ACT 35 Borough of Acton ANNUAL REPORT OF THE Medical Officer of Health TOGETHER WITH THE Report on the Medical Inspection of Schools FOR THE YEAR 1932. J. KNOWLES & CO. LTD. PRINTERS & STATIONERS ACTON HALL, ACTON, W. ANNUAL REPORT of the Medical Officer of Health FOR THE YEAR 1932. Public Health Department, Municipal Offices, Acton, W.3. To the Mayor, Aldermen and Councillors of the Borough of Acton. Ladies and Gentlemen, I herewith submit the Annual Report required by the Ministry of Health, together with the Annual Report on the School Medical Services. The estimated population is that of the Registrar General for the end of June, 1932. The birth-rate is considerably lower than that given in the Report for 1931 and is the lowest recorded in the district. The causes of the decline in the Birth-rate are well known and have been discussed from time to time in these Reports. The Death-rate is higher than in 1931, but this is the inevitable result of an ever increasing number of aged people in the population. The epidemic diseases, especially diphtheria, have also, of course influenced this rate. The infantile mortality is slightly lower than last year and the principal cause of death was prematurity. The incidence of all infectious diseases was considerably higher than in 1931 ; these diseases have been reported on fully. two deaths occurred from Cerebro-Spinal Meningitis, but there were none from Encephalitis Lethargica or Anterior Poliomyelitis. Cancer is still increasing and there were 101 deaths. 4 The following is a summary of the vital and other statistic for the year 1932:— Area of Borough 2,305 acres Population (estimated midsummer 1932) 70,640 Population (Census 1931) 70,510 Number of inhabited houses (Census 193l)—figures not yet available. Number of inhabited houses (end of 1932) according to Rate Book 15,803 Number of families or separate occupiers (Census 1931) figures not yet available. Rateable Value (1st October, 1932) £718,486 Net produce of a penny rate (year ending 31st March, 1932) £2,793 15s. 9d. Total number of births registered 970 Legitimate 932 Illegitimate 38 Birth-rate per 1,000 inhabitants 13.8 Number of deaths 786 Death-rate per 1,000 inhabitants 11.1 Number of women dying in, or in consequence) of childbirth— 7 from sepsis 3 from abortion - from other causes 4 Maternal mortality per 1,000 births 7.2 Deaths of infants under 1 year of age— 60 Legitimate 54 Illegitimate 6 Infantile mortality per 1,000 births 62 Death-rate per 1,000 Total Deaths. Population. Measles 12 .17 Whooping Cough 6 .08 Diphtheria 21 .29 Scarlet Fever 6 .08 Influenza 12 .17 Tuberculosis of Lungs 48 .68 Tuberculosis (other forms) 11 .15 Tuberculosis (all forms) 59 ,83 5 POPULATION. Only the preliminary results of the census have yet been received and in these the population has been estimated as 70,510. The Registrar General estimated that the population at the end of June 1932 was 70,640 and this figure has been accepted as the basis of the population. SOCIAL CONDITIONS OF THE DISTRICT. There is no change in the social conditions of the district. the northern part of the district is almost entirely covered with factories. The north-east and south-east wards are mainly residential in character and so is the southern part of the north-west ward. In the south-west ward are situated most of the laundries in the district and the houses in this ward are small and occupied chiefly by persons of the artisan and labouring classes. AMBULANCE FACILITIES. The ambulance facilities are similar to those described in last year's report. A motor ambulance is provided for the removal of infectious cases to the hospital. There are two ambulances provided for accident and noninfectious cases. These are housed in a garage at the fire station and are available at all hours. A new ambulance was purchased by the Council in 1928, but the old one is still kept for emergencies. last year the ambulance was called out to 393 street accidents, and on 522 occasions to private cases. Fees amounting to £103 13s. 0d. were paid for the use of the ambulance for private cases. HOSPITAL PROVISION. General.—The only General Hospital in the district is the Acton Hospital, Gunnersbury Lane, which has an accommodation of 62 beds. During the year 1,298 in-patients were admitted; this is an increase of 12 on the previous year. Of these 222 were in for only 1 day and 138 for 2 or 3 days. 6 The Education Committee has an agreement with the Hospital for payment for the removal of tonsils and adenoids and the patients are kept in the Hospital for at least 1 night. 7,218 out-patients were treated during the year, a decrease of 5, and the out-patient attendances were 31,442, a decrease of 168 as compared with 1931. The Hospital supplies a great need in the District, is greatly appreciated and most of the beds are continuously occupied. Last year the average number of beds in daily occupation was 56.26 and from this figure it can be assumed that vacant beds are a rarity. Fever.—Acton Council Fever Hospital normally contains 88 beds, but during the year this number was increased to 122 in order to cope with the epidemics of Scarlet Fever and Diphtheria. Small-Pox.—Acton was one of the constituent bodies which formed the Middlesex Joint Small-Pox Board. Under the Provisional Order Confirmation Act of 1929, the Joint Board was dissolved from the 1st April, 1929, and the duties of the Board transferred to the Middlesex County Council. Tubericulosis.—The Tuberculosis scheme is administered by the Middlesex County Council which has sanatoria at Clare Hall and Harefield. Child Welfare Consultation Centres.— (a)-47, Avenue Road—Every Monday, Tuesday, Wednesday and Thursday afternoon at 2 p.m. (b)—Noel Road—Every Thursday afternoon at 2 p.m. (c)—East Acton—Every Thursday afternoon at 2 p.m. (d)—Steele Road—Every Tuesday afternoon at 2 p.m. 7 Ante-Natal Consultation Centre.—School Clinic every and and 4th Wednesday. Day Nursery.—169, Bollo Bridge Road. School Clinic.—45, Avenue Road. (The above are provided and maintained by the Borough Council). Tuberculosis Dispensary.—School Clinic on Tuesdays at 5 p.m. and Thursdays at 10.30 p.m. Treatment Centres for Venereal Diseases.—Various Hospitals in London. (The two latter are provided by the Middlesex County Council). SANITARY CIRCUMSTANCES OF THE AREA. These have been noted in previous reports. All the inhabited bouses are supplied from the mains of the Metropolitan Water Board. A few industrial works and the Public Baths obtain their water supply from deep wells. By arrangement with the London County Council the sewerage is discharged into the London Sewers. Storm water is filtered and emptied into the Thames. All the inhabited houses are provided with water closets and are drained into the main sewerage system. The house refuse is collected by the Council and burnt in the Destructor. Last year 19,457 tons of house refuse were collected and burnt . PROFESSIONAL NURSING IN THE HOME. General.—There are two district nurses employed by the Acton Hospital, who visits the homes of both the poor and those who are able to pay. There are also nursing associations which provide nurses for different classes of cases. Midwives.—The Supervising Authority under the Midwives Act is the Middlesex County Council and from the County Council 1 understand that there are 20 certified midwives practising in the Borough. 8 LEGISLATION IN FORCE. The following local acts, special local orders, general adoptive acts and byelaws relating to Public Health are in force in the district. Adopted. Infectious Diseases (Notification) Act, 1889 1889 Public Health (Amendment) Act, 1890 1890 Infectious Diseases Prevention Act, 1890 1899 Notification of Births Act, 1907 1907 Public Health Act, 1907 (Clause 50) 1921 Public Health Act, 1925 (Parts 2, 3, 4 and 5) 1920 The Acton Improvement Act, 1904 - New Streets and Buildings 1925 Removal of House Refuse 1899 Common Lodging Houses 1898 Slaughter Houses 1924 Nuisances, &c. 1924 Offensive Trades 1903 Tents, Vans and Sheds 1906 Removal of Offensive or Noxious Matters 1908 Houses Let in Lodgings 1925 Cleansing of Cisterns 1912 Employment of Children 1920 Fouling of Footpaths by Dogs 1929 Smoke Abatement 1930 HOUSING. There has been a good deal of discussion recently about slums and the so-called slum problem, and to those who have not studied the question closely the statements made by the different people are apt to be puzzling. On the one hand, it is freely stated that certain property is slum property and on the other it is held that we have no slums in Acton. The misconception arises from the loose way in which the term slum is used. It may be a convenient word but it is a very vague one, and it not officially recognized. There is no legal definition of a slum, and the term is excluded from Acts of Parliament. The word slum is convenient and expressive, and is used to describe a varying range of dwellings. It is important that we should discriminate between a slum and a clearance area. A clearance area will include slums, but it does not necessarily follow that the houses we regard as slums will 9 stitute a clearance or even an improvement area. Although some of the houses in our district cannot be included in a clearance area scheme, it does not follow that the conditions are satisfactory. In order to obtain a closing order we must prove that the structural condition of the house or its environment is such as to render it unfit for human habitation. Although the houses structurally may be in a fair condition the state of the houses may be deplorable, and although there may be no legal over-crowding the houses have for too many inmates for the common decencies to be observed. In some respects the housing question in and around London differs from that in the provinces, but one aspect of the problem is common to all localities. Over-crowding has always been associated with what is called the slum problem and usually it was one of the worst features. At present I mean by the term overcrowding simply the over-crowding of people in a house, and not the over-crowding of houses on a site. This kind of over-crowding can and does occur in a house which is structurally quite fit. The solution of over-crowding is not therefore the simple matter of providing more houses. You cannot abolish over-crowding by pulling down houses which are supposed to be unsatisfactory from a structural point of view. If that could be done we should not be faced, with a difficult problem. I have explained in previous reports that we have no area which could be scheduled as a clearance area or an improvement area. There were some houses which had become unfit and have been closed. There are other houses in the district which are becoming old and may have to be dealt with, but there are no areas in which a considerable number of the houses are structurally unfit for human habitation. The inhabited part of the district is comparatively new; the majority of the houses have been built within recent years; we have not received a heritage in the form of courts, narrow alleys, back-to-back houses, cellar dwellings, and other conditions which are associated with slum areas in the older industrial centres. We sometimes hear remarks from well intentioned people that they would like to blow up all the houses in certain roads. One may sympathise with the views expressed by these people and yet remain entirely sceptical of the results which would accrue from such drastic action. Overcrowding in this Borough is more a matter of economic and social factors than it is a sanitary problem, and the solution is not so simple as the pulling down of old houses and the erection of new ones. Though possibly of minor importance it may be well to define what we mean by over-crowding in a house. There are many and varied standards. The standard adopted when an attempt is made gauge the extent of over-crowding from an examination of the Census reports is based upon the number of inhabitants occupying a room. It is assumed that a house is over-crowded if the number 10 of occupants exceeds two per room. It is unnecessary to point out the facilities which underlie this classification. The most important depend on the size of the room and ages of the occupants. The standard we adopt is that contained in the Bye-Laws regulating houses let in lodgings. The Bye-laws now in force provide that a room used wholly or partly as a sleeping apartment must have 300 cubic feet of air space for every occupier over In years of age and 150 cubic feet for each child under 10 years of age.. If the Rent Restrictions Acts lapse then the amount of cubic space for an adult will be 400 cubic feet and 200 cubic feet for a child. Certain census figures have been published, and these throw a certain light upon the housing conditions in the district. It should be remembered that these figures refer to the district as a whok or to the wards and not to any limited areas or houses. The conditions in the whole district or in every ward may have improved but those which obtain in a limited area may have remained stationary or even deteriorated. It is interesting to note that certain conclusions which may be drawn from these figures coincide in the main with the experience of the officers of the Public Health Department. The first tables reproduced are No. 3 in the Census Reports for Middlesex, in which the population, number of private families, number of structurally separate dwellings and the room? occupied are given. 