a week to provide them with lodging and washing and part board outside. I think this arrangement should be adopted as it would set free certain beds which could be used for nurses and save the expenditure involved from time to time through the Medical Superintendent having to obtain private nurses on supply. Perhaps too, it might be less difficult to get the necessary domestic staff by giving applicants the option of living out. The 13 beds or so which would be freed by this arrangement does not provide sufficient accommodation to enable the 48 hour week to be adopted at once, and the Committee will require to consider how they propose to provide the necessary additional accommodation indicated in my report on the 48 hour week. Mess room accommodation and cloak room accommodation will also be required for those members of the staff who live out as there are no existing rooms available at the hospital. GEORGE F. BUCHAN, Medical Officer of Health. 138 APPENDIX I. To the Health Committee. 28th June, 1020. Small Pox Hospital Accommodation. Report of interview with the Ministry of Health at the Offices of the Ministry, Monday, June 28th, at 11 a.m. Present:—Ministry of Health—Dr. Reece and a Clerk. Willesden Council—Councillor Wm. Riley, J.P., and Dr. Buchan. The position generally was talked over. Dr. Reece appeared to think that Small Pox was more or less imminent and referred to charts in support of his opinion. He stated that Small Pox waves occur in cycles and from his reading of Small Pox history he appeared to think that the next wave would be about 1930 or so. It was suggested that in the event of an outbreak of Small Pox in Willesden, application would be made to the Metropolitan Asylums Board to receive the first case and such subsequent cases if any as they would take. Failing their acceptance of these cases the existing arrangements at Kingsbury permit of the admission of the first case and immediate steps would be taken to provide the necessary additional temporary accommodation by means of huts or tents on the Kingsbury site. Dr. Reece did not consider that temporary buildings to be run up when an outbreak had begun was a satisfactory solution. As alternatives it was suggested:— (a) That Willesden might join in the Middlesex Districts Joint Hospital Board; (b) That temporary buildings might be erected on the Kingsbury site suitable for the admission of Small Pox cases. These buildings would only be used for Small Pox, the site at Kingsbury not being suitable for the erection of permanent buildings for continuous use. (c) That a site or estate of about 50 acres might be found outside Willesden suitable for the erection of buildings for continuous use which buildings would be used for convalescent cases arising in connection with Maternity and Child Welfare and School Children, with a provisional building erected thereon for Small Pox, the whole of the buildings to be emptied if Small Pox occurred. Dr. Reece asked that the Health Committee and Council should consider and submit alternative proposals on the foregoing lines. He indicated that the failure of the Council to do anything in connection with the provision of Small Pox Hospital Accommodation might result in the Ministry putting into operation the Epidemic Regulations whereby the Willesden area would be taken over by the Ministry for Small Pox purposes and Small Pox Hospital accommodation be provided by the Ministry at the expense of the Council. GEORGE F. BUCHAN, Medical Officer of Health. APPENDIX J. To the Health Committee. 28th fune, 1920. Memorandum re Utilisation of Medical Inspection Centres for Clinic Purposes, Excess Attendances at Clinics, etc. (Council Minutes, 1920-21, p. 103, paras. 15 and 16). 1. Lower Place Medical Inspection Centre. Utilisation.—As a Cleansing Centre. Additional Estimated Costs:— (i.) Initial. £ s. d Alterations including baths, sinks, etc. 150 0 0 Furniture, Instruments and other equipment 90 18 0 Linen 137 17 0 £378 15 0 (ii.) Annual. Two Nurses Salaries and uniforms 392 0 0 Cleaning of premises—wages 50 0 0 Laundry 100 0 0 Soap, ointments, dressings, etc. 80 0 0 Cleaning materials 20 0 0 Heating, lighting 40 0 0 Printing, stationery and postage 25 0 0 £707 0 0 139 2. Bridge Road Medical Inspection Centre. Utilisation.—As a Dental Centre. Note.—This will free Dental Suite at Clinic (2) for Medical Purposes. Additional Estimated Costs:— (i.) Initial. £ s. d. Alterations; Electrical Work; Dental Work 140 0 0 Furniture and equipment, Linen 100 0 0 Total £240 0 0 (ii.) Annual. Cleaning of premises—wages 50 0 0 Cleaning materials 20 0 0 Heating, lighting 40 0 0 Printing, stationery and postage 12 0 0 £122 0 0 3. Upper Flat, Ringworm Clinic, 225, High Road, Kilburn. Utilisation.—As a Dental Centre. Note.—This will free Dental Suite at Clinic (1) for Medical Purposes. Additional Estimated Costs:— (i.) Initial. £ s. d. Alterations : electrical work, dental work 196 5 0 Furniture and equipment. Linen 100 0 0 £296 5 0 (ii.) Annual. Cleaning of premises—wages 50 0 0 Cleaning materials 20 0 0 Heating, lighting 40 0 0 Printing, stationery and postage 12 0 0 £122 0 0 The M.D. After-Care Committee are at present granted the use of one of these rooms on Wednesday mornings. 4. Dental Suite Clinic (1). Utilisation.—Medical Purposes. Additional Estimated Costs:— (i.) Initial. £ s. d. Alterations 67 0 0 Furniture and equipment 310 0 0 Instruments 45 0 0 £422 0 0 (ii.) Annual. Salaries—1 Doctor, 4 Health Visitors, 1 Clinic Nurse, 1 Clerk £2,277 17 0 5. Dental Suite, Clinic (2). Utilisation.