AC 4413(1) WIMBLEDON WIMI Borough of Wimbledon. Annual Report OF THE MEDICAL OFFICER OF HEALTH For the Year 1923. TOGETHER WITH THE REPORT of the SCHOOL MEDICAL OFFICER AND OF THE SANITARY INSPECTOR. J. B. Blackmore & Co., Ltd., Printers, Wimbledon, S.W.19. 1 Borough of Wimbleden. ANNUAL REPORT MEDICAL OFFICER OF HEALTH Year ended 31st December, 1923. PUBLIC HEALTH COMMITTEE. Chairman: Councillor F. W. Daffen. V ice-Chairman: Councillor H. Dormer. Members: The Mayor (Alderman Shirl Mussell). Alderman J. S. H. Abbott. Councillor A. Hickmott. „ G. Clement. „ H. Lee. Councillor H. Bevis. „ J. R. Miller. „ Mrs. Chalkley. „ A. J. Penman. „ J. R. Ellis. „ Lady Roney. OP THE FOR THE STAFF. Whole-time: Medical Officer of Health; School Medical Officer; Medical Superintendent of the Isolation Hospital; Maternity and Child Welfare Officer. ‡* A. Gilmouk, M.I)., M.R.C.P.E., D.P.H. Assistant Medical Officer of Health, School Medical Officer and Maternity and Child Welfare Officer: ‡ Effit: M. D. Craig, M B., Ch.B. Chief Sanitary Inspector: a * † Henry Johnson. Assistant Sanitary Inspectors: If a f R. T. Avis. a t D. P. S. Flynn. Health Visitors—School Nurses: § a || Mtss F. Hulse. If § II Miss M. Gii.es. 11 b Miss H. Hurst. Clerk: Miss N. Low. Clerk to the Maternity and Child Welfare Department: Miss M. A. Weller. Part-time: Bacteriologist: J. H. Johnston, M.Sc., F.I.C. * Salary contribution under Public Health Acts. | „ „ by Exchequer Grants. a Certificate of the Royal Sanitary Institute for Inspector of Nuisances, f Certificate of the Royal Sanitary Institute for Inspector of Meat and other Foods. || Certificate of the Central Midwives Board. § Certificate of the Royal Sanitary Institute for School Nurse and Health "Visitor. II Certificate of the Sanitary Inspector s' Examination Board for Sanitary Inspector. b Health Visitor's Diploma, Battersea Polytechnic. CONTENTS. Medical Officer's Report. PAGE Public Health Committee 1 Staff 2 Administration 5 Extension of Sewage Works 8 Day Nursery Buildings 9 Heating at Isolation Hospital 9 Housing 10 Population 10 Vital Statistics—general 11 Births 12 Deaths 12 Infantile Mortality 13 Maternity and Child Welfare Work 15 Record of Work of Health Visitors 15 General Report 16 Classes for Mothers 17 Report of Work at Centres 18 Assistant Medical Officer's Report 19 Dental Clinic—Dental Officer's Report 21 Supply of Milk to Expectant and Nursing Mothers 22 South Wimbledon Day Nursery 23 Notifiable Diseases 24 Ophthalmia Neonatorum 24 Death-rate from Zymotic Diseases 25 Ward Distribution of Infectious Disease 27 Scarlet Fever 27 Diphtheria 28 Phthisis and other Tuberculous Diseases 29 Disinfections 30 Isolation Hospital 30 Summary of Local Nursing Arrangements 33 Laboratory Work 35 Mortuary 35 List of Adoptive Acts, Local Acts, &c. 36 Sanitary Inspection of District .37 Factories and Workshops .38 Table of Housing Conditions 40 Poor Law Relief 41 Table I.—Vital Statistics 42 Table II.—Causes of Death 43, 44 Sanitary Inspector's Report. Abatement of Nuisances, &c. 45 Bakehouses 39 Common Lodging Houses 48 Dairies, Cowsheds and Milkshops 48 Disinfection 48 Diseases of Animals Acts 51 Factories and Workshops 49 Food Inspection 50 Food and Drugs Acts .50 House Drainage 46 House Inspection 46 House to House Inspection 46 3 PAGK Houses Let in Loggings 47 Legal Proceedings 50 Notices issued (Public Health Acts) 45 Overcrowding 40 Opening up of Drains 45 Petroleum Acts 51 Kent (Restrictions) Acts 51 Sanitary Inspection 37 Slaughterhouses 50 Stable Premises 49 Shops Acts 49 Van Dwellings 48 Verminous Rooms 47 Yard Paving 49 Table III.—Summary of Nuisances 53 School Medical Officer's Report. Staff 54 Co-ordination 55 School Sanitary Conditions 57 Inspection Clinic 58 Employment Certificates 62 Medical Inspection—age groups, &c. 60 Assistant Medical Officer's Report 59 Finding of Medical Inspection and Treatment 60 Uncleanliness 60 Minor Ailments 60 Tonsils and Adenoids 61 Tuberculosis 61 School Oculist's Report 61 Ear Diseases 62 Dental Defects—Dental Officer's Report 62 Exceptional Children 63 Mentally Defective Children.65 (a) General Report 65 (b) Queen's Road Special .School 71 Table I.—Numbers Examined.73 Table II.—Numbers of Defects found 74 Table III.—Exceptional Children 76 Table IV.—Treatment of Defects 79 4 Borough of wimbledon. PUBLIC HEALTH DEPARTMENT. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE Year ended 31st December 1923. To the Mayor, Aldermen, and Councillors of the Borough of Wimbledon. Mr. Mayor, Ladies, and Gentlemen, I have the honour to submit the Annual Reports on the work of the Public Health Department for the year ending 31st December, 1923, together witli my Report as School Medical Officer. The Reports have been prepared in accordance with the requirements of the Ministry of Health and the Board of Education. In my last Annual Report I outlined the development of the Public Health Service in Wimbledon, and stated that consolidation of the different branches of the work was essential for economy and efficiency. This consolidation was begun in 1923 by amalgamating the Maternity and Child Welfare and School Medical branches, but the best results can only be attained 5 through further centralisation of administration. The work of separate branches may be excellent, but the full value of their work depends on the information acquired in one branch being readily available by all other branches so that "team work" is possible. In the same way medical records of cases should be continuous, and should be transferred from branch to branch or from medical officer to medical officer. The nature and scope of Public Health work have altered greatly in recent years and the change of name alone, from "sanitary" to "public health," is an indication of the new aims and ideals. It is no longer sufficient to confine attention to sanitation and abatement of nuisances. The health of the individual citizen as well as that of the community as a whole must be safeguarded, and the only way to achieve this is to educate the individual as to health. This change of attitude in public health matters has been partly brought about by the labours and discoveries of medical research workers who are adding almost daily to our knowledge of disease. Diseases which were formerly regarded as conditions to be alleviated or cured by drugs alone, are now known to be caused by the absence of certain vital elements in the organs of the human body or in diet. In this respect the recent work on the chemistry of the pancreas has led to the use of insulin in the treatment of diabetes, and research work on food stuffs has revealed the necessity for the presence of vitamines. Bacteriology has also added to our knowledge of the prevention and treatment of diseases by the use of vaccines and sera. The discovery of the cause of disease is frequently followed by the discovery of the means to prevent and cure the disease, and several of the more dread diseases have practically been stamped out by following this line of investigation. The position of public health workers in regard to such advances in Medical Science is one of educating and assisting the public to realise what health actually is and how medical advice should be sought even for trifling ailments. It is only by studying the beginnings of a disease that a full knowledge of the disease may be obtained which may lead to the discovery of the cure. It is, therefore, by linking up the records of antenatal work with infant welfare work and, by passing such records to the school medical service, to juvenile employment bureaus, and ultimately to the panel medical practitioners, that the best results can be attained. It is difficult for anyone not actually engaged in public health work to realise the ignorance that prevails in regard to health. The teaching of simple physiology in public elementary schools is undoubtedly of service, but before this knowledge can be applied it is too often forgotten, or put on one side, in the more serious business of wage-earning. Modern social and economic conditions have unfortunately done much to prevent 6 the old home instruction—often acquired unconsciously in other days—in what might be termed "Home Hygiene." It is in such cases that Welfare Centres and School Clinics are proving of inestimable value in imparting education, though the full results are not apparent at the moment. A glance at the Table on page 14 will reveal at once that many of the deaths under one year of age could be prevented by instruction and education, and few are attributable to congenital debility and malformation. Every member of the Public Health staff must therefore regard himself or herself not merely as an agent assisting in stamping out disease but as a teacher who, should seize every opportunity of preaching the gospel of health. However accomplished, whether by a quiet talk to an expectant or nursing mother at a Welfare Centre, or by a few words to a scholar or class in schools, or by the wider publicity of lectures or other means of propaganda, the work must go on. This teaching at Centres and Clinics by the medical staff, and in homes by sanitary inspectors and health visitors, has been supplemented in Wimbledon during the first week of January 1924 by a short "Health Week," held at the Baths Hall, Latimer Road, under the auspices of the Public Health Committee of the Borough Council. The exhibition lasted four days, and at two sessions daily lectures, illustrated by cinema films, were delivered by medical experts on such subjects as general public health questions, infectious diseases including tuberculosis, housing, milk supplies, dental hygiene, and venereal diseases. An exhibit of Welfare work proved of great attraction, and the questions which the welfare workers in charge of the exhibit were asked showed how keenly the public desired information on health subjects. Lectures have also been given to parents of children in certain schools in connection with the routine medical work, and a special lecture was delivered to all nurses in the district. During 1923, the general health in the Borough of Wimbledon has been excellent. Notifiable infectious diseases have been lower than in preceding years, while the non-notifiable infectious diseases have not assumed epidemic form. Outbreaks of measles and whooping cough occurred in two schools and chicken-pox cases were scattered throughout all schools. Owing to a prevalence of a ;mild form of small-pox in certain areas in England, these chicken-pox cases required careful supervision, but fortunately no case of small-pox occurred. Towards the end of the year cases of influenza became common and were increasing in number. No new measures affecting the work of the Public Health Department were introduced during the year, but the following developments are to be noted. 7 (a.) Extension of Sewage Works. I am indebted to Mr. J. Bowen, the Borough Surveyor and Engineer, for the following particulars:— There has been no material alteration to the sewerage system of the district during the last twelve months. As you are aware, improvement works are in course of construction as approved by the Ministry of Health on 19th March, 1923, consisting of the following:— 1. The provision of six circular percolating filters 98ft. in diameter capable of dealing with approximately 460,000 gallons of sewage in twenty-four hours when in use as primary and secondary filters. Diverting apparatus has been provided in order that, when the sewage is to be treated over three times the dry weather flow, the filters will all become primary. Distributing chambers have been provided which also act as humus chambers. In excess of these two, special humus tanks are provided after the filtration has taken place approximately 30ft. in depth, the capacity of each being 6,330 cubic feet. 2. Difficulty has been experienced in the past owing to the original six precipitation tanks being arranged so that sludging could not be carried out without putting most of the tanks out of action. The walls of these tanks have been raised, so increasing their capacity to approximately 100,000 gallons. The conduits, weirs, valves, etc., have been arranged in such a way that the tanks can be worked either in series or in parallel at will and any unit may be sludged without interference with either of the others. A very material improvement has been experienced since these have been at work. 3. A new air compressor of 350 cubic ft. per minute city has been installed which can be driven either by electricity or suction gas plant. This will be capable of dealing with two outlying districts, one approximately three-quarters of a mile and the other a quarter of a mile from tha Pumping Station where the power is generated. At the same time it duplicates the horse power which was originally installed. 4. Gauging apparatus, whereby both the flow of sewage and the flow of air can be recorded, and other instruments, have been installed. 5. Alterations and improvements to the sludge tanks, including the covering in of the exposed portion and supplying adequate ventilation have been carried out. 6. One-and-a-half acres of allotments situated on the east side of the Sewage Farm have been reclaimed for the extension of the filtration area. 8 (b.) Day Nursery. The Public Health Committee has under consideration at present the question of the Day Nursery. Twenty-five years ago a house in the Haydons Road, South Wimbledon, was acquired for the purposes of a Day Nursery by a small committee of voluntary workers. Beginning with some twenty children, the numbers steadily increased, and the two adjoining houses were acquired and all thrown into one. The Institution was carried on by voluntary subscription, for the charge made on the mothers only covered a small part of the expenses. On the passing of the Maternity and Child Welfare Act 1918, the Committee of Management decided to transfer the South Wimbledon Day Nursery to the Wimbledon Borough Council "to be administered by them as the Authority under the Maternity and Child Welfare Act 1918, and they (the Committee) have now arrived at the decision to offer the buildings, Nos. 176, 178, and 180, Haydons Road, Wimbledon, with the furniture, fittings and equipment, to the Council." This offer was accepted by the Council in June 1919, since which time the administration has been under the Maternity and Child Welfare Sub-Committee. The present premises, having been adapted from dwelling houses, are faulty in construction, the rooms are badly arranged, and much space is lost by old passages and staircases. The annual cost of repairs due in some part to vibration caused by heavy motor traffic is excessive, and the Committee are considering alternative schemes (a) of entire reconstruction, (b) of new premises on a different site, (c) of temporary accommodation. One difficulty in regard to new premises is that a suitable site for a day nursery is not easily found, for it requires to be in healthy surroundings and yet of easy access for the families using it. (c) Heating of the Isolation Hospital. The Committee is at present making enquiry into different systems of heating with. a view to reducing expenditure as the present system is expensive and wasteful. (d) Housing. The Wimbledon Borough Council decided at the end of 1923 to build 87 working class dwellings of the parlour type. It may be considered that this small number indicates a lack of enterprise on the part of the Borough Council, but a knowledge of local conditions reveals the true position in regard to this Housing question. The present shortage of labour and materials prevents a general building of houses which could be sold or let at prices satisfactory to present economic conditions, but in Wimbledon there is the additional factor 9 that suitable sites are unavailable. With the exception of a few isolated sites, many of which are in districts where)there are restrictive regulations, or are not on "transport" lines, the Wimbledon area it) practically built up. The Plough Lane site might be available for building, but in this ease there would be the additional expense necessary to meet the Council's Bye-laws in regard to building on low-lying sites. Wimbledon has always been regarded as one of London's most desirable "dormitories," alike from reasons of health, amenity and accessibility. Many persons are desirous of residing in this district, but to build houses, which would only be attractive to those at present residing outside the district, would do nothing to relieve the overcrowding that exists. It is a matter of some difficulty to gauge the extent of this overcrowding or to state in which Ward it is most acute. In many cases the overcrowding is only brought to the notice of the Public Health Department when some disagreement arises between the tenants. Sub-letting of rooms, furnished or unfurnished, the taking in of lodgers, and boarders all exist. In many cases temporary arrangements made during the War, which were quite suitable to all parties, have now become quite unjustifiable, either from the increase in family or other reasons. In such cases both parties may be alive to the drawbacks and may be anxious to remedy the conditions, but they are