1931. Private Number. Families. Population. Structurally separate Rooms occupied. Persons per room. Acton 18997 69145 13812 80185 0.86 N.E. Ward 6090 21889 4444 25732 0.85 N.W. Ward 4622 16388 3709 22766 0.72 S.E. Ward 4122 14745 3195 17969 0.82 S.W. Ward 4163 16123 2464 13718 1.18 1921. Acton 14941 60490 11503 65529 0.92 N.E. Ward 4053 16007 3050 18418 0.82 N.W. Ward 3138 12142 2551 16384 0.74 S.E. Ward 3735 14982 3092 17297 0.86 S.W. Ward 4015 17359 2810 13430 1.3 11 An explanation is necessary of one obvious discrepancy. The tables make it appear as if the number of cases in the South West Ward was less in 1931 than in 1921, as there were only 2,464 structurally separate dwellings in 1931 compared with 2,180 in 1921. The figures in the next column contradict this assumption as the number of rooms occupied was 13,718 in 1931 compared with 13,430 in 1921. This obvious paradox probably arose from the different interpretations given by the enumerators of a structurally separate dwelling. In the report a structurally separate dwelling has been defined for the Census as any room or set of rooms intended or used for habitation, having separate access either to the street or to a common landing or staircase. Thus each flat in a block of flats is a separate unit ; a private house which has not been structurally sub-divided is similarly a single unit whether occupied by one family or by several families. Where a private house has been sub-divided into maisonettes or portions, each having its front door opening on to the street or to a common landing or staircase to which visitors have access, then each portion is treated as a separate unit. The discrepancy is easily understood ; everyone knows that the number of houses in the South West Ward increased slightly in the intercensal period. The column in which the total number of rooms occupied is given, is therefore a safer index for comparison. A comparison of these tables would tend to the conclusion that the housing conditions in the district as a whole have improved but that a deterioration has occurred in the North East Ward, and this is probably a correct conclusion. The number of persons per room has increased in the North East Ward from 0.82 to 0.85. This is partly due to the fact that the houses newly erected are smaller than the older ones, but it is also due to another factor. The older and larger houses are now sublet and more than one family is in occupation. We have noticed this tendency and in some instances notices have had to be served for over-crowding or some other nuisance. The only figures which were surprising were those for the South East Ward. The number of persons per room in that Ward was 0.86 in 1921 and 0.82 in 1931. It is known that in this Ward also there has been considerable sub-letting of houses. The numbers for the South West Ward were 1.30 in 1921 and 1.18 in 1931. Those who have had long acquaintance with housing conditions in this ward are of opinion that the conditions 12 throughout the ward have improved. While admitting this, it must also be conceded that in certain isolated areas, the conditions have not improved. The black spots may be more limited in extent; some of the streets have improved very considerably in many respects; but in certain areas the standard is still much below that which is desirable. This will become evident if we examine Table II. of the Census Reports. In this table the private families are classified by size of family, rooms occupied and density of occupation. Only a portion of the table is given, but this is the important part of it. Houses of more than 5 rooms have been omitted, as they would not appreciably affect the question of overcrowding. There were a few cases of over-crowding in the larger houses, but they were few and far between, and are not vitally important. Number of persons in family. Number of families occupying the rooms. 1 2 3 4 5 1 542 (406) 251 (146) 257 (133) 121 (66) 53 (57) 2 279 (286) 741 (461) 1494 (732) 704 (447) 499 (385) 3 123 (169) 484 (410) 1250 (900) 977 (612) 743 (589) 4 72 (65) 234 (188) 866 (737) 768 (567) 650 (588) 5 27 (12) 122 (91) 511 (563) 458 (386) 473 (462) 6 13 (5) 49 (44) 263 (353) 245 (268) 267 (301) 7 7 (1) 31 (25) 137 (213) 126 (171) 143 (176) 8 1 (1) 8 (11) 62 (121) 71 (100) 78 (130) 9 1 (1) 6 (5) 36 (48) 39 (52) 40 (69) 10 1 (1) 22 (25) 16 (29) 18 (38) 11 2 (1) 7 (7) 5 (18) 10 (16) 12 1 (3) 5 (1) 2 (4) 13 - (1) - (1) 3 (7) 14 1 (2) 15 or over 1 - The figures in brackets are the corresponding numbers in 1921. If we adopt the standard that a house is over-crowded if more than 2 persons occupy a room, the conditions in one and two roomed tenements are less favourable than in 1921 and more favourable in three-, four- and five-roomed tenements. 13 HOUSING. Number of Houses erected during the year:- (a) Total (including number given separately under (b) 186 (b) With State assistance under the Housing Acts: (i) By the Local Authority 8 (ii) By other bodies or persons Nil. 1. Inspection of Dwelling-houses during the Year 1931: — (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1890 (b) Number of inspections made for the purpose 5760 (2) (a) Number of dwelling-houses (included under sub-head (1) above, which were inspected and recorded under the Housing Consolidated Regulations, 1925 1405 (6) Number of inspections made for the purpose 4917 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation Nil. (4) Number of dwelling-houses (exclusive of those ferred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 1687 2 Remedy for Defects during the Year without Service of formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 1463 14 3. Action under Statutory Powers during the Year:— A.—Proceedings under sections 17, 18 and 23 of the Housing Act, 1930: (1) Number of dwelling-houses in respect of which notices were served requiring repairs 163 (2) Number of dwelling-houses which were ered fit after service of formal notices:— (а) By owners 163 (b) By local authority in default of owners Nil. B.—Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 61 (2) Number of dwelling-houses in which defects were remedied after service of formal notices: — (a) By owners 61 (b) By local authority in default of owners Nil. C.—Proceedings under sections 19 and 21 of the Housing Act, 1930: (1) Number of dwelling-houses in respect of which Demolition Orders were made Nil. (2) Number of dwelling-houses demolished in pursuance of Demolition Orders Nil. D.—Proceedings under section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil. 15 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil. E.—Proceedings under section 3 of the Housing Act, 1925: — (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil. (2) Number of dwelling-houses which were ered fit after service of formal notices: — (a) By owners Nil. (b) By local authority in default of owners Nil. (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil. F.-Proceedings under sections 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which Closing Orders were made Nil. (2) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit Nil. (3) Number of dwelling-houses in respect of which Demolition Orders were made Nil. (4) Number of dwelling-houses demolished in suance of Demolition Orders Nil. 16 TABULAR STATEMENT OF INSPECTIONS & DETAIL OF WORK CARRIED OUT BY THE SANITARY INSPECTORS. Number of Inspections and Action Taken. Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 1890 (1) Dealt with by service of Informal Notice 1463 (2) Dealt with by service of Statutory Notice under Section 3, Housing Act 1925 and Section 17, Housing Act, 1930 163 (3) Dealt with by service of Statutory Notice under Public Health Acts 61 Premises (other than defective dwelling houses) inspected for nuisances and miscellaneous defects 71 (1) Dealt with by service of Informal Notice 601 (2) Dealt with by service of Statutory Notice under Public Health Act, &c. 7 Reinspections subsequent to service of Notice 6714 Enquiry visits on notification of Infectious Disease 673 Number of Premises under Periodical Inspection. Workshops and Workplaces 136 Bakehouses 29 Slaughterhouses 2 Public Health Urinals 37 Common Lodging Houses 1 Houses-let-in-lodgings 33 Butchers Shops 45 Fish Shops 29 Premises where food is manufactured or prepared 34 Milk Purveyors 116 Cowsheds Nil Piggeries Nil Rag and Bone Dealers 7 Mews 4 Schools 13 Show Grounds Nil Rent Restriction Act. Number of Certificates granted 9 17 Detail of Work carried out. Sanitary Dustbins provided 438 Yards paved or yard paving repaired 215 Insanitary forecourts remedied 34 Defective drains repaired or reconstructed 62 Defective soil pipes and ventilating shafts repaired or renewed 68 Defective fresh air inlets repaired or renewed 51 Defective gullies removed and replaced by new 67 Rain water downpipes disconnected from drain 10 Dishing and curb to gullies repaired and new gratings fixed 203 Defective W.C. pan and traps removed and replaced by new 62 Defective W.C. flushing apparatus repaired or new fixed 303 Defective W.C. seats repaired or new fixed 162 Defective flush pipe connections repaired 74 Insanitary sinks removed or new fixed 46 Sink waste pipes repaired or trapped 127 Insanitary wall surface over sinks remedied 89 Ventilated food cupboards provided 4 Drinking water cisterns cleansed 205 Defective covers to drinking water cisterns repaired or new fixed 77 Insanitary sites beneath floors concreted 12 Spaces beneath floors ventilated 106 Dampness in walls from defective damp-proof course remedied 94 Dampness from defective roof, rain water gutterings, etc., remedied 648 Defective plastering repaired (number of rooms) 392 Rooms where dirty walls and ceilings have been cleansed and redecorated 2473 Defective floors repaired 109 Defective or dangerous stairs repaired 30 Defective doors and windows repaired 285 Defective kitchen ranges and fire grates repaired 122 Defective washing coppers repaired 97 Coal cupboards provided or repaired 8 New W.C. apartments provided 5 Accumulations of offensive matter removed 21 Drains unstopped and cleansed 246 Overcrowding nuisances abated 15 Drains tested, exposed for examination, etc. 62 Smoke observations taken 143 Smoke nuisances abated on service of notice 18 Nuisances from pigs and other animals abated 7 Notifications of waste of water sent to Metropolitan Water Board 124 18 INSPECTION AND SUPERVISION OF FOOD. MILK SUPPLY. There are no cowsheds in the Borough, all the milk being produced outside. There are 91 persons or firms retailing milk in the district under the following categories:— Dairymen. Purveyors of Milk No. with rounds not occupying premises in the Borough. No. with rounds occupying premises in the Borough. No. of General shops from which milk is sold from covered pans only No. of shops from which milk is sold in closed and unopened receptacles only 4 26 24 62 Special Designated Milk. The number of persons or firms licenced to sell Special Designated Milk are as follows: — 4 'Certified ' 6 'Grade A (Tuberculin Tested)' — 'Grade A ' 11 'Pasteurised ' 1 'Grade A Pasteurised ' The Council has decided to enforce strictly Article 21 of the Milk & Dairies Order of 1926. This Article requires that every milk vessel shall be thoroughly washed and cleansed and scalded with boiling water or steam before it is used again. All new Applicants to be registered as Dairymen, will be required to instal at once an approved steam raising plant and steam chest so as to comply with the Article, and Dairymen already registered will be given a reasonable time in which to instal such apparatus. Article 32 of the Order requires every person engaged in the conveyance or distribution of milk to use all practicable precautions for preventing the milk from being unnecessarily exposed to heat and from being contaminated by dirt, dust, rain-water or otherwise. 19 In an adjoining district, retailers of milk in bottles have been called upon to provide an insulated box in which to store the milk during warm weather but such an appliance is not asked for by this Council. We have 24 general shops in which milk is being sold from pans on the counter. There are 62 other general shops in which milk is only sold in sealed bottles or cartons. I do not think that in any of the 24 general shops in which milk is sold from pans on the counter, the conditions are entirely satisfactory, but it is difficult to prove that the public health is likely to be endangered by the methods in use. Most of these retailers would be willing to sell the milk from sealed receptacles only, if the practice were made compulsory and universal. In most of these shops in addition to the objection of the sale of other goods which create dust, the shop itself is overcrowded, and it is impossible for the premises to be kept clean and free of dust. In my opinion there are 8 of these general shops in which, under present conditions, milk should not be sold from open cans. In the present report I do not wish to deal specifically with the general shops in which milk is sold in closed receptacles, but shops in which the .principal article sold is milk. As stated there are 62 general shops which sell milk only from closed receptacles. There are 26 premises registered in or on which milk is the principal article sold, and one other purveyor resides in Acton, and sells his milk here, but the premises are situated and registered at Willesden. On one of the premises 2 persons are registered, and on another, 3 persons are registered. In all the 26 cases, there are milk rounds, and in three cases very little milk is sold on the premises. On all these premises milk is sold over the counter or otherwise in open pans, but although other articles are sold there, the condition of the premises is satisfactory. There is one article of the Regulations to which I wish to pall the attention of the Committee, because in the majority of instances one part of the article is now ignored. Article 32 of the Order states that every person engaged in the conveyance or distribution of milk shall use all practicable precautions for preventing the milk from being unnecessarily exposed to heat and from being contaminated by dirt, dust, rain-water or otherwise. 20 In only 10 shops in the district is there a refrigerator installed in the shop and used to store milk in warm weather. In the other shops, the milk is kept on the counter. Some use muslin, others do nothing. It is for the Committee to decide what they consider to be all practicable precautions. The question will not arise until next summer. We have made enquiries in other districts, and I may say that the practice varies very greatly in different districts. In most districts no specified method is prescribed, but in one district the installation of refrigerators in the shops is being asked for. Periodically the question of milk comes up for debate and discussion, and, incidentally, it might be mentioned that this is not surprising. It should be remembered that milk is an important article of food ; to infants it is the sole food, and to many young children it is the principal food, and should loom more in the dietary of young persons. It is almost universally admitted that the consumption of milk is too low. Milk is the most valuable of all foods. It is much less used than it should be—in this country less than in any part of the world where it is obtainable. The Scandinavian countries are well ahead of Great Britain in this matter. Because of its value as a food, dieteticians are constantly advocating its increased consumption. The nutritional value of milk as a corrective to deficiencies of various types in the diet is now generally accepted. It is valuable to the adult and probably indispensable to the child. In many diets it is the chief source of the fat soluble vitamins, of protein of good quality, and of calcium salts. If it be suggested that milk is expensive, the answer is that it is not so expensive as many other commodities (e.g. meat) which are considered essential by most caterers. The fact is, that no poor person should buy meat till they have afforded at least one pint per head of milk. It is for these reasons that dieticians are persistently advocating a larger consumption of milk, and it is becoming an essential article in the diet of an increased number of individuals. But as epidemiologists, we have to look upon another side of the question. It is an undoubted fact that milk can act as a vehicle of numerous infections; milk-spread disease is a common phenomenon. Milk probably comes next to water as a vehicle of the most extensive outbreaks of disease. Scattered throughout literature are numerous accounts of outbreaks due to a tainted milk supply. 