—Medical Purposes. Additional Estimated Costs:— (i.) Initial. £ s. d. Alterations 35 0 0 Furniture and equipment 237 0 0 Instruments 45 0 0 £317 0 0 (ii.) Annual. Salaries—1 Doctor, 4 Health Visitors, 1 Clinic Nurse and 1 Clerk £2,277 17 0 140 6. Summary of Additional Estimated Costs. Initial. Annual. £ s. d. £ s. d. Lower Place Medical Inspection Centre as a Cleansing Centre 378 15 0 707 0 0 Bridge Road Medical Inspection Centre as a Dental Centre 240 0 0 122 0 0 Upper Flat, Ringworm Clinic, as a Dental Centre 296 5 0 122 0 0 Dental Suite, Clinic 1, used for Medical Purposes 422 0 0 2,277 17 0 Dental Suite, Clinic 2, used for Medical Purposes 317 0 0 2.277 17 0 Total £1,654 0 0 £5,506 14 0 7. Recommendations. It is recommended that the above be carried out subject to the approval of the Ministry of Health and Board of Education as required. It will be some considerable time before the extension of Clinic 2 or the erection of the Stonebridge Clinic is completed. At present the work of the Clinics is seriously hampered by an ever increasing pressure. During the 4 weeks ended 12th June, 1920. which included the Whitsun Holidays, 6,384 medical attendances were recorded at the Clinic's as follows:— Medical. Cleansing (Total 551) 275 Minor Ailments (Total 3,269) 1,635 Throat, Nose and Ear Diseases 566 Eye Diseases 544 Mothers and Infants 3,364 6,384 During the same time, on the basis of 60 patients per doctor per day, which is a high working average, 4,800 attendances would have been made. The provision recommended in this report will relieve the present congestion with a little to spare to meet increased work until enlarged or new clinic premises have been provided as determined by the Council. GEORGE F. BUCHAN, Medical Officer of Health. APPENDIX K. To Householders and Shopkeepers in Willesden. June, 1920. FLIES. Flies breed in manure, ashbin refuse and decaying matter. A single fly lays about 500 eggs, which in hot weather will develop into full grown flies in two to three weeks. A great increase in the number of flies is noticeable in July, with a maximum in August and September. Flies carry filth from manure heaps and human excrement to foodstuffs, especially fish, meat and milk, in the pantry and shops. The contamination of food is a common cause of Summer Diarrhcea, a very fatal disease amongst young children. Having regard to the dangers to health brought about by the presence of large numbers of flies, the Health Committee urge on the people of Willesden the importance of the following rules:— Rules. Do not purchase foodstuffs where flies are tolerated. Do not allow your children to buy sweets or fruit from shops where flies abound. Do not buy your milk from a Diary which is not kept free from flies. Keep flies out of your house and out of your pantry. Keep flies away from the milk by covering with white muslin. Use fly catchers if necessary. Be scrupulously clean in all things. Cultivate personal cleanliness. Cultivate cleanliness of the home. Keep food and milk clean by storing in a clean, light, cool, dry and airy place. Clean thoroughly and wash when possible all fruit and vegetables before consumption. Burn as much waste as possible. Keep the Dustbin clean, covered and dry. Do not put into the Dustbin animal or vegetable matter likely to decompose and serve as a breeding ground for flieS. Keep manure heaps on allotments or elsewhere covered with earth. By direction of the Health Committee, GEORGE F. BUCHAN, Medical Officer of Health. 141 APPENDIX L. To the Health Committee. 9th August, 1920. MOTOR AMBULANCE SERVICE.—SIXTH ANNUAL REPORT. I beg to report on the above for its sixth complete year ending March 31st, 1920. The seven motor vehicles of the motor ambulance service were delivered in December, 1913, and up to the end of March, 1920, had covered a total of 316.605 miles and were all in use. During the year certain work occasioned by the war was continued, namely, Food Control and the Conveyance of Wounded Soldiers to Hospitals. In addition many cases were removed for other Authorities, notably Acton, Hendon and Wealdstone District Councils, Acton War Pensions Committee and the Willesden Board of Guardians, while a number of miles were run for various departments of the Council. A day and night ambulance service is now available, but there is only one man on duty from 5.30 p.m. to 6 a.m. and from 2 p.m. on Saturday to 6 a.m. Monday. Double-handed calls during these periods are met by calling out the resident drivers on overtime. Calls for the ambulance are still increasing and at times several cases are waiting. In these circumstances as far as can be ascertained the most serious are removed first. Delays have taken place with Acton calls owing to the Willesden demand which is given preference. A certain number of accident calls have not been answered owing to car or driver being engaged. The following table shews the number of miles run under the various headings since the inception of the service:— Miles Run during year ending 31st March. 1914. 1915. 1916. 1917. 1918. 1919. 1920. Total. School Work - 20,592 17,579 20,530 22,933 23,365 24,454 129,453 Medical Officer — 6,343 9,857 9,664 7,857 8,731 9,222 51,674 Accidents, Sickness and Infectious Cases - 9,491 8,002 7,871 6,965 12,703 20,275 65,307 Disinfection — 5,977 4,998 4,488 3,337 4,534 5,055 28,389 Conveyance of Wounded Soldiers to Hospitals and Entertainments - - 1,978 5,020 1,636 1,173 49 9,856 Conveyance of Grave Diggers — — — — — 263 - 263 Concert Parties to Hospitals for Wounded Soldiers, &c. - - 138 378 72 126 77 791 Education Department — - - — — 123 287 410 Accountant's Department — 416 2,292 1,546 1,321 1,290 647 7,512 Engineer's Department Clerks' Department — 243 90 119 120 205 67 844 — — — 75 89 105 8 277 Health Department — — — — — 313 239 552 Registration Department — — 1,217 — — 15 — 1,232 Refugee Work — 774 209 56 — 78 84 1,201 Recruiting Demonstration — 28 681 — — — — 709 Hospital Work — 181 242 73 275 256 238 1,265 Dollis Hill House Hospital Committee - - 75 311 200 82 95 763 Food Control — — — — 1,591 601 407 2,599 Coal „ —. — — — — 24 — 24 Miscellaneous 53 75 — 496 — 30 654 General, including all foregoing 12,571 — — — — — — 12,571 Elections — — — — — 187 72 259 Total 12,571 44,098 47,433 50,131 46,892 54,174 61,306 316,605 142 Miles Run by Each Vehicle. The following table shews the number of miles run by each vehicle during the six complete financial years from April 1st, 1914 to March 31st, 1920, and since delivery to the latter date. Car No. Delivery to 31/3/14. 1/4/14 to 31/3/15. 1/4/15 to 31/3/16. 1/4/16 to 31/3/17. 1/4/17 to 31/3/18. 1/4/18 to 31/3/.19. 1/4/19 to 31/3/20 Miles run since delivery to 31/3/20. Disinfecting Van M.X. 1884 2,755 6,440 5,196 4,605 3,926 5,229 5,318 33,469 Landaulette M.X. 2056 1,466 6,385 10,579 10,248 7,981 8,947 9,358 54,964 School Bus M.X. 2057 1,801 7,648 6.915 10,208 8,735 7,275 8,711 51,293 Infectious Ambulance M.X. 2058 1,418 5,591 3,912 2,803 3,596 4,728 11,383 33,431 School Bus M.X. 2059 2,254 7,176 9,036 10,680 9,060 7,604 8,609 54,419 Accident Ambulance M.X. 2060 725 3,900 4,686 4,961 6,240 8,899 11,235 40,646 School Bus M.X. 2061 2,152 6,958 7,109 6,626 7,354 11,492 6,692 48,383 Totals 12,571 44,098 47,433 50,131 46,892 54,174 61,306 316,605 Calls. The following table shews the number of calls for the Disinfecting Van, Infectious Ambulance, and Accident Ambulance respectively during the six complete financial years April 1st, 1914 to March 31st, 1920, and since delivery to the latter date. Delivery to 31/3/14. 