C.I. AC 448(1) Wimbledon Borough of Wimbledon Annual Report of the MEDICAL OFFICER OF HEALTH For the Year 1933 Together with the Report of THE SCHOOL MEDICAL OFFICER and of THE SANITARY INSPECTOR Borough of Wimbledon Wima ANNUAL REPORT of the Medical Officer of Health for the Year ended 31st December, 1933 Public Health Committee Chairman: Councillor E. Fielder. Vice-Chairman: Councillor Miss D. H. Carver. Members: The MAYOR (Councillor J. W. Ramshaw, J.P.), ex-officio. Alderman A. W. Hickmott Councillor W. B. James. Councillor F. T. Bowen. „ A. R. Kelly. „ B. J. Chard. „ Lady Roney. „ H. A. Crowe, O.B.E. „ S. B. Stone. A. A. Drake. „ J. W. Wyles. Maternity and Child Welfare Committee Chairman: Councillor Lady Roney. Vice-Chairman: Councillor A. A. Drake. Members: The MAYOR (Councillor J. W. Ramshaw, J.P.), ex-officio. Alderman A. W. Hickmott. Councillor E. Fielder. Councillor F. T. Bowen. „ T. E. Jenner. Miss D. H. Carver. Mr. G. Edwardes-Jones, K.C. „ T. R. Daniel. Mrs. Chard. „ Daniel. „ Fielder. „ Sheerman. STAFF Whole-Time : Medical Officer of Health; School Medical Officer; Medical Superintendent of the Infectious Diseases Hospital; Maternity and Child Welfare Officer: ‡ * Harold Ellis, M.B., B.S.(Lond.), M.R.C.S., L.R.C.P., D.P.H. Assistant Medical Officer of Health, Assistant School Medical Officer: ‡ Effie M. D. Craig, M.B., Ch.B. Chief Sanitary Inspector: * Henry Johnson, M.B.E., F.R.San.I., F.S.I.A., (g), (h). Sanitary Inspector: * R. T. Avis, M.R.San.I., M.S.I.A., (d), (g), (h). Assistant Sanitary Inspector: D. F. S. Flynn, (g), (h). Health Visitors—School Nurses: Miss M. Giles, (b), (d), (/), (resigned 31st March, 1933). Miss E. M. Skelton, (a), (b), (f), (resigned 15th May, 1933). Miss H. A. Blackburn, (a), (b), (c), (e), (g), (resigned 31st May, 1933). Miss V. B. Woodroff, (b), (d), (i), (appointed 1st March, 1933). Miss C. Hughes, (a), (b), (e), (appointed 1st June, 1933). Miss A. Thompson, (a), (b), (e), (appointed 1st July, 1933). Senior Cleric: A. L. Taylor. Clerks: R, L. Brown. H. R. Fry. Clerk to the Maternity and Child Welfare Department: A. L. Taylor. Matron of Isolation Hospital: Miss L. McCrory. Matron of Day Nursery: Miss I. Cutler. Part-Time: Dan McKenzie, M.D., F.R.C.S., Consulting Oto-Laryngologist to Infectious Diseases Hospital. R. W. Butler, M.Ch., F.R.C.S., Orthopiedic Surgeon. A. McAllister, F.R.C.S., Consulting Obstetrician under Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1986. Col. E. Middleton Perry, C.B.E., F.R.C.V.S., Veterinary Inspector. J. H. Johnston, M.Sc., L.S.A., Bacteriologist. * Salary contribution under Public Health Acts. ‡ „ „ by Exchequer Grants. a. S.R.N. b. C.M.B. c. Certificate Fever Training. d. Certificate Sanitary Inspectors Examination Board (London). e. New Health Visitor's Certificate, Royal Sanitary Institute. f. Health Visitor's Certificate Royal Sanitary Institute. g. Certificate Royal Sanitary Institute for Inspector of Nuisances. h. Certificate Royal Sanitary Institute for Inspector of Meat & Other Foods. i. Diploma Board of Education (Health Visitors' Training) Regulations, 1919. Borough of Wimblebon Public Health Department ANNUAL REPORT of the Medical Officer of Health for the Year ended 31st December, 1933 To the Mayor, Aldermen, and Councillors of the Borough of Wimbledon. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit the Annual Report on the work of the Public Health Department for the year ending 31st December, 1933, together with my Report as School Medical Officer. The Report for 1933 is an ordinary Report, set out on the lines suggested in Circular 1346 of the Ministry of Health. Examination of Employees.—During the year 1933, one hundred and thirty-two employees were medically examined by the Medical Officer of Health. In addition thirty-three candidates were medically examined for superannuated posts Under the Wimbledon Borough Council. 3 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres—Census, 1931) 3,221 Population (Census, 1931) 59,524 Population (Estimated, 1933, R.G.) 58,770 Number of inhabited houses:— 1921 (Census) 11,926 1931 (Census) 13,325 1933 (According to Rate Books) 14,200 Number of families or separate occupiers:— 1921 (Census) 13,998 1931 (Census) 15,883 Rateable Value:—£709,618. Sum represented by a penny rate:—£2,956. Social Conditions.—Wimbledon is one of the suburbs on the outer ring, and may be regarded mainly as a dormitory for workers in London. A great many of these are engaged in professional and commercial occupations. Wimbledon is fortunate in possessing such beautiful open spaces as The Common, and Wimbledon Park. These not only make the Borough most attractive from a residential point of view, but also contribute, to a large extent, towards the excellent health enjoyed by the inhabitants. There is no doubt that it is one of the most healthy districts in London. In the southern part of the Borough there are a number of factories and workshops. Three hundred and fifty-one premises are registered under the Factory and Workshop Acts. For the most part these premises are small. There are twenty-two laundries registered in the district, employing a large number of women. In addition, there are leather works, gas mantle works, tool and file works, and a railway stock and repair depot, which employ a considerable number of people. 4 These works cannot be said to exert any particular influence on the public health of the district. The figures for unemployment amongst Wimbledon residents registered at the Employment Exchange show a decrease of three hundred and thirty-three as compared with those at the same period in 1932. The following table shows the position with regard to unemployment for the past three years:— Classification. 31st December, 1931. 31st December, 1932. 31st December, 1933. Male Adults 1,266 1,434 1,248 Male Juveniles 34 78 23 Female Adults 253 273 230 Female Juveniles 36 56 7 Totals 1,589 1,841 1,508 Extracts from Vital Statistics of the Year 1933. (Registrar-General's Figures). Total. M. F. Legitimate ... 572 301 271 Live Births Illegitiment 30 15 15 Birth Rate per 1,000 of the estimated resident population 10.24. Stillbirths 17 10 7 Rate per 1,000 total (live and still) births 27.46 Deaths 636 285 351 Death Rate per 1,000 of the estimated resident population 10.82 Percentage of Total Deaths occurring in Hospitals and similar Institutions 41.51 5 Deaths from puerperal causes (Headings 29 and 30 of the Registrar-General's Short List):— Deaths. Rate per 1,000 total (live & still) births. No. 29. Puerperal sepsis — ... — No. 30. Other puerperal causes 3 ... 4.84 Total 3 ... 4.84 Death Rate of Infants under one year of age:— All infants per 1,000 live births ... ... 49.83 Legitimate infants per 1,000 legitimate live births ... ... 41.95 Illegitimate infants per 1,000 illegitiment live births ... ... 200.00 Deaths from Measles (all ages) ... ... 1 „ „ Whooping Cough (all ages) ... ... 3 Diarrhoea (under 2 years of ages) ... 2 6 7 BIRTH-RATE, DEATH-RATE, AND ANALYSIS OF MORTALITY DURING THE YEAR 1933. (Provisional Figures). The Rates for England and Wales have been calculated on a population estimated to the middle of 1933, but those for the towns have been calculated on populations estimated to the middle of 1932). Bate per 1000 Total Population Annual Death-rate per 1000 Bopulation Bate per 1000 Live Births Percentage of Total Deaths Live Births Stillbirths All Causes Typhoid and Paratyphoid Fevers Smallpox Measles Scarlet Fever Whooping Cough Diphtheria Influenza Violence Diarrhoea and Enteritis (under two years) Total Deaths under One Year Certified by Registered Medical Practitioners Inquest Cases Certified by Coroner after P.M. No Inquest Uncertified Causes of Death England and Wales 14.4 0.62 12.3 0.01 0.00 0.05 0.02 0.05 0.06 0.57 0.54 7.1 64 90.90 6.30 1.90 0.90 118 County Boroughs and Great Towns, ineluding London 14.4 0.67 12.2 0.00 0.00 0.06 0.02 0.06 0.08 0.55 0.49 9.4 67 91.00 6.00 2 50 0.50 132 Smaller Towns (Estimated Resident Populations, 25,000 to 50,000 at Census 1931) 14.5 0.63 11.0 0.00 0.00 0.04 0.02 0.04 0.04 0.53 0.44 4.9 56 91.70 5.80 1.50 1.00 London 13.2 0.45 12 2 0.00 0.00 0.02 0.02 0.08 0.08 0.51 0.58 11.6 59 88.30 6.30 5.40 0.00 W'dn (Estimated Population 68,770) 10.2 0.28 10.8 0.00 0.00 0.01 0.00 0.05 0.03 0.28 0.61 3.3 49 86.01 12.11 1.88 0.00 Population, Birth, and Death Rates for each Ward in 1933. WARD. Factor. Population. Birth Rate. Death Rate. St. Mary's 4.46 6668 6.74 11.54 St. John's 4.77 5083 6.88 12.39 Cottenham Park 4.33 7433 6.99 11.83 Wimbledon Park 3.88 4404 9.76 10.21 North Wimbledon 4.36 23588 7.41 11.57 Dundonald 5.15 7836 13.91 10.71 Trinity 5.59 11633 11.43 9.97 South Park 4.63 8462 11.34 11.22 Haydon Park 5.47 7251 12.55 9.37 South Wimbledon 5.21 35182 12.19 10.31 Whole District 4.20 58770 10.24 10.82 Births.—The statistics supplied by the Registrar-General show that during 1933 the total number of registered live births belonging to Wimbledon amounted to six hundred and two (three hundred and sixteen males and two hundred and eighty-six females). This gives a birth rate equal to 10.24 per thousand of the population. Thirty (or 4.98 per cent.) of the births were illegitimate. Of this number, fifteen were males and fifteen females. In addition, seventeen stillbirths (ten males and seven females) were registered. The following table gives the birth rates in Wimbledon for the past ten years, together with the comparative figures for England and Wales. In 1923, the birth rate in Wimbledon was 14.9. Since that year the figure has been steadily falling. For the third year in succession the birth rate in the Borough is slightly lower than the death rate. 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Wimbledon: Number of Births 814 760 807 717 691 759 766 642 667 602 Birth Rate 14.01 13.06 13.9 12.3 11.6 12.7 12.9 10.9 11.2 10.2 Birth Rate for England & Wales 18.8 18.3 17.8 16.7 16.7 16.3 16.3 15.8 15.3 14.4 8 Notification of Births Acts, 1907 and 1915. During the year, six hundred and fifteen births were notified by the following persons:— Parents 12 Midwives 277 Doctors 42 Other persons 284 Total 615 Seventeen of these notifications were in respect of stillbirths. Of the six hundred and fifteen notifications, two hundred and fifty-nine were received from Medical Officers of Health of outside areas, and related to births which had occurred to Wimbledon residents confined outside the Borough. Similarly, forty-five confinements occurred in Wimbledon amongst women whose homes were situated in other districts. The net number of notified births belonging to Wimbledon is therefore five hundred and seventy. During the past few years, special attention has been paid by the Public Health Department to the prompt notification of births occurring in Wimbledon. It is gratifying to report that with very few exceptions the requirements of the Notification of Births Acts are now being complied with. Deaths.—The total number of deaths registered in the district was four hundred and sixty-six (one hundred and ninety-seven males and two hundred and sixty-nine females), equal to a death rate of 7.92 per thousand of the population per annum. The deaths occurring outside the district, of persons belonging to this Borough, were two hundred and thirty-two, namely:— Kingston and District Joint Hospital 88 Nelson Hospital, Merton 30 S.C.C. Sanatorium, Godalming 6 St. Thomas's Hospital 10 Others 98 Total 232 9 The deaths occurring within the district, of persons not belonging thereto were sixty-two, namely:— North Wimbledon Hospital 16 Infectious Diseases Hospital 2 Atkinson Morley Hospital 3 Private Nursing Homes 27 Others 14 Total 62 Taking these into consideration, the total number of deaths properly belonging to Wimbledon is six hundred and thirty-six and the death rate 10.82 per thousand of the population. The rate for England and Wales for the same period was 12.3 per thousand. The death rate shows a decrease over the figure for the previous year and is considerably below that for England and Wales. The following table gives the death rate in Wimbledon for the past ten years together with the comparative figures for England and Wales:— 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Wimbledon : No. of DeathS 645 638 579 620 632 774 648 724 713 636 Death Rate 11.1 10.9 9.9 10.6 10.7 13.03 10.9 12.3 11.9 10.8 Death Rate for England & Wales 12.2 12.2 11.6 12.3 11.7 13.4 11.4 12.3 12.0 12.3 10 Graph showing Birth Rates and Death Rates per thousand of the population for Wimbledon and England and Wales. 11 Table II gives the causes of, and ages at, death during 1933. Deaths due to notifiable infectious diseases are given on page 73. The principle causes of death, apart from zymotic deaths, are as follows:— Cancer 92 Heart Disease 151 208 Cerebral Hæmorrhage 29 Aneurysm 4 Other Circulatory Diseases 24 Pneumonia 46 69 Bronchitis 20 Other Respiratory Diseases 3 Influenza 17 Tuberculosis (Respiratory) 35 Cancer. Cancer and malignant disease were responsible for ninety-two deaths or 14.46 per cent. of the total number recorded. The following table gives the percentage figures since 1922:— Deaths from Cancer. Year Total Deaths Cancer Deaths Percentage 1922 616 91 14.77 1923 546 68 12.45 1924 645 86 13.33 1925 638 90 14.10 1926 579 104 17.96 1927 620 75 12.09 1928 632 84 13.29 1929 774 103 13.30 1930 648 106 16.35 1931 724 103 14.22 1932 713 104 14.58 1933 636 92 14.46 Although these figures vary considerably from year to year, there appears to be no direct evidence that cancer is on the increase in Wimbledon. Diseases of the Heart and Circulation. One hundred and fifty-one deaths were due to heart disease. In addition there were twenty-nine deaths from cerebral hæmorrhage, four from aneurysm and twenty-four from other circulatory diseases. Thus, two hundred and 12 eight deaths occurred from diseases of the heart and circulation. This figure represents 32.70 per cent. of the total number of deaths recorded. The following table, which gives the figures for the past ten years, seems to indicate that diseases of the heart and circulation are becoming increasingly important factors in the causation of death in Wimbledon. 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Deaths from diseases of the heart and Circulation 171 193 143 171 179 208 188 243 219 208 Total deaths (all causes) 645 638 579 620 632 774 648 724 713 636 Percentage of deaths from heart & circulatory diseases in relation to total deaths 26.51 30.02 24.69 27.58 28.32 26.87 29.01 33.56 30.71 32.70 Bronchitis, Pneumonia, and Other Respiratory Diseases. Twenty deaths were due to bronchitis, forty-six to pneumonia and three to other respiratory diseases. This gives a total figure of sixty-nine, or 10.84 per cent. of the total deaths occurring amongst residents of the Borough during 1933. The following table gives the figures for these diseases for each year since 1924:— 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Deaths from Bronchitis, Pneumonia & other Respira tory Diseases 101 98 102 89 81 117 79 80 88 69 Total Deaths, (all causes) 645 638 579 620 632 774 648 724 713 636 Percentage of Deaths from Bronchitis, Pneumonia & other Respiratory Diseases in relation to Total Deaths 17.20 15.36 17.61 14.35 12.81 15.11 12.19 11.04 12.34 10.84 13 Deaths due to Violence. The figures set out below give an indication of the manner in which twenty-eight Wimbledon residents met their deaths from violence. It will be noted that twelve of the deaths, equal to 1.88 per cent. of the total deaths occurring in Wimbledon residents, were clue to traffic accidents. Eight of these occurred outside the Borough. In a further six cases the deaths resulted from fractures due to falls, occurring for the most part in elderly people. Traffic deaths 12 Burns 2 Electrocution 2 Fractures due to falls 6 Drowning 1 Other causes 5 Total 28 Three persons living outside the Borough were killed in Wimbledon as the result of traffic accidents. A further death was due to a railway accident. In addition to the above, eight cases of suicide occurred amongst Wimbledon residents during 1933. Infantile Mortality. There were thirty infant deaths during the year (including transferable deaths) giving an Infantile Mortality Rate of forty-nine per thousand births. This figure shows a gratifying decrease over that of sixty-seven per thousand for the previous year. During 1933 the Infantile Mortality Rate for England and Wales was sixty-four. The following table gives the Infantile Death Rate in Wimbledon for the past ten years together with the comparative figures for England and Wales:— 1924 1925 19'26 19-27 1928 1929 1930 1931 1932 1933 Wimbledon: No. of Infantile Deaths 59 46 '27 37 38 35 38 45 45 30 Infantile Death Rate (per thousand births) 70 60 33 50 55 46 49 70 67 49 Infantile Death Rate for England and Wales 75 75 70 69 65 74 60 66 65 64 14 Of the thirty children under one year who died, the cause of death in seven cases was prematurity and debility. Five died as the result of congenital defects. Four of the deaths were due to bronchitis or broncho-pneumonia, two to influenza, and one to whooping cough. Infantile diarrhoea was responsible for only one death. The Infantile Death Rate for illegitimate children in Wimbledon was 200.00 per thousand births. The following table shows the causes of death, and ages at death, of infants under one year:— Infantile Mortality during the Year 1933. 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. Whooping Cough ... ... ... ... ... ... 1 ... ... 1 Influenza ... ... ... ... ... 1 1 ... ... 2 Broncho-pneumonia ... ... ... ... ... ... 1 1 ... 2 Bronchitis ... ... ... ... ... ... 2 ... ... 2 Tuberculous Meningitis ... ... ... ... ... 1 ... ... ... 1 Enteritis ... ... ... ... ... ... 1 ... ... 1 Pylorio Stenosis ... ... ... ... ... 1 ... ... ... 1 Marasmus ... ... ... ... ... ... 1 ... ... 1 Hirschsprung's Disease 1 ... ... ... 1 ... ... ... ... 1 Prematurity and Debility 3 ... ... 3 6 1 ... ... ... 7 Spina Bifida 1 ... ... ... 1 ... ... ... ... 1 Other Congenital Defects 1 1 ... ... 2 ... 1 ... ... 3 Birth Trauma 2 ... ... ... 2 ... ... ... ... 2 Asphyxia ... ... ... ... ... ... ... 2 ... 2 Pyelitis ... ... ... ... ... ... 1 ... ... 1 Other Causes 1 1 ... ... 2 ... ... ... ... 2 Total 9 2 ... 3 14 4 9 3 ... 30 Neo-natal Mortality. Fourteen deaths occurred amongst infants during the first four weeks of life. This is equal to a mortality rate of 23.25 per thousand total live births. Six of these deaths were due to prematurity and debility, four to congenital defects, two to birth trauma, and two to other causes. 15 Graph showing Infantile Mortality Rates per thousand births for Wimbledon and England and Wales. 16 GENERAL PROVISION OF HEALTH SERVICE FOR THE AREA. Public Health Officers of the Local Authority. A complete list of the Staff of the Public Health Department is given at the commencement of this report. Laboratory Facilities. The Corporation employ a part-time bacteriologist for the examination of pathological specimens. The number of specimens sent by Medical practitioners for examination is shown in the following table:— Positive Negative total. Diphtheria Swabs 7 345 352 Tuberculosis (Sputum) 9 99 108 Pus (Ophthalmia Neonatorum) ... ... ... Reaction Obtained. Reaction Not Obtained. total Typhoid (Blood, and other specimens) 1 17 18 Positive. Negative. Total. Cerebro-spinal Fluid ... ... ... In addition to the above facilities, the laboratory provided at the Health Centre, is utilised for the examination of pathological specimens from the Infectious Diseases Hospital. This work is carried out by the staff of the Public Health Department. One thousand two hundred and twelve specimens were examined in 1933. Most of these specimens were swabs taken from the nose and throat of suspected diphtheria patients or from contacts in the homes or schools. The following additional specimens from the Infectious Diseases Hospital were also reported upon:— Blood 1 Ringworm 2 Cerebro-spinal Fluid 3 Urine Specimens 4 Sputum Nil Smears 3 17 Ambulance Facilities. (i) For Infectious Diseases.—Two motor ambulances are maintained by the Wimbledon Borough Council at their Infectious Diseases Hospital, Gap Road. A new well-equipped Austin ambulance was purchased during July, 1932, for the removal of infectious patients, the other ambulance being retained for disinfecting purposes. (ii) For Non-infectious Cases and Accidents.—One motor ambulance is maintained by the Wimbledon Borough Council at the Fire Station, Queen's Road. Professional Nursing in the Home. General and Midwifery.—The Wimbledon and District Nursing and Midwifery Association, which is supported by voluntary contributions, has a staff of a matron and seven nurses. Five of the staff are district nurses, and two district midwives. The Association attended one hundred and thirtyfour midwifery cases during the year. Ninety of these were midwives cases and forty-four were cases with doctors in attendance. In all, 2,191 visits were paid to maternity cases. Furthermore, five hundred and twenty ante-natal visits were made by the nursing staff of the Association. The total number of cases dealt with during 1933, including midwifery, amounted to 1,036, the total visits paid to these cases being 25,481. The Wimbledon Borough Council make an annual contribution of ten guineas to this Association. Clinics and Treatment Centres :— (i) Maternity and Child Welfare Centres. (a) Wandle Park House, Wandle Bank, Wimbledon. Every Wednesday from 2 p.m. to 4.30 p.m. (b) Health Centre, Pelham Road, Wimbledon. Every Friday from 2 p.m. to 4.30 p.m. (ii) Ante-natal Clinic. Wandle Park House, Wandle Bank, Wimbledon. Second and fourth Thursday in each month from 2 p.m. to 4.30 p.m. 18 (iii) Mothercraft Classes. (a) Health Centre, Pelham Road, Wimbledon. Every Tuesday from 3 p.m. to 4.30 p.m. (b) Wandle Park House, Wandle Bank, Wimbledon. Every Thursday from 3 p.m. to 4.30 p.m. (iv) Dental Treatment Centre. Health Centre, Pelham Road, Wimbledon. Every morning (including Saturday) from 9.15 a.m. to 12 noon. (v) School Clinic. Health Centre, Pelham Road, Wimbledon. (a) Minor Ailment Clinic. Every morning (including Saturday) from 9 a.m. to 12 noon. (b) Special Inspection Clinic. Every Wednesday from 9 a.m. to 12 noon. (vi) Day Nursery. Hubert Road, Wimbledon. All the above are provided and maintained by the Wimbledon Borough Council. (vii) Tuberculosis Dispensary. Council Schools, Aston Road, Raynes Park, S.W.20. The Dispensary is provided and maintained by the Surrey County Council and is available to Wimbledon patients as follows:— Every Wednesday from 1 p.m. to 3.30 p.m. Every Friday from 9.30 a.m. to 11.30 a.m. First Tuesday in each month from 5 p.m. to 7.30 p.m. (viii) Venereal Diseases. Under the scheme of the Surrey County Council, facilities for treatment are available through the out-patient departments of the large London Hospitals. 19 Hospitals. (1) Hospitals provided or subsidised by the Local Authority or the Surrey County Council:— (i) Tuberculosis.—Most Wimbledon patients suffering from pulmonary tuberculosis are admitted to the Sanatorium at Milford which is under the administration of the Surrey County Council. The majority of the cases of surgical tuberculosis are sent to St. Anthony's Hospital, Cheam, or similar institutions. (ii) Maternity.—The Maternity Block of the Nelson Hospital was opened in September, 1931, and has accommodation for twenty beds, together with an Ante-natal Department. Although this hospital is situated just outside the boundary, one hundred and fifty-seven Wimbledon patients were admitted for their confinements during 1933, an increase of thirty on the figure for the previous year. One hundred and fourteen of these patients were admitted to the general maternity ward and forty-three to the private maternity wards. (iii) Children.—There are no special Children's Hospitals in Wimbledon. The general hospitals in the area are available for the purpose. Many of the children in the Borough receive treatment from the large London Hospitals such as Great Ormond Street and Tite Street. (iv) Infectious Diseases.—The Corporation's Infectious Diseases Hospital, at Gap Road, has accommodation for one hundred and six beds for the treatment of patients suffering from scarlet fever, diphtheria, enteric, erysipelas, meningitis, etc. Cases of measles and whooping cough are also admitted where the home conditions render this desirable. In addition, treatment is provided for certain cases of puerperal sepsis. As the result of the review of the hospital accommodation available for infectious cases in the County of Surrey, under Section 63 of the Local Government Act, 1929, the Wimbledon Corporation now admit to their Infectious Diseases Hospital all cases of scarlet fever and diphtheria requiring hospital treatment from the Royal Borough of Kingstonupon-Thames. 