21 A public water supply unquestionably reaches a larger percentage of the people than any other single potential disease vehicle, but milk follows a close second. As milk is also a natural growing medium for certain disease producing bacteria, it can be appreciated how milk-bourne epidemics occur. In the past, outbreaks of typhoid fever, scarlet fever, sore throats, etc. were traced to the milk supply. Fortunately such outbreaks have become exceedingly rare, but we occasionally have a reminder that care is still necessary. A few years ago a sharp outbreak of para-typhoid in the west of London and in which Acton participated was traced to contaminated cream, and an extensive outbreak of sore throats in Brighton was traced to an infected milk supply. At the present time the most prominent aspect of the milk question is the prevalence of tuberculosis in milch cows. It is generally admitted that an improvement has been secured in the cleanliness of the milk supply. The risk of typhoid and scarlet fever from an infected milk supply is remote and it is possible now to feed a baby on cow's milk even in the summer without much fear of epidemic diarrhoea. It can be safely said that the markedly improved methods of production and distribution in recent years made our milk supply cleaner and safer. But whether there has been any corresponding decrease in the frequency with which milk is infected with tubercle bacilli, it is not possible to say with certainty. As the Committee was asked by a Voluntary Association to pass certain resolutions, it may be necessary to state the grounds on which this course of action is based. In the report of the Ministry of Agriculture for 1929, it was stated that there were over two million cows and heifers in England and Wales in milk, in addition to nearly 300,000 cows in calf but not in milk and 364,763 heifers in calf. It is estimated that about 40 per cent of these are tuberculous, that is, would give a positive tuberculin test. That does not mean, of course, that the milk. from. 40 per cent of these contains the tubercle bacilli. The figures are important only as far as they show the magnitude of the problem. The tuberculin test is a qualitative one and not a quantitive one; it thus gives no indication of the degree of infection present, except that heavily affected animals may not re-act to the test. So great is the risk of the spread of tuberculosis in. a herd from a re-actor to the tuberculin test that for practical purposes such re-actors are to be regarded as infective. In view of: the high incidence of bovine tuberculosis it would obviously be futile to recommend the immediate elimination of all re-actors irrespective of whether or not they are giving tuberculous milk. All the re-actors to the tuberculin test do not give tuberculous milk, and in order to estimate the proportion of cows which are doing so, it is important 22 to have information with regard to the prevalence of tuberculous disease of the udder. Primary udder tuberculosis is extremely rare, and in one half of the cows found to be tuberculous on slaughter the disease is generalised in the body. Tuberculous mastitis is much commoner in older cows than in quite young animals, and it is possible that the disease is encouraged by the artificial stimulation of the mammary gland and the unnatural demands made upon it by milking. The Ministry of Agriculture conclude, from the information at their disposal, that probably from 1 to 1.5% of cows in herds in which the disease has been discovered under the operations of the Tuberculosis Order and the Milk and Dairies Acts, yield tuberculous milk. But this does not represent the proportion of tuberculous milk in any area; this will depend very largely upon the extent to which the milk is mixed or bulked before distribution. It is calculated that between 6 and 7% of the raw milk sold in the kingdom contains living tubercle bacilli; it should be noted that this refers to raw milk and not milk as delivered to the consumer. The latter has been treated and this will be referred to in a subsequent paragraph. Of 69,901 unselected samples of raw milk examined, 4,690 or 6.7% were found to contain living tubercle bacilli. Certain estimates have been made of the extent of tubercle in man due to infection from milk. There are four types of tubercle bacilli—the cold-blooded, avian, bovine and human which are distinguishable from each other by certain tests. Tuberculosis, as it affects man, is due to infection with the human and bovine types. The infection of man with the human type occurs mainly by the respiratory tract. Infection of man with the bovine type, on the other hand, occurs almost exclusively by the alimentary canal, and the chief vehicle is cow's milk. Since however the type of the infecting organisms can be determined only by bacteriological methods, it follows that our knowledge of the extent of bovine infection in man rests solely on the data accumulated by the examination of specimens of tuberculous material collected either during life or after death. The process of 'typing' is arduous, time-consuming and demands considerable experience. For this reason the type of the infecting organisms is not usually determined as a routine, and the number of the determinations that have been made is not very large. It is necessary to bear this in mind when considering the estimates that have been based upon them. 23 It has been estimated that 4,000 fresh cases of human infection due to the bovine type of tubercle occur annually, and that in 1928 the deaths from the bovine type were approximately 2,000. Although these facts are serious, the figures of the Registrar General suggest that the menace is a diminishing one, and that the measures already in operation have not been in vain. There has been a steady fall in the death-rate from tuberculosis, both of the pulmonary and of the non-pulmonary type, but the fall in the death-rate from that of the latter type has been much more marked than in the pulmonary death-rate. This has been noticeable in recent years and it suggests that the improvement is due to improved methods in the general production of milk. It may therefore be advisable to examine the methods which have recently been adopted and which appear to have been partially successful, because the increased fall in the non-respiratory type has been particularly noticeable since the operation of the Milk & Dairies Consolidation Act and the new Milk & Dairies Orders. Although the Milk and Dairies (Consolidation) Act was passed in 1915, its provisions did not operate until 1925, and the Milk & Dairies Order was issued in 1922, under which the Milk, (Special Designations) Orders 1922 and 1923 were issued. Prior to these ordinances, except in the case of private Acts of Parliament, the Regulations governing the production and distribution harked hack to the Dairies & Cowsheds Orders of 1885. Before deeding with the condition of distribution, it might be well to examine the provisions of the Milk (Special Designations) Orders. In the Order, details are set forth concerning the production and sale of four kinds of milk—Certified, Grade A (Tuberculin Tested), Grade A and Pasteurised Milk. The highest grade of milk is the Certified Milk, but the Grade A (Tuberculin Tested) differs from it only in the kind of milk containers required. Both milks must be produced from Tuberculin Tested cows, the bacterial count is similar and the licenses to produce must be obtained from the Ministry of Health. In the Grade A Milk, the herd is not Tuberculin Tested, but the cows must be examined every three months by a veterinary surgeon and certified free from clinical signs of Tubercle. The bacteria must not exceed 200,000 per cubic centimetre of milk. The County Councils and County Borough Councils are the licensing authorities. 24 The essential condition in the matter of the treatment of Pasteurised Milk is that the milk must be held at a temperature between 145° and 150° F. for at least half an hour and cooled immediately afterwards to not more than 55° F. The prescribed conditions definitely exclude the 'flash pasteurisation' process by which milk is heated for short periods. It is illegal to use the designation 'pasteurised' in connection with the sale of milk except under the terms of licence. The ultimate object in view, of course, is the attainment of a raw milk free of the tubercle bacillus and it is only when the milk is Certified, Grade A (Tuberculin Tested), or Grade A, that object can be said to be obtained. But can that goal be attained in a reasonable time? Since 1923 when grading of milk came into operation, there has been an increase of producers of Certified Milk and Grade A (Tuberculin Tested) from 101 to 403 in 1930. By the end of 1930 about 14,300 non-reacting cattle were licensed by the Ministry of Health. But the cow population of England and Wales in 1930 was estimated at 2,674,934. Thus only about .5% of the dairy stock or 1 in 200 is guaranteed tubercle free by the tuberculin test and the amount of milk from tubercle free herds is probably not more than .6 or .7% of the total milk supply. The contribution of grading to the improvement of the milk supply up to the present has been almost negligible. Besides, the labouring artisan classes cannot afford to pay the price demanded. Probably in time as the benefits of healthy cattle will be appreciated, the farmers will make endeavours to own tubercle free herds, but in the immediate future others means will have to be devised. Undoubtedly the best protection is given by pasteurisation. In London most of the milk which is being sold has been treated by heat in accordance with some of the regulations of the Ministry of Health, but it is not sold as pasteurised milk. For instance, in this district, although most of the purveyors of milk sell milk which is heated, comparatively only a small portion is sold as pasteurised milk. The 8 branches of the United Dairies and the 2 branches of the Express Dairy have licences to sell Certified, Grade A (Tuberculin Tested) and pasteurised milk, 1 other has a licence to sell Certified, and 3 have a licence to sell Grade A (Tuberculin tested) and 1 has a licence to sell pasteurised milk. The importance of selling the milk as 'pasteurised' lies in the fact that unless the process is properly carried out, there are certain dangers in connection with it. For instance, if the milk is under-heated, dangerous organisms may not be destroyed, whilst, if it is overheated, some of the Vitamins may be destroyed. It is unnecessary here to enter into the question of the effect of pasteurisation upon th nutritive value of milk, though this matter is a most important 25 one, and cannot be lightly dismissed. There is no evidence of loss of Vitamins A, B, D and E ; it is possible that a certain amount of loss to Vitamin C occurs. There is some small loss of the diffusible calcium content through pasteurisation. On the whole, the evidence points to the fact that pasteurisation properly carried out, destroys the pathogenic organisms and does not materially affect the nutritive value of the milk, but once the milk has been pasteurised, it should not again be boiled or wanned above a certain point. Here lies the importance of knowing whether the milk has been pasteurised or not. The public should know whether the milk sold has been pasteurised or not, and if pastcurised, if the process has been carried out properly. It needs to be emphasized most strongly that pasteurisation-is something more than a process by which the milk can be made to keep without souring for a longer time especially in the summer. It is well, known that pasteurisation was adopted by the distributors of milk for the purpose of adding to its keeping properties and thus enabling it to be delivered to the consumer in a marketable condition. Some people looked upon it as a good process to prevent wastage from souring etc. of milk which was produced and handled badly. Unfortunately, this is the view which is still taken by man}' purveyors of milk. I was speaking to a large distributor in the district a short while ago, and he bluntly and baldly stated that heating was of use only in the summer because the milk would not otherwise keep sweet. Such things as the destruction of vitamins, interferences with calcium diffusibility and the effects of these upon children never altered his mind. From one point of view, it is fortunate that heat much above 145° Fahrenheit affects the taste, flavour and cream line. For instance at a temperature of 148° Fahrenheit the cream line is sometimes decreased by 40%, and so long as the cream line is exalted to a fetish, it is not likely that a temperature above 150° Fahrenheit will be used in pasteurising. But unless some control is exercised, a lower temperature than 145° may be used and some of the pathogenic organisms remain unaffected. I am afraid that I have appeared to labour this question rather extensively, but I find that the question of pasteurisation is but very inadequately understood even by purveyors of milk. The objections, of course, that will be raised to compulsory pasteurisation are two,—expense, and the tendency to delay the production of a cleaner and better milk supply. Anything which would have a tendency to raise the price of milk must be deprecated. If there is to be an increase in the consumption of milk, the price must be kept as low as possible. 