1/4/14 to 31/3/15. 1/4/15 to 31/3/16. 1/4/16 to 31/3/17. 1/4/17 to 31/3/18. 1/4/18 to 31/3/19. 1/4/19 to 31/3/20. Total. No. of calls for Disinfecting Van 370 1,167 957 787 653 716 1,276 5,926 *No. of calls for Infectious Ambulance 250 940 696 528 641 672 1,601 5,328 *No. of calls for Accident and Illness Ambulance 40 372 388 471 426 797 1,009 3,503 *Owing to the demand on the ambulances it is impossible to keep them to the work specified and infectious cases are sometimes removed on the Accident Ambulance and non-infectious on the Infectious Ambulance. Disinfection is always carried out between the cases. Petrol Consumption and Cost Per Mile. The following is a statement of mileage petrol consumption, and cost per mile for the six complete years ended March 31st, 1920:— Year ending 31st March. 1915. 1916. 1917. 1918. 1919. 1920. Total number of miles run by the seven vehicles 44,098 47,433 50,131 46,892 54,174 61,306 Total number of gallons of petrol consumed 3,998.5 4,035.5 4,673 4,619 5,569 6,388 Number of miles per gallon of petrol consumed 11.0 11.75 10.73 10.15 9.73 9.59 Cost in pence per mile run 13.4 12.08 11.78 13.64 15.03 16.98 Storage Plant.—The petrol storage plant installed in January, 1915, is still working satisfactorily. This plant which finished paying for itself last year by its saving in taking bulk supply has not yet cost anything for maintenance. Staff.—The staff employed consists of 1 Mechanic Superintendent and 9 Motor Drivers, who are on a 47 hours week. Workshop Plant.—The workshop plant is in good order and is the means of effecting a great saving both in Motor and Hospital repairs. 143 Work Undertaken.—The Mechanic Superintendent now undertakes repairs to the following motor vehicles in the Council's service:— Health Department 7 vehicles. Fire Brigade 4 Engineer's Department 1 „ as well as the engineering work of the Municipal Hospital. Repainting of Vehicles.—Three vehicles of the Health Department and one of the Engineer's have been overhauled in the workshop and repainted by Tuckers' as per contract during the year. The Motor Ambulance Service is much appreciated by the Public and the demands on it are rapidly increasing. At least one new vehicle is required as a stand-by and to assist in the work. The vehicles attached to this service have now been in constant use for 7 years and it is due to the efficiency and watchfulness of the Mechanic Superintendent that these vehicles after 7 years hard service with many changes of drivers are still efficient and capable of meeting the many calls made upon them. GEORGE F. BUCHAN, Medical Officer of Health. WILLESDEN URBAN DISTRICT COUNCIL—ACCOUNTANT'S DEPARTMENT. October, 1920. MOTOR SERVICES. Year Ended 31st March. 1920. Cost per mile. Expenditure. Running Expenses:— £ s. d. £ s. d. d. Petrol 846 15 7½ Oils and Greases 19 18 4 Tyres 533 19 0 1,400 12 11½ 5.483 Wages and Emoluments:— Mechanical Superintendent 275 5 8 Drivers 1.681 8 1 State Insurance (Employers' Contributions) 5 4 0 1,961 17 9 7.68 Fixed and General Charges:— Rent (Garage and Mess Room) 187 0 0 Coal, Gas, etc. 88 0 10 Uniforms and Overalls 88 7 1 Repairs to Plant 118 15 2 Insurance of Vehicles 51 4 9 Motor Car Tax 7 1 0 Drivers' Licenses 1 15 0 Telephone Rental 5 10 0 Painting, etc., Vehicles 118 8 6 Motor Accessories 93 17 10½ 760 0 2½ 2.975 16.138 Loan Charges 397 4 5 1.555 4,519 15 4 17.693 Less—Petrol Tax rebate (applicable to Ambulance Work and School Services only) 131 14 9 .707 4,388 0 7 16.986 Income Use of Vehicles for Purposes of Conveyance of Patients 292 8 3 Food Committee 19 8 3 Profiteering Committee 1 15 0 Election 4 12 0 318 3 6 Petrol consumed 6,388 galls. Miles run by all vehicles 61,306 ,, per gallon of petrol consumed 9.6 144 APPENDIX M. To the Health Committee. 5th October, 1920. Contemplated Capital Expenditure prior to 31st March, 1922, and in the Years Immediately Following. Year. Works. Reasons and Other Particulars. Estimated Capital Expenditure. Approximate Allocation. Maternity and Child Welfare. School Medical Service. Hospital. Motor Service. £ £ £ £ £ 1921-22 Utilization of Medical Inspection Centres for Clinic purposes Excess attendances at Clinics Alterations 700 350 350 — - Equipment 1,200 600 600 — - 1921-22 Acquisition of 9, Willesden Lane Rental £75, Ground rent £12 12s. (58 years unexpired). Council's tenancy expires 24/6/22 1,200 600 600 - - ,, 24, St. Julian's Road Rental £40, Ground rent £10 (58 years unexpired). Council's tenancy expires 24/6/27 400 200 200 - - ,, 25, St. Julian's Road Not in occupation of Council Excess attendances at Clinics, extension of dental work 500 250 250 - - 1921-22 Erection of Stonebridge Clinic Excess attendances at Clinics Site 1,305 652 653 — - Inaccessibility of existing Clinics for certain parts of the area Buildings 138,203 69,102 69,101 — - To enable a start to be made again with routine school medical inspection Equipment 8,000 4,000 4,000 - - 1921-22 Extension of Municipal Hospital (approximately 200 beds) To meet work of Clinics, the demand for Hospital accommodation especially Diseases of Women and Children, Measles and Whooping Cough, and 48 hours week for Staff. Building and Equipment 300,000 132,000 48,000 120,000 - 1921-22 Convalescent Home (approximately 50 beds) Cases referred from Clinics, Hospital and Schools; enables more patients to pass through Hospital; need emphasised by L.G.B. in Maternity and Child welfare Memorandum No. 4; also to provide Small Pox hospital accommodation in the event of an outbreak Land and Buildings 20,000 10,000 10,000 10,000 —- Alterations 5,000 Equipment 5,000 30,000 1921-22 Renewal of 1 Motor Vehicle Depreciation. Increased demand 1,200 —- — — 1,200 Total for year 1921-22 482,708 217,754 133,754 130,000 1,200 145 Year. Works. Reasons and Other Particulars. Estimated Capital Expenditure. Approximate Allocation. Maternity and Child Welfare. School Medical Service. Hospital. Motor Service. £ £ £ £ £ 1922-23 Erection of Clinic in Harlesden Kensal Rise area Excess attendances at Clinics; inaccessibility of existing clinics for certain parts of area; to meet the needs of routine school medical and dental inspection Site 2,000 1,000 1,000 — — Buildings 138,203 69,102 69,101 — — Equipment 8,000 4,000 4,000 —- —- 1922-23 Erection of Clinic in South Kilburn