20 (2) Hospitals available for the area:— There is only one general hospital in the district, viz.: the Wimbledon Hospital, Thurstan Road, Copse Hill, which has accommodation for seventy-two bed cases. In addition there is the Nelson Hospital for Wimbledon, Merton and District, which is situated just outside the boundary. This hospital has sixty-two beds for medical and surgical cases and twenty beds for maternity patients. The Kingston and District Hospital, which is at Norbiton, has five hundred beds. This hospital is administered by the Public Assistance Committee of the Surrey County Council. (3) Institutions for unmarried mothers:— The Southwark Diocesan Maternity Home at 56, Gap Road, has accommodation for twelve mothers. Public Assistance. The following information has been furnished by the Chief Public Assistance Officer concerning relief in this district:— Amount paid in Out-door Public Assistance in 1933 £7,688 Average weekly number of persons in receipt of Domiciliary Assistance 494 Average weekly number of persons in receipt of Medical Relief only 6 Number of persons admitted to the Public Assistance Institutions from Wimbledon Area:— (a) Hospital 479 (b) Institution 56 MATERNITY AND CHILD WELFARE. Continued progress has been maintained in the work of this section of the Public Health Department in spite of the changes which occurred in the personnel of the Health Visiting staff. Three new Health Visitors were appointed and for a period of three months it was found necessary to 21 obtain the services of a temporary Health Visitor. It is for these reasons that the number of visits paid shows a considerable reduction. The total number of visits paid by the Health Visitors during 1933 amounted to 4,321, the figure for the previous year being 5,603. The attendance of the children at the Centres has continued to be most satisfactory. At the Pelham Centre the average attendance per session was 84.35 as compared with 77.56 in 1932, 69 in 1931 and 64 in 1930. The average attendance per session at the Wandle Park Centre was 46.02, comparing very favourably with the figures of 46.91 in 1932, 42 in 1931 and 40 in 1930. The Ante-natal Clinic is held at Wandle Park House in the afternoon on the second and fourth Thursdays in the month. The average attendance per session at this Clinic was 5.83. The figure for the previous year was eight. The total number of expectant mothers who attended at the Ante-natal Clinic during the year was eighty-one, equal to 14.21 per cent. of the total number of live- and still-births notified. Two hundred and forty-four of these births were attended by midwives. It is most desirable that a larger number of expectant mothers attended by midwives should be examined by a doctor during the ante-natal period. The midwife may be able to carry out her ante-natal examinations with considerable skill and care, but unless an expectant mother is seen by a doctor during this period she is precluded from having an overhaul of her general health, which is so essential at this time. It is to be hoped that the practising midwives will realise the value of this and endeavour to co-operate more completely, and to utilise more fully the facilities for ante-natal care provided by the Council. Steady attendance has been maintained at the classes for mothers, which are held at both of the Centres. Home nursing, mothercraft, hygiene, and singing, are taught. The average attendance of mothers at the Pelham Centre was 25.63 and at the Wandle Pai-k Centre 13.51. Steps are being taken at the latter Centre to provide a separate singing class for the older mothers. It is felt that most of the women attending these classes no longer require the instruction which is being given, and every effort is being made to encourage the younger mothers to attend. It is 22 hoped that in the near future a gratifying increase in the attendance will result. Midwifery and Maternity Services. There are no midwifery or maternity services provided by the Corporation. Institutional Provision for Mothers or Children. With the exception of the Day Nursery, which has accommodation during the day for fifty children under five years of age, the Corporation make no institutional provision for mothers or young children. Details of the work of the Day Nursery are given on page 34. The Council, however, in certain cases, arrange convalescent treatment for children under school age. During 1933 six children were sent to convalescent institutions for varying periods. The arrangements are made through the local branch of the Invalid Children's Aid Association. Midwives Acts, 1902-1926. The Borough Council is the Local Supervising Authority for the Midwives Acts in Wimbledon. Twenty-two midwives notified their intention of practising in the Borough during the year, together with eleven midwives resident in outside areas. Nine of the former eventually removed to other districts, leaving thirteen practising midwives in Wimbledon at the end of 1933. There are, in addition, a number of midwives acting purely as maternity nurses in the maternity homes. Two hundred and fifty-five confinements were attended by the midwives and eighty-six by the maternity nurses. In the latter cases doctors had been engaged by the patients. Regular inspection of the midwives was carried out by the Assistant Medical Officer, who is the Inspector of Midwives for the Borough. These inspections, with few minor exceptions, again showed that the records, bags, instruments, etc., were being maintained in a satisfactory manner. Special attention is devoted to the Ante-natal records of the midwives during the routine visits of inspection paid to them, and on the whole a very considerable improvement has been observed as compared with previous years. 23 Midwives are invited to attend with their patients at the Ante-natal Clinic. Every woman should have the advantage of a medical examination during pregnancy in addition to the usual ante-natal supervision given by the midwife she has engaged. Some of the midwives in Wimbledon are finding difficulty in obtaining sufficient employment. The declining birth rate and the increasing facilities available for women to have their confinements in neighbouring hospitals has considerably affected their practices. No uncertified women living in Wimbledon were known to be attending confinements under the direction and supervision of registered medical practitioners. During September, the Surrey County Council, as the Local Supervising Authority for Surrey, arranged a course of lectures and demonstrations for the midwives in their area as in previous years. The midwives in Wimbledon were kindly invited to attend, if they so desired, and a number availed themselves of the opportunity of being present. Several lectures were also given to the Wimbledon midwives by the Medical Officer of Health at the Town Hall during the year. The local branch of the Midwives' Institute, of which the Chairman of the Maternity and Child Welfare Committee of the Wimbledon Borough Council is President, continued to meet every month in the room placed at their disposal at the Town Hall. The following notifications were received from midwives practising in the district:— Stillbirths 3 Artificial Feeding 1 Liability to be a Source of Infection 11 Notification of Death 5 Total 20 Medical Aid forms were received in seventy-six instances, and the following table shows the conditions for which medical help was obtained:- Albuminuria 9 Ante-partum Hmæorrhage 4 Delayed Labour 15 24 Retained Placenta 1 Malpresentation 2 Collapse 2 Threatened Abortion 1 Abnormal Pelvic Measurements 1 Post Partum Haemorrhage 4 Ruptured Perineum 21 Rise of Temperature 6 Inflamed Eyes 3 Miscellaneous 7 Total 76 The total fees paid to doctors by the Corporation during the year under Section 14 (1) of the Midwives Act, 1918, amounted to £65 17s. 9d. The amount recovered from the patients' relatives was £11 l1s. 6d. Home Visitation.-—The record of home visitation work carried out by the Health Visitors during 1933 is as follows: Number of births notified 570 „ „ „ registered 389 „ „ „ visited 563 „ „ „ re-visited—under 1 yr. 756 „ „ „ —over 1 yr. 1,151 „ „ visits to Ophthalmia cases 8 „ „ visits to expectant mothers 101 „ „ re-visits to expectant mothers 25 „ „ ineffectual visits 786 „ „ special visits 165 Total welfare visits 3,555 „ „ school visits (half-day) 216 „ „ visits to parents of schoolchildren 133 „ „ Tuberculosis visits 88 „ „ Puerperal Fever visits 2 „ „ visits re Children Act, 1908 327 766 Total of all visits 4,321 Centres.—The work carried out at the Centres during 1933 is indicated in the following table:— 25 26 Centres.—The work carried out at the Centres during 1933 is indicated in the following table:— month PELHAM ROAD WANDLE PARK Infant Welfare Consultations ClaaseB for Mothers Infant Welfare Consultations Ante-Natal Clinic Classes for Mothers No. of Sessions Children under 1 Year Children from 1-5 Years Total Average Attendance No. of New Cases No. of Sessions Attendance Average Attendance No. of Sessions Children under 1 Year Children from 1-5 Years Total Average Attendance No. of New Cases No. of Sessions Attendance Average Attendance No. of Sessions attendance Average Attendance January 4 284 31 315 78.75 25 4 111 27.75 4 127 25 152 38.00 10 2 13 6.50 3 33 11.00 February 4 206 44 250 76.00 21 4 119 29.75 4 131 30 161 40.25 14 2 13 6.50 4 63 15.75 March 4 286 79 365 91.25 49 4 115 28.75 5 184 60 244 48,80 21 2 13 6.50 5 80 16.00 April 4 292 94 386 96.50 30 3 76 25.33 3 148 45 193 64.33 16 2 13 6.50 3 58 19.33 May 4 266 95 361 90.25 23 5 108 21.60 5 175 48 223 44.60 18 2 10 5.00 4 72 18.00 June 5 297 121 418 83.60 33 3 63 21.00 4 130 81 211 52.75 11 2 15 7.50 5 83 16.60 July 3 166 113 279 93.00 20 4 77 19.25 4 118 95 213 53.25 7 2 11 5.50 4 46 11.50 August 3 154 93 247 82.33 22 1 20 20.00 3 63 75 138 46.00 5 2 7 3.50 ... ... ... September 5 264 177 441 88.20 35 4 87 21.75 4 107 88 195 48.75 7 '2 15 7.50 4 37 9.25 October 4 222 103 325 81.25 27 5 137 27.40 4 113 64 177 44.25 14 2 10 5.00 4 29 7.25 November 4 233 128 361 90.25 30 4 128 32.00 5 130 89 219 43.80 14 2 14 7 00 4 43 10.75 December 4 212 89 301 75.25 28 3 87 29.00 3 55 28 83 27.66 6 2 6 3.00 1 10 10.00 Totals 48 2882 1167 4049 84.35 343 44 1128 25.63 48 1481 728 2209 46.02 143 24 140 5.83 41 554 13.51 Children and Young- Persons Act, 1932; Children Act, 1908 (Part 1).—The following figures relate to the administration of the above Act in Wimbledon during 1933:— (i) Number of foster parents on the Register— (a) At the beginning of the year 25 (b) At the end of the year 37 (ii) Number of children on the Register— (a) At the beginning of the year 31 (b) At the end of the year 42 (c) Who died during the year Nil (d) On whom inquests were held during the year Nil Every foster child was visited regularly throughout the year and if the conditions were not satisfactory, more frequent visits were paid. In all, three hundred and twentyseven visits were made to the homes of foster mothers. Although three of the Health Visitors hold appointments under Section 2 (2) of the principal Act, it has been found expedient to make one Health Visitor responsible for the entire visiting. The standard of care devoted to the foster-children in Wimbledon was found to be very satisfactory. In a few cases it was necessary to insist on a suitable and proper cot being supplied for a child. These requirements were promptly complied with. Attention was also paid to the provision of suitable fireguards in the home of every foster-mother. Where a foster-child was found not to be making satisfactory progress the foster-mother was informed that it was necessary for her either to obtain private medical attention or to take the child to the Health Centre. One foster-child, who became seriously ill. was admitted to a general hospital where it ultimately recovered. This child had received every attention before admission to hospital and had been under medical supervision at the local Child Welfare Centre. All the requirements of the Children Act had been fully complied with. The Children and Young Persons Act, 1932, which came into operation on 1st January, 1933, considerably amends the Children Act, 1908. One of the most important alterations is the raising of the age of the foster-child from seven 27 to nine years. Furthermore, the Authority now has to receive seven days' notice before a woman undertakes the care of a foster-child for the first time. This is a valuable amendment of the existing regulations, as it allows time for full inquiry and investigation of the home circumstances of the foster-mother by the Infant Protection Visitor before the foster-child is received. Notice of these alterations was given to the general public in December, 1932, by means of advertisements published in the local press, and by posters which were exhibited in various parts of the town. In two instances the Council made Orders fixing the number of foster-children to be kept by certain fostermothers. In no case was it necessary for an order to be obtained from a Justice under Section 67 of the Act of 1932, with a view to the removal of a child from the home of a fostermother. It was not necessary to take any legal proceedings under the Act. Orthopaedic Treatment.—The scheme of the Wimbledon Borough Council for orthopedic treatment, which came into operation in July, 1931, provides for the treatment of schoolchildren as well as for children below school age. The Surgeon visited the Orthopedic Clinic at the Health Centre once every month. The Orthopaedic Nurse, who supervises the remedial exercises and massage, attends two sessions each week, except during the school holidays when the Orthopedic Clinic is closed. 28 The children admitted to Pyrford for in-patient treatment were suffering from genu valgum due to rickets, and rachitic bowing of the legs respectively. Unfortunately, in the first case, the parents took the child home before the requisite treatment for the correction of the deformity could 29 No. of Children under 5 Years of Age. 1931 1932 1933 Examined by the Surgeon—New Cases 3 9 10 —Old Cases ... 12 33 Referred to Pyrford for treatment 1 1 2 Referred to St. Thomas'6 Hospital for X-ray Examination ... 1 ... For whom Surgical Appliances or Special Boots were ordered 1 6 9 Referred for Remedial Exercises at the Health Centre 1 1 ... No. of Attendances made for Remedial Exercises 8 9 ... be carried out. The second child was still under treatment at Pyrford at the end of the year. In addition to the foregoing, the Maternity and Child Welfare Committee also accepted responsibility for half the cost of maintenance of a Wimbledon child under school age who had been admitted by the Royal National Orthoptedic Hospital to their country branch at Stanmore. This child was suffering from septic arthritis of the hip and knee. She was still under treatment in hospital at the end of the year. Ophthalmia Neonatorum.—The following table shows the number of cases of ophthalmia neonatorum notified and the final results of treatment. These cases were mild and no impairment of vision resulted. Home nursing was provided in all three cases through the Wimbledon "District Nursing Association:— CASE6. Treated. Vision Total Impaired Blindness. Deaths Notified. paired. At Home. Hospital. 3 3 3 ... ... ... In addition to the above, intimations were received from the midwives that they had called in medical assistance on account of several infants suffering from "sticky eyes." The conditions from which these children were suffering were not notifiable under the Public Health (Ophthalmia Neonatorum) Regulations, 1926, but in every case they were followed up by the staff of the Public Health Department until all signs of inflammation of the eyes, however slight, had subsided. The fact that serious cases of ophthalmia neonatorum have been absent from Wimbledon during recent years is probably due to two facts, namely, that no unqualified woman is practising midwifery in the Borough, and that the certified midwives call in medical assistance when the slightest sign of eye trouble in an infant appears. Ophthalmic Treatment.—Four new cases from the Maternity and Child Welfare Centres were seen by the Ophthalmic Surgeon at the refraction clinic during the year. In addition to this, six children who were already wearing glasses, were re-tested. No new case was found to require spectacles. 30 Treatment of Minor Ailments.—One hundred and fortyseven children below school age attended the Health Centre for treatment. Forty-four of these were new cases attending for the first time during the year and one hundred and three were re-attendances. The conditions treated consisted chiefly of septic sores, impetigo, running ears, blepharitis, and miscellaneous skin conditions. Treatment of Tonsils and Adenoids.—Arrangements were made for the operative treatment of tonsils and adenoids in two cases under the Council's Maternity and Child Welfare scheme. Ear Diseases and Defective Hearing.—Adequate facilities are available for the treatment of children below school age suffering from ear diseases and defective hearing. A consulting otolaryngologist was appointed by the Council in 1929 at the Infectious Diseases Hospital. Where necessary his services are utilised in the case of patients who develop ear complications after they have been admitted to the hospital suffering from scarlet fever and diphtheria. In addition, it has been the practice in recent years to admit an increasing number of complicated cases of whooping cough and measles to the Infectious Diseases Hospital. This ensures the adequate treatment of a large number of children suffering from ear diseases and defective hearing, as the common infectious diseases are the most frequent cause of these defects. Treatment is available for the less serious forms of ear trouble at the Minor Ailment Clinic at the Health Centre. The Ear, Nose, and Throat Hospitals, and the out-patient departments of the large London Hospitals are also readily available for the treatment of children resident within the Borough. Maternal Mortality. There were three maternal deaths amongst Wimbledon mothers in 1933. These all occurred in hospitals outside the district. One death was due to pyelitis in pregnancy. The second death followed an operation for Cesarean section in a woman with chronic heart disease. The third death was due to hajmorrhage in a patient suffering from severe anaemia. There was no death from puerperal sepsis. During the previous year there was only one maternal death and in this case puerperal sepsis was the cause. 31 The following table gives the maternal mortality rates for Wimbledon and also for England and Wales:— 1933 Puerperal Sepsis Others Total Wimbledon: Per 1000 Live Births 0.00 4.98 4.98 Per 1000 Total Births 0.00 4.84 4.84 England and Wales: Per 1000 Live Births 1.79 2.63 4.42 Per 1000 Total Births 1.71 2.52 4.23 Ante-natal care is a most important factor in the reduction of maternal mortality. There are now two Antenatal Clinics immediately available for expectant mothers in Wimbledon. One is the Ante-natal Clinic of the Corporation which is held every fortnight at Wandle Park House. This is conducted by the lady Assistant Medical Officer. The other Ante-natal Clinic is run in conjunction with the new maternity block at the Nelson Hospital. Hospital Treatment for Complicated Obstetric Cases.—In July, 1932, the Council made arrangements with the Maternity Department of the Nelson Hospital for the treatment of complicated obstetric cases occurring in the Borough. The services of a consultant, obstetrician are available together with facilities for any operative treatment that may be found necessary. Patients admitted to hospital under this scheme are required to contribute towards the cost of their maintenance, whilst undergoing treatment, in accordance with a scale which has been adopted by the Council. The medical practitioners in the area were notified of these facilities when the scheme came into operation. During 1933 three patients received treatment under this scheme for the following conditions :— (i) Breech presentation with contraction of pelvis— Cesarean section performed. (ii) Ante-partum haemorrhage due to placenta praevia. (iii) Ante-partum haemorrhage due to placenta praevia. These facilities should ultimately prove to be an important factor in reducing the number of maternal deaths occurring among Wimbledon mothers. Although they have 32 been available for eighteen months, only four complicated cases have received treatment under the scheme during this period. It is to be hoped that more advantage will be taken of these arrangements in the future. Supply of Milk to Expectant and Nursing Mothers and Infants.—During the year five hundred and ninety-four applications for free milk supplies under the Maternity and Child Welfare Scheme were received from one hundred and fortyone families, compared with six hundred and fifty-seven applications from one hundred and forty-three families in the preceding year. Five hundred and thirty-seven of the applications were granted, a decrease of ninety-nine on the figure for 1932. The milk is granted on medical grounds and the circumstances of each case are carefully considered by the SubCommittee dealing with this question. A close co-operation is maintained between the SubCommittee and the Public Assistance Committee in dealing with applicants who are already in receipt of Public Assistance Benefit. Dental Treatment. Dental treatment is also available for children under school age and for nursing and expectant mothers. The Dental Surgeon devotes one session a week at the Health Centre to Maternity and Child Welfare cases. Forty-seven mothers and ninety-seven children under school age attended for treatment. One hundred and four general ana;sthetics and fourteen local anassthetics were administered. Where necessary, nursing and expectant mothers are provided with dentures. Eighteen dentures were supplied to mothers through the dental clinic during 1933. One denture was repaired. The dental treatment of expectant and nursing mothers is of the greatest importance. A woman whose mouth is in a septic condition during the ante-natal period runs a definitely increased risk of septic complications after her confinement. The ability of a woman to nurse her child is generally dependent on her general health. Decayed and septic teeth impair the health and vitality of a nursing mother, and for this reason dental treatment is of great importance during this period. The following table gives an indication of the work carried out by the Dental Surgeon in connection with the 33 Maternity and Child Welfare Department for the year ended 31st December, 1933:- Mothers—attendances for treatment 170 „ teeth extracted 133 „ „ filled 13 „ scalings 23 „ other operations 28 „ dentures supplied 18 „ dentures repaired 1 ,, other prosthetic operations 108 Children—attendances for treatment 174 ,, teeth extracted 184 „ filled 4 „ other prosthetic operations 108 Total number of fillings inserted 20 „ „ „ local anaesthetics ministered 14 „ „ „ general do. do. 104 Voluntary Helpers.—I should again like to draw attention to the work which is being carried out by the voluntary helpers in the Maternity and Child Welfare movement in Wimbledon. The Centres at Pelham Road and Wandle Park House are fortunate in having such enthusiastic workers. Their activities are much appreciated by the mothers in Wimbledon. Municipal Day Nursery.—The work at the Day Nursery at Hubert Road during 1933, continued to be most satisfactory. The total attendances made by children amounted to 10,988 whole days. The average daily attendance was fortyfive. These children came from one hundred and eighteen families, one family sending four children, three families three children, sixteen families two children, and the remainder one child each. The number of children on the register on 31st December, 1933, was sixty-eight. The Nursery has accommodation for fifty children— twenty infants and thirty toddlers. Infants are admitted from the age of three weeks and toddlers remain until they commence school at five years. The children are brought to the Nursery between 7.30 and 9.0 a.m. They are then undressed, bathed, and re-dressed in nursery clothes, their 34 own clothes being placed in numbered string bags and fumigated. Their heads are washed at the Nursery once a week, and oftener if this is found necessary. All the clothing worn by the children at the Nursery is hand-made. The children are provided with three meals during the day. Infants up to the age of eight or nine months are bottle-fed. Whenever possible, arrangements are made for a breast-fed infant to be kept on the breast for the morning and evening feeds, bottle feeds being given at the Nursery during the day as required. The older children receive an excellent dietary suitable to their age. This is supplemented by fruit juice and cod liver oil and malt or virol. All preserves consumed by the children and staff are made on the premises. Infants up to the age of nine months are weighed weekly, and thereafter monthly up to the age of two years. Toddlers from two to five years are weighed every three months. During 1933 one thousand and eight "weighings" were carried out. The children respond well to the nursery life and show a satisfactory gain in weight. A charge of sixpence per day is made for each child attending the Nursery. No children residing outside the Borough are admitted. The revenue from this source amounted to £273 3s. 6d. during 1933. A medical record card is made out for each child. This card has been drawn up to conform with those used in the Maternity and Child Welfare and School Medical Departments. This enables the medical record to be transferred with the child and attached to its school medical record when it commences school. The children at the Day Nursery were medically inspected four times during the year. During these inspections suitable advice was given with regard to their diets and where defects were discovered the parents were notified accordingly. Children suffering from minor ailments were referred to the Health Centre for treatment. One child, aged eighteen months, suffering from congenital nystagmus was supplied with suitable glasses at one of the London hospitals. One other child, suffering from squint and wearing glasses previously supplied through the Health Centre, was re-examined by the Oculist. 35 One child attending the Day Nursery was referred to the Orthopaedic Clinic and sent to the St. Nicholas' and St. Martin's Orthopaedic Hospital at Pyrford for treatment on account of rachitic deformity of the legs. This condition had developed prior to the child's admission to the Nursery. Operative treatment for the removal of tonsils and adenoids was not found necessary in any case. If the condition of a child was not considered satisfactory it was referred by the Matron for examination by the medical staff during their frequent visits to the Nursery. All the toddlers were inspected by the Dental Surgeon in January and June. The condition of the teeth of the older children continued to be remarkably good. Approximately fifty per cent, of them were found to be entirely free from dental caries. Two children were found to require dental treatment, and this was carried out at the Health Centre. The parents appear to appreciate these facilities and it is quite unusual for treatment to be refused. Any child who, on admission to the Nursery, was found to be suffering from any suspicious illness, was immediately placed in the isolation room and all precautions were taken until it had been medically examined. This room is now fully equipped, a new "Auto-lock" Safety Cot and white enamelled locker having been obtained during the previous year. One mild case of smallpox occurred in a toddler attending at the Day Nursery. No other case of infectious disease occurred amongst the infants, toddlers, or staff throughout the year and the standard of health of all concerned continued to be very satisfactory. Every week the Public Health Department forwards to the Matron of the Day Nursery the names and addresses of school children who are absent on account of infectious diseases. This enables the Matron to ascertain whether any of the Nursery children are coming from infected homes. Such children are immediately excluded. There is no doubt that the Nursery meets a very real need in South Wimbledon. Each application for admission is carefully considered. A child is only admitted when it is genuinely necessary for the mother to go out to work. The programme of re-decoration of the interior of the Nursery was continued and is now nearly complete. With the exception of two staff bedrooms, which will be attended 36 to in 1934, the whole of the Nursery has been done out in washable paint. The Corporation now grant a Certificate to the Nursery Nurses who, after a two years' course of training, pass an examination in written and practical work in the theory and practice of nursery nursing. Three nurses were awarded this Certificate during 1933. After they have completed their two years' training at the Day Nursery many of the nurses proceed to take their general and fever training. 