Urban District of Acton. ANNUAL REPORT OF THE Medical Officer of health TOGETHER WITH THE REPORT ON THE Medical Inspection of Schools FOR THE YEAR 1908 BS x 1/18 Act 16 Urban District of Acton. ANNUAL REPORT OF THE Medical Officer of health FOR THE YEAR 1908 2 By the Order of the Local Government Board, dated March 23rd, 1891, article 18, section 14, it is prescribed that the Medical Officer of Health shall make an Annual Report to the Sanitary Authority, up to the end of December in each year, comprising a summary of the action taken, or which he has advised the Sanitary Authority to take, during the year, for preventing the spread of disease, and an account of the sanitary state of his district generally at the end of the year. The Report shall contain an account of the enquiries which he has made as to conditions injurious to health existing in the district, and of the proceedings in which he has taken part or advised uijder any Statute, so far as such proceedings relate to those conditions ; and also an account of the supervision exercised by him, or on his advice, for sanitary purposes, over places and houses that the sanitary authority have power to regulate, with the nature and results of any proceedings which may have been so required and taken in respect of the same during the year. The Report shall record the action taken by him, or on his advice during the year, in regard to offensive trades, to dairies, cowsheds and milk shops. The Report shall also contain tabular statements (on Forms to be supplied by us, or to the like effect) of the sickness and mortality within the district, classified according to diseases, age and localities. In a memorandum issued by the Local Government Board in November 1908, it is recommended that the Report shall deal with the extent, distribution and causes of disease within the district ; and should give an account of any noteworthy outbreak of epidemic diseases during the year under review, stating the result of investigations into their origin and propagation, and the steps taken to check their spread. As these Report are for the information of the Local Government, and of the County Council, as well as of the Council of the District, a statement of the local circumstances and a history of local sanitary questions, which may seem superfluous for the latter, may often he needed by the former bodies. Under section 132 of the Factory and Workshop Act, 1901, the Medical Officer of Health is also required in his Annual Report to report specifically on the administration of the Act in workshops and workplaces, and to send a copy of his Annual Report, or so much of it as deals with this subject, to the Secretary of Mate. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH for the year 1908. 130, Churchfield Road, Acton, W. February, 1909. To the Chairman and Members of the Acton District Council. Gentlemen, I have the honour to submit to the Council a report on the sanitary conditions of the district, together with the vital and other statistics for the year 1908. The death-rate was lower in 1908 than in 1907 and 1906. The death-rale amongst children under 12 months of age was also lower. In view of the hot summer experienced, resulting in an increase of the deaths from Diarrhœa, the lower infantile mortality is satisfactory. There was an extensive epidemic of Measles, which resulted in 38 deaths. The outbreak of Scarlet Fever which commenced in 1907, continued practically throughout the year. These two diseases are dealt with at length on a later page. There were 7 deaths from Diphtheria as compared with 6 in 1907, but only two from Enteric Fever as compared with three in the previous year. Bye-laws dealing with the Employment of Children were adopted during the year. Arrangements were made early in the year for the Medical Inspection of School Children, and this subject is dealt with in a separate report. The accommodation at the Isolation Hospital has been the subject of reports and discussions, and plans have now been prepared for an additional pavilion. The following is a summary of the vital statistics for the year: Estimated population 55,000. Birth rate 28.5 per 1,000 inhabitants. Death rate 13.1 „ 4 Infantile mortality 120 per 1,000 births. Zymotic death rate 2.2 per 1,000 inhabitants. Respiratory death rate (including Phthisis) 3.2 per 1,000 inhabitants. Phthisis death rate 1 per 1,000 inhabitants. Death rate from other forms of Tuberculosis 5 per 1,000 inhabitants. POPULATION. Eight years have now elapsed since the official census was made, and the further we are removed in time from that census until the next, the more inexact our estimates become, and the less reliable are all vital statistics. In former reports the various methods by which an estimate of the population is made were discussed, and reasons were given for adopting the number of houses in occupation as the basis. But even this method is liable to considerable error. The number of inhabitants in each house rose from 5.9 at the census of 1891 to 6.2 at the census of 1901. This increase was due to the fact that houses formerly occupied by one family were converted into flats This process is still going on, and some of the new houses have been erected in the form of double tenements. Between June 30th 1907, and June 30th, 1908, 310 single tenement dwelling house were erected and 25 double tenement ones. An average of 6.2 persons per house is probably below that which obtains at the present time. On the other hand, the percentage of uninhabited houses is higher now than in 1901. At the census of 1901 there were 6,540 inhabited houses in the district. Between March 31st, 1901, and June 30th, 1908, 2,62 dwelling houses were erected. In this latter figure double tenement houses are reckoned as one house. If the same number of persons per house and the same percentage of " empties" as the figures at the census disclosed, t allowed, the estimated population would be 55,176. The figures in this report have been based upon an estimate population of 55,000. This figure is more likely to be an under estimate than an over estimate of the population. 5 BIRTHS. There were 1568 births registered as having occurred within the district. This number corresponds to a birth-rate of 28.5 per 1,000 inhabitants. Although the aggregate number of births exceeds that recorded in any previous year, the birth-rate last year was the lowest on record. It was .5 per 1,000 inhabitants less than that of 1907, and .9 per 1000 less th in the average for the ten years 1898—1909. The birth-rate has shown a continuous decline throughout the kingdom since 1894, and in Acton the rate is still above that of England and Wales. Last year, the birth-rate in England and Wales was 26 5 per 1000; in the 76 large towns it was 27, and in the 142 smaller towns it was 26 per 1,000. Usually the number of male children born exceeds the number of female ones, but last year the order was reversed, and there were 785 females and 783 males. The births were distributed amongst the Wards as follows:— Noith-East 363 North-West 215 South-East 338 South-West 662 As usual the North-West Ward showed the lowest rate per 1,000 inhabitants and the South-West the highest. In the latter the rate was more than twice that of the former—39 and 18 per 1,000 respectively. The infants registered as having been born out of wedlock numbered 42, which figure corresponds to a rate of 26.8 per 1,000 birihs. This is lower than the illegitimate birth rate of England and Wales,but higher than that of Acton in 1906 or 1907. DEATHS. Number 723 Death Rate per 1,000 13.1 Death Rate per 1,000 in England and Wales 14.7 Death Rate per 1,000 in 76 large towns 14.9 Death Rate per 1,000 in 126 smaller towns 14 There were 590 deaths registered in the district, one of these did not belong to Acton and occurred in a public institution, 6 133 deaths of residents occurred in public institutions outside the district, and this number has to be added. The total number of deaths belonging to the district is 723 which corresponds to a death-rate of 13.1 per 1,000 inhabitants. It has been explained in previous reports that in order to compare the death-rate of one district with that of another it is necessary to make an allowance for the difference in age and sex constitution of the various districts. Females live longer than males, and a district containing a preponderance of women would show a lower death-rate other things being equal. But the most important factor is the age-constitution of a population. The tendency to death is greatest among persons living at the extremes of life, among infants and old people. The ages at death last year were as follows:— Under 1 year. 1 to 5. 51015. 151025. 251065. over65. 188 106 29 23 209 168 The Registrar General has published a table of "factors" for all the large towns &c. by applying which to the "crude death-rate' it becomes corrected for age and sex distribution, so that the "corrected death-rate" gives the death-rate of any place, calculated on the basis that the age and sex distribution in that place is the same as that for the whole country. Thus all "corrected" deathrates, being reduced to a common basis, may fairly be compared. The "factor for correction" for Acton is 1.04240. If the "crude death-rate," 13.1, be multiplied by this figure, the corrected deathrate is 13.6. The corrected death rate for the 76 large towns is 15.8 and for the 142 smaller towns 14.7. The death rate is .8 per 1,000 lower than that of 1907; there was a diminution in the number of deaths in children under 1 year of age, and in the age-periods 5 to 15, 15 to 25, and 25 to 65 years. There was an increase in the age-periods 1-5 and over 65 years. The increase in the number of deaths in children between the ages of 1 and 5 years was mostly due to the out-break of Measles which occurred in the Spring. 7 There was a most marked drop in the number of deaths from Pneumonia and Heart Disease. Ward Distribution. North East. North West. South East. South West. 144 124 124 331 Based upon the estimated population of each ward, the death-rate per 1,000 was:— North East. North West. South East. South West. 10.3 10.3 10.3 18.3 The death-rate in the North-East South-East & South-West Wards is lower than it was in 1907, but that of the North-West is higher. The most marked improvement appears in the South-West Ward, but a death-rate 80 per cent. above that of the rest of the district is far from satisfactory. It was pointed out in last year's report that some of the causes of the enhanced death-rate are not entirely dependent upon sanitary conditions. The birth rate in the South-West Ward is much higher than in the rest of the district, and the Ward therefore contains an abnormal percentage of persons peculiarly sensitive to adverse influences. The age distrubition of the population though, is not sufficient to account for the marked difference in the death-rate of this Ward as compared with the rest of the district. Diseases of childhood would naturally be more prevalent in the Ward, but even from such diseases as Measles, Diarrhoea, &c., the mortality is excessive. Out of 38 deaths from Measles 25 occurred in the South-West Ward; and some of the other diseases claimed their victims from the Ward in the following proportions:— Scarlet Fever 10 out of 15 Whooping Cough 9 „ ,,15 Diarrhoea 33 „ „ 46 Prematurity 17 ,, „ 25 The same phenomenon is observed in other diseases which are more or less dependent on social conditions. Out of 56 deaths from Phthisis, 26 belonged to the South West Ward, from Pneumonia 25 out of 55 deaths and from Bronchitis 28 out of 50. Persons living under such conditions as overcrowding, badly lit and badly 8 ventilated dwellings, and physical fatigue associated with under nourishment are rendered more susoeptible to the attacks of the above diseases, and when attacked are more prone to succumb. When we turn to diseases that would not be affected with the conditions named, we find that an abnormal toll is not levied on the South-West Ward. Out of 48 deaths from Cancer, belonged to the Ward, and 17 out of 43 deaths from Heart Disease. From Alcoholism and Cirrhosis of the Liver there were only 3 deaths in the South-West Ward as compared with twice that number in the North-West Ward. One of the most marked features in the death returns is the increased percentage of deaths in public institutions. The death returns of Acton residents who had died in public institutions outside the district were first obtained in 1905. In that year 119 deaths or a percentage of 19 of the total deaths occurred in public institutions. Last year the number was 164, or a percentage of 23 of the total deaths. The following list gives the names of the institutions together with the number of deaths in each:— Fever Hospital 18 Cottage Hospital 13 Isleworth Infirmary 82 West London Hospital 13 Middlesex County Asylum 8 St. Mary's Hospital 4 St. George's Hospital 4 Cancer Hospital, Chelsea 3 Children's Hospital, Great Ormonde Street 3 Victoria Hospital 3 Queen Victoria Hospital, Bethnal Green 2 Middlesex Hospital 1 King's College Hospital 1 St. Bartholomew's Hospital 1 Chelsea Hospital for Women 1 New Hospital for Women 1 Queen Charlotte's Hospital 1 National Hospital j 9 Children's Hospital, Paddington Infants' Hospital, Vincent Square 1 St. Peter's Hospital 1 London Fever Hospital 1 ZYMOTIC DISEASES. Deaths, 124. Death-rate, 2 25. The so called Zymotic death-rate includes deaths from seven Zymotic diseases, Small-pox, Measles, Whooping Cough, Scarlet Fever, Diphtheria, "fever ' and Diarrhœa. The district was entirely free of Small-pox and the other diseases are dealt with separately. MEASLES. In 1908,38 deaths were registered as due 10 Measles and 37 of these occurred in the months of March, April, May and June. In the Annual Report for 1906, an attempt was made to trace briefly the history of the disease during the last quarter of a century. The experience of Acton has been somewhat similar to that of the whole of England and Wales. Daring the third quarter of the last century, there was a decided improvement, but this was followed by a serious rise towards the end of the century. In Acton the improvement was noticed up to the year 1885, but since that date, the means adopted for the prevention of Measles have not had the effect of steadily and continuously reducing the death-rate. An epidemic has made its appearance almost every second year, and the district has been visited by an epidemic causing a death-rate of more than 50 per 1,000 inhabitants at intervals of 4, 3, 4. 6, 4 and 2 years respectively. The following table gives the annual number of deaths per ico,000 inhabitants in quinquenial periods for the 26 years 1884 to 1908:— 1884 — 1888 34 per 100,000 1889 — 1895 38 „ „ 1894 — 1898 41 „ „ 1899 — 1903 25 „ „ 1904 — 1908 39 „ „ 10 During the past 5 years the death-rate per 100,000 has been as follows:— 1904 32 1905 8 1906 52 1907 38 1908 65 In the 25 years, 1884—1908, Measles was accountable for 250 deaths, and no other Zymotic disease, with the exception of Diarrhœa plays so important part in the mortality returns of children under 5 years of age. We have to face two problems, the prevention and control of epidemics, and the reduction of the fatality of the disease. The latler is to some extent dependent on the former, for after a certain period, the older the child, the less susceptible he is to the disease, and even if the disease be contracted, children over 5 years of age rarely succumb. The age at which relatively the greatest number of children die of Measles is the second year of life, while after the third year has passed there is a rapid decrease in the fatality of the disease. Dr Theodore Thompson in his report in the Local Government Board on the control of Measles states "that the incidence of attack is different from that of death. For while the main incidence of death is on the second year, the incidence of attack is chiefly on the third, fourth and fifth year. From this different incidence of attack anddeath it resultst hat the fatality from Measles is very much higher in the second year of life than in any of those succceding years. While, therefore, more children die of Measles in the second year of life than at any other age, more children are attacked by this disease in each of the three years following ; so that children in the second year of life, although less susceptible to attack are much more likely to die if attacked than any other children." This aspect of the question is worthy of consideration, as bearing upon the epidemicity of the disease. If the assumption be correct and it probably is, the length of the inter-epidemic period is of importance. If the inter-epidemic period could be lengthened, not only some children would have reached an age when they would be less 11 susceptible to an attack, but a larger number of children will, when the epidemic arrives, have reached ages at which the disease is little fatal. It is generally conceded that the attendance of a child at school whilst suffering from the initial symptoms of the disease is usually the starling point ofan epidemic, and unless "preventive measures are taken before the fall of the first crop, the chances of preventing or controlling an epidemic are remote. In the past, very seldom did information of the first case reach the Sanitary Department, and the first intimation received usually referred to the absence of about a dozen children from school on account of Measles. When inquiries were made it was elicited that our earliest information referred to the first crop, and that a case had occurred about a fortnight previously, but had passed unnoticed. In the hope of obtaining information of the earliest cases (as well as for other reasons), the compulsory notification of Measles has been tried in several towns. In the Annual Report for 1906, the experience of Aberdeen and Burton-on-Trent was given. In both these towns compulsory notification was tried, and in neither place could the result be deemed satisfactory. The reason is not far to seek. The notification was probably of an incomplete character. Measles is not regarded by the public as a serious disease, and in many instances a doctor is not called in to attend the child. Last year in Acton, 337 cases were inquired into, and it was ascertained that 198 of these were attended by a doctor. In 1907, 390 cases were investigated, and of these 191 were treated by a doctor. Roughly speaking, in this district, about one-third of the Measles cases are not attended by a doctor. If compulsory notification were adopted, it would take many years before any considerable number of those unattended by a doctor would be notified. For the same reason, early knowledge of the first cases would not invariably be obtained through the agency of the Infectious Diseases Notification Act. In view of the experience gained by those towns that have placed Measles amongst the compulsory notifiable diseases, it appears that guccess is more probable along other paths more especially in a 12 development of School notification. It is to be hoped now that the Medicnl Inspection of School Children is an accomplished fact, this system may be utilized in conjunction with Health Visiting to secure the detection of the earliest cases, and to adopt preventive measures before an Epidemic has become out of control. There is one difficulty under present conditions which always confronts us. When a case occurs in a class, the only practicable method is to close that class for a fortnight, and to keep all the children under observation during the incubation period. Unfortunately, the closure of a single class is more serious financially than the closure of the whole department, and the occurrence of a single case does not justify the latter course. It may be of interest to record the result of closing a school on the occurrence of a single case. A case of Measles, N.S. was notified from the South Acton Infant School, on December 16th, 1908. The child had been ill since December nth, and the rash appeared on December 14th. The introduction of the disease into the district can be traced with a fair decree of definiteness. A child D.I. aged 14 months, attended the out-patients department of the Paddington Green Children's Hospital on November 19th. At the time, Measles was prevalent in the Western boroughs of the administrative County of London. The child exhibited symptoms of Measles on November 28th, and the rash appeared on December 3rd. The disease was of a severe type and the child died on December 5th. As stated above N.S. was notified on December 16th, and inquiries made amongst children absent from school revealed two more cases. One of the latter attended South Acton School and was taken ill on December 9th. This child used to live in the same house as D.I. did, and had been to see the latter during her illness. Two classes in the school were affected, and the children above referred to had attended when suffering from the initial symptoms of Measles. The first crop would be due to fall somewhere between December 18th and December 23rd. As the interference with the work of the school would be very slight, it was decided to close the department for the Christmas 14 Holidays on Friday, December 18th, instead of December 23rd. The names and addresses of all the children attending the two classes were obtained, and the houses visited before the school re-opened after the holidays. Five cases of Measles were found and these had sickened after the closure of the school. The regulations for exclusion of children from premises where Measles existed were observed, and no cases occurred in other houses. It is probable that Measles would not spread very extensively amongst the children attending these two classes, as one class was exceedingly well protected. 90 per cent, of the children in one of the classes had suffered from a previous attack. The other classes in the school were not so well protected, and it is reasonable to assume that a large number of children would have been infected if the five cases had attended school when suffering from the initial symptoms. The closure of single classes has been tried in some districts with varying success. Some state that this has been the means of postponing an epidemic at any rate for some months. Even if the epidemic were postponed only for a few months, in some circumstances this might mean a saving of life. In the poorer districts, it ts well known that an epidemic of Measles is more serious and more fatal if it occurs in the winter months than it is in the summer. A large number of the deaths are due to lung complications and these are far more frequent during a winter than a summer epidemic. Apart from the question of a lengthened inter-epidemic period, if the first case were detected in a school during the winter months, the closure of a class for a fortnight would be well worth a trial. During the late epidemic, the earlier cases were not detected, and the Schools were not closed until the outbreak had got beyond the stage of effective control. Rothschild Road was the first school to be affected, and by the end of February the attendance had fallen so low that it was decided to close the school from February 28th, to March 23rd. Acton Infant's Department was closed from March 16th to April 6th; Priory Infant's from March 27th to April 27th, South Acton Infant's from April 10th to April 27th ; Beaumont Park Infant's from April 10th to April 27th and East Acton from May 1st to May 18th. 14 These measures were taken after the mere exclus ion of affecte children and contacts had failed. All the children in a house where Measles existed were not exclude!, but the following regulations were adopted by the Education Committee. Children suffering from Measles must be excluded for at least one month. Children coming from houses where Measles exist, but who are not themselves suffering from the disease, should be dealt with as follows:—A child attending other than an infant school who has had Measles need not be excluded from attendance at school. A child attending other than an infant school who has not had Measles, must be excluded from attendance at school until the Monday following the expiration of fourteen days from the commencement of the last case. A child attending an infant school, whether or not it has had Measles, must be excluded from attendance at school until the Monday following the expiration of fourteen days from the com mencement of the last case. The non-success of the policy of exclusion of individual scholars is easily explainable. Measles is infectious during the period in which the patient has running from the eyes and nose and before the rash appears. Every endeavour is made by the teacher during a Measles epidemic to exclude all childien who have a cold in the head, but it is impossible by this means to prevent every child who is suffering from the initial symptoms of Measles from attendance at school. A considerable difference of opinion exists as to the time for which a child suffering from Measles should be excluded from school. Inquiries were made of different Sanitary Authorities, and in one district the period of exclusion was two weeks, in 5 the period was 3 weeks, and in 7 it was at least a month. It is more than probable that Measles does not remain infectious for more than a couple of weeks, but children who have suffered from the disease are rendered very liable to lung complications, and any premature exposure would render the children liable to broncho-pneumonia. We do not think it necessary to keep children away for a period of 4 weeks, if there is a doctor in attendance, and he certifies that it 15 is safe for the child to be at school, the period of exclusion could be reduced to a fortnight; otherwise, it is not safe for the child to return under three weeks. The rule could be made to read as follows:—Children suffering from Measles must be excluded for a period of three weeks from the appearance of the rash, unless a medical certificate be obtained, when the child can return at the end of a fortnight. It was stated above that a lengthening of the inter-epidemic period would in itself be the means of saving a number of lives, as the incidence of attack is different to the incidence of death. The following table gives the ages at death in this district in 1908:— Under 1 year. 1—2. 