area Excess attendances at Clinics; inaccessibility of existing Clinics for certain parts of area; to meet the needs of routine school medical and dental inspection Site 2,000 1,000 1,000 - —- Buildings 138,203 69,101 69,102 - - Equipment 8,000 4,000 4,000 —- - 1922-23 Renewal of 2 Motor Vehicles Depreciation. Increased demand 2,400 — — — 2,400 Total for year 1922-23 298,806 148,203 148,203 - 2,400 1923-24 Acquisition of Site for erection of Clinic in Willesden area To meet the needs of existing Clinic 2, the extension of which has been discussed by the Committee and not found to be practicable Site 2,000 1,000 1,000 - - 1923-24 Acquisition of Site for erection of Clinic in Roundwood area To meet the Clinic needs of the area Site 2,000 1,000 1,000 — — 1923-24 Acquisition of site for erection of Clinic in Cricklewood area To meet the Clinic needs of the area Site 2,000 1,000 1,000 — — 1923-24 Renewal of 2 Motor Vehicles Depreciation. Increased demand 2,400 - - — 2,400 Total for year 1923-24 8,400 3,000 3,000 — 2,400 146 Year. Works. Reasons and Other Particulars. Estimated Capital Expenditure, Approximate Allocation. Maternity and Child Welfare. School Medical Service. Hospital. Motor Service. £ £ £ £ £ 1924-15 Renewal of 2 Motor Vehicles Depreciation. Increased demand 2,400 - - - 2,400 Summary 1921-22 482,708 217,754 133,754 130,000 1,200 1922-23 298,806 148,203 148,203 - 2,400 1923-24 8,400 3,000 3,000 - 2,400 1924-25 2,400 — — — 2,400 Total 792,314 368.957 284,957 130,000 8,400 Less Government Grants 326,957 184,478 142,479 — — Net Expenditure 465,357 184,479 142,478 130,000 8,400 147 CAPITAL EXPENDITURE. Notes. School Medical Service. The above Capital Expenditure of £792,314 includes Capital Expenditure of £284,957 on the School Medical Service to bring this service up to the requirements of the Board of Education. This item of expenditure cannot be separated from the other items. Provision of Meals. Special Schools. The total Capital Expenditure of £792,314 does not, however, include expenditure which is contemplated under the Education (Provision of Meals) Acts for the acquisition or erection of a suitable Feeding Centre in the South Kilburn area or in connection with Special Schools including Open Air Schools. Capital Expenditure under the School Medical Service, Provision of Meals, and Special Schools is expenditure for which the Education Committee are responsible and should therefore be deducted from the Council's Capital indebtedness. Government Grants. The total Capital Expenditure of £792,314 includes expenditure of £368,957 on Maternity and Child Welfare and £284,957 on School Medical Service, and £184,478 of the expenditure on Maternity and Child Welfare and £142,479 of the expenditure on School Medical Service is returnable by Central Departments, making the total Capital Expenditure which the Local Authority would have to find £465,357. Small Pox Hospital Accommodation. Hospital Steward's Accommodation. Admission of Maternity Cases to Willesden Infirmary. 48 Hour Week at Hospital. Increased Power for Hospital Machinery. Clinic Extension. These problems have all been and are still before the Committee. The approval of the above Capital Expenditure would enable them to be solved. GEORGE F. BUCHAN, Medical Officer of Health. J o be submitted to the Health Committee on 5th October, 1920. APPENDIX N. To the Hospital Committee. 28th October, 1920. X-RAY OUTFIT FOR MUNICIPAL HOSPITAL. In accordance with instructions, I beg to report on the above. As suggested at the last meeting of the Committee, in company with Mr. Campbell, Surgeon to the Municipal Hospital, I visited the Willesden Cottage Hospital, Harlesden Road, and was shewn the apparatus used for Radiography at this Institution. Surgical Conditions. General Considerations.—It is undesirable in many instances to move fractures any distance, and it should be possible to have such conditions radiographed on the premises. In connection with such conditions as a needle in the foot or hand which may be referred from the Schools or the Clinics, it is important to localise accurately and indeed in many cases it is necessary to remove the foreign body under X-Rays, the forceps being applied to the needle while it is being shown up on the screen by the X-Ray apparatus. 148 Children occasionally swallow coins, pins, etc. Usually these can be removed at once before any damage is done to the surrounding tissues if an X-Ray apparatus and screen are available at the hospital to which the children are brought. Renal Calculus.—In such cases where the patient is suffering excruciating pain, it is undesirable for him to be moved any distance to be X-Rayed. Bone Work.—A considerable amount of bone work is done at the Hospital in connection with diseases of children and an X-Ray apparatus on the spot to see how a bone graft (for example) is progressing, is necessary. It is equally important when a fracture has been set under X-Rays to have a subsequent X-Ray examination done to see that the position remains satisfactory. Where bone plating has been done, a subsequent X-Ray examination is necessary to see that the proper relationship of the bones is maintained. Such work can be done properly only on the spot. Tubercular Diseases of Spine, Hip, Ankles, etc., in Children.—Early diagnosis of these conditions in children is very important so that treatment may be applied before bone or tissue destruction has taken place. Medical Work. Recently there was in Hospital a boy with liver abscess which for a time baffled diagnosis— the patient was extremely ill and emaciated. X-Rays would have been able to define this condition and would probably have detected the pus at an earlier date and possibly saved this patient's life. The patient would not have stood removal any distance. Subdiaphragmatic Abscess.—The same remarks apply here as to Liver Abscess above. It is important in cases of this description to watch the movement of the diaphragm on the screen under X-Rays. This can only be achieved by having the apparatus on the premises. Tubercular Bronchial Glands and Tubercular Chests.—Doubtful cases of these diseases in the early stages are often diagnosed solely by X-Ray examination. The apparatus requires to be strong so that the necessary print is obtained within the period of a breath. If a longer period elapses the various organs in the chest and the condition of these organs are ill-defined. Dyspepsia, Gastric Ulcer, Intestinal Growths, etc.