entirely unable to do so from want of other suitable accommodation. Even in cases where young couples have lodged with parents or other relatives little domestic difficulties are liable to occur. To take legal action in such cases would only accentuate the hardships, and, while the Council is fully alive to the dangers to health from overcrowding, there is little that can be done except to safeguard the health of the community as far as possible. It would be easy to give numerous examples of such cases but this would not reduce the overcrowding. The congestion in Wimbledon can only be relieved by building in other neighbouring districts, and, as it would be unreasonable to expect such local Authorities to bear the brunt of expense for Wimbledon's benefit, the solution would appear to be National rather than Parochial. Once suitable accommodation is available, immediate steps can and will be taken to reduce local overcrowding. Population. The Registrar General states that the reduction of population shewn by the 1923 estimate for the Borough of Wimbledon, is due almost entirely to an adjustment in respect of a 10 temporary Defence Corps encamped on Wimbledon Common at the date of the Census. This Corps numbered 3,757 persons. (1) GENERAL STATISTICS—1923. Area (Acres) 3,173 Population (1923) 58,000 Number of inhabited houses (1923) 12,064 Number of families or separate occupiers (1923) 13,032 Rateable Value—£529,260 Sum represented by penny rate £1,900 (2) EXTRACTS from VITAL STATISTICS of the Year (1923) Total. M. F. J Legitimate 830 401 429 Bllths {Illegitimate 38 15 23} Birth Rate (R.G.) 14.9 Deaths 547 260 287 Death Rate (R.G.) 9.4 Number of women dying in, or in consequence of, childbirth from sepsis 1 do. do. other causes — Total 1 Deaths of Infants under one year of age per 1,000 births 43.7 Legitimate 36 Illegitimate 2 38 Deaths from Measles (all ages) 4 „ „ Whooping Cough (all ages) 4 „ „ Diarrhosa (under 2 years of age) 5 Vital Statistics for 1923 (Provisional Figures). Registrar-General's Returns. Annual Rates per 1,000 living. Infant Mortality of infants under 1 year per 1,000 Births. Births. Deaths from all Causes. England and Wales 19.7 11.6 69 105 Great Towns 20.4 11.6 72 155 Smaller Towns 19.8 10.6 69 WIMBLEDON 14.9 9.4 44 11 BOROUGH OF WIMBLEDON. Population. Births and Death Rates for each Ward, 1 923. WARD. Factor. Population. Birth Rate. Death Rate. Wimbledon Park 4.19 7406 13.6 12.01 St. Mary's St. John's 4.68 5553 11.1 8.8 Cottenham Park 4.34 7404 6.6 7.5 North Wimbledon 4.34 20363 10.5 9.9 Dundonald 4.11 8021 13.3 10.2 Trinity 4.59 12957 15.6 7.7 South Park 4.36 16659 18.7 9.6 Haydon Park South Wimbledon 4.25 37637 16.5 9.1 Whole District 4.36 58000 14.9 9.4 Births:— The number of births registered in the district was 838 (407 males and 431 females), an increase of four over last year, and equal to a birthrate of 14.4 on a population of 58,000. The corrected birthrate produced by transferable births notified to us by the Registrar General is 14.9. 38 (or 4.3 per cent.) of the births were illegitimate. Notification of Births Act, 1907:— During the year 707 births were notified by the following persons:—Parents, 100; Midwives, 525; Doctors, 64; other persons, 18. Twenty three notifications of Still-births were received. Deaths:— The total number of deaths registered in the district was 439 (183 males, 256 females) equal to a death rate of 7.5 per thousand of the population (R.G) per annum. The deaths occurring outside the district of persons belonging to this Borough were 172, viz.:— Kingston and District General Hospital 74 Brookwood Asylum, Woking 12 Nelson Hospital, Merton 15 Others 71 Total 172 12 The deaths occurring within the district of persons not belonging thereto were 65, viz.:— Atkinson Morley's Convalescent Hospital 3 North Wimbledon Hospital 9 Isolation Hospital 2 Others 51 Total 65 Taking those into consideration, the total number of deaths properly belonging to Wimbledon is 546 and the death rate 9.4. The rate for England and Wales for the same period was 11.6. Table showing the births, deaths and death rates in the Borough of Wimbledon in the last five years. 1923 J 922 1921 1920 1919 1918 Births 868 868 1033 1144 861 759 Deaths 546 616 634 557 634 742 Death-rates 9'4 9 9 10'2 8.9 10'6 14'5 Table II. (pp. 43 and 44) gives the causes of, and ages at, deaths during 1923. Deaths due to notifiable infectious diseases are given on p. 26. The principal causes of death, apart from Zymotic deaths, are as follows:— Heart Disease 79 Cerebral Haemorrhage 42 Arterio-.Sclerosis 21 Pneumonia 41 Bronchitis 33 Other Respiratory Diseases 10 Acute and Chronic Nephritis 17 There was no unusual or excessive mortality during the year calling for comment. Infantile Mortality—There were 38 infant deaths during the year (including transferable deaths), giving a rate of 44 per thousand registered births, a decrease of 14 per thousand on last year's figures when there were fifty deaths and a rate of 58. The infantile death rate calculated on the Registrar General's figures is 43.7 per thousand births. The infant death rate for illegitimate children was 50 per thousand births. The following table shows the causes of death, and ages at death, of Infants under one year:— 13 Infant Mortality during the Year 1923. Deaths in Wimbledon District only. Deaths from stated Causes at various ages under One Year of Age. Causes of Death. Under 1 week. 1-2 Weeks 2-3 Weeks. 3-4 Weeks. Total under 4 weeks. 1-3 Months. 3-6 Months. 6-9 Months. 9-12 Months. Total Deaths under One Year. Measles - - - - - - - 1 - 1 Whooping Cough - - - - - - 1 1 — 2 Influenza — — — — 1 - — — 1 Bronchitis — 1 — — - — - — - 1 Pneumonia (all forms) - - - - - 1 1 — 2 Enteritis — — — — 1 4 — — 5 Congenital Malformations 1 — — — 1 — — — — 1 Premature Birth 11 2 — — 13 — — — — 13 Atrophy, Debility and Marasmus — — — — — 2 — — — 2 Other causes 3 — 1 3 7 2 1 — — 10 Totals 15 3 1 3 22 6 7 3 — 38 14 Maternity and Child Welfare Work. During 1923 the record of Home Visitation work was as follows:— Number of births notified 707 „ „ „ registered 838 Number of births visited 570 „ „ „ revisited—under 1 yr.2,957 „ „ » „ —over 1 yr. 3,040 „ „ Still Births and Deaths 22 „ „ Ophthalmia cases visited 5 „ „ Expectant mothers visited 151 ,, „ revisits to expectant mothers 83 „ „ ineffectual visits 667 „ „ Special visits 546 Total welfare visits 8,041 Number of tuberculosis visits ... 74 „ „ school visits (half-day)... 172 „ „ visits to parents of school children ... 94 340 8,381 The number of infants visited in each "Ward was as follows : Wimbledon Park 6 St. Mary's 3 St. John's 17 Cottenham Park 18 Dundonald 83 Trinity 232 South Park 29 Haydons Park 182 570 Breast fed on first visit 470 Artificially fed on first visit 47 Mixed feeding „ „ „ 53 The record of the work carried out at the Centres is given on p. 18. 15 Reference has already been made to the reduction in the staff and to the amalgamation of the Maternity and Child Welfare and School Medical Branches. Under the re-arranged scheme a reduction in staff, equivalent to the services of one wholetime Health Visitor, has been brought about, and the number of home visits during 1923 has been reduced by 1,256. The increased control over all children from birth to 14 years of age, the prevention of duplication of work, the visits made to the schools and homes for school purposes, and the increased amount of ''class'' teaching at the Centres, must all be placed against the fact of this reduction. The staff, still on duty, equivalent to two full-time Health Visitors, is still ample to cover the work, and exceeds the standard laid down by the Ministry of Health. The value of Infant and Child Welfare work must not be judged, however, by such figures as the number of home visits made during the year. The "value of a visit" is exactly the amount of good that results from it, and one mother may require longer instruction to grasp a point than another. A more correct estimate can be formed by studying the Infantile Mortality rate in a district from year to year, but here again many fallacies may creep in, for an outbreak of infectious disease may cause a sudden rise in rate at any time. In a residential area such as Wimbledon, all births are not visited, and a selection is made as far as possible by streets. The general medical practitioners of the district also frequently send mothers to the Centres or advise them to attend in some cases. Of the 838 total births, 570 (or 68 per cent.) were, visited. Of these 570 visited, 198 (or 35 per cent.) subsequently attended the Centres. It might be considered that some proof of the /value of Infant Welfare work might be obtained by calculating an Infantile Mortality rate for each of those three groups, namely, a rate for all infants, a rate for those visited in their homes by the Health Visitors, and a rate for those attending the Welfare Centres, but such figures would be absolutely worthless for the purpose of comparison. The first few hours or days of life are of vital importance to all infants, but more especially to the premature and weakly or those with congenital defects, and of the 42 infants (including transferable) dying within the first year, 21 (or 50 per cent.) died within ten days. As the doctor, nurse, or midwife is still in attendance on such cases, the Health Visitors do not visit, and the statistics would be calculated on a wrong basis. It would be just as reasonable to state that Infant Welfare work should be abolished because 13 of the remaining 21 deaths occurred among infants visited in their houses, and four other among infants who had attended the Centres (17 in all). Analysing the causes of these 21 deaths under ten days, it is found that 12 may be attributed to "prematurity" varying 16 from five months (in the ease of twins) to eight months; four were certified as due to atelectasis (want of proper expansion of the lungs); two were due to Icterus Neonatorum (jaundice of the new-born); and one each to convulsions, congenital debility and want of attention at birth—the last infant found dead in Belvedere Grove (inquest). Any conclusions drawn from the above figures merely emphasise the necessity for increased ante-natal visitation and instruction, and for Maternity Homes wherein mothers and infants can receive adequate attention. Only two of the twenty mothers had received advice as "expectant" mothers. It is difficult to see how ante-natal work can be increased, for it is a matter for the expectant mothers themselves and is purely voluntary. The question of a maternity home is also one which requires full consideration. With the 12 premature babies, some effort could have been made to preserve their lives under proper conditions in a Home, but prematurity must be regarded as a condition that cannot always be foreseen and provided for. Until this question of a Maternity Home has been thoroughly investigated, ante-natal work must be carried as far as possible, and teaching of the mothers in any case must continue. Classes for Mothers. Classes were held at each Centre in 43 weeks during the year. At these classes, Mothercraft, Domestic Science, Sewing and Knitting arc taught, and short "talks" or lectures are given on elementary physiology and hygiene. The Mothercraft class deals with the health of the expectant mother, the preparation for confinement and nursing of the infant, and with the care and rearing of children through infancy to school years. This teaching qualifies the class to compete in the National Mothercraft Competitions organised by the Association of Infant Welfare and Maternity Centres and a team entered from each Centre. The Wimbledon teams were bracketed equal in the fourth place out of 87 competing centres, and each team gained two honours certificates, two first class, and one second class, certificates. The sewing and knitting classes were well attended, ,'and the garments made by the mothers are either bought by the mothers for the cost of ithe materials or are retained at the Centres for future demonstration purposes. The garments made during 1923, were exhibited at the "Health Week" Exhibition and attracted considerable attention. Probably the best practical results are obtained from the discussions following the Health talks and lectures. The mothers choose their own subjects and the questions asked show how keenly the discussions have been followed. 17 During 1923, the "Daily News" offered a prize to the district showing the greatest reduction in male infantile mortality rate. Though Wimbledon did not gain mention, the figures showed a drop from 93.5 per thousand to 69.8 per thousand, which lis gratifying, as the first year was low comparatively with other areas to start with. Welfare Centres. As it is sometimes stated that Municipal Welfare Centres are taken advantage of by people who are in a position to pay private doctors, a full investigation of the social conditions of those attending the Wimbledon Welfare Centres was made from records of the last two years. The following interesting facts were shown:—60 percent. of the mothers come from what might be termed ''Average'' Clinic attenders, 28 percent. were "below the average" and 12 percent. were "above average." Of those who were classed as "above average" only 25 percent. took advantage of the cheap milk sold at the Clinics and in every one of these cases there were large numbers in the family so that economy was absolutely necessary. Of the remaining 75 per cent. (i.e. dealing only with those for whom it could not be stated that the "cheap milk" was the attraction), it was found that they fell naturally into two categories, (a) young mothers who were keen on instruction and attended the classes regularly, and (b) other mothers whose children were not thriving and who attended their family doctor regularly, but who apparently came to the centres occasionally to get confirmation of opinion. Taking all mothers who attended, it was found that 50 percent. attended occasionally, and a very small proportion only attended once. These figures are extremely gratifying, showing, without doubt, that the Centres are not being exploited. At the other end of the social scale it is found that the Wimbledon experience coincides with that in other areas—50 percent. only of the very poorest families attend the Centres. These cases are of course, visited in their own homes and tactful inquiries as to reasons for not visiting the Centres have elicited a variety of excuses. These may be grouped into three classes:— 1. A small class where the father objects to the wives mixing, or where there is interference with the husband's meal hours. 2. A slightly larger class where the young mothers live with their mothers or mothers-in-law, and the latter does not agree with the " new-fangled ideas." 3. The largest class where the mothers do not like mixing with their neighbours, who object to the undressing of their children from reasons of pride or because 18 "last time, baby caught cold," or because "they had to wait too long to see the doctor." The great majority of this class, however, belong to the lazy, slothful, and indifferent mothers, who either do not care or have become disheartened. On the other hand it is pleasing to record that some mothers prefer "Home Visits" as it gives them an opportunity to ask the Visitors questions about their children, which they would be afraid to ask in front of other mothers. Dr. Effie M. D. Craig, the Assistant Medical Officer, reports as follows on the work of the year:— "I beg to submit to you my Report for the Maternity and Child Welfare Work for the year 1923. "The work has been continued on much the same lines as in 1922. There has been, however, some alteration in the staff. The three health visitors, who formerly devoted their whole time to the Health Visiting, Maternity and Child Welfare work, etc., have since April also been employed for the preparation for medical inspection and attendance with the Medical Officer at the schools. A third of the time of each visitor has been employed with school work. The Maternity and Child Welfare work has thus been to a certain extent curtailed, and no new work has been undertaken. "Clinics have been held at the two Centres, Wandle Park House and Queen's Hall. Infant consultations have been held once a week at each of the centres, and Ante-natal consultations at Wandle Park House every alternate Thursday. "The work of prevention of disease and saving of infant lives and improving the health of the children has been both at the Centres an'd in the homes. Infant Welfare Consultations. "At these consultations the children are weighed, and every child attending for the first (time is examined by the Medical Officer, who also examines them at regular intervals throughout their infancy and childhood. An attempt is made to keep the children as much as possible under observation; all cases are followed up by the Health Visitors, who visit the homes, and give any necessary instructions. The most effective part of the work is the education, of the motherseither at their homes or at the Centres. Classes are held weekly by the Health Visitors, who instruct the mothers in mothercraft, needlework, and domestic science. They also give little health talks which the mothers greatly appreciate. The mothers are instructed to attend the Clinics as regularly as possible, and instructions are given as to the best means of improving the physical development of the children. 