37 Nursing Homes Registration Act. 1927. The Wimbledon Borough Council is responsible for the supervision of Nursing Homes in Wimbledon. At the end of the year there were fourteen registered nursing homes, namely:— Nursing Homes for Maternity Cases 1 Nursing Homes for Medical, Surgical, and Maternity Cases 3 Nursing Homes for Children and Maternity Cases 1 Nursing Homes for Medical, Surgical, and Chronic Cases 1 Nursing Homes for General Medical and Chronic Cases 1 Nursing Homes for Chronic Cases 7 Total 14 A certificate of re-registration was issued by the Council in respect of a Nursing Home for children and maternity cases. Intimation was also received that Nursing Homes for the following types of patient were being discontinued:— Nursing Homes for Chronic Cases 2 Nursing Homes for Maternity Cases 1 Nursing Homes for Medical and Maternity Cases 1 Nursing Homes for Maternity and Chronic Cases 1 Total 5 The Nursing Homes were periodically inspected and supervised. Several alterations were found necessary and these were carried out. In one case it was found necessary to replace fire extinguishers which had become inefficient. In another Nursing Home an electric fire was installed in a room in which there had previously been a gas fire with an inadequate flue for ventilation. The Nursing Homes in Wimbledon during the year under review were again found to be maintained in a satisfactory manner. 38 MORTUARY. The existing mortuary is situated within the grounds of the Cemetery at Gap Road. The Council have now decided 011 the construction of a new and larger mortuary with a modern post-mortem room attached. This work will be put in hand in 1934. It was decided to erect the building on the same site as the existing one in the Cemetery grounds. The new mortuary will provide accommodation for at least eight bodies. From information received from the Superintendent of the Cemetery there were one hundred and seven bodies received into the existing mortuary during 1933. Postmortems were conducted on sixty-seven bodies. This figure is equivalent to 14.38 per cent, of the deaths registered as occurring in the Borough. 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—17th December, 1890. Public Health Acts (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, 6-5, 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 VIII (Fire Brigade)—Sections 87, 88, 89 and 90. Part IX (Sky Signs)—Section 91. Part X (Miscellaneous)—Sections 92, 93 and 95. 39 (All the preceding 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, 191-1—7th August, 1914. (Sections repealed:—46, 48, 49, 50, 51, 52, 53, 57, 58, 60, 75, 76, 80, 84, 91, 100, 101, 102, 104, 108, 109, 110). Public Health Act, 1925. Part II (Streets and Buildings)—Sections 13, 14, 15, 16, 17, ]8, 19, 21, 23, *24, 25, 26, 27, 28, 30; 31; 32, 33, 34, 35, 38. Part III (Sanitary Provisions)—Sections 41, 43, 44. Part IV (Verminous Premises, etc.)—Sections 45, 46, 47, 48, 49, 50. Part V (Watercourses, streams, etc.)—Sections 51, 52, 53, 54, 55. (All the above Sections became operative from 1st January, 1928, except Section 38, which was adopted later and became operative from 1st February, 1929). The Wimbledon Corporation Act, 1933—28th July, 1933. Bye-laws, Regulations, etc.:— Bye-laws with respect to Houses let in Lodgings (Revised 1928). do. do. Common Lodging Houses, do. do. Slaughter-Houses (Revised 1922). do. do. Nuisances, do. do. Offensive Trades. Bye-laws with respect to Tents, Vans, Sheds and Similar Structures. Bye-laws as to Employment Agencies. Bye-laws with respect to the keeping of Water-closcts supplied with sufficient water for flushing. Bye-laws for the Management, Use and Regulation of Public Baths. Bye-laws under Advertisements Regulations Act, 1907. Bye-laws with respect to the Fouling of Footways by Dogs. Regulations as to Underground Sleeping Places (Section 18 [i]) Housing Act, 1925. 40 Provisional and other Orders affecting the Borough :— Croydon and Wimbledon Joint Small pox Hospital Order, 1898. 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. Dated 6th June, 1914. The Wimbledon Credit Drapers' Half-Holiday Order, 1914. Dated 2nd July, 1914. The Wimbledon Barbers' and Hairdressers' Closing Order, 1919. Confirmed 27th October, 1919. The Wimbledon Fruiterers' and Greengrocers' Half-Holiday Order, 1931. Confirmed 15th July, 1931. 41 do. do. do. do. do. do. do. do. do. 1903. 1908. 1912. SANITARY CIRCUMSTANCES OF THE AREA Water.—The Metropolitan Water Board is responsible for the water supply of the Borough. In a great number of houses the drinking water is obtained from a supply tank on the premises. Attention is paid to these tanks by the Inspectors during their house-tohouse visits. The tanks require periodical cleansing, and in many cases it is found that this is not carried out as frequently as necessary. Only in a few instances are the occupiers of houses dependent on an outside water supply, which in each case is situated in the same curtilage. Rainfall. -The following table gives details of the monthly rainfall in inches in Wimbledon during 1933, together with the mean for each month during the period from 1929 to 1932 inclusive. It will be noted that tlie figures for 1933 are considerably below the mean for tlie four previous years:- Year. Rainfall in Inches. Total for Year. Jan. Feb. Mar. Apr May June Jul) Aug. S<pt. Oct. Nov . Dec. Mean for four years 1929-1932 inclusive. 1.73 0.74 0.87 2.21 2.85 1.12 2.14 2.90 2.11 2.44 3.33 1.94 24.37 1933 1.27 2.75 2.36 0.62 2.46 1.56 1.46 0.63 2.95 1.55 0.92 0.34 18.86 Drainage and Sewerage.—There has been no large extension of the sewerage system in Wimbledon during 1933. Normal extensions have, however, taken place to meet building development in the Borough. At the end of 1933, twelve percolating filters were in operation at the Sewage Disposal Works. Four new ones are also being constructed and these will come into operation during 1934. The filters are giving a high degree of purification to the sewage. All the houses in Wimbledon are provided with adequate water closet accommodation, none of the premises being dependent on closets of the conservancy type. 42 There are only three houses in the district without separate water closet accommodation situated within their own curtilages. These three houses have one outside water closet which is used in common. Refuse Collection.—All the motor vehicles used for the collection of house refuse are fitted with sectional covers which securely enclose the refuse and prevent the usual nuisances connected with the open type of lorry. A further covered refuse collecting motor vehicle has been added to the fleet bringing the total up to eight. Street Gully Cleansing-.—As in previous years, the gullies are emptied and re-sealed with fresh water by means of a mechanical vehicle. The detritus is drawn straight into a sealed tank in the machine, thus obviating the practice of allowing the detritus to lie in the channels until collected. 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 1933:— Reason of Visit No. Infectious Diseases 868 House Inspections 3,067 House to House Inspections 1,248 Rent Act Inspections 27 Houses .Let in Lodgings; Inspections 168 Inspection of Factories, Workshops, Work-places and Out-workers' Premises 570 Common Lodging Houses; Inspections 9 Dairies and Cowsheds; Inspections 84 Inspections under Shops Acts 438 Application of Tests to Drains 178 Inspections under Diseases of Animals Acts 46 Obtaining Samples of Foods and Drugs 2 Miscellaneous (including Inspections of food, slaughter-houses, mews, stables, caravans, . Petroleum Acts, water supply, piggeries, mosquitoes, etc.) 1,301 8,006 43 Eight hundred and twenty-three preliminary or informal notices were served in respect of seven hundred and twentythree houses. Eighty-two Statutory Notices were served in respect of eighty-four houses. The necessary work was executed in all but ninety cases, which were not completed by the end of the year. In fifty-three of these, the work was actually in hand at the close of the year. Table III gives a summary of the nuisances abated, and improvements carried out under the supervision of the staff of the Public Health Department. FACTORIES, WORKSHOPS AND WORKPLACES. 1. Inspection of Factories, Workshops and Workplaces. Premises Number of Inspections. Written Notices. Plosecutions. Factories 125 4 ... (Including Factory Laundries) Workshops 133 7 ... (Including Workshop Laundries) Workplaces (Other than Outworkers' Premises) 35 ... ... Total 293 11 ... 44 2. Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects. Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts.—* Want of Cleanliness 29 29 ... ... Want of Ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors ... ... ... ... Other Nuisances 9 9 ... ... Sanitary Accommodation— Insufficient ... ... ... ... Unsuitable or Defective 8 8 ... ... Not Separate for Sexes ... ... ... ... Offences under the Factory and Workshop Acts:— Illegal occupation of underground bakehouse (s.101) ... ... ... ... Other Offences (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921.) ... ... ... ... Totals 46 46 ... ... * Including those specified in sections 2, 3f 7 and 8 of the Factory and Workshop Act, 1901, as remodiable under the Public Health Acts. Outwork in Unwholesome Premises—(Section 108). Nature of Work Instances Notices Served Prosecutions Wearing Apparel — Making, Etc. ... ... ... Others ... ... ... Outwork in Infected Premises—Sections 109-110 Nil. 45 HOME WORK. Lists received:— Twice in the year - Number of Out-workers - Once in the year 1 Number of Out-workers 2 Number of addresses received from other Councils 54 Number of addresses forwarded to other Councils 12 Notices served on occupiers as to keeping or sending lists Prosecutions—Failing to keep Outworkers' Lists Prosecutions—Failing to furnish Lists Inspections of Out-workers' premises 72 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:— Bakehouses (including eight Factory Bakehouses 25 Boot Repairing 55 Builders 16 Coach Builders 3 Cycles 7 Dining Rooms 14 Dressmaking 30 Furniture Repairers 8 Jewellers and Watch Repairers 11 Laundries 22 Millinery 4 Motors 28 Printing 9 Smiths 4 Tailoring 18 Woodworkers 26 Miscellaneous 71 351 46 OTHER MATTERS. Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of Act Nil Action taken in matters Notified by H.M. referred by H.M. In- Inspector Nil spector as remedial Reports of action under the Public taken sent to Health Acts. H.M. Inspector Nil Underground Bakehouses in use at the end of the year 3 I submit herewith the report of Mr. Johnson, the Chief Sanitary Inspector. The report deals in detail with the work of the Sanitary Inspectors. This is Mr. Johnson's last complete year of office after thirty-six years of service under the Corporation. He has been a most loyal, efficient, and conscientious colleague, and he will carry with him in his retirement the good wishes of all who have been connected with him in the Public Health Department. REPORT OF CHIEF SANITARY INSPECTOR. I beg to submit my Report of the work carried out for the year ended 31st December, 1933. Table III gives a summary in detail of the various nuisances abated and sanitary improyements effected. Notices Served.—Eight hundred and twenty-three preliminary notices or intimations were served during the year in respect of 723 houses. It was found necessary to serve 82 Statutory Notices upon the owners or occupiers of 84 houses. Seven hundred and seven enquiries received from the Town Clerk's Department were replied to, regarding 866 properties where negotiations for sale were in progress. Opening up of Drains under Section 41 of the Public Health Act, 1875, and Amending Acts.—As a result of the application of the smoke or chemical test, application was made to the Local Authority with respect to the opening up of drains at six houses. 47 The front rain-water drains of one of these houses were found to be badly obstructed and, as a builder employed by the owner was unable to remove the obstruction the matter was dealt with by this department. After excavations were made, it was found that the drains of five other houses were also connected with the drains of this house, the single private drain eventually running across a main road to a sewer some 30 feet away from the boundary of the premises. Following the report to the Local Authority, Statutory Notices were served upon the owners, who all asked that the work should be done by the Council at their expense. This was satisfactorily done. House Drainage.—The drainage systems and sanitary arrangements of 7 houses have been entirely reconstructed, extensive amendments or repairs were carried out at 94 houses, and at 28 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 211 houses. The following list shows the particular streets, and the number of houses inspected in each. A list of the work carried out at the houses is included in Table III, page 59. Goodenough Road 31 Wandle Road 63 Palmerston Road 117 211 House Inspection.—As a result of inspections made on complaint, or in consequence of the occurence of infectious disease, request by occupiers, or other general inspections, 1,282 houses were visited. Table III shows a list of sanitary works executed at these houses, together with defects remedied during house to house inspection. Once more I would like to emphasise the difficulty being experienced by the department in having necessary repairs effected. In a large number of cases it is due to lack of funds rather than to wilful negligence on the part of the owners. It is usual for owners or their representatives, after receipt of notices, to call and explain their difficulties, and 48 whenever possible extension of time has been granted provided the serious defects are immediately and satisfactorily remedied. As a result much more work than is asked for is frequently done, as the owner appreciates his obligation and the assistance rendered to him. In this connection I am inclined to be somewhat optimistic, because it was my experience towards the close of the year to find owners able and willing to proceed much quicker, thereby avoiding the service of notices and the subsequent revisiting of the property. Overcrowding-.—In addition to cases of overcrowding discovered during general inspections, 9 complaints were received and investigated. In 4 cases following the service of notices the overcrowding was abated by the sub-tenants obtaining more satisfactory accommodation elsewhere. In 2 cases conditions were somewhat improved by rearrangement of sleeping accommodation; in one case the Statutory Notice had not been complied with at the end of the year, but the matter is still being dealt with, and in the other 2 cases no overcrowding was found to exist. In large families the separation of sexes and the provision of adequate sleeping accommodation are problems which, in most cases, are rather difficult of solution. Additional accommodation at an economic rent is extremely hard to obtain, and, when it is available, landlords prefer to let only to small families. Houses Let in Lodgings.—There are now 73 of these houses on the Register. One hundred and sixty-eight visits of inspection have been made, and in addition, during the periodical house to house inspection, a number of the houses let in lodgings were inspected, but these visits will appear in the report of house to house inspection. Verminous Rooms.—During the year, 36 rooms have been dealt with. As previously, the necessary notices were served upon the persons responsible, whether occupier or owner. Every assistance has been given to those anxious to free their premises from vermin, and fumigants have been supplied at cost price, or fumigation carried out by the Public Health Department at the owner's expense, after the walls had been stripped as required. 49 Common Lodging Houses.—There is one registered Common Lodging House, namely, 42, Merton High Street, for which an annual Certificate of Registration was granted from 1st January, 1933 to 31st December, 1933. These premises have been visited from time to time, when a few minor defects have been found. The defects have been remedied immediately the owner's attention has been directed to them, and the premises generally are kept in a satisfactory condition. Van Dwellings.—One hundred and forty-six visits were paid to these dwellings. There are 11 sites used by van dwellings and these are confined to Trinity and Haydon Park Wards. 50 The following table shows the position and number of vans, together with the total occupants:— 51 Site. No. of Dwellings. Type. No. of Families. Occupants. A. c. Total. Adjoining 38, Deburgh Road 7 1 caravan 6 16 9 25 6 old tram6 Adjoining 49, Deburgh Road 4 4 old trams 4 11 6 17 Adjoining 52, Deburgh Road 3 2 trams 3 8 5 13 1 Rly. Coach Rear of 7, East Road 3 caravans 2 6 6 Rear of 11, East Road 1 old tram 1 4 4 Rear of 13, East Road 2 caravans 2 2 4 6 Adjoining 2, Hubert Road 3 caravans 9 4 1 5 Rear of 61, Norman Road 3 2 Rly. Coaches 3 6 6 11 1 caravan Adjoining 39, South Road 4 1 bungalow 4 10 3 13 1 caravan 2 trams Side of 88, South Road' ... 2 (and 1 Shed) caravans 1 5 5 10 Adjoining 8, Wandle Bank 4 3 caravans 3 5 1 6 1 shed Totals 37 31 77 39 116 All the sites are provided with a water closet, a water supply, and a sufficient number of dustbins. In two cases the sites are concrete paved. Every endeavour is being made to reduce the number of these dwellings on certain sites, and up to the present time 5 have been removed from one site, 3 from another, and 1 from a third. The owners have been warned against any attempt at replacement. By section 76 of the Wimbledon Corporation Act, 1933, additional powers are given for dealing with these dwellings, but as the section was not in force at the end of the year, the matter cannot be dealt with in this Report. Dairies, Cowsheds, and Milkshops.—Six applications were received during the year from persons desirous of being registered under the Milk and Dairies (Consolidation) Act, 1915, the Milk and Dairies (Amendment) Act, 1922, and the Milk and Dairies Order, 1926. Eighty-four inspections have been made of the premises of dairymen and purveyors of milk in the district, during which certain matters were discovered which required to be dealt with by the Public Health Department. As in previous years, much attention has been paid to retailers of milk in the Borough, particularly with regard to bottling in the streets. Milk is an article of diet which demands scrupulous cleanliness and care in handling, and I am convinced that the time spent by the department's officers in supervision is well repaid. The fact that offenders, who I am sure are few in number, are difficult to catch is evident by the fact that not a single case has been reported to the Authority throughout the year. I am, however, satisfied that in course of time this type of offender will be stamped out, and no one will be more pleased than the conscientious dairyman. Infectious Disease and Disinfection.—During the year, visits for the purpose of investigating cases of notifiable infectious disease were made to 187 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 into this country on which cases of infectious disease had occurred, and of which notice had been received at the Public Health Office from the Port Sanitary Authorities concerned. 52 At 30 houses from which cases of notifiable infectious 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 Public Health 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 room from which the cases had been removed were stripped and re-papered or distempered. The number of rooms disinfected was 423, and the number of articles, bedding, wearing apparel, etc., 6,304, full details of which are given in the Report of the Medical Officer of Health, under the heading "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, 64 yards were found to be in an unsatisfactory state, due either to the absence of any paving or to the defective condition of that which existed. Stable Refuse.—During the year continued attention has been paid to stable premises and to allotments where such refuse has at times been deposited some time prior to being used. Occupiers of stables have been warned as to the necessity for frequent removal in order to prevent nuisance from smells and from flies. Allotment holders have been persuaded to either cover accumulation with a layer of clean earth at least six inches deep, or to dig it into the ground as soon as possible in order to prevent a nuisance arising from such deposits. The majority of the persons interviewed have willingly complied with our requirements, and in only one case was the service of a notice found necessary. Inspections under the Factory and Workshop Act, 1901. —There are 351 factories, workshops, and work-places on the Register, to which 570 visits of inspection were made. Eighteen written notices were served referring to sanitary conveniences and other nuisances. 53 Shops Acts, 1912-28.—Pour hundred and thirty-eight visits were made for the purpose of observing contraventions of the Acts, advising shopkeepers regarding the Regulations in force, and in cases of complaints. In four cases legal proceedings were instituted, with the following results:— (a) For failing to close shop on weekly half-holiday. Fined 10s. and £1 Is. Od. costs. (b) For failing to close shop on weekly half-holiday. Case dismissed on payment of 4s. Court Costs. (c) For failing to close shop on weekly half-holiday. Case dismissed on payment of 10s. Court Costs. (d) (1) For failing to give assistant weekly half-holiday. Fined 10s. and 10s. Costs. (2) For failing to affix Assistant's Weekly Halfholiday Notice. Fined 10s. Three of these offences were committed during holiday periods notwithstanding the fact that each defendant had been previously advised of the provisions of Orders in force in the district. Your officers are always willing to give information respecting this matter, yet offenders continually plead ignorance of the law and make no attempt to seek official advice. Happily these instances are few, the Acts being particularly well observed throughout the district. The type of offender most difficult to detect is the case of the "mixed" shop, where exempted and non-exempted goods are sold. Observations are kept over long periods without an offence being detected, whilst at the same time it is believed that breaches of the Act are being committed. It is more in the nature of an accident that an offender is caught red-handed and in such a case it is usually followed by a plea of a first offence. The hawkers who come into the district on the weekly half-holiday have received considerable attention during the year, and quite a number have received written warnings from the department that further contraventions would result in proceedings being taken against them. As in previous years, the Home Secretary made an Order suspending the operation of the general Early Closing Order from 18th to 23rd December, inclusive. This did not, of course, relieve occupiers of the obligation to comply with the Weekly Half-Holiday Order in force, and, as a consequence, a number of enquiries were dealt with by the Public Health Department. 54 Slaughter Houses and Food Inspection.—The number of slaughter houses on the Register at the beginning of the year was one. At this one, very few animals were killed during the year, and the requisite notices having been received prior to the slaughtering, it was possible for complete examinations to be made before the carcases, etc., were removed. On an inspection of certain shop premises being made, a quantity of poultry was found to be in such a condition as to be unfit for food. These were seized and were subsequently condemned by a Magistrate. Legal proceedings before the Wimbledon Petty Sessional Court followed and the defendant was convicted and fined £10 and costs (£6 6s. Od.). The defendant thereupon appealed to the High Court of Justice (King's Bench Division) when the decision of the Justices was upheld. Three hundred and thirteen visits have been made to shops of butchers, fishmongers, fruiterers and other premises where food is stored, prepared or exposed for sale, and the following were surrendered and destroyed as trade refuse, being found unfit for human food:— 20-lbs. Prawns. Stale and foul smelling. 56-lbs. Skate and Skate Wings. Stale and foul smelling. 19-cwt. Bananas. Wet and rotting Food and Drugs (Adulteration Act), 1928.—One sample of sweets, suspected to be the cause of illness, was submitted to the Public Analyst. He reported that the sweets were free from injurious ingredients and were unlikely to be the cause of the illness complained of. Petroleum Acts.—Ninety-two applications were received for permission to keep petroleum, eighty-two being for the renewal of existing licences. Three hundred and "two inspections were made of the various premises in respect of which licences had been issued. Following a report made by the Commissioner of Police, the driver of a petrol tank (lorry) was prosecuted for a breach of the Regulations made by the Secretary of State under the Petroleum (Consolidation) Act, 1928 for smoking when driving a petrol lorry. 55 He was convicted and fined £1, the Chairman remarking "This is the first case of the kind we have had, but in future the Bench will take a very serious view of such cases because of the extreme danger." Diseases of Animals Acts, 1894 to 1925.— Parasitic Mange and Sivine Fever.—No cases of these diseases were notified in the district during the year. Foot and, Mouth Disease.—The Bath and West Show, it will be remembered, was held in Wimbledon this year, and on the first day an animal was found to be suffering from this disease. The animal, together with several others in definite contact, was immediately isolated by the Ministry's Inspector, and restrictions of movement were put into operation. I attended frequently and rendered all assistance possible. Happily the disease did not spread and animals were permitted to be moved from the Show Ground provided a licence was first obtained. Tuberculosis.