26 The opinion of the milk purveyors on the price which has to be paid for pasteurisation must be respected, and any figures which they may possess of the cost examined. Althoug no milk is produced in the district, its production affects us very closely, though no administrative measures here can directly have any effect upon the supply. We are entitled though to give a considered opinion upon even the source of supply. There is one aspect which concerns us in one sense more directly, and that is the retail distribution of the milk in the district. One of the questions which periodically crops up is the desirability or otherwise of registering certain traders as purveyors of milk. Under Section 2 of the Milk & Dairies (Amendment) Act 1922, the Council has power to refuse registration, or remove from the register certain retailers of milk. The powers conferred upon the Council are vague. The section states that if the local authority is satisfied that the public health is or is likely to be endangered by any act or default of any person who is registered or seeks to be registered therein as a retail purveyor of milk, in relation te the quality, storage, distribution of milk, they may refuse to register him or remove him from the register as the case may be. It is to be observed that the act or default is not necessarily one which is against any statute, order or regulation, but simply that it may, or is likely to endanger the public health. Some cases are easy to decide. For instance on Tuesday afternoon, September 27th, Mr. Kinch and I went to a shop and asked to see the receptacle in which the milk was kept. The mlik was kept in a churn on the floor of the shop near the door without a lid or any other covering. The shop is a general shop, in which wood, and other dusty articles are sold, and the conditions were such that the public health might be endangered. The general appearance of the place was unsatisfactory. Noticing also about a dozen crates of bottles filled with milk and knowing that the trade done there was a small one, we enquired into the storage of this milk. We were told that this milk had been bought to be kept until after October 1st as there would be a rise in the price of milk after that date. In former years we used to class the premises on or from which milk was sold as dairies and general shops. These terms are now hardly applicable. Most of those premises which formerly registered as dairies are now general shops, from which many and diverse articles are sold. These premises differ from general shops only in the fact that milk is the principal ingredient 27 gold, and also the list of articles sold is not quite so comprehensive as in the smaller general shops. In several of the shops in which formerly only milk and general dairy produce were sold, such articles as sauces, vinegar, boot polish, potted meats of various brands, to mention but a few of the different commodities, are sold over the counter. This practice makes the control of milk distribution a much more difficult matter. The general shop-keeper feels that the dairyman has trespassed on his preserves, and he therefore thinks that he has to stock milk as one of his commodities. That, of course, is no concern of ours ; we are only concerned with the conditions under which milk is retailed. BAKEHOUSES. Of the 29 bakehouses in the Borough 5 are underground and these were licensed on the coming into force of the Factory Acta of 1901. SMOKE INSPECTION. Very few complaints are received with regard to smoke nuisances from Factory Chimneys. Where there is any cause for complaint a notice is at once served upon the occupier of the premises, who as a rule is very willing to carry out any suggestions which might obviate the nuisance. In two cases where complaints had been received, it was found that the boilers were being over-loaded ; in one case the firm decided to put a second boiler into operation and in the other, a better quality of coal was obtained and more attention paid to the stoking, with the result that only occasionally are any complaints received in respect of these chimneys. MEAT INSPECTION. There are two slaughter-houses in the Borough, in one pigs only are slaughtered and in the other cattle and sheep only. Every carcase is thoroughly examined by a certificated Meat and Foods Inspector at the time of slaughter, and it will be seen from the accompanying table, that a considerable number of carcases are affected with disease. It has not been necessary to institute any Police Court proceedings for offence against persons dealing in food. 28 UNSOUND FOOD SURRENDERED DURING 1932. TABLE X. Diseased Meat. Tuberculosis. Pigs. Pleurisy. Pigs. 37 Carcases with Heads. 2 Forequarters. 6 Forequarters. 18 lbs. Ribs of Pork. 55 lbs. Pork. 216 Heads. Cattle. 297 Plucks. 2 Calves' Carcases with Offal. 2608 lbs. Chitterlings. 2 Ribs of Pork. 3 Forequarters of Veal. Cattle. 15 Breasts of Veal. 1 Rib of Veal. 3 Stirks' Carcases with Offal. 11 Calves' Plucks. 6 Calves' Carcases with Offal. 18 sets Calves' Lungs with Hearts. 2 Hindquarters of Veal. 1 Cow's Head & Tongue. 3 Stirks' Heads & Tongues. Sheep. 3 Calves' Heads & Tongues. 10 Breasts of Mutton. 1 set Cow s Lungs with Heart. 6 Sheeps' Plucks. 3 sets Stirks' Lungs with Hearts. 1 set Sheep's Lungs with Heart. 2 sets Calves' Lungs with Hearts. Pleurisy and Dropsy. 1 Stirk's Pluck. 1 Sheep's Carcase.. 30 Calves' Plucks. 1 Calf's Liver. Suppurating Pleurisy. 3 Calves' Kidneys. 3 sets Calves' Lungs with Hearts. Parasites. Cattle. 2 Breasts of Veal. 1 set Cow's Lungs. 1 Forequarter of Veal. 1 Cow's Liver. Abscesses. 2 Stirks' Livers. 2 sets Stirks' Lungs with Hearts. Pigs. 2: Legs of Pork. 1 set Calf's Lungs with Heart. Sheep. Cattle. 19 Sheeps' Plucks. 3 Calves' Heads. 92 sets Sheeps' Lungs. 4 Calves' Plucks. 27 Sheeps' Livers. 8 Calves' Livers. 29 1 Shoulder of Veal. Pigs. 1 piece Flank of Beef. 1 Leg of Pork. Pseudo-Hodgkins Disease. Urticaria. 1 Calf's Carcase with Offal. 56 lbs. Pork and Rind. Pneumonia. Sarco-Sporidia. 4 Calves' Carcases with Offal. 1 Pig's Carcase. Sheep. Leukaemia. 2 Sheeps' Plucks. Actinomycosis. Cattle. Cattle. 1 Calf's Carcase with Offal. 2 Stirks' Heads & Tongues. Melanosis. Jaundice. 1 Calf's Carcase with Offal. 4 Calves' Carcases with Offal. 2 Calves' Plucks. 1 Calf's Pluck. Moribund. Dropsy. Pigs. 1 Cow's Carcase with Offal. 2 Carcases with Heads. Dropsy and Emaciation. Cattle. 1 Cow's Carcase with Offal. 1 Stirk's Carcase wrth Offal. 2 Stirks' Carcases with Offal 14 Calves' Carcases with Offal. 2 Calves' Carcases with Offal. Sheep. Dead. 4 Sheeps'Carcases with Offal Pigs. Cystic. 1 Carcase wth Head. Cattle. Cattle. 1 Calf's Kidney. 1 Calf's Carcase with Offal. Adenitis. 6 Calves' Plucks. Cirrhosis. 2 Calves' Livers. Cattle. Arthritis. 1 Cow's Liver. 2 Stirks' Livers. 2 Knuckles of Veal. 2 Calves' Livers. 30 Bruised, Fractured, etc. Congestion. Pigs. 1 Calf's Pluck. 1 Pig's Carcase with Haed. Unsound. 6 Hindquarters of Pork. 3 Legs of Pork. Pigs. 2 Shoulders of Pork. 2 Pigs' Carcases. 1 short Forequarter of Pork. 2 Sides of Pork. 164 lbs. of Pork. 27 lbs. Shoulder of Pork. Cattle. Cattle. 2 Calves' Carcases with Offal. 2 Calves' Plucks. 2 lbs. Loin of Veal. 1 Leg of Veal. 4 Calves' Kidneys. Other Foods. Unsound. 150 punnets Strawberries. 3 stone Skate Wings. 75 (1-lb.) Tins Loganberries. 1 lb. 14 ozs. Cooked Pork. 1 Box Codlings. 1 Box Cod Roe. 14 lbs. Tinned Liver. 1 (6 lb.) tin Corned Beef. 440 Turkeys (2¼ tons). 6 Boxes Cod Fillets. 31 TABLE 11. NUMBER OF PIGS' CARCASES INSPECTED FROM 1st JANUARY to 31st DECEMBER, 1932, WITH ANALYSIS OF SURRENDERS ON ACCOUNT OF DISEASE. 1932. No. of Carcases Inspected. No. of Heads Diseased. No. of Carcases Diseased. No. of Sides Diseased. No. of Fore Quarters Diseased. No. of Hind Quarters Diseased. No. of Legs . Diseased. No. of Shoulders Diseased. Plucks (Lungs, Livers and Hearts). Mesenteries, Stomachs and Intestines Pieces of Pork. January 1285 14 1 - 2 - 1 - 39 352 lbs. - February 1368 9 2 - - - - - 29 256 ,, 100 lbs. March 1407 14 4 — - 1 - 2 23 208 ,, 94 ,, April 1536 19 4 - 3 2 2 - 31 280 ,, 52 ,, May 1264 21 3 — - 4 1 - 19 152 „ 67 „ June 940 17 5 — — — — — 19 136 „ - July 894 24 1 2 — — 1 — 22 208 „ 14 „ August 852 17 3 — 1 — — - 14 128 „ - September 1622 28 4 — 4 — - - 25 248 ,, - October 1675 39 5 — 1 - 1 - 26 240 ,, 18 „ November 1600 36 3 — - 2 - - 27 208 ,, 10 ,, December 2037 32 3 - 1 - — — 25 216 „ - Total 16480 270 41 2 12 9 6 2 299 2632 „ 355 ,, 32 BIRTHS. Table 7 gives particulars of the births registered and notified in the district, and the births belonging to the district which have occurred and been registered outside the district. The total number of births are those registered during the calendar year and are corrected for inward and outward transfers. This figure is obtained at the end of the year from the Registrar General, and is simply the total for the district. It does not allocate 'the births to the wards, and from this total it is not possible to make a ward allocation. Last year the total number was 970 ; 483 males and 487 females, and the figure is equal to a birth-rate of 13.8 per 1,000 inhabitants. In addition 43 still births were returned as belonging to the district. The ward allocation is made from the notifications which are received under the "Notification of Births Act. The number ol notifications does not exactly correspond always with the number df registrations. The births have to be notified within 36 hours, whilst a delay of 6 weeks may occur in the registration of a birth. There is not much difference in the number notified and registered in the district in the year as the births which occur towards the end df the year and are not registered until the following year are equalised-by the'births which have occurred towards the end of another year and have .not been registered in the same year under similar conditions. In 1931 the births numbered 1,019 corresponding to a birthrate of 14.4. This fall in the birth-rate was discussed at length in the Annual "Report 'for last year. DEATHS. 483 deaths were registered in the district; and 303 deaths of residents occurred outside the district. The total number of deaths belonging to the district is 786, which corresponds to a death-rate of 11.1 per 1,000 inhabitants. The table giving the causes of death, age distribution, etc., k given on.a later page. Causes of Death. The number of deaths from Cancer are again on the increase 101 deaths occurring compared with 91 last year. 33 Deaths in Public Institutions. Of the total number 386 occurred in Public Institutions and 17 in nursing homes. Qf this total 263 occurred in hospitals outside and 105 in hospital in the district. Inquests and Coroner's Inquiries. 38 inquests were held and in 26 instances the Coroner issued acrtificate without an inquest after he had ordered a post-mortem examination. INFECTIOUS DISEASES. Scarlet Fever. 37 cases were notified during the year as compared with 95 cases in 1931. Reference to the following table will show that this is the highest number of cases which have occurred in any year 1921. Year. No. of Cases. No. of Deaths. Scarlet Fever, Death-rate per 1,000 population. 1890 108 3 .12 1891 63 4 .16 1892 74 - - 1893 192 10 .39 1894 86 3 .11 1895 67 3 .1 1896 193 1 .034 1897 93 - - 1898 167 3 .09 1899 111 2 .06 1900 243 6 .16 1901 82 2 .05 1902 109 1 .025 1903 76 2 .05 1904 129 1 .02 1905 137 2 .04 1906 170 7 .13 1907 267 6 .11 1908 484 15 .272 1909 469 16 .28 1910 109 2 .035 34 Year. No. of Cases. No. of Deaths. Scarlet fever Death-rate per population 1911 234 6 .1 1912 315 L .08 1913 80 2 .03 1914 252 1 .016 1915 163 2 .030 1916 64 1 .018 1917 45 - - 1918 38 - - 1919 95 — - 1921 630 1 .016 1920 176 - - 1922 305 3 .05 1923 160 - — 1924 105 1 .06 1925 83 1 .06 1926 103 — - 1927 137 1 .05 1928 243 — - 1929 235 1 .012 1930 207 1 .02 1931 95 - - 1932 537 5 .07 35 SCARLET FEVER —1932. (Cases in weeks, ages and wards) Week Ending Total No. N. E. Ages in Wards. S. W. N. W. S. E. Jan. 2nd 1 9 Jan. 9th 1 9 Jan. 16th 2 7, 4 Jan. 23rd 1 4 Jan. 30th Nil. Feb, 6th Nil. Feb. 13th 2 5. 6 Feb. 20th 4 4, 2, 5, 5 Feb. 27th 3 8 5 1½ Mar. 5th 2 11 4½ Mar. 12th 1 6 Mar. 19th 3 5½ 8 5 Mar. 26th 5 15, 4, 11 12, 15 Apr. 2nd 3 5, 28 4½ Apr. 9th 8 20 2, 26, 17 10 4, 11, 7 Apr. 16th 4 8, 4, 2½, 29 Apr. 23rd 5 2, 39, 38 12 26 Apr. 30th 5 12, 4 4, 11 2 May 7th 3 5 8, 5 May 14th 6 3 5½, 5 5, 7, 6½ May 21st 3 4½, 5, 6 May 28th 2 2 4 June 4th 4 16, 7, 2½ 3 June 11th 2 5 8½ June 18th 7 7½, 12, 11, 21 7½, 4, 10 June 25th 9 2½, 25, 1½, 7, 4 3½, 11, 7, 12 July 2nd 4 10 13, 16 6 July 9th 5 8, 8 9 3 9 July 16 th 8 4 12, 13, 16½, 8 9, 12, 11 Juy 23rd 15 12, 6½ 11 17, 19, 6, 7, 9, 15 11, 7, 7, 5, 20, 10 July 30th 8 41 19, 7, 4, 7, 4 1, 3 36 SCARLET FEVER — 1932. (Cases in weeks, ages and wards). Week Ending Total No. N. E. Ages in Wards. S. W. N. W. S. E. Aug. 6th 7 5 7, 4, 4, 8 8 31 Aug. 13th 6 5 1½ 13, 19 27, 7 Aug. 20th 5 5 10, 18 5½, 4 Aug. 27th 12 10 34, 6, 9. 10.6 5 18, 3, 3, 1, 12 Sep. 3rd 19 6 8, 8, 4½ 108 8, 5, 6, 13, 5½, 10, 8, 16, 11, 4, 6, 5, 5. Sep. 10th 11 1 33, 11 3, 5½ 11, 4, 4, 14, 13, 12 Sep. 17th 10 9 9, 1, 3, 7, 8, 25, 8, 13, 8 Sep. 24th 12 2, 6 3 21, 8, 9, 12, 3, 13, 2, 2, 11 Oct. 1st 34 13, 11, 11, 12, 11, 11, 2, 15,9, 2 15, 6, 35, 5½ 4 7, 5, 3, 3 6, 11, 5, 2, 5, 6, 6, 4, 26, 8, 10, 22, 29, 6. Oct. 8th 29 13, 5, 10, 14, 12, 5 12, 3, 7 5, 6, 5, 20, 6, 6, 12, 5, 9 8, 11, 6, 3, 2, 8, 10, 10, 8, 6, 9 Oct. 15th 35 6, 11, 5, 11, 4, 6, 5 6, 2, 4 5, 12, 3½ 5, 8, 11, 12, 4, 8, 6, 12 2, 8, 7, 6, 10, 5, 8, 2, 1½ 11, 7,12,8, 10 Oct. 22nd 39 7, 7, 7, 12, 7, 15, 1½ 7, 12 13, 11 33, 8, 11, 5, 11, 27, 8 2, 5, 8, 4, 5, 6 19, 5, 9, 32, 2, 4, 40, 2, 5, 6, 4, 8, 5, 5, 1½ 5 Oct. 29th 30 13, 6, 3, 9, 13, 9, 0 20 36, 10 8, 6, 4, 5, 4, 3, 34, 6, 8, 10, 7, 2, 6, 9, 9, 7, 9. 11, 4, 2 Nov. 5th 20 12, 12, 13, 32, 4, 12, 7 35 14, 6, 3 17, 1, 11, 22, 7, 4, 9, 4, 11 Nov. 12th 18 25, 4, 4, 11, 25, 7, 2½ 13 13, 3 12, 8, 7, 12, 5, 3, 10, 41 Nov. 19th 23 45, 28, 9, 3, 3 12, 4, 2, 11 4, 12 41, 6, 10, 10, 7, 7, 4, 20, 2, 7, 26, 6 Nov. 26th 18 9, 8, 6, 10 12, 20, 12 5, 49, 7 5, 2, 26, 3, 2, 4, 12, 12 Dec. 3rd 14 5, 8, 7 28, 8, 4, 7 5, 5, 6, 4, 8, 4, 9 Dec. 10th 21 6, 5, 13 7, 17, 14 2, 10, 34 10, 10, 6, 6, 9, 12, 10, 22. 4, 12, 3½, 5 Dec. 17th 19 8, 3, 3, 15, 10 10, 32, 7 12, 8 3, 1½, 12, 8, 13, 8, 7, 11, 11 Dec. 24th 14 5½, 7, 5, 4, 7 4, 6, 6, 2 7 7, 34, 2, 5 Dec. 31st 15 10, 22 11, 3, 7 40, 4, 1 6, 12, 5, 8, 5, 8, 17 Total. 537 37 Age Distribution. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 Over 65 — 185 286 33 32 1 — Ward Distribution. N. E N. W. S. E. S. W. 115 69 110 243 The typg of the disease varied in severity and this will be referred to later on, but it is the mildness of many of the cases which is largely responsible for the increased incidence. Diagnosis is difficult in mild cases, many are overlooked and unattended, while the medical practitioner frequently hesitates to diagnose Scarlet Fever on indefinite symptoms in order to avoid putting a family to inconvenience. For a number of years the mildness of Scarlet Fever has been a subject of comment and the opinion has been expressed that the danger to life of this disease has almost gone. It may be so, but unfortunately the weight of evidence does not justify such optimism. It is not so much the variation in the mortality of Scarlet Fever in different countries in recent years as the past history of the disease which suggests caution in our outlook. In 1675 Sydenham described Scarlet Fever as "an ailment, we can hardly call it more," and yet in the very year of Sydenham's death it was epidemic in London and became the severe disease of which malignant attacks were recorded. Again, that illustrious teacher Bretonneau taught that Scarlatina, which he had formerly heard spoken of as a dangerous malady, was then a mild infection, and he said that from 1799 to 1822 he did not recollect seeing a single fatal case. In 1824 an epidemic of severe type broke out in Tours and its neighbourhood and the result was that Bretonneau who had previously looked upon Scarlet Fever as a slight malady now learned to regard it as equally mortal with plague, typhus and cholera. In 1834, Graves in referring to what he terms " the destructive epidemic of Scarlet Fever " then prevailing in Dublin, goes on to say that in September, October, November and December, 1801, Scarlet Fever committed great ravages in Dublin and 38 continued its destructive progress until the Spring of 1802. Then he says that for the next 27 years, epidemics of Scarlet Fever though frequent, were always of a benign type. In 1831 however, there was a notable alteration in the character of the disease when occasional cases unexpectedly proved fatal. According to Farr, Scarlet Fever was an exceedingly fatal disease in England and Wales during the years 1848-1855. There is no doubt that in the past, Scarlet Fever has varied greatly in severity, having been at times a benign disease and at others a very fatal one. Scarlet Fever has evidently remained a mild disease for periods amounting to about a quarter of a century and then assumed a grave form. It would seem then, that the behaviour of this disease during recent years is not unlike what has happened in the past, and consequently it would be wise to regard it with suspicion and to be on our guard. From personal observation it appears that the type of Scarlet Fever prevalent in 1932 was less benign than in the immediately preceding years. There were 6 deaths from the disease during the year, corresponding to a death rate of .096 per 1,000 of the population. This is the highest death rate in the Borough since 1911. 