19 "Mothers are taught to pay attention to the little things, which, ,if neglected, interfere with healthy development. Children requiring treatment are referred to their private medical practitioners or to hospital. The Welfare of the Expectant Mother. "At the Ante-Natal Clinics, routine inspection is carried out for the purpose of finding out and dealing with any abnormal symptom which may arise. The mothers are given simple instructions as to their mode of life and clothing during the period, and an endeavour is made to help and encourage them. "As elsewhere, the housing question is still very acute. It is no uncommon thing for husband, wife, and two children to be living in one room. The pregnant mother is the one to suffer most through these conditions, and she is always advised to go to a Maternity Home or Hospital for her confinement. Unfortunately, she cannot always do this on account of the additional expense and the reluctance to leave her young children in someone else's care. Sometimes she has to endure the misery of living with a quarrelsome neighbour in the same house, and not infrequently she is given notice to leave as soon as the landlord discovers that another baby is coming. She cannot always be turned out of her house, but the miserable feeling of being there on sufferance affects her health. After the birth of her child she is so frightened that the baby will cry and disturb the neighbours, that the most important early training of the child is neglected, and he often acquires bad habits which are sometimes injurious to health. "Pregnant and nursing mothers and children needing dental treatment are referred to the Dental department at Southey Hall and the cases dealt with there. "The Day Nursery at 176, Haydons Road has been visited every week, and any child examined whose condition was not considered satisfactory." During 1923, the record of work is as follows:— Infant Welfare Consultations. Queen'6 Hall Centre. Wandle Pk. Centre. Number held 51 49 Total number of attendances 2,384 1,703 Average number of attendances 46.74 34.75 Total number seen by Doctor . 1,051 870 Number of new cases—under 1 year 141 117 „ „ „ „ over 1 year 35 17 Ante Natal Clinic Consultations. Number held ... 20 Total number of attendances ... 71 Average number of attendances ... 3.55 20 Classes for Mothers. Queen's Hall Wandle Pk. Centre. Centre. Number held 43 43 Total number of attendances 490 856 Average number of attendances 11.3919.91 Subjects taught {Mothercraft Mothercraft Needlework Needlework Health Talks Health Talks Domestic Domestic Science. Science. Welfare Dental Clinic.—Cases are recommended by the Assistant Welfare Officer to the Dental Clinic at Southey Hall on Friday afternoons of each week. If the mothers require dentures, payment by instalment is permitted or the Committee in certain cases may remit payment in whole or part. Mr. A. MacGregor Whyte, the Surgeon Dentist, reports:— "I have pleasure in submitting the Annual Report on Dental Inspection and Treatment carried out under the Maternity and Child Welfare Scheme. "Each Friday afternoon is devoted entirely to this Clinic, but it has been found necessary to carry out much' of the denture work on other afternoons after the School Clinic by appointment. "Forty-one Friday afternoons were devoted to Inspection and Treatment, and Dr. Scott administered Nitrous Oxide gas for 48 cases requiring extraction of teeth, twenty-nine Wednesday afternoons half-sessions being arranged. ''With a view to reducing cost of dentures, all preparatory mechanical work is done by myself at the Clinic and completed under my supervision at the Laboratory. The Laboratory work has been highly satisfactory, and the charges moderate. "Seventeen dentures have been supplied, and two dentures repaired. "Extraction of teeth with a view to supply of dentures has been completed in six cases, of which only two are not yet in satisfactory state for completion. The amount assessed in the other four cases has not yet been received. As result of investigation of circumstances in three cases, the Committee authorised a reduction of the amount assessed to be paid by the natient." The following table is a complete summary of the year's work. Number of half-days devoted to treatment 41 „ „ mothers treated 35 „ „ attendances for treatment—mothers 178 „ „ children treated 59 „ „ attendances for treatment—children 128 „ „ temporary teeth extracted 64 ,, ,, ,, ,, filled 57 „ „ other operations 49 21 Number of permanent teeth extracted 159 „ „ ,, Med 20 „ „ other operations 43 Total number of fillings 104 Local Anaesthetics 25 General Anaesthetics 48 Number of half-session Anaesthetics, Dr. Scott 29 „ „ scalings 29 „ „ dentures repaired 2 „ „ dentures supplied 17 „ „ patients rendered dentally fit 46 Supply of Milk to Expectant and Nursing' Mothers and Infants. 217 families applied for free milk supplies and it was granted to 196. Each case is considered individually by the Sub-Committee and a full statement of income from all sources, including pension and Guardian relief, children working, etc., has to be submitted by the applicant. The amount paid for rent and insurance is deducted from the income, and the sum remaining should not exceed 5s. per head except in special cases. This average was exceeded in the 21 applications refused. The following facts were elicited in the course of these enquiries. Where the husband was alive, in 57 percent. of the cases he was out of employment through inability to get work. The usual occupation given was ''labourer.'' In 12 percent. the unemployment was due to temporary sickness or accident, and in 5 percent. it was due to war disability. The remaining 25 percent. were "casual workers," or earning very small wages. The rent paid averaged about 8s. per week. In some cases the rent was as high as 15s., in which case, part of the house was usually sub-let. Other families lived with the parents or other relatives and paid no rent. In two cases, the mothers had been deserted by their husbands, and three were unmarried mothers. In two families there were twin infants. Of the mothers. 50 percent. of those applying attended one or other Welfare Centre. Milk was granted to 23 expectant mothers, to 45 nursing mothers, and in the remaining cases to infants or young children. The number of quarts granted was roughly 7,272, at ai cost to the Council of £164. Several of the families have been in receipt of assistance for some considerable time, and might almost be regarded as "milk pensioners." The following examples might be given:(a) family of father, mother and 10 children, 6 under 14 years, (b) ,, ,, ,, ,, ,, 9 ,, 6 ,, ,, ,, (c) ,, ,, ,, ,, ,, 10 ,, 8 ,, ,, ,, (d) ,, ,, ,, ,, ,, 11 ,, 9 ,, ,, ,, 22 South Wimbledon Day Nursery. The work of this Institution has been much impaired during the year under review by the necessity for internal structural repairs which required the closure of the infants' room. An outbreak of measles towards the end of the year also affected the numbers in attendance. 1. From January to November 16th, when certain children were excluded owing to want of accommodation:— Number of children on Register 64 Total number of attendances 8,098 „ „ „ half-day attendances 991 Average daily number of attendances 43 2. For the remainder of the year: Number of children on Register 46 Total number of attendances 736 „ „ „ half-day attendances 47 Average daily number of attendances 28 At the end of the year it was found that only 30 children (12 infants) could be accommodated. There is a waiting list of about 46. It would appear from a careful study of the records of this Institution that it undoubtedly serves a great purpose in the area. Since its foundation there has practically been an average for 40-46 on the register each year. One reason for this is that there are many laundries in Wimbledon which attract working mothers who are enabled to leave their children in the Nursery when at work. The payments are extremely moderate, being 6d. for one child, l0d. for two, and 1s. 2d. for three per diem. The staff employed consists of one matron, one nurse, one cook, and five young maids. A careful note is kept of the occupation or employment followed by the mothers. Since taken over by the Council, the record is as follows:— 1920. 1921. 1922. 1923 Laundress 18 20 27 22 Domestic Servant 9 2 6 6 Charwoman 8 17 23 9 Railway worker 1 1 2 1 Milliner — — — 1 Factory hand 1 1 — 1 Relief stamper — — — 1 Polisher — — — 1 Other 3 2 1 — Illness — — 2 — 23 Notifiable Diseases during 1923. Table A shows the total cases notified of all notifiable diseases. The following table shows the number of infectious cases notified, and the deaths from each disease in the district during the last 5 years. DISEASES. 1923 1922 1921 1920 1919 1918 Cases Notified. deaths Cases Notified. Deaths, Cases Notified. Deaths. Cases Notified. Deaths. Cases Notified Deaths. Cases Notified. Deaths. Small Pox - - - - - - - - - - - - Diphtheria 88 5 159 7 181 14 123 12 86 8 111 7 Erysipelas 10 — 11 1 10 — 30 2 20 2 13 1 Scarlet Fever 94 — 227 1 265 1 230 2 119 1 73 — Enteric Fever 2 — 4 — 4 1 3 — 14 — 12 1 Polio Encephalitis 1 - - - - - - - - - - - Puerperal Fever 1 — 3 1 1 1 3 — 5 2 4 1 Totals 196 5 404 10 461 17 389 16 244 13 213 10 It will be noted that the number of deaths is small compared with the number of cases notified, indicating the mildness of the diseases. The following table shows the number of cases of ophthalmia neonatorum notified, and the result of the early treatment. CASES. Vision. Unimpaired. Vision Impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 5 4 1 5 — — — 24 Table showing the death-rate from Zymotic Diseases, including Tuberculous Diseases, for the last ten years. YEAR. Zymotic Death-rate. Death-Rate From Small Pox. Scarlet Fever. Diphtheria. " Fever." Whooping Cough. Measles. Diarrhoea. Phthisis and other Tuberc los Diseases. 1914 .75 - .03 1 - .1 •06 .43 •78 1915 .83 — •01 •14 •03 .08 •1 •39 •62 1916 .59 - 03 .16 •03 •1 07 •18 .82 , 1917 l.25 - — .2 .05 •01 •65 .29 1.36 1918 .68 - — 13 .01 .23 •09 .19 1.27 1919 .26 — •01 •13 — — •03 •08 .8 1920 .46 - 03 .19 — •03 .09 •11 .72 1921 •63 - •01 .22 .01 •06 — •3 •79 1922 1.06 - .00 .1 - .08 .00 •05 .76 1923 l.00 - 05 .08 — •06 •06 •08 •63 The figures given in these Tables are those obtained after correction by exclusion of "Non-Residents" and the inclusion of " Residents " beyond the district. 25 26 TABLE A. NOTIFIABLE DISEASES—1923. Table showing the total cases notified and deaths in age groups, the numbers removed to hospital and the total deaths. DISEASE. Total cases Notified. Under 1 Year. 1— 2— 3- 4— 5— 10— 15— 20— 35— 45— 65 and over. Cases admitted to Hospl. Totals Death Diphtheria Notified 88 - 3 3 6 1 31 33 4 3 4 - - 73 5 Deaths — - 1 - - - 2 2 — — — — — — Scarlet Fever Notified 94 2 2 2 11 4 30 15 13 10 2 3 — 74 3 Deaths — — — — 2 — — — — 1 — — — — Enteric Fever Notified 2 - - - - - - - - 1 1 - - 2 - Deaths - - - - - - - - - - - - - - Puerperal Fever Notified 1 — — — — — — — — 1 — — — 1 - Deaths - - - - - - - - - - - - - - Pneumonia Notified - - - - - - - - - - - - - - 41 Deaths — 2 4 — — — 1 — 2 1 3 13 15 — Erysipelas Notified 10 - - - - - - - - 1 2 7 — 1 - Deaths - - - - - - - - - - - - - - Encephalitis Lethargica Notified - - - - - - - - - - - - - - 1 Deaths - - - - - - - - 1 - - - - - Cerebro-Spinal Meningitis Notified - - - - - - - - - - - - - - - Deaths - - - - - - - - - - - - - - Malaria Notified - - - - - - - - - - - - - - - Deaths - - - - - - - - - - - - - - Dysentry Notified - - - - - - - - - - - - - - - Deaths - - - - - - - - - - - - - - Polio Encephalitis Notified 1 — — — — — 1 — — — — — — — - Deaths — — — — — — — — — — — — — — Tuberculosis Notified 65 — — — — 2 2 4 15 19 11 12 — — 37 Deaths - - - - - - 1 1 7 10 6 9 3 — Totals Notified 261 2 5 5 17 7 64 52 32 35 20 22 — 151 87 Deaths - 2 5 2 — 4 3 10 12 9 22 18 — Table showing the Ward Distribution of Infectious cases notified in 1923, and the numbers removed to hospital. Notifiable Disease. All Ages. Total Cases Notified in Each Locality (e g. Parish or Ward) of the District. Total Cases removed to Hospital. Wimbledon Park Ward St. Mary's Ward. St. John's Ward. Cottenham Park Ward. Dundonald Ward. Trinity Ward. South Park Ward. Haydon Park Ward. 1 2 3 4 5 6 7 8 Diphtheria (including Membranous croup) 88 5 7 8 5 9 26 14 14 73 Erysipelas 10 1 2 — 1 — 4 2 - 1 Scarlet Fever 94 5 7 7 12 13 27 12 11 74 Enteric Fever 2 — - — — - - 1 1 2 Puerperal Fever 1 — — — — — - - 1 1 Cerebro-spinal Meningitis — — — — — — - - - - Pulmonary Tuberculosis 55 9 3 5 2 8 16 6 6 - Other forms of Tuberculosis 10 1 2 — — - 8 4 - - Ophthalmia Neonatorum 5 — — 1 — — 1 1 2 1 Encephalitis Lethargica - - - - - - - - - - Pneumonia — - - - - - - - - - Influenzal Pneumonia - - - - - - - - - - Malaria — — — — — — — — — — Dysentery — — — — — — — — — — totals 265 21 21 21 20 30 77 40 35 152 In one house there were six cases, in one house five cases, in one house four cases, in one house three cases, and in eight houses two cases, and in the remaining sixty houses, one case. 74 or 69 per cent, of the cases were treated in the Borough Isolation Hospital, Gap Road. 27 Scarlet Fever.—The total number of cases notified during tne year was 94 from 72 houses. The attack rate was 1.6 per thousand of the population. There were no deaths. Attack-Rate. Death-Rate 1891-1895 4.8 .02 per thousand of the population. 1896-1900 3.3 .04 1901-1905 2.3 .02 1906-1910 4.07 .05 1911-1915 3.03 .01 1916-1920 1.8 .01 In Table A. the deaths, from pneumonia are in excess of the notifications received, and it would appear as if all cases were not notified. The explanation probably lies in the fact that the deaths include all forms of pneumonia, whereas notifications are confined to Acute Primary Pneumonias and Acute Influenzal Pneumonias. 42 per cent, of the cases notified were children of School age, five to fifteen years, and of these, 41 attended the following Schools:— Effra Road Girls', and Infants' Schools 4 Durnsford Road Mixed and Infants' Schools 3 Queen's Road Girls' and Infants' Schools 2 Queen's Road Boys' School 1 Pelham Road Boys' School 5 Pelham Road Girls' and Infants' Schools 9 Dundonald Road Boys' School 1 Dundonald Road Girls' and Infants' Schools 3 Russell Road Mixed School 2 Russell Road Infants' School 1 Private Schools 9 Schools outside the district 1 Total 41 Diphtheria.—The total number of cases notified during the year was 88 from 70 houses. The attack-rate was 1.5 per thousand of the population. There were 5 deaths, corresponding to a death-rate of .08 per thousand of the population. In 1 house there were 5 cases, in one house 4 cases, in 1 house 3 cases, in 9 houses 2 cases, and in the remaining 5 houses 1 each. 56 or 64 per cent. of the patients were treated in the Isolation Hospital. 56 per cent. of the cases notified were children of School age, five to fifteen years, and of these, 60 attended the following Schools:— Queen's Road Girls' and Infants' Schools 4 Queen's Road Boys' School 3 Haydon's Road Boys' School 2 Hay don's Road Girls' and Infants' Schools 6 Central Infants' School 1 Central Mixed School 2 Dundonald Road Girls' and Infants' Schools 2 Durnsford Road School 1 Effra Road Girls' and Infants' Schools 4 Pelham Road Infants' School 4 Pelham Road Boys' School 5 Pelham Road Girls' School 5 Private Schools 19 Schools outside the district 2 Total 60 28 A sharp outbreak of 'diphtheria occurring in a private boarding and day school was controlled by swabbing and isolation of infected cases. All the children in one of the Guardians' Homes were swabbed on a case occurring, but none of the contacts developed diphtheria. Tuberculosis. The following table shows the number of new cases notified during the year, and the number of deaths from tuberculous diseases. NEW CASES. DEATHS. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. Males. Females. Males. Females. Males. Females. Males Females. Under 1 year - - - - - - - - 1—5,, — — — 2 — - — — 5 — 10 ,, — — 1 1 — — - 1 10 — 15 ,, — 2 — 2 — 1 - — 15 — 2 ,, 7 7 1 — 4 2 - 1 20 — 25 ,, 3 4 — 1 2 — - — 25 — 35 „ 5 6 — — 3 5 — - 35 — 45 ,, 6 4 1 — 5 1 - — 45 — 55 ,, 6 1 — 1 7 — - — 55 — 65 ,, 3 1 - — 2 — — — 65 upwards — — — 1 2 — — Totals 30 25 3 7 24 11 — 2 Of the 24 male and 11 female deaths from pulmonary tuberculosis, 9 males and 2 females died in the districts outside the Borough, i.e. notification of death was transferred to Wimbledon. Of the total 37 deaths, 27 (73 per cent.) had been notified as suffering from tuberculosis. Of the 10 non-pulmonary notifications, 4 were notified as " glands," 3 as " abdominal," 1 of " metacarpals," 1 " skin," and 1 " testicle. " A new system of keeping Tuberculosis returns lias been started, and it is hoped that a full record of all Tuberculous cases in the district may be completed during 1924. This should enable closer co-operation with the Tuberculosis Officer for the county. 29 Disinfection.