—No outbreak of this disease was reported during the year. The usual quarterly returns, under the provisions of the Tuberculosis Order, 1925, were rendered to the Ministry of Agriculture. In consequence of Orders made by the Ministry, particularly with regard to Foot and Mouth Disease, a number of enquiries were dealt with, and, when necessary, licences for the movement of animals were issued. In August, the Ministry of Agriculture and Fisheries confirmed new Regulations made by the Council with respect to Sheep Scab. The Public Health (Meat) Regulations, 1924.—Continued attention has been devoted to the provisions of these Regulations and I have pleasure in reporting that they have been well observed. The notice required when animals were to be slaughtered was given in every case, making it possible for inspection to be made when killing was in prpgress. Rent (Restrictions) Acts, 1920 and 1933.—Under these Acts, five applications were received from occupiers of premises requesting that inspections be made as, in their opinion, the owners had failed in their obligations. In each case a complete survey of the house, both internal and external, was made and a notice prepared specifying the 56 works to be executed in order to make the premises in all respects reasonably fit for human habitation. The applications were submitted to the Committee together with a report of the conditions existing in each case. In only one case was the issue of a certificate authorised, and this was afterwards cancelled as the result of the applicant's subsequent action. In two eases the necessary work was completed before the applications were submitted to the Committee, and in the other two the conditions of the premises did not warrant the making of the application. Water Supply.—The water supply was withdrawn from 49 houses during the year, for the following reasons—28 by request; 16 owing to arrears of rates; and 5 for other reasons. Employment Agencies.—Visits have been paid, at irregular intervals, to the premises of the 8 licensed keepers, and the Bye-laws have been found to be well observed. I have also accompanied the County Council's Officer on visits of inspection and discussed with the keepers the provisions of the Bye-laws, etc. Employment of Children Bye-laws.—In connection with the employment of children, observations have been made during the year and five breaches were reported to the Education Authority. This work is done mainly outside office hours on Sunday and public holidays. Speaking generally, the bye-laws are quite well observed. Fouling of Footways by Dogs.—As in previous years attention has been given to the Bye-laws in force in the Borough, and in addition to general inspections all complaints received have been promptly investigated. It does not appear to be clearly understood that the bye-laws refer only to dogs on a lead, because in a number of complaints investigated we were told that certain dogs were sent out to roam at will. It is extremely difficult to understand the lack of common decency displayed by any person who, having charge of a dog secured by a lead, permits the animal to foul the public footway. 57 As a rule, the fouling takes place at some distance from the person's own premises and for this reason alone it is obvious that the nuisance is objectionable to them. If these people would give just a moment's thought to the matter and consider the comfort of others, I am confident the need for the Bye-law would soon disappear. Smallpox Contacts.—In connection with the smallpox cases occurring in the district, and local contacts of cases occurring outside the district, 92 visits of enquiry were made. As the majority of these contacts are persons employed in London, it necessitated the visits being paid during the evenings and week-ends, after they had returned from their business or occupation. Mosquitoes.—As in previous years the lakes, pools, ditches, and other known breeding places of mosquitoes have been efficiently sprayed with paraffin. Complaints have received prompt attention and where necessary further spraying has been carried out with satisfactory results. Complaints of this nature are at times extremely difficult to investigate because it is necessary to make inspections over a wide area in order to locate possible breeding grounds. In one instance, after careful searching, a disused artificial pond in private grounds was proved to be the source of the trouble but, on the owner being acquainted of the nuisance caused to other residents, the matter was promptly and effectually dealt with. Offensive Trades.—The fish-frying premises have been inspected during the year, and in practically all cases the Bye-laws were found to have been adhered to. A few minor alterations were found necessary, and these were promptly attended to when pointed out to the occupiers. No new premises have been established and none have been closed, there being 16 on the Register at the close of the year. I take this opportunity of again recording my appreciation of the loyal support and assistance rendered by the staff generally, and to acknowledge the kind co-operation of Dr. Ellis, the Medical Officer of Health, and my colleagues of other departments. HENRY JOHNSON, M.B.E., F.R.San.I., F.S.I.A., Chief Sanitary Inspector. 58 TABLE III. The following is a summary of the nuisances abated, and sanitary improvements carried out, under the supervision of the Sanitary Staff of the Public Health Department:— Accumulations removed 37 Cisterns provided 8 Cisterns repaired, cleansed or covered 17 Drains, new, provided 12 Drainage Systems made water-tight by patent process 28 Drains, repaired or altered 61 Drains, stoppages removed 56 Dustbins provided 133 Flushing cisterns, new and provided 53 Flushing cisterns repaired 67 Manure receptacles provided 1 Overcrowding nuisances abated 4 Rain-water pipes disconnected 1 Roofs repaired 108 Rooms stripped and cleansed 771 Verminous rooms cleansed 36 Soilpipes, new, provided 15 Soilpipes, repaired or altered 10 Vent pipes, new, provided 20 Vent pipes, repaired or altered 18 Waste pipes, new, provided 95 Waste pipes repaired, disconnected or trapped 27 Water-closets, new, provided 88 Water-closets, repaired or ventilated 13 Water services restored 27 Yards paved 4 Yards repaired 60 Guttering repaired 62 Floors ventilated 6 Nuisances abated from damp walls 87 Water supply direct from main 13 Sinks provided 17 Rooms fumigated 423 Other nuisances 1,159 3,537 59 SCHOOLS. Information concerning the sanitary condition of the schools, together with the means adopted to prevent the spread of infectious diseases among school children, is given in the section of the report dealing with the School Medical Service. 60 HOUSING (a) HOUSING STATISTICS FOR THE YEAR 1933. 1. Inspection of Dwelling-houses during the Year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1,282 (b) Number of inspections made for the purpose 4,315 (2) (a) Number of dwelling-houses (included under sub-head [1] above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 211 (b) Number of inspections made for the purpose 1,248 (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 subhead) found not to be in all respects reasonably fit for human habitation 723 2. Remedy of defects during the year without service of formal notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers ... 823 3. Action under Statutory Powers during the year:— A.—Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices : (a) By owners Nil (b) By local authority in default of owners Nil B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 84 61 (2) Number of dwelling-houses in which defects were remedied after service of formal notices: (a) By owners 74 (b) By local authority in default of owners Nil C.—Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made ... Nil (2) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil D.-—Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate fentments or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil (b) HOUSING CONDITIONS. There are no changes to report in the housing conditions of the Borough and the observations made during previous years, to a large extent, still apply. Seventy-four houses and sixteen flats were erected by private enterprise during 1933. According to the Registrar-General's estimate for the middle of 1D33 there has been a slight decrease in the population since the 1931 Census. As stated in previous Reports, the absence of suitable building sites for the erection of houses for persons of smaller means, is largely responsible for the housing shortage in Wimbledon. It has been pointed out that the economic factor is undoubtedly of great importance from the point of view of overcrowding. It is also largely responsible for the amount of sub-letting which is taking place. In many cases the accommodation sub-let is by no means adequate for the needs of the sub-tenants and the rent charged is often far higher 62 than the circumstances justify. Many people to-day, however, who are either unemployed or partially employed are quite unable to find the rent for the houses which they have occupied in the past, and sub-letting offers a solution to their difficulty. It is not easy to deal with the overcrowding which arises from this practice. In the worst cases, the Authority is empowered to place the premises on the register of houses let-in-lodgings, in order that the accommodation may be governed by the bye-laws which have been made for controlling such establishments. In accordance with the procedure which has been adopted in past years a table is appended hereunder giving details of the housing conditions in three streets which are fairly representative of an artisan and working-class area. An indication is tiiven of the extent to which overcrowding exists. The estimate of the overcrowding is based on the legal requirements set out in the bye-laws for houses let-inlodgings, that is, for adults 360 cubic feet, and for children under ten years of age 2l50 cubic feet. Road Total No. of Houses Inspected No. of Separate Lettings No. of Occupiers Average No. of Rooms per Letting Average No. of O'cupiere per Room Average Rent per Room per Letting Under 10 Years Over 10 Years Wandle Road 64 82 59 284 3.9 1.05 2/7 Palmerston Road 114 142 55 432 4.2 0.81 3/8 Goodenough Road 31 48 31 139 3.1 1 13 3/9 Total 209 272 145 855 3.9 0.93 3/4 Road No. of Separate Lettings Consisting of 1 room 2 rooms 3 rooms 4 rooms 5 rooms 6 rooms 7 rooms Wandle Road 7 9 7 17 42 ... ... Palmerston Road 3 6 44 9 68 9 3 Goodenough Road 5 4 22 15 1 1 ... Total 15 19 73 41 111 10 3 63 Overcrowding, based on the standard of the bye-laws for houses let-in-lodgings, was found to exist as follows:— Road Lettings Overcrowded by 1 Child 1 Adult 2 Adults Wandle Road 5 1 ... Pal merstonRoad 1 1 ... Goodenough Road 6 ... 1 Total 12 2 1 It will thus be seen that in the two hundred and nine houses inspected in detail, overcrowding was found to exist to the extent of four adults and twelve children. No difficulties were experienced during the year in taking action under the Public Health Acts when dealing with housing conditions. Many houses are continually coming to the notice of the Public Health Department on account of sanitary defects. These defects are remediable under the provisions of the Public Health Acts. They were continuously dealt with throughout the year. Such houses can be, and are being, rendered perfectly fit in every way for human habitation when the nuisances are abated. Overcrowding, which undoubtedly exists in all urban areas to-day, does not, in itself, imply that the dwellinghouses themselves are insanitary. 64 INSPECTION AND SUPERVISION OF FOOD Milk Supply.—Practically all the milk for retail sale is brought into the area from other districts. A few cows are kept by private individuals for milk, but such milk is not retailed. There were on the registers on 31st December, 1933, one cowkeeper, thirty-six dairymen, seventeen dairymen and purveyors, and twenty-one retail purveyors. Frequent periodical inspections of the dairies were made. The conditions under which the milk is stored and distributed were found to be satisfactory. A number of dairymen residing outside the Borough were again found to be retailing milk in Wimbledon without having been registered by this Authority. The purveyors were informed of these contraventions, and as a result of this, applications for registration were received. In all cases registration waa granted. It was not necessary to take any action under the Milk and Dairies Order, 1926, during the year. No action was necessary as to tuberculous milk or cattle. The number of licences granted under the Milk (Special Designations) Order, 1923, was as follows:— Pasteuriser's Licence 1 Dealers Licences: Certified Milk 5 Grade A (T.T.) Milk 4 Grade A Milk 2 Pasteurised Milk 1 Supplementary Licences 15 Bacteriological Examination.—Two samples of milk, taken for bacteriological examination under the Milk (Special Designations) Order, were found not to comply with the bacteriological standards laid down. Enquiries shewed that the failure to maintain a satisfactory standard in these cases was due to temporary difficulties, which were immediately remedied. The remaining five samples were all found to be satisfactory. 65 SLAUGHTER HOUSES. In In In 1920. Jan. 1933. Dec. 1933. Registered 4 1 1 Licensed 1 ... ... Totals 5 1 1 There is now only one slaughter-house used in Wimbledon, and very little slaughtering is carried on at these premises. Food and Drugs (Adulteration) Act, 1928. The Public Analyst under the Food and Drugs Acts is appointed by the Surrey County Council. I" am indebted to the County Medical Officer of Health for the information set out in the table below, which deals with the work carried out in Wimbledon during 1933. ARTICLES Analysed adulterated OR Deteriorated Formal Informal Total Formal Informal Total Milk 69 ... 69 4 ... 4 Cream 6 ... 6 ... ... ... Artificial Cream ... ... ... ... ... ... Butter ... ... ... ... ... ... Meat 5 ... 5 ... ... ... Tea ... ... ... ... ... ... Cocoa 4 ... 4 ... ... ... Sugar 4 ... 4 ... ... ... Sausages 4 ... 4 ... ... ... Confectionery and Jam 1 3 4 ... ... 1 Drugs 4 4 8 1 ... 1 Lemonade Powder 3 ... 3 ... ... ... Dried Peaches 1 ... 1 ... ... ... Dried Apple Bings 1 ... 1 ... ... ... Dried Apricots 2 ... 2 1 ... 1 Dried Fruit Salad 2 ... 2 ... ... ... Lemon Extract 1 ... 1 1 ... 1 Dried Mint ... 1 1 ... ... ... Totals 107 8 115 7 1 8 66 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS AND OTHER DISEASES In 1933, three hundred and twelve cases of infectious diseases were notified as compared with three hundred and eighty-one during the previous year. The most notable change was the very considerable fall in the number of cases of diphtheria. There were one hundred and twenty-six cases of scarlet fever, the same figure as in 1932. Twenty-one cases of diphtheria occurred, forty-three less than in the previous year. The incidence of diphtheria has shown a steady decline since 1928, when the number of cases notified amounted to one hundred and seventy. During 1933 there were two deaths from diphtheria amongst Wimbledon residents. No death from scarlet fever occurred. The deaths from the non-notifiable infectious diseases during the past four years were as follows:— 1930. 1931. 1932. 1933. Measles 10 Nil 4 1 Whooping Cough ... 2 4 Nil 3 Diarrhoea (under 2 years) 2 5 4 2 Measles.—Measles was prevalent in epidemic form during March, April and May, 1932, and three hundrd and thirty-one cases came to the notice of the Public Health Department during that year. In 1933 information was received of sixtyseven cases, and only one death was registered as being due to this disease. Whooping Cough.—Whooping cough was more prevalent, fifty-eight cases being notified to the Public Health Department by the Head Teachers of the Public Elementary Schools. Three deaths occurred from this disease on account of broncho-pneumonia. Diarrhoea (under two years).—Two deaths occurred from this cause. Both these children died in local hospitals, the ages at death being four months and fourteen months respectively. Influenza.—Influenza was prevalent in a mild form during the latter part of 1932 and a number of cases occurred during the commencement of 1933. Twenty cases of influenzal pneumonia were notified during the first three months. 67 Seventeen deaths (seven males and ten females) were attributable to influenza during the year under review. Smallpox.—Three cases of smallpox were notified, two of them occurring in the same family. The disease was of the usual mild modified type prevalent in London at the time. One patient was an adult who became infected from a previous unrecognised case which had occurred in the same house. This latter individual had contracted the disease at his place of employment in one of the Metropolitan boroughs, and was already free from all infection when the origin of the secondary case was traced to him. The other two cases were children. The first was under school age and had attended the Day Nursery until the onset of the rash. The parents of unvaccinated children were notified and arrangements were made for the Public Vaccinator to attend at the Nursery to vaccinate those children whose parents were agreeable to this being carried out. No further case occurred at the Day Nursery. The patient's brother, a school child, subsequently developed the disease. These patients were all removed to the Smallpox Hospital at Clandon. Information was received by the Public Health Department periodically throughout the year of persons resident in Wimbledon who had been in contact with cases of smallpox outside the Borough. In all, nine contacts were notified from other Health Departments. They were kept under observation for sixteen days by the sanitary staff. None of these contacts developed the disease. Ninety-two visits were paid to the houses of smallpox contacts. As in 1932, it was not considered necessary to make chicken-pox notifiable in Wimbledon. Scarlet Fever.—The total number of cases notified during the year was one hundred and twenty-six from one hundred and fifteen houses. The attack rate was 2.14 per thousand of the population. Attack Rate. Death Rate. 1891-1895 4.80 0.02 Per thousand of the Population. 1896-1900 3.30 0.04 1901-1905 2.30 0.02 1906-1910 4.07 0.05 1911-1915 3.03 0.01 1916-1920 1.80 0.01 1921-1925 3.04 0.02 1926-1930 2.40 0.003 68 In one house there were four eases, in two houses there were three cases, in eight houses there were two cases, and in the remaining one hundred and four houses, one case. One hundred and sixteen, or ninety-two per cent, of the cases, were treated in the Infectious Diseases Hospital, Gap Road. There were no deaths amongst Wimbledon residents. Fifty-four per cent, of the cases notified were children of school age, five to fifteen years, and of these, sixty-nine attended the following schools :— Old Central School 1 Dundonald Road Infants' School 3 Wimbledon Park Mixed School 2 Russell Road Mixed School 5 Haydon's Road Boys' School 5 Haydon's Road Girls' School 7 Haydon's Road Infants' School 6 Cottenham Park Mixed School 2 Cottenham Park Infants' School 3 Queen's Road Boys' School 4 Queen's Road Infants' School 1 Special School (Queen's Road) 1 Effra Road Girls' School 2 Effra Road Infants' School 1 Pelham Road Infants' School 6 Central School for Boys 1 Central School for Girls 3 Private Schools 11 Schools outside the Borough 5 Total 69 Diphtheria.—The total number of cases notified was twenty-one from nineteen houses. The attack rate was 0.35 per thousand of the population. In one house there were three cases, and in the remaining eighteen houses, one case. Twenty, or ninety-five per cent, of the patients received hospital treatment. 69 Two deaths occurred, giving a death rate of 0.03 per thousand of the population. Forty-two per cent, of the cases notified were children of school age, five to fifteen years, and of these, nine attended the following schools:— Dundonald Road Girls' School 1 Effra Road Infants' School 1 Wimbledon Park School 3 Schools outside the Borough 4 Total 9 Careful investigation is carried out after each case of diphtheria has been notified. School children from infected houses are swabbed and not re-admitted to school until a negative result lias been obtained. These swabs are either taken by the family doctor or by the staff of the Public Health Department, according to the circumstances of the case. Adult contacts living in the same house are also advised to have swabs taken from the nose and throat and in most cases they agree to this precaution being carried; out. Food Poisoning.—No case of food poisoning was reported to the Public Health Department. Puerperal Fever and Puerperal Pyrexia.—In accordance with the Public Health (Notification of Puerperal Fever and Puerperal Pyrexia) Regulations, 1926, the Council have appointed an obstetric physician to act as consultant in this area. Facilities are also available for bacteriological diagnosis. Hospital treatment is provided for at the following institutions:— (i) Queen Charlotte's Maternity Hospital Isolation Block, Hammersmith; (ii) Borough of Wimbledon Infectious Diseases Hospital; (iii) Kingston and District Hospital. It was not found necessary to call in the obstetric physician in consultation. Two cases of puerperal fever and five cases of puerperal pyrexia were notified, as compared with three cases of puerperal fever and seven cases of puerperal pyrexia in 1932. 70 Three of the eases notified were removed to the Queen Charlotte's Maternity Hospital Isolation Block, Hammersmith, for treatment. All these patients made good recoveries. There was 110 death from puerperal sepsis amongst the seven patients notified under the Regulations. During the previous year there was one death from puerperal sepsis, equal to a mortality rate of 1.47 per thousand of the total births. Cerebro-Spinal Fever.—Two cases of cerebro-spinal fever occurred. One was a child who had been admitted from Wimbledon into the Kingston and District Hospital, and was notified subsequently as a case of cerebro-spinal meningitis. This patient died. The second case, which was transferred to the Infectious Diseases Hospital as a case of encephalitis lethargica from a general hospital, was found after admission to be suffering from cerebro-spinal meningitis. This case also terminated fatally. Encephalitis Lethargica.—There were 110 cases of encephalitis lethargica among Wimbledon residents in 1933. Malaria, Dysentery, etc.—No cases of malaria or of dysentery were notified. Ophthalmia Neonatorum.—Three cases of ophthalmia neonatorum were notified. Particulars regarding these cases are given in the section dealing with Maternity and Child Welfare. Erysipelas.—Notifications were received in respect of twenty-nine cases of erysipelas. In all but ten instances these were nursed at home. Six patients requiring removal were sent into the Kingston and District Hospital for treatment, and four into the Infectious Diseases Hospital at Gap Road. There was one death, which gives a death rate of 0.01 per thousand of the population. 71 TABLE A—NOTIFIABLE DISEASES DURING 1933. DISEASE Number of Cases Notified in Various Age Groups Total Cases Notified Total Cases Removed to Hospital Under 1 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20—35 35—45 46—65 65 and over. Smallpox ... ... ... 1 1 ... ... ... 1 ... ... ... 3 3 Scarlet Fever ... 2 8 7 9 45 25 15 14 1 ... ... 126 116 Diphtheria (including Membranous Croup) ... ... 2 ... 1 8 ... ... 5 2 3 ... 21 20 Enteric Fever (including Paratyphoid) ... ... ... ... ... ... ... ... 1 ... ... ... 1 1 Puerperal Fever ... ... ... ... ... ... ... ... 2 ... ... ... 2 2 Puerperal Pyrexia ... ... ... ... ... ... ... ... 5 ... ... ... 5 1 Acute Primary Pneumonia 1 ... ... ... 1 4 ... 1 1 1 6 7 22 ... Acute Influenzal Pneumonia ... ... 1 ... 1 2 ... ... 3 4 4 5 20 ... Cerebro-Spinal Fever ... 1 ... ... ... ... ... ... ... ... 1 ... 2 2 Acute Poliomyelitis ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... Acute Polio-encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... ... ... ... Dysentery ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ophthalmia Neonatorum 3 ... ... ... ... ... ... ... ... ... ... ... 3 ... Erysipelas ... ... ... ... ... ... ... 1 4 4 15 5 29 10 Tuberculosis (all forms) ... 1 ... ... ... 4 1 9 38 13 9 2 77 55 Totals 4 4 11 8 14 63 26 26 74 25 38 19 312 210 72 Table showing Ages at Death from Notifiable Infectious Diseases. Disease. ages at Death. Total Deaths Under 1 Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and over Smallpox ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria(including Membranous Croup) ... ... ... ... 2 ... ... ... ... ... ... ... 2 Enteric Fever (including Paratyphoid) ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... ... Acute Primary Pneumonia 2 ... ... ... ... ... ... 1 4 1 8 30 46 Acute Influenzal Pneumonia ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebro-Spinal Fever ... l ... ... ... ... ... ... ... ... 1 ... 2 Acute Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... ... Acute Polio-encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 1 1 Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... Dysentery ... ... ... ... ... ... ... ... ... ... ... ... ... Ophthalmia Neonatorum ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... 1 1 Tuberculosis (all forms) 1 ... ... 1 ... 2 1 5 15 7 6 4 42 Totals 3 l ... 1 2 2 1 6 19 8 15 36 94 The figures given in this table are those obtained after correction by inward and outward transfers of deaths. 73 Table showing- Zymotic Death Rate, the Death Rates from Zymotic Diseases, and Death Rate from Tuberculous Diseases for the last ten years. YEAR. Death Rate Per 1,000 Population Zymotic Death-rate. Smallpox Scarlet Fever. Diphtheria. *Enteric Fever. Whooping Cough. Measles. Diarrhoea. Phthisis and other Tuberc'los Diseases. 1924 1.10 0.00 0.06 0.01 0.01 005 0.15 0.05 0.75 1925 1.01 0.00 0.03 0.01 0.00 0.10 0.00 0.08 0.77 1926 0.70 0.00 0.00 0.00 0.00 0.00 0.10 0.00 0.60 1927 0.94 0.00 0.01 0.03 0.00 0.05 0.00 0.03 0.80 1928 1.10 0.00 0.00 0.10 0.00 0.08 0.11 0.03 0.70 1929 1.06 0.01 0.00 0.10 0.00 0.08 0.00 0.05 0.80 1930 0.99 0.00 0.00 0.06 0.00 0.03 0.16 0.03 0.69 1931 0.15 0.00 0.00 0.00 0.00 0.06 0.00 0.08 0.90 1932 0.16 0.00 0.00 0.01 0.01 0.00 0.06 0.06 0.80 1933 0.13 0.00 0.00 0.03 0.00 0.05 0.01 0.03 0.71 •Including Paratyphoid. The figures given in this Table are those obtained after correction by exclusion of "Non-Residents" and the inclusion of "Residents" beyond the district. Table showing Ward Distribution of Infectious Cases in 1933. DISEASE. Cases Notified at All Ages. Cases Notified in each Ward. Total Cases removed to Hospital. St. Mary's St. John's Cottenham Park Wimbledon Park Dundonald Trinity South Park Haydon Park Smallpox 3 ... ... ... ... ... 