2—3. 3—4. 4—5. 5—6. 6—7. 8 17 3 4 3 2 1 The ages of the cases reported and visited by ttie Sanitary Authority were as follows:— Under 1 year 1—2. 2—3. 3—4. 4—5. 5—6. 6—8. over 8. 10 17 9 9 14 159 80 38 The cases visited by us do not represent fairly the age incidence of the disease in the district. Practically, all the children of school age suffering from Measles are reported, and most of the cases occurring in a house from which a child attends school are included in the above table, but if a case of Measles occurs in a house, and there are no other children from that house attending school, we have no means of ascertaining the existence of such a case. For that reason the second table does not represent the true incidence of attack in children under 5 years of age. One point though, the table does make clear. The fatality of the disease in children over 5 years of age is less than one per cent. whilst the number of deaths from the disease in the second year of life alone represents a mortality of more than one per cent. of the children living in that age period. 1 he tables suggest that children suffering from Measles in their second year of life, are specially liable to succumb, and every measure which would effect a lengthening of the interepidemic period would lower the death-rate from the disease. But age is not the only factor which affects the fatality of the 16 disease. The distribution of the deaths in the district will make it apparent that social conditions play a most important part. The street distribution was as follows:— Colville Road 6 deaths. Palmerston Road 3 „Kingswood Road 3 „ Winchester Street 2 ,, Somerset Road 2 ,, Berrymead Gardens 2 „ Berrymede Road 2 „ Park Road East 1 „ Junction Road 1 ,, Essex Park Mews 1 ,, Meon Road 1 „ Saville Road 1 ,, Fletcher Road 1 „ Osborne Road 1 ,, Park Road North 1 ,, Holland Terrace 1 ,, Shaftesbury Road 1 ,, Nelson Place .., 1 ,, York Road 1 ,, Stirling Road 1 „ Bollo Bridge Road 2 deaths. Hanbury Road 1 death. Petersfield Road 1 ,, Southfield Road 1 „ Measles occurring amongst children who live under favourable conditions may be a benign disease, and such children have a small percentage of fatality; but children with lowered vitality from poor food and insufficient ventilation develop complications which make their percentage of deaths abnormally high. It is estimated that a house is overcrowded if the average number of persons per room exceeds two. Taking this standard as a basis in 13 cases out of the 36 there was overcrowding, and the vitiated atmosphere which resulted, probably caused the large number of deaths from lung complications. 17 Death very seldom occurs during the eruptive stage, and only two deaths took place during the first week of the illness. The period which elapsed between the onset of the disease and death in the other 36 cases was as follows:— 1—2 weeks 15 4—5 weeks 4 2—3 „ 7 5-6 „ 1 3—4 „ 7 over 6 weeks 2 The liability to complications is enhanced by the fact that the employment of the mother compels a large number of them to leave their homes during the day. In 14 instances the mother was employed in laundry work. On the subsidence of the symptoms associated with the eruptive stage, the child would often be left in the care of some person in the house other than the mother, or taken to a neighbour's house to be looked after. In either case, the same care would not be taken to avoid exposure as would be exercised by the mother. In the last Annual Report, it was pointed out that doubtless many lives would be saved if all cases of Measles which were seriously ill could have skilled nursing. Almost every case is now visited and instructions given, but facilities are wanting in many of the houses, not only for the proper nursing of the sick, but also for the isolation of the patients. Once a house in the industrial portion of the district is invaded by the disease, usually, all the susceptible children are attacked. Duritig the late epidemic, there were 3 deaths each in two houses and 2 deaths in 1 house, so that altogether, deaths occurred in 31 houses. Where a second case occurred in a house, the infection took place during the early stages in the illness of the previous one, and it is very doubtful if systematic disinfection would have any effect in preventing the spread of the disease in a household. In the Annual Report for 1906, reasons were given to show that the ordinary domestic cleansing usually suffices for the disinfection after Measles, and no facts came to light during the late epidemic which would influence one in altering the opinion then held. 18 WHOOPING COUGH. There were 15 deaths from Whooping Cough: 2 of these occurred in the Isleworth Infirmary. The disease was most prevalent during the second and fourth quarters. No deaths resulted in the third quarter and only one in the first. Under present conditions, Whooping Cough is the most difficult of infectious diseases to control. The difficulties arise from many causes. Not only is the nature of the virus unknown, but the length of the infection is doubtful. Moreover, the disease is infectious before a diagnosis can possibly be made. It is true that the same remark applies to Measles and Scarlet Fever, but in the two latter diseases, the initial symptoms are fairly characteristic whilst in Whooping Cough, in the catarrhal stage, the child has the symptoms of an ordinary cold, and there is nothing to distinguish the cough until it assumes its "whooping" character. The paroxysmal stage marked by the characteristic cough does not usually manifest itself until a period of a week or ten days has elapsed, and during the whole of this time the child is infectious. Another difficulty lies in the age of the persons attacked. The Registrar General in his Annual Report for 1891 discusses the diseases to which infants succumb. He says "Very notable is the comparative immunity of infants in the earlier months from the several Zymotic diseases. The earliest to declare itself is Whooping Cough, which is the assigned cause of some deaths even in the first month, but becomes much more frequent later on; next comes Measles, but with no great number of deaths until the eighth or ninth month is reached, after which it takes many victims; while Scarlet Fever is still later in its appearance, and scarcely carried off any infants at all in their first year." This peculiarity in the behaviour of W'hooping Cough is specially noteworthy; it renders the application to it of preventive measures compared with other Zymotic diseases particularly difficult. 19 NOTIFICATION OF INFECTIOUS DISEASES. The following notifications of Infectious Diseases were received:— Diphtheria 83 Enteric Fever 14 Erysipelas 35 Purperal Fever 1 Scarlet Fever 484 Phthisis 3 On Table III will be found the age incidence and the ward distribution of the above diseases, together with the number of cases removed to Hospital. SCARLET FEVER. During the past two years, Scarlet Fever has prevailed in much greater degree than in the immediately preceeding years. 484 cases were notified in 1908, and this figure represents the highest number yet recorded in the district. The cases notified are equal to a rate of 8.8 per 1,000 inhabitants. Fifteen deaths were registered as due to the disease giving a case fatality of 3.1 per cent. With the exception of 1906, the case fatality of 1908 was higher than in that of recent years, but this bare fact is not a sufficient criterion that the disease generally was of a more severe type The vast majority of the cases in the district were of a mild character, but on some occasions, a group of cases exhibited symptoms of a most severe type, and usually the primary case of this latter group had contracted the disease outside the district. One instance of this might be given. On October 12th, W.H. aged 18, was notified of Scarlet Fever. He contracted the disease outside. A second case was notified from the same house on October 26th, and a third on October 30th. On October 25th, a girl L.F, of Antrobus Road, called to see the case notified on October 26th, and on October 30th, L. F. and her brother were notified of the disease. Altogether five cases occurred, and two deaths resulted. It was the mild type of the disease which was one of the factors in its perpetuation. Instances of "missed" cases are given on a later page. The outbreak assumed serious proportions towards the end of September, 1907, and continued with remissions and exacerbations 20 throughout the year 1908. The following table gives the number of notifications in each week throughout the year:— January 4th 5 cases July 11th — 6 ceses „ 11th 6 „ „ l8th 8 „ „ 18th 8 „ „ 25th 11 „ „ 25th 7 „ August 1st 1 case February 1st 15 „ „ 8th 4 cases 8th 7 „ 15th 3 „ „ 15th 11 „ 22nd 1 case „ 22nd 14 „ „ 29th 1 „ „ 29th 6 „ September 5th 9 cases March 7th 9 „ „ 12th 10 „ „ 14th 0 „ „ 19th 11 „ „ 21st 2 „ „ 26th 9 „ „ 28th 11 „ October 3rd 24 „ April 4th 13 „ „ 10th 10 „ „ 11th 6 „ „ 17th 15 „ „ 18th 4 „ „ 24th 5 „ „ 25th 6 „ 30th 17 „ May 2nd 7 „ November 7th 16 „ „ 9th 10 „ „ I4th 14 „ „ 16th 11 „ „ 21 st 9 „ „ 23rd 11 „ „ 28th 19 „ „ 30th 10 „ December 5th 16 „ June 6th 1 case „ 12th 11 „ „ 13th 9 cases 11 19th 19 „ „ 20th 9 „ „ 26th 11 „ „ 27th 10 „ To „ 31st 8 „ July 4th 8 „ There is one point of exceeding interest in the se sonal incidence of the disease. It will be noticed that for the five weeks ended August 29th, there is a sharp drop in the number of notifications, followed by a rise which culminated in the week ended October 3rd. The elementary schools of the district were closed for the summer holidays on July 23rd, and re-opened on August 25th. 21 Allowing the usual time for the incubation of the disease, the period extending from July 26th to August 29th may be represented as that in which the effect of the school holidays operated. During these 5 weeks, 12 cases were notified, while in the ptevious 5 weeks, 43 notifications were received, and in the 5 subsequent weeks 62. It is true that a large number of school children would be out of the distiict during the holidays, but this fact alone is insufficient to explain the sudden drop which occurred on the closure of the schools, and the rise which occurred on their re-opening. We are compelled to regard school attendance as one of the factors in the spread of the disease. One mode in which school attendance operates, is through the occurrence of "missed" cases, and probably the "missed " case plays the most important role. The distribution of the cases among school children was as follows:— Beaumont Park 91 Willesden Junction 4 Southfield Road 74 East Acton 3 South Acton 72 Roman Catholic 2 Priory 47 Haberdasher's 2 Central 19 County 1 St. Mary's 15 Private 12 Rothschild Road 13 Outside 4 During the earlier part of the year, the incidence of the disease was heaviest on South Acton School, but after the summer holidays, the schools that suffered most severely were Southfield Road, Beaumont Park, Priory and South Acton. In all these schools increased incidence was associated with the occurrence of missed cases. In South Acton, Beaumont Park and Southfield Road, missed cases were found attending school. In South Acton a boy had been ill since August 24th, but was not notified until September 8th. Between August 25th and August 28th, he had attended schcol. similarly in Beaumont Park a case was notfiied on October 5th, and had been ill since Septe nber 17th, and had attended school up to October 2nd, 22 In Southfteld Road School, the "missed" cases, subsequently detected, were more numerous. The first "missed" case that occurred after the re-opening of the school after the summer holidays, was notified on September 17th. The girl had been 111 since September 4th, and had attended school up to September 15th. On October 12th a boy was excluded from school as the skin of his hands was peeling. He had had a rash and a sore throat on September 9th, but his doctor had certified that he could attend school. It may have been a coincidence, but the exclusion of the boy from school attendance was associated with the cessation of cases from the class he attended. On October 13th, two children were found in attendance, in both of whom the skin of the body and hands was peeling. In one case there was a history of sore throat and a rash on September 24th, and in the other on September 27th. These 4 cases attended either the Infants or Junior Department. It is also an interesting fact that the disease in Southfield Road was practically limited to these departments. It maybe assumed that the children in the Infants and Junior Departments mix to some extent with those of the Senior Department outside the school, but it seems as if the close aggregation of children in class rooms (and in the homes, &c.) were a necessary factor in an extensive spread of the disease. The argument that the children in the Senior Department were less susceptible and more protected is hardly a sufficient one. A girl in the Priory School was notified of Scarlet Fever on December 3rd. Two days previously she had a sore throat and was sick at school. Four girls attending the same class, all over the age of 13 years, developed Scarlet Fever within a few days. This case is given as an instance that the age-distribution of the children in the Senior Departments is not a sufficient protection against the spread of infection. A detailed account has been given of some of the "missed" cases, as they play so important a role in the spread of the disease. It is admitted that the "missed" case will always be a. problem difficult of solution, as it depends partly upon the type of the disease, 23 But one significant fact should be borne in mind; in spite of the extreme mildness of the disease in this district last year, when enquiries were carefully made afterwards, in all the "missed" cases subsequently detected, there was a history of a sore throat and a rash on the trunk and limbs. These cases had remained undetected in spite of the usual symptoms of Scarlet Fever. True, the sore throat was slight, and the rash was faint, but the conjunction of these two symptoms is known to most people to be associated with Scarlet Fever. There is not the slightest reason to believe that the parents intentionally concealed the existence of the disease. Nor could the dread of removal to Hospital have influenced them, as in many instances, the cases could well be isolated at home. Moreover, every care is exercised by the teachers to detect any case of infectious disease at school, and testimony should be borne to the valuable assistance rendered by the teachers. It would be almost impossible to detect the "missed" cases, but for the assistance rendered at the schools. Unless the children are very ill, they are loath to complain, even to their parents, so anxious are they not to be absent from school. It is difficult to suggest a remedy, as under existing conditions an enhanced attendance means, not only an increased grant, but a gain of prestige for the school. The importance of a high average attendance might be less highly magnified, and in some districts the practice of giving medals and prizes for a full attendance has been abolished. The occurrence of missed cases is not the only factor in school attendance which affects the spread of Scarlet Fever. There is little doubt but that the early infection of Scarlet Fever is also one of the means by which the disease is spread. There is hardly any disease concerning which opinions have recently more profoundly changed. It was formerly held that the disease was not infectious until peeling had commenced, and that the infection was connected with the desquamation. This theory has been exploded, and we now know that infection can be conveyed during the earlier stages of the illness. It is still held in some quarters that until the appearance of the rash, there is no fear of infection. There are grounds to believe that the disease is infectious from the commencement of the sore throat and the initial sickness. Mention may be made again of the case notified in December, and who attended the Priory School, 24 She had a sore throat and was sick in school on December 1st. She did not attend school after the appearance of the rash, but four girls from the same class-room contracted the disease. This early infection is consistent with the views now held of the mode in which the disease is propagated. It is generally held that the infection lies in the throat, nose and mouth. When a person is sick, the epithelial layer of the mucous membrane is denuded and the vomit is almost certain to be infectious. It is important to recognise the possibility of this early infection for disinfection purposes. Where disinfection has been faulty or incomplete, often it may be due to something which has been exposed to infection prior to the appearance of the rash, and not subjected to any form of disinfection. Other instances might be given which point to this early infection. It is within the experience of most people that cases will crop up one after the other in a class-room, though no "missed" cases have occurred, and the children have not attended school after the appearance of the rash. But some of them had attended school with a sore throat which proved to be the precursor of the other symptoms of Scarlet Fever. When the outbreak ceased in a class, sometimes it is found that the last cases had a rash on a Monday or a Tuesday and the sore throat commenced on a Saturday or Sunday. Another factor which may affect the spread of the disease amongst school children is the possibility of prolonged infection. This aspect will be discussed more fully when dealing with return cases and the recurrence of Scarlet Fever after prolonged periods in houses, but an instance may be given of the persistence of the disease in a class due in all probability to a prolonged period of infectiousness in a child. J. B., of Clovelly Road, was notified of Scarlet Fever on June 29th, and removed to hospital on the same day. He was in the Hospital until September 3rd. He suffered from no complications, but the reason for his prolonged detention was the presence of enlarged tonsils and adenoids. Five days after his discharge from the Hospital his brother was notified of Scarlet Fever. J. B. was examined on September 8th, and the probable conditions which would give rise to a "return" case, were the enlarged tonsils and adenoids. There was also a slight discharge from the nose, but no abrasion. At the end of three 25 weeks from his discharge from the Hospital, J. B. attended the Beaumont Park School. The two "babies" class-rooms at Beaumont Park are situated in that part of the school farthest from the Girl's Department, and the entrances to the two rooms are nearly opposite each other. Between October 27th and November gth, four children from the same class-room as J. B. were notified of Scarlet Fever, and in the other class room the same number of cases was notified during the same period. All the children in these two class-rooms were examined on several occasions, but there was no suspicion of a "missed" case. It was noticed that J. B. had a slight discharge from his nose, but no abrasion of the mucous membrane. On November 9th, it was decided to exclude him from school, and the only case that occurred after J. B.'s exclusion was notified on November 21st, but this case was probably infected at home, as two cases had been removed from the same house on November 2nd, and a third on November 4th. J. B. was kept out of school until the end of the year, and the parents have been advised to have the child's adenoids removed before he resumes school attendance. We have so far dealt mainly with infection as it occurs in the school, but the same factors operate in the home. The number of children exposed under the latter conditions is smaller, and possibly the infection may be more diluted. We shall deal with the spread of infection in the home under three heads:— 1. Multiple cases occurring probably as a result of infection from previous cases in the house. 2. Cases occurring in a house within a definite period of the discharge of another member of the family from the hospital. 