—The following Table shows the number of rooms and articles disinfected:— se. Bedding Disinfected. Clothing. No Of Rooms Disinfected Totals Mattresses. Palliasses and Counterpanes. Beds. Pillows and Bolsters. Blankets and Sheets Dresses Suits. Other Articles. Scarlet Fever 648 203 44 752 1448 152 159 4530 148 8084 Diphtheria 184 181 31 292 629 32 23 1132 108 2612 Typhoid Fever 3 3 3 5 15 — — 7 2 38 Erysipelas 5 4 2 12 17 — — 28 4 72 Tuberculosis 51 '26 12 119 158 4 5 317 48 740 Cancer 38 28 10 107 63 5 12 189 25 477 Pneumonia and Influenza 10 5 1 33 20 — - 22 2 93 Encephalitis Lethargica 1 2 2 5 - 1 2 13 Vermin 4 3 1 9 11 — 1 27 10 66 Sundries 60 21 12 203 155 9 13 387 22 882 Totals 1004 476 116 1534 2521 202 213 6640 371 13077 Wimbledon Isolation Hospital. The following table gives the number of patients treated in the hospital for each disease during 1923. Carried over from 1922 Over 5 years. Under 5 years. Total. Deaths. Remarks. Over 5 years. Under 5 years Total. Scarlet Fever 37 9 46 - - - Daily average number of cases, 30. Diphtheria 15 1 16 — - — Cases Admitted in 1923. From Wimbledon. Scarlet Fever 52 18 70 — — — Average number of days in hospital, 51.33. Diphtheria 60 11 71 2 - 2 Enteric Fever 2 — 2 — - — Scarlet Fever-Staff 1 — 1 — - — Diphtheria—Staff 1 — 1 — - — From Kingston. Scarlet Fever 43 12 55 1 1 2 Kingston cases, 67. Diphtheria 8 4 12 - - - Total Treated in 1923 219 55 274 3 1 4 30 Diphtheria.—84 eases were admitted as diphtheria, of which 43 (51 per cent.) were mild, 31 (37 per cent.) were moderately severe, and 10 (12 per cent.) were severe. Two cases died, (one within 12 hours), giving a case rate of 2.4 per cent. One case required tracheotomy and made a good recovery. In four cases the evidence of diphtheria was bacteriological only. Complications: In practically all cases there was some degree of adenitis on admission. The severe cases had typical severe adenitis ("bull-neck"). Fifteen cases suffered from post-diphtheritic paralyses, of which two were severe necessitating a prolonged stay in hospital. One child developed myocarditis. Virulence tests: All cases are swabbed (nose and throat) and tested twice bacteriologically before being dismissed. When the swabs are returned " positive " after several consecutive swabbings the cultures are forwarded to the Wellcome Laboratories for a Virulence test. This procedure allows in certain cases a non-virulent positive carrier to be dismissed sooner than if reliance were only placed on an examination microscopically of the culture. This question of the virulent carrier case is one of some difficulty, for they cannot be discharged from hospital to spread infection generally. Local applications and general treatment would appear to have little or no effect, and the patients remain, sometimes for weeks, without any sign of change, and then, suddenly for no explainable reason they clear up and become free from infection. This may be attributed to the treatment being given at the time of clearing, but more probably it is pure coincidence, and for this reason the use of special remedies, such as vaccines, cannot definitely be recommended. Active surgical treatment, such as tonsillectomy or clearing of the nasal passages, has been advised, but in such cases special expert skill, combined with a thorough bacteriological control, is necessary—a matter of considerable difficulty in smaller isolation hospitals. Scarlet Fever.—123 cases were admitted as scarlet fever. Of these 110 (89 per cent.) were mild, 10 (8 per cent.) were moderately severe, and 3 (2.4 per cent.) were severe. 2 cases died, giving a case rate of 1.6 per cent. Of these two fatal cases, one was a septic infection occurring in a debilitated child, and death took place four weeks after admission from general septic infection. The second case was admitted with acute toxic scarlet fever and died with meningeal signs, four days later. One case was admitted desquamating. One case advanced in pregnancy ran an uncomplicated course in hospital, and was safely confined shortly after discharge from hospital of a healthy infant. Eight cases were atypical scarlet and were of the nature of an acute tonsillitis with a diffuse erythematous rash. Three 31 true cases of scarlet developed secondary rashes at the end of the third week. Complications:—43 per cent, of the cases were uncomplicated, 11 (8.9 per cent.) suffered from nephritis, and the same number from rhinorrhea. The remaining cases suffered from septic sores, onychia, rheumatism, blepharitis and other minor infections. One child developed a diffuse erythema multiforme in hospital, but this could not strictly be called a complication of scarlet fever. "Return" cases:— 10 (8 per cent.) return cases occurred The history obtained in all these cases was similar. The patient, on dismissal from hospital was free from all discharges, but developed a "cold" shortly after returning home. Six of the cases were Wimbledon cases and four were from Kingston. This number of " return " cases is rather high and it would almost appear as if the cases which were mildest in hospital are more likely to give rise to secondary cases of infection. It was observed that children with slightly enlarged tonsils appeared to cause such return cases more frequently than children with ear or nose discharge. It would almost seem as if these latter cases became attenuated in virulence after a prolonged stay in hospital, and could, safely be dismissed from hospital although the discharge from ear or nose had not ceased. From these remarks it might almost be advisable to have a consulting aural surgeon on the staff of the isolation hospitals. Mixed Infections.— Scarlet Fever and Whooping Cough. Two cases of double infection were admitted, but as notification had been given, isolation in side wards prevented any spread. .Scarlet Fever and Chicken-Pox.—One child was admitted with scarlet fever who was also incubating chickenpox, which developed eight days later. No warning was conveyed by the notifying practitioner so that no precautions were taken. Four susceptible children developed chicken-pox. Scarlet Fever and Diphtheria.—One child was admitted as a pure diphtheria case, clinically and bacteriologically. There was no evidence of rash on admission, but as the tongue was suspicious, " barrier-nursing " was begun at once. The medical practitioner notifying the case was communicated with and he stated that he had seen no evidence of scarlet fever. Seven days later the boy in the next cot, who had been in hospital three weeks, developed typical scarlet fever. Further enquiries from the parents of the suspected infecting case elicited the fact that the mother had noticed, on the day previous to calling in the family 'doctor, a faint rash which only lasted a few hours. 32 This outbreak was interesting for two reasons, (1) the incubation between cases was exactly ten days, and (2) three children of the same family were infected. As the " susceptable " contacts were kept under close observation, and were isolated immediately there was the slightest complaint of sickness, headache, or temperature, it would appear that a comparatively short period of contact may suffice to spread the disease and that probably there is a family susceptibility as well as an individual one. Typhoid Fever -The two cases admitted were both atypical; and some question as to diagnosis was raised, as both patients had served in the Army and both had been inoculated against typhoid. The Widal reaction was positive in both. Further Widal reactions were carried out subsequently, and from these observations it was considered that one patient had actually a mild attack of the disease, but the other ;was doubtful. Both made good recoveries. Sickness among Staff.—Two nurses suffered from tonsillitis. Both were working in the 'diphtheria wards. One case was bacteriologically negative and the other, though not suffering from clinical diphtheria, was harbouring a virulent diphtheria bacillus and was treated for true diphtheria. Both made good recoveries. A third nurse suffered from a mild attack of scarlet fever. .Scarlet Fever and Measles.—At the end of December a child was admitted with scarlet fever. Eight 'days later a true measles rash developed. The child was at once isolated but two other susceptibles developed measles at the end of a, fortnight. Fortunately, the hospital was comparatively empty at the time, and a fresh ward was opened at once. No further cases developed. Lectures, etc. —The usual lectures for the Fever Nurses' Certificates were given. Two nurses sat for the examination and both passed. Seven out of eight nurses also passed the St. John's Ambulance examination in First Aid. Summary of Nursing Arrangements, Hospitals and other Institutions available for the District. Professional Nursing in the Home. (a) General South Wimbledon District Nursing Association. (b) Infectious Diseases None. Midwives. —Under the supervision of the Surrey County Council, there are 13 midwives practising in the district. 33 Clinics and Treatment Centres:— Maternity and Child Welfare Centres— (1) Wandle Park House, Wandle Bank, Wimbledon. (2) Queen's Hall, Queen's Road, Wimbledon, under the Wimbledon Borough Council (vide p. 20.) Day Nursery, 176-180, Haydons Road, Wimbledon, under the Wimbledon Borough Council. School Clinic:—Southey Hall, Southey Road, Wimbledon (vide p. 21), under the Wimbledon Education Committee. Tuberculosis:—Dispensary, 145, Merton Road, Wimbledon, under the Surrey County Council. Venereal Diseases:—Richmond, under the Surrey County Council. Hospitals:— (!) Tuberculosis Crooksbury Sanatorium under the Surrey County Council. (2) Maternity None. (3) Children Received into don Hospital and into Wimbledon, Merton and District (Nelson) Hospital (voluntary). Children sent for Tonsils and Adenoid operations under arrangements with Education Committee. (4) Fever Isolation Hospital, Gap Road, Wimbledon Borough Council. 105 beds. (5) Small-pox Cheam Small-pox pital, Surrey. Croydon and Wimbledon Joint Board. (6) Other None. Institutional provision for Unmarried Mothers—Southwark Diocesan Maternity Home, Gap Road, Wimbledon. 34 Ambulance Facilities:— (a) For Infectious cases—two motor ambulances, Isolation Hospital, Gap Road. (b) For non-Infectious and Accidents—one motor ambulance, Fire Station, Queen's Road, under the Wimbledon Borough Council. LABORATORY WORK. Bacteriological examinations of pathological specimens and the use of antitoxin were first undertaken in the Wimbledon area about 1896. The number of specimens of serum, sputum and blood submitted for bacteriological examination during the year in doubtful cases of diphtheria, pulmonary tuberculosis and typhoid fever, and the result of such examinations are given below. Fifty-two bottles of anti-diphtheritic serum were supplied through the Public Health Department for use by medical practitioners for the treatment of diphtheria. The antitoxin syringe which is kept at the Fire Station, was borrowed on one occasion by a medical practitioner in the district. Bacteria Found. Bacteria Not Found. Total. Diphtheria Secretion 141 929 1070 Phthisis (Sputum) 16 90 106 Reaction Obtained. Reaction Not obtained. Total. Typhoid (Blood) 3 28 31 MORTUARY. From information received from the Superintendent of the Cemetery, there were 33 bodies received into the mortuary during the year. Inquests were held by the Coroner with respect to 27 bodies, equal to 6.1 per cent, of all deaths registered in the Borough. 35 LOCAL ACTS, SPECIAL LOCAL ORDERS, OR GENERAL ADOPTIVE ACTS IN FORCE IN THE BOROUGH. Infectious Diseases (Prevention) Act, 1890-17th December, 1890. Public Health Acts (Amendment) Act, 1890: (Parts II., III. and V.)—17 th December, 1890. Housing of the Working Classes Act, 1890: (Part III.)—7th June, 1899. Public Health Amendment Act,1907. Part II. (Streets Buildings)—Sections 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 26, 28, 29, 31, 32, 33, and Sections 25, 27 and 30 with modifications. Part III. (Sanitary provisions)—Sections 34, 36, 37, 39, 40,' 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 and 51 and Sections 35 and 38 with modifications. Part IV. (Infectious Diseases)—Sections 52, 53, 54, 55. 56, 57, 58, 60, 61, 62, 63, 64, 65, 67, and 68, and Section 59 with modifications. Part V. (Common Lodging Houses)—Sections 69, 70, 71, 72, 73, 74 and 75. Part VI. (Recreation Grounds)—Section 76 (with modifications), and Section 77. Part VII. (Police)—Sections 84, 85, 86, and section 81 with modifications. Part VII1. (Fire Brigade)—Sections 87, 88, 89 and 90. Part IX. (Sky Signs)—Section 91. Part X. (.Miscellaneous)—Sections 92, 93 and 95. (All the above Sections of the 1907 Act were adopted on 28th July, 1913, except those in Parts VII, VIII. and IX., which became operative on 21st December, 1908.) The Wimbledon Corporation Act, 1914.—7th August, 1914. Bye-laws, Regulations, etc.— Bye-laws with respect to Houses let in Lodgings. Do. do. Common Lodging Houses. Do. do. Slaughter-houses (Revised 1922). Do. do. Nuisances. 36 Bye-laws with respect to tents, vans, sheds and similar structures. Do. do. the keeping of water-closets supplied with sufficient water for flushing. Regulations with respect to Dairies, Cowsheds and Milkshops. Provisional and other Orders affecting the Borough:— Croydon and Wimbledon Joint Small-pox Hospital Order, 1898. Do. do. do. 1903. Do. do. do. 1908. Do. do. do. 1912. Order of Local Government Board under the Public Health Acts (Amendment) Act, 1907, declaring certain trades to be offensive. Dated 14th January, 1914. Order of Town Council under Shops Acts, 1912 and 1913, relating to Second-hand Clothes Dealers. Dated 5th November, 1913. The Wimbledon General Half Holiday Order, 1914. 6th June 1914. The Wimbledon Credit Drapers' Half Holiday Order, 1914. 2nd July, 1914. The Wimbledon Barbers' and Hairdressers' Closing Order, 1919. 27th October, 1919. Sanitary Inspection of District.—The following is a statement showing the number and nature of inspections made, the number of informal and statutory notices served, with the result of such notices, for the year 1923, as reported by the Sanitary Inspector. Reason of Visit. No. Infectious Disease 623 House Inspection 2488 House to House Inspection 2976 Rent Act Inspections 113 House Let in Lodgings; Inspections 20 Inspection of Factories, Workshops, Workplaces and Out-workers' Premises 82 Common Lodging Houses; Inspections 10 Dairies and Cowsheds; Inspections 45 Inspections under Shop Acts 222 Application of Tests to Drains 290 Inspections under Diseases of Animals Acts 212 Obtaining Samples of Food and Drugs 21 Miscellaneous (including Inspections of Food, slaughter-houses, mews, stables, caravans, Petroleum Acts, water supply, piggeries, mosquitoes, etc. 758 7860 37 One thousand and forty-eight preliminary or informal notices were served in respect of 1,157 houses. Ninety-seven statutory notices were served in respect of 136 houses. The necessary work was executed in all but 85 cases, which were not completed by the end of the year. In 78 of these, the-work was actually in hand at the close of the year. Table III. gives a summary of the nuisances abated, and sanitary improvements carried out under the supervision of the Inspectorial Staff. Factories and Workshops. In the Table below is shown the work done in the supervision of workshops and workplaces :— PREMISES. Inspection. Written Notices. Prosecutions. Factories 30 6 - Workshops 40 17 — Workplaces 9 - - Total 79 23 — Defects Found. NATURE. Number of Defects. Found. Remedied. Referred to H.M. Inspector. Prosecutions. Want of Cleanliness 13 13 — — Other Nuisances 4 4 - — Sanitary Accommodation- Insufficient 1 1 — — Uusuitable or Defective 4 4 — — Not Separate for Sexes 2 2 — — Breach of Special Sanitary Requirements to Bakehouses — — — — Other Offences 2 2 — — Totals 26 26 — — 38 HOME WORK. Lists received:— Twice in the year 1 Number of Out-workers 11 Once in the year 2 Number of Out-workers 2 Number of addresses received from other Councils 41 Number of addresses forwarded to other Councils 9 Notices served on occupiers as to keeping or sending lists — Prosecutions—Failing to keep Out-workers' lists — Prosecutions—Failing to furnish lists — Inspections of Out-workers' premises 2 Number of unwholesome premises — Notices served to remedy — REGISTERED WORKSHOPS. The following are the principal classes of workshops on the register at the end of the year:— Boot repairing 42 Dressmaking 34 Bakehouses (including three Factory Bakehouses) 27 Laundries 34 Tailoring 17 Millinery 11 Dining Rooms 13 Cycles 6 Other trades 136 320 OTHER MATTERS. Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of Act — Action taken in matters Notified by H.M. referred by H.M. In- | Inspector — spector as remedial - Reports of action under the Public taken sent to Health Acts V H.M. Inspector — Underground Bakehouses ,in use at the en'd of the year 3 39 HOUSING CONDITIONS. Statistics. Year ended 31st December, 1922. 1.—GENERAL. (1) Census (corrected) population 58,000 (2) General death-rate 9.4 (3) Death-rate from tuberculosis 63 (4) Infantile mortality 44 (5) Number of dwelling-houses of all classes (separately rated) 12,995 (6) Number of working-class dwelling-houses (approximate) 8,910 (7) Number of new working-class houses erected 52 2.