1 of the deaths occurred outside the Borough, but the other 5 occurred at the Borough Isolation Hospital. One of these patients, a man of 29 years, was undoubtedly a true case of toxic Scarlet Fever. He was admitted to hospital in an almost moribund condition and died in three hours, and within 48 hours of the onset of illness. There was an intense dusky rash with only moderate faucial symptoms. Another patient, a child of 18 months, was admitted on the 2nd day of illness, with a heavy rash and severe faucial symptoms. In spite of anti-scarlatinal and anti-streptococcal sera the child died on 15th day of the illness. The third patient, a woman of 33 years, was admitted on the 3rd day of illness with a sharp attack of Scarlet Fever. She was treated with anti-scarlatinal serum but the symptoms did not abate with the disappearance of the eruption and the temperature remained up and assumed a remittent type. The possibility of a coincident typhoid infection was considered and excluded, and the patient drifted downhill until her death on 14th day from the commencement of the illness. 37 Age Distribution. Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 Over 65 - 185 . 286 33 32 1 — Ward Distribution. N. E. N. W. S. E. S. W. 115 69 110 243 The type of the disease varied in severity and this will be referred to later on, but it is the mildness of many of the cases which is largely responsible for the increased incidence. Diagnosis is difficult in mild cases, many are overlooked and unattended, while the medical practitioner frequently hesitates to diagnose Scarlet Fever on indefinite symptoms in order to avoid putting a family to inconvenience. For a number of years the mildness of Scarlet Fever has been s subject of comment and the opinion has been expressed that the danger to life of this disease has almost gone. It may be so, but unfortunately the weight of evidence does not justify such optimism. It is not so much the variation in the mortality of Scarlet Fever in different countries in recent years as the past history of the disease which suggests caution in our outlook. In 1675 Sydenham described Scarlet Fever as "an ailment, we can hardly call it more," and yet in the very year of Sydenham's death it was epidemic in London and became the severe disease of which malignant attacks were recorded. Again, that illustrious teacher Bretonneau taught that Scarlatina, which he had formerly heard spoken of as a dangerous malady, was then a mild infection, and he said that from 1799 to 1822 he did not recollect seeing a single fatal case. In 1824 an epidemic of severe type broke out in Tours and its neighbourhood and the result was that Bretonneau who had previously looked upon Scarlet Fever as a slight malady now learned to regard it as equally mortal with plague, typhus and cholera. In 1834, Graves in referring to what he terms " the destructive epidemic of Scarlet Fever " then prevailing in Dublin, Uoes on to say that in September, October, November and December, 1801, Scarlet Fever committed great ravages in Dublin and 38 continued its destructive progress until the Spring of 1802. Then he says that for the next 27 years, epidemics of Scarlet Fever though frequent, were always of a benign type. In 1831 however, there was a notable alteration in the character of the disease when occasional cases unexpectedly proved fatal. According to Farr, Scarlet Fever was an exceedingly fatal disease in England and Wales during the years 1848-1855. There is no doubt that in the past, Scarlet Fever has varied greatly in severity, having been at times a benign disease and at others a very fated one. Scarlet Fever has evidently remained a mild disease for periods amounting to about a quarter of a century and then assumed a grave form. It would seem then, that the behaviour of this disease during recent years is not unlike what has happened in the past, and consequently it would be wise to regard it with suspicion and to be on our guard. From personal observation it appears that the type of Scarlet Fever prevalent in 1932 was less benign than in the immediately preceding years. There were 6 deaths from the disease during the year, corresponding to a death rate of .096 per 1,000 of the population. This is the highest death rate in the Borough since 1911. 1 of the deaths occurred outside the Borough, but the other 5 occurred at the Borough Isolation Hospital. One of these patients, a man of 29 years, was undoubtedly a true case of toxic Scarlet Fever. He was admitted tu hospital in an almost moribund condition ana died in three hours, and within 48 hours of the onset of illness. There was an intense dusky rash with only moderate faucial symptoms. Another patient, a child of 18 months, was admitted on the 2nd day of illness, with a heavy rash and severe faucial symptoms. In spite of anti-scarlatinal and anti-streptococcal sera the child died on 15th day of the illness. The third patient, a woman of 33 years, was admitted on the 3rd day of illness with a sharp attack of Scarlet Fever. She was treated with anti-scarlatinal serum but the symptoms did not abate with the disappearance of the eruption and the temperature remained up and assumed a remittent type. The possibility of a coincident typhoid infection was considered and excluded, and the patient drifted downhill until her death on 14th day from the commencement of the illness. 39 Our 4th fatal case, a child of 5£ years, came into hospital on the 4th day of the illness. There was profuse nasal and ear disdarge, and the glands of the neck were much enlarged. The land was treated with serum on admission, but the symptoms abated only slightly and she died on the 7th day from the onset. The last fatal case was a girl of 8 years who was admitted on the 5th day of illness. The rash had faded and the faucial symptoms were moderate were moderate but the general toxaemia was sevre. Anti-streptococcal serum was given, but signs of Prevmonia developed within a few days of admission and the child diod on the 12th day from the onset of disease. The child who died from the disease outside the Borough was originally a patient at the Borough Isolation Hospital. She was a girl of 5½ years. Until the 3rd week she made uneventful progress; purpura haemorhagica then developed and she was freaferred to the London Fever Hospital for blood transfusion and operative treatment. Unfortunately the condition became very much worse and the child died. We have been struck by the fact that the cases admitted to hospital in the early stages of the disease have made more satisfactory progress than those admitted a few days later after the on set. This is undoubtedly due to the fact that anti-scarlatinal Senun is given to all but mild cases on admission to the hospital as long as they are admitted sufficiently early for the serum to be of benefit. The injection of serum is found to have a marked effect upon the course of the disease, provided that it is given sufficiently early. Complications are prevented and the stay of the Patient in hospital considerably shortened. Dick testing for susceptibility to Scarlet Fever and immunisation against the disease is less commonly used than is Schick testing for Diphtheria, probably owing to the relative mildness of Scarlet Fever. In the hospital, passive immunisation against Scarlet Fever has been of tremendous value in checking the spread of the disease when a case has arisen in one of the Diphtheria or Measles wards. Meningococcal Meningitis. There were only two cases of Meningococcal Meningitis notofied during the year. 40 Encephalitis Letharigca. There were no notifications of Encephalitis Lethargica and no deaths occurred from the disease, or other germ diseases of the central nervous system. Small-Pox. No cases of Small-Pox were notified during the year. Several contacts of the cases which occurred outside the district have how ever been notified to us and kept under supervision. Ophthalmia Neonatorum. 5 cases of Ophthalmia Neonatorum were notified. The Council has agreement with the London County Council for the admission, if necessary, of cases into St. Margarets Hospital. Two cases were admitted under the terms of the agreement. All the cases recovered and the sight was not affected. Whooping Cough. During the year 6 deaths occurred from Whooping Cough As Whooping Cough is not compulsorily notifiable, it is not easy to estimate the probable number of cases which occurred here last year. Whooping Cough is admittedly a most difficult disease to prevent. In the early stages, it is impossible to diagnose it. The initial cough is no different from coughs from other causes to which children are liable, and the characteristic spasm and whoop do not occur until about the second week. The disease is infectious dunring the early catarrhal stage and opportunity for contact is abundantly afforded by the usual conditions of urban life. As far as schocts are concerned the efforts to control it are almost useless. Exclusion of cases from the schools after they have become clinically manifest cannot be effective in controlling an outbreak. It has been assumed that the epidemic cycle in Whoopig Cough is due to the fact that there is some cycle of activity of the bacillus influenced by seasonal conditions. It is well known that Whooping Cough is more severe when it occurs during the winter months. This theory however is discounted by the fact that the epidemic period is not identical in different towns. Even in the areas of London streets whose populations are continually mixing with each other, the cycle can be in a different phase by severed months. 41 When an epidemic occurs in the winter months the difficulties of treatment appear to be greater. There is no specific treatment tor the disease. The results obtained from the use of the Bordetbengon vaccine have been unsatisfactory. The Bordet-Gengon bacillus is characterised by a signal absence of toxin formation in culture, and a remarkably low virulence towards laboratory animals. Cultures of the bacillus in strength of billions of bacteria per c.cm. have been injected into small guinea-pigs without producing untoward results. Similarly, in the use of vaccine for prophylaxis and curative action in cases of whooping cough, children have shown a remarkable tolerance for quite enormous doses of the bacillus. In view of the immunity which an attack of whooping cough confers upon a child, it is reasonable to doubt if the Bordet-Gengon bacillus is the real cause of whooping cough. It is well known that second attacks are very rare, and artificial immunisation should not therefore be difficult. Measles. There were 12 deaths from Measles in 1932. In the early part of the year there was an extensive outbreak of Measles, which comemnced in the southern part of the district but which ultimately spread through all the wards. When the schools re-opened after Christmas several cases of Measles were found to have occurred during the holidays. Although we are not self contained as we were formerly, and the first cases which occurred in the district were fairly easily traced, we still frequently trace the source of the infection of Measles. In this instance, though, the original case which gave rise to the present outbreak was not traced. It had been known that Measles became prevalent in London towards the end of 1931. The administrative County of London is such a huge area that deaths from Measles appear in every weekly return of deaths. In this respect it differs from all other towns in England and Wales. In other places Measles is an explosive outbreak and then "the town is entirely free of the disease for a year or two and no deaths from Measles appear in their returns. In the autumn, London was almost entirely free from the disease, only one death being usually recorded from the disease, and on three occasions two deaths occurred in one week. In the week ended November 14th, 6 deaths were recorded, but the number was only 2 in each of the weeks ended November the 21st and 28th. In December the number of deaths steadily increased, and in the week ended January 16th, the number was 22. 42 Measles may therefore be said to have been prevalent in London towards the end of 1931. Having regard to the intercommunication between Acton and the Metropolitan Boroughs, it can easily be understood that the disease would soon be introduced here. Usually we are able to trace the first case, but in this instance we were unable to do so. We were aware of a case in the South West Ward in December, but this child was under school age, and was probably not the source of infection of the school cases. The family came from Scotland, and the child was ill on arrival, so ill that he was confined either to bed or to the house during his stay in the district. On the reopening of the schools after the Christmas holidays, 3 cases were reported, one from the South-East Ward, and 2 from the South West Ward. The 3 children all attended the Rothschild Infants Department, and the course of the outbreak throughout, coincided with the school distribution of the victims. In January the cases were limited to the South West and South East Wards west of Acton Lane, and south of the North London Railway, because the children of the Rothschild Road Infants Department and Beaumont Park Infants Department were drawn from this area, and these two were the departments in which the disease first made its appearance, afterwards the outbreak spread northwards and eastwards throughout the district. No disease observes so regular a periodicity as Measles, and once an outbreak occurs in a populous district, it is doubtful if any measures are efficient to control an epidemic. In Acton, the disease appears almost regularly every other year. Formerly, we used to have a major epidemic and a minor epidemic or as they are sometimes called an epidemic and a hypo-epidemic at regular intervals. In recent years, the epidemics do not vary much in their virulence or fatality from year to year. Although an epidemic cannot be controlled there has been a very considerable reduction in Measles mortality. Many factors have entered into the causation of this reduced fatality. Part of it is due to the lowered birth rate, though this only explains a small part of the reduced morbidity of Measles. A fuller appreciation of the causes of death in the sufferers from the disease, and an application of methods of prevention of these causes probably have had a much greater influence. 