—In the medical diagnosis of these conditions for possible subsequent operative interference or otherwise, X-Rays are now largely made use of. Bismuth is given and the variations, movements, and dispositions of the stomach are traced on the screen immediately after the taking of Bismuth and at regular stated intervals thereafter according to the information the physician wants to elicit. It is not possible to carry out work of this kind by moving the patient continually to and fro. Other Conditions.—There are other conditions which require the use of X-Rays and the number of these conditions is rapidly increasing owing to the increasing use of X-Rays in connection with medical and surgical diagnoses but the above are probably sufficient to indicate to the Committee the need of the establishment of an apparatus of this kind in their hospital. Radiographer. It is essential that the radiographer should be a man who has got a medical degree and is familiar with pathological conditions. If he is not so familiar he is unable to produce the radiograms necessary to prove the existence or absence of the condition which may be thought to exist. GEORGE F. BUCHAN, Medical Officer of Health. APPENDIX 0. To the Finance Committee. 16th November, 1920. SCARLET FEVER AND DIPHTHERIA IN WILLESDEN. The Present Epidemics. Between January 1st and November 13th, 1920, 532 cases of Scarlet Fever have been notified and it is likely that at least 650 cases will be notified before the end of the year. It is 6 years ago since as big an epidemic of Scarlet Fever occurred in Willesden and 6 years before that again since an epidemic of like proportions. 569 cases of Diphtheria have already been notified this year up to November 13th, 1920, and it is likely that 700 cases will be notified before the end of the year. This is the largest epidemic of Diphtheria that has ever occurred in Willesden and unfortunately it occurs at a time when an epidemic of Scarlet Fever is also raging. It is not common to have an epidemic of Diphtheria coincident with an epidemic of Scarlet Fever. A similar coincidence occurred in the year 1919, but the 149 epidemics of Scarlet Fever and Diphtheria last year were not on so great a scale. Tracing the prevalence of Scarlet Fever and Diphtheria in Willesden backwards it is not till we come to the consecutive years 1901 and 1902 that we again find Diphtheria and Scarlet Fever in epidemic form at the same time. So far as the present epidemics are concerned and judging by previous years and past experience, it is likely that they will die down towards the end of the year. If we could be sure that no similar epidemic or concurrence of epidemics would occur again, anxiety need not arise, but we have to remember that Scarlet Fever and Diphtheria, like all other epidemic diseases, are specially liable to considerable fluctuations both in prevalence and fatality. Scarlet Fever shews a tendency so far as Willesden is concerned to assume epidemic proportions in cycles of about 6 years and of course both Scarlet Fever and Diphtheria shew a seasonal prevalence every autumn. It is further noteworthy that Scarlet Fever, like all epidemic diseases, appears in conditions of increased activity after longer or shorter periods of quiescence. Scarlet Fever was at a low ebb in Willesden in the years 1917 and 1918. In those two years together, fewer cases of Scarlet Fever occurred than in any single year during the past 25 years. In 1919 and 1920, however, we got as it were compensating epidemics of considerable magnitude. The epidemic disease which shows this tendency of recrudescence after quiescence most characteristically is Influenza. There was a great epidemic of Influenza in 1889-92, which was followed by a long period of quiescence during which only a few cases of the disease occurred. Then in 1918 and 1919 Influenza appeared again in Great Britain as an epidemic of unparalleled magnitude and now once more has lapsed into quiescence. The Utility of Isolation Hospitals. It may properly be asked what steps have been taken to prevent the spread of Scarlet Fever, and of Diphtheria in Willesden. The measures taken have included the establishment of an Isolation Hospital and the isolation of cases therein, the Disinfection of bedding and clothing and the Quarantine of contacts, i.e., the isolation for a period of persons who have been in contact with others suffering from these diseases. It would have been reasonable to expect that with a greater amount of isolation of Scarlet Fever and Diphtheria cases there would have been a diminished prevalence of Scarlet Fever and Diphtheria in Willesden, but an examination of the available statistics for the past 28 years fails to establish this fact. In 1894, Scarlet Fever cases occurred at the rate of 3.6 per thousand of the population in Willesden when only 31 per cent. of cases were removed to Hospital; in the year 1914, the number of cases of Scarlet Fever per thousand of the population was 4.6, when as many as 89 per cent. of cases were isolated in Hospital. Similarly with Diphtheria, in 1894, Diphtheria cases occurred at the rate of 17 per thousand of the population when only 6.2 per cent. of cases. were removed to Hospital; in 1914, Diphtheria cases occurred at the rate of 1.8 per thousand of the population when no less than 85 per cent. of the cases were taken into Hospital. Similarly we would expect that fewer secondary cases would occur in households after the first case was removed to Hospital, but an examination of the available statistics between the years 1910 and 1919 shews no change in this respect. Again as a result of the removal to Hospital of a high percentage of cases we would expect that the number of houses with two or more cases of Scarlet Fever occurring in them would have diminished but an examination of the statistics during the years 1910-19 again shews practically no change. Having regard to all these facts we are forced to conclude that Isolation Hospitals which were established with the intention of the prevention of the spread of Scarlet Fever and Diphtheria have failed in that object. There are reasons however, why isolation has failed in its primary object. For example there is the unrecognised case in a household, a mild case perhaps, in which the child is thought to have a cold or to be merely out of sorts, and in which the doctor is often not called in, but subsequent to the occurrence of which other members of