3. Cases recurring in houses after prolonged periods. It will be convenient when dealing with the first group of cases to adopt some fixed period. The incubation period of Scarlet Fever is stated to be from one to seven days. For various reasons it is advisable not to take so short a period. If we took from the exposure to infection to the time when symptoms were first exhibited ye might be justified in limiting the time to one week. But it is 26 often very difficult to obtain an exact history of the commencement of the illness, and it will therefore be better to take the date of notification of the multiple cases and extend the period to one month from the occurrence of a previous case in the house. Multiple cases coming under the above head occurred in 43 houses. In each of 28 houses there were 2 cases, in 9 there were 3 each, in 5 there were 4 each, and in 2 houses there were 5 each. Of the 28 houses where a second case occurred, in 12 instances both notifications were received on the same day, in the others the interval that elapsed between the receipt of the first and second notifications was as follows:— 1 day 1 case 3 days 3 cases 4 ,, 3 ,, 5 „ 1 case 6 1 „ 8 days 2 cases 11 „ 1 case 12 ,, 2 cases 14 „ 1 case 20 ,, 1 ,, With three exceptions, the cases were removed to the Hospital on the date of the receipt of the notification. The three exceptions were nursed at home ; in one of these the two notifications were received on the same day, and in the two others an interval of 8 days elapsed between the receipt of the first and second notification. In the 9 instances where 3 cases had occurred in each house, in one of them the 3 notifications were received on the same day, in 4 the first and second notifications were received on the same day, followed by the third at intervals of 5, 8, n and 11 days respectively. In one instance the second and third were received on the same day, 11 days after the receipt of the first. The intervals between the three notifications in the others were as follows:— 1. Between 1st and 2nd—11 days. 2nd and 3rd—2 days. 2. ,, ,, ,, „ 11 ,, ,, ,,,, 4,, 3. ,, ,, ,, ,, 13 ,, ,, ,, ,, 2 ,, In one instance the children were nursed at home ; the first and second notifications were received on the same day and the third after an interval of 11 days. In 2 of the instances where four cases occurred, all notifications 27 were received on the same day. In the third, 2 were received on the same day, with an interval of 8 days between the 2nd and 3rd, and one day between the third and fourth. In the fourth, 2 were received on the same day with an interval of 20 days between the second and third, and 19 days between the third and fourth. In the fifth, the third and fourth notifications were received on the same day, four days after the second case, and 15 days after the first case in the house. Where 5 cases had occurred the dates of the notifications were as follows :— 1. October 13th, 24th, 29th, 29th, 31st. 2. November 2nd, 2nd, 4th, 21st, 26th. In almost all the instances where two or more notifications were received on the same day, one of the cases had been ill for some time, and the others had been infected in the house. It is most rare to find the disease simultaneously introduced into the house by more than one member of the family. Occasionally the disease is not diagnosed until a second member of the family has been attacked. But even when a diagnosis has been made as early as possible, the other children have already been exposed to infection. It has been stated on a previous page that there is reason to believe that a patient is infectious from the very start of the illness, and before the rash has appeared. Very seldom is isolation practised at the commencement of the illness, and the above instances show how difficult it is to fulfil the most essential conditions of the spread if the disease is to be prevented. One of the conditions is, that the infection must not be handed on by the patient before seclusion, but in all the above instances, in all probability, the secondary cases were infected before the previous patient had been removed to Hospital, or had been isolated in the home. The difficulty of isolation in the early stages is one reason why Isolation Hospitals have not been instrumental in stamping out Scarlet Fever in districts where most of the cases are removed to a Fever Hospital. There can be hardly any doubt, though, that Hospital Isolation was in this district the means of limiting the spread of infection. In the vast majority of instances, there was no possibility of obtaining any kind of isolation in the homes, and the limited outbreaks in classes 28 and families which resulted from "missed" cases are sufficient proof of the necessity of Hospital Isolation. Another factor which militates against the complete success of Isolation Hospitals is the occurrence of what are called "return" cases. Whether isolated at home or in the hospital, the patient should have recovered perfectly before he is cleaned and discharged from seclusion, but we have no means of ascertaining whether the patient is absolutely free from infection or not. In Diphtheria, the conditions are different; the germ has been isolated, and a bacteriological examination can always be made before the patient is discharged from the Hospital. It is this difficulty which gives rise to the second group of cases of Scarlet Fever, viz. those that occur in a house soon after the discharge of a member of the family from the Hospital. Probably this group of cases is more closely related to the third group (where cases recur in houses after a prolouged period) than we have hitherto recognised, but it will at the present time be convenient to treat the occurrence of cases in the two groups as separate phenomena. For this purpose, an arbitary period of one month has been fixed, and cases occurring within one month have been included either in groups one or two, and those over in group three. Twenty-seven cases discharged from the Hospital were followed within one month by the occurrence of other cases of Scarlet Fever in the same house. Twenty-two of these were discharged from the Council's Hospital and five from the London Fever Hospital. Many authorities believe that the phenomenon of return cases is essentially due to imperfections in Hospital management, and that there is reason to believe that recent association of discharged patients with acute cases is responsible for most, if not all return cases. It has been found in some districts that by placing patients in a convalescent ward for about a fortnight before their discharge, and systematically disinfecting the skin, nose and auditory canals, not a single return case had occurred. This statement is probably true, but it certainly will not explain everything in connection with return cases. Return cases are not unknown after home isolation. There was one such instance in this district last year. A case was notified on September 14th. The case was nursed at home, certified as free 29 from infection on November 3rd and disinfected the same day. On November 5th, a sister was taken ill and notified of Scarlet Fever on November 6th. It is not even fair, as far as return cases are concerned, to compare home isolation with Hospital isolation Home isolation is usually attempted when there are no other susceptible persons in the house, so that when the patient is released from exclusion, there is little chance of a return case in the house. Moreover, as is shown in dealing with the next group of cases, Scarlet Fever displays a tendency to recur in houses and amongst families after a prolonged period has elapsed since the occurrence of a previous case. But whilst contending that the return case is not solely a hospital phenomenon, it must be admitted that a large majority of them arise as a result of hospital treatment and administration. The most fruitful cause probably is the overcrowding of wards and the failure to separate the convalescent from the acute cases. It has been pointed out to the Health Committee on several occasions that until the proposed extension of our Hospital is completed, the necessary separation and preparation of the patients prior to their discharge cannot at all times be carried out. Not only is it necessary to separate the convalescent from the acute cases, but it is desirable that the patients should during the last week or fortnight of their stay in the Hospital, be kept under conditions which approximate as nearly as possible to those which obtain at their homes. In almost all the "infecting" cases, it was found that a few days after their arrival home, there was a history of a slight cold and a discharge from the nose. The causi of this is not far to seek. In the Hospital, the wards are kept at a fairly uniform temperature, but when the patients go home, they sleep usually in bedrooms which have no fire. It was shown in the report for 1907, that between May and November no return cases occurred, and last year there was a sharp rise in November. It is generally found that the relative incidence of return cases is less in the summer than in the winter months. Another fruitful cause of nasal discharge after arrival home, was the disinfecting bath, &c., on the morning of discharge, but whenever 30 possible the disinfection and preparation. of the patient is now carried out some days before the day of discharge. Although a better classification and a more satisfactory system of preparation before discharge will greatly reduce the number of "return" cases, it is doubtful if they will entirely disappear. The wider recognition of the occurrence of return cases has been the means of raising other questions. One of these relates to the length of time during which a person attacked by Scarlet Fever may be infectious, and in this connection it is of interest to note the liability of cases to recur in families after a prolonged period. Last year Scarlet Fever cases occurred in 376 houses, and during the last three years 708 houses have been invaded. There are over 9,000 inhabited dwelling houses in the district. During the year recurrent cases occurred in 90 houses. 43 of these houses came under group 1, where the secondary case occurred within the month of the removal of the previous case to Hospital; in 27 of the houses the cases came under group 2—the "return" cases referred to on a previous page, and the remainder, 20, referred to houses from which a recurrent case was notified after a lengthened period had elapsed, and the interval which elapsed between the first and second case was as follows :— 6 weeks 1 case 7 ,, 2 cases 11 ,, 1 case 4 months 2 cases 5 ,, 3 ,, 10 „ 2 „ 11 months 1 case 17 ,, 1 ,, 18 ,, 1 ,, 23 ,, 2 cases 24 ,, 2 ,, 27 „ 1 case It is impossible to state accurately what are the chances of a second case occurring in a house, apart from contact and return cases. There are many factors which operate, the most important depending upon the number of susceptible persons in the houses, and the chances of infection in school. Numerically, the last group does not seem very important, but taken in conjunction with the return cases, it may repay analysing, as some light may be thrown on the epidemiology of the disease. 31 In three of the above cases the circumstances in which the disease recurred suggest some connection with incomplete disinfection. G. D. was notified on October 27th and removed to Hospital on the same day. At the end of six weeks the mother was in the usual way informed that the patient was ready for discharge, but after the mother was informed, the glands of the neck became slightly enlarged and he was not discharged. On December 15th, the two other children in the house were notified as suffering from Scarlet Fever. A somewhat similar case was that of J. W. The two brothers T. W. and W. W. were notified on March 24th, and removed to Hospital on the same day. On account of a nasal discharge, they were kept in the Hospital for a couple of weeks after the mother had been informed that they were ready to go home. They were ultimately discharged on June 20th, but J. W. referred to above, was notified as suffering from the disease on June 11th. In the third case V.B. was removed to Hospital on May 15th, and discharged on the afternoon of June 27th. The child did not arrive home until 2 p.m , and did not come in contact with her brother, J.B. until tea-time, when he came into the house complaining of a sore throat. The same evening he developed a rash. These three cases suggest the possibility of an incomplete disinfection. The result of disinfection after Scarlet Fever is rendered, to some extent, uncertain, because the specific germ causing the disease has not been isolated. It is quite as important to know what to disinfect as how to disinfect. Until quite recently, it was held that Scarlet Fever was not infectious "until desquamation had set in, and this theory has taken deep root in the mind of the public. Even now the possibility of infection before the rash has appeared is but seldom borne in mind, and it can easily be understood how articles exposed to infection in the early stage of the illness, can be overlooked and not handed up for disinfection. Apart from this, some of the public look upon disinfection as a fetish, and it is not surprising that some of the more expensive articles are occasionally put aside, before the sanitary authorities arrive to disinfect. These are taken out on the receipt of an intimation that the patient is ready 32 for discharge from the Hospital. It is understood that the article referred to are those that have in some way come in contact with the mucous discharged from the patient. The other 16 cases will not allow of this explanation. Even allowing the most liberal margin for error, the occurrence of recurrent cases in these 16 houses in one year cannot be explained on the ground of mere coincidence. Not only is the number too high, but the conditions under which some of these occurred, were not favourable to the recurrence of Scarlet Fever. In 3 instances there were no persons under 20 years of age in the house. The theory has been advanced " that in a small minority of cases, Scarlet Fever may remain infectious for a very long period. It does not follow that such cases are continuously infectious during this time. All the facts seem to indicate that continuous infectiousness is not a feature of Scarlet Fever." Dr. Butler read a paper on this subject before the Epidemiological Society in November 1908, and emphasized the following three points. 1. Under varying but occasionally recognisable conditions, persons recovered from Scarlet Fever are capable of conveying the infection to others after intervals frequently of prolonged duration, when apparently they had ceased to be infectious. 2. There are persons who have not suffered from the disease who appear to harbour the infection in their tissues in such a manner that while t here is no ground for considering them during this passive stage a danger to others may yet, by a critical lowering of their resistance, become the source of their own infection. 3. There are others again, of whom, while it would be incorrect to say they had suffered from an attack of Scarlet Fever, have yet in some degree reacted to an invasion of the poison and are capable of communicating to those with whom they come in contact the disease to which as such they are themselves immure. These matters are of great epidemiological interest and three instances may be given which seemed to indicate that it was something in the persons attacked and not in the buildings which was determining the persistence of the infection. 33 A married man was notified of Scarlet Fever on December 5th, 1907, and discharged from the Hospital on January 17th, 1908. On his discharge from Hospital, he and his wife and child moved from the house in which he contracted the disease. He was visited occasionally by an elder sister who fell with the disease on May 22nd, 1908. This sister lived with her parents and the father, mother, sister and servant were the only occupants of the house. No connection with any other case of Scarlet Fever could be traced. H. H. was notified of Scarier Fever on July 18th, 1907. The family then lived at St. Alban's Avenue, but moved from there towards the end of the year. In July, 1908, the brother wasnotified, and no other cases had occurred in the school where he attended. In one sense the following case is more interesting still. J. C., a lodger, contracted Scarlet Fever in September, 1906. He married his landlady's daughter and went to live in another part of the district, and two teachers lodged in his house. One of the teachers contracted the disease in October, 1907, though there was a definite history that she had had the disease in her childhood. It may be objected that this teacher would come in contact with children and thus rendered liable to contract the disease, but in March, 1908, J. C.'s sister-in-law (aged 26) was notified of the disease, and in the latter case, no other source of infection could be traced. These three cases have not been included in the 16 instances where Scarlet Fever had recurred after a prolonged period. The 16 only include those where the disease had recurred in the same house. A case occurred in the Cottage Hospital during the year, which illustrates the possibility of a person harbouring the infection in their tissues and after some time becoming the source of their own infection. On February 1st, two cases of Scarlet Fever were notified from the Cottage Hospital. One of these, D. M., was a patient who had contracted the disease outside, and the second was a nurse. Both were removed to the Isolation Hospital. In the bed next to D. M. was a boy, W. K., who had fractured his leg. On March 22nd, seven weeks after the removal of the last case, W. K. was notified of Scarlet Fever. Inquiries were made, and no visitors at the Cottage Hospital could be suspected of harbouring infection. The nurse had not been discharged from the Isolation Hospital, 34 It is of course possible, that the infection was harboured in the ward, and it may be mentioned that when the Cottage Hospital was' emptied and the place thoroughly disinfected, no further cases occurred there. On the other hand, it seems that a few days after D. M. was removed to the Isolation Hospital, W. K. had a slight sore throat; he was thoroughly examined, but there was no other symptom of Scarlet Fever. The outbreak has been dealt with at considerable length, as some of the matters discussed involve details of great importance from an administrative point of view. It is obviously insufficient to exclude from school and to isolate acute cases only, when there is sometimes the possibility of a person harbouring the infection for a prolonged period. It is proved that the germs of Typhoid and Diphtheria have been harboured for years by a very small percentage of the persons who have suffered fromthe disease, and a similar phenomenon is not impossible in Scarlet Fever. The age incidence and the ward distribution of the disease are given on Table III. DIPHTHERIA. Eighty-three cases of Diphtheria were notified and 7 deaths were caused by the disease. There is a slight increase both in the number of notifications and deaths. The disease was fairly uniformly distributed throughout the year, and in no instance did an outbreak of the disease assume serious proportions. Diphtheria is a disease which stands out in striking contrast to some of the other infectious diseases such as Scarlet Fever, Measles and Whooping Cough. Although the latter diseases have been known for a long time, our knowledge of them is limited. The specific germs have not been isolated, and their mode of spread is open to argument. We are in a far happier position when dealing with Diphtheria. Not only is its microbial origin fully proved, but we have means within our reach which enable us to deal with outbreaks of the disease. Diphtheria is only acquired directly or indirectly from another case, and cannot arise from bad drains or insanitary conditions, though the latter conditions may predispose by lowering the resistence. 35 It has been shown conclusively that a certain proportion of those who are brought into contact with Diphtheria patients harbour the bacilli in their throats or nasal cavities. The percentage is highest in the immediate contacts, that is, in members of the same family; it diminishes rapidly as we enlarge the interpretation so as to include school-fellows and when the term is so widened as to include such extremely remote contacts as the general inhabitants, the percentage showing the bacilli is a negligible one. The following instances show the importance of carrier cases in spreading the disease, and the desirability of making a bacteriological examination of the immediate contacts. Last July, several cases were notified from St. Alban's Avenue and Rusthall Avenue. These children were all in different classes; but an examination of the other members in the families revealed a carrier case. The isolation of the latter was followed by an immediate cessation of the notifications. A similar phenomenon was noticed in Valetta Road, but usually the disease assumes more formidable proportions when a carrier case attends school. There were no extensive outbreaks in any of the schools during the year, but probably this was in part due to the action taken to detect any carrier cases. On the re-opening of Rothschild Road School after the summer holidays, two cases were notified, and both children attended the same class. Swabs were taken from the throats of some of the other children, and this revealed two other cases of Diphtheria. The exclusion of these cases from school stopped the notifications among the pupils of this school. ENTERIC FEVER. Fourteen cases of Enteric Fever were notified and two deaths occurred. In most of the cases, the disease was introduced from some outside district. Two persons were infected in Hadlow, Kent. One of these was a resident of Hadlow, and came on a visit to his brother in Acton on October 3rd, but had been ailing for some days prior to his 36 arrival here. A brother, a sister and two neighbours in Hadlow contracted the disease about the same time. The second case was a resident of Acton, and contracted the disease when "hopping" in Kent. She was taken ill at Hadlow on September 17th, and returned to Acton on October 1st. This latter case was the direct means of infection to 5 other persons. One of these was the patient's husband, and in his case the infection was probably a direct one. Both husband and wife were removed to Hospital, but prior to their removal they were nursed by a woman from Ramsey Road. When the husband and wife went to the Hospital, their baby was taken to Ramsey Road. Four cases occurred in the latter house. Infants often suffer from an undetected attack of Enteric Fever, and it is possible that the disease was introduced to Ramsey Road by the child. The risk attached to the baby was pointed out, but the warning went unheeded. The eighth case probably contracted the disease in Margate. The notification was received on June 1st, and the patient had been taken ill about May 24th. She had been in Margate from May 7th to May 24th. The ninth and tenth cases were probably due to the consumption of contaminated shell-fish. In the other cases the source of infection was not traced. All of them had most of their meals outside the district. ERYSIPELAS. Thirty-five cases of Erysipelas were notified, but there was no death from the disease. Opinions differ as to usefulness of retaining Erysipelas amongst the notifiable infectious diseases. With the possible exception of Puerperal Fever, no connection with other notifiable infectious diseases has been traced, but Erysipelas can be caused by various organisms, and can no more be regarded as a specific disease in its etiology than an ordinary abscess or a gum-boil is. PUERPERAL FEVER. There was only one case of Puerperal Fever notified, and this patient recovered, 37 TUBERCULAR DISEASES. There were 56 deaths from Phthisis or Consumption and 28 deaths from other Tubercular Diseases. Of the 56 deaths from Phthisis, 41 were Males and 15 Females, and of the deaths over 15 years of age, 39 were Males and 13 Females Prior to their attack of illness the 52 persons over 15 years of age were employed as follows :— MALES. Laundrymen 6 Labourer 3 Clerk 3 Barman 3 Carman 2 Engineer 2 Butcher 2 Horsekeeper 2 Baker 1 Carpenter 1 Upholsterer 1 Brushmaker 1 Gas Fitter 1 Optician 1 Chemist 1 Grocer 1 Polisher 1 Packer 1 Machinist1 Paperhanger 1 Lodging House Deputy 1 Draughtsman 1 Market Porter 1 Sponge-dealer 1 39 FEMALES. Household 7 Laundress 3 Barmaid 1 Domestic Service 1 Machinist 1 13 38 18 of the deaths from Consumption occurred in the Isleworth Infirmary, and the vastly increased treatment of advanced cases of pulmonary tuberculosis in infirmaries and other institutions has been most valuable in securing segregation of patients from their families, as well as securing humane treatment for the patients themselves. Early cases, where any traces of the Bacilli occur in the sputum, are dangerous, but the danger from them is trifling compared to that from the advanced and fatal cases. The last 4 or 5 weeks are the most deadly in the spread of the infection. It cannot be too strongly emphasised that Tuberculosis is an infectious disease caused by the tubercle bacillus. It is true that in 9 instances last year there was a history of Consumption in the family, but the transmission of the disease in these cases was due solely to the simplest processes of infection. The immediate relatives did not regard the process as an infective one, because the consequences did not appear at once, but after the lapse of years. In only 2 of the 9 did the family occupy more than three rooms. At night, the patient had to sleep in the same room as other inmates of of the family, and it is difficult not to be a source of infection to some of the other occupants of the house when a case occurs amongst the poor. In the memorandum issued by the Local Government Board, great stress is laid upon the early diagnosis of the disease. One of the most valuable agencies for securing early diagnosis is the bacteriological examination of the sputum. The Council arranges for the gratuitous bacteriological examination of the sputum, and last year the sputum of 38 patients was examined. In .28 of them the tubercle bacilli were not found and in 10 the bacilli were found. In spite of every facility for securing early diagnosis, the Council has not been successful in obtaining a sufficient number of suitable applicants to occupy continuously the two beds maintained at the Northwood Sanatorium. 