2 1 ... 3 Scarlet Fever 126 3 12 17 2 17 39 12 24 116 Diphtheria (including Membranous croup) 21 3 1 2 8 4 1 1 1 20 Enteric Fever (including Paratyphoid) 1 ... ... ... ... ... ... 1 ... 1 Puerperal Fever 2 ... ... 1 ... ... 1 ... ... 2 Puerperal Pyrexia 5 ... ... ... 1 1 ... 3 ... 1 Acute Primary Pneumonia 22 ... 2 8 1 1 2 4 4 ... Acute Influenzal Pneumonia 20 1 ... 2 ... 5 1 5 6 ... Cerebro-spinal Fever 2 1 ... 1 ... ... ... ... ... 2 Acute Poliomyelitis 1 ... ... ... ... ... ... 1 ... ... Acute Polio-encephalitis ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... Dysentery ... ... ... ... ... ... ... ... ... ... Ophthalmia Neonatorum 3 ... ... 2 ... 1 ... ... ... ... Erysipelas 29 2 1 2 1 8 5 6 4 10 Pulmonary Tuberculosis 70 3 6 5 4 16 12 15 9 53 Non-pulmonary Tuberculosis 7 1 ... ... ... 1 4 ... 1 2 Totals 312 14 22 40 17 54 67 49 49 210 74 Table showing Number of Cases of Infectious Diseases Notified during each year from 1924 to 1933. Disease 1924 1925 1926 1927 1928 1929 1930 1931 1932 1934 Smallpox ... ... ... 1 ... 2 2 1 ... 3 Scarlet Fever 150 170 165 169 126 131 127 75 126 126 Diphtheria (including Membranous Croup) 42 33 26 52 170 150 140 74 64 21 Enteric Fever 3 3 4 4 4 7 ... 1 ... ... Paratyphoid Fever 6 ... ... 7 6 ... 2 1 2 1 Puerperal Fever 3 3 3 1 2 2 4 4 3 2 Puerperal Pyrexia ... ... ... 9 6 12 9 7 5 Acute Primary Pneumonia 10 16 39 42 32 39 23 21 28 22 Acute Influenzal Pneumonia 2 1 1 9 3 9 1 7 33 20 Cerebro-spinal Fever 2 ... 1 2 1 2 2 1 1 2 Acute Poliomyelitis 2 ... 4 ... 1 ... ... ... ... 1 Acute Polio-encephalitis 2 ... ... ... ... ... ... ... ... ... Encephalitis Lethargica 10 5 3 2 1 ... 1 ... 1 ... Malaria 1 ... ... ... 2 ... ... ... 1 ... Dysentery ... ... ... ... ... ... ... ... 1 ... Ophthalmia Neonatorum 2 3 3 4 3 1 3 4 7 3 Erysipelas 13 20 17 24 19 33 29 18 29 Pulmonary Tuberculosis 64 63 48 66 65 56 56 67 81 70 Non-pulmonary Tuberculosis 18 7 6 19 14 13 5 13 8 7 Totals 330 324 320 401 455 457 404 301 381 312 TUBERCULOSIS. Seventy-seven cases of tuberculosis were notified. This figure shows a decrease of twelve over the number for the previous year. The deaths from tuberculosis were six less than in 1932, the total figure being forty-two. Of the thirty-five deaths from pulmonary tuberculosis, fourteen died outside the district (nine males and five females). These deaths were transferred to Wimbledon by the Registrar-General. There were seven non-pulmonary deaths. Of these, three males and two females died outside the district. The causes of death in these cases were as follows:— Tuberculous meningitis 3 Miliary tuberculosis 1 Tuberculous disease of the spine 1 Tuberculous osteomyelitis of hip 1 Tuberculosis of the kidneys 1 75 At the end of the year there were three hundred and seventy-nine eases remaining on the tuberculosis register, two hundred and eighty-eight being cases of pulmonary, and ninety-one being cases of non-pulmonary tuberculosis. The register is revised quarterly as the result of information given by the Tuberculosis Officer regarding cases in attendance at the Dispensary. There is a close co-operation between the Public Health Department and the Tuberculosis Department of the Surrey County Council. An inspection of the home conditions and sanitary environment of every tuberculous patient is carried out by the staff of the Public Health Department as soon as the notification is received. In many cases the isolation of patients who are nursed at home is far from satisfactory. A great deal, however, has been done to try and improve conditions and mitigate the risk of infection to other members of the household concerned. A large number of visits are paid by the members of the sanitary and nursing staff. Insanitary conditions have been remedied and arrangements made, where possible, for the patients to sleep in separate bedrooms. Where necessary, disinfectants are also supplied. In a certain number of cases it has been possible for convalescent treatment to be arranged for children who are contacts of the disease. The Surrey County Council make all arrangements for the provision of sanatorium and hospital treatment. During 1933, fifty-five Wimbledon patients were admitted to sanatoria or hospitals. Public Health (Prevention of Tuberculosis) Regulations, 1925.—No action was necessary in regard to tuberculous employees in the milk trade. Public Health Act, 1925 (Section 62).—No action was required under this section of the Public Health Act, 1925. 76 TUBERCULOSIS.—The following table shows the number of new cases added to the register during the year, and the number of deaths from this disease. AGE GROUPS NEW CASES DEATHS Primary Notifications (Form A) New Casesidiscovered otherwise than by Notification Total New Cases Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary Pulmonary NonPulmonary Males Females Males Females Males I | Females Males Females Males Females Males Females Males Females Males Females Under 1 year ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1—5 „ ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... ... 1 5—10 „ 2 ... 1 ... ... ... 1 ... 2 ... 2 ... ... ... 2 ... 10—15 „ ... 1 ... ... ... ... ... ... ... 1 ... ... ... 1 ... ... 15—20 „ 3 3 ... 1 2 ... ... ... 5 3 ... 1 ... 5 ... ... 20—25 „ 4 7 ... ... 1 1 ... ... 5 8 ... ... 4 1 1 ... 25—35 „ 6 9 ... ... 6 4 ... ... 12 13 ... ... 6 2 1 ... 35—45 „ 6 5 ... ... 2 ... ... ... 8 5 ... ... 6 1 ... ... 45—55 „ 4 1 1 ... 1 ... ... ... 5 1 1 ... 4 1 1 ... 55—65 „ 1 ... ... 1 ... ... ... ... 1 ... ... 1 ... 1 ... ... 65 and over 1 ... ... ... ... ... ... 1 1 ... ... 1 2 1 ... ... Totals 27 26 2 3 12 5 1 1 39 31 3 4 22 13 5 2 53 5 17 2 70 7 35 7 58 19 77 42 77 77 Wimbledon Infectious Diseases Hospital Disease Cases admitted Deaths Under 5 Years Over 5 Years Total Under 5 Years Over 5 Years Total Brought forward from 1932 Scarlet Fever 9 22 31 ... ... ... Diphtheria 5 17 22 ... ... ... Whooping Cough 1 ... 1 ... ... ... Cases admitted in 1933 From Wimbledon— Scarlet Fever 20 96 116 ... 1 1 Diphtheria 3 16 19 1 ... 1 Erysipelas ... 4 4 ... ... ... Measles ... 1 1 ... ... ... Cerebro-spiral Meningitis ... 1 1 ... 1 1 Enteric Fever ... 1 1 ... ... ... Chicken Pox 1 ... 1 ... ... ... From Kingston— Scarlet Fever 17 85 102 ... ... ... Diphtheria 8 21 29 1 ... 1 „ (Baby born) 1 ... 1 ... ... ... From Mitcham— Whooping Cough 1 ... 1 ... ... ... From Tolworth— Scarlet Fever ... 1 1 ... ... ... (Transferred to Tolworth) Totals 66 265 331 2 2 4 Daily Average Number of Cases in Hospital 37 Average Number of Days in Hospital (per Case) 43 Total Number of Kingston Cases 132 The revenue derived from the admission of patients from outside areas since 1919 now exceeds £32,620. Two hundred and seventy-seven cases were admitted to the Infectious Diseases Hospital during 1933. As there were fifty-four cases in hospital at the end of 1932, the total number of cases under treatment during the year amounted to three hundred and thirty-one. One hundred and forty-three of these cases were from Wimbledon, one hundred and thirty-two from Kingston, one from Mitcham, and one from Tolworth. 78 There were thus two fewer cases admitted to the hospital in 1933 as compared with the previous year. Scarlet Fever.—Two hundred and nineteen cases were admitted to hospital during the year as scarlet fever. In one case, the patient was found to be suffering from German measles and in another case the patient was suffering from diphtheria. One death from scarlet fever occurred. The following complications were noted amongst the cases under treatment:— Rhinitis 6 Acute Otitis Media (with Otorrhœa) 20 Acute Otitis Media (without Otorrhcea) 5 Mastoiditis 2 Adenitis 16 Acute Nephritis 5 Albuminuria 4 Rheumatism 8 Whitlows 2 Jaundice 2 Secondary Tonsillitis 3 Secondary Rashes 2 Acute Pericarditis 2 Streptococcal Pleurisy 1 Erythema nodosum 1 The most frequent complications that arose were those involving the ears, nose, and glands. Twenty-seven patients developed acute otitis media. In five cases the inflammation subsided without discharge from the ear. In two patients acute mastoiditis supervened, one of these requiring to be operated on for double mastoidectomy. The other case of mastoiditis subsided without operative treatment. Paracentesis on one or both ears was performed in four cases. The patient who was operated on for bilateral mastoid disease made a good recovery and was sent home with good hearing and free from ear discharge. In all the patients with ear complications the trouble completely cleared up before they left hospital and in on case did any apparent deafness result. 79 Five cases of scarlet fever were admitted with otorrhœa and one case with chorea and old-standing otitis media. These cases are not included amongst the ear complications which were noted after the patients had been admitted to hospital. Five patients developed acute hæmorrhagic nephritis and four albuminuria. These patients made complete recoveries. Two patients developed acute pericarditis and in one case this was further complicated by a streptococcal pleural effusion. In this latter patient the effusion was treated by aspiration and a complete recovery resulted. The other patient with pericarditis was admitted from a general hospital where she had been undergoing treatment for acute rheumatism complicated by endocarditis. This case terminated fatally although the attack of scarlet fever from which she was suffering was mild. Eight patients suffering from scarlet fever developed rheumatism as a complication. The rheumatism was not severe and in no instance was there any cardiac complication. One of these patients was suffering from chorea on admission. Two children suffering from scarlet fever developed jaundice during their convalescence. During the previous year one case of jaundice was noted. There was one case of scarlet fever following burns. Three other cases of scarlet fever were admitted from other hospitals where they had been undergoing treatment for the following conditions:—operative treatment for tuberculous glands of neck; osteoclasis of legs for deformity due to rickets; appendix abscess. As in previous years anti-scarlatinal serum was used fairly extensively. Most of the patients, with the exception of those who had the disease in a very mild form, received an injection of this serum on admission. The serum appeared to lower the temperature considerably and to make the patients much more comfortable. In the more severe forms of the disease, undoubted improvement in their condition resulted. Four return cases occurred. This amounts to just under two per cent. of the patients discharged. Diphtheria.—Forty-eight patients were admitted to the Infectious Diseases Hospital as cases of diphtheria. This shows a very great reduction on the figure for 1932 when one hundred and three patients were admitted as cases of this disease. Of the forty-eight admissions only forty proved 80 to be suffering from true clinical diphtheria. These latter cases included two children suffering from laryngeal diphtheria and one child with laryngeal and faucial diphtheria. Four patients were admitted as a result of "positive" swabs and were found to be harbouring the bacilli in the nose and throat but not actually suffering from the disease. Three other patients, on admission, were found to be suffering from non-diphtheritic infections of the throat. It will thus be seen that diphtheria was not prevalent in the Borough during the year under review. The following complications were noted amongst the forty patients suffering from clinical diphtheria under treatment:— Palatal Paralysis 6 Ciliary Paralysis 4 Multiple Neuritis 3 Pharyngeal Paralysis 1 The three patients admitted with respiratory obstruction due to laryngeal diphtheria made good recoveries and tracheotomy was not found to be necessary. Two deaths from diphtheria occurred amongst the forty cases under treatment in the hospital. This gives a fatality rate of five per cent. One of these patients was admitted from outside the Borough. The Wimbledon patient who died was found on admission to be suffering from severe congenital disease of the heart. Three negative swabs were obtained from the nose and throat of all patients prior to discharge. Two patients, however, gave persistent positive swabs from the throat. Animal inoculation tests proved that the organisms present in these cases were virulent. These patients were operated upon for the removal of their tonsils by the Oto-laryngologist attached to the hospital and were ultimately discharged after the usual negative swabs had been obtained. Four other patients became temporary carriers and this necessitated a longer stay in hospital than is usually required before they could be pronounced safe for discharge. No return cases of diphtheria were reported during the year. One patient was admitted to hospital with diphtheria whilst in the eight month of pregnancy. A female child was born whilst she was in the hospital. Both were discharged to their home in due course, the patient having made an uninterrupted recovery. 81 Enteric Fever.—One patient was admitted to hospital as a case of typhoid fever. Further investigation failed to confirm the diagnosis, and he was discharged to his home after the expiration of thirteen days. Meningitis.—One patient was admitted as a ease of encephalitis lethargica from a general hospital in the district. This patient was found to be suffering from meningococcal cerebro-spinal meningitis. She died after being in hospital nearly six weeks. Erysipelas.—Four patients were admitted to the hospital suffering from erysipelas. Three of these were discharged, having made good recoveries. The fourth patient, whose illness was complicated by hasmorrhagic nephritis and pyelitis, was still in hospital under treatment at the end. of the year. Measles.—Only one patient was admitted to the hospital suffering from this disease. Whooping Cough.—One child with whooping cough was admitted, at the request of the Medical Officer of Health for Mitcham, on account of the unsatisfactory home conditions. Other Diseases.—One girl, with a suspicious rash, was admitted into a cubicle at the Infectious Diseases Hospital for further observation. She was subsequently found to be suffering from a mild atypical form of smallpox and was transferred two days later to the County Smallpox Hospital at Clandon. Thirty-three patients remained in hospital at the end of 1933. Twenty-six of these were suffering from scarlet fever, six from diphtheria, and one from erysipelas. Staff.—During the year under review two of the junior nurses contracted scarlet fever whilst four others had attacks of tonsillitis. Otherwise, there was very little sickness of importance amongst the members of the hospital staff. I should again like to take the opportunity of thanking the matron and staff for the loyal and enthusiastic way in which they have carried out their duties. 82 Disinfection.—The following table shows the number of rooms and articles disinfected. Disease. Bedding Disinfected Clothing Disinfected No. of Booms Disinfected. Totals. Mattresses. Palliasses and Counterpanes. Beds. Pillows and Bolsters. Blankets and Sheets. Dresses Suits. Other Articles. Scarlet Fever 231 120 12 466 882 3 13 2027 137 3891 Diphtheria 37 23 82 117 1 5 476 24 765 Cancer 15 5 2 52 29 ... ... 21 24 148 Tuberculosis 50 18 2 181 130 ... 1 56 82 520 Erysipelas 10 10 1 25 41 1 ... 29 14 131 Measles 3 6 ... 1 16 ... 4 137 5 172 Whooping Cough 2 ... ... 2 11 ... ... 2 ... 17 Puerperal Fever 5 7 1 14 20 ... ... 48 1 96 Puerperal Pyrexia 2 1 ... 6 8 ... ... 14 1 32 Pneumonia ... ... ... ... ... ... ... ... 1 1 Enteric Fever 1 ... ... 3 5 ... ... ... 1 10 Cerebro-Spinal Fever 1 1 ... 2 3 ... ... ... ... 7 Smallpox 7 7 1 13 21 ... ... 50 7 106 Chickenpox 1 ... ... ... 6 ... ... 60 4 71 Encephalitis Lethargica 1 ... ... 3 2 ... ... 1 ... 7 Venereal Diseases 2 1 ... 2 ... 1 ... 8 ... 14 Vermin 16 9 1 25 27 ... ... 32 75 185 Sundries 52 11 4 190 124 ... 2 124 47 554 Totals 436 219 24 1067 1442 6 25 3085 423 6727 It will be noted that four hundred and twenty-three rooms and six thousand three hundred and four articles of bedding, wearing apparel, etc., were disinfected by the Public Health Department. In addition to the above, one hundred and thirty-one articles were destroyed. Speaking generally, infectious diseases are chiefly spread by mild unrecognised cases and "carriers," and not by inanimate objects. Experience has shown that thorough cleansing with soap and water together with the free admission of sunlight and fresh air into infected rooms is a safe and wholesome procedure to adopt. The modern tendency is to rely less upon the older methods of disinfection. In spite of this the public often request disinfection to be carried out in many cases where it is not really essential. 83 I am indebted to Mr. Taylor, the Senior Clerk, for the help which I have received from him in the preparation of this report, and especially for the care with which he has drawn up the statistical tables. I should like to take this opportunity of expressing my gratitude to the staff for the loyal and efficient way in which they have carried out their duties, and to thank my colleagues in other departments for their kind help and co-operation. I have the honour to be, Your obedient servant, HAROLD ELLIS. 84 TABLE 1. (.—Vital Statistics of Whole District during 1933 and Previous Years. YEAR. population estimated to middle of each Year. Births. Total Deaths Registered in the District. Transferable Deaths Net Deaths Belonging to the District. Uncorrected Number. Net. Under 1 year of Age At all Ages. Number. Rate. Number. Rate. of Non residents registered in the District. of Residents not registered in t'ne District. Number. Ft ate per 1000 Net Births Number. Rate 1924 58,090 763 814 14.01 495 8.5 49 199 59 70 645 11.1 1925 58,170 712 760 13.06 524 9.0 85 199 46 60 638 10.9 1926 58,030 722 807 13.90 479 8 2 83 183 27 33 579 9.9 1927 58,150 671 717 12.30 494 8.4 93 219 37 50 620 10.6 1928 59 070 637 691 11.60 476 8.05 84 240 38 55 632 10.7 1929 59,370 703 759 12.70 573 9.R 81 282 35 46 774 13.03 1930 59.370 691 766 12.90 444 7.4 57 261 38 49 648 10.9 1931 58,840 600 642 10.90 524 89 80 280 45 70 724 12.3 1932 59,440 519 667 11.22 506 8.5 68 275 45 67 713 11.9 1933 58,770 389 602 10.24 466 7.9 62 232 30 49 636 10.8 85 TABLE II.—Causes of, and Ages at, Deaths during- the year 1933. CAUSES OF DEATH. ALL AGES Net 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. Under 1 year. 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20—35 35—45 45—65 65 and over. All Causes Certified 636 30 4 1 4 4 10 6 7 39 28 151 352 94 Uncertified 1. Typhoid and Paratyphoid Fevers ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2. Measles 1 ... ... ... ... ••• 1 ... ... ... ... ... ... ... 3. Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... 4. Whooping Cough 3 1 ... ... ... 1 1 ... ... ... ... ... ... ... 5. Diphtheria 2 ... ... ... ... 2 ... ... ... ... ... ... ... 3 6. Influenza 17 2 ... ... ... ... ... ... ... ... ... ... 15 4 7. Encephalitis Lethargica 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... 8. Cerebro-spinal Fever 2 ... 1 ... ... ... ... ... ... ... ... 1 ... 1 9. Tuberculosis of respiratory system 35 ... ... ... ... ... ... 1 5 13 7 6 3 1 10. Other Tuberculous diseases 7 1 ... ... 1 ... 2 ... ... 2 ... 1 ... ... 11. Syphilis 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... 12. General paralysis of the insane, tabes dorsalis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 13. Cancer, malignant disease 92 ... ... ... ... ... ... ... ... 3 34 53 5 14. Diabetes 10 ... 1 ... ... ... ... ... ... ... ... 2 7 1 15. Cerebral Hæmorrhage 29 ... ... ... ... ... ... ... ... ... 1 8 20 2 16. Heart Disease 151 ... ... ... ... ... 1 ... ... 1 6 34 109 19 17. Aneurysm 4 ... ... ... ... ... ... ... ... ... ... 3 1 1 18. Other Circulatory Diseases 24 ... ... ... ... ... ... ... ... 1 ... 8 15 7 19. Bronchitis 20 2 ... ... ... ... ... ... ... ... ... 4 14 5 20 Pneumonia (all forms) 46 2 ... ... ... ... ... ... 1 4 1 8 30 6 86 TABLE II,—continued CAUSES OF DEATH. ALL Ages Net Deaths at the subjoined ages of " Residents " whether occurring within or without the District. Total Deaths whether of 'residents' or 'non- Residents' in Institutions in the District. Under 1 year. 1—2 2—3 3—4 4—5 5—10 10—15 15—20 20—35 35—45 45—65 65 and over. 21. Other Respiratory Diseases 3 ... ... ... ... ... ... ... ... 1 ... 2 ... 1 22. Peptic Ulcer 1 ... ... ... ... ... ... ... ... ... ... 1 ... 2 23. Diarrhœa, etc. (under 2 years) 2 1 1 ... ... ... ... ... ... ... ... ... ... 1 24. Appendicitis 7 ... 1 1 ... ... 1 ... ... ... 1 ... 3 6 25. Cirrhosis of Liver 1 ... ... ... ... ... ... ... ... ... ... 1 ... ... 26. Other Diseases of Liver, etc. 3 ... ... ... ... ... ... ... ... ... ... 1 2 2 27. Other Digestive Diseases 16 1 ... ... ... ... 1 ... ... ... 1 7 6 1 28. Acute and Chronic Nephritis 16 ... ... ... ... ... ... 1 ... 1 1 5 8 ... 29. Puerperal Sepsis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 30. Other Puerperal Causes 3 ... ... ... ... ... ... ... ... 2 1 ... ... ... 31. Congenital Debility, Premature Birth, Malformations, etc. 15 15 ... ... ... ... ... ... ... ... ... ... ... ... 32. Senility 32 ... ... ... ... ... ... ... ... ... ... 1 31 6 33. Suicide 8 ... ... ... ... ... ... ... ... 2 ... 5 1 1 34. Other Violence 28 3 ... ... 1 1 1 ... 1 3 2 5 11 11 35. Other Defined Diseases 56 2 ... ... 2 ... 2 4 ... 6 5 14 21 7 36. Causes Ill-defined or unknown ... ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 636 30 4 1 4 4 10 6 7 39 28 151 352 94 Special Causes (included in No. 35 above). Smallpox ... ... ... ... ... ... ... ... ... ... ... ... ... ... Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... Polioencephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 87 STAFF (a) Whole-time Officers: School Medical Officer: *‡Harold Ellis, M.B., B.S. (Lond.), M.R.C.S., L.R.C.P., 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: (a), (c), (f). Miss A. M. L. Holman. Health Visitor—School Nurses: *(b),(d),(f). Miss M. Giles (resigned 31st March, 1933). *(a),(b), (f). Miss E. M. Skelton (resigned 15th May, 1933). *(a),(b),(c),(d),(e). Miss H. A. Blackburn (resigned 31st May, 1933). *(b),(d),(g). Miss V. B. Woodroff (appointed 1st March, 1933). *(a), (b), (e). Miss C. Hughes (appointed 1st June, 1933). * (a), (b), (e). Miss A. Thompson (appointed 1st July, 1933). Senior Clerk Public Health Department: *‡ A. L. Taylor. Dental Attendant: Miss K. O'Hara. Clerk: Miss C. Coysh. (b) Part-time Officers: Orthopcedic Surgeon: R. W. Butler, M.Ch., F.R.C.S. Oculist: J. P. Crawford, M.D. Anæsthetist: S. Taylor Harris, M.R.C.S., L.R.C.P. * Maternity and Child Welfare Officers, ‡ Public Health Officers. (a) S.R.N. (b) C.M.B. (c) Certificate of Fever Training. (d) Certificate San. Inspect. (e) New Health Visitors Certificate R.S.I. (f) Health Visitors Certificate R.S.I. (g) Diploma Board of Education (Health Visitors' Training) Regulations, 1919. 88 Borough of Wimbledon Education Committee ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE Year ended 31st December, 1933 To the Chairman and Members of the Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit my Annual Report for the year 1933 on the work of the School Medical Department. There are ten public elementary schools, with nineteen departments under the control of the Local Education Authority. These schools provide accommodation for 7,069 children, including accommodation for fifty children at the Special School, Queen's Road. The average number of children on the school registers on March 31st, 1933, was 5,234, and the average number in attendance 4,6'27, thus making an average attendance of 88.40 per cent. 1. STAFF. Full particulars of the staff of the School Medical Service are given at the commencement of this report. Considerable changes have taken place in the personnel of the staff of School Nurse-Health Visitors. Miss Giles relinquished her duties on account of ill-health on 31st March, and on 15th May, Miss Skelton left for the same reason. Miss 89 Blackburn resigned to take up an appointment under another Authority on 31st May. To fill the vacancies thus created Miss Woodroff, who had been acting in a temporary capacity since November of the previous year, was appointed to the staff on 1st March. Miss Hughes commenced duties on 1st June, and Miss Thompson on 1st July. During this period the work was carried on under considerable difficulties and for a period of three months the services of a temporary School Nurse-Health Visitor were necessary. In spite of the disorganisation caused by these changes the work was carried out during the year with remarkably little disturbance. 2. CO-ORDINATION. (a) There is complete co-ordination between the work of the School Medical Service and that of the Maternity and Child Welfare Department. In addition to the Senior School Nurse, who devotes her whole time to the School Medical Service, there are three School Nurse-Health Visitors. These latter devote two-thirds of their time to Maternity and Child Welfare work, and one-third to the School Medical Department. Children attending the Infant Welfare Centres remain under the supervision of the same Health Visitor after they commence school. The School Medical Department with its Ophthalmic and Dental branches, and the Maternity and Child Welfare Department are centralised in the Health Centre at Pelham Road. This promotes a very complete co-ordination of the services. (b) No Nursery Schools have been established in Wimbledon. (c) Children between the ages of twelve months and five years are visited twice a year by the Health Visitors. Debilitated children are visited more frequently. The Maternity and Child Welfare Committee have made arrangements whereby debilitated children requiring convalescent treatment may be sent to recognised convalescent institutions. The School Medical Service in Relation to Public Elementary Schools. 3. SCHOOL HYGIENE. The sanitary condition of the Public Elementary Schools in Wimbledon continues to be satisfactory. Twenty new dual locker desks and forty chairs of a modern type were provided during the year at Queen's Road Boys' School, and six new dual locker desks and thirteen chairs at the Girls' Central School. 