the family are stricken down with Scarlet Fever or Diphtheria as the case may be. Again there is the case which comes to knowledge too late for isolation to be of much, if any, avail. Such a case is that in which a member of a household is thought to be suffering from say Influenza before the appearance of the Scarlet Fever rash. In this interval before the correct diagnosis is made he has, however, often infected other members of the family. Another reason why Isolation has failed to prevent the spread of disease is because cases of Scarlet Fever and Diphtheria are intermittently infectious for an indefinite period. Take the so-called return case of Scarlet Fever, infected by a case discharged from Hospital well with healthy mucous membranes, no glandular enlargements and no discharges of any kind. Shortly after such a case returns home it develops a cold and with the development of a cold becomes infectious again and infects other members of the family. A case of Diphtheria, too, may often be negative so far as the existence of the Diphtheria bacillus in the upper respiratory passages is concerned on discharge from the hospital, but after a shorter or longer period extending in my own experience to eleven months, the bacillus reappears in the throat and again renders the person infectious and dangerous to others. But while these various causes have operated to make Hospital Isolation as a means of the prevention of Scarlet Fever and Diphtheria ineffective, it must not be understood that Isolation Hospitals are of no value or of no use. Isolation Hospitals are wanted for the treatment of severe or complicated cases of Scarlet Fever or Diphtheria or other Infectious Diseases. They are wanted where the person suffering is without suitable lodging or accommodation for treatment at home and this applies to the large bulk of cases which occur. They are wanted in cases where if the patient remains at home some other member or members of the family would suffer pecuniary loss and above all they have been of great value to the community by reducing the fatality rate of the diseases specially admitted. In 1894. the fatality rate from Scarlet Fever in Willesden was at the rate of 26 per thousand cases, in 1914, the fatality rate had fallen to 7 per thousand cases. Similarly in Diphtheria, the fatality rate in 1894 was 126 per thousand cases, while in 1914, it was only 79 per thousand cases. It is open to argument that the fall in the fatality rate in Diphtheria has been due to the use of Diphtheria Anti-toxin. 150 The Functions of the Municipal Hospital. The Willesden Isolation Hospital was extended to a total of 162 beds in 1904, when the population of Willesden was estimated at 130,000. During the War a re-arrangement of the Bed Accommodation was effected and a few structural alterations made which resulted in an increase of the accommodation to 213 beds now utilised as follows:— For Infectious Diseases 150 beds. For Women (Maternity Cases, Diseases of Women) 17 beds and 14 bassinettes. For Diseases of Children up to 14 years of age 32 Cots. It is interesting to note that the Willesden Hospital was extended in 1904, after concurrent epidemics of Scarlet Fever and Diphtheria had occurred in each of the two successive years 1901 and 1902, and now after a lapse of 18 years and after concurrent epidemics of Scarlet Fever and Diphtheria, have again taken place in two successive years, namely 1919 and 1920, in a population increased to 170,000 the question of the extension of the Hospital again becomes acute. The admissions to the Municipal Hospital since 1904, when the Hospital was extended, have been as follows:— Year. Total Admissions. 1904 552 1905 613 1906 818 1907 760 1908 854 1909 775 1910 437 1911 470 1912 599 1913 721 1914 979 1915 706 1916 590 1917 510 1918 763 1919 1,704 1920 2,500 On Monday midnight th 15th November, the beds at the Hospital were occupied as follows:- Scarlet Fever 75 139 Diphtheria 54 Other Infectious Diseases 10 Total Infectious Diseases Maternity Cases 18 plus 18 babies 57 plus 21 babies Diseases of Women 9 plus 3 babies Children under 5 17 School Children 13 Total Mothers and Children Other cases (Women) 5 Total Other Cases 5 Total No. in Hospital at Midnight, Monday, 15/11/20 201 plus 21 babies Empty Beds 5 12 Empty Cots 7 Total No. of Empty Beds It will be noted that the number of beds here given, exceeds the recognised number in the Hospital, as various makeshift arrangements have had to be introduced to meet the epidemic conditions. No case of Diphtheria has been refused admission to the hospital, but in addition to the 75 ases of Scarlet Fever in Hospital at Midnight on the 15th inst., there were 55 which were being nursed at home. Present Difficulties. The difficulties at the present time occur firstly, on account of actual lack of accommodation to deal with the occurrence at the same time of epidemics of Scarlet Fever and Diphtheria, and secondly, because there are no separation beds at the Hospital. Infections Diseases.—In respect of Infectious Diseases cases, it is often requested that a case in which the diagnosis is doubtful should be taken in for observation. There is no separation bed or cubicle to put such a case. In non-epidemic times, such a case used to have a whole ward allocated 151 to itself. Again cases are not infrequently sent in as cases say of Scarlet Fever or Diphtheria which do not prove to be these diseases but perhaps German Measles or Measles or some other Infectious Disease. Meanwhile, such cases have been admitted to the Scarlet Fever or Diphtheria Ward and very likely infected other cases in these wards. Isolation beds or cubicles are required not only for the case wrongly sent in to Hospital, but also for the cases of mixed infection arising as a result of this occurrence. Then again a case of Diphtheria may be sent into Hospital while it is incubating Chicken Pox or a case of Scarlet Fever may be sent in which is incubating Whooping Cough. The diseases which such cases are incubating develop during the stay of the case in the Diphtheria or Scarlet Fever Ward as the case may be, and suitable and adequate provision for the separation or isolation of such cases is immediately required. Diphtheria again is not infrequently a sequel of Scarlet Fever and no provision exists in connection with the Wards or otherwise for the separation of these cases as they arise. The Wards generallv at the Hospital are large long Wards and in none of these long Wards is there any Side Ward or Separation Ward. The result is that there is no separation accommodation for a very ill case in any Ward and the general noise in the Ward from the more or less convalescent patients or children is not good for the treatment of very ill cases. Then again in respect of the Diphtheria Ward Tracheotomy has to be performed in this Ward with screens around the operating table as no side room of any kind exists which might be used for the operation. Mothers and Diseases of Women.