43 The specific cause of Measles has not been discovered ; it is probable that the disease is due to some living virus in the blood of the sufferer and is of the nature of a " filter passer." Whatever the cause whether it be a "germ" or a " filter virus," the proper mortality from "Measles" is trivial ; nearly all the deaths occurring during the disease are due to added symbiotic infection. We may have little control over Measles, but we have considerable powers over its symbioses. These are mainly pneumococci and haemolytic streptococci, which spread by droplet infection, and whose striking distance is short. Consequently, spacing has an enermous influence on the mortality from this disease. These facts have influenced our methods of combating the disease. We have sufficient accommodation for the immediate reception of all Many years ago, Sir Arthur Newsholme when Medical Officer of health for Brighton, showed that terminal disinfection after Measles was useless, and few authorities now trouble to carry out the disinfection. School closure has also been given up as worse than useless. Our efforts are concentrated on preventing the wortality, rather than preventing the spread of the disease. An endeavouris is made to obtain early information of all cases, and to secute good nursing. Where good nursing can be obtained in the home. this is sufficient, but in most industrial districts, this is nof possible in a considerable number of cases. Most authorities now andeavour to secure the necessary treatment in hospital, where the home conditions are unsatisfactory. Unfortunately, few authorities have sufficient accommodation for the immediate reception of all cases in which the home conditions are unfavourable with the result that many sufferers are not admitted to hospital until serious complications have intervened. We were comparatively fortunate in the matter of hospital accommodation during the epidemic, but shows impossible to arrange for the immediate admission of all cases which required removal from the home. Many of the cases admitted were suffering from bronchoprenmonia and this fact accounted for most of the deaths in hospital. The great majority of the cases in the disease did not develop complications and rapidly recovered from the disease. Other fators have operated in reducing the mortality from Measles. Among these may be mentioned the work which is done for Child Welfare and in the School Medical Service. The Health Visctors School Nurses endeavour to teach parents that Meastas is a serious disease and that its spread and danger may a reduced by avoiding the herding together of children during an epcdenic. 44 Moreover the advice given to mothers in the upbringing of children, the improvement in the physical condition of the children and the care of the teeth, nose and throat which is given at clinict have all contributed towards raising the immunity and increasing the resistance of the child to attacks of Measles and its complications. Diphtheria. In the year 151 cases of -Diphtheria were notified and there were 21 deaths from the disease. There was a considerable increase in the number of notifications, but the most marked increase was in the number of deaths which occurred. The increased incidence and fatality were due to a most virulent type of disease which made its appearance in the early autumn. In the early part of the year, the incidence of Diphtheria in the district was low. Up to the end of July the notifications from the different schools had been as follows: — Berrymede 5 Priory 4 Beaumont Park 3 Southfield Road 2 John Perryn 2 Turnham Green R.C. 3 Acton Wells 1 Derwentwater 1 In the same period, 8 cases occurred in children under school age, distributed amongst the wards as follows: — North East North West South East South West 2 113 In addition, 3 cases occurred in persons over school age in the North East Ward and 1 in the South West Ward. In August 4 cases occurred amongst school children: 2 from Beaumont Park and 1 each from the Central and Turnham Green R.C. Schools. Altogether 37 cases were notified up to thr end of August and 5 deaths had occurred. 45 Until September the disease could be said to have followed a farly normal course. Its incidence was slightly higher than that obseved in inter-epidemic years, but there were no cases of extreme vorulence in the earlier part of the year. The deaths which occurred were in young children—1 in an infant under 1 year of age, 1 in a child in his second year and 3 in children between the ages of 2 and 5 years.. Although the spread of Diphtheria in recent years has become associated with elementary schools, its fatality is still greater amongest children under 5 years of age. When extensive outbreaks occure. Diphtheria is typically a disease of schools and institutions where children are brought together at susceptible ages. But through its incidence is greatest at school ages its fatality is greater at ages under 5 years. It is not common in the first year but it becomes increasingly fatal, until the maximum morbidity is reached somewhere between the second and fifth year. The incidence declines slowly in the age group 5-10 years, after which the probaof contracting Diphtheria is small. Daring the earlier part of the year, the incidence of the disease conformed with that observed in other parts of the country, but the autumn the course of the disease was abnormal in many respects. Its age distribution was different, but its most marked characteristic was its extreme virulence. The earlier cases all occurred among pupils attending Southfield Road Junior School. Subsequently cases of a virulent type occurred in other schools, but it is of interest that a connection between these children and those who attended Southfield Road School could be traced. Of the two cases notified from pupils attending Southfield Read School early in the year, one had occurred in January and the other in March. Both were of a mild type and recovered. After the summer holidays, the first case was notified on September 24th and four others were notified in September, the dates being, September 26th—2 cases, September 27th—1 case, and September 28th- 1case. From the dates of onset of the latter 4 cases, it is Possible that the infection was contracted on the same date, but if at was a school infection, it was not a class infection. The children were in 5 different classes. These 5 cases were all severe, and three of them proved fatal. In the first fortnight in October, 8 other cases occurred in the school; 7 in the Junior Department and 1 in the Infants' 46 Department. The infection in the case of the child in the Infants Department was probably contracted in the home, as another case occurred in the family a few days previously. The course of the disease in the Southfield Road junior School will be referred to in a subsequent paragraph. The other schools which suffered were the County School Rothschild Road and John Perryn Schools. It is probable that the infection in the John Perryn School was an independent one. The type was not as virulent as that in the other schools, and there did not appear to be in intimate connection between the cases. 8 case occurred in John Perryn School, but there were no deaths. The first case which occurred in the County School was in a boy who resided in Bedford Park, and some of the cases were similar in character to those which had occurred in Southfield Road School. The type was probably modified, because the pupils were older and it is well known that Diphtheria is more fatal in young children. 4 cases occurred in Rothschild Road Infants Department in October and 5 other cases occurred in the first fortnight in November. There is a connection between Rothschild Road School and Southfield School, the senior boys of Southfield School being recruited from the Rothschild Road Junior School. Up to the end of the year, most of the cases of school ape occurred in these schools—^Southfield Road, Rothschild, John Perryn and County. 3 cases occurred among Acton girls attendin; Chiswick County School. These cases were also of a very virukm type. Cases occurred amongst children under school age in other parts of the district. The ward distribution is given on another page, but this was of less importance in the incidence of the disease than the school distribution. In the past four years outbreaks of extreme virulence have been reported not only in this country, but in other countries Europe. In this country, outbreaks of unwonted severity have been reported from several parts, and in districts in and around London outbreaks of the severe type of Diphtheria have occurred It has been suggested that Diphtheria generally is entering upon a more severe stage. If the disease is about to vary in virulence the first indication will be increased variation in local fatality. In the last few years, the numbers of districts which record rates higher 47 than the average have been increasing, and various factors have been assigned as a cause of this increased virulence. The chief causes are said to be, an increased virulence of the organism, and a lowered communal immunity. The work originating in Leeds suggests two strains of corynebacterium Klebs Loeffler. In 1931, when investigating a severe outbreak of Diphtheria in Leeds, it was ascertained that there were two kinds of Diphtheria bacilli, to which the names of Diphtheria Bacillus Gravis and Diphtheria Bacillis Mitis were given. The cultural characteristics of the two types are said to be a definite and constant, though there are intermediate types. As a result of .this work it was suggested (a) that the gravis type is mainly, or even solely, associated with severe forms of Diphtheria, (b) that the mitis type causes only mild attacks, and (c) that attacks caused by the gravis strains respond less satisfactorily to the ordinary anti-toxin prepared from the Park-Williams bacillus, and that a special anti-toxin is called for. Dr. O'Brien of the Wellcome Research Laboratories kindly examined some swabs from the most severe of our cases. 10 swabs were sent to him, and he reported that 6 were of the gravis type, 2 of the mitis type, and 2 contained bacilli of the gravis and mitis types. Exaltation of virulence has been denied by some bacteriologists, and in an article in the British Medical Journal of November, 19th, 1932, Dr. O'Brien and his co-workers set forth the result of their experience. They stated that there is no satisfactory evidence that the gravest types of Diphtheria are generally associated solely or even mainly with the gravis types of bacillus. If gravis and mitis cultures are injected into groups of guinea pigs the two groups can be saved with' equal readiness by Park 8 antitoxin given some hours later. Guinea pigs immunised with prophylactic mixture which are impervious to human immunisation in England and which are prepared from Park 8 strain survive the injections of large doses of gravis cultures. Bacteriologists, of course, can only determine virulence of human parasites by the reaction upon adventitious hosts. It is possible that Diphtheria may very in virulence towards man, its natural host, and yet show no alteration in its behaviour to rabbits or guinea pigs. There is room therefore for the clinicians to express their opinion as to the character of the disease. It is impossible for the clinicians to adduce evidence which is acceptable to the pure scientist. It is always difficult to attain a reliable history in a large number of cases. This is more particularly true of the mild type of disease and of small children. But in some of these cases, we were satisfied that the history was correct and that 48 anti-toxin was given within 36 hours of the onset; in spite of this the patient died. We have been used to a rapid improvement and recovery when anti-toxin is administered early, especially when the disease occurs in older children. The early cases in the autumn were in older children; of the deaths which occurred, 2 were aged 12 years, one 11 years, one 10 years and two 8 years. As previously stated, most of these were admitted in a comparatively early stage of the disease. In these older children anti-toxin was given intravenously and in large doses. There is always a tendency to blame the therapeutic agent placed in our hands when we are face to face with an outbreak of Diphtheria, but these details are mentioned not with the object of finding fault with the anti-toxin, but to emphasize the difference in the reaction of these cases to treatment as compared with that observed in the ordinary way. It cannot be said that these children would be peculiarly liable to a fatal result if attacked by any serious illness. The children in these particular schools would compare favourably not only with the children in the other schools in the district, but with those of any elementary and secondary school in and around London. We are forced to the conclusion that in the present instance the type of the disease was a very virulent one and this virulence was probably caused by an exaltation of virulence in the germ. The other factor which might have been operative was a low communal immunity. In the present century much attention has been paid to the study of epidemics, and the conditions under which outbreaks of infectious diseases occur, and in order to appreciate the importance of certain procedures which have been adopted to prevent Diphtheria, it is necessary to take a wider view of the subject. Diphtheria is not a disease of modern times, but until late in the last century it was confused with other diseases. The discovery of the Klebs Loeffler bacillus in 1883-84 contributed towards the correct diagnosis of the disease. Ten years later antitoxin was discovered and this affected mortality from the disease to an enormous extent. From 1895 onwards, the use of anti-toxin became general and although other factors may have operated, the introduction of anti-toxin has been one of the principal factors in the reduction of the fatality. For nearly 30 years there was a continuous decline, but in the last 10 years the mortality from Diphtheria has been almost stationary. On account of the smaller population our deathrate has been different from that of the rest of the kingdom, but the tendency has been a downward one. 49 The following table gives the number of notifications and deaths from Diphtheria since the adoption of the Notification of infectious Diseases Act, 1889. Year. Population. Notifications Deaths. 