10 applications were received for admission during the year ; 3 of these were rejected on account of unsuitability and 7 patients were treated at the Sanatorium. As far back as July, 1905, an agreement was entered into whereby the Council maintained 3 beds at the Northwood Sanatorium. In 1907, the number of beds was reduced to two. 39 The medical inspection of school children will, it is hoped, secure the detection of previously unrecognised cases among school children. Two of the seven cases treated at the Sanatorium last year were detected in the course of the medical inspection of School Children. Voluntary notification of cases of Consumption has been in force in the district since June, 1903, the sum of 2/6 being paid for each case notified. It cannot be said that the system has been a success, as in addition to the ten patients for whom application was made for admission to the Sanatorium, only three notifications were received. The want of success is probably due to the impression that notification would have a prejudicial effect on the individual suffering from the disease. It is admitted that it is not absolutely necessary to notify all cases of consumption, but where owing to domestic conditions, the patients are a source of danger to the people in contact with them, it is essential the cases should be notified so that instructions may be given and precautions taken. In no instance are the enquiries made as to prevent the patient from continuing to earn his livelihood. Our duty ends when advice has been tendered as to the precautions to be taken. Very seldom is our offer to disinfect the premises after a death refused. Last year, with 4 exceptions, all the premises where a death from Phthisis occurred were disinfected. One hundred and seventy-four deaths under 1 year of age were registered in the district, and 14 infants under 1 year of age died in public institutions beyond the district, making a total of 188. This latter figure corresponds to an infantile mortality of 120 per 1,000 births The infantile mortality in England and Wales last year was 121; in the 76 large towns it amounted to 128; and in the 142 smaller towns it was 124 ; INFANTILE MORTALITY. The deaths were distributed as follows:— North-East Ward 30 North-West Ward 26 South-East Ward 29 South-West Ward 103 40 The infantile mortality in each ward would be:— North-East Ward 82 per 1,000 deaths North-West Ward 121 ,, „ „ South East Ward 88 ,, „ „ South-West Ward 155 „ „ ,, The infantile mortality is 10 per 1,000 lower than it was in 1906 and 1907. Compared with 1907 the mortality is higher in the North-West Ward, but lower in the three other wards. There was a marked increase in the number of deaths from Measles and Diarrhœal diseases and a more marked decrease in the number of deaths from Bronchitis and Pneumonia. The increase in the deaths from Measles has been referred to in another paragraph. There were 42 deaths from Diarrhoea and 14 from Enteritis. In 1907 there were 22 infantile deaths from Diarrhceal Diseases and in 1906 the number was 80. There is an increase in the number of deaths from diarrhoeal diseases as compared with 1907, and whatever views may be held as to their causation their can be no doubt as to the beneficial influence of an excessive rainfall. In this latter respect, 1908 compared unfavourably with 1907. The amount of rainfall may be beyond the control of a sanitary authority, but the manner in which a hot summer operates upon the infantile mortality should teach us something in the prevention of Diarrhceal diseases. Out of the 42 children who died from diarrhoeal diseases only 2 were breast-fed. 18 were brought up on cow's milk, 14 on condensed milk, and 8 on one or other of the patent foods on the market. It is difficult to estimate what percentage of the children are breast-fed and hand-fed, but if we contrast the conditions in deaths from respiratory diseases the above figures will appear significant. Out of 21 deaths from Bronchitis and Pneumonia, 12 of the children were breast-fed, 5 were fed on cow's milk, 2 on condensed milk, and 2 on a patent food. 41 Nothing replaces human milk in its nutritious qualities for the infant. Most artificial foods are but poor substitutes for the natural food unless prepared with the utmost care. Breast-milk is comparitively sterile, and it passes directly from the mother to the child, without any intermediate state of transit during which infection may take place. But with hand-feeding, infection may lurk in the milk, in the vessels in which it is carried and in the bottle. In 15 of the cases where death occurred from diarrhœal diseases the mother was employed in some industry which entailed leaving the home and placing the infant under the care of some other person. Married female labour undoubtedly enters into the question of premature weaning, but under present social conditions it is doubtful if it is so important a factor in infantile mortality as it is somtimes represented to be. The Registrar General in his Report for 1905, discusses the question of Infantile Mortality and the employment of married women. He took two groups of fifteen towns, each containing respectively the lowest and the highest proportions of occupied married women, and compared their birth rate and infantile mortality in two quinquennia. The birth rate is, as might have been anticipated, lower in the towns having a high proportion of the married women industrially employed. The relationship between industrial employment of married women and infant mortality is however, not very visible. In the first group of towns, having only 4 to 8 per cent. of its married women engaged in occupations, the infant mortality in 1901-5 varied from 104 in Burton-on-Trent to 202 in Aberdare, the average for the 15 towns being 161; in the second group of towns having from 20 to 39 per cent. of its married women engaged in occupations, the infant mortality varied from 140 in Rochdale to 206 in Longton, the average for the 15 towns being 168. Evidently the result thus stated is dubious. In a former Annual Report for Acton, the effect on the child of married female labour was discussed, and the investigations made last year point to the same conclusion as was arrived at on the previous occasion. Out of 13 deaths of Prematurity which we investigated, only two of the mothers were employed in industrial 4i Occupations, and out of 11 deaths from Congenital Debility, two of the mothers were so employed. It is doubtful if work is injurious to the expectant mother, provided it be not heavy or prolonged. Possibly, the improved food and greater comfort which their work means, more than counteract its disadvantages. But if the antenatal effect of married female labour is not obvious, the conditions under which the child is brought up as a result, do affect the infantile mortality. Out of 111 infant deaths inquired into last year, in 38 instances, the mother was occupied in some industrial occupation, the majority being employed in laundry work. In former years the mother had no option but to leave the child in the charge of a "baby minder." The mother did not select the house where the baby was cared for, on sanitary grounds, and the standard of cleanliness which usually obtained in the " babyminder's " house was below that of the average for the neighbourhood. In January, 1908, the South Acton Day Nursery was opened, and undoubtedly it has fulfilled a long-felt want. One of the objections raised against creches is their liability to encourage premature weaning, and in many creches it must be admitted that this danger is not sufficiently appreciated. In Acton every safeguard is adopted to obviate this. The creche is not too large, and is so situated as to be convenient for the mothers to leave their work twice a day for the purpose of suckling their children. The creche has 28 cots and all the mothers work at laundries within easy reach. Every encouragement is given at the creche to the mothers to suckle their children. A glass of milk, or a cup of cocoa and a biscuit are given to the mothers free whenever she comes to suckle her child. In addition, the Notification of Births Act enables the Sanitary Authorities to advise mothers in time against premature weaning. Formerly many mothers weaned their children before the latter had reached the age of one month. Another objection urged against the establishment of creches is based upon their liability to act as foci in the spread of infectious disease. This objection refers almost entirely to Measles. 43 one admits that wherever young children congregate, Measles is liable to spread among these children. It is too early to draw conclusions from our experience in Acton, but as may be seen on a previous page, the district last spring passed through one of the most extensive epidemics in its history, and in no instance did the disease spread amongst the children of the creche. It was stated in a previous paragraph, that the role of married female labour (under present social conditions) in the production of infantile mortality is not very obvious. It was also stated that possibly the better food, &c., which result, outweigh the disadvantages. One fact though, should be borne in mind, that last year in Acton one seventh of the total loss of life in infancy occurs in the first week of extra-uterine life. This fact tends to moderate our hope of affecting a large percentage of the total infantile mortality, unless it be by measures affecting the mother during pregnacy. It is well known that social conditions play an important part but the following figures suggest that ignorance of the duties of motherhood is also an important factor. Out of 42 deaths from diarrhoeal diseases, 7 of the children were first-born, out of 46 deaths from diseases other than diarrhoeal and prematurity, 10 of the children were first-born, but out of 13 deaths from prematurity, 6 of the children were first-born. As usual the mortality amongst illegitimate children was excessive, Out of 42 children born out of wedlock, 17 died before reaching the age of 12 months. These figures represent an infantile mortality of 404 per 1,000 births. In 1907 the infantile mortality amongst illegitimate children was 480 per 1,000 births, and in 1906, 564 per 2,000; so that in the last three years nearly one half the illegitimate children died before reaching the age of 12 months. NOTIFICATION OF BIRTHS ACT, 1907. The Council passed a resolution to adopt the above Act on November 26th, 1907, and application for the sanction of the Local Government Board was made forthwith. The resolution of the Council was advertised in the " Acton Gazette" and "Acton Express" on December 6th, 1907. 44 The sanction of the Local Government Board was obtained and the Act came into force on January 7th, 1908. The provisions of the Act were advertised in the local newspapers, and a copy of the advertisement was posted on hoardings and outside the churches and chapels of the district. Circulars containing the notice of adoption and the provisions of the Act were sent to all the dectors and midwives in the district and stamped notification letter cards were sent to each doctor and midwife practising in the district. One thousand three hundred and fifty notifications were received, 1315 live births and 35 still births. Four hundred and ninty-two of these were made by doctors, 727 by midwives and 131 by the fathers of the children. Over 100 notifications were received as a result of communications sent to those who were responsible for the notifications. Three hundred and eight births occurred which were not notified within the statutory period. During the earlier months of the year the number of births not notified was as high as 30 per cent., but since the Council instituted proceedings against defaulters the number in any week seldom exceeds 10 per cent. CANCER. 48 deaths occurred from Cancer or Malignant Disease. The Ward distribution was as follows :— North-East 14 South-East 9 North-West 8 South-West 17 19 of the deaths were in males and 29 in females, but the preponderance of females is more than accounted for by the number of deaths from Cancer of the Reproductive organs. There were 12 deaths from Cancer of the Breast and 4 from Cancer of the Uterus. The most marked increase was in the number of deaths from Cancer of the Alimentary Canal. In 13 instances the bowels were affected, in 6 the Stomach, in 4 the Liver and Bile Ducts, and in 1 the Pancras. 45 Although the number of deaths from Cancer generally is on the increase, the greatest increase in recent years has been due to the frequency with which the Digestive Organs are attacked. The site of the disease in others was as follows:—Throat and Neck 3. Tongue 1, Face 1, Shoulder 1. In two instances the seat of the disease was not mentioned. ISOLATION HOSPITAL. During the year 423 patients were admitted. On January 1st, 1908, there were 48 patients under treatment and on January 1st, 1909, 51. During the year, 408 patients were discharged and there were 18 deaths. Diphtheria. Fifty-four cases of Diphtheria were admitted, and there were 4 deaths. Scarlet Fever. Three hundred and sixty-nine cases were admitted and there were 14 deaths "Return" cases have been dealt with in another paragraph. The question of extending the accommodation at the Hospital has been considered by the Council during the year, and the following report by the Chairman of the Health Committee and the Medical Officer of Health was submitted to the Works Committee in October:— " At a mseting of the Health Committee held on July 28th " the Chairman of the Committee and the Medical Offier of Health were requested to prepare a statement of the accommodation and kind cf building required and submit the same to the Works Committee at at there next meeting :— 1. Extent of Additional Accommodation. The amount of permanent Hospital accommodation whLh should be provided in proportion to the population will depend upon various considerations, amongst the most important of which are the character of the population, whether urban or rural; the rate of 46 crease of population; the houses and habits of the people ; and the amount of intercourse with other places from which infectious disease may be introduced. As a rough estimate, one bed for every thousand inhabitants is sometimes adopted, but in view of the diverse circumstances of different districts, this cannot be regarded as a definite standard. Some idea as to the number and nature of the diseases to be treated, may be gained from the following table, which gives the number of Scarlet Fever, Diphtheria, and Typhoid cases notified since the adoption of the Infectious Disease Notification Act, Scarlet Fever. Diphtheria. Typhoid. 1890 108 14 13 1891 63 8 13 1892 74 27 15 1893 192 41 19 1894 86 22 15 1893 67 32 28 1896 193 23 14 1897 93 89 10 1898 167 35 9 1899 111 49 46 1900 243 28 29 1901 82 34 27 1902 109 33 14 1903 76 22 40 1904 129 32 8 1905 137 49 12 1906 170 46 12 1907 267 63 13 It will be seen that, in recent years the number of Typhoid cases is comparatively small, and it is the experience of most districts throughout the kingdom, that this disease is becoming less frequent. During the first half of the year Acton is usually free from this disease. In the circumstances, we consider that the permanent accommodation for this disease can be provided for in the observation block, 47 The two diseases which take up the major portion of the accommodation at the Hospital are Scarlet Fever and Diphtheria, and more especially the former. Under present conditions the average stay of Scarlet Fever patients in the Hospital extends to a period of 45 days. On this basis 33 beds would be required and continually occupied to accommodate the number of cases notified last year. This figure is given simply as a basis for calculations, but several factors have to be taken into consideration. The first is the fact that Scarlet Fever tends to recur in epidemics, and 1907 was to an extent an epidemic year. The second factor is the seasonal epidemicity of Scarlet Fever. The disease shows a maximum and a minimum seasonal incidence ; that is to say, Scarlet Fever is usually at its height in the Spring and Autumn, and least prevalent in the Summer and W inter. Consequently, it is not sufficient to provide only such a number of beds that would accommodate the cases if spread evenly over the year ; and whilst only 33 beds would have been required in 1907 if the cases had been uniformly distributed throughout the year, the fact was that during limited periods 60 beds were occupied, and at another time not more than ten were used. It is therefore necessary to provide at least 50 per cent. more beds than the average required. Another factor that has to be considered is the increase of the population. It increased from 24,206 in 1891, to 37,448 in 1901. and the estimated population at the present time is 55,000. It is reasonable to assume that, during the next ten years, it will increase considerably, though possibly not at the same rate as during the past dedennium. All cases of Scarlet Fever need not be isolated in the Hospital, but it has been found in this district that the demand for Hospital accommodation, now that the residents have come to appreciate its benefits, has increased beyond what was anticipated. In 1906, 152 cases out of 170 notified were removed to the Hospital, and in 1907 232 out of 267. This high percentage of cases desiring removal to Hospital will probably be maintained, owing to the character of the housing accommodatiou, and the extent of the laundry industry. A large number of houses formerly occupied by one family, are now 48 sub let and occupied by two or more families, and no facilities exist for nursing and the isolation of the patients at their houses. Moreover, in the southern part of the district where most of the houses are occupied by more than one family, a large number of the households have one or more of their msmbers occupied in the laundry industry, and the importance of the immediate removal of any infectious cases is obvious. It must therefore be assumed that a high percentage of the cases notified will continne to be removed to the Hospital. There is one important paint of difference bjtween Scarlet Fever and Typhoid Fever. Scarlet Fever is essentially a disease of Childhood, and a large proportion of the cases are of children under ten years of age. Less danger, therefore, results if the number of beds in a Ward slightly exceeds that allowed on the 2,000 cubic feet basis, so long as this overcrowding is only of a temporary character. Having taken all the factors into consideration, we are of opinion that an accommodation of 50 beds for Scat let Fever would suffice the district for at least ten years, and we propose for the consideration of the Committee the following arrangement of the accommodation:— 1. Two rooms in the observation block for Typhoid patients. 2. The third room for observation purpose. 2 beds. 3. Present Pavilion A for Diphtheria. 14 beds. 4. Present Pavillion B for convalescent Scarlet Fever and discharge purposes. 14 beds. 5. An additional Pavilion of 36 beds for Scarlet Fever cases. 2—Administration Block. Before considering the kind of building which we suggest for this additional pavilion, it may be well to discuss the accommodation for the staff. For a Hospital of 70 beds, accommodation should be provided for a nursing staff of 15 and a domestic staff of 10. At the present time the administrative block is barely sufficient for the present pursing and domestic staff, 49 The accommodation is made up as follows :— A. Basement. 1. Kitchen. 4. Servant's sitting room. 2. Scullery. 5. Attendant's bedroom. 3. Housemaid's pantry. 6. Partitioned off Dispensary B. Ground Floor. 1. Waiting room. 3. Matron's room. 2. Committee room. 4. Nurses dining room. C. First Floor. 5 bedrooms, linen room and 2 bath rooms. D. Second Floor. On this floor are 7 rooms, 6 of which are used as bedrooms, and the seventh is a small room used as a store room. Of the 6 used as bed-rooms, all have sloping roofs, and 5 of them have a maximum height of only 6 ft. 6 ins., and the roofs slope down to a height of less than 3 ft. It will at once be appreciated that these do not conform to the requirements of a healthy bedroom. The sixth bedrcom also has a sloping roof with a height varying from 5 ft. 6 in. to 8 ft. If the Hospital be extended, the present administrative Block will be inadequate, and the present building is very difficult, if not impossible of extension. The Committee will probably have to decide between (a) taking down the present building and erecting a new Administrative Block (b) erecting a separate building for the accommodation of the increased staff. The former alternative is worthy of the serious consideration of the Committee, as being ultimately the more economical and efficient course to take. The present administrative block is not a suitable one for the purpose. It is an old dwelling house, the repair and maintenance of which will mean a considerable and an increasing annual outlay. The number of bedrooms is too small, and in size some of them are too large. At the present time, 3 of the nurses sleep in one bedroom. The kitchen, for working purposes, is an underground one, and this, of course, necessitates additional labour. Almost every time the telephone rings, one of the domestic staff has to run up a flight of stairs. 50 The rooms on the second floor are damp. In the winter the walls reek with moisture and fires have to be occasionally lit in them. These are only some of the disadvantages, which obviously entail extra expense in the upkeep of the present building. On the other hand, the initial expense of entirely rebuilding will be greater than that of a separate smaller building. But which plan would entail the least annual charge, should be carefully enquired into by the Committee. 