—UNFIT DWELLING-HOUSES. I.—Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1,348 (2) Number of dwelling-houses which were spected and recorded under the Housing (Inspection of District) Regulations, 1910 479 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 1,157 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 964 III.—Action under Statutory Powers. (a) Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919 Nil (b) Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 136 40 (2) Number of dwelling-houses in which defects were remedied:— (a) By owners 108 (b) By; Local Authority in default of owners Nil (c) Proceedings under Section 17 and 18 of the Housing, Town Planning, etc. Act, 1919 Nil 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 Nil The following points are noted for general information:— Water Supply.—The water supply was withdrawn from 22 houses during the year, for the following reasons—4 by request, 10 owing to arrears of rates, and 8 for other reasons. Slaughter Houses.—There are six registered premises. Dairies, Cowsheds, and Milkshops Order.—On 31st December, 1923, there were 3 cow-keepers, 23 dairymen, 33 dairymen and Purveyors, and 23 Purveyors on the Register. Schools.—See Report of School Medical Officer. Poor Law Relief.—The following information has been furnished by the Clerk of the Kingston Union respecting Poor Law Relief in this District:— Amount paid in Out-door Relief in 1923 £6,552.0.1 Average weekly number of persons in receipt of relief 435 Number of persons admitted to the Guardians' Institution from the Hospital Central Relief Institution 206 Wimbledon area 87 293 I desire to thank Mr. Johnson, the Chief Sanitary Inspector, and the other members of my staff, for their loyal assistance and co-operation in the work of the Department. I have the honour to be, Your obedient servant, A. GILMOUR, Medical Officer of Health. Town Hall, Wimbledon, S.W.19. March, 1924. 41 42 TABLE 1.—Vital Statistics of Whole District during 1923 and Previous Years. YEAR. Population estimated to middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths Nett Deaths Belonging to the District. Uncorrected Number. Nett. Under 1 year of Age At all Ages. Number. Rate. Number. Rate. of Nonresidents registered in the District. of Residents not registered in the District. Number. Rate per 1000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1916 60,333 Birth-rate 55,451 Death-rate 1007 1011 16.7 484 8.7 33 168 71 70 619 11.1 1917 59,678 Birth-rate 53,536 Death-rate 866 868 14.5 511 9.5 17 164 74 85 653 12.2 1918 57,155 Birth-rate 51,009 Death-rate 779 759 13.2 613 12.01 51 180 57 76 742 14.5 1919 62,283 Birth-rate 59.791 869 861 13.8 512 8.5 64 186 43 50 634 10.6 1920 Death-rate 62,311 Birth-rate 62,174 Death-rate 1124 1144 18.3 462 7.4 58 153 71 62 557 8.9 1921 61,730 1033 1033 16.7 521 8.4 62 175 72 69 643 10.2 1922 61,730 834 868 14.0 485 7.8 70 201 50 58 616 9.9 1923 58,000 838 868 14.9 439 7.6 65 172 38 43.7 546 9.4 CO TABLE II.—Causes of, and Ages at, Deaths during the year 1923. CAUSES OF DEATH. Nett Deaths at the subjoined ages of " Residents" whether occurring within or without the District. Total Deaths whether of 'Residents' or ' Nonresidents in Institutions in the District. All Ages. Under 1 year. 1 2 3 4 5 10 15 20 35 45 65 and over. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 All Causes Certified 546 38 8 1 5 1 10 6 15 22 33 145 262 64 Uncertified - - - - - - - - - - - - - - Enteric Fever - - - - - - - - - - - - - - Small-pox - - - - - - - - - - - - - - Measles 4 1 1 - 1 - 1 - — - - - - - Scarlet Fever 3 - — - 2 — - — — 1 — — — 2 Whooping Cough 4 2 1 1 - - - - - - - - - - Diphtheria and Croup 5 - 1 - - — 2 2 — - - - - 2 Influenza - 1 - - - - - - - - - 1 5 1 Encephalitis Lethargica 1 - — - — — — — 1 — — - - - Meningococcal Meningitis 1 — — - - — 1 — — — - — — — Tuberculosis of Respiratory System 35 - - - - - - 1 6 10 7 8 3 — Other Tuberculous Diseases 2 — — - — — 1 — 1 — — — — 1 Cancer, malignant disease 68 — 1 - — — — — — 1 5 35 26 5 Rheumatic Fever 4 — — - — — 1 1 1 — — 1 — — Diabetes 5 — — - — — — — — 1 - 2 2 - Cerebral Hæmorrhage 42 - - - - - - - - — — 12 30 15 Heart Disease 79 2 — - — — 1 — — — 7 23 46 10 Arterio Sclerosis 21 — — - — — — — — — — 2 19 4 Bronchitis 33 1 — - — — — — — - — 9 23 1 Pneumonia (all forms) 41 2 4 - — — 1 — 2 1 3 13 15 5 44 TABLE II,—continued. CAUSES OP DEATH. Nett Deaths at the subjoined ages of " Residents " whether occurring within or without the District. Total Deaths whether of 'Residents' or 'nonResidents' in Institutions in the District. All Ages. Under 1 year. 1 2 3 4 5 10 15 20 35 45 65 and over. 1 2 3 4 5 6 7 8 9 10 11 12 13 #] Other Respiratory Diseases 10 2 - - 1 - - - - - 1 5 1 Ulcer of Stomach, or Duodenum 4 - - - - - - - - - 1 3 - Diarrhoea, &c. (under 2 years) 5 5 - - - - - - - - - - - - Appendicitis and Typhilitis 5 - - - - - - 1 1 1 - 1 1 - Cirrhosis of Liver 3 - - - - - - - - - - - - - Acute and Chronic Nephritis 17 - - - - - - - - - - 1 2 - Puerperal Sepsis - - - - - - - - - - - 5 12 - Other Accidents and Diseases of Pregnancy and Parturition - - - - - - - - - - - - - - Congenital Debility & Malformations Premature Birth 20 20 - - - - - - - - - - - - Suicide 4 - - - - - - - - 1 - 2 1 - Other Deaths from Violence 9 - - - - 1 2 - 2 - - - 4 - Other Defined Diseases 114 2 - - 1 - - 1 1 6 9 22 72 - Causes ill-defined or unknown - - — — - — — - - - - - - Totals 546 38 8 1 5 1 10 6 15 22 33 145 262 64 sub-entries included in above figures. Poliomyelitis Polio-Encephalitis Borough of wimblebon, SANITARY DEPARTMENT. ANNUAL REPORT of the SANITARY INSPECTOR. for the Year Ended 31st December, 1923. To the Mayor, Aldermen, and Councillors of the Borough of Wimbledon. Ladies and Gentlemen, I beg to submit to you my Report of the work carried out in my Department for the year ended 31st December, 1923. Table III. gives a summary in detail of the various nuisances abated and sanitary improvements effected. Notices Served.—One thousand and forty-eight Preliminary Notices or intimations, were served during the year in respect of 1,157 houses. It was only found necessary to serve 97 Statutory Notices upon the owners or occupiers of 136 houses. 217 letters respecting 249 houses were received through the Town Clerk's Department, and answered, enquiring if any sanitary notices were outstanding with respect to properties for which negotiations for sale were in progress. Opening up of Drains under Section 41 of the Public Health Act, 1875.—As a result of the applications of the smoke or chemical tests, it was found necessary to exercise the 45 powers with respect to the opening up of ground and exposing of drains granted to the Local Authority by this Section at 15 houses, authority first having been obtained from the Council, and due written notices given to the occupier in each case. The conditions found were duly reported to the Public Health Committee, and notices served on their instructions, requiring the re-construction or amendment of the defective drains, etc., as the circumstances required. House Drainage.—The drainage systems and sanitary arrangements of 9 houses have been entirely reconstructed, extensive amendments or repairs were carried out at 69 other houses, and at 22 houses the drainage systems have been made water-tight by the patent internal process. House to House Inspection.—During the year, house to house surveys were carried out at 479 houses. The following list shows the particular streets and the number of houses inspected in each. A list lof the work carried out at the houses is included in Table III., p. 53. Balfour Road 36 Caxton Road 47 Cecil Road 74 Haydons Road 195 Russell Road 127 479 House Inspection.—Either as the result of inspections made on complaint, in consequence of the occurrence of infectious disease, request by occupiers and other general inspections, 684 houses were visited. Table III. shows a list of sanitary works executed at these houses, together with defects remedied during house to house inspection. Overcrowding.—It is regrettable that the shortage of houses in the district still continues, and that very few houses of the smaller type have been erected during the year ; consequently, overcrowded conditions of many houses in this district, a circumstance common to many in the vicinity of the Metropolis, continues. There are very few sites left in the Borough where houses of the small type can be built. Houses originally built for occupation by one family, with sanitary conveniences, washing facilities, etc., suitable and sufficient, are now occupied by two, three, and sometimes four families, The use in common of the conveniences provided, is the cause of much friction, unhappiness, and bad feeling. 46 Many cases of overcrowding have been brought to the knowledge of the Department. In these cases, whenever possible, the better distribution of the occupants of the rooms have been advised, and where neglected Conditions existed, occupiers were instructed to remedy them. Apart from this, nothing further can be done until the house shortage is remedied. I give here some details of typical cases of those reported to the Public Health Committee. No. of families. Occupants. Parts Occupied Remarks. a. Two (1) 8a. lc. 3 bedrooms. Adult daughter delicate & said to require separate sleeping room. 1 living room. (2) 5a. 2c. 1 bedroom. 1 living room. b. Pour (1) 2a. 4c. 1 room. (2) 2a. 4c. 1 bedroom. 1 living room. (3) 3a. 3c. 1 bedroom. 1 living room. (4) 2a. 2c. 1 room. c. Two (1) 7a. 2c. 3 bedrooms. 1 living room. (2) 2a. 2c. 1 room. Expectant mother. d. Two (1) 2a. lc. 1 bedroom. 2 living rooms. (2) 2a. 2c. 1 room (very small) e. Three (1) 2a. — 1 bedroom. 2 living rooms. (2) 2a. lc. 1 bedroom. 1 living room. (3) 2a. 2c. 1 room (very small & crowded with furniture.) f. Two (1) 3a. 2c. 2 bedrooms. 1 living room. (2) 5a. 5c. 3 bedrooms. 1 living room. upon the persons responsible, whether occupier or owner. Every assistance has been given to those who were anxious to free their premises from vermin, and fumigants have been supplied at cost price, or fumigation carried out by the Department at the owner's expense, after the walls have been stripped as required. Common Lodging Houses.—There are two Common Lodging Houses in the district, viz., Nos. 42 and 188, High Street, South Wimbledon, for which, Annual Certificates of Registration were granted from 1st January to 31st December, 1923. Ten inspections of the premises have been made from time to time at irregular intervals, and I am pleased to report that all the provisions of the Bye-laws were rigidly observed. Van Dwellings.—As usual, these dwellings have been inspected at various times during the year, and the provisions of the Bye-laws enforced. In only a few instances has it been necessary to warn occupiers, who have immediately taken steps to comply with the regulations. In April, a plot of land in Plough Lane, formerly used as allotments, was occupied by showmen as a fair ground. Complaints were received from residents complaining of noise, etc. The ground and the vans thereon were frequently inspected, but no nuisance or breach of the regulations was found. Frequent visits were paid during the occupation of the land and at no time did I find anything calling for the attention of the Local Authority. The vans generally were well-kept, and provision was made for water supply and latrine accommodation. Dairies, Cowsheds, and Milkshops.—Twenty-five applications were received during the year from persons desirous of being registered under the Dairies, Cowsheds and Milkshops Order, and the Milk and Dairies (Amendment) Act, 1922. Forty-five inspections have been made of all the premises of dairymen and purveyors of milk in the district, during which, one matter was discovered which required to be dealt with by the Department. Infectious Diseases and Disinfection.—During the year visits for the purpose' of investigating cases of notifiable infectious diseases were made to 201 houses. Special visits were also made, as required, for the purpose of following up and enquiring after the health of persons who had been passengers on vessels coming to this country on which cases of infectious disease had occurred, and of which notice had been received from the Port Sanitary Authorities concerned. The information obtained was handed to the Medical Officer of Health. At 96 houses from which cases of notifiable infectious 48 disease had been reported, defective drains or other insanitary conditions were found to exist, all of which were subsequently remedied under the supervision of the officers of the Department. Disinfection of rooms, bedding, clothing, etc., was duly carried out after the removal to hospital or recovery of each patient. Where necessary, the walls of the rooms from which the cases had been removed were stripped and re-papered or distempered. The number of rooms disinfected was 371, and the number of articles, bedding, wearing apparel, etc., 12,706, full details of which are given in the Report of the Medical Officer of Health under the heading of " Disinfection." School Disinfection.—All the Public Elementary Schools in the district were thoroughly disinfected during the summer vacation. Yard Paving.—In the course of the inspections made during the year, 77 yards were found to be in an unsatisfactory state, due either to the absence of any paving or the defective condition of that which did exist. Stable Refuse.—Continued attention has been paid to the mews and stable yards in the district, 25 visits having been made to such premises during the year. Inspections under the Factory and Workshop Act, 1901.— There are 360 factories, workshops and workplaces on the Register, to which 82 visits of inspection were made, and twenty-one written notices were served, referring to sanitary conveniences and other nuisances. I have no doubt many more factories, workshops and workplaces, and premises coming under the provision of the Shops Acts are in occupation, but with the present staff it is not possible to bring either of these registers np to date. Shops Acts, 1912-13. —Two hundred and twenty-two visits were made to the occupied shops in the district to ascertain if the provisions of the Acts were being complied with. The Sunday evening closing of shops has been a feature of special attention, in consequence of complaints having been received that several shops, chiefly refreshment rooms, were selling non-exempted articles after 8 p.m. This necessitated special observations being kept between 8 and 10 p.m. on Sunday evenings. In each case where a contravention was observed, the shop-keeper was warned and the matter reported at the next Meeting of the Public Health Committee. In June, the Town Clerk circularised the shop-keepers, giving them particulars as to closing of shops on week-days and Sundays. 49 Only one prosecution was taken, and that for failing to close premises on the weekly half-holiday. The ease was fully reported to the Committee, who decided and did institute proceedings. The case was dealt with by the local magistrates, who dismissed the summons on payment of costs amounting to four shillings. Slaughter Houses and Food Inspection.—The number of registered slaughter-houses remains the same as last year, viz., six. Two of these, however, have not been used for some considerable time and the use of one other has been discontinued since June, 1923. Ninety-eight inspections have been made during the year whilst slaughtering was in progress, and as far as possible all animals killed, in the town have been examined prior to being exposed for sale. In addition, 210 visits have been made to shops of butchers, fishmongers, and fruiterers, and other places wherei food is prepared or exposed for sale, and the following were surrendered and destroyed as trade refuse, being unfit for human food:— Cod, 14 st. Crabs, 1 st. Haddocks 3 st. Kippers 1½ st. Ox Liver, 30 lbs. Picnic Hams, 2 cwt. 1 qr. 22 lbs. Rabbits, 6. Skate, 5 st. Winkles, 2 bags. Sale of Food and Drugs Acts, 1875 to 1907.— The following Table shows the number and nature of articles purchased and submitted for analysis during the year. The preliminary or test samples were examined by the Council's Analyst. Particulars of samples of food and drugs taken and subsubmitted for Analysis. Year ended 31st December, 1923. Articles. Test Samples. No. Genuine. Adulterated or Inferior. Slightly Inferior or Deteriorated. Milk 40 39 - 1 Chocolates 1 1 — - Total 41 40 — 1 Milk (Special Designations) Order=5 samples. 50 Petroleum Acts.—Fifty-seven applications were received for permission to keep petroleum, 49 being for the renewal of existing licences and eight for new ones. Eighty-five inspections were made of the various premises in respect of which' licences had been issued. Diseases of Animals Acts, 1894 to 1911. Parasitic Mange.—No case of this disease was notified during the year, but one affected horse remaining under treatment at the close of 1922 was, towards the end of January, certified to have recovered. The necessary cleansing and disinfecting of the premises was executed and the restrictions subsequently withdrawn. Foot and Mouth Disease.