90 The Central Schools in Pelham Road were painted externally. The artificial lighting in the Haydons Road Girls' and Infants' Schools, which had not been quite satisfactory, was greatly improved by the installation of higher power lamps and the addition of several new points. The lighting in these Schools is now thoroughly adequate. The drainage of the schools was inspected and defects discovered at Dundonald, Queen's Road, and Wimbledon Park Schools were made good. The drinking water facilities were also improved. The surfaces of the playgrounds at Dundonald and Queen's Road Schools were treated with tar. At the Health Centre the remainder of the internal decoration was completed. All the rooms, with the exception of the laboratory, have now been painted with a smooth, washable paint, and new shelves and brackets have been fitted to the radiators. This has rendered the problem of keeping the premises in a clean condition much easier. 4. MEDICAL INSPECTION. (a) The children medically examined were those in the three groups required by the Code of the Board of Education. These included:— (i) Entrants: i.e., those children admitted to school for the first time since the last routine medical inspection. (ii) Second Age Group: i.e., those children who have attained their eighth birthday since the last routine medical inspection, or who will be nine, years of age during the current year. (iii) Third Age Group: i.e., those children who have attained their twelfth birthday since the last routine medical inspection, or who will be thirteen years of age during the current year. There were medically inspected in the schools during the year 1933:— Entrants 635 Second Age Group 577 Third Age Group 681 Total 1893 91 In addition there were one hundred and six other routine inspections in. the schools, making a total of 1,999. Apart from these routine inspections there were 2,421 special inspections and 5,193 re-inspections carried out at the Health Centre. The total number of routine and non-routine medical inspections during the year, excluding the 5,193 re-inspections, amounted to 4,420. The number of children examined at the routine inspections in the schools shows an increase of two hundred and eighty-six as compared with the figure for the previous year. This increase is accounted for by the very much larger number of children inspected in the Third Age Group. These were children born in the year 1920. During that year the birth rate in Wimbledon rose to 18.3 per thousand. In 1919 the birth rate was only 13.8 per thousand. Towards the end of the year the opportunity was taken of checking off with the school registers the children due to be examined in the three age groups in 1933. This ensured that no child who was due to be examined was missed at the routine inspections. The number of special inspections and re-inspections at the Health Centre shows a decrease of 1,300. This has been the result of fewer school-children attending the Health Centre for medical examination during the morning sessions. A large number of children are now referred to their private doctors for treatment. Consequently the numbers have been more manageable. (b) The Board's Schedule of Medical Inspection has been adhered to in every respect. (c) Medical inspection causes a certain amount of disturbance, especially in the older type of schools. In nine departments the inspection is carried out in the Head Teachers' rooms. In the older schools a classroom is utilised for this purpose. Owing to the fact that no classroom is available at Haydons Road Girls' School, nor at Haydons Road Infants' School, the medical inspection of these scholars was carried out as in previous years at the Church Institute which is situated quite near. The accommodation here for the purposes of medical inspection: is quite suitable. The same difficulty has arisen in connection with St. Mary's Junior and Senior Mixed School at Russell Road. As this school is situated quite near the Pelham Road Health Centre, the medical inspection of these scholars was carried out there. 92 5. FINDINGS OF MEDICAL INSPECTION. In Table IIa (which is given in the Appendix) a list of all defects found during medical inspection, whether routine or non-routine, is shown. Table 11b gives the number of individual children found at the routine medical inspection to require treatment, excluding uncleanliness, and dental diseases. There were 1,999 children examined at the routine medical inspections. Three hundred and twenty-two or 16.1% were found to be suffering from defects (excluding uncleanliness and dental diseases) requiring treatment. The percentage of defects was found to be slightly higher in the Second Age Group than in the Entrants and Third Age Groups. Among the 2,421 children specially examined there were found 1,318 defects requiring treatment and one hundred and sixty-nine requiring to be kept under observation. (a) Malnutrition. Malnutrition was not found to be of frequent occurrence amongst the children attending the elementary schools in Wimbledon. Of the 1,999 children examined during the year as routines twelve were found to be suffering from malnutrition to such an extent as to require treatment. This gives an incidence of approximately 6.00 per thousand inspected. The figure for the previous year was 4.1 per thousand. Three cases of malnutrition were also found at the routine inspections where the defect was of a minor degree. These cases were kept under observation. There has been a tendency for the figures for malnutrition to show a slight increase during the past four years as the following table indicates. Year. Incidence per 1,000 Children Inspected as Routines. 1930 3.00 1931 3.60 1932 4.10 1933 6.00 The incidence of malnutrition amongst the school children of the whole of England and Wales for the year 1932 amounted to 10.7 per thousand inspected as routines. It is thus evident that the position in Wimbledon as compared with the rest of the country is very favourable. 93 The prevailing economic depression was no doubt responsible to a considerable extent for the increase in the figure for Wimbledon. At the same time, it should be pointed out that since unemployment has become so prevalent an increasing amount of attention has been paid to malnutrition by the members of the Medical Staff carrying out these inspections. At the special examinations at the Health Centre, twentytwo children were found to be suffering from malnutrition requiring treatment. During the previous year the figure was fourteen. It should also be borne in mind that the children of parents in good economic circumstances are not infrequently found to be under weight and exhibiting a poor and subnormal standard of physique. Particulars as to the methods taken for dealing with these cases of malnutrition are indicated in the section of this Report relating to treatment. The standard of clothing and footgear continued to be satisfactory. (b) uncleanliness. Twenty-one or 1.04% of the children at the routine medical inspection were found to be unclean and excluded from school. In addition twelve were found to require further observation in school on account of this condition, and were kept under supervision. During the year 1932, eight children or 0.46% of those examined at the routine medical inspection required to be excluded from school on account of uncleanliness. The School Nurse-Health Visitors continued to carry out the systematic inspection! of all the scholars in their schools three times a year, i.e., after the Christmas, Easter, and Mid-Summer holidays. This inspection reveals not only unclean children, but also children suffering from defective vision, minor ailments, anaemia, malnutrition, etc. These latter children are referred either to their own doctors or to the Health Centre where they are seen by one of' the School Medical Staff. The number of examinations of children carried out in the schools by the School Nurses amounted to 12,508. This means that nearly every child was inspected for uncleanliness three times during the year. On an average, the nurses paid seven visits to each school. A much higher standard of cleanliness has been insisted upon during the last few years and there is no doubt that a very considerable improvement has been effected. One hundred and fifty-three children were cleansed at the Health Centre in accordance with the arrangements made by the 94 Education Committee. This figure is considerably higher than that for the previous year. The total number of unclean children found by the nurses during their systematic inspections of the schools during 1933 amounted to four hundred and seventy-three. During 1932 the number was one hundred and eighty. In the latter half of 1933 it was decided to keep a record of every unclean child found by the nurses during their inspections, no matter how slight or trivial the degree of uncleanliness. It is for this reason that the figures for unclean children found by the nurses show such a considerable increase over the. figures for the previous year. Actually, the standard of cleanliness in the schools has been raised very considerably. A few years ago, children who were admitted to the Isolation Hospital, suffering from various infectious diseases, were not infrequently found to have unclean heads. During 1933, the Matron informs me, no unclean heads were found among the children admitted to the wards. (c) Minor Ailments and Diseases of the Skin. The minor ailments found at the routine and non-routine inspections are indicated in Table II. Ringworm of the head and body, scabies, impetigo, other skin diseases, minor injuries, diseases of the ears and eyes (including otorrhœa and blepharitis) together with miscellaneous conditions such as sores and chilblains were the common ailments detected. Of the children examined as routine cases in the schools, 0.85% were found to be suffering from skin diseases. One was suffering from scabies, three from impetigo and eleven from other minor skin ailments. Three hundred and three or 12.51% of the special cases examined at the Health Centre were discovered to be suffering from diseases of the skin. A great number of these cases were sent up by the teachers and attendance officers. There were eighteen cases of ringworm of the body, sixteen cases of scabies, one hundred and thirty-six of impetigo, and one hundred and thirty-three of other skin conditions. Ringworm of the scalp and scabies are not of frequent occurrence amongst school children in Wimbledon. Impetigo, however, is common amongst all school children. As it is contagious, a number of children suffering from impetigo have to be excluded temporarily from school. In many cases, however, it is possible for the sore to be covered by a dressing, and these children, as a rule, are allowed 95 to continue at school and to attend at the Health Centre daily for treatment. A considerable amount of loss of school attendance is obviated in this way and no difficulties have arisen as a result of the cases continuing at school. (d) Visual Defects and External Eye Disease. There were twelve cases of external eye disease amongst the 1,999 routine children examined. This gives a percentage of 0.60%. Eleven of the cases were due to blepharitis and some of these were very mild. In addition, there was one case of conjunctivitis. No case of keratitis was discovered. At the special inspections there were sixty-six cases or 2.72% due to external eye disease. Thirty-three were due to blepharitis, thirty-one to conjunctivitis, and two to keratitis. Serious conditions such as keratitis and corneal opacities are fortunately not commonly found amongst the school children in Wimbledon. Defective vision is one of the most important defects discovered amongst school children. At the routine medical inspection fifty-nine children were found to be suffering from defective vision requiring treatment, and thirteen to be suffering from squint. This makes a total of seventy-two cases requiring treatment or 3.60% of the children examined. The figure for the previous year was 4.14%. The actual incidence of defective vision requiring treatment is, however, higher than 3.60%. Of the 1,999 children examined as routine cases six hundred and thirty-five were entrants and in the majority of these it was impossible to carry out subjective visual tests on account of their age. In addition, ninety-nine children with slighter degrees of defective vision were found at school. These cases did not require treatment but required to be kept under observation. In the absence of medical inspection a large number of children would undoubtedly be handicapped in their school life by uncorrected defective vision, and their education would suffer very considerably. Of the children examined as special cases at the Health Centre there were forty-three with defective vision and four with squint requiring treatment, and eight with defective vision or squint requiring to be kept under observation. The cases which are kept under observation and not referred for immediate treatment are those with minor defects of vision. These children are re-examined by the Medical Officer when the school is next visited. If necessary, they are then referred to the Refraction Clinic for examination by the Ophthalmic Surgeon. 96 The eyes of nearly all infants are Inclined to be long sighted. As children grow up the eyes become increasingly used for reading and study and a tendency to short sight develops. For this reason I would again stress the necessity of all children's books and papers having a large, clear, type. There is considerable danger of short sight developing when children convalescing after illness are permitted to read in bed, especially by artificial light. (e) Nose and Throat Defects. At the routine medical inspections there were twenty-three cases of enlarged tonsils, one case of adenoids, and twelve cases of adenoids with enlarged tonsils requiring treatment. Thus out of 1,999 children examined in the routine way, thirty-six or approximately 1.80% were found to need operation. In addition, there were eighty-one children or 4.05% with enlarged tonsils or with adenoids and enlarged tonsils requiring to be kept under observation but not requiring treatment. At the Health Centre fifty-six other cases were found on special examination to require operation for this condition. The percentage figure for those requiring treatment is lower than that for the preceding year. There are fewer cases recommended for the removal of tonsils and adenoids now than formerly. (f) Ear Diseases and Defective Hearing. At the routine inspections six children were found to be suffering from defective hearing, and six from otitis media, all requiring treatment. There were also five children with defective hearing and one who had recently suffered from otitis media requiring to be kept under observation. In other words 0.90% of the children examined in the schools were found to be suffering from defective hearing or from discharging ears. Furthermore, two children with defective hearing, sixty-six with otitis media, and fifty-one with other ear diseases, all requiring treatment, were examined as special cases at the Health Centre. Deafness and running ears are still of too frequent occurrence amongst school children. A discharging ear is a source of considerable discomfort and unpleasantness to a child. The impairment of hearing which is nearly always associated with it gives rise to a considerable handicap in school life. The chronic discharging ear is also a source of danger owing to complications of the mastoid region which are liable to arise. Infectious diseases such as measles and scarlet fever are common causes of discharging ears. Nearly all the cases of scarlet fever, however, that occur in the Borough are treated in the Infectious Diseases Hospital, and it is uncommon for a child to be discharged with a running ear or with impaired hearing. Infections such as measles, 97 scarlet fever, influenza, and the common cold, occurring in children with enlarged tonsils and adenoids are the chief cause of ear trouble. Dental sepsis is also an important contributory factor. Removal of enlarged tonsils and adenoids and attention to oral and nasal hygiene are the principal measures for preventing ear diseases. Greater supervision in the pre-school period would also undoubtedly help to reduce the incidence of these defects. (g) Dental Defects. At the routine inspections by the Medical Officer two hundred and fifty-eight children were found to have defective teeth requiring treatment, and nineteen to have defective teeth requiring to be kept under observation. Thus out of a total of 1,999 children examined in school, two hundred and seventy-seven or 13.85% were found to have dental caries to such an extent as to require treatment or to require their being kept under observation. During the year 1932 the percentage was 13.95. Amongst the '2,421 children who attended the Health Centre as special cases, sixteen were found to be suffering from dental defects which required treatment. (h) Orthopaedic and Postural Defects. At the routine inspections five cases of deformity due to rickets were discovered. Four of these cases required treatment and one required to be kept under observation. In addition there were twenty-four cases of spinal curvature, sixteen requiring treatment and eight requiring to be kept under observation. There were also twenty-eight other cases of orthopaedic and postural defects, eighteen of which required treatment and ten requiring to be kept under observation. At the special inspections at the Health Centre, one case of deformity due to rickets and ten cases of spinal curvature were detected, all requiring treatment. Nine other cases of orthopaedic and postural defects were found at these inspections, eight of which were referred to the Orthopaedic Clinic and one kept under observation. The conditions found at the routine and special inspections, and classified under "other deformities," were due to old infantile paralysis, flat foot, knock knee, congenital deformities, paralysis following birth, tumour of bones, old injuries, etc. Nearly all these cases were referred for examination by the Surgeon at the Orthopaedic Clinic and details of the defects found are given under the section devoted to treatment. (i) Heart Disease and Rheumatism. Particulars regarding children suffering from heart defects at the routine and special inspections are shown in Table II. 98 Serious heart disease was not discovered amongst the 1,999 children examined as routines. Only one child with organic disease of the heart was discovered and in this case the condition was quiescent and she was kept under observation. There were, however, eight children with functional heart disease requiring treatment and nine requiring to be kept under observation. At the special inspections four of the children examined were found to have organic disease of the heart. Three of these cases required treatment. The remaining case was quiescent and was kept under observation. In addition, one child with functional heart disease was found requiring treatment. Nearly all the cases with organic disease of the heart occurring amongst school children are of rheumatic origin. Amongst the 1,999 children examined as routines ten, or 0.50%, were found to be suffering from rheumatism in its milder and sub-acute forms. In the case of the 2,421 special inspections there were twenty-one children, or 0.86%, with symptoms of rheumatism. These figures do not accurately indicate the incidence of rheumatism amongst school children. In the routine inspections, unless the parents are present, and in the absence of any abnormality of the heart, it is obvious that the mildest and most insidious forms of rheumatism are easily missed unless the child itself complains to the doctor of "growing pains" or symptoms of a similar nature. (j) Tuberculosis. Cases of tuberculosis are not frequently found amongst school children in Wimbledon. During 1933 only one case of non-pulmonary tuberculosis was discovered at the routine medical inspections and this child had made such progress that the condition merely required to be kept under observation. All suspected cases are referred to the Tuberculosis Physician between whom and the School Medical Staff a close co-operation exists. (k) Other Defects and Diseases. A considerable number of children were found at the routine and special inspections to be suffering from conditions not designated as specific defects in Table II. These conditions are shown in the Table under the heading "Other defects and diseases." A great number of these conditions were due to colds, influenza, and infectious diseases. 99 There were also many children found to be suffering from debility and gastro-intestin.al disturbances, including several cases of suspected appendicitis. The remainder were cases of minor accidents, chilblains, etc. 6. FOLLOWING UP. The procedure of following up defects discovered during the routine medical inspection in 1933 was as follows:— Parents were informed of the defects detected in their children during the medical inspection in the schools. Where the defect was of a minor nature they were informed verbally. In the case of more important defects the parents received a printed notice advising them of the nature of the trouble and of the need for obtaining treatment. A re-examination card was made out for each such child. As soon as convenient, after the inspection of the school had finished, the nurse returned to the school with all the re-examination cards. The nurse then ascertained in each case whether the defect from which the child had suffered was receiving attention. When necessary, visits to the homes were paid and the parents interviewed. The Medical Officer visited each school in the district twice during the year in order to carry out the routine medical inspections. The re-examination cards of all children with defects were taken to the school at each of these visits. These children were then re-examined. If the defects had not received attention further notices were sent to the parents. Previously, the following up had been carried out at a Special Inspection Clinic which was held at the Health Centre every Tuesday afternoon. This clinic has been discontinued. An alteration was also carried out in the following up of children, with defective vision. The particulars of every child for whom glasses had been prescribed were entered up on a special eye card. These cards were taken to the school with the other re-examination cards at each visit/ of the medical inspector. Where the vision with glasses was found to be no longer satisfactory appointments were made for the children to be examined once more at the Refraction Clinic by the Oculist. These periodical inspections of children suffering from defective vision also ensured that the glasses which had been prescribed for them were being continuously worn. Furthermore, lenses which were dirty or broken, bent or broken frames, and spectacles which could no longer be worn without some discomfort, were quickly detected and steps were taken to rectify matters. This arrangement has also taken a great deal of pressure off the Refraction Clinic, thus enabling the time of the Oculist to be devoted almost entirely to retinoscopies. 100 In addition, a considerable amount of following up has been carried out by the School Nurses in the case of children who have been referred for treatment to their own doctors or where hospital treatment has been found necessary. By these means undesirable delay in obtaining treatment has been obviated. 