1931 70,560 61 4 1930 69,565 103 9 1929 68,600 68 1 1928 67,645 78 7 1927 66,700 69 1 1926 65,760 42 2 1925 64,845 63 1 1924 63,945 45 5 1923 62,720 61 3 1922 62,170 223 12 1921 61,299 205 16 1920 61,000 141 18 1919 61,732 54 2 1918 59,000 116 2 1917 65,219 67 3 1916 57,913 81 4 1915 58,238 78 14 1914 61,000 116 10 1913 60,000 117 8 1912 59,000 100 8 1911 58,048 115 9 1910 57,000 118 8 1909 56,000 104 22 1908 55,000 83 7 1907 53,000 63 5 1906 52,000 46 2 1905 50,000 49 4 1904 46,780 32 2 1903 43,803 22 4 1902 41,000 33 6 1901 38,373 34 4 1900 36,508 28 4 1899 34,901 49 7 1898 33,404 35 8 1897 31,952 89 28 1896 30,564 23 8 1895 27,648 32 5 1894 27,600 22 5 1893 26,000 41 2 1892 25,000 27 4 1890 23,500 14 7 50 Before 1905, the figures for the deaths are not strictly accurate. Since 1905, all the outside deaths have been included but prior to that date, a complete return of the outside deaths was not available. Although I have not worked the figures as percentages of the total population, they plainly show the periodicity ot the disease. In recent years Diphtheria has made its appearand in certain epidemic waves, the crests of which attain their maxima at intervals of a certain number of years, although the general tendency has been towards a diminution of the mortality. What are the factors which influence the appearance of these waves? I have already referred to one factor which may be operative I have mentioned the extreme virulence of the type and it is suggested that this is due Jp an alteration in virulence of the causal agent. This theory would account for the outbreak by the appearance of a very virulent type of bacillus, which has been mentioned in a previous paragraph as the Diphtheria Bacillus Gravis. It means that an alteration in the type of the disease has occurred in the epidemic period. During the inter-epidemic periods the disease is less potent and also less infectious, and it is suggested that this increase in potency and infectivity gives rise to the epidemic. This factor may be operative, but a more important factor probably is the gradual accumulation of susceptible persons in the population. This factor may act over longer or shorter periods We have an example of the shorter period in the periodicity of Measles, which in this country makes its appearance almost regularly in the large towns every 2 years. The same factor probably operates in the case of Diphtheria, but the outbreak of a less explosive character and epidemics occur at longer intervals. It is a matter of common knowledge that any group of individuals contains susceptibles and insusceptibles or immunes In the case of Diphtheria, the immunity is acquired by repeated exposure to diphtheria infection. If a district remains comparatively free from diphtheria for a long time, a considerable amount of susceptible material accumulates in that community, and as explosive outbreak sooner or later occurs. When the herd immunity is lowered to a certain point that community is particularly vulnerable. We do not know what rates of susceptibles cause parasitic infections to become epidemic, and it is quite possible that a slight raising or a slight lowering of susceptibles may make an enormous difference in disease incidence. The measures hither, employed against the spread of this disease which aim at the truction of the germ—disinfection, bacteriological search carriers, isolation of clinical cases—have proved inadequate. In the past our mode of procedure consisted of hospital treatment of 51 actual cases, swabbing of contacts and the search for carriers. At the onset of an outbreak this method may prove successful in cutting it short, at any rate for a time, but when the cases are distributed throughout a school or are in different schools, the number in which diphtheria bacilli are found in the throats is so oreat, that isolation of all suspected cases is impossible. Our best method of success is by raising the herd immunity of the community. The problem is to render the susceptible, insusceptible. In the last annual report of the Ministry of Health, Sir George Newman states that in the case of Diphtheria this is not only feasible and practicable but eminently desirable. As far as this district is concerned Schick-testing and active immunization' are inovations, and it may be advisable to give a short account of the process. The Schick-test of susceptibility was introduced in 1913 and involves the injection into the skin of a minute dose of Diphtheria toxin diluted with saline solution. The reaction depends on the local irritant action of Diphtheria toxin when so injected. If the blood of the person injected contains an insufficient amount of anti-toxin to protect him against Diphtheria, he is liable to contract the disease if he comes in contact with another person suffering from Diphtheria. In this case he will give what is called a positive reaction. This reaction is characterised by an area of redness about half &n* inch or more around the site of injection. If the person tested is immune or not susceptible to diphtheria, no redness occurs and he is said to be a negative reactor. The next step is the active immunisation of the susceptible persons or the positive reactors. Passive immunity is frequently brought about by injecting small doses of anti-toxin and this is made use of to protect children in a general hospital exposed to infection when Diphtheria occurs in a ward. Doctors also give doses of anti-toxin to other members of the family when a case has occurred in a house. This kind of immunity is called passive because the cells of the blood do not produce any anti-toxin, but the anti-toxin is introduced from without and circulates in the blood. The immunity thus conferred is transient and probably lasts only for a few weeks. Active and prolonged immunity can only be conferred when the cells of the body manufacture anti-toxin, and this form of immunity is produced when a person suffers from the disease. This is the reason why a person rarely suffers more than once from such diseases as Measles, Scarlet Fever, Diphtheria, etc. The patient tas stored in his tissues sufficient anti-body to fight the particular disease for the rest of his life. The same process can be introduced 52 in the case of Diphtheria without actually suffering from a clinical attack of the disease. Von Behring in 1913 suggested the use ot toxin anti-toxin as an immunising agent, the toxin being sufficiently neutralised by anti-toxin to antagonise its dangerous properties. The use of toxoid-antitoxin as a prophylactic was first adopted on a large scale in 1921 .in New York City. Three injections of the prophylactic are needed to develop gradually an immunity against Diphtheria. It is estimated that about 95% of the Schick-positives become Schick negatives in less than six months after inoculation. As far as this country is concerned prophylactic immunisation has only been used extensively to deal with staffs of nurses and inmato of large institutions and schools where outbreaks of Diphtheria have occurred or are likely to occur. America and Canada are far ahead of this country in instituting general prophylactic measures against Diphtheria. An idea of the work done in the United States may be gauged by the records of Philadelphia where 364,000 children had been immunised by the end of 1929 ; the attack-rate had fallen to the low level of 0.4 per thousand inhabitants and no hospital for Diphtheria was required. In this country opposition is fairly strong and it is difficult to get people to understand the benefits of the process. Stress is laid upon the accidents which have occurred, these are admitted, but they have occurred under conditions which are not likely to occur in this country. No accidents have occurred in England. The report of the Chief Medical Officer of the Ministry of Health deals with this aspect. "As a necessary preliminary to such a process as immunisation it is necesasry to be satisfied that the reagents employed will in fact effect that which is claimed for them and that they are otherwise innocuous. Thcie is no doubt that given the safeguards now supplied by the provisions of the Therapeutic Substances Regulations, these claims have been fully substantiated as far as the immunising reagents used in this country are concerned." Those who most appreciate the value of immunisation are by no means eager to press it unduly ; they feel that its future is assured if it is allowed to make its own way on its merit. A report was submitted to the Health Committee and the School Management Committee and it was decided to offer immunisation to all those who desired it. As two of the schools were affected the procedure was primarily adapted to the school population. Requests were also received from parents of children in other schools for the immunisation of their children. It was therefore decided to carry out this part of the work at the School Clinc 53 on Saturday mornings. The Saturday morning clinic is still being carrued on, but it is now attended mostly by children under school ags. It was explained that if the response from Southfield Road and the County Schools was favourable, it would be impossible to carry out the Schick testing without outside assistance. A circular was issued to all the parents, and it was stated that acceptance was to be entirely voluntary, and that the immunisation could be carried out by the family doctor if the patents so desired. There were 484 acceptances from Southfield Road School, and 257 from the County School. Arrangements were made with Dr. Guy Bousfield to do the Schick test. Dr. Bousfield has probably done more Schick testing" and immunisation than any other person in this country, and we were fortunate in obtaining his services. In the other schools the problem was not so urgent and Dr. Howell and myself were able to arrange to carry out the work. It is impossible at the present time to give a full report of the work done, a.s it is Shell going on. It will be more convenient to give an account of in at a later stage. It may be mentioned that up to the end of February, 1933, we had Schick tested 1,922 children and immunised partly or wholly 1,909 children. Because of the necessity of controlling the epidemic in the Schools we had to concentrate our attention very largely on the children of school age. It is recognised, though, that if preventive measures are undertaken to stamp out Diphtheria, it is essential that a large proportion of the most susceptible subjects—children' of pre-school age^should be immunised. Recent work has-shown that although fifty to. seventy per cent, of children of school age have been protected, it was not until at least an additional thirty per cent. or more of those under five years had been immunised any fall in the Diphtheria rate of the community as a whole was produced. If success is to be attained, our efforts must be drected towards the protection of the pre-school child who is exposed to greater risk from his higher susceptibility and from home contact with older children attending school. The tendency recently has been to urge immunisation at on earlier age than was formerly the practice. Formerly it was usual to delay immunisation until the second year of life, but It has been found that the supposed maternal transmitted immunity in infants varies considerably during the first twelve months of life. Compared with other districts, we must consider that our compaign has been very successful. This has bene due partly to the severe type of disease which was experienced. Opposition has 54 of course been met, but the opposition has been due to some misundrstanding as to the object of the process, and also to a want of appreciation of the seriousness of the disease. Diphtheria has for some time been mild in character, and the fathers in particular have not been very helpful. The opposition of the fathers has arisen in many instances from their experience of inoculations in the army. Many of them state that unfavourable symptoms followed their inoculation for Typhoid and vaccination for SmallPox. The mothers, on the other hand, have seen for themselves the freedom from pain at the inoculatoin and the subsequent absence of reaction. Many mothers have come to us to complain that their children could not possibly have been inoculated, because the children have not felt the prick of the needle, nor was there the slightest mark or reaction following the inoculation. It is not claimed, of course, that there is no reaction in any case. A slight redness of the arm does occasionally result and rarely a local reactions may persist for a day or two. But in the vast majority of cases there is not the slightest local or constitutional reaction. The mothers are also more familiar with the facts connected with cases of Diphtheria which have occurred in their neighbour's homes and that the cases have occurred with a persistent regularity amonges those children whose parents had refused immunisation. The fathers, being at work, would not be so cognisant of these facts and possibly not so appreciative of any new procedure in the prevention of the disease. Naturally, some people confuse immunisation with vaccination against Small-Pox. One parent refused because she said that her neighbour's child had been vaccinated but in spite of this, had contracted Measles, Whooping Cough and Scarlet Fever. Many people do not appreciate that immunisation is against one particular disease, and that it has no effect upon any other disease. Tuberculosis. 96 cases of Pulmonary Tuberculosis and 18 cases of other froms of Tuberculosis were notified during the year. There were 48 deaths from Pulmonary Tuberculosis and at deaths from other forms of Tuberculosis. 55 The death notification interval of the 48 patients who died of Pulmonary Tuberculosis in 1932 was:— Information from Death Returns 12 Died within 1 month after notification 7 Died between 1 and 3 months after notification 6 Died between 3 and 6 months after notification 2 Died between 6 and 12 months after notification 5 Died between 1 and 2 years after notification 6 Died between 2 and 3 years after notification 3 Died over 3 years after notification 7 On December 31st the following is a statement of the particulars appearing in the Register of cases of Tuberculosis. Pulmonary. Non-Pulmonary. Total Males. Females. M ales. Females. Number of Cases of T.B. on the Register at the commencement of year 130 124 28 21 303 Number of Cases notified for the first time during the year 45 42 11 4 102 Number of Cases previously removed from the Register which have been restored thereto during the year 1 2 - - 3 Number of Cases added to the Register other than by notification 4 3 1 2 10 Number of Cases removed from the Register during the year 22 21 5 2 50 Number of Cases remaining on the Register at teh end of the year 158 150 35 25 368 In 1932, the Tuberculosis Officer examined 95 new cases at Pulmonary Tuberculosis and 15 new cases of Non-Pulmonary Tubrculosis. 53 patients were admitted to Sanatoria under the country scheme and 23 were admitted to Hospitals. 56 Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0— - - - - - - - 1 1— - - 3 1 1 - 1 1 5— 1 1 1 1 - - - 1 10— - 1 1 - - - - - 15— 6 8 2 1 2 4 1 1 20— 4 16 - - 3 4 - 1 25— 10 11 1 2 4 7 - - 35— 9 4 2 1 3 5 - - 45— 11 3 - - 4 3 1 1 55— 7 2 2 - 3 2 1 1 65 and upwards 1 1 — - 2 1 — — Totals 49 47 12 6 22 26 4 7 57 ISOLATION HOSPITAL. The Acton Council Isolation Hospital contains 88 beds normally. During 1932 we had to increase these to an emergency member of 122 in order to cope with the epidemics of Scarlet Fever and Diphtheria. 758 cases were admitted during the year compared with 262 cases during 1931. On January 1st, 1932 there were 29 cases in the hospital and on January 1st, 1933 there were 107. The following is a list of the cases admitted for the different desease. Scarlet Fever. Diphtheria. Measles. 382 134 81 Wembley 77 25 7 Kagsbury 28 21 3 Total 758 The 39 deaths were distributed as follows: — Scarlet Fever. Diphtheria. Measles. 5 20 9 Wembley — 4 1 Kagsbury — — — A discussion on the deaths from Scarlet Fever will be found the report on that disease. A report on the Diphtheria epidemic is given above but the at deaths in hospital need some explanation. While admitting that the type of Diphtheria was in many instances a most virulent one, yet several apparently hopeless cases which were sent in at an early stage of the disease recovered. We must however, emphasise the fact that many of the cases were so ill on admission to hospital that all our efforts were almost bound to be in vain. 9 of the patients who died were admitted on or after the at day of disease while 4 were admitted on the 3rd day. 58 Under these circumstances the case mortality is bound tc be extremely high whether the infecting strain of diphtheria bacillus is of exalted virulence or not. 6 patients died within 36 hours of admission to hospital and of these 1 died within an hour and 1 other within 12 hours. 