— During the year quite a large number of orders were issued by the Ministry of Agriculture, placing towns within the Infected, Restricted, and Prohibited areas. On two occasions Wimbledon was for a long time in the prohibited area, and, consequently, animals could not be moved into, within, or without, the district, except under licence. Special attention was at all times paid with respect to the condition of animals brought into the district under licence. In November, the Ministry gave permission for licences to be granted for the killing of pigs on piggery premises, thus minimising the movement of animals. Twenty-one licences were issued, and numerous inquiries were dealt with during the periods of the Orders. Rent (Restrictions) Acts, 1920 and 1922. Under these Acts, twenty-two applications were received from occupiers of premises for inspections to be made, alleging that their premises were not kept in all respects reasonably fit for human habitation, or were otherwise not in a reasonable state of repair. This necessitated a survey of the whole of these houses, both internally and externally and the preparation and serving of notices specifying in detail the works to be executed in order to make the premises in all respects reasonably fit for human habitation. Certificates were granted in eighteen cases. In seventeen cases the works were executed by the owners, and remaining one was still being 'dealt with at the close of the year. Offensive Trade.—In October, the Committee had before them an application for consent to establish a fish-frying business on premises in a main road. The application was received only two hours prior to the Meeting, and consequently consideration was adjourned until the November meeting. In the meantime a petition requesting the Council not to grant the licence was 51 received from a number of persons residing in the vicinity. After careful consideration, the Council decided not to grant the licence applied for. I have much pleasure in testifying to the loyal support given me by my Staff generally, and to acknowledge the kind co-operation at all times by Dr. Gilmour, Medical Officer of Health, and my colleagues of other Departments. I remain, Ladies and Gentlemen, Your Obedient Servant, HENRY JOHNSON, F.S.I.A., M.R.S.I. 52 TABLE III. The following is a summary of the nuisances abated and sanitary improvements carried out under the supervision of the Inspectorial Staff:— Accumulations removed 25 Cisterns provided 8 Cisterns repaired, cleansed, or covered 79 Drains (new) provided 9 Drainage systems made water-tight by patent process 22 Drains, repaired or altered 69 Drains, stoppage removed 71 Dustbins provided 136 Flushing boxes (new) provided 66 Flushing boxes repaired 99 Manure receptacles provided 1 R.W. pipes disconnected 17 Roofs repaired 223 Rooms disinfected 371 Rooms stripped and cleansed 1,278 Verminous rooms cleansed 13 Soil pipes (new) provided 22 Soil pipes repaired or altered 8 Ventilating pipes (new) provided 48 Ventilating pipes repaired or altered 44 Waste pipes (new) provided 189 Waste pipes repaired, disconnected, or trapped 52 Water-closets (new) provided 117 Water-closets repaired or ventilated 12 Water services restored 22 Yards repaired 19 Yards paved 58 Guttering repaired 176 Floors ventilated 21 Nuisances abated from damp walls 98 Water taken direct from main 13 Sinks provided 48 Other nuisances 1,571 Total 5,005 53 STAFF. (a) Whole-time Officers: School Medical Officer: * ‡ A. Gilmour, M.D., M.R.C.P.E., D.P.H. Assistant School Medical Officer: * ‡ Effie M. D. Craig, M.B., Ch.B. School Dental Surgeon: * A. MacGregor Whyte, L.D.S., R.F.P.S.G. School and Treatment Clinic Nurse: Miss A. M. L. Holman (S.R.N.) Health Visitor—School Nurses: * Miss F. Hulse. * Miss M. Giles. * Miss H. Hurst. Dental Attendant: * Miss N. Fowler, V.A.D. (B.R.C.S.) Cleansing Attendant: Mrs. M. Potts. Clerks: Miss S. J. Allnutt. Miss N. Burges. (b) Fart-time Officers: Oculist: G. Cowie, M.B., C.M. Ancesthetist: J. C. Scott, M.D. * Maternity and Child Welfare Officers. ‡ Public Health Officers. 54 Borough of Wimbledon. EDUCATION COMMITTEE. ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE Year Ended 31st December, 1923. To the Members of the Education Committee of the Borough of Wimbledon. Mr. Chairman, Ladies and Gentlemen, I have the honour to submit my Annual Report on the Medical Inspection and Treatment of School Children in the Wimbledon area for the year ending 31st December, 1923. The Report has been prepared on the lines suggested by the Chief Medical Officer of the Board of Education in 1920. The Board of Education have also issued in Circular 1321, dated 27th December, 1923, revised Medical Statistical Tables, and the Tables for 1923 have been prepared as far as possible in accordance with instructions in that Circular. Co-ordination. During 1923 the scheme of Medical Inspection and Treatment of school children was altered in order to secure closer co-ordination with (a) Infant and Child Welfare Work (b) with the Teachers. 55 (a) Co-ordination with Infant and Child Welfare Work. This was rendered possible early in the year by the resignation of Miss Walker, School Nurse, on her marriage. Miss Holman, the remaining School Nurse, was placed in charge of the Treatment Clinic and of two Schools for Inspection work. The other schools were divided as far as possible according to districts between the three Health Visitors. In this way it is hoped that the medical histories of children who have attended the Welfare Centres or who have been under supervision in their homes by the Health Visitors before entering schools will be more satisfactorily linked up with the school medical records. The Assistant School Medical Officer is also Assistant Maternity and Child Welfare Officer, and treatment of special cases under 5 years of age is now conducted on similar lines to that among school children. Such treatment refers specially to dental work, tonsil and adenoid operations, and refraction work. In the same way, debilitated children under 5 years are kept under observation and are exempted on attaining schoolage if necessary. The children in the Day Nursery are regularly inspected by the Assistant Medical Officer. (b) Co-operation with Teachers. New schemes of keeping scholars' medical records and of card-indexing were introduced at the beginning of the year. My object in altering the old system was to increase the efficiency of medical supervision and to decrease the amount of clerical work carried out by the teachers and by the medical staff. Briefly, the medical record cards are now kept in cardboard boxes in "classes," and the cards are transferred with the scholars. In this way it is a simple matter for the class teacher or the medical staff to see whether a child is due for routine examination, whether any defect has been noted, or whether the child is under treatment or observation. A printed slip, giving general instructions, interpretation of symbols, and infectious diseases regulations, is kept in each box for use by the teacher. Progress notes are also entered on the scholars' medical record cards from time to time by the School Nurses. The hours for holding the Treatment Clinic, the method of checking the scholars' attendances at the Clinic, and the granting of exclusion certificates, were arranged after consultation with the Head Teachers. These schemes are now working smoothly and increased efficiency will undoubtedly result. 56 The School Medical Service in Relation to Public Elementary Schools. School Hygiene. (i) Lighting:—Electric lighting was substituted for gas lighting in Hay dons Road School, Girls' and Infants' Departments. (ii) School Desks:—A special report on school desks was submitted to the Education Committee during the year. The equipment in schools was summarised as follows:— Good:—Pelham and Dundonald—all departments, Queen's Infants, and Russell Road Infants. Satisfactory:—Queen's, Boys and Girls, Haydons Girls. Fairly satisfactory:-Wimbledon Park, Cottenham Park, Central, Russell Road Mixed, Effra Road, Haydons Infants. Poor:—Haydons Road Boys. The Committee decided to begin replacing the old desks in Haydons Road Boys' School by modern dual desks, and, where possible, old desks were reconstructed to meet modern requirements. (iii) I am indebted to Mr. J. Bow en, Borough Surveyor and Engineer, for the following particulars in regard to alterations in heating and decorations in schools carried out during 1923:— Heating:—Dundonald School:—New Boiler: Hot-water system remodelled and extended to the Manual Training Centre. Queen's Road School:—New Boiler: Old system overhauled and repaired. Queen's Road Special School and Special Subjects:— New Boiler to serve the Special School and Kitchens No. 1 and 2. Wimbledon Park School:—New section added to boiler and an accelerator pump driven by electric motor. Decorations, Repairs, etc. Queen's Road School:—Periodic external painting of main building, Manual Training Centre, Playground Shelters, Caretaker's Cottage, Iron Classroom and Fences, etc., wall of back playground replaced by fencing. Manual Training Centre:—Defective ceilings repaired and internal decoration throughout. 57 Temporary Iron Classroom —Internal Decoration. Special Subjects Centre:—Partial Internal Decoration. Pelham School:—Periodic external painting of main block, Conveniences, Shelters, and Fences. During the holidays, the drains of all schools were tested, the water supplies and fittings overhauled, and the schools were thoroughly disinfected and cleansed. Medical Inspection. Numbers Inspected. Owing to the above-mentioned changes in scheme and staff the numbers examined at Routine Inspections during 1923 were reduced. The number of Individual Children examined was 3,046. In addition to the 1,421 children inspected at Routine Examinations, 48 children attending the Special School were also examined, and the special census detailed at the end of this Report necessitated the examination and re-examination of 461 children. " Inspection Clinic." This special Clinic is held on Tuesdays between the hours of 2-5 p.m. The children, who are brought by their parents, are examined by the Assistant Medical Officer, and advice is given as to general health, exclusion from school, and other matters of similar nature. No medical treatment is given or prescribed, and cases requiring such treatment are either referred to the family doctor or to hospitals. Many of the ailments are of such a simple nature that no medical practitioner would be consulted even if the parent were able to pay, for the children would simply be kept from school for an indefinite period without treatment until "they felt better." From the attendance point of view alone it is better that thq parents of these children should receive advice as to the duration of exclusion for an earlier return to school is thus ensured. Children with simple sore throats, for example, can be excluded until the result of the swabbing is known, or, in other "suspected infections," until all danger from possible infection is obviated. A general indication of the work carried out is given by the following summary:— General conditions, Debility, Anaemia, etc. 48 Chest 55 Ear, Nose and Throat conditions (tonsils and adenoids, etc.) 51 Acute "colds," "chills," "pains " 40 Defects of the Special Senses—Vision, Speech, Mental 16 Suspected Infections and Contagions 53 58 Cardiac Conditions (physical drill, etc.) 30 Nervous Conditions (Headaches, Chorea, Fits, etc.) 34 Skin Conditions 16 Congenital Deformities 13 Accidents 10 Total 366 The School Medical Officer is also Certifying Officer for Juvenile Employment, for change of school, etc. The following certificates were granted after examination:— For Juvenile Employment 68 For change of school 5 For change of class (Drill, etc.) 10 Total 83 Exclusion certificates were also granted for reasons:— the following Suspected Infections and "Colds" 231 General Conditions 103 Skin Conditions, etc. 142 Total 476 It should be noted that many of the above children are sent by the family doctor for certification just as many cases are referred for treatment. Children attending hospitals are also certified by the School Medical Officer and of the above 476, 89 were under such treatment. Report of Assistant School Medical Officer. Dr. Effie M. D. Craig reports as follows:— "During the last year there have been great alterations in the Staff and working of the Department at Southey Hall. Owing to the resignation of Nurse Walker, one of our most able nurses, a vacancy was created which it was decided not to fill. The work for the preparation of Medical Inspection and attendance with the Medical Officer at the schools was taken over for the most part by the three Health Visitors, Miss Hulse, Miss Giles, and Miss Hurst. The work was arranged as follows:— Miss Hulse, Central, Cottenham Park and Dundonald Road Schools. Miss Giles, Wimbledon Park and Pelham Road Schools, Miss Hurst, Queen's Road and Effra Road Schools, 59 the remaining schools, Haydons Road and Russell Road, were retained by Nurse Holman, who also has entire charge of all Clinic work. Medical Inspection. Age Groups inspected:—During the year, all new entrants to school, children of 8 and 9 years, Intermediates, and children of 12 and 13 years, Leavers, have been inspected. Notifications, formerly sent by the Head Teachers, to parents whose children were subjected to Routine Medical Inspection were sent by the clerk. Friendly co-operation has existed between the teachers and Medical Staff, and endeavour has been made to carry on the work of improving the physical and mental development of the children. The Assistant School Medical Officer has attended the Clinic at Southey Hall every morning and has seen all cases sent by the teachers or by the parents before going up to inspect the schools. At the Clinic, parents have attended in large numbers and children found to have serious defects have been referred either to their own doctors or to a hospital. (a) Uncleanliness. The examination of uncleanliness at the schools has been wholly taken over by Mrs. Potts, who examines the schools in rotation and attends the Clinic three mornings a week for the purpose of treating necessitous cases who cannot be attended to at home. Children suffering from scabies have also been bathed and treated. Treatment of Uncleanliness. Table IV. Group V. (b) Minor Ailments. Table IV. Group I. There have been 5,027 attendances at the Petty Ailments Clinic held each morning at Southey Hall. Numbers. Total Attendances. Average Attendance. Impetigo 215 1219 5.67 Scabies 27 256 9.48 Ringworms—Head 11 164 14.91 Body 51 227 4.45 Minor Injuries 140 742 5.3 Septic Sores, etc 266 1389 5.22 Otorrhœa 72 391 5.43 Blepharitis and Conjunctivitis 79 206 2.61 Total 861 4594 60 (c) Tonsils and Adenoids. Table IV. Group III. The severe eases requiring operation were treated at the two local hospitals, Nelson Hospital and Copse Hill Hospital, and arrangements were made for the children to remain in hospital for one or two days after the operation. Slight cases, not requiring treatment, were kept under observation at the Schools and at the Clinic. For the children sent to hospital a charge is made for the operation according to the means of the parents, and the balance is defrayed by the Education Committee. Number of cases treated at the hospitals 46 „ „ „ privately 4 „ „ „ „ outstanding at the end of the year 56 In many cases it has been necessary to remove septic teeth previous to operation. These have been referred to the Dental Department and dealt with there. (d) Tuberculosis. Suspicious cases, not already under observation, were referred to the Tuberculosis Officer, who treated them and kept them, under close observation for some time. After treatment at the Dispensary, some cases were returned to the School Clinic whero they were still kept under observation. The slight glandular cases were kept under observation at the School Clinic. Number of cases of Bronchitis which were attended to at Southey Hall 32 Average attendance per case 3.28 During the year there were 926 atendances at the Special Inspection Clinic held on Tuesday afternoon. (e) Skin Diseases. Table IV. Group I. (f and g) Eye Diseases. Table IV. Group II. Serious cases of external eye disease were either referred to the special hospitals or to their own doctor. Such cases as mild conjunctivitis and blepharitis were treated at the Clinic. During the year under review Dr. Cowie examined 228 children, of whom 219 had glasses provided. Dr. Cowie, M.B., C.M., reports as follows:— Defects. Number of cases, Myopia 20 Hypermetropia 18 Astigmatism 52 Compound Astigmatism 116 Mixed Astigmatism 13 Total 219 (signed) GEORGE COWIE, Oculist. 