7. ARRANGEMENTS FOR TREATMENT. Table IV gives a return of the defects treated during the year under arrangements made by the Education Committee. (a) Malnutrition. Milk was provided in school for thirtythree children. The milk is only given on medical grounds and the financial circumstances in each case are considered by the Committee. These children were suffering from malnutrition and debility. As a rule the milk was supplied for a period of at least three months in quantities varying from one third to half a pint daily. (b) Uncleanliness. The Education Committee have, for a number of years, made arrangements for the cleansing of children with dirty heads at the Health Centre. A cleansing room has been equipped with all the necessary facilities for this work and is under the charge of the senior school nurse. As a rule, no child is cleansed at the Health Centre unless the mother, on account of illness or other bona fide reasons is unable to cleanse the child herself. During 1933 one hundred and fifty-three children were cleansed by the school nursing staff. In no case were legal proceedings necessary, under the School Attendance Byelaws, for absence from school due to uncleanliness. (c) Minor Ailments and Diseases of the Skin. The work of the Minor Ailment Clinic at the Health Centre is shown in Table IV. This clinic is well attended and the number of cases dealt with shows an increase of one hundred and fifteen over the figure for the previous year. The senior school nurse is in attendance at this clinic daily, including Saturdays, from 9 to 11 a.m. The Committee have made arrangements for the treatment of children with ringworm of the head by means of X-rays at the St. John's Hospital. No case of ringworm of the scalp was detected either at the routine or the special inspections during the year. Twenty-one children with ringworm of the body, sixteen with scabies, one hundred and thirty-seven with impetigo and one 101 hundred and sixteen with other diseases of the skin received treatment at this clinic. (d) Visual Defects and External Eye Disease. Details of the work of the Refraction Clinic are given in Table IV, Group II. This clinic is held every Monday afternoon from 2 to 4.30. Occasionally during the year it was necessary to hold further sessions on Thursday afternoons. The Refraction Clinic continued to be well attended and the table given hereunder shows the number of children who received treatment. New cases (examined for the first time) 77 Old cases (re-examinations) 167 Re-attendances 251 Total 495 Of the twenty-one cases of myopia examined six were found to be suffering from higher degrees of short sight where the refractive error was greater than minus four dioptres. Where necessary, instructions were sent to the Head Teachers of the schools which the children attended, modifying the curriculum with a view to preventing the condition becoming more marked. Similar advice was also given to the parents. The children suffering from myopia are re-examined at the clinic twice a year. Children suffering from other types of defective vision are re-examined in the schools during each visit of the medical inspector and where necessary new appointments are sent for them to re-attend the Refraction Clinic. In a few instances difficulty was experienced in persuading parents to provide spectacles for their children. The assistance 102 Glasses were prescribed in eighty-six cases, and the following figures indicate the errors of refraction found. Hypermetropia 15 Hypermetropia and Astigmatism 18 Hypermetropic Astigmatism 7 Myopia 21 Myopia and Astigmatism 19 Myopic Astigmatism 6 of the N.S.P.C.C. was of the greatest help in dealing with these parents, and in every case spectacles were ultimately obtained. Six children were referred from the Refraction Clinic to hospital for further treatment. These children were found to be suffering from the following defects:— Choroiditis 1 Keratitis 2 Cataract 1 Trichiasis 1 Squint (Operative Treatment) 1 One hundred and fifteen children with external eye diseases received treatment at the Health Centre. A few of the more serious cases were referred to the Oculist at the Refraction Clinic. Many of these children require daily treatment over fairly long periods. As in the case of many other minor ailments it is very difficult for a great number of the parents to carry out this treatment adequately at home. At the Health Centre it is done by the school nurses under the guidance of one of the Medical Staff. If the children are irregular in their attendance they are followed up at home. These defects are consequently more rapidly rectified and a considerable gain in school attendance results. The Education Committee have an arrangement with the Nelson Hospital whereby school children suffering from eye disease are admitted for in-patient treatment at a cost of three shillings per day. No child required treatment under this arrangement in 1933. (e) Nose and Throat Defects. Forty-one children were operated on for enlarged tonsils and adenoids during 1933 at the Nelson and North Wimbledon Hospitals under the Education Committee's scheme. These patients remain in hospital overnight after their operations. The children are examined by the Medical Officer at the Health Centre before they return to school. In addition, two other children were operated on for enlarged tonsils and adenoids by private practitioners or at the voluntary hospitals. This makes a total of forty-three children who received surgical treatment. It will thus be seen that fifty-two fewer children were submitted to operation for the removal of tonsils and adenoids during 1933 as compared with the previous year. Full details are outlined in Table IV., Group III. (f) Ear Disease and Defective Hearing. Ninety-eight children with minor ear defects were treated at the Health Centre. Most of these cases were suffering from otorrhoea, wax in the 103 ear, or eczematous conditions of the meatus. It is most important that children with running ears should receive regular treatment. Here again it is often difficult for parents to carry this out properly at home. These children attend daily at the Health Centre until the condition is cured. Where necessary, operative treatment is provided for the removal of the tonsils and adenoids. (g) Dental Defects. In 1931 the routine inspection by the School Dental Surgeon was extended so as to include all children attending school. In 1933 there were 4,527 children dentally inspected in the routine age groups in school. A further one hundred and thirtyfour children were inspected as special cases. The total number of children thus examined amounted to 4,661. This represents a decrease of six hundred and eleven on the figure for 1932. There were 3,833, or 82.23%, found to require treatment and their parents were notified accordingly. During the previous year the figure was 75.79%. The number of children actually treated was 2,038 or 53.16% of those found to require treatment. It is still difficult to obtain consent for treatment in a considerable number of cases. When appointments are not kept visits are paid to the homes by the school nurses, and every effort is made to get the parents to attend with their children at the Dental Clinic. The Saturday morning sessions which were started during 1930 have been entirely justified, and continue to show a good average attendance. Forty-four half days were devoted to dental inspection in the schools and three hundred and, sixty-one half days to treatment at the Health Centre. The number of attendances made by children for treatment amounted to 4,180. This is sixty-nine more than the figure for the previous year. The average number of children attending for treatment per session was 11.57, a slight increase over the figure for 1932. The total number of fillings amounted to 2,412 or one hundred and twelve more than during the previous year. The number of teeth extracted shows an increase of forty-nine, the total figure for the year being 3,409. Six hundred and forty general anaesthetics were administered for dental extractions. The work of the Dental Clinic has shown a progressive increase during the past four years. All the children attending school are now dentally inspected annually. The average attendance per session of children undergoing treatment has risen to 11.57 This is a satisfactory figure and it is gratifying to note that 104 the average number of children attending for treatment per session has been continually increasing during the past four years. In addition, much greater time is devoted to the filling of permanent teeth. As a consequence of this, the number of temporary teeth filled has dropped from three hundred and fiftysix in 1929 to five in 1933. (h) Orthopaedic and Postural Defects. Sessions of the Orthopiedic Clinic, which was commenced in July, 1931, were held every month during 1933. Sixty-six new cases were seen and two hundred and twenty cases were re-examined. The average number of children seen by the Orthopædic Surgeon per session was twenty-six. During the previous year the figure was twenty-two. The following table shows the nature of the defects from which the children were suffering. Congenital Defects 9 Infantile Paralysis 9 Hemiplegia and Diplegia 3 Birth Paralysis 1 Old cases of Osteomyelitis 1 Old amputations of limbs 1 Trauma 6 Deformities due to previous Rickets 6 Tuberculous joints (arrested) 1 Pseudo-coxalgia 1 Tumour of bone 2 Flat foot, knock-knee, pes cavus, etc. 20 Postural defects 64 Other defects 9 Children not suffering from orthopædic defects 7 Total 140 The following table gives an indication of the treatment carried out through this Clinic:— Number of children referred to Pyrford for in-patient treatment 6 Number of children referred to St. Thomas's Hospital for in-patient treatment 4 105 Number of children referred to St. Thomas's Hospital for out-patient treatment 3 Number of children referred to St. Thomas's Hospital for X rays 2 Number of children referred for alterations to surgical boots, etc. 20 Number of children for whom spinal jackets were obtained 1 Number of children for whom new artificial limbs were obtained 1 Number of children referred for exercises and massage 47 Total 80 The Orthopædic Nurse attended seventy-six sessions in order to carry out the remedial exercises and massage. Forty-seven children were referred by the Orthopaedic Surgeon for treatment of this nature. Six hundred and thirty-eight attendances were made. The average number of children attending at each session for exercise and massage was just over eight. The Orthopædic Nurse reports that most of the children appear to enjoy attending the classes for exercises and that on the whole the parents have co-operated well. When this has been the case, the progress made has been much more marked than when the parents have been unable to attend, owing to their own domestic work preventing them, or owing to lack of interest. By far the greatest number of children attending have been cases of defective posture and flat foot. The Orthopaedic Clinic in Wimbledon is fulfilling a very definite need, and the work during 1933 has been most successful. 106 The six children sent in to Pyrford, under the orthopaedic scheme, for in-patient treatment were suffering from the following defects:— Infantile Paralysis with spinal curvature 1 Pseudo-coxalgia (left hip) 1 Spastic Diplegia 1 Tuberculous hip (arrested) 1 Old Osteomyelitis (right femur) 1 Contractures of hand and ankle following burns 1 I am indebted to Mr. II. W. Butler, the Orthopædic Surgeon, for the following review of the cases seen at the Health Centre. "Work was continued during the year on the same general lines as previously, and without any radical changes. It appeared to be definitely noticeable that the children with postural curves of the spin,e attending during this year as new patients were caught at an earlier stage of their deformity than previously, and that therefore the chances of getting good results with this type of case were increased. Early and mild curvatures, especially high kyphoses of the 'round shoulders' type, are often masked by the patient during a routine medical examination and only seen in the early days as an habitual posture in school or at play, so that this appeared to suggest a welcome increase in co-operation by the school teachers. The Orthopædic Nurse has obtained, as previously, some very good results with these postural deformities of the spine by remedial exercises, work which requires much patience and the ability to evoke co-operation by both the child and its parents. The difficulty of getting some mothers to attend with their children when coming for exercises, so that they may supervise these intelligently at home, has been unavoidable at times in the past year. Many of the fathers have been unemployed, so that the mothers, when possible, have had to go out to work. When the high standard of health of Wimbledon school children is considered, it seems unlikely that the work done by the Orthopaedic Clinic will increase markedly in the near future, but I believe that the Clinic, as at present constituted, can, and does, carry out very useful and necessary work." (i) Heart Disease and Rheumatism. Children suffering from heart disease and rheumatism are sent to Certified Special Schools for treatment. The majority of these cases are admitted to the Heart Home, at West Wickham. In all, seven children were admitted to such institutions during the year. Four of these children were suffering from heart disease, two from recurring rheumatism without cardiac complications, and one from chorea. 107 Many of these children require to be away for several months before their convalescence is sufficiently established for them to be returned home with any degree of safety. They are then kept under periodical observation by the School Medical Staff and suitable instructions are sent to the Head Teachers of the schools which they attend, advising any necessary modifications in their school lives. (j) Tuberculosis. The Surrey County Council is the Authority responsible for the treatment of tuberculosis in Wimbledon. Two children suffering from pulmonary tuberculosis and two children with non-pulmonary tuberculosis were patients in hospitals or sanatoria at the end of the year. One of these children, with tuberculosis of the hip, was at the Holy Cross Convent, Ramsgate, and a second child, suffering from tuberculous disease of the spine, was at the Hospital for Diseases of Children, Sevenoaks. (k) Other Defects and Diseases. Children suffering from defects other than those indicated above obtain treatment either through private practitioners or at the out-patient departments of the local or big London hospitals. Very little difficulty is experienced in. getting parents to obtain the necessary treatment as there are so many facilities available in this area. Artificial Light Treatment. There are no facilities for providing artificial light treatment at the Health Centre. This is available at the local hospitals as well as in neighbouring institutions. In only three cases were children sent direct to such institutions for ultra-violet ray treatment. A considerable number of children, however, who were found to be suffering from debility, the milder forms of anaemia, and slight rheumatism, were referred to their own doctors with a view to their receiving artificial light treatment. Many of the practitioners in the district are equipped with the necessary apparatus. SPEECH CLINIC. During the year forty-three cases were treated in the Speech Clinic. Of these, twenty-two were stammerers and twenty-one were cases of defective speech. 108 The following table shows the number treated and discharged:— Defect. No. treated. Cured & Discharged. Provis'nally Discharged. Stammerers 22 5 3 Defective Speech 21 6 — Total 43 11 3 The number of children attending the Speech Clinic has been higher than in any previous year, and the attendance has been very regular. In the autumn a number of stammerers of eight years of age were admitted and a special class formed for them. At the end of the term, when reports were received from the schools, each case had shown improvement. The class has since been so successful that it is felt that this is a particularly good age for treatment. The value of relaxation in the treatment of stammering is becoming increasingly recognised. The stammer is a symptom of an underlying nervous disorder, and is frequently accompanied by other symptoms such as chorea, enuresis, nervous fears, and an acute sense of inferiority. Speech-training methods, such as articulation, and breathing exercises, are not fundamental. They may, by suggestion, effect a temporary improvement, but actually they increase the nervous tension of the stammerer, and exaggerate his condition. Relaxation, on the other hand, goes to the root of the trouble and, by release of the nervous tension, effects a change so fundamental, that not only the stammer, but all other nervous symptoms, gradually disappear. I am indebted to Miss Crickmay and Miss Gardner for the above particulars of the year's work. The work of the Speech Clinic is of the greatest importance. Treatment of this nature not only has the greatest bearing on the educational progress which the children are able to make in school, but also has a considerable influence on their ultimate chance of obtaining suitable and remunerative employment. 8. INFECTIOUS DISEASES. The means adopted to prevent the spread of infectious diseases among school children are:— (n) The exclusion of children suffering from infectious diseases or coming from infected houses; 109 (b) Closure of schools or departments; (c) Disinfection of schools. (a) To-day, the first procedure is the one which is almost entirely relied upon. As soon as a case of infectious disease is notified a visit is paid to the house by one of the members of the Sanitary Staff. Home contacts are excluded from school until the end of the necessary quarantine period. Notices to this effect are sent out from the Public Health Department to the Head Teachers concerned and also to the School Attendance Department. New "Regulations as to Exclusion for Infectious Disease" were issued to Head Teachers during the year. These regulations embodied the recommendations outlined in the most recent memorandum of the Ministry of Health and the Board of Education. A detailed account of the early symptoms of the common infectious disorders was also appended for the information of the Head Teachers. (b) School closure is rarely resorted to to-day and on no occasion was it found necessary to recommend this during the year under review. When the attendance, however, falls below 60%, certificates may be supplied by the School Medical Officer to that effect as outlined in Paragraph 15 (ii) of Administrative Memorandum No. 51, 1927. No certificate in accordance with this Rule was required to be issued during 1933. (c) During the summer holidays, the disinfection of each school was carried out as in previous years. Disinfection of classrooms was also carried out periodically as the necessity arose. Much less reliance is now placed in the efficacy of this procedure in the control of infectious diseases. Valuable information is obtained from the weekly returns of absences due to infectious diseases furnished by the Head Teachers. The numbers of cases of non-notifiable infectious diseases reported from the schools during 1933 were as follows:— Measles 67 German Measles 8 Whooping Cough 58 Mumps 3 Chicken Pox 138 It will be seen that the schools were relatively free from infectious diseases of an important nature. Chicken pox was prevalent during the months of June, July, October, and November. The schools chiefly affected were 110 Wimbledon Park, Cottenham Park, Dundonald, and Haydons Road. This disease, although not serious, is very infectious and is responsible for quite a lot of loss of attendance. In spite of the fact that 1933 was an inter-epidemic year as regards measles, sixty-seven cases were reported as occurring in children attending the elementary schools. Whooping cough was also fairly common, fifty-eight cases coming to the notice of the Public Health Department. One schoolchild was notified as suffering from smallpox and was removed to the County Smallpox Hospital at Clandon. He was unvaccinated and suffering from a mild, modified form of the disease. The only other child in the house, who was under school age, had previously been removed to Clandon. No further cases occurred. The first case was probably infected from a neighbouring area where several cases of smallpox had been notified at the time. Frequent visits were paid to the schools after children had been removed to the Isolation Hospital suffering from diphtheria or scarlet fever. It is quite common for children to attend school whilst sickening for these diseases. In all such cases, the class contacts were carefully examined and in a number of instances swabs were taken for bacteriological examination. Several carriers were detected in this manner and promptly excluded. In accordance with Article 20(b) of the Education Code, eighty-four children were excluded from school during 1933 for the following conditions:— Conjunctivitis 3 Impetigo 9 Ringworm of Head — Ringworm of Body 3 Scabies 17 Other contagious or infectious conditions 52 Total 84 9. OPEN AIR EDUCATION. There are no Day Open-Air Schools nor Residential OpenAir Schools in Wimbledon. Where circumstances permit, in the summer months some of the classes in the schools are conducted in the open air. Another holiday camp was arranged during the year by the Wimbledon Rotary Club. Twenty-eight boys from various 111 elementary schools in the district were selected and sent away to Swanage for two weeks during August. The children were weighed and medically examined before leaving Wimbledon. Twenty-three boys were re-weighed after their return. Only one was found to have lost weight, and the average gain, was nearly 2¾ lbs. Besides having a very enjoyable holiday the boys improved considerably in health. Fifty-five scholars from the Central Girls' School were medically examined before leaving for a fortnight's stay at Sandown in May. This visit was arranged through the School Journey Association. The curriculum of the children whilst away included geography, history, art, literature and nature study. Many educational visits were paid to places of interest in the island. Ample time was also available for physical training and sports. Holiday Camps are greatly appreciated by the children. Apart from the almost invariable improvement in health which occurs, the change of environment) is associated with considerable educational value. 10. PHYSICAL TRAINING. Physical exercises and organised games are carried out in all the schools, the instruction being given by the class teachers on the lines laid down in the syllabus issued by the Board of Education. Swimming instruction is given at the Wimbledon Corporation Baths to children over ten years of age. The children attend once a week and the instruction is given by the class teachers. The cost of admission to the Baths is twopence for each child and this is paid by the Education Committee. Under this arrangement 13,153 attendances were made. Where swimming is considered inadvisable for a child on medical grounds, such as disease of the ears or heart, the Head Teacher is notified accordingly by the School Medical Department. 11. PROVISION OF MEALS. Meals are provided mid-day by the Education Committee for the children attending the Special School. A good hot lunch is served. The quality of the food is excellent and many of the children remain for this meal. No meals were provided during the year for children attending the other schools. Thirty-three children, however, on account of malnutrition and anaemia received half a pint of milk daily in school for periods of three months and longer. 112 In the undermentioned schools arrangements have been made through the National Milk Publicity Council for children to be supplied with milk each day:— Haydons Road (Girls and Infants). St. Mary's R.C. (Mixed and Infants). Dundonald Road (Boys, Girls and Infants). Old Central (Mixed and Infants). Queen's Road (Boys, Girls and Infants). Effra Road (Girls and Infants). The milk is supplied in a sealed bottle containing one-third of a pint, at a cost of 1d. to the parent. The reports from the Head Teachers indicate that the children in receipt of this milk benefited considerably. It is to be hoped that this scheme will be adopted later by other public elementary schools in Wimbledon, and that more of the parents will avail themselves of the facilities ofiered. 12. CO OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND VOLUNTARY BODIES. Co-operation Of Parents. Parents are invited to be present at the school during the routine inspection of their children. Out of 1,999 children examined at the routine inspections, 1,099 or 55% were accompanied by one or other parent. This percentage has shown a continuous and considerable fall during the past three years. The reduction is not due to any cessation of interest on the part of the parents in the health of their children. Owing to the prevailing unemployment, more of the mothers are going out to work than during past years, and many of them are consequently unable to spare the necessary time to attend at the inspections. There is a great advantage in obtaining the co-operation of the parents as it enables the school medical inspector to give detailed advice in the case of children found to be suffering from defects. A large number of parents also attended at the special examinations at the Health Centre. Co-operation of Teachers. I have again to acknowledge the valuable assistance which the teachers have rendered to the School Medical Department during the year. They have facilitated the medical inspection work in the schools, and given every assistance to the school nurses during the routine cleansing examinations, and when following up cases found to be defective. 113 They have also co-operated, as in past years, by bringing defective children to the notice of the School Medical Staff and arranging for their attendance at the Health Centre. Co-operation of School Attendance Officers. A close cooperation has been maintained between the School Medical Department and the School Attendance Officers. A considerable number of children were medically examined at the request of the Attendance Department on account of prolonged absence from school through ill-health. As the result of these examinations many children were returned to school considerably earlier than would otherwise have been the case. Co-operation of Voluntary Bodies. The Invalid Children's Aid Association, and the Wimbledon Guild of Social Welfare have rendered, as in past years, invaluable services to the school children of this Borough. The Local Branch of the Invalid Children's Aid Association arranged convalescent treatment for sixty-eight Wimbledon children in 1933. Ten of these cases were referred from the School Medical Department. These children were principally suffering from anaemia, debility, bronchitis, rheumatism, or were convalescing after acute illnesses. Education is generally provided for the children whilst they are away. Great assistance has been received from the Invalid Children's Aid Association in connection with the orthopaedic scheme of the Education Committee. In three cases they kindly arranged for the transport of patients to Pyrford by car. In other cases, where the mothers were out at work all day, they arranged for their visitors to take children up to the out-patient department, St. Thomas's Hospital, for treatment. Surgical requirements were provided in seven cases, whilst in another eight suitable clothing was granted. In the case of several children the Surgeon had ordered special alterations to the boots which they were to wear, and as in many instances the. parents were in poor circumstances the Invalid Children's Aid Association came to their assistance in providing new footgear. The approximate number of children who were on their books, and being visited, in 1933, was three hundred and three. This is but a small part of the work the Association is carrying out. The assistance they are rendering to the parents, 114 especially in the poorer parts of Wimbledon, is of the greatest value and much appreciated. The Local Representative of the National Society for the Prevention of Cruelty to Children has always been ready to co-operate in every way with the staff of the School Medical Department. 13. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. A special register is kept in the School Medical Department of all defective children. Information regarding new cases is furnished by the Head Teachers, School Attendance Officers, and School Nurse-Health Visitors. In addition, special visits were paid to all the schools by the School Medical Staff at least twice during the year for the purpose of ascertaining and examining suspected cases of mental deficiency. Communications were addressed to the Head Teachers of the schools asking them to forward a list of all children considered to be defective within the meaning of Part V of the Education Act, 1921. Children requiring education in Myope or Sight-saving Schools were referred by the Oculist from the Refraction Clinic, whilst physically defective children in need of education in Special Schools were brought forward from the Orthopaedic Clinic. A special circular was also addressed to the Head Teachers requesting them to furnish particulars regarding children with defective hearing. Blind and Partially Blind Children. There were two blind children on the register at the end of the year. One is a child aged five years who is also a suspected case of mental deficiency and arrangements are being made for him to be re-examined in the early part of 1934 with a view to ascertaining the type of institution most suitable for his condition. The second case is a girl aged fifteen years whose family had only removed into the district in December. Arrangements have already been made for her to be sent to a Certified School for the Blind at Brighton. Two boys and two girls are in attendance at the Ravenstone Myope School (L.C.C.) at Balham. There is one girl in attendance at the Wickersley Road School (L.C.C.), Battersea. These are children suffering from such a degree of short sight that they cannot read ordinary school books without injury to their eyesight. Deaf and Partially Deaf Children. There were no children in attendance at Certified Schools for the Deaf at the end of 1933. 