—In connection with these cases there is often one of difficult labour where the patient should be put into a recovery room for some time before joining the patients in the Ward, but an arrangement of this kind is not available at the Hospital. Similarly other serious cases in connection with women require separation. Diseases of Children.— In connection with all children's wards, separation accommodation is exceedingly necessary because children are frequently admitted to Hospital during the incubation period of Measles, Whooping Cough, Chicken Pox, Scarlet Fever and other exanthemata common amongst children. These diseases frequently develop during their stay in the Ward and immediate arrangements for separation should be available. Then again cases of school children suffering from Scabies, Impetigo and other infectious skin conditions in chronic form are admitted for treatment. Such cases should not mix with others and really require separation cubicles. General.—Owing to the pressure on the available accommodation at the Hospital it has to be observed that the general arrangements as to patients are from time to time unsatisfactory. For example, in connection with the present epidemic of Scarlet Fever, it has been necessary to put bigger boys and girls in the same Ward and this is an arrangement which may very properly be objected to. Similarly in some of the Wards, it is necessary to have adults with children or babies and the playing of the children or the crying of the babies cannot be said to aid the recovery of the adult. It is very necessary during seasons of particular stress in Hospital that sufficient provision should be made for an adequate staff. The staff at the Municipal Hospital works long hours and unless adequate provision is made for their rest and recreation especially during epidemic times they may themselves go down with illness which may be serious not only to themselves but to patients. GEORGE F. BUCHAN, Medical Officer of Health. 152 APPENDIX P. To the Health Committee. 20th January, 1921. Amount Per Week Expended on Milk, and Dried Milk Free or at Reduced Rates by Willesden and Neighbouring Local Authorities. Population, 1919. Births, 1919. Approximate net cost per week to the Authority. > Approximate net cost in pence to the Authority per week per birth. Original Return, (November, 1920). Amended Return. (December, 1920). Original Return, (November, 1920). Amended Return. (December, 1920). Cost. £ Relative position as spending Authority. Cost. £ Relative position. as spending Authority. Cost in pence. d. Relative position. Cost in pence. d. Relative position. Poplar 160,051 3,951 348 1 340 2 21.1 1 20.6 1 Lambeth 294,097 5,518 230 2 No Reply. 10.0 4 — — Islington 336,506 6,067 182 3 444 1 7.2 7 17.6 2 Stepney 242,202 5,397 180 4 No Reply. 8.0 . 6 — — St. Pancras 228,585 3,893 110 5 120 3 6.7 . 8 7.4 7 Wandsworth 347,610 5,079 100 6 100 5 4.7 12 4.7 8 Battersea 165,960 3,075 92 7 110 4 6.5 9 8.6 6 St. Marylebone 102,038 1,492 71 8 70 8 11.4 3 11.2 4 West Ham 299,975 7,078 58 9 58 10 2.0 21 2.0 16 Hackney 225,774 4,141 54 10 66 9 3.1 15 3.8 11 Greenwich 102,591 1,953 53 11 74 7 6.5 10 9.1 5 Camberwell 285,220 5,183 50 12 75 6 2.3 18 3.4 13 Woolwich 141,918 2,737 50 13 54 11 4.3 13 4.7 9 Lewisham 174,750 2,844 40 14 44 12 3.3 14 3.7 12 Hampstead 91,682 1,156 40 15 No Reply. 8.3 5 — — Holborn 39,747 539 30 16 33 14 13.3 2 14.7 3 Southwark 187,476 4,092 30 17 27 16 1.7 22 1.6 —. Hammersmith 136,443 2,246 25 18 32 15 2.6 16 3.4 14 Bethnal Green 114,676 2,564 25 19 25 17 2.3 19 2.3 15 Chelsea 63,099 917 21 20 No Reply. 5.5 11 — .—- Croydon 191,922 2,964 20 21 25 18 1.6 23 2.0 17 Willesden 167,629 2,924 20 22 19 19 1.6 24 1.5 18 Tottenham 147,233 2,711 17 23 No Reply. 1.5 25 — — Finsbury 78,431 1,595 15 24 No Reply. 2.2 20 — — Deptford 115,843 2,381 10 25 39 13 1.0 26 3.9 10 Stoke Newington 53,079 894 10 26 No Reply. 2.6 17 — — Paddington 149,941 2,328 8 27 No Reply. 0.8 27 — — Westminster 132,851 1,592 5 28 5 20 0.8 28 0.8 19 Total No. of Districts 28 20 28 19 Original Returns prepared by Dr. MacMillan, Medical Officer of Health, Woolwich, November, 1920, and verified and amended in December, 1920. GEORGE F. BUCHAN, Medical Officer of Health. 153 APPENDIX Q. GRANTS IN AID. 1.—Maternity and Child Welfare (Local Government Board). Summary of expenditure during the 12 months ended 31st March. 1916. 1917. 1918. 1919. 1920. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. Inspectors of Midwives and Health Visitors— Salaries including War Pay 167 8 10 447 8 3 987 3 8 1,281 4 8 1,602 10 10 Allowances for Uniform (Included with Salaries) 19 13 9 70 18 0 174 16 4 90 17 2 Travelling Expenses (Assistant Medical Officers & Health Visitors) 8 12 6 19 12 7½ 44 1 5 46 8 4½ 67 3 9 486 14 7½ 1,102 3 1 1,502 9 4½ Centres— Salaries of M.O.H. and A.M.O.s. 55 8 2 410 4 1 681 2 8 3,044 3 7 4,449 16 10 Kent, Rates and Taxes 9 15 0 64 5 6 120 16 9 140 0 11½ 108 4 3 Furniture and Equipment 0 15 3 155 13 11 195 16 8½ 1,435 19 3½ 43 8 8 Healing, Lighting and Cleaning 1 12 0 30 4 7 76 15 2½ 430 5 10 512 14 11 Drugs and other Medical requisites 5 7 4 17 3 11 154 1 3 305 19 8 532 9 0 Food—Dried Milk 129 6 10 227 16 4 1,,914 4 8½ 5,900 12 7 2,706 0 8 "Virol" 2 12 11 221 12 8 55 11 9 Meals provided for Mothers and Children - - 537 0 8 405 3 3 719 16 0 Alteration and adaptation of Premises — 215 6 8 341 12 2 978 17 6½ — Repairs — — - — 21 0 0 1,123 7 11 4,021 10 1½ 12,S62 15 4½ Creches— Salaries of Medical Officers During the year 1917-18 certain expenditure was incurred in connection with a Day and Night Nursery established for the care of children of Munition workers, amounting to £955 1 4½ Salaries of Matrons Salaries of Nurses and other paid officers Rents, Rates and Taxes Furniture and Equipment Heating, Lighting and Cleaning Food and Provisions Contribution to a Creche Provision of Midwives and Maternity Nurses for— Necessitous Women - 1 9 0 36 19 9 