61 (h) Ear Diseases. Table IV. Group I. Out of 82 cases referred, 71 received treatment at the Clinic and four were treated privately. Employment Certificates. The children were only employed in accordance with the Byelaws under the Employment of Children Act, 1903, as amended by Section 13 of the Education Act, 1913. Employment certificates were given in 68 cases. The children examined were between 12 and 14 years. During the last year only one child had to have his Employment certificate cancelled on account of ill health." Report of School Surgeon Dentist. Mr. A. MacGregor Whyte, L.D.S., reports as follows:— "The Routine Inspection of children in all Elementary Schools was completed towards the end of November. At the Special School, all children in attendance were inspected and treatment offered where necessary, instead of Routine Age Groups only. The Routine Age Groups for Inspection in school have now been increased to include all ages under 10 years, and selected cases aged 10 years who obtained treatment during previous years. Inspection and Treatment of older age groups are available at Clinic daily at 11 a.m., the treatment being limited to extraction of teeth and other simple operations. Recommendations to Private Practitioners and Dental Hospitals are given where extensive filling, regulation or denture work is necessary. Subsequent investigation indicates that in most of these cases the treament has been duly obtained. Attendances of parents and guardians, both at School Inspection and the 11 o'clock Clinic for consultation and advice, have greatly increased, and much additional time has been spent, but as a result there is a marked improvement in attendance and regularity of revisiting the Clinic by the children. Parents seem also to be more interested in and appreciative of the treatment carried out. Thirty-eight afternoon sessions were devoted to Inspection at the schools. Of 2,486 children inspected, 1,942 (78 per cent.) were notified as Dentally Defective, 22 per cent. being free from caries or not requiring Dental treatment. These figures indicate a decrease of 8 per cent. on the Dentally Defective Index Figure of the preceeding year. 214 children found defective and notified, await offer of treatment during 1924. This delay is unavoidable owing to the annual increase in the number of children to be inspected, the scheme being to retain the older groups in addition to' new entrants. 62 This can only be maintained if further dental assistance is given as the work increases. 69 per cent. of the children offered appointments for treatment, attended Clinic and were treated, indicating a 10 per cent. increase on previous year. The total number of children (all ages) inspected at school and at the Clinic, was 2,736, treatment being recommended to 2,192. 1,438 (65.6 per cent.) children received treatment at the Clinic during the year, necessitating 2,719 attendances, 232 children treated being over 10 years of age. As the result of treatment, 1,194 children were rendered Dentally sound. Dr. Scott administered Nitrous Oxide Gas for 310 cases requiring extraction of teeth; in all other cases local anaesthetic was employed when practicable. 2,154 temporary and 203 permanent teeth were extracted. Many cases referred by the Medical Staff for multiple extraction of teeth as preliminary treatment before operations for Enlarged Tonsils and Adenoids were found unsuitable for general anæsthesia owing to respiratory difficulty. 803 temporary and 777 permanent teeth were filled, the total number of fillings being 2,007. There is little or no indication at School Inspection of treatment other than extraction of teeth being obtained privately in cases where Clinic Treatment is regularly refused. This may be due partly to reluctance and inability on the part of Private Practitioners, other than Surgeon Dentists, to perform conservative operations, and partly due to the cost of the treatment. Every advantage is taken of all available opportunities for propaganda work, emphasising the importance of oral hygiene, suitable diet, correct breathing, etc. A steady improvement is noticeable at the School Inspections, but the serviceable toothbrush is too 'dear a commodity for many of the poorer classes with large families, and that abomination, the family toothbrush still persists. This menace can only be combated by supplying at Schools and Clinics a suitable brush at cost price to selected cases. No expense need be incurred, and the price at cost would be within the means of most. At the Special School each child is provided with a tooth-brush, and tooth-brush drill is carried out each day under supervision. This is a highly commendable practice and the advantages are self-evident. In conclusion, it should be mentioned that Kolynos and Pepsodent manufacturers have been very generous with samples of dentifrice. These have been distributed at the various Clinics and highly appreciated." Exceptional Children in Wimbledon Schools. At the end of my Annual Report for 1922, I stated that I would make in 1923 a special census of all exceptional 63 dren attending the public elementary schools. My object in so doing was to ascertain the necessity or otherwise for the provision of special schools. The Wimbledon Education Committee in 1905 established a school for mentally defective children, but there are no special schools for physically defective children, for children suffering from Tuberculosis ("openair") schools, for debilitated children and those recovering from serious illness ("recovery" schools), or for children falling within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893. The object (as stated above) of making this census, and the method in which it was carried out must be carefully borne in mind in reading this section of my Report. I asked the Head Teachers to prepare a list of all abnormal children who, in their opinion, would be suitable for such special schools, if provided. I then visited the classrooms and picked out such of the scholars as appeared to be " below par." No strict medical examination was made of the scholars selected by the teachers and myself, but enquiry was confined to present health, previous illnesses, home conditions, and scholastic attainments. The results can only be regarded as approximately correct for the purpose stated and must not be accepted as accurate figures for the conditions specified. It might be considered that more accurate results would be obtained from the scholars' medical record cards or from the cards at the "Inspection" Clinic. The former, however, only note the results,of " routine " inspection carried out every three years, and old defects have been cured, or new defects may have arisen, since the examination was carried out; the latter records are of children under actual observation at the Clinic, and children under treatment by the family doctor, or suffering from chronic defects requiring no treatment at all, would consequently be overlooked. Results of Special Census. 48 children were noted as having been under observation or treatment during the previous twelve months for Tuberculous conditions (Chest, 38; Bones and Joints, 5; Glands, 5; Lupus, 1). The great majority of the chest cases had been '' under observation only '' at the Tuberculosis Dispensary. 66 children suffered from "Nervous Conditions." Of these 66, 24 had Infantile Paralysis of the legs or arms or both; 9 suffered from Chorea; 18 were stated to have " epileptiform " seizures and 15 were classed under the general term, "nervous." It was interesting to note that all who required special treatment, or special mechanical supports, had obtained such. Practically none of the epileptics had had seizures in school, the attacks being infrequent and usually occurring at night. 86 other scholars were noted. Of these, 23 were characterised as "delicate" children, 13 had serious "cardiac" 64 trouble, 13 had deformities of the spine, and the remainder had congenital malformations or serious defects of the special senses and of speech. The children classified as dull or backward and mentally defective are dealt with under that heading. The necessity for Special Schools is, however, not governed by actual numbers. In the case of physically defective children, for example, other factors must be considered. The nature of the defect, the need for special treatment, the effect of the effort on the child to "keep up with" normal children in ordinary schools, the home environment, more especially diet, the distance to and from school, the means of conveyance, must all be weighed. In the case of Tuberculous children, the question of "infection" enters, and in Chorea, the danger of imitation. Having carefully considered all such points I am of opinion that a Special School or Class for Physically Defective children is not at present required. Blind or partially blind, deaf or partially deaf, children coming within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893, are best dealt with as at present, by sending to Special Institutions. In regard to "Recovery" Schools further consideration is still necessary. There are undoubtedly many children who would benefit by some such school, but actual numbers must be more accurately gauged. In some cases the return of children to ordinary schools after illness is hastened too much, and. in others again, there is unnecessary delay. If such a school were formed, children "under observation" might be admitted for six months or a year. Mentally Defective Children. A. General Report. In submitting the following report, I desire to emphasise that I have endeavoured to approach the question of mentally 'defectives in the school population in as unbiassed a manner as possible, and that the results are my own personal findings. In judging Mental Deficiency, the personal equation of the examiner must always enter. Some Medical Officers place reliance on educational tests, others again rely on physiological standards, and some are influenced by the child's general demeanour and behaviour. The definitions of Mental Deficiency under the different Acts allow for considerable latitude. In the Mental Deficiency Act, 1923, the following definitions are given :— "(b) Imbeciles; that is to say, persons in whose case there exists from birth or from an early age 65 mental defectiveness not amounting to idiocy, yet so pronounced that they are incapable of managing themselves or their affairs, or, in the case of children, of being taught to do so. (c) Feeble-minded persons; that is to say, persons in whose case there exists from birth or from an early age mental defectiveness not amounting to imbecility, yet so pronounced that they require care, supervision, or control for their own protection or for the protection of others, or, in the case of children, that they by reason of such defectiveness appear to be permanently incapable of receiving proper benefit from instruction in ordinary schools." Under the Elementary Education (Defective and Epileptic Children) Acts, 1899 and 1914, a School Authority shall make arrangements for ascertaining, and providing education for, " (a) What children in their district, not being imbecile, and not being merely dull or backward, are defective, that is to say, what children by reason of mental or physical defect are incapable of receiving proper benefit from instruction in the ordinary public elementary schools, but are not incapable by reason of such defect of receiving benefit from instruction in such special classes or schools as are in this Act mentioned." The Board of Education by a circular letter to Education Authorities, by the Mental Deficiency (Notification of Children) Regulations, 1914, and by the Revised Model Arrangements of 31st August, 1914, gives further instructions as to the administration of these different Acts. It is recognised, for example, that certain low-grade feeble-minded children are practically incapable of profiting by instruction in a special school, "but such children should be given an adequate trial under suitable instruction in a Special School, in order that it may be ascertained by actual experience whether they are in fact incapable of profiting by instruction in such a School." In the same way, the Board are careful to safeguard against a child being certified without adequate trial as being "incapable of being instructed in a Special School without detriment to the other children" or by reason of "uncleanlv habits." Two other points should be noted, both having a bearing on this special investigation. In the Revised Model Arrangements, Sec. 2, "The Head Teacher of every Public Elementary School shall bring to the notice of the Local Education Authority any children attending the school who appear, by reason of mental defect, to be incapable of receiving proper benefit from the 66 struction in an ordinary Elementary School." The second point is that in the Certificate of the Certifying Medical Officer (Schedule A), the word " proper " before benefit is omitted. I have entered into the above detail in order that the duties and difficulties may be clearly understood. On taking over charge of the Queen's Road Special School for Mentally Defectives, I found that the numbers were below what might have been expected. Usually, a proportion of 1 per cent. of the school population is considered to be mentally defective, but my experience in other areas had led me to believe that the number was slightly less. If my estimate were correct, the numbers should have been between 50-60 children as against the 43 on the school roll. It followed then either that Wimbledon had an especially low ratio or that, for some reason, cases had not been notified. It was for this reason that I adopted a new procedure. I sent a preliminary notice to all Head Teachers asking them to prepare lists of all exceptional children under their charge. Mr. Bellman, Chief Attendance Officer, also prepared a list of abnormal children coining within his purview, to which I asked him to add the names of brothers and sisters of pupils already in the Special School, and children from "troublesome" families. I then visited each school and inspected each class separately. During the inspections I learned that no estimate could be accurately made from the "age-average" of the class, because in some cases the children were automatically promoted from class to class, and in others, "because they were too big physically for the class of their mental standard." The names of all children two or more years backward were noted, and the medical and family history, scholastic progress, etc., were discussed by the Head Teacher, the Class Teacher and myself. The "Special" lists were checked in each school. A second round of all the schools was then made to check the results, to classify doubtful cases as far as possible, and to pass definite cases into the Special School. A third round was made in November to examine new cases and receive progress notes. In addition to these children I received the names of 9 others who had never attended school, but who had received temporary exemption by Medical Certificate for "Mental Instability" or similar reason. These children were subsequently visited in their homes. Summarising the results of those three visits to schools, the children were classified as follows:— Dull or backward 188 Doubtful or "Border-line" cases 45 Mentally Defective 23 Total 256 67 Dull or Backward Children. Among the 188 children grouped as dull or backward, the condition in 27 could be definitely attributed to severe illness. In 30, bad or irregular atendance probably played some part and in others, malnutrition and poor environment. For the education of such backward children, no definite scheme has been adopted in the Wimbledon Schools. In some departments, where accommodation permits, a separate backward class is formed; in other departments each class is subdivided into a normal and a backward group, and in other schools again special individual coaching is given to such pupils by Head Teachers and Class Teachers. I desire to express my appreciation of the work done by all teachers for these pupils, and that the parents also appreciate it is evidenced by the fact that many desire their children to remain in school after attaining the ''leaving age.'' At the last examination at the end of the year those who were still in school had all made some progress educationally. Where the backwardness had been due to illness, the progress was rapid in the majority of cases. Doubtful or "Border-line" Children. The problem presented by this group of children is one of great difficulty both to the teacher and to the Medical Officer. It is absolutely impossible in many cases to state with any certainty how such children should be classified even after close observation, and many points must be carefully weighed before a decision is given. Take, for example, the standpoint of the Head Teacher who is in doubt whether he should call the attention of the Medical Officer to some child who is making little or no progress educationally. He knows the parents (perhaps taught them himself) and he has had the other children of the same family through his hands. There is nothing to account for the child's backwardness, his behaviour is correct, and his " intelligence " apparently is good. Similar children in school have, after some years, "made a spurt, and competition with normal children proves a stimulus." So he decides that the boy should not be reported, for he is deriving "benefit" from the school though accurately, not "proper benefit." So the boy remains in school, a drag to the class and a trial to the class teacher. His