3. The Hospital Pavilion. The following suggestions outline briefly the character of the accommodation which should be provided in the pavilion. It should provide accommodation for 36 beds. A separation ward should be provided leading out of the main wards. A bathroom should be provided for each ward with two baths in each room. The walls should be ceiled at the level of the wall plate, as otherwise it is impossible to avoid dust. The walls up to a height of 9 ft. should be covered with some impermeable material, such as Keen's cement. The inlet ventilators should be so arranged that they can easily be cleaned. The hall should be arranged so as to provide cupboard accommodation for the ward linen. There should be a ventilated cupboard for keeping food. The sanitary appliances should be in an annexe at the end of each ward; in each such room one sink should be provided for flushing bed pans and connected directly with the drain. The question of providing hot water should be considered. It would probably be more economical to obtain the hot water for the three blocks from one boiler. At the present time, the hot water for the baths is obtained from a small boiler in the nurses' kitchen. Such an arrangement would be extravagant, if not impossible, for a pavilion of 36 beds, and it might be better to provide one boiler for the three blocks." The recommendations in the report were adopted by the Committee, and the Surveyor was instructed to prepare plans for the 51 erection of another pavilion. These plans have been prepared and approved by the Council. REFUSE DESTRUCTOR. The year 1908 marks the close of the old method of Refuse Disposal. The Refuse Destructor was completed in February 1909, and all the refuse will in future be burnt. The question of disposing of the town's refuse without creating a nuisance has been before the Council for about 15 years, and during this period the refuse has been tipped on part of the surplus land near the Cemetery. The refuse heap had become so large and obnoxious that in 1907 the Council entered into an agreement with a local brick company to receive and burn the refuse at is. per load. This arrangement was not entirely satisfactory. The company was not able to burn all the refuse as it was collected, and a large heap accumulated near the works. The following description of the Refuse Destructor, together with a history of the scheme has been kindly supplied by Mr. Yorath, the Chief Assistant Engineer to the Council. The question of destroying the town's refuse by burning was first mooted in 1894, and after careful consideration, it was decided to erect a destructor. The original intention was to erect a combined refuse destructor and electricity works on surplus land at the Council's Sewage Works. Tenders were invited, and that of Messrs. Beaman and Deas was accepted. Before the contract could be sealed, a decision was given in the High Court which closely affected the scheme. In the case of Lord Jersey v. Hanwell District Council it was held that land bought for a specific purpose could not be used for another. In the circnmstances, this scheme was abandoned. The next scheme was for the erection of a Refuse Destructor alone, on a portion of the Friar's Estate, but this site was objected to so strenuously that it was deemed advisable not to proceed with that scheme. The Council then obtained Parliamentary powers for the purchase of land adjacent to the Sewage Works on which to 52 erect a destructor. This was successfully accomplished, but some time elapsed before tenders for the building, &c., could be obtained, and in the meantime an elementary school had been erected on the adjoining land. At the Local Government Inquiry a most strenuous opposition was offered to the erection of a dust destructor on that site. Opinion on the Council was so evenly divided as to the desirability of proceeding with the scheme, that the Local Government Board refused its sanction. The Council then bought the land upon which the destructor has been erected, and the site is in some respects almost an ideal one. The land is a portion of a brickfield, and a considerable area of it had been excavated to a depth of 20 feet. Inclined roadways to the tipping platform were consequently avoided. The Destructor is provided with 8 top charging cells, with drying hearths. Each cell is capable of destroying 18 tons of house refuse per 24 hours. The temperature of the gases in the combustion chambers is to be readily maintained at 2,000 degrees Fahr., and the total residum left after burning the house refuse is not to exceed 27 per cent. by weight of the refuse consumsd. INQUESTS. 26 inquests were held the cause of death being :— Accidental burns 5 Overlaying 2 Fracture of skull 2 Run over by a cart 1 Coal gas poisoning 1 Ptomaine poisoning 1 Injury at birth 1 Heart disease 7 Childbirth 1 Weakness from birth 1 Improper feeding 1 Gastric ulcer 1 Apoplexy 1 Alcoholism & Morphinism 1 MORTUARY. Twenty-six bodies were deposited in the Mortuary and 17 postmortem examinations were made. OFFENSIVE TRADES. Only two offensive trades are carried on within the district—fatextraction and the manufacture of a chemical fertilizer. 53 SLAUGHTER HOUSES. There are two licensed and two registered slaughter houses in the district. COMMON LODGING HOUSES. Two Common Lodging Houses are registered annually in the district and there was no addition to the number last year. These two houses have accommodation for 150 lodgers. DAIRIES AND COWSHEDS. There are 2 cowkeepers and 76 purveyors of milk on the register. There were 19 changes of occupation, and 14 new premises were registered. SEWAGE DISPOSAL. The sewage and disposal works carried out for the purpose of giving effect to the provisions of the Acton Sewage of 1905 have now been completed. The reasons which led to an application to Parliament have been given in a previous report and it is not necessary to go over that ground again. Clause 33 of the Act fixes the amount of sewage which will be received by the London County Council, viz., an average of 50 gallons per head per diem of the population and a maximum rate of flow of 100 gallons in the 24 hours. Clause 21 gives permission to discharge storm water into the River Thames, and places upon the Acton Council the obligation of discontinuing the discharge of the same into the sewers of the London County Council. Clause 36 was inserted for the protection of the Chiswick District Council and it provides that storm water up to a flow amounting to 125 gallons per head per diem must be screened and passed through filter beds 4 feet deep and 2| acres in area. The result of the Sewage Act of 1905 will be that all the sewage will be taken out of the district immediately. In ordinary circumstances the sewage will pass directly into the Metropolitan Sewers, and in cases of storm the overflow will be filtered and emptied into the Thames. 54 FACTORY & WORKSHOP ACT, 1901. The number of Workshops on the Register at the end of 1908 was 394. During the year 22 new workshops were registered. The inspection of Factories comes mainly within the province of H.M. Inspector of Factories. The enforcement of Scction 22 of the Public Health Amendment Act, 1890, is entrusted to the local authority. Where any sanitary defects is discoveted by H.M. Inspector in a Factory, which is remediable under the law relating to public health, and not under the Factory and Workshop Act, he informs the Council of the defect, and it is the duty of the Council to arrange for the remedy of the defect. Twelve references from H.M. Inspector were received during the year, and particulars of the defects found and remedied will be found in the Home Office Table. LAUNDRIES. On January 1st, the Factory and Workshop Act of 1907 came into force. From a sanitary point of view its most important provisions relate to domestic laundries. Under Section 103 of the Factory and Workshop Act of 1901, if the laundries were worked by members of the family, or with the assistance of not more than two persons from outside, they were excluded from the Act. Section 103 of the Act of 1901 is now repealed, and if any person from outside is employed, the house is deemed a workshop. If the work is carried on by members of the same family, Section 114 of the Act of 1901 applies, and the premises are not exempt from the provisions of the Act, which apply to domestic workshops, unless the labour is exercised at irregular intervals, and docs not provide the whole or principal means of living to the family. The provisions of the Factory and Workshop Act of 1907 were advertised by the Council, but only three domestic laundries have been registered during the year. The provisions of the Act are of the greatest importance, and the danger of spreading infection is far greater in the domestic laundry than in the factory laundry. In the former the clean and dirty linen comes into close contact in the narrow passage and in the other parts of the house, and there is every opportunity for infection to be conveyed from one article to another. The actual washing is 55 done in some small outbuilding, reeking with steam and in an atmosphere loaded with all forms of impurity. The conditions are very different in the large laundry. Although infection may reach the latter, and some of those who sort the foul linen may contract the disease, the temperature in modern rotary machines is sufficiently high, and thorough treatment is carried out for a sufficiently long time to sterilize the linen. In a laundry properly planned and built for the purpose, the sorting room, where the foul linen is received, and the packing room, where it is put into hampers for delivery are distinct. They are frequently separated by the whole length of the laundry, so that the risk of direct infection conveyed from the foul to the clean linen is practically non-existent. I have to thank the staff of the Health Department for assistance throughout the year. The County Council Tables have been compiled entirely by Mr. Kinch. The year has been an arduous one, and I regret that the strain has told upon some members of the staff. Miss Williams had to resign owing to a break down in health Miss Stevens was prcmoled, but the secured a iimilar appointment under the Metropolitan Borough of Lewisham. Miss Bhose was appointed Assistant Health Visitor, and on the resignation of Miss Stevens was promoted to the Senior post. Mr. Fearns also suffered a break down in health in July, and was off duty during the rest of the year. In April, 1909, he sent in his resignation. Mr Arthur Thomas was appointed to Mr. Fearns' post, I may express the sincere regret which these resignations have caused. I remain, Your obedient servant, D. J. THOMAS, 56 Table 1. VITAL STATISTICS OF WHOLE DISTRICT DURING 1908 AND PREVIOUS YEARS. Year. Popula- iion estimated to Middle of each Year. Births. Total Deaths Registered in the District. Total Deaths in Public Institutions in the District. Deaths of Non-Residents registered in Public Institutions in the District Deaths of Residents registered in Public Institutions bevond District. Nett Deaths at all Ages belonging to the District. No. Rate.* Under 1 Year of age. At all ages. No. Rate per 1,000 Births Registered No. Rate.* No. Rate.* I 2 3 4 5 6 7 8 9 10 11 12 13 1898 33,404 995 29.8 181 182 507 15.2 ... ... ... ... ... 1899 34,901 1,068 30.6 200 187 509 14.6 ... ... ... ... ... 1900 36,508 1,080 29.5 182 168 528 14.4 15 ... ... ... ... 1901 38,373 1,211 31,5 206 170 5'9 13,5 6 ... ... ... ... 1902 41,000 1,242 30.3 186 150 593 14,4 12 ... ... ... ... 1903 43,802 1,422 32,4 150 105 430 9.8 8 ... ... ... ... 1904 46,780 1,450 30 207 143 576 12.3 9 ... ... ... ... 1905 50,000 1,527 30,5 162 106 537 10.7 27 1 92 628 12.5 1906 52,000 1,533 29.4 193 125 597 11.5 29 7 97 687 13.2 1907 53,000 1,535 29 183 119 605 11.4 25 8 140 737 13.9 Averages for yrs 1898-1907 429,768 13,063 30.4 1,850 141 5,401 12.6 ... . ... .. ... 1908 55.000 1,568 28.5 174 111 592 10.8 31 1 133 724 13.1 * Rates in Columns 4, 8, and 13 calculated per 1,000 of estimated population. Total population at all ages, 37,744. Number of inhabited houses, 6,114. Average number of persons per house, 6.2. Area of District in acres (exclusive of area covered by water) 2,304. 57 Table 2. VITAL STATISTICS OF SEPARATE LOCALITIES IN 1908 AND PREVIOUS YEARS. ACTON. 1906. 1907. 1908. Population estimated to middle of each year 52,000 53,030 55,000 Births registered 1,533 1,535 1,568 Deaths at all Ages 687 737 724 Deaths under 1 year 201 200 188 NORTH-EAST WARD. Population estimated to middle of each year 13,000 13,500 14,000 Births registered 325 331 363 Deaths at all Ages 37 53 145 Deaths under 1 year 32 31 30 NORTH-WEST WARD. Population estimated to middle of each year 11,000 11,500 12,000 Births registered 229 213 215 Deaths at all Ages 135 105 124 Deaths under 1 years 34 23 26 SOUTH-EAST WARD. Population estimated to middle of each year 11,000 11,000 12,000 Births registered 255 320 328 Deaths at all ages 122 120 124 Deaths under 1 year 28 32 29 SOUTH-WEST WARD. Population estimated to middle of each year 17,000 17,000 17,000 Births registered 724 671 662 Deaths at all Age 293 347 331 Deaths under 1 year 107 114 103 58 Table 3 CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1908. Notifiable Disease. Cases notified in whole District. Total cases notified in each ward. Number of cases removed to Hospital from each Ward. At all Ages At Ages—Years. North-East. North-West South-East. South-West North-East. North-West South-East. South-West Total cases removed to Hospital. Under 1. 1 to 5. 5 to 15 15 to 25 25 to 65 Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphthera (including Membranous croup 83 1 33 39 6 4 17 14 18 34 10 10 15 23 58 Erysipelas 35 1 2 ... 6 26 8 4 5 18 I ... .. ... 1 Scarlet Fever 484 .. 111 317 39 17 76 48 152 209 56 34 107 193 390 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever 14 ... ... 3 3 8 3 4 1 6 1 3 ... 7 11 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever 1 ... ... ... ... 1 1 ... ... ... 1 ... ... ... 1 Plague ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Phthisis 3 ... ... ... 1 2 1 1 ... 1 ... ... ... ... ... Totals 620 2 146 359 55 58 106 71 176 268 69 47 122 223 46l 59 Table IV. CAUSES OF, AND AGES AT, DEATH DURING YEAR 1908. Causes of Death. Deaths at the subjoined ages of " Residents" whether occurring in or beyond the District. Deaths at all ages of "Residents" belonging to Localities, whether occurring in or beyond the District Total Deaths whether of 'Residents' or "NonResi dents" in Public Institutions in the District. All Ages. Under 1 year 1 and under 5. 5 and under 15. 15 and under 2 25 and under 65. 65 and upwards North East Ward. N'th-West Ward. South East Ward. S'th-West Ward. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... Measles 38 8 26 3 1 ... ... 2 5 6 25 ... Scarlet Fever 15 ... 9 4 1 1 ... 1 ... 4 10 14 Whooping Cough 15 6 8 1 ... ... 1 2 3 9 ... Diphtheria (including Membranous croup) 7 ... 6 1 ... ... ... 1 ... 2 4 4 Croup ... ... ... ... ... ... ... ... ... ... ... ... Fever— Typhus ... ... ... ... ... ... ... ... ... ... ... ... Enteric 2 ... ... ... 1 1 ... ... 1 ... 1 ... Other continued ... ... ... ... ... ... ... ... ... ... ... ... Epidemic influenza 14 ... ... ... 1 9 4 6 1 3 4 1 Cholera ... ... ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... Diarrhœa 46 42 4 .. ... ... ... 7 3 3 33 ... Enteritis 17 14 ... ... ... 1 2 5 4 1 7 ... Puerperal Fever ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... Phthisis (Pulmonary Tuberculosis 56 1 ... 3 5 43 4 13 5 12 26 ... Other Tuberculous diseases 28 10 9 4 3 2 ... 2 6 6 14 ... Cancer, malignant disease 48 ... ... ... ... 32 16 14 8 9 17 ... Bronchitis 50 15 6 ... ... 5 24 8 5 9 28 1 Pneumonia 55 11 19 3 2 14 6 10 9 11 25 2 Pleurisy 1 ... ... ... ... 1 ... ... ... 1 ... ... Other diseases of Respiratory Organs 17 3 5 ... ... 3 6 3 3 2 9 ... Alcoholism— Cirrhosis of Liver 12 ... ... ... 1 9 2 2 6 1 3 ... Venereal diseases ... ... ... ... ... ... ... ... ... ... ... ... Premature birth 25 25 ... ... ... ... ... 2 4 2 17 ... Diseases and accidents of parturition 5 ... ... ... 2 3 ... 1 ... 1 3 ... Heart diseases 45 1 ... 6 3 23 10 7 11 8 17 ... Accidents 12 2 4 2 .. 2 2 2 2 1 7 4 Suicides 1 ... ... ... ... 1 ... 1 ... ... ... ... All other causes 216 50 10 2 3 59 92 56 49 38 73 5 All causes 723 188 106 29 23 209 168 144 124 124 331 31 6o Population estimated to middle of 1908, 55,000 Births in the year legitimate, 1526. Illegitimate, 42. Table 5. INFANTILE MORTALITY Deaths from stated causes in Weeks CAUSE OF DEATH. Under 1 week 1-2 weeks. 2-3 weeks. 3-4 weeks. Total under 1 month, 1-2 months. Common Infectious Diseases, Small-pox ... ... ... .. ... ... Chicken pox ... ... ... ... ... ... Measles ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... Diphtheria ing Membranous Croup ... ... ... ... ... ... Whooping Cough ... ... ... ... ... 1 Diarrhœal Diseases. Diarrhoea, all form ... ... ... ... ... 3 Enteritis, Mucoenteritis, Gastroenteritis ... ... ... 2 2 2 Gastritis Gastrointestinal Catarrh ... ... ... ... ... ... Wasting Diseases. Premature Birth 12 6 1 5 24 ... Congenital Defects 2 ... ... ... 2 ... Injury at Birth 3 ... 1 ... 4 ... Want of Breast-) milk, Starvation ... ... ... . ... 1 Atrophy, Debility, Marasmus 3 3 2 2 10 3 Tuberculous Diseases. Tuberculous, ingitis ... ... ... ... ... ... Tuberculous Peritonitis; Tabes Mesenterica ... ... ... ... ... ... Other Tuberculous) Diseases ... ... ... ... ... ... Other Causes Erysipelas ... ... ... ... ... ... Syphilis ... ... ... ... ... ... Rickets ... ... ... ... ... ... Meningitis (not Tuberculous) ... ... ... ... ... ... Convulsions 1 1 ... ... 2 1 Bronchitis ... ... 1 2 3 4 Laryngitis ... ... ... ... ... ... Pneumonia ... ... ... ... ... 2 Suffocation, overlaying 1 ... ... ... 1 ... Other causes 3 1 ... ... 4 ... 25 11 5 11 52 17 61 DURING THE YEAR, 1908. and Months under One Year of age. onths. 3-4 months. 4-5 months. 5-6 months. 6-7 months. 7-8 months. 8-9 months. 9-10 months. 10-11 months. 11-12 months. Total Deaths under One Year. ... ... ... ... ... ... ... ... ... .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 ... 2 1 3 8 ... ... .. ... ... ... ... ... .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 2 1 ... 6 3 3 5 7 4 5 3 6 1 2 42 2 2 4 ... 2 ... ... ... ... ... 14 ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 25 ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... ... ... ... ... 4 1 ... ... 1 1 ... ... ... ... ... 4 4 ... 1 1 1 ... 1 1 ... ... 22 ... ... 1 ... 1 ... 1 1 1 ... 5 1 2 1 ... ... ... ... ... ... 1 5 ... ... ... 1 ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... .. ... 1 ... 1 . ... ... ... ... ... 2 .. ... ... ... ... ... ... ... ... ... ... ... ... 1 ... .. ... ... ... ... ... 1 1 .. ... ... ... ... ... ... 1 1 6 2 ... ... 1 ... ... 1 2 ... 2 15 ... ... 2 ... ... ... ... ... 1 .. 3 ... 1 ... ... ... 2 1 2 1 2 11 ... ... ... 1 ... ... ... ... ... ... 2 1 1 1 ... 2 1 ... ... ... ... 10 16 10 16 14 12 10 7 l6 7 11 188 Deaths in the year of legitimate infants, 171. Illegitimate infants, 17. 62 INFANTILE MORTALITY. WARD DISTRIBUTION. North East North West South East South West Total. Measles 1 1 3 3 8 Whooping Cough ... 2 1 3 6 Diarrhœa 6 3 3 30 42 Enteritis 5 4 5 14 Premature Birth 2 4 2 17 25 Congenital Defects 1 ... ... 1 2 Injury at Birth ... 1 2 1 4 Want of Breast Milk, Starvation ... 1 1 2 4 Atrophy, Debility, Marasmus 6 3 4 9 22 Tuberculous Meningitis 2 ... 1 2 5 Tuberculous Peritonitis, Tabes Mesenterica ... ... ... 5 5 Other Tuberculous Diseases ... ... ... 1 1 Syphilis ... 1 ... 1 2 Meningitis (not Tuberculous) ... ... ... 1 1 Convulsions 1 2 1 2 6 Bronchitis 2 2 5 6 15 Laryngitis ... ... ... 3 3 Pneumonia 1 1 4 5 11 Suffocation Overlaying ... ... ... 2 2 Other causes 3 1 2 4 10 Totals 30 26 29 103 183 FACTORIES, WORKSHOPS, WORKPLACES AND HOMEWORK. I. INSPECTION. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. lnspecttions. Written Notices. Factories (including Factory Laundries) 25 10 Workshops (including Workshop Laundries) 107 — Workplaces (other than Outworker's premises included in Part 3 of this Report) — — Total 132 10 2. DEFECTS FOUND. Particulars. Nuisances under Public Health Acts:— Found. Remedied Want of cleanliness 6 6 Want of ventilation 5 5 Overcrowding - - Want of drainage of floors 10 10 Other Nuisances 10 10 Sanitary accommodation insufficient 11 11 unsuitable or defective 17 17 not separate for sexes — — Total 60 60 63 3. HOME WORK. OUTWORKERS' LISTS, SECTION 107. NATURE OF WORK. Twice Yearly Once Yearly Outworkers received from other Councils Outworkers forwarded to other Councils Notices served on occupiers as to keeping or sending lists Inspection of outworkers premises. Infected premises instances Lists Outworkers Lists Outworkers Wearing Apparel— (1) making, etc. 21 33 6 6 30 ... ... 33 ... (2) cleaning and washing 21 61 2 4 ... ... 72 61 4 Brush making 4 10 ... ... 3 ... ... 30 ... Stuffed toys 2 84 ... ... ... 8 ... 76 ... Total 48 208 8 10 33 8 72 200 A 4. REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. Laundries 249 Dressmaking 47 Millinery 8 Tailoring 7 Bakehouses 29 Others 54 Total number of workshops on Register 394 5. OTHER MATTERS. Matters notified to H.M. Inspector of Factories. Failure to affix Abstract of the Factory and Workshop Act (s. 133) — Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory and Workshop Act (s. 5) Notified to H M. Inspector 12 Reports (of action taken) sent to H.M. Inspector 12 Underground Bakehouses (s. 101):— In use at the end of the year 8 Your obedient servant, D. J. THOMAS. April, 1908. 64 SANITARY WORK. Inspections.—Number of premises inspected on complaint 1583 Number of premises inspected in connection with infectious diseases 621 Number of premises under periodical inspection 333 Houses inspected from house-to-house 661 Total number of inspections and re-inspections made 9936 Notices.—Cautionary or intimation notices given 1282 Statutory orders issued 1032 Summonses served 1 Dwelling Houses. - Houses, premises, etc., cleansed, repaired, etc. 1122 Common Lodging Houses—Number registered under bye-laws 2 Number of inspections made 190 Movable Dwellings, Caravans. Tents, etc.—Number observed during the year 13 Number of nuisances therefrom abated 11 Number removed from disrict 10 Bakehouses.—Number in district 29 Slaughter-houses.—Number on register 4 Number of inspections made and frequency of inspections weekly 148 Cow-sheds.—Number on register 2 Number of inspections made and frequency of inspection monthly 24 Number of milch cows in district 105 Dairies and Milkshops.—Number on register 76 Number of inspections made and frequency of inspection yearly 152 Unsound Food.-(a) Animals seized (6) Article or parcels seized (a) 40 (b) 141 Articles or parcels surrendered 181 Adulterated Food.—Samples taken (if any) by the District Local Authority 74 Found adulterated 3 Offensive Trades.—Number of premises in district 1 Number of inspections made 25 WATER SUPPLY AND WATER SERVICE. Percentage of Houses supplied from Public Water Service 100% Cisterns.—New provided 39 Cleansed, repaired, covered, etc. 232 Draw-taps placed on Mains 45 Percentage of Houses supplied on Constant System 100 per cent Water Closets.—Repaired, supplied with water, or otherwise improved 558 65 drainage and sewage of existing buildings. Pecentage of Houses provided with Water Closets 100 per cent. Drains.—Examined, tested, exposed, etc. 381 Unstopped, repaired trapped, etc. 983 Waste pipes, rain water pipes, disconnected, repaired, etc. 705 New soil pipes or ventilating shafts fixed 326 Existing soil pipes or ventilating shafts repaired 136 Disconnecting traps or chambers inserted 412 Reconstructed 77 Cesspools.—Rendered impervious, emptied, cleansed, etc. 3 Abolished, and drain connected to sewer 3 Percentage of Houses draining into sewers 100 per cent Disinfection. — Rooms Disinfected (a) ordinary infectious diseases (a) 527 (b) Phthisis (b) 31 Rooms stripped and cleansed 112 Articles disinfected or destroyed, (a) ordinary infectious disease, (6) Pthisis — All textile articles in infected rooms removed and steam disinfected. Dust,—New bins provided 246 How frequently is dust removed from each house weekly Number of complaints of non-removals received 6 Method of disposal By burning in destructor Sundry Nuisances Abated.—Overcrowding 47 Smoke 14 Accumulatian of refuse 157 Foul ditches, ponds, etc., and stagnant water 9 Foul pigs and other animals 26 Dampness 227 Yards repaved or repaired 341 Other nuisances 195* *These refer to hoods ventilated at Fish Shops, Houses and bedding cleansed and washed, side passages paved, additional W.C.'s provided. Obediently yours, maurice w. kinch, (Chief Inspector of Nuisances. Report on the Medical Inspection of Schools FOR THE YEAR 1908. 68 The Urban District Council of Acton. To the Chairman and Members of the Educational Committee. Ladies and Gentlemen, In accordance with paragraph 13 of Circular 576 issued by the Board of Education in November 1907, we beg to submit the following report on the schools and school children under the control of the Local Educational Authority. The report deals with the period ending December 31st, 1908. This period has been adopted so as to secure in future reports an effective basis for comparison of the work done in different parts of the country and to correspond with the annual period fixed for the closely related annual report of the Medical Officer of Health. The report is necessarily incomplete as the provisions of the Education (Administrative Provision) Act 1907, relating to medical inspection were not put into operation until the month of April 1908. The scope of the Report is defined in Circular 596 of the Board of Education, and this report will follow as closely as possible the lines laid down in that Circular. As the report is for the information of the Board of Education as well as of the Local Education Authority, statements of local circumstances and conditions are included which may seem superfluous to the latter. As regards the scope of the report, the Board consider it desirable that it should cover as much as possible of the ground indicated under the following heads:— a. Hygienic conditions of schools. b. Description of arrangements for co-ordinating School Medical Service and Public Health Service including (1) Use of Board's Schedule. (2) Assistance given by Teachers, Nurses, Attendance Officers, etc. (3) Co-operation of Parents. (4) Disturbance of School Arrangements. c. Extent and scope of Medical Inspection during the year. d. Review of results of Medical Inspection. e. Relations of home and industrial conditions to health and physical conditions of children. 