129 19 0 20 19 8 Areas which are insufficiently supplied with this service - — — — - Provision of Home Helps - 3 15 0 54 15 0 219 19 5 28 10 0 Provision for Necessitous Women of a Doctor—for illness connected with Pregnancy and for aid in Confinement - - 20 7 6 74 2 6 - Provision in Necessitous Cases of Home Nursing—for cases of Measles, Whooping Cough and Epidemic Diarrhoea in young children and cases of Ophthalmia Neonatorum and Puerperal Fever - - - - 79 11 3 Hospital Provision— Directly by the Council, Maintenance Expenses — 60 15 0 (b)3,115 10 0 (a) 1,994 17 0 — (b)4,929 13 0 6,924 10 0 8,824 4 0 . Furniture and equipment (Renewals) - — - - 104 13 0 Alteration and Adaptation of Premises at Municipal Hospital - - 1,714 10 2 1,019 18 2* - Furniture and Equipment — — 1,270 18 8½ 377 6 0 — 2,985 8 10½ 1,397 4 2 19,967 11 9 *This amount was reduced by £593 10s. 3d. 154 Sundries— Printing. Stationery, Postage, etc. 26 6 6 31 7 7½ 168 5 2 347 16 11½ 422 6 4½ Other items of Expenditure incurred:— Clerical Stall of M.O.H. (including War Pay) 5 10 0 80 8 2 608 16 5½ 644 0 11 727 5 8 Establishment Expenses—Clerk's and Accountant's Dept. - 83 10 0 300 0 0 612 14 9 539 17 9 Medical Officer's Travelling Expenses - 20 0 0 28 15 0 113 10 7 117 8 4 Provision of Offices and maintenance 32 0 0 139 1 1 173 0 0 173 0 0 204 0 0 Registrar's Returns 38 8 4 35 12 9½ 28 6 5 32 8 10 33 3 0 State Insurance — 1 12 0 7 12 9 12 1 7 14 12 6 Grant to Voluntary Centre — 20 0 0 25 0 0 — 20 0 0 Sundries 10 11 2 4 2 9½ 11 2 8½ 61 15 11J 89 2 11½ 415 14 5½ 1,350 18 6 1,997 9 7 Total £491 1 11 £2,091 16 0 £12,687 12 10 £25,108 9 4¾ £22,135 8 4 Deduct Receipts:— Sales—Dried Milk and "Virol" 120 5 8 223 9 1 850 7 10 1,439 8 1 1,848 0 6 „ Drugs - — - — 36 17 0 Gift towards alterations to Clinic - — 100 0 0 — — Sale of Waste, etc. — — 2 11 8 — — Sundries (including School for Hygiene, £16 2s. 6d.) — — - 61 1 1 86 9 10 £370 16 3 223 9 1 952 19 6 1,500 9 2 1,971 7 4 £1,868 6 11 £11,734 13 4 £23,608 0 2¾ £20,164 1 0 'Grant from Ministry of Health - 142 1 9 790 17 3 5,504 19 0 13,664 0 11 (a) Maternity cases. (b) Children under 5 years. II.—School Medical Service. Summary of payments made and amounts received during the year ended 31st March. 1915. 1916. 1917. 1918. 1919. 1920. 1. Salaries— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. (a) Salary of School Medical Officer 89 15 1 148 0 0 100 0 0 75 0 0 107 16 9 164 1 3 (b) Salaries of Assistant School Medical Officers 424 13 10 1,178 8 11 456 18 6 499 10 0 941 3 9 1,079 7 0 (c) Salaries of Specialist Officers (e.g. Ophthalmic Surgeon, Dental Surgeon), Specialist, X-Ray Clinic 140 4 2 150 6 7 119 13 5 91 7 11 328 18 6 628 2 8 (d) Salaries of School Nurses 447 17 10 935 16 0 649 6 10 805 4 4 1,917 18 3 2,534 8 2 (e) Clerical assistance 315 0 1 732 2 3 537 3 1 512 10 2 839 16 61 1,296 12 8 (f) Uniforms for Nurses — - — — — 192 1 4 2. Travelling expenses 126 11 5 128 1 2 146 6 1 136 10 11 148 6 61 181 18 7 3. Printing, stationery, postage, etc. 267 2 8 257 2 4 112 10 10 198 15 2½ 284 13 11 165 16 8 4. Drugs, materials, etc. 36 5 7 61 17 11 68 9 10 78 7 4 143 18 8 298 0 7 5. Apparatus (e.g., weighing machines, ophthalmoscopic, dental, X-ray apparatus) 95 7 3 42 7 9 0 8 4 28 17 1 20 17 7 29 16 2 6. Provision of spectacles 80 0 11 63 1 9 84 4 10 158 1 3 197 6 7 407 14 3 7. Contributions to external bodies (e.g., Hospitals, Infirmaries Nursing Associations) - - - - - - 8. Cost of conveyance of children to centres for examination or treatment 0 7 0 — — — — — 9. Provision of premises, including payments in respect of loans 118 1 9 134 12 7 110 5 6 173 15 8 2,316 5 0 423 17 10 10. Maintenance of premises (e.g., rent, rates, heating, lighting, cleaning, upkeep of furniture) 146 19 0 320 2 0 226 14 6 139 16 5 384 8 6 872 14 7 11. Any expenditure not included in 1-10 above 7 11 3 14 9 2 10 15 1 12 6 10½ 33 8 10 26 17 1 Total £2,295 17 10 4,166 8 5 2,622 16 10 2,910 3 2 7,664 19 5 8,301 8 10 Total amount paid by, or recovered from, parents 1 17 9 3 15 6 6 2 9 7 10 3 23 16 9 56 15 3 From other sources — - - - — 29 7 9 Net Total £2,294 0 1 4,162 12 11 2,616 14 1 2,902 12 11 7,641 2 8 86 3 0 Grant from Board 997 3 7 1,014 8 3 1,854 18 11 1,177 10 4 1,306 3 9 8,215 5 10 2,514 7 7* *Now merged in the substantive grant 155 III. Provision of Meals (Board of Education). Summary of payments actually made and sums actually received within the year ended 31st March. 1916. 1917. 1918. 1919. 1920. 1. Payments— £ s. d. £ s. d. £ s. d. £ s. d. £ s. d. (1) Purchase of food 1,202 1 5 749 11 9 1,794 18 2 2,216 19 9 1,438 4 9 (2) Salaries and wages 956 6 11 659 11 3 871 4 4 1,451 2 1 1,423 8 6 (3) Provision of premises — 11 5 7 404 1 11 — 886 9 2 (4) Maintenance of premises (e.g., heating, lighting, cleaning, rent, rates, taxes) 364 18 10 345 18 7 351 18 4 475 2 1 345 10 9 (5) Furniture and equipment— (a) Initial equipment of new premises 51 12 1 — 36 7 10 11 5 3 - (ft) Annual repairs, replacements, etc. 48 19 3 12 1 8 41 4 4 81 11 8 76 0 2 (6) Printing, stationery, postages, etc. 27 4 6 25 19 11 26 15 6 44 18 10 16 6 6 (7) Conveyance of Children — — — — — (8) Carriage of food, etc. — — — — — (9) Any expenditure not included in (1)— (8) above 57 15 1 28 1 7 32 14 2 40 18 6 17 6 10 2,708 18 1 1,832 10 4 3,559 4 7 4,321 18 2 4,203 6 8 Less meals supplied to children attending Special Schools 237 6 3 221 5 8 155 10 8 209 14 3 350 0 2 Total £2,471 11 10 1,611 4 8 3,403 13 11 4,112 3 11 3,853 6 6 2. Receipts— Amount paid or recovered from parents 44 7 3 79 7 6 197 5 11 252 11 8 178 3 3 Amount received from voluntary contributions — — - - - Miscellaneous receipts — — 18 4 0 36 1 4 31 4 0 Maternity and Child Welfare — 518 10 9 649 6 4 465 15 3 Total 4 4 7 3 79 7 6 734 0 8 937 19 4 675 2 6 Amount received in respect of M. & C.W., for year 1916-17 — — 30 3 5 — — Net total expenditure £2,427 4 7 1,531 17 2 2,639 9 10 3,174 4 7 3,178 4 0 Total number of meals provided:— 1918. 1919. 1920. Dinners 111,570 144,662 94,945 Other Meals 343 28 1,834 Total 111,913 144,690 96,779 Average total cost per meal 6.174d. 5.737d. 8.895d. Average cost per meal for food only 3.053d. 2.943d. 3.043d. Charge fixed under Section 2 of the Act of 1906 for each meal 4d. 4d. 4d. Number of children whose meals were paid for by their parents:— Wholly Nil. 488 276 Partly 378 Nil. 5 Part of Year Paying and Part of Year Free — — 70 Grant received from Board £680 18 9 £1,319 14 11 £21,587 2 3* *Now merged in the substantive grant.