progress from class to class is automatic, he gives no trouble by his behaviour, he learns little of future value to him, and leaves probably to join the ranks of unskilled labour. Such children are sometimes termed "social inefficients." On the other hand, the same boy is discovered by the School Medical Officer, the facts are elicited, and finally one on other of the systems of Intelligence Tests is applied. By such tests it is proved that he is below normal, but does not quite 68 fall into the category of mentally defective. Two courses are now open to the Medical Officer—to leave him where he is, or to pass him into some Special School or Class. In the former case he progresses as above but he may develop what is known to psychologists as an "inferiority complex," with consequent deterioration of his character; in the latter he may be trained to follow some useful trade or occupation. Uudoubtedly, such children do remarkably well in residential institutions and even in day schools, but is it correct to give them even the temporary stigma of mental deficiency? Each child must be judged on his own merits and under the present system of education there is undoubtedly a loss. Of the 45 children judged "border-line" cases the great majority will remain in the public elementary schools. Is there any other solution? I would advise the Wimbledon Education Authority to consider the question of establishing two classes for such children in two centrally placed schools (say Dundonald and Queen's Road). Such classes would be under the Head Teacher of the schools selected, but would be equipped on the lines of a Special School and taught by specially trained teachers. The scholars would be directly under the supervision of the Medical Officer, and frequent re-examinations would be carried out for more accurate re-grading. The formation of such classes would undoubtedly be advantageous to scholars and teachers, would be welcomed by parents, and would simplify the work of the Medical Officer. It should be noted that Wimbledon abounds with small private schools, and it frequently happens that a parent, 011 receiving a hint that his child will be tested for the Special School, withdraws his child from the public elementary school and places him in a private school over which the Authority has no jurisdiction. Two cases of this nature have occurred in the last year. I also discovered that one child had been withdrawn from and subsequently re-admitted to an elementary school on change of Teacher or Medical Officer, while a second, certified as "uneducable" had been enrolled in an ordinary school without the parent divulging the fact that the child had been previously examined and certified by the Medical Officer. Mentally Defective Children. Of the 23 children who were placed in this category, 12 were "high grade" the majority of whom were within a few months of leaving school. In all, the behaviour was satisfactory and nothing was to be gained by passing them into the Special School. The presence of these 12 would indicate that under strict supervision the numbers in the Special School should have been higher in previous years, but no negligence can be attributed to Medical Officers or Teachers. The 69 ity of these children would have been discovered if the routine work of medical inspection had not been disturbed by the war. The following table shows the number of children admitted each year from 1912 onwards. Numbers 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 Admitted 27 24 10 18 7 13 9 14 9 8 7 17 In 1912, the results of routine medical inspection with a full-time staff were just beginning to show; from 1916-19 parttime officers were in charge, and during 1920-22 there were changes of Medical Officers, including assistants. It is improbable that the numbers of mentally defective children born will show much variation from year to year, and in that case, taking an estimate of 60-70 children in the area the admissions should be between 6 and 10 annually. At the present time 59 children between 7 and 16 years are actually known in the Wimbledon area to be receiving education suitable for ment.allv defectives Their ages are as follows:— Age Periods. 7 8 9 10 11 12 13 14 15 Total. Boys 1 4 7 8 4 8 2 2 2 38 Girls 0 1 1 2 5 3 5 3 1 21 Totals 1 5 8 10 9 11 7 5 3 59 Of the above children, 3 attend private schools, 3 have been transferred to other schools or institutions, and 6 of the senior boys attend Littleton Road School of the L.C.C. This table definitely confirms the shortage among scholars of 13, 14, and 15 years of age, and if the 12 mentioned above were added, the estimate would probably be correct. These children were probably overlooked during the rush of war years. Children below 7 years of age are also known, but it is almost impossible to persuade parents to allow them to attend the Special School. The difficulty of children travelling to and from schools has to be considered, and the majority of parents beg that the children should first be permitted a trial in the nearest elementary school. Most mentally defectives show little outward evidence of their infirmity and their actual scholastic work and intelligence cannot be adequately grouped under 7 years of age. Why there should be such marked difference between the number of boys and girls, I am unable to state, but, of 14 children (between the ages of 7 and 9 years) at present under observation, 7 are boys and 7 girls. 70 Summary of Census. Taking the above facts into consideration it would appear as if the number of mentally defective children in the Wimbledon area is probably between 50-60. If, however, no Special Backward Classes are formed, and "border-line" cases are passed directly into the Special School, the numbers may rise to 70. Under the new system all abnormal scholars have been "card-indexed" and their progress will be carefully watched. Frequent re-examinations and tests will also be made, more especially about the time the scholars should be leaving the Infant Departments. B. Queen's Road Special School. Owing to the time occupied in making the above census, I was unable to devote as much time as I desired to the examination of the children within this School. The children were, however, all examined physically, and treatment was given when defects were discovered. The School Surgeon Dentist makes a special note on the scholars of this school in his Report (P) During the year, arrangements were made whereby Mrs. Potts, the Cleansing Attendant, gave two morning sessions of her time to superintend the bathing of the children. A full Report of the educational and manual training given in this school was detailed in my Annual Report for 1922. During 1924, the training in manual work will be extended. Miss Clarke, the Headmistress, carried out in December, 1923, the Binet-Simon tests (Stanford Revision) on all the scholars in the school. The results were most interesting. Of the 48 children examined, the great majority had an Intelligence Quotient denoting true mental deficiency. The Intelligence Quotient (often designated I.Q.) is the ratio of mental age to chronological age, and an I.Q. of 80-90 is classified usually as dullness, 70-80 as "Border-line" deficiency, below 70 definite feeble-mindedness. During the year, 13, boys and 4 girls were admitted, and 2 boys and 1 girl re-admitted, and 10 boys (6 transfers) and 2 girls left. Of the 10 boys leaving—6 were transferred to Littleton Road School, L.C.C. 1 left district. 1 transferred to ordinary elementary school. 2 attained 16 years of age. Of the two girls leaving—1 attained 16 years of age. 1 ill health (temporary removal). 71 Of these 10, one girl was reported to the Board of Control; one boy obtained employment as a gardener, and one boy is "cobbling" at home. My medical work at this School has been a matter of some difficulty owing to the fact that my duties, as Medical Officer of Health and as Medical Superintendent at the Isolation Hospital, in some instances prevent stated hours being kept. For this reason I have asked the Wimbledon Education Committee to approach the Board of Education with a view to sanctioning the appointment of my Assistant as Certifying Officer under the Acts. The actual examinations in school could thus be conducted with regularity and the supervision of the scholars would be more thorough. In conclusion I desire to thank all Head Teachers and Teachers who have given their cordial assistance in a year when reconstruction of medical work caused some disturbance of routine. I have the honour to be, Your obedient servant, A. GILMOUR, School Medical Officer. 72 MEDICAL INSPECTION RETURNS. TABLE I. RETURN OF MEDICAL INSPECTIONS. A.—ROUTINE MEDICAL INSPECTIONS Number of Code Group Inspections:— Entrants 580 Intermediates 333 Leavers 508 Total 1,421 Number of other Routine Inspections — B.—OTHER INSPECTIONS. Number of Special Inspections 1,874 Number of Re-Inspections 1,419 Total 3,293 73 TABLE II. A.—RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDING 31ST DECEMBER 1923. DEFECT OR DISEASE Routine Inspection. Special Inspection. No. of Defects. No. of Defects. Requiring Treatment. Requiring to be kept under observation but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation but not requiring Treatment. (1) (2) (3) (4) (5) Malnutrition 1 - - - Uncleanliness (See Table IV., Group V.) - - - - Skin Ringworms—Scalp - - 19 3 Body - - 54 2 Scabies 1 - 30 - Impetigo 1 - 216 2 Other Diseases (Non-Tuberculous 1 275 8 Eye -i Blepharitis - 1 39 1 Conjunctivitis - - 31 - Keratitis - - - - Corneal Opacities - - - - Defective Vision (excluding Squint 62 68 199 1 Squint 2 2 12 - Other Conditions - - 17 - Ear Defective Hearing 2 2 15 2 Otitis Media 1 1 45 1 Other Ear Diseases - - 19 1 Nose and Throat Enlarged Tonsils only 20 57 27 4 Adenoids only 1 4 12 1 Enlarged Tonsils and Adenoids 15 19 31 1 Other Conditions - 2 4 110 Enlarged Cervical Glands (Non-Tuberculous) - 4 14 13 Defective Speech - - 2 - Teeth—Dental Diseases (See Table IV., Group IV.) - - 15 - Heart and Circulation Heart Diseases: - - - - Organic - - 1 13 Functional - 7 - 7 Anaemia - 2 6 6 74 TABLE II.—continued. DEFECT OR DISEASE. Routine Inspections. Special Inspections. No of Defects, No. of Defects. Requiring Treatment. Requiring to be kept under observation but not requiring Treatment. Requiring Treatment. Requiring to be kept under observation but not requiring Treatment. (1) (2) (3) (4) (5) Lung Bronchitis 1 16 9 16 Other Non-Tuberculous Diseases — — — — Tuberculosis Pulmonary Definite — — — — Suspected 2 — 4 1 Non-Pulmonary: Glands — — 2 — Spine — — — — Hip — — — — Other Bones and Joints 1 1 1 — Skin — — — — Other Forms — — 1 — Nervous System Epilepsy — — — 3 Chorea — 1 4 7 Other Conditions — — 1 5 Deformities Rickets — 1 — — Spinal Curvature — 1 2 — Other Forms — 1 7 2 Other Defects and Diseases 1 23 304 179 1.—NUMBER OF INDIVIDUAL CHILDREN FOUND AT ROUTINE MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEANLINESS AND DENTAL DISEASES). GROUP. Number Children. Inspected Found to require Treatment. of Children found to require Treatment, (1) (2) (3) (4) Code Groups: These figures cannot be given for 1923, owing to the way in which the Records were kept. Entrants Intermediates Leavers Total (Code Groups) 1421 115 12.35 Other Routine Inspections — — — 75 TABLE III NUMERICAL RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA IN ]923. Boys. Girls. Total. Blind (including partially blind.) (i.) Suitable for training in a School or Class for the totally blind. Attending C e r t i fi e d Schools or Classes for the Blind ... 1 1 Attending Public Elementary Schools ... — At other Institutions... — — — At no School or Institution — — — (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind Attending Public Elementary Schools ... _ At other Institutions... — — — At no School or Institution — — — Deaf (including deaf and dumb and partially deaf.) (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the deaf. 2 2 ' i Attending Public Elementary Schools ... _ At other Institutions... — — At no School or Institution — — ' — (ii.) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the deaf. Attending Public Elementary Schools ... 1 1 At other Institutions... — — — At no School or Institution — — — Mentally Defective. Feeblemin ded (cases not noti fiable to the Local Control Authority.) Attending Certified Schools for Mentally Defective Children.. ■Ai 20 54 Attending Public Elementary Schools ... i 3 7* At other Institutions.. — — — At no School or Institution — — ' — * To be transferred 1924. 76 TABLE III.—Continued. Boys. Girls. Total Mentally Defective contd. Notified to the Local Control Authority during the year Feebleminded — 1 1 Imbeciles — 1 1 Idiots — — — Epileptics Suffering from severe epilepsy Attending Certified Special Schools for Epileptics — 1 1 In Institutions other than Certified Special Schools — — — Attending Public Elementary Schools — — — At no School or Institution — — — Suffering from epilepsy which is not severe. Attending Public Elementary Schools 8 10 18 At no School or Institution — — — Physically Defective Infectious pulmonary and glandular tuberculosis At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At other Institutions — — — At no School or Institution — — — Non-infectious but active pulmonary and glandular tuberculosis At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At Certified Residential Open Air Schools — At Certified Day Open Air Schools — — — At Public Elementary Schools 12 23 35 At other Institutions — — — At no School or Institution — — — 77 TABLE III.—Continued. Boys. Girls. Total Physically Defective continued Delicate children (e.g., pre- or latent tuberculosis, malnutrition, debility, etc.) At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — At Public Elementary Schools 10 13 23 At other Institutions. — — — At no School or Institution — — — Active non- pulmonary tuberculosis At Sanatoria or Hospital School approved by the Ministry of Health or the Board — — — At Public Elementary Schools 3 4 7 At other Institutions — — — At no School or Institution — — — Crippled Children (other than those with active tub erculous disease), e.g., children suffering from paralysis, etc., and including those with severe heart disease At Certified Hospital Schools 1 — 1 At Certified Residential Cripple Schools — 1 1 At Certified Day Cripple Schools — — — At Public Elementary Schools 24 27 51 At other Institutions — — — At no School or Institution 1* — 1 *Awaiting admission. 78 TABLE IV.—RETURN OP DEFECTS TREATED DURING THE YEAR ENDING 31ST DECEMBER 1923. TREATMENT TABLE. GROUP I.—Minor Ailments (excluding Uncleanliness, for which see Group V.). disease or defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme Otherwise. Total, (1) (2) (3) (4) Skin— Ringworm—Scalp 6 13 19 Body 51 3 54 Scabies 27 4 31 Impetigo 215 1 216 Other skin disease 266 9 275 Minor Eye Defects— 79 4 83 (External and other, but excluding cases falling in Group II.) Minor Ear Defects 71 3 74 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 235 5 240 Total 950 42 992 GROUP II.—defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). DEFECT or DISEASE. Number of Defects dealt with. Under the Authority's Scheme Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme. Otherwise. Total. (1) (2) (3) (4) (5) Errors of refraction (including Squint). 228 4 — 232 Other Defects or Disease of the Eyes (excluding those recorded in Group I.) — — — — Total 228 4 — 232 Total number of children for whom spectacles were prescribed:— a. Under the Authority's Scheme 219 b. Otherwise — Total number of children who obtained or received spectacles— a. Under the Authority's Scheme 219 b. Otherwise — 79 TABLE IV.—continued. GROUP III.—TREATMENT OP DEFECTS OP NOSE AND THROAT. NUMBER OF DEFECTS. Received Operative Treatment. Received other forms of Treatment. Total number Treated. Under the Authority's Schema, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (i) (2) (3) (4) (5) 46 4 50 4 54 GROUP IV.—DENTAL DEFECTS. 1. Number of Children who were:— a. Inspected by the Dentist. Aged Aged Routine Age Groups 5 179 10 339 Total 2486 6 413 11 9 7 597 12 7 8 602 13 5 9 332 14 3 Specials 250 Grand Total 2736 b. Found to require Treatment 2192 c. Actually Treated 1438 d. Re-treated during the year as the result of periodical examination 750 2. Half-days devoted to:— Inspection, 38. Treatment, 336 Total 374 3. Attendances made by Children for Treatment 2719 4. Fillings:— Permanent Teeth,777. Temporary Teeth, 803 Total 2007 5. Extractions:— Permanent Teeth,203. Temporary Teeth,2154 Total 2357 6. Administrations of general anaesthetics for extractions 310 7. Other Operations:— Permanent Teeth,1281 Temporary Teeth,103 Total 2311 GROUP V.—UNCLEANLINESS AND VERMINOUS CONDITION. 5 Average number of visits per school made during the year by the School Nurses 12 ii Total number of examinations of children in the Schools by School Nurses 39747 iii. Number of individual children found unclean '-'41 iv. Number of children cleansed under arrangements made by the Local Education Authority 141 v. Number of cases in which legal proceedings were taken:— a. Under the Education Act, 1921 — 6. Under School Attendance Bvelaws 3 80