69 f. Methods employed or available for the treatment of defects, including work of School Nurses. g. Review of action taken to detect and prevent the spread of infectious diseases, including closure of schools or exclusion of children from Schools. h. Review of methods adopted for dealing with blind, deaf, mentally or physically defective and epileptic children. i. Review of methods of instruction in personal Hygiene and temperance in Public Elementary Schools, including physical or breathing exercises and arrangements for open air or camp schools. The Urban District of Acton has an area of 2304 acres and an estimated population at the end of June 1908 of 55,000 inhabitants. The average number of children on the books was 8564 and the average number of children in attendance throughout the year was 7708. There are in the district 10 schools and 23 departments. Some of these schools have been erected quite recently and conform to the highest standard of hygiene. The older schools leave much to be desired in the matter of sanitation and hygiene. A short description is given of each school, and in order that the condition of the buildings may be compared with what is demanded in new schools a short summary is given of the building regulations issued in 1907 by the Board of Education, These regulations are plainly unsuitable for any rigid application to proposals for enlarging or otherwise improving existing buildings. Every part of a school building should be thoroughly adapted to the work of school teaching. The rooms should be grouped compactly and conveniently so as to secure proper organisation and supervision; every building intended for use as a public elementary school must be planned so that the children who will attend can be seated in the best manner for being taught. For large departments containing from 350 to 600 places the most suitable plan is that of the Central Hall with the class rooms grouped round it; as a rule such a department would require from 70 seven to ten classrooms. Smaller departments may be planned conveniently with the classrooms opening from a corridor. In large Schools there should be provided for the use of the Teachers a small room with suitable lavatory accommodation. The classrooms should not be passage rooms from one part of the building to another nor from the schoolrooms to the playground or yard. Both schoolrooms and classrooms must have independent entrances. The rooms should be arranged so that each can easily be cleared without disturbing the work proceeding in any other room. Cloakrooms should not be passages, and should be external to the schoolrooms and classrooms. Cloakrooms should be amply lighted from the end and should not be placed against the gable wall which should be fully utilised for windows giving light to the rooms used for teaching. There should be separate ingress and egress so that the children can enter and leave the cloakroom without contusion or crowding. Thorough ventilation and disconnection are essential so that smells are not carried into the School. Lavatory basins are needed. Lighting:— Every part and corner of a school should be well lighted. The light should, as far as possible, and especially in classrooms, be admitted from the left side of the scholars. All other windows in classrooms should be regarded as supplementary or for ventilation. When left light is impossible, right light is next best. Windows full in the eyes of scholars cannot be approved. The size and position of the windows are especially important in their bearing on the eyesight of the children. A large portion of each window should be made to open for ventilation and for cleaning. The sills of the main lighting windows should be placed not more than 4 feet above the floor; the tops of the windows should as a rule reach nearly to the ceiling. Large spaces between the window heads and ceiling are productive of foul rooms. Skylights are objectionable. They cannot be approved in schoolrooms or classrooms. They will only be allowed in central halls having ridge or apex ventilation, 71 The windows should be properly distributed over the walls of the classrooms so that every desk shall be sufficiently lighted. Ventilation. The chief point in all ventilation is to prevent stagnant air; particular expedients are only subsidiary to the main principle. There must be ample provision for the continuous inflow of fresh air, and also for the outflow of foul air. The best way of providing the latter is to build to each room a separate air chimney carried up in the same stack with smoke flues. An outlet should be by a warm flue or exhaust, otherwise it will frequently act as a cold inlet. Outlets in ceilings must not open into a false roof, but must be properly connected with some form of extract ventilator. Inlets are best placed in corners of rooms furthest from doors and fireplaces, and should be arranged to discharge upwards into the room. Gratings in floors should never be provided. The size of the inlets and outlets must be carefully adapted to the method of ventilation proposed. A much larger area is required when no motive force is provided. Besides being continually ventilated by the means above described, rooms should as often as possible be flushed with fresh air admitted through open windows and doors. Sunshine is of particular importance in its effects on ventilatioD and also on the health of the children. Although lighting from the left is considered so important, ventilation demands also the provision of a small swing window as far from the lighting as possible, and near the ceiling. Warming. The heat should be moderate and evenly distributed so as to maintain a temperature of from 56 to 60 degrees. Where schools are wholly warmed by hot water, the principle of direct radiation is recommended. In such cases open fireplaces in addition are useful for extra warming on occasions, and their flues for ventilation always. A common stove, with a pipe through the wall or roof, can in no circumstances be allowed. Stoves are only approved when:— (1) provided with proper chimneys (as in the case of open fires). 72 (2) of such a pattern that they cannot become red-hot or otherwise contaminate the air; (3) supplied with fresh air, direct from the outside, by a flue of not less than 72 inches superficial. (4) not of such a size or shape as to interfere with the floor space necessary for teaching purposes. A thermometer should always be kept hung up in each room. Sanitary arrangements:— W ater-closets within the main school building are not desirable, and are only required for women teachers. All others should be at a short distance and completely disconnected from the school. The latrines and the approaches to them must be wholly separate for boys and girls. The following table shows approximately the number of closets required:— Girls. Boys. Infants Girls & Infants Under 30 children 2 I 2 2 „ 50 „ 3 2 3 3 „ 70 „ 4 2 3 4 „ 100 „ 5 3 4 5 „ 150 „ 6 3 5 6 „ 200 „ 8 4 6 7 „ 300 „ 12 5 8 8 There should be urinals in the proportion of 10 feet per 100 boys, urinals are required for Infant's (boys). If the numbers in the school are not very large, offices common to Girls and Infants can be' approved ; a proper proportion of the closets must then be made of a suitable height for infants. The above rules apply to new school buildings, and it is practically impossible to make all old schools comply with these regulations in every respect. On the other hand, if no other consideration than economy entered into the question, it is desirable that, in some respects, an improvement be made. For instance the old fashioned grates in some of the schools are not only lacking in heating capacity, but 73 are most extravagant in coal consumption. It is true that if there were sufficient permanent inlet openings, these grates would greatly assist in the ventilation of the rooms, but in the older schools the number of the permanent ventilating openings is too low and in size they are far too small. Moreover, the difficulty of maintaining a sufficiently high and uniform temperature by means of these old fashioned grates precludes the teacher from opening many of the windows in severe weather. The question of efficient ventilation is always most difficult, and except in the most modern schools, the size of the permanent openings is too small. A much larger use is made by some teachers than by others of the means at their disposal. Some misconception exists as to the mode in which a ventilating grate acts. Is is not always appreciated that the opening which leads from the cavity behind the grate into the room is placed there so as to increase the heating capacity of the grate, it is also the most efficient ventilating opening in the class-room. But we often find that these openings are covered over by a picture or a board, and the value of the ventilating grate is thus considerably diminished. Not only are the ventilating grate openings covered over, but some of the inlet openings under the windows are permanently closed; in fact, some of the grids have become fixed in a closed position and cannot be moved. The lighting of each school has been dealt with separately, and attention is drawn in the report wherever the lighting area is insufficient or the direction of the light is unsatisfactory. In some of the class-rooms, though the area is sufficient the light comes from the wrong direction to some of the scholars owing to the arrangement of the desks. In order to accommodate the requisite number of children in the room some of the desk have been placed at right angles to the others. In a few of the class-rooms the light is rendered still more unsatisfactory by the presence of curtains which partition off the rooms. PRIORY SCHOOL. This school was erected in 1883 and enlarged in 1893, 1896 and 1901. A portion of the school is built as a one-storey building, but 74 most of it is in two-storeys. It consists of 3 departments—Infants Girls and Boys. The school has a very large central hall, which is used by the Girls' and Infants' departments. The entrance to the classrooms is not direct from the hall, but from each corner of the hall corridors radiate, and the classrooms on the ground floor are situated alongside these corridors. The school has 1 small and 2 large playgrounds. One of the large playgrounds and the small one are used in common by the Girls and Infants. The sanitary conveniences for the Girls and Infants are situated in the same playground, all the closets are of the trough type, and are automatically flushed. For the girls there are 15 separate compartments, for the Infants (boys) there 5 and an urinal measuring 10 linear feet, and for the boys, there are 7 compartments and an urinal measuring 15 linear feet. Infants' Department consists of 6 classrooms. Two of the rooms are partitioned, so that there is accommodation for 8 classes. Five of the classrooms are on the ground floor and one is on the first floor. There are two cloakrooms, and in each there are lavatory basins for the children. There is no separate room for the teachers of this department. The cloakrooms, corridors and central hall are heated by hotwater pipes. In the cloakrooms, the pipes are carried alongside the wall; in the central hall the pipes are placed beneath iron gratings in the floor, in the corridors there are radiators. The classrooms with one exception are solely heated by open fireplaces; in one room, in addition to a fireplace, hot water pipes are carried along one of the walls. The fireplaces are of a recent type and of the ventilating pattern. Behind each grate is an air cavity which communicates with the outside atmosphere and with the interior of the classroom. The air is drawn from the exterior of the buildings, is led into the cavity, is heated by the warm surface of the grate and passes into the classroom. This type of grate not only enhances the heat value of the fireplace but also acts as an inlet ventilator, 75 In all the classrooms in the Infants' department, there is an outlet opening for ventilation purposes in the breast of the chimney. There are also the usual ventilation openings ; under each window are placed inlets, and in the roof there is an outlet. The window area in all the classrooms appears ample, but in 3 of the rooms the light comes entirely from behind the scholars. In one room, the light comes entirely from the right, in one it comes partly from the right and partly from the left, and in only one room does the light come entirely from the left. Priory Girls' School consists of 8 classrooms, but 1 room is partitioned so as to accommodate two classes, 6 of the rooms are situated on the ground floor and 2 on the first floor. It has 2 entrances, 1 from the main street in Acton Lane, and one from the smaller playground on the northern side of the Infants' Department. The department has 3 cloakrooms, one of these is practically a continuation of the corridor which leads from the Girls' to the Boys' department. This latter cloakroom is lighted on one side by means of borrowed light from one of the classrooms, and requires great care to keep it well ventilated, as thorough ventilation cannot be obtained. Five of the classrooms are heated by open fireplaces, these fireplaces have ventilating grates, but there is not an outlet opening in the breast of the chimney. One classroom is heated by hot water pipes. All the rooms have inlets for ventilation purposes under the windows, and in two of the rooms there are in addition 3 Tobin's tubes. In 5 of the rooms there are special outlet openings in the roof provided for ventilation purposes; in the other 3 classrooms there are no special outlet openings. The window area in all the rooms is ample, but in one of the rooms the light is much impeded by proximity to other buildings. In only 4 rooms does the light come from the left; in one other room it comes partly from the left, in 2 it comes from the right and in 1 it comes from behind. In the latter, though, there is some borrowed light coming from the left. Priory Boys' School also consists of 8 classrooms, and one room is 76 partitioned so as to accommodate 2 classes. Three of the rooms are situated on the ground floor and 5 on the first floor. All the classrooms are heated by open fireplaces, with ventilating grates. All the classrooms have also inlets under the windows. The three rooms on the ground floor have no outlet openings in the roof, but in each one there is an opening in the breast of the chimney, and the upper part of the windows is made to open. In all the classrooms on the first floor there are outlet openings in the roof, but in one of the rooms there are no inlets under the windows The window area in all the classrooms is ample, and in 5 of them the light comes almost entirely from the left, in 2 it comes from the right and in one it conies from behind and the right, with a little borrowed light from the left. In one of the rooms where the light comes from the side of most of the scholars, a few of the desks have been so arranged as to make the direction of the light on these comes entirely from behind and in front. SOUTH ACTON. This school consists of two separate and distinct buildings situated on the southern and northern sides of Osborne Road. In one of the buildings are the Infants' and Girls' departments, and in the other are the Junior and Senior Boys. Infants and Girls' School is situated between Osborne Road and Bollo Bridge Road, and has entrances from both streets. The building is a two-storey one, and was erected in 1880 and enlarged in 1897. On the ground floor is the Infants' department, and on the first floor is the Girls' department. The arrangement of the rooms in the two departments is similar. Each department consists of 10 rooms, together with a wide corridor, cloak room and lavatory accommodation. In the Infants' department one of the rooms is used as a hall for drill purposes. In all the rooms the window area is ample, but in three of the class rooms most of the light comes from behind the scholars. In 11 one of the rooms in the Infants' department the light is impeded by surroundiug buildings. All the class rooms are heated by open fireplaces, with ventilating grates. The corridors and cloak rooms are heated by hot water pipes. In both departments there are inlet openings under the windows, but apart from the outlet opening in the breast of the chimney, there are no permanent outlets in the Infants' department. In the Girls' department there are openings in the ceiling of each class room. There is a large playground, which is used in common by the two departments. The surface of the playground is asphalted, and a small portion of it is covered. The sanitary conveniences are of the rough variety and auto, matically flushed. For the Girls there are 10 compartments, and for the Infants (girls) there are 6 For the Infants (boys) there are 5 compartments and an urinal measuring 12 linear feet. The Boys' School consists of two departments—junior and senior. The building is a two-storey one and was erected in 1903. The two departments are arranged in a similar manner. The Junior department is on the ground floor and the Senior on the first floor. Each department consists of 6 class rooms together with a central hall, cloak room and lavatory accommodation. The school is a modern one, well lighted, ventilated and heated. In all the class rooms the light comes almost entirely from the left. The artificial lighting is by electricity. In every room there are inlet and outlet openings for ventilation purposes. The building is heated by hot water from a central boiler, and radiators are placed in all the rooms. The playgronnd is asphalted, and a portion of it is covered over. In the playground is a manual centre. The sanitary veniences are of the pedestal type, and automatically flushed. There are ten separate compartments and 3 urinals with 33 stalls. BEAUMONT PARK. This School was erected in 1890, and enlarged in 1898. It consists of three departments—infants, girls, and boys. The infants' department is a one-storey building and the girls' and boys' departments are in two-storeys. In addition there is a temporary iron structure with accommodation for three classes. There is a separate playground for each department. All the surface is asphalted and a portion of the boys' playground is covered. The sanitary conveniences are of the trough pattern and are not automatically flushed. There is a flushing cistern for each set of offices. These cisterns are supplied from two large tanks fixed near the head teacher's room in the boys' Department. A good deal of the caretaker's time is taken up in flushing the various offices, and it would conduce to greater cleanliness if the cisterns were made to discharge automatically. For the infants (girls) there are 8 compartments and for the infants (boys) 6 compartments and 10 linear feet of urinal accomodation. For the girls there are 9 compartments, for the senior boys 6 compartments and 46 linear feet of urinal accommodation. The school is heated by hot water and by open fireplaces. The corridors and cloakrooms are heated by hot water. In all the classrooms there are open fireplaces, but in the infants' departments the rooms are also heated by hot water radiators. The open fireplaces are furnished with ventilating grates, and in all the rooms there is an outlet opening in the breast of the chimney. In the classrooms of the infants' and boys departments, there is also an outlet opening in the ceiling. The ventilation of the infants' and boys' departments is more efficient than that of the girls'. This is due to the fact that the latter department is situated on the ground floor, and it has over it the classroom of the boys' department. The permanent outlet 79 openings for ventilation purposes in the girls' school are limited to those placed in the breast of the chimney, except in one classroom where a window has been placed near the ceiling. In all the classrooms there are inlet openings placed under the window. Infants' Department consists of 8 class rooms tcgether with corridors, cloak rooms, and lavatory accommodation. The corridors do not extend uninterruptedly the whole length of the department, but the school has two entrances, the s.outh entrance, from which access is gained to three class rooms, and the north entrance (used in common with the girls) from which access is gained to the other 5 class rooms. Five of the class rooms face Acton Lane, and the building is separated from the street by a row of trees. These trees have recently been lopped, but throughout last summer the light in two of the class rooms was obstructed. The foliage of these trees was pleasant, but it undoubtedly interfered with the efficient lighting of the school. The proportion of window area is ample. In seven of the class rooms the light comes from the left. In the eighth, 3 of the windows are on the right, and one behind. There is also borrowed light from the left. There is no separate lavatory accommodation for the teachers in this department. Girls' Department consists of 9 class rooms on the ground floor of the main building and one class room in the iron building, together with lavatory and cloak room accommodation. A corridor runs through the whole length of the school and separate entrance is gained to each class room Five of the class rooms face Acton Lane, and the lighting of one of the rooms in this department also was formerly adversely affected by the trees situated between the building and the roadway. The lighting of class rooms 10 and 12 is unsatisfactory. In class room 10 the window area is about seventh of the 80 floor space, but the light from two of the windows is impeded by the Infants' School. The third window is situated behind the scholars. The class room is occasionally partitioned off by a curtain, and then most of the light to a part of the class room comes from behind. Class room 12 is somewhat similarly situated, as far as the lighting is concerned. The light here is impeded on the north side by a portion of the girls' and boys' school. In classroom 11 most of the light comes from the three windows situated behind the scholars. In the other class rooms the lighting is satisfactory. Boys Department consists of 9 class rooms in the main building and 2 in the iron building. The class rooms in the main building are on the first floor, and the arrangement of the rooms and corridor is similar to that of the Girls' department. The lighting is better than that of the rooms on the ground floor, as the windows are not obstructed by surrounding buildings. In the two rooms which correspond to class rooms 10 and 12 on the ground floor the window area in the Boys' department is larger. The Iron Structure is situated in the playgrounds and consists of 3 class rooms and 2 cloakrooms, but it has no lavatory accommodation. One of the class rooms is occupied by the girls and the other two are occupied by the boys. The 3 rooms are heated by open fireplaces, but in the Girls' class room there is in addition a gas stove. The efficient heating of the building is very difficult of attainment, and this difficulty accounts for the presence of the gas stove. Its presence can be justified on no other grounds. SOUTHFIELD ROAD. Southfield Road School was erected in 1907 and is a three-storey building. On the ground floor is the Infants' Department, on the first floor is the Junior mixed and on the second floor is the senior mixed. Each floor is arranged on the same plan and consists of 7 class- 81 rooms arranged around a central hall, together with cloakrooms, lavatories, and teachers' room. There are two playgrounds, one for the Senior and Junior boys, and the other for the Infants and Girls. There is a covered playshed in each playground. In the Girls' playground is a Cookery School. The sanitary conveniences are of the pedestal type. The cistern automatically discharges each time the closet is used. For the Infants (Girls) there are 8 compartments and for the Junior and Senior Girls there are 12 In the boys' playground there are 4 separate compartments and an urinal measuring 18 linear feet for the Infants' and 10 compartments and 58 linear feet of urinal accommodation for the Juniors and Seniors. The heating is by means of hot water. In the babies' class rooms there are also open fireplaces. The water is heated by two boilers. The larger boiler supplies the radiators in the halls and the radiators along the outer walls of the classrooms The smaller boiler supplies the radiators along the inner walls of the classrooms. The latter boiler is only used during very severe weather. All the classrooms are well lighted ; the light in all instances coming almost entirely from the left of the scholars. The artificial lighting is by electricity. In each room are placed inlet and outlet ventilators. CENTRAL SCHOOL. This is a 3 storey building erected in 1905 and enlarged in 1908. The Infants' Department is on the ground floor, the Junior department on the first floor, and the Senior (mixed) is on the second floor. Originally, the 3 floors were similar to each other in arrangement, and each department consisted of 7 classrooms arranged round a central hall, together with lavatories, cloak rooms and teachers' rooms. In both the Junior and Senior departments 2 classrooms have been added. The School, being a recent one, is well lighted, ventilated and heated. The light is in all instances from the left, there are inlet and outlet ventilators in each room, and the building is heated by hot water from 82 a central boiler. In all the rooms are placed radiators, and in two classrooms in the Infants' Department, there are in addition open fireplaces. The artificial lighting is by electricity. There are two playgrounds, one for the boys and the other for the girls and infants. In each playground there are two fives courts and a covered play shed. There are also laundry, cooking, and manual centres. The playgrounds are asphalted, with the exception of a small area in each, which is laid out as a garden. The sanitary conveniences are of the pedestal type and are flushed automatically. For the Girls there ate 15 separate compartments; for the Infants' (Boys) there are 6 closets and urinals with 19 stalls, and for the Junior and Senior boys there are 10 compartments and 3 urinals with 32 stalls. WILLESDEN JUNCTION SCHOOL. This is a mixed school housed in temporary buildings, one of these is an iron structure, in which there are 5 classrooms together with a cloakroom and lavatories. Three of the classes are accommodated in St. Luke's Mission Church. The School has 2 playgrounds, one for the boys and the other for the girls and infants. The playgrounds are not asphalted and the surface drainage is obviously insufficient. During the winter months the playgrounds can hardly be used for any purpose. The sanitary conveniences are of the trough type, and consist of 7 compartments for the girls and 6 compartments and urinal accommodation measuring 14 linear feet for the boys. The closets and urinals are automatically flushed. The classrooms in the main building are heated by open fireplaces, and the church is heated by a gas radiator. , In each classroom is a louvre opening in the roof. These premises will shortly be discontinued as school buildings. The Acton Wells School, which is intended to supply the needs of this part of the district, is now in course of erection. 