115 One girl was attending the Hearnville Road Partially Deaf School (L.G.C.) at Balham. Epileptic Children. One girl, suffering from severe epilepsy requiring institutional treatment was admitted to the Chalfont Colony, Bucks., and was in residence there at the end of the year. PHYSICALLY DEFECTIVE CHILDREN. (а) Tuberculous Children. The Surrey County Council is the Authority responsible for the treatment of tuberculosis in Wimbledon. Two children suffering from pulmonary tuberculosis and two suffering from non-pulmonary tuberculosis were in suitable institutions at the end of December. (b) Delicate Children. Four delicate children (two boys and two girls) were at the undermentioned institutions at the end of the year:— Farningham Home for Boys, Swanley. St. John's Home, Brighton. Brooklands Home, Worthing. White Oak Hospital, Swanley. Three other delicate children were discharged from similar institutions during the course of 1933 and subsequently attended ordinary elementary schools. Forty-three delicate children attending public elementary schools were under the observation of the School Medical Staff. A great number of these were home contacts of tuberculosis and were in attendance at the Dispensary. (c) Crippled Children. At the end of' December, there were four crippled children at Certified Special Schools, twenty attending public elementary schools, and one at no school or institution. The four cases at Certified Special Schools were at the following institutions:— St. Nicholas' & St. Martin's Orthopaedic Hospital & Special School, Pyrford 1 Heritage Craft Schools, Chailey 2 Frogmore Road Physically Defective School (L.C.C.) 1 Five crippled children (four boys and one girl) who had been undergoing orthopaedic treatment at the St. Nicholas' and St. 116 Martin's Orthopædic Hospital and Special School, Pyrford, were discharged during the course of the year. The majority of the twenty crippled children in the public elementary schools attended the Orthopaedic Clinic and were periodically examined by the Surgeon. (d) Children with Heart Disease. One child with severe heart disease was undergoing treatment at The Heart Home, West Wickham, at the end of 1933. Two other children, suffering from rheumatism with cardiac complications were discharged from this institution during the course of the year. These, together with four other children with heart disease, were in attendance at public elementary schools at the end of December. They were kept under observation periodically and the school curriculum was modified in a manner suitable to their requirements. SPECIAL SCHOOL. The Education Committee has its own Special School, with accommodation for fifty children. This is sufficient to meet the requirements of the Borough. At the end of 1933 there were thirty-six children (seventeen boys and nineteen girls) in attendance. In addition, one boy was attending the Littleton Street (L.C.C.) Special School and one boy and one girl were receiving education in special residential institutions. The total number of Wimbledon children attending such Special Schools at the end of the year was thirty-nine, as compared with thirty-seven at the end of 1932. Four boys and three girls were admitted during 1933. One boy left the school as his parents had removed from the district. Two boys and three girls left the school, either having attained the age of sixteen years or having attained such a standard as to justify their leaving to take up suitable employment. Every child attending the school is examined at least once a year in addition to the routine medical inspections. The School Medical Officer visited the school, on an average, once a week for this purpose. Fourteen children were examined in the routine way in the following prescribed groups:— Second Age Group 3 Third Age Group 8 117 Number of Other Routine Inspections 3 The following defects requiring treatment were found:— Malnutrition 1 Enlarged Tonsils 1 Defective Vision 1 Dental Caries 5 The defects requiring observation, discovered in the children examined in the routine way were:— Defective Vision 2 Defective Speech 2 Functional Heart Disease 1 Bronchitis 2 In addition there were eighteen special inspections and thirty-one re-inspections at the Health Centre of children attending this school. Fourteen children were referred from the special inspections for treatment at the Minor Ailment Clinic, with the undermentioned defects:— Ringworm of the Body 1 Impetigo 1 Other Diseases of the Skin 7 Minor Eye Defects 1 Miscellaneous 4 Two children were examined as new cases by the Oculist at the Refraction Clinic whilst two other children attended for re-examination. The total number of attendances made amounted to six and glasses were prescribed in two instances. Two old cases attended at the Orthopaedic Clinic for examination by the Surgeon. At the routine dental inspections twenty-eight children were examined. Nineteen of these were found to require treatment. Six of the children were actually treated, and made eleven attendances at the Dental Clinic. Seven temporary teeth and four permanent teeth were extracted. In six cases general anaesthetics were administered. In addition four other dental operations were performed on permanent teeth in children from this school. Frequent visits were paid to the school by the senior school nurse in the course of her periodical examinations. As a rule, the nurse visits the school about once a fortnight. In all, fifteen such visits were paid and four hundred and thirty-five 118 inspections carried out. Five children were excluded during these visits. Provision is made for children attending this school to receive a bath once a week and a special attendant is employed by the Education Committee for the purpose. Many of the parents are glad for their children to take advantage of these facilities. A cooked mid-day meal of excellent quality is served at the school. On an average, sixteen children stayed for this meal for which a charge of threepence is made. In six cases it was found necessary to forego the amount owing to the financial circumstances of the parents. In addition to the routine class teaching special attention is paid to handicraft instruction. Carpentry, gardening, cookery, and laundry-work were taught. A list is kept of all retarded school children in the district. These children are examined on an average every six months in order to ascertain their suitability for transference to the Special School. In addition every school is visited periodically by one of the School Medical Staff with the view to ascertaining from the Head Teachers the number of backward children in attendance. Children. who have left the Special School on attaining the age of sixteen and who are in need of supervision and care are notified to the Local Authority under the Act of 1913, as amended. Two boys were notified for this purpose. In other cases, where the school report is satisfactory, the home influence good, and the prospect of employment favourable, the names are passed on to the Committee of the Guild of Social Welfare which acts in Wimbledon as the Local Committee of the Surrey Voluntary Association for Mental and Physical Welfare. One girl who was not attending any school and who was unsuitable for the Special School was also notified to the Local Authority under Article 2 of the Mental Deficiency (Notification of Children) Regulations, 1928. Children leaving the Special School in nearly all cases succeed in obtaining employment. The boys take up work in the local factories, or on milk and paper rounds, or acting as carriers for local business houses. The girls are generally employed in factories, laundries, in indoor service or doing daily work. Only one of the children who has left the Special School in recent years is at present reported not to be in employment. The home conditions are good and he should experience no difficulty in obtaining suitable work. 119 14. FULL-TIME COURSES OF HIGHER EDUCATION FOR BLIND, DEAF, DEFECTIVE AND EPILEPTIC STUDENTS. The Surrey County Council is the Authority responsible for Higher Education for blind, deaf, defective, and epileptic children. Recommendations are sent to the Surrey County Council by the Wimbledon Education Authority, in suitable cases, where Higher Education for such defective children is considered desirable. 15. NURSERY SCHOOLS. No Nursery Schools have been established in Wimbledon. The Municipal Day Nursery, however, has accommodation for thirty toddlers under five years of age. Particulars of the medical and dental inspection of these children are given in the Maternity and Child Welfare Section of the Medical Officer of Health's Report. The medical record cards of these children follow them when they enter the elementary schools on attaining the age of five years. 16. SECONDARY SCHOOLS AND OTHER INSTITUTIONS OF HIGHER EDUCATION. The medical inspection of Secondary Schools in Wimbledon is under the control of the Surrey County Education Authority. 17. PARENTS' PAYMENTS. The parents of children attending public elementary schools are required to contribute towards the cost of treatment in accordance with approved scales adopted by the Education Committee. The scheme includes treatment given at the Minor Ailment and Dental Clinics, together with the operative treatment for tonsils and adenoids, and hospital treatment under the orthopædic scheme. No charge is made for the examination of children at the Refraction Clinic but the parents are required to pay the cost of the spectacles which are obtained for their children at a contract price. In exceptional cases of financial difficulty the Committee, after considering all the circumstances, have provided the spectacles free of charge. Where children are receiving hospital treatment for other conditions under arrangements made by the Education Committee, the financial circumstances are considered in each case and a suitable assessment for the parents' contribution is then made. These latter cases include children suffering from rheumatism and heart disease, delicate children, as well as children suffering from eye diseases requiring a period of in-patient hospital treatment. 120 18. HEALTH EDUCATION. During the year, two thousand copies of "Better Health" were issued monthly in Wimbledon. Of these copies, 1,070 were distributed every month to the schools. This publication deals with simple health matters, and there are many indications of the interest with which it is received. Short articles on health topics were contributed regularly by the Public Health Department. 19. SPECIAL INQUIRIES. No special inquiries were undertaken by the School Medical Department during 1933. 20. MISCELLANEOUS. All candidates for appointment as teachers under the Education Committee are required, as a condition of their appointment, to pass a satisfactory medical examination. These examinations are carried out by the School Medical Staff. Employment of Children and Young Persons. Under the Bye-laws any school child over the age of twelve years may be employed for two hours from 5 p.m. to 7 p.m., and on week days when the school is not open, for five hours between 7 a.m. and 7 p.m. Certain forms of employment are prohibited. During 1933 ninety-three employment cards were issued to school children in accordance with the above conditions. Children who are employed for not more than one hour in the morning before school must be medically examined before an employment card is issued to them. Furthermore, such children may only be employed one hour after school and then not later than 7 p.m. Forty-six children were medically examined for employment during the year. They were all granted medical certificates of fitness for delivering newspapers and for work in connection with milk rounds. No prosecution was taken under these Bye-laws in 1933. 121 There has again been considerable sickness amongst the School Nurse-Health Visiting Staff during 1933 and the work has been carried on under difficulties. In spite of this, steady progress has been maintained. I desire to take this opportunity of expressing my appreciation of the loyal co-operation which I have received from all the members of the staff during the year under review. I am, Your obedient servant, HAROLD ELLIS. 122 Wimbledon Education Authority. MEDICAL INSPECTION RETURNS, 1933. TABLE I. RETURN OF MEDICAL INSPECTIONS. A.—ROUTINE MEDICAL INSPECTIONS. Number of Inspections in the prescribed Groups:— Entrants 635 Second Age Group 577 Third Age Group 681 Total 1,893 Number of other Routine Inspections 106 B.—OTHER INSPECTIONS. Number of Special Inspections 2,421 Number of Re-inspections 5,193 Total 7,614 123 TABLE II. A.—RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31ST DECEMBER 1933. 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) Malnutrition 12 3 22 — Skin Ringworm—Scalp — — — — Body - — 18 — Scabies 1 — 16 — Impetigo 3 — 136 — Other Diseases (Non-Tuberculous) 11 2 133 — Eye Blepharitis 11 — 33 — Conjunctivitis 1 — 31 — Keratitis — — 2 — Corneal Opacities — — — — Defective Vision (excluding Squint) 59 82 43 6 Squint 13 17 4 2 Other Conditions 6 2 62 6 Ear Defective Hearing 6 5 2 — Otitis Media 6 1 66 — Other Ear Diseases — — 51 — Nose and Throat Chronic Tonsillitis only 23 71 28 - Adenoids only 1 2 — — Chronic Tonsillitis and Adenoids 12 8 28 - Other Conditions 6 - 178 — Enlarged Cervical Glands (Non-Tuberculous) 5 18 21 1 Defective Speech 5 8 23 5 Heart and Circulation Heart Disease: Organic - 1 3 1 Functional 8 9 1 — Anaemia 1 1 1 — 124 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) Lungs Bronchitis 12 13 22 2 Other Non-Tuberculous Diseases 1 - 1 3 Tuber¬culosis Pulmonary: Definite - - — — Suspected — — — — Non-Pulmonary: Glands - - — — Bones and Joints - - — — Skin - - — - Other Forms - 1 — — Nervous System Epilepsy - 5 5 - Chorea - — 4 - Other Conditions — — — 1 Deformities Rickets 4 1 1 - Spinal Curvature 16 8 10 - Other Forms 18 10 8 1 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 80 24 347 141 B.—NUMBER OF INDIVIDUAL CHILDREN FOUND AT ROUTINE MEDICAL INSPECTION TO REQUIRE TREATMENT (EXCLUDING UNCLEANLINESS AND DENTAL DISEASES). GROUP. Number of Children. Percentage of Children found to require Treatment Inspected Found to require Treatment. (1) (2) (3) (4) Prescribed Groups:— Entrants 635 95 15.1 Second Age Group 577 98 16.9 Third Age Group 681 109 16.0 Total (Prescribed Groups) 1893 302 15.9 Other Routine Inspections 106 20 18.8 125 TABLE III. Return of all Exceptional Children in the Area CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Number of children suffering from any combination of the following defects:—Blindness (Not Partial Blindness); Deafness (Not Partial Deafness); Mental Defect; Epilepsy; Active Tuberculosis; Crippling (as defined in the penultimate category of the Table); Heart Disease 1 BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — — — 2 2 126 PARTIALLY BLIND CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Wlementary Schools. At Other Institutions. At no School or Institution. Total. — 5 — — — 5 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — — — — — TABLE III—continued. PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — 1 - — — 1 MENTALLY DEFECTIVE CHILDREN. FEEBLE-MINDED CHILDREN. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 39 - — — 39 127 EPILEPTIC CHILDREN. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 1 — — — 1 PHYSICALLY DEFECTIVE CHILDREN. A.—TUBERCULOUS CHILDREN. I.—Children Suffering from Pulmonary Tuberculosis. (Including pleura and' intra-thoracic glands). At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — — 2 — 2 TABLE III—continued. 11.—Children Suffering from Non-Pulmonary Tuberculosis. (This category should include tuberculosis of all sites other than those shown in (I) above). At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — 1 2 — 3 B—DELICATE CHILDREN. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 4 43 1 — 48 C.—CRIPPLED CHILDREN. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 4 20 — 1 25 D—CHILDREN WITH HEART DISEASE. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 1 6 — — 7 128 TABLE IV. RETURN OP DEFECTS TREATED DURING THE YEAR ENDED 31ST DECEMBER 1933. TREATMENT TABLE. GROUP I.—MINOR AILMENTS (excluding Uncleanliness, for which see Group VI.). DISEASE OB 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. (Shown separately in brackets the number which were treated by X-Rays.) - - - Ringworm Body 21 — 21 Scabies 16 — 16 Impetigo 137 2 139 Other skin disease 116 7 123 Minor Eye Defects— 115 2 117 (External and other, but excluding cases falling in Group II.) Minor Ear Defects 98 8 106 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc ) 589 - 589 Total 1092 19 1111 129 TABLE IV.—continued. GROUP II.—defective vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). DEFECT OR DISEASE. Number of Defects dealt with. Number of Children for whom Spectacles were Under the Authority's Scheme (See note b) By private practitioner or at hospital, apart from the Authority's Scheme. Otherwise. Total. Prescribed (1) Obtained (2) (1) (ii) (i) (ii) Under the Authority's Scheme. Otherwise. Under the Authority's Scheme. Otherwise. (1) (2) (3) (4) (5) Errors of refraction (including Squint) 226 45 — 271 86 35 86 35 Other Defects or Disease of the Eyes (excluding those recorded in Group I.) 14 1 — 15 — — - Total 240 46 — 286 86 35 86 35 130 TABLE IV—continued. GROUP III.—TREATMENT OF DEFECTS OF NOSE AND THROAT. NUMBER OF DEFECTS. Received Operative Treatment. Received other forms of Treatment. Total number Treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) ... 1 40 ... ... ... 2 ... ... 1 42 ... 18 61 131 (i) Tonsils only. (ii) Adenoids only. (iii) Tonsils and Adenoids. (iv) Other defects of the nose and throat. TABLE IV.—continued. GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS Under the Authority's Scheme (1) Otherwise (2) Total Number Treated Residential treatment with education Residential treatment without education Non-residential treatment at an orthopedic clinic Residential treatment with education Residential treatment without education Non-residential treatment at an orthopa3dic clinic (i) (ii) (iii) (i) (ii) (iii) Number of Children Treated 10 2 143 — 8 163 132 TABLE IV.—continued. GROUP V.—DENTAL DEFECTS. 1. Number of Children who were:— a. Inspected by the Dentist. Aged Routine Age Groups 5 140 Total 4527 6 398 7 501 8 480 9 481 10 581 11 469 12 474 13 583 14 420 Specials 134 Grand Total 4661 6. Found to require Treatment 3833 c. Actually Treated 2038 2. Half-days devoted to:— Inspection, 44. Treatment, 361 Total 405 3. Attendances made by Children for Treatment 4180 4. Fillings:— Permanent Teeth, 2407. Temporary Teeth, 5 Total Teeth 2412 5. Extractions:— Permanent Teeth, 605. Temporary Teeth, 2804 Total 3409 6. Administrations of general anaesthetics for extractions 640 7. Other Operations:— Permanent Teeth, 2065. Temporary Teeth, 216 Total 2281 133 TABLE IV.—continued. GROUP VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. 1. Average number of visits per School made during the year by School Nurses 7 2. Total number of examinations of children in the Schools by School Nurses 12,808 3. Number of individual children found unclean 473 4. Number of children cleansed under arrangements made by the Local Education Authority 153 6. Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 - (b) Under School Attendance Bye-laws — 134 INDEX Committee, Maternity and Child Welfare 1 „ Public Health 1 Medical Examinations 3 Staff, official 2,88 Statistics and. Social Conditions of the Area 4-16 Area 4 Birth Rate 5 „ „ Graph showing 11 Births, Registered 5,8 „ Notification of 9 Cancer 12 Death Rate 5 „ „ Graph showing 11 Deaths 5,9 Families, number of 4 Houses, inhabited 4 Infantile Mortality 6,14,15, l6 „ „ Graph showing 16 Mortality, analysis of 7 Mortality, Cancer 12 Bronchitis and Respiratory Diseases 13 Heart and Circulatory Diseases 12,13 Infantile 6,14,15,16 Neo-natal 15 Violence 14 Penny Rate, product of 4 Population 4 Rateable Value 4 Social Conditions 4 Stillbirths 5 Unemployment 5 Vital Statistics, Extracts from 5 Ward, Birth Rates 8 „ Death Rates 8 „ Population 8 General Provision of Health Services in the Area 17-41 Ambulance Facilities 18 Ante-natal Clinic 18,22,26 Assistance, Public 21 Clinics and Treatment Centres 18,19,26 Day Nursery 19,34,35,36,37 Dental Treatment 19,33,34 Dispensary, Tuberculosis 19 Facilities— Ambulance 18 Laboratory 17 Hospitals, Tuberculosis 20 Children's 20 General 21 Infectious Diseases 20 Maternity 20 Institutional Provision for Mothers or Children 23 Laboratory Facilities 17 Legislation in force 39,40,41 135 Midwifery and Maternity Services 23 Midwives' Acts 23,24 Medical Aid 24,25 Mortuary 39 Mothercraft Classes 19,22,26 Nursing Homes 38 Inspection of 38 Nursing in the Home 18 General 18 Midwifery 18 School Clinic 19 Venereal Diseases 19 Maternity and Child Welfare 21-37 Children Act, 1908 (Part I); Children anil Young Persons Act, 1932 27,28 Day Nursery 34,35,36,37 Dental Treatment 34,34 Ear Diseases and Defective Hearing 31 Home Visitation 25 Maternal Mortality 31,32 Minor Ailments, Treatment of 31 Obstetric Cases, Treatment for Complicated 32 Ophthalmia Neonatorum 30 Ophthalmic Treatment 30 Orthopedic Treatment 28,29,30 Supply of Milk 33 Table of Attendances at Centres 26 Tonsils and Adenoids, Treatment of 31 Voluntary Helpers 34 Sanitary Circumstances of the Area 42-60 Common Lodging House 50 Dairies, Cowsheds and Milkshops 52 Diseases of Animals Acts 56 Disinfection 52 School 53 Drainage, House 48 Drainage and Sewerage 42 Drains, opening up under Section 41 47 Employment Agencies 57 Employment of Children 57 Factory and Workshop Acts 44,45,46,47 Inspections under 53 Food and Drugs Acts 55,66 Food Inspection 55,66 Foot and Mouth Disease 56 Fouling of Footways by Dogs 57 Home Work 46 Houses let-in-lodgings 49 Infectious Disease 52 Inspection of District 43 Inspection, House to House 48 House 48,49 Legal Proceedings 54,55,56 Mosquitoes 58 Notices served 44,47 Nuisances Abated, Table of 59 Offensive Trades 58 Overcrowding 49 Parasitic Mange 56 136 Petroleum Acts 55 Public Health (Meat) Regulations 56 Rainfall 42 Refuse Collection 43 Rent (Restrictions) Acts 56,57 Sanitary Inspector's Report 47 Schools 53,60 Sewage Disposal 42 Shops Acts 54 Slaughter Houses 55 Smallpox Contacts 58 Stable Refuse 53 Street Gully Cleansing 43 Swine Fever 56 Tuberculosis Order, 1925 56 Van Dwellings 50,51,52 Verminous Rooms 49 Water Supply 42,57 Workshops, Registered 46 Yard Paving 53 Housing 61-64 Action under Public Health Acts 64 Housing Conditions 62,63,64 Overcrowding 49,64 Statistics for the Year 61,62 Tents, Vans and Sheds 50,51,52 Inspection and Supervision of Food 65-66 Bacteriological examination 65 Food and Drugs (Adulteration) Act, 1928 66 Inspection 65 Licences issued under Milk. (Special Designations) Order, 1923 65 Milk Supply 05 Registrations 65 Slaughter Houses 66 Prevalence of, and Control over Infectious and other Diseases 67-83 Cerebro-Spinal Fever 71,82 Diarrhoea (under two years) 67 Diphtheria 69,70,80,81 Complications Noted 81 Disinfection 83 Encephalitis Lethargica 71 Enteric Fever 82 Erysipelas 71,82 Food Poisoning 70 Infectious Diseases Hospital 78-82 Cases admitted, Table of 78 Revenue 78 Staff 82 Infectious Diseases, Incidence of 67 „ „ Non-Notifiable 67 Influenza 67 Laboratory Work 17 Malaria, Dysentery, etc 71 Measles 2 Ophthalmia Neonatorum 30, 71 137 Pathological examinations 17 Pneumonia 72 Puerperal Fever and Puerperal Pyrexia 70, 71 Scarlet Fever 68,69,79,80 Complications Noted 79 Smallpox 58,68,82 Table showing number of Cases Notified during year 72 „ „ Admission to Infectious Diseases Hospital 78 „ „ Ages at Death from Notifiable Diseases 73 „ „ Cases and Deaths from Tuberculosis 77 „ „ Disinfection carried out 83 „ „ Number of Cases Notified in last ten years 75 „ „ Ward Distribution of Cases 74 „ „ Zymotic and Tuberculosis Death Bates 74 Tuberculosis 75,76,77 Whooping Cough 67,82 Table I.—Vital Statistics 85 Table II—Causes of, and Ages at Death 86,87 School Medical Service 88-134 Arrangements for Treatment 101-109 Artificial Light Treatment 108 Blind, Deaf, Defective and Epileptic Children 115,116 Full-time Courses of Higher Education for 120 Blind and Partially Blind Children 115 Co-operation of Parents 113 School Attendance Officers 114 Teachers 113 Voluntary Bodies 114 Co-ordination 90 Crippled Children 116 Crippling Defects 98, 105, 106, 107 Deaf and Partially Deaf Children 115 Defective Hearing 97 Defective Vision 96,97 Delicate Children 116 Dental Defects 98,104,105 Disinfection of Schools 110 Ear Diseases and Defective Hearing 97,103,104 Employment of Children and Young Persons 121 Epileptic Children 116 Eye Disease, External 96,102,103 Following up 100 Health Education 121 Heart Disease and Rheumatism 98,99,107,108 Heart Disease, Children with 117 Infectious Disease 109,110,111 Malnutrition 93,94,101 Meals, Provision of 112 Medical Inspection 91,92 „ „ Findings of 93-100 Medical Treatment 101-109 Milk in School 113 Minor Ailments 95,101 Miscellaneous 121 138 Nose and Throat Defects 97,103 Nursery Schools 120 Open Air Education 111,112 Orthopaedic Treatment 98,105,106,107 Parents' Payments 120 Physical Training Physically Defective Children 116, 117 Postural Defects 98,105,106,107 Provision of Meals 112 Rheumatism and Heart Disease 98,99,107,108 School Accommodation 89 School Baths 119 School Disinfection 110 School Hygiene 90,91 Secondary Schools, etc. 120 Skin Disease 95,101 Special Inquiries Special School 117,118,119 Speech Clinic 108,109 Staff 88,89 Swimming Instruction 112 Table I—Return of Medical Inspections 123 „ II—Return of Defects 124,125 „ III—Return of All Exceptional Children 126,127,128 „ IV—Treatment Table 129-134 Tonsils and Adenoids 97,103 Treatment, Arrangements for 101-109 Tuberculosis 99, 108 Uncleanliness 94,95,101 Visual Defects 96,97,102,103 139 Printed by J, B, Blackmore & Cc. Ltd 85. High Street, Merton, S.W 19.