83 ROTHSCHILD ROAD SCHOOL, (INFANTS). This is a temporary iron building and consists of 5 class rooms grouped round a central hall, together with cloakroom, lavatory and teachers' room. It has a large playground which is drained but not asphalted. The sanitary conveniences are of the pedestal type, and the closets are automatically flushed. There are 6 compartments for the girls and 5 compartments and an 8 stalled urinal for the boys. All the classrooms and the central hall are heated by open fireplaces. The fireplaces have ventilating grates. There are outlet openings for ventilating purposes in the roof, but there are no permanent inlet openings, apart from the fireplaces. EAST ACTON SCHOOL. This school was erected in 1870, and is a one-storey building. It is a mixed School for boys, girls' and infants. The building has 3 class rooms, together with cloakroom and lavatory accommodation. Neither the lighting nor the ventilation of the school can be considered satisfactory. In one of the class rooms the window area measures about one-eighth of the floor space and in the other two about one-seventh. In one class room there are 4 windows, 3 of these are situated behind the scholars and the other one faces them. In the second room the light comes from behind and the right and in the third room it comes entirely from the right. There is also a certain amount of obstruction to the light from the trees which are situated between the building and the road. The ventilation openings are somewhat similar to those in St. Mary's School and described on a preceeding page. There are outlet openings in the roof and arrangements in the floor which were intended for inlet openings. The latter are closed. The heating is by open fireplaces and the artificial lighting is by gas. There is no hall or corridor and the main entrance opens into one of the cloakrooms. The latter immediately adjoins one of the class rooms and is lighted entirely from the roof; this fanlight is also 84 the only means of ventilation. There is another cloakroom situated on the playground side of the building. The lavatory basins are placed in a separate room. There is a large playground, part of which is asphalted. The sanitary conveniences are situated in the playground and consist of a separate compartment for the teachers, 2 compartments for the girls and 2 compartments with an urinal measuring 4 linear feet for the boys. The closets are of an old-fashioned trough variety, and the method of flushing is of a primitive kind. The cistern is situated in the school and placed in the passage between the main room and the lavatory. From the cistern the pipe is carried through the wall into one of the classrooms ; it passes along the side of the classroom and then through the wall into the open air. The pipe is carried across a portion of the playground into the cistern which supplies the urinal and into the closet. In one of the classrooms is a turncock which regulates the flow of water into the closets. The lower end of the trough is stopped by a ball valve arrangement, which has to be raised by hand when the trough is emptied. Some of the rain water pipes empty directly into the drain. ST. MARY'S. This School is situated in Oldham's Terrace and consists of 3 departments—Infants', Girls' and Boys'. There are two separate buildings, the one in which the Infants, department is housed being about 90 yards distant from the other. The School is the oldest in Acton; the present Infants School was erected in 1837, and the Boys' and Girls' School in 1862. The Infants' department is a one storey building and consists of a main room and two classrooms with cloakroom and lavatory accommodation. The school has no central hall or corridor, and the main room and one of the classrooms are entered into directly from the playground. The entrance to the other classrooms is through the cloakroom and through the main room. The main room is partitioned off by glass sliding doors intp two classrooms—A and B. 85 Room A measures about 500 square feet, but the roof is low, varying from 9 feet to 11 feet 9 inches in height. The window area is ample and measures about one-fifth of the floor space. The direction of the light is not entirely satisfactory. Four of the windows are situated behind the pupils, two to the left and one to the right. The light from the latter window is considerably interfered with owing to the proximity of buildings. The room is furnished with a gallery. Room B measures 371 square feet. It has only one window and this is placed to the right of the scholars. There is also a fanlight, and some further borrowed light is obtained from Rooms A and C. For ventilation it has an arrangement in the floor and inlet openings under the windows and outlet openings in the roof. The arrangement in the floor which was intended for an inlet opening was closed and practically it is impossible to use it as an inlet. It is doubtful if its permanent closure is very harmful, as the atmosphere that would be admitted through it must be laden with dust and other suspended impurities. Classroom C measures 263 square feet and is entered from the playground. There is no porch but there is a small lean-to structure over the door. The room has a gallery. It is well lighted by a window situated on the left, which has an area of about one-fourth of the floor space. There are two outlets for ventilation but no special openings for inlet purposes. Classroom D measures 171 square feet but with a height of only 9 feet. There is one window in the room and this is situated on the left hand side. The window area measures about one-eighth of the floor space. Classroom D was originally a living room of a dwelling house, and the present cloakroom was formerly the kitchen. Opening into the classroom is a staircase which leads to two rooms over the classrooms. These two rooms were formerly bedrooms. The cloakroom has two lavatory basins, but there is no separate lavatory accommodation for the teachers. 86 The playground is ashphalted but there is no covered portion. On the eastern side is a stable, and occasionally the smell of manure is marked in the playground. Sanitary conveniences. There are 3 separate compartments of the trough variety for the boys and a urinal measuring about 5 linear feet. For the girls there are 3 separate compartments of the pedestal type. Heating throughout the School is by open fireplaces. Artificial lighting is by gas. St. Mary's Girls' Department is a one storey building consisting of two rooms A and B, together with cloak room and lavatory accommodation. Class A measures 714 sq. feet and is entered directly from the playgrounds. It has five windows, with lighting area measuring one-seventh of the floor space. Four of the windows are situated behind the scholars and the sill is 5 feet from the floor. The fifth window is situated on the left and is 6 ft. from the floor. There are 8 ventilation outlets and two openings in the floor which are intended to act as inlets. The heating is by two open fires. Class-room B measures 562 sq. ft. and is lighted by 4 windows behind and one window on the right. The sill of the latter window is ft. from the floor. The total window area measures about oneseventh of the floor space. There are 6 ventilating outlets. The room is heated by an open grate and closed stove. The Cloak-room is situated at the western end with a separate entrance from the playground. There are two lavatory basins. Sanitary conveniences There are 5 separate compartments of the trough variety which are flushed automatically. These adjoin the cloak-room and are within 4½ ft. of the boys' class-room. St Mary's Boys' Department is a one storey building adjoining the Girls' school and consisting of a main room and a class room together with cloak-room and lavatory accommodation. 87 The main building is partitioned into 3 class rooms A. B. C. Room A measures 420 sq. ft. and is lighted by two windows from behind, 5 ft. from the floor, and one window on the right situated 7 ft. from the floor. There are 4 inlets below the windows and two outlets. Room B measures 502 sq. ft. and is entered through A. or C. It is lighted from behind by two windows. There are six ventilating inlets and one outlet. Room C measures 420 sq. ft. and is entered through A. and B. There is a window at the back of the room and a fanlight. The lighting of the main room is not satisfactory. The window area in classroom A is only one-eighth and of class-room B only one-tenth of the floor space, and in none of the rooms does the light come from the left. Room D is situated off C. and measures 290 sq. ft. The lighting is by means of two windows situated 6 ft. from the floor, one from behind and one in front. There is a ventilator with a louvre opening at each end of the classroom, the opening of which is regulated by a board which moves up and down. The Cloakroom is situated at the western end and has a separate entrance from the playground. There is no Teachers' room. Sanitary Conveniences are of the trough type and consist of 5 separate compartments, and a urinal measuring about 9 linear feet. Playground. There is a common playground for the boys and girls' department. Only a small portion in front of the school is asphalted—the rest is gravel and is very uneven. In the centre of the playground is a covered portion. On the north and south sides of the building many of the rainwater pipes appear to enter the drain directly; and one of these down pipes was defective. The windows reach nearly to the eaves, and in some instances are quite close to the down pipes. Heating throughout the building is by open fireplaces. The artificial lighting is by gas. 88 CATHOLIC SCHOOLS, ACTON LANE. This is a one-storey building and has two departments—one for the infants, and a mixed School for the boys and girls. The building was erected about 25 years ago, but has been altered on several occasions, and though improvements have been secured with each alteration, the arrangements leave much to be desired. A very small percentage of the rainwater from the roof is conducted to open gullies by means of down pipes, but most of the water passes into a short pipe and falls a distance of about 10 or 12 feet into a gully. The wall in the neighbourhood of the gully is damp, and some of the pointing of the wall is washed away. There is one playground and this is asphalted and suitably drained. 1 he sanitary conveniences consist of 3 separate compartments for the girls, and 3 closets and 3 utinal accommodation measuring about 8 linear feet for the boys. The closets are of the pedestal type, and there are 2 flushing cisterns—one for each group of closets These cisterns do not discharge automatically, but the water has to be turned on each lime the closet is flushed. There are two cloakrooms, and these are built as annexes to the main building. They are ventilated by means of perforated bricks. Each cloakroom contains 3 lavatory basins. The Boys' & Girls' Mixed Department, consists of one large room and 3 classrooms, together with cloakroom and lavatory accommodation. There is no central hall or corridor, and entrance to the north and south classroom is only obtained by passing through the main room. The main room measures about 990 sq. ft., and the lighting, heating and ventilation are unsatisfactory. There are three windows and though the. window area is about one-sixth of the floor space, all the windows are situated at the back of the desks and the light comes to the scholars from behind. The room is heated by means of an iron stove, with a pipe carried into the wall. The stove itself is situated inside the room and some of the products of combustion are not carried outside. It is well known that under some conditions carbon monoxide is produced by slow combustion stoves. 88 There are small ventilating inlets under each window, and one outlet in the roof. North classroom measures about 256 sq. ft. The lighting of this classroom is satisfactory. There is one window and the light comes from the left hand side. The window area is about one-fifth of the floor space. There is a ventilating outlet in the roof but there are no special openings intended for outlets. The heating is by mean:* of an open fireplace but the grate is old-fashioned, and not calculated to supply the maximum amount of heat for the coal consumed. South classroom measures about 368 sq. ft. The window area is about one-fifth of the floor space but though there are three windows in the classroom, in no instance does the light come from the left. One window is situated behind the scholars, one in front and one to the right. The room is heated by means of an open fireplace, but the remark made of the grate in the north classroom applies also to this one. There is a ventilating outlet in the roof but no special inlet. West Classroom measures 388 square feet. The lighting of this classroom is also unsatisfactory. It has one window and also a fanlight situated in the roof. Though the window area is ample, the light can only come from behind and in front of the scholars. The heating is by means of an open fireplace, and a modern grate has been placed in the room. There is a ventilating outlet but no special inlet. The Infants' Department consists of two rooms, one of which is the babies' room. The entrance to the babies' room is through the west classroom of the mixed school. The Babies' Room measures 310 square feet. It has two windows and a fanlight. The windows are situated on opposite walls, one of them is on the right and the other on the left of the scholars. The room is provided with galleries, and is heated by means of 96 an open fireplace. The grate is an old fashioned one, and to obtain the necessary heat in the room, the amount of coal which must be consumed is excessive. The other classroom in the Infants' department measures 360 square feet. The light comes from one window situated behind the scholars There are also small windows on the left hand side, but these do not admit much light, as the glass is opaque. The room is heated by a stove. In the Infants' departments, with the exception of the fanlight, there are no special openings designed for ventilation purposes. The building throughout is artificially lighted by gas. Table 1. PUBLIC ELEMENTARY SCHOOLS WITHIN THE DISTRICT, TOGETHER WITH ACCOMMODATION. Name of School. Accommodation. 1. Acton Boys 164 Girls 129 Infants 142 2. Beaumont Park Boys 635 Girls 590 Infants 499 3. Central Senior 428 Junior 488 Infants 403 4. East Acton Mixed 64 Infants 80 5. Priory Boys 550 Girls 542 Infants 494 6. Rothschild Road Infants 280 7. South Acton Boys 720 Girls 564 Infants 618 8. Southfield Road Senior 412 Junior 378 Infants 383 91 Name of School. Accommodation 9. Turnham Green R.C. Mixed 201 Infants 74 10. Willesden Junction Mixed 123 Infants 90 ,, (in Mission Church) 130 9,181 In March 1908, arrangement was made by the Education Committee for carrying out the requirements of the Education (Administrative Provisions) Act of 1907, and Dr. Lilian E. Wilson was appointed to devote her whole time to the work of Medical Inspection. In accordance with the suggestions contained in the Memorandum of the Board of Education every endeavour was made in drawing up the scheme to associate the medical inspection with the general public health of the district. Dr. Wilson was also appointed Assistant Medical Officer of Health, and the Medical Officer of Health was appointed School Medical Officer and carried out the inspection of the boys over 10 years of age. The co-ordination of the two services was rendered less difficult as a system of school notification of illness had been in existence in the district for some time. All cases of infectious disease not scheduled in the Notification of Infectious disease Act of 1889, and occurring amongst children of school age were reported by the teachers. In 1903 a Health Visitor was appointed by the District Council, and her duties included visits to and reports upon the cases reported by the teachers. As the system of school notifications developed, it was felt that one health visitor could not cope with the school work as well as carry out efficiently her other duties. In 1907 an Assistant Health Visitor was appointed, and she was to devote her time primarily to school work. The appointment was made by the Health Committee and the salary paid by the Education Committee. On a re-arrangement of the staff, owing to the resignation of the Senior Health Visitor, the Assistant 92 Health Visitor was promoted and a nurse was appointed in place of a second Health Visitor. The school nurse visits all the cases notified by the teacher and also children referred to her in the course of medical inspection. The teachers have rendered great and willing assistance, many of them taking the greatest interest in the work. Not only have they filled in the particulars as to the name and address, previous illness &c., but have in many cases supplied information which was only available to those who came into intimate and daily contact with the children. As far as possible the Board's schedule has been followed. When a child is admitted to school the head teacher enters on the register the particulars as to name, address, age, previous illnesses, These particulars are copied by a clerk on the medical inspection cards. In the case of the younger children a notice is sent to the parents notifying them of the intention to medically examine the children and inviting the parents to be present. In the case of the older children a verbal notice is sent to the parents. The parents have only in a small percentage of cases availed themselves of the opportunity to attend. All the children entering and leaving the schools have been examined, in addition to 192 scholars kept apart for inspection by the teachers and 62 mentally defective children. The conditions revealed by medical inspection are enumerated in the following tables. 93 Table 2. Showing the number of children examined classified according to age and sex. No. examined years 13-14 years 14-15 years 15-16 years 16-17 SENIOR BOYS, 159. South Acton 32 30 2 ... Roman Catholic 13 11 2 ... ... Priory 37 32 5 ... ... Beaumont Park 25 24 ... ... ... St. Mary's 12 8 4 ... ... Southfield Road 28 12 15 1 ... Central 7 2 3 1 1 Willesden Junction 5 3 2 ... ... 159 122 34 2 1 SENIOR GIRLS, 160. ... ... Priory 26 24 2 ... ... South Acton 38 35 3 ... ... Southfield Road 33 20 12 ... ... Beaumont Park 27 24 3 ... ... Central 11 2 2 4 3 Roman Catholic 7 5 2 ... ... Willesden 6 5 1 ... ... Acton 12 9 3 ... ... 160 125 28 4 3 INFANTS (MALE) 671. No. examined years of age. over 7 3 4 5 6 7 East Acton 20 ... 11 4 3 1 1 Acton 40 6 10 18 5 1 ... Beaumont Park 93 19 31 31 10 2 ... Central 73 10 23 24 12 4 ... Southfield Road 117 9 40 31 33 4 ... Priory 95 23 21 27 16 8 ... South Acton 115 35 40 26 13 1 ... Roman Catholic 18 2 4 6 1 5 ... Rothschild Road 77 9 26 13 7 17 5 Willesden 23 4 7 4 6 1 1 671 117 213 184 106 44 7 INFANTS (FEMALE) 683 East Acton 27 7 3 9 4 1 3 Acton 58 7 16 25 8 2 ... Beaumont Park 115 25 32 41 17 ... ... Central 65 7 18 25 19 5 ... Southfield Road 102 6 34 30 26 6 ... Priory 93 24 16 35 14 4 ... South Acton 106 32 38 20 15 i ... Roman Catholic 24 5 3 7 7 2 ... Rothschild Road 66 9 19 21 5 11 1 Willesden 27 5 7 9 4 2 ... 683 127 186 222 110 34 4 94 Table 3. Giving the number of children examined in each school together with the conditions found on examination. INFANTS. No children examined. Mai-Nutrition. Clothing. Want of Cleanliness. Verminous Carious Teeth. Enlarged Tonsils. Adenoids. Enlarged Glands. External Eye Disease. Defective Vision. Ear Disease. Defective Hearing. Heart Disease. Lung Disease. Rickets. Spinal Disease. Defective Speech, Tuberculosis. Other Diseases and Defects. Infectious Disease. Average Below Average Head. Body. Rothschild (Boys) 77 1 74 3 2 4 6 8 16 3 4 1 2 1 ... 1 7 3 1 ... ... 3 2 (Girls) 66 ... 64 2 3 9 3 7 11 ... 4 4 ... ... 1 1 4 1 ... 1 ... 2 1 East Acton (Boys) 20 ... 19 1 ... ... ... 3 2 ... ... ... ... ... ... ... ... 1 1 ... ... (Girls) 27 1 24 3 1 8 1 8 ... ... 2 1 ... ... ... ... 1 1 ... ... ... 1 ... Priory (Boys) 95 3 81 14 10 2 2 20 10 6 10 1 ... 1 ... ... 3 4 ... ... ... 2 4 „ (Girls) 93 4 76 17 7 25 5 18 8 4 10 3 I 4 1 ... 8 7 1 ... ... 3 ... Willesden (Boys) 23 1 23 ... ... ... ... 3 9 3 2 1 ... ... ... ... ... 4 ...... ... ... ... 1 „ (Girls) 27 ... 27 .. 1 3 ... 7 5 2 4 ... ... ... .... ... ... ... ... ... ... ... ... Beaumont Park (Boys) 93 5 75 18 8 5 11 20 10 3 4 4 2 1 ... ... 10 10 ... ... ... 2 5 „ (Girls) 115 9 100 15 6 29 14 16 14 1 6 4 1 3 1 ... 14 3 1 ... ... 2 1 Southfield Road (Boys) 117 ... 113 4 5 2 7 14 18 4 5 3 ... 1 ... 6 5 13 ... ... 1 3 6 „ (Girls) 102 2 99 3 1 14 10 21 15 6 1 2 ... 1 1 3 4 6 3 2 ... 1 ... South Acton (Boys) 115 6 97 18 15 9 19 14 13 4 10 7 ... 1 ... ... 10 19 ... ... ... 2 5 „ (Girls) 106 4 88 18 12 43 17 10 9 4 1 3 ... .... ... ... 8 9 ... ... ... 1 6 Central (Boys) 73 1 71 2 ... 2 2 7 11 1 2 ... ... 3 1 ... 4 7 ... ... 1 4 ... ,, (Girls) 65 ... 65 ... ... 1 ... 13 8 1 2 1 ... 1 ... ... 3 2 ... ... ... 3 1 Roman Catholic (Boys) 18 1 14 4 2 1 ... 4 3 ... 4 ... 1 1 ... ... 3 ... 2 ... 1 ... ... „ (Girls) 24 3 19 5 2 8 ... 3 2 ... 3 ... 1 ... ... ... 3 ... ... 1 I ... 1 Acton Infants (Boys) 40 1 40 ... 1 ... 2 10 2 1 ... ... ... ... ... ... ... ... ... ... ... 2 2 (Girls) 58 ... 56 2 2 11 3 10 8 3 ... 2 ... 1 ... 1 2 3 ... ... ... 2 ... 1354 42 1225 129 78 176 103 215 174 46 74 37 8 19 5 12 89 93 9 4 4 33 35 Table 3 —continued. SENIOR GIRLS No Children ex mined. MalNutrition Clothing Want of Cleanliness Verminous Carious teeth Enlarged Tonsils Adenoids. Enlarged Glands. External Eye Disease Defective Vision. Defective Hearing. Ear Disease. Defective Speech. Heart Disease. Lung Disease. Infectious Diseases. Other Diseases. Average Average Below Head Body Central Girls 11 ... 11 ... ... 2 ... 3 3 2 1 1 2 1 ... ... 1 ... ... 1 Actcn Girls 12 ... 12 ... 1 1 1 2 1 ... 2 ... 3 1 1 ... ... ... ... Willesden Girls 6 ... 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Roman Catholic 7 ... 6 1 ... 4 ... 1 1 ... ... ... ... ... ... ... 1 ... ... ... Priorv Girls 26 ... 26 ... ... 5 2 2 10 2 6 ... 7 ... ... ... ... 1 1 ... Sth. Acton Girls 38 4 30 8 7 24 3 5 8 3 ... 2 6 5 ... ... ... ... 4 ... Southfield Road 33 ... 32 1 2 4 ... 4 8 ... ... 1 3 2 ... ... ... ... ... 3 (Senior) Beaumont Prrk 27 3 19 8 2 6 3 4 5 2 ... ... 6 4 ... ... ... ... ... 1 160 7 142 18 12 46 9 21 36 9 9 4 27 13 1 ... 2 1 2 5 SENIOR BOYS. No. Examined. Clothing and Footgear. Under Nourished Verminous, Carious Teeth. Polypus of Nose. Enlarged Tonsils. Adenoids. Enlarged Glands. Eye Disease. Defective Vision. Ear Disease Impaired Hearing. Speech Impaired Heart Disease Lung Disease Tubercle. Rickets. Deformities Average Below Average Head. Body. South Action 32 25 7 5 2 2 5 1 13 3 ... ... 11 ... 1 ... 2 3 ... ... ... Priory 37 28 9 5 ... 1 10 ... 2 ... ... ... 4 2 5 3 1 ... ... ... ... Beaumont Park 25 17 8 4 2 2 9 1 8 ... 1 2 8 I 1 ... 3 1 ... ... 2 Catholic 13 11 2 1 •• ... 3 ... 2 ... 1 ... ... ... ... ... 1 ... ... 1 ... St. Marry's 12 12 ... 1 ... ... 4 ... 4 ... 1 ... 2 ... ... 1 1 1 ... ... ... Southfield Road 23 28 ... 1 ... ... 6 ... 2 2 ... ... 6 2 3 ... ... 1 ... 1 I Central 7 7 ... ... ... ... 1 ... 1 ... ... ... 2 ... ... ... ... 1 ... 1 ... Willesden junction 5 5 ... 1 ... ... ... 1 2 ... ... ... 1 ... ... 1 1 ... ... ... ... Total 159 123 26 18 4 5 38 3 34 5 3 2 34 5 10 5 6 7 ... 3 3 96 Defective Vision. Of the 159 boys inspected between the ages of 13 and 16 years, 34 or 21 per cent, were found defective to the extent of requiring treatment, Of the 160 girls inspected, 27 or 17 per cent, were found so defective. During the past year the examination in the schools has been by testing the sight with Snellen's Test Type. By this method it is possible to form a rough general estimate of the amount of defective vision in schools, but the diagnosis was not of strict scientific accuracy. Children with perfectly acute vision should, in a good light, be able to read the smallest type (technically known as 6/6), As however, the illumination in several of the classrooms was not good at the time of the examination, a lower standard had to be taken, and those who were unable to read a larger type (6/12) at a distance of 20 feet are classed as defective in vision. Many of these "children have also been examined with the ophthalmoscope, and where the result of this method of examination confirmed the earlier tests the parents of the children were urged to obtain medical treatment. In some oases suitable spectacles were obtained, but in many instances it was found that parents were too poor to provide glasses for the children, so in November, 1908, the Urban District Council granted the sum of £50 towards the provision of spectacles in necessituous cases. Teeth As might be expected the examination of the children revealed the extremely bad condition of the teeth. An arbitrary standard had to be observed, and in the above tables, only those who had 4 or more carious teeth are included amongst the children who have defective teeth. Unsuitable foods leads to decay of the teeth, which is due to the cessation of the use of food which requires good mastication, and the soft or starchy foods are more apt to leave particles behind which cause decay. In children, attending the Priory, Beaumont Park and South Action Schools the greatest number of carious teeth was observed 97 and associated with this were found many cases of enlarged cervical glands probably due to the septic condition of the mouth. It is difficult to suggest a remedy. It is well known that children should be trained to use a tooth brush, but this is a matter for home attention, which is difficult to secure owing to the poverty of the homes in which the children attending these schools live. The advantages of fresh air are seen on examining the scholars of East Acton and Willesden Junction, the majority of whom maintain a high standard of physical health. Ear discharge Treatment here is difficult, as the children have often suffered for many years from the complaint, and it is hard to convince parents that the disease is not a necessary accompaniment of " teething " or bronchitis. Where there is much discharge, the mothers are given directions as to syringing, but in many cases the advice is not systematically carried out. The services of a School Nurse would be most helpful as the Health Visitors are unable to superintend treatment of these cases Pediculosis. Children in a badly verminous condition are excluded from school and cards of notification are sent by the Head Teacher to the Education Offices. The Health Visitor is notified and visits at the home, giving directions for treatment and endeavouring to get the children's hair cut where this is necessary. Owing to the industrial character of the district, there is often much difficulty in finding the mothers of the children at home, as those who work in the laundries are engaged on all days except Saturday and Monday. This is apt to render the work disheartening as improvement is only obtained by repeated visits, often rendered ineffective by the absence of the parents. In all cases effort is made to render the time of exclusion from school as short as possible. Ringworm. The methods of dealing with this disease are very unsatisfactory and no other complaint leads to such prolonged absence from school, 98 When children are excluded under a medical certificate visits are no longer paid by the Health Visitor, and in these cases on renewal of certificates (usually valid for about 3 months) it is not uncommon to have children absent from school for so many months that considerable educational loss is sustained. Where Health Visitors give directions to the parents and pay visits to ensure that the treatment is carried out the recovery is comparatively rapid, but much time is lost by the absence of the mothers from home when visits are paid. At present no means of treatment by X Rays is available. This method is to be urged in case of a large outbreak of ringworm in the district, but at present the number of cases has not been sufficient to necessitate measures being taken. The method adopted is either to instal the necessary apparatus, or as an alternative to arrange with a medical practitioner to carry out the X Ray treatment in selected cases. The latter plan does away with the necessity of purchasing an elaborate electrical apparatus, and also provides for the treatment of ringworm without unduly curtailing the amount of time that could be devoted to other urgent School work. Table 3. NUMBER OF CHILDREN REFERRED FOR FURTHER EXAMINATION—149 These were from the following Schools:— Infants. Girls. Boys. Priory 9 3 13 South Acton 9 5 12 Beaumont Park 10 4 12 Roman Catholic 4 1 1 Rothschild Road 10 ... ... Southfield Road 16 5 4 Acton 9 3 2 East Acton 2 ... ... Willesden Junction 3 ... ... Central 10 2 ... 82 23 44 99 Table 5 AVERAGE HEIGHT, without Shoes, and AVERAGE WEIGHT with Clothes. (Anthropometric Committee 1883) MALES. FEMALES. Age last birthday. Height in inches. Weight in lbs. Height in inches. Weight in lbs. 3 35 31.2 35 30 4 38 35 38 34 5 41 41.2 40.5 39.2 6 44 44.4 42.8 41.7 7 46 49.7 45.5 47.5 8 47 54.9 46.6 52.1 9 49.7 60.4 48.7 55.4 10 51.8 67.5 51 62 11 53.5 72 53.1 68 12 55 76.7 55.6 76.4 13 57 82.6 57.7 87.2 14 59.3 92 59.8 96.7 15 62.2 102.7 60.9 106 Table 6—giving heights & weights at different ages No examined 13-14 14-15 15-16 16-17 Height Weight Height Weight Height Weight Height Weight senior—girls. South Acton 38 56.3 81 57.8 72.5 ... ... ... ... Roman Catholic 7 58 85.3 59 5 85 ... ... ... ... Priory 26 56.75 82 .5 57 85 ... ... ... ... Beaumont Park 27 60 82.3 60.3 97.8 ... ... ... ... St Mary's 12 63.5 82.25 60.5 106.3 ... ... ... ... Southfield Road 33 60 85.5 6l.3 88.8 ... ... ... Central 11 60 94.5 61 98.75 60.2 101.1 60.5 92.6 Willesden Junct 6 60 80.5 60.5 99 ... ... ... ... SENIOR—BOYS South Acton 32 56 73½ 55½ 76¼ ... ... ... ... Roman Catholic 13 55½ 73 64 1.13 ... ... ... ... Priory 37 56½ 79 56½ 77½ ... ... ... ... Beaumont Park 25 57 79½ 56 81 ... ... ... ... St. Mary's 12 56 79½ 56¾ 78½ ... ... ... ... Southfield Road 28 57½ 79½ 60½ 82¾ 64½ I07½ ... ... Central 7 60½ 87½ 55½ 85½ 69 138 63 100 Willesden Junct. 5 58½ 86 57¾ 833¾ ... ... ... ... 100 Table 6. INFANTS.—GIRLS. No. of Scholars exam'd. 3-4 4-5 5-6 6-7 7-8 Height. Weight Height Weight Height Weight Height Weight Height Weight South Acton 106 35.8 31.1 38.3 34.3 39.8 36.4 42.9 40.8 46 48 Roman Catholic 24 34.8 29.4 37.8 35.6 39.8 37.4 41.6 39.5 44.5 44.5 Priory 93 36.3 31.4 38.3 33.6 40.7 42.9 41.7 37.1 43.8 39.7 Beaumont Park 115 35.8 31.6 37.6 32.9 40.2 35.3 45.2 42 43.8 ... St. Mary's 58 36 33.8 38.1 35.4 40.7 38.3 43 42.2 45.5 46.7 Southfield Road 102 36.8 30.5 19.6 35.4 42.7 38.9 44.1 42.3 46.4 47 Central 65 36.5 31.6 39.6 37.03 43.3 41.8 44.1 41 41.4 42.4 Rorhschild Road 00 37.3 31.1 39.3 35.5 41.9 38.2 44.7 43.2 45.5 44.8 East Junction 27 37.3 32.3 41 47.6 40.4 38.1 43 44 46.5 50 Willesden Junction 27 34.8 29.4 37.5 33.9 41.3 37.1 43.2 43.6 45.7 44 INFANTS.—BOYS. South Acton 115 36 33 38½ 38 40½ 38½ 42 39½ 41 38 Roman Catholic 19 35 31½ 39½ 37¼ 42 38½ 44½ 44 42¾ 40½ Priory 95 36½ 31½ 38½ 35 37½ 37¾ 43 41 45½ 45½ Beaumont Park 93 37 32½ 38¾ 35 41½ 39 41 40 41 400 St. Mary's 40 37¼ 33½ 38½ 35½ 40¾ 39½ 43 42¾ 44 47 Southfield Road 117 30½ 33 40 36 42 38½ 44 42 45 43 Central 73 37½ 33½ 40½ 36½ 42¾ 39 45½ 46½ 46¾ 44½ Rothschild Road 77 38 33¼ 39* 35¾ 43 40¾ 43½ 45½ 45½ 46 East Action 20 ... .. 39¼ 35¼ 41¾ 41½ 44½ 40½ 48 47 Willesden junction 23 37¼ 34 39¾ 37 41 39¾ 43½ 43¾ 46 48 101 The numbers are too small to draw any definite conclusions, but taken in conjunction with the inquiry made into the question of underfed children, the figures are significant. At almost all age periods the children in the South Acton, Priory, Roman Catholic and Beaumont Park Schools are below the weight of the children in the other schools of the district. Last summer 86 children were selected by the teachers in the schools as being badly nourished. These children were weighed at intervals, and it was found that 26 of them were below the normal weight, and had not increased in weight during the 3 months they were under observation. Out of the 26, in 19 of them poverty was the probable cause of the malnutrition. To find out the real state of affairs with regard to the underfeeding of children attending elementary schools is an almost insoluble problem. Teachers, as a rule, have a fairly intimate acquaintance with the home circumstances. Each teacher in his own class has a good idea, inasmuch as he knows that certain children turn up at school, either looking pinched and pale, or very neglected. The child bears in his own person some evidence that the home is not altogether what it might be. But in dealing with a large number of children, it is difficult to separate completely the robust from the delicate, and still more difficult to detect those who are slightly under-noutished, and whose home conditions upon enquiry are found to be deplorable. Poverty probably is the most common cause of the malnutrition in the children attending the Beaumont Park, Priory, Roman Catholic and South Acton Schools, but it does not account for all the cases. Improper and injudicious feeding is common, and though not restricted to the poorer classes, would seem to be more frequent among the children attending these schools. Out of the 26 children mentioned above, in 7 instances the parents were earning good wages and in constant employment, but in most of the cases the mother was employed in some work which took her away from her home. Habitual use of improper food produces every evidence of malnutrition. Among the social factors peculiar to the district, the occupation of the parents, which has a bearing direct or indirect upon the children's health, must be considered. 162 In Acton at the census of 1901, there were 2488 women employed in the laundries of the district. The number has considerably increased since then. There are at the present time 93 factory laundries registered and 230 workshop laundries. In addition, about 300 women are employed as homeworkers. It is probably no exaggeration to state that 3500 women are employed in the laundry industry alone, and of these about 1500 are married women or widows. From enquiries made, it may be stated that one third of the married women in the S.W. ward are employed in laundry work. These women are occupied in this employment, not from choice, but from necessity, but as a result it follows that a large number of infants are artificially fed, often on tinned milks deficient in fat or on preparations of various foods. In South Acton a Creche has been established since January 1908 which will accommodate about 24 children. It is too soon to fully estimate the value of the institution, but within a few weeks of its establishment, children had to be refused because all the beds were occupied. In the S.W. ward alone, there are about 200 babies under 12 months of age placed out with neighbours during the day, and the conditions under which they are cared for is extremely unsatisfactory. Children placed in these circumstances cannot tail to show signs of their faulty upbringing when they reach school age, and it was found that a higher percentage of children attending South Acton Schools suffered from rickets than in any of the oiher schools of the district. The ill-effects due to the employment of the mothers does not end with those attending the Infants' Departments. As so many of the women work in the laundries it follows that many of the school children do not obtain a proper meal in the middle of the day, either because the mothers do not come home, or because they have not time or energy to prepare a meal. The children are often given coppers to buy food which they spend on attractive but unwholesome material, and thus acquire a habit of passing over wholesome food which is not tasty. In this district poverty, and to a minor degree married female 103 labour, are probably the most common causes in the production of malnutrition. In the one case, the diet is insufficient, and in the other, it is improper. In both, null ition is affected, and every endeavour should be made to improve the knowledge of correct feeding, and to direct attention to instances of inadequate feeding. In the Report of the Royal Commission on Physical Training occur these sentences: "We consider that the question of the proper and sufficient feeding of children is one which has the closest possible connection with any scheme which may be adopted for the physical, and equally for their mental work. It is evident that among the causes which tell against the physical welfare of the population, the lack of proper nourishment is one of the most serious. The subject demands special notice, not only as regards the existing state of affairs, but still more in view of any increase of physical training, throughout the State-aided Schools which may commend itself. We are aware of the danger of further encroaching upon the independence of parents, and of entering upon the wide question of how far the State should go in relieving them of their primary responsibility. But we are not on that account deterred from calling attention to the necessity for better feeding, which, in our opinion, has been fully demonstrated, nor from considering a practical remedy. We have no desire to give encouragement to any inclination of the parent to abandon any of his duties and responsibilities in regard to the feeding and clothing of his children; but it must be remembered that, with every desire to act up to their parental responsibility, and while ready to contribute in proportion to their power, there are often impediments in the way of the home provision of suitable food by the parents. The proper selection, cooking and preparation may often be a matter of serious difficulty to many parents." The matter has attracted the earnest attention of the Education Committee, and as a result of the inquiries made locally the Provision of Meals Act 1906 has been adopted. Physically and mentally defective children, In May 1908 an enquiry was made as to the number of school children in ihe district considered either physically or mentally defective. Lists were obtained from the teachers of those children whg 104 were considered unable to obtain educational advantage from the ordinary work in the School. Sixty-two cases were reported and 56 of these children were specially examined. The examination either took place at the school or in the homes of the children. Those cases which by reason of physical or mental defect were unable to attend school were visited at home and there examined: special enquiry being made to discover what medical treatment the child had previously undergone, and what arrangements (if any) were being adopted by the parents for the education of these children. Briefly, the children may be classified as follows:— a. Very backward 23 b. Mentally defective 9 c. Imbecile 6 d. Infantile paralysis 4 e. Infantile paralysis and epilepsy 2 f. Defect of vision 2 g. Epilepsy 1 h. Deafness 1 i. Dumbness 1 j. Microcephaly 1 50 a. Backward The 23 backward children show variations from a slight deviation from the normal to a condition closely approaching the mentally defective. Their ages vary from 6 to 13 years. Many of the children are about 3 years behind the normal development to be expected from their age, and remain in the same standard nearly 2 years. They are not specially troublesome in class but make very little progress and are a source of much difficulty to the teachers. b. Mentally defective By this term are included those who to some extent fail to reach a certain level in the general summation of mental qualities. 105 The class is a wide one, and presents many shades of difference, ranging from the most backward children to those who appear slightly imbecile. Ages vary from 6 to 14. The nine children examined are at present all attending School. The highest standard reached was Standard III in the case of a boy of 14, but his mental attainments were not typical of this class. c. Imbeciles. Are those individuals whose mental powers are at present beyond the reach of reason and appear likely to remain so. Among the imbecile children examined, four would be unable to attend any school, two children might possibly obtain benefit from special schools. d. Infantile Paralysis. One case examined is unsuitable for school, another child might obtain benefit from a school for the physically detective. e. Infantile paralysis and epilepsy. One child has such frequent fits that school is impossible, another has had no fits for two years, and the paralysis is improving, but the child is mentally defective. f. Vision One of the two children with defective vision is unable to attend school as an operation will be necessary during the next six months. The second child is suffering from a high degree of astigmatism and the parents have been urged strongly to take the child to a hospital to obtain glasses. Special arrangements were made to have the child seen at Moorfields Eye Hospital, but so far the parents have not availed themselves of the opportunity. g. Epilepsy. The child examined is attending school as the fits do not occur too frequently to make school attendance inadvisable. h. Deafness- The child who is deaf speaks much better than is usual with completely deaf children, and therefore would not gain much benefit from an ordinary school for the deaf. 106 i. Dumbness The child who is dumb, has never been to school but is somewhat mentally weak. A special school might produce some improvement. j. Microcephalv This child was unsuitable for school attendance. The Committee asked for a further report on these children showing what classification should be suggested for their education in special classes or schools. Roughly, the following classification might be adopted:— 1. Those who might remain in an ordinary school—26 cases. 2. Those for whom a special school is advisable—8 cases. a. Mentally defective 5 cases. b. Physically defective 3 cases. 3. Those for whom a special class is advisable—14 cases. 4. Those unsuitable for any school—8 cases. At present it has not been found possible to arrange a special class for backward or mentally defective children though in some ways this would be a great advantage. In favour of the special class are the benefits derived from the greater individual attention which the pupils would obtain, and there is a tendency for the pace of the rest of the class in an ordinary school to be slackened in order that the backward children may keep abreast of the others. On the other hand the association of the backward children with the brighter ones undoubtedly tends to sharpen the wits of the former. Deaf children in the district are sent to the L.C.C. school for the deaf in Ackmar Road. They are conducted to school and fetched from it by a guide, and at present six Acton children are attending this school. Blind children are provided for in a similar manner to those who suffer from deafness, and attend the Blind School in Edinburgh Road. No children from the district are now in attendance, but arrangements are being made to take a child from Beaumont Park Girls' School who is suffering from progressive myopia in a high 107 degree. Two other blind children are being kept under observation, but they are young children receiving medical treatment, and a special school is not necessary at present. Physically defective Children Are sent to the special school at Brook Green, arrangements being made for their safe conveyance to and from school. At present no children from the district require this method of education. Epileptic Children No children suffering from fits are in attendance at a special school. Examination of Teachers Eleven candidates, who desired to become pupil teachers were medically examined since May 1908. Of these 10 were passed and 1 postponed. This candidate was passed on a subsequent medical examination. Twenty-two teachers have been examined on appointment to schools in this district, 21 of these were passed and one was rejected on account of defective health. A record of each physical examination together with the family history of the candidate is entered on a card and filed for subsequent reference. This method has been found useful, when for various reasons, it is necessary to make a second examination. Special examination of Teachers One teacher has been examined as the Committee required a special report concerning her health. 108 SWIMMING. During Season of 1908, 16 Swimming Classes were held during School hours and 8 out of School hours. Total 24. School.3e Classes per week. Total No, of Scholars who have attended the baths during the season. Total No. of attendances made during the season. No of Scholars in the School who can swim No. of Scholars who have learned to swim this season. Acton Boys 1 24 182 13 6 Beaumont Park Boys 3 104 951 57 38 Beaumont Park Girls 1 39 402 5 3 Central Senior 5 128 1,800 82 31 Central Junior 3 100 1,440 36 26 Priory Boys 4 131 1,173 57 49 Priory Girls 1 44 368 12 10 South Acton Senior Boys 2 45 990 38 28 Southfield Rd. Senior 2 119 990 49 30 Willesden Junction 2 35 490 20 12 Totals 24 769 8,786 369 233 In conclusion we beg to thank the staff of the Education Depart ment and the teachers for the assistance we have received, not only in compiling this report, but also in the work of medical inspection. We remain, Your obedient servants, D. J. THOMAS. L. E. WILSON. Woodgaths' Electric Printing Works, Strafford Road S. Acton.