2 patients died on the 2nd day, 5 between the 4th and 6th days, and 7 between the 6th and 14th days. The other 4 developed complications and died later in the course of the disease. All were given large doses varying from 40,000 to 50,0fK) units of anti-toxin intravenously as a first dose together with a solution of glucose and colloidal iodine by the same route. It is perhaps not amiss to remind practitioners of the heavy responsibility which lies upon them in waiting for the result of a swab before giving anti-toxin in a suspicious case during the present epidemic. BACTERIOLOGICAL EXAMINATIONS. (a) For Diphtheria. Positive. Negative. Total Examinations 2245 231 2014 Sent by Medical Practitioners 97 582 do. (re-examinations) 9 167 Sent from Isolation Hospital 79 683 do. (re-examinations) 1 84 Convalescents (1st Swabs) 2 52 Contacts 33 289 do. (2nd examinations) 4 76 do. (3rd examinations) — 16 Precautionary Swabs — 26 School Sore Throats 6 39 (b) For Ringworm. Total Examinations—9 6 3 (c) For Tubercle. Total Examinations—137 31 106 59 MATERNITY AND CHILD WELFARE. Infantile Mortality. 17 of the deaths were due to prematurity or to causes Iaocated with prematurity. There is no material change to report upon the conditions generally. Maternal Mortality. 7 deaths occurred in child bearing women, 4 of which spurred within the Borough and were investigated. The first case was a woman of 32 who had received antemantal care during this her first pregnancy. Caesarean section was advised on account of a generally contracted pelvis and the patient was admitted to hospital ; death occurred on the 11th day after operation; post-mortem multiple abscesses were found in the uerus. The second case, a woman of 38 in her 2nd pregnancy was seen twice before her confinement. There was retention of the placenta and post partum haemorrhage. The patient was removed to hospital, but death took place from haemorrhage and- shock. The 3rd case was a woman of 28 who had received antenatal treatment throughout her pregnancy. The home conditions were excellent and we were satisfied that all possible precautions had been taken at the confinement, but the woman died of puerperal septicaemia. The 4th case was a woman who had been admitted to hospital curing the 6th month for severe vomiting. She remained an inpatient for 5 weeks and then returned home ; 3 weeks later she was re-admitted and a healthy child was bom. On the 10th day the discharged herself from hospital but had a fit on arrival at home. She was re-admitted the same day in coma, pneumonia supervened and she died 5 days later. Of the 3 cases which died outside the Borough, 1 died during the 3rd month of uncontrolled vomiting, the 2nd of chorion opitheloma and the 3rd of puerperal sepsis. 60 Pre-Natal Clinic. The clinic is held once a fortnight in the School Clinic premises in Avenue Road and Dr. Bell is in charge. 25 sessions were held with a total of 231 attendances. This dees not represent the whole of the pre-natal work done. In the case of those who apply for admission to Park Royal Hospital, Dr. Bell usually sees the expectant mothers when application is first made and generally refers them to the pre-natal clinic at Park Royal Hospital. Maternity Home. The Council has an agreement with Middlesex County Council for the admission of maternity cases into Park Royal Hospital. The arrangements were reported fully in last year's report. During 1932 122 cases were admitted under this agreement. Day Nursery. The'Nursery is situated in Bollo Bridge Road, and is open on five days a week. The Nursery was open on 231 occasions, and 4,871 whole day attendances were made. There has been an improvement in the number of attendances this year. Nurse Children. At the end of the year 1931, there were 53 children and at the end of the year 1932 there were 57 children on the register, and 5 between 7 and 9 years of age. Child Welfare Centres. There has been no change in the arrangements for the Child Welfare Centres since last year. Seven sessions are held weekly— 4 in Avenue Road, 1 each in Steele Road Mission, John Perry" School and St. Gabriel's Hall. 61 TABLE F. BIRTH-RATE, DEATH-RATE, AND ANALYSIS OF MORTAL BY DURING THE YEAR 1932 The Mortality rates for England & Wales refer to the whole population, but for London and the towns to Rate per 1,000 Population Annual Death-rate per 1,000 Population. Rate per 1,000 Births Percentage of Toran Deaths Live Births. StillBirths. All Causes Enteric Fever Small Pox Measles Scarlet Fever Whooping Cough Diphtheria Influenza Violence Diarrhœa and Enteitti (under 2 year) Total deaths unfar 1 year Certified by Registered Medical Practitioners Inquesy Cases Certified by Coroner after P.M. No Inquest Uncerfied Causes of Death England and Wales 15.3 0.66 12.0 0.01 0.00 0.08 0.01 0.07 0.06 0.33 0.54 6.6 65. 91.1 62 1.8 0.9 118 County Boroughs and Great Towns, Including London 15.4 0.64 12.2 0.00 0.00 0.12 0.01 0.08 0.07 0.28 0.54 8.6 70. 91.3 5.9 2.3 0.5 126 Smaller Towns (1931 Adjusted Population, 25,000—50,000) 15.2 0.68 11. 4 0.01 0.00 0.07 0.01 0.07 0.04 0.31 0.53 5.3 61. 91.9 5.8 1.3 1.0 London 14 3 0.46 12.3 0.00 0.00 0.19 0.02 0.08 0.07 0.28 0.57 12.5 67. 89.4 6.2 4.4 0.0 Acton 13.7 0.61 11.1 0.00 0.00 0.18 0.10 0.08 0.28 0.24 0.55 8.2 62. 01.6 5.1 3.3 0.00 The maternal mortality rotes for England and Wales arc as follows:— Puerpernl Sepsis. Others. Total. per 1,000 Live Births 1.61 2.63 4.24 per 1,000 Total Births 1.54 2.52 4.06 62 TABLE 2. VITAL STATISTICS FOR THE WHOLE DISTRICT DURING 1932 AND PREVIOUS YEARS Year Population estimated to Middle of each Year Births Total Deaths Registered in the District Transferable Deaths Nett Deaths belonging to the District Nett Under 1 year of Age At all Ages Number Rare Number Rate of Non-Residents Registered in the District of Residents Registered outside Dist. Number Rate per 1,000 Births Number Rate per 1,000 inhabitants 1922 62,170 1203 19.35 404 6.50 14 214 75 62 632 10.02 1923 62,060 1171 18.57 368 5.84 11 243 77 65 599 9.50 1924 63,945 1158 18.11 448 7.01 8 235 65 56 715 11.18 1925 64,845 1047 16.15 446 6.88 18 241 80 76 669 10.32 1926 , 65,760 1098 16.70 422 6.42 15 250 60 55 657 9.99 1927 66,700 1026 15.60 445 6.67 21 280 62 60 704 10.55 1928 67,645 1003 14.83 479 7.08 29 244 55 55 694 10.26 1929 68,600 1026 14.96 540 7.87 21 307 85 83 826 12.04 1930 69,565 1105 15.88 440 6.33 31 284 56 50 693 9.96 1931 70.560 1018 14.43 456 6.46 35 321 62 61 742 10.52 1932 70,640 970 13.7 486 6.88 29 302 60 62 786 11.11 63 TABLE AGES AT DEATHS AND EARD DISTRIBUTION OF DEATHS IN 1952 AGES IN YEARS Causes of Deaths All age Under 1 year 1 and under 2 2 and under 5 5 and under 15 15 and under 25 25 and under 45 45 and under 65 65 and upwards WARD DISTRUBUTION North East North West South East South West Measles 12 2 4 6 - — — — — 1 1 2 8 Scarlet Fever 6 — 1 1 2 — 2 - — 1 3 1 1 Diphtheria 21 1 1 10 9 — — — — 3 3 12 3 Whooping Cough 6 3 1 2 — - — - — 1 — - 5 Influenza 12 — 1 — — 1 3 3 4 4 5 2 1 Cerebro-spinal meningitis 2 1 — — — — 1 — — — — 1 1 Phthisis 48 — 1 — — 13 19 12 3 11 6 13 18 Other tubercular diseases 11 1 2 — 1 3 — 4 — 5 3 - 3 Cancer 101 — — —- — — 11 40 50 27 32 21 21 G. P. I. & Tabes 3 — — — — — — 1 2 3 - - - Rheumatic Fever 2 — — —. — 1 — 1 — 1 - 1 - Syphilis 1 1 — - — — — — — — — — 1 Diabetes 5 — — - — — — 1 4 3 — 2 - Heart Disease 95 — — - 1 2 8 30 54 29 28 18 20 Cerebral Hæmorrhage 33 — — — — — — 6 27 11 12 4 6 Other circulatory diseases 54 - - - - - - 16 38 16 17 11 10 Bronchitis 46 — — — — 1 2 21 22 12 10 12 12 Pneumonia 41 9 3 2 2 1 2 12 10 11 8 10 12 Other respiratory diseases 5 — — 1 — — 3 1 — 2 2 1 — Diarrhœa 8 8 — — — — — — — 3 — - 5 Peptic Ulcer 7 — — — — — 2 3 2 2 - 1 4 Appendicitis 5 - - - - - 2 2 1 3 1 1 — Cirrhosis of Liver 4 - - - - - 1 3 — - - 2 2 Other Liver Diseases 1 — — — — — - — 1 1 - - - Nephritis 27 1 — — — — 5 7 14 7 3 8 9 Puerperal Sepsis 3 - — — — 1 2 — — 1 — 1 1 Other diseases or accidents of Parturition 4 — — — — 1 3 — — 2 — 1 1 Prematurity &c. 27 27 — — — — — — — 12 5 2 8 Senility 95 — — — — — — 2 93 19 31 20 25 Suicide 14 — — — — 3 10 1 7 2 3 2 Other violent deaths 25 2 — 2 - 4 5 4 8 8 7 4 6 Other defined diseases 64 4 1 — 4 4 12 21 18 20 14 21 9 TOTALS 788 60 15 24 19 32 86 200 352 226 193 175 194 64 TABLE 4. INFANTILE MORTALITY, 1932. Causes of Death. Ages. Wards. Total Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks 1—3 months 3—6 montns 6—9 montns 9—12 montns North East North West South Baal South West Prematurity 17 12 2 2 - 1 - - - 9 4 - 4 Marasmus 3 — - — - - 3 — - - — 1 2 Pneumonia 7 - - — - 4 1 - 2 1 2 1 3 Pyloric Stenosis 3 - - - - 1 1 - 1 — 1 2 - Swallowing vomited matter into trachea 1 - - - - - 1 - - 1 - - - Tuberculous Meningitis 2 — - - - - 1 1 - 1 - 1 - Measles 1 - - - - - - 1 - - - 1 - Cerebro-spinal Meningitis 2 — — — - — — 1 1 — - 1 1 Diphtheria 1 — — — - — 1 - - — - - 1 Whooping Cough 3 — — - - - 1 - 2 1 - - 2 Accidental suffocation in pram 1 — — - - - 1 - - - - - 1 Overlaying 1 - — - - 1 — - - — — - 1 Prolonged labour 1 1 - - - - - - - - — - 1 Diarrhœa 8 — 2 - - 1 3 1 1 2 1 - 5 Septic Finger toxaemia 1 — - - 1 - - - - - 1 - - Syphilis 1 - - - - 1 - - - - - - 1 Congenital Heart disease 1 1 - - - - - - - 1 - - - Congenital Pyloric Stenosis 1 - - - - 1 - - - - - 1 - Congenital atresia of oesophagus 1 1 - - - - - - - 1 - - - Cellulitis of scalp 1 1 - - - - - - - - - 1 - Acute Nephritis 1 1 - - - - - - - - 1 - - Injury at birth 1 - - - - - 1 - - - - - 1 Pemphigus Neonatorum 1 1 - - - - - - - - - - 1 TOTALS 60 18 4 2 1 10 14 4 7 17 10 2 24 65 TABLE B. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1932. Notifiable Disease. Cases notified in whole District. At Ages—Years. Ward Distribution. At all Ages Under 1 1 to 5 5 to 15 15 to 25 25 to 45 45 to 65 Over 65 North East North West South East South West Small-Pox 1 - - - 1 - - - 1 - - - Scarlet-Fever 537 — 185 286 33 32 1 - 115 09 110 243 Diphtheria 151 1 47 85 12 5 1 - 38 25 31 57 Enteric Fever 1 — - - - - 1 - - 1 - - Paratyphoid B. 2 — — - 1 - 1 - - 2 - - Pneumonia 41 1 5 5 4 11 8 7 10 12 5 14 Puerperal Fever 3 - - - 2 1 - - - 1 1 1 Puerperal Septicaemia 1 - - - - 1 - - 1 - - - Cerebro-Spinal Fever 2 - 1 - 1 - - - 1 - 1 - Ophthalmia Neonatorum 5 5 - - - - - - 1 1 1 2 Erysipelas 19 — 2 3 1 6 6 1 3 7 4 5 Acute Anterior Poliomyelitis 1 — — 1 — - - - 1 - - - Tuberculosis (resp.) 96 — - 4 35 35 20 2 28 22 18 28 Tuberculosis (other) 18 - 5 3 2 6 2 - 4 4 3 7 TOTALS 878 7 245 387 92 97 40 10 203 144 174 357 66 OPHTHALMIA NEONATORUM. Cases. Vision unimpaired Vision impaired Total Blindness Deaths. Notified Treated. At home. In hospital. 5 3 2 5 — - - 67 TABLE 6. CASES REMOVED TO HOSPITAL. Total Notified. Small-Pox 1 1 scarlet Fever 382 537 Diphtheria 134 151 Enteric Fever 1 1 Paratyphoid B. 2 2 Pneumonia 14 41 Puerperal Fever 3 3 Puerperal Septicaemia 1 1 Cerebro-Spinal Fever 2 2 Ophthalmia Neonatorum 2 5 Erysipelas 7 19 Acute Anterior Poliomylitis 1 1 TABLE 7. BIRTHS. Live Births. Male. Female. Total 483 487 Legitimate 465 467 Illegitimate 18 20 Still Births. Total 26 17 Legitimate 25 17 Illegitimate 1 — Notified Live Births. Ward Distribution. Total. N. East. N. West. S. East. S. West. Total Births notified in the district 657 208 146 98 205 Notifications received from other districts 298 91 75 55 77 Births registered but not previously notified 2 1 1 — — 957 300 222 153 272 Notified Still Births. Inside 15. Outside 19 Total 34 Notifications were received from: — Doctors and Parents 685 Midwives 304 68 TABLE 8. INFANT WELFARE CENTRES, 1932. Number of Centres provided and maintained by the Council 4 Total number of attendances at all centres during the year:— (a) by children under 1 year of age 10,490 (b) by children between 1 and 5 years of age 6,668 Average attendance of children per session 53 Number of children who attended for the first time during the year: — (a) under 1 year of age 713 (b) between 1 and 5 years of age 272 Percentage of notified live births represented by number of children who attended a centre for the first time during the year 74.6 Children treated at Dental Clinic 196 Children treated at Ophthalmic Clinic 13 Mothers treated at Ophthalmic Clinic 2 Children treated for Enlarged Tonsils and Adenoids 4 table 9. ANTE-NATAL CLIINC. Number of attendances by Dr. Bell 25 Number of Expectant Mothers who attended 193 Number of attendances made by Expectant Mothers 231 Mothers referred fro Dental treatment at the Clinic 39 Mothers supplied with Dentures 14 Expectant Mothers to whom Dried Milk was supplied 24 Number of packets of Dried Milk supplied 283 table 10. INQUESTS. Inquests—41. Suidde 13 Fall from Motor Car 1 Run over by Motor Car 6 Accidental Bums 1 ,, ,, ,, Motor Van 2 Found drowned 1 ,, ,, ,, Train 2 Surgical Operation 1 ,, ,, ,, Motor bus 1 Childbirth-retained placata 1 ,, „ „ Taxi 1 Injury at football 1 ,, ,, ,, Motor Cycle 1 Accidental suffocation in pram 1 69 Motor Collision 1 Overlaying 1 Run over by horse drawn cart 1 Kidney disease 1 Accidental fall 2 Coal gas poisoning 1 Fall from Motor Cycle 1 Coroner's Certificate after Post-Mortem without Inquest—26. Pneumonia 4 Scarlet Fever 1 Thrombosis of Coronary Artery 1 Nephritis 1 Cancer 1 Fatty Heart 1 Myocardial degeneration 5 Valvular Heart Disease 3 Cerebral Haemorrhage 1 Aortic Aneurysm 1 Intestinal obstruction 2 Aortic Stenosis 1 Acute pyelonephritis 1 Influenza 1 Swallowing vomited matter into lachea 1 Coronary artery disease 1 FACTORIES, WORKSHOPS AND WORKPLACES. 1.—Inspection of Factories, Workshops and Workplaces including Inspections made by Sanitary Inspectors. Premises. Inspections. Written Notices. (i) (2) (3) Factories (Including Factory Laundries). 103 15 Workshops (Including Workshop Laundries) 427 12 Workplaces (Other than Outworkers' Premises). 16 Nil Total 546 27 -—Defects found in Factories, Workshops and Workplaces. Nuisances under the Public Health Acts: — Particulars. Found. Remedied. (1) (2) (3) Want of Cleanliness 29 29 Want of Ventilation Nil Nil Overcrowding Nil Nil Want of drainage of Floors Nil Nil Other Nuisances 5 5 70 Sanitary Accommodation: — Insufficient 10 10 Unsuitable or defective 28 28 Not separate for sexes Nil Nil Offences under the Factory and Workshop Acts:— Illegal Occupation of underground Bakehouses Nil Nil Other Offences Nil Nil Total 72 72 3.-Outwork in unwholesome premises, Section 108 Nil STAFF. D. J. Thomas, m.r.c.s., l.r.c.p., d.p.h., Medical Officer of Health (Medical Superintendent of the Isolation Hospital and School Medical Officer). Nancy G. Howell, m.r.c.s., l.r.c.p., d.p.h., Assistant Medical Officer of Health and School Medical Officer. P. H. Slater, l.d.s.. School Dentist. M. W. Kinch, M.R.San.I., Cert, of Royal Sanitary Institute; holds Meat and Smoke Certificates Sanitary Inspector (Inspector under Diseases of Animals Acts and the Rag Flock Act). J. J. Jenkins, Cert, of Royal Sanitary Institute ; holds Meat and Smoke Certificates, Sanitary Inspector (Inspector under Fabrics Misdescription Act). E. W. Brooks, Cert, of Royal Sanitary Institute. Sanitary Inspector. J. J. Matthews, Cert, of Royal Sanitary Institute ; holds Meat Certificate, Sanitary Inspector. Miss A. Cooksey, A.R.San.I., Certificate of Royal Sanitary Institute. Health Visitor. 71 Miss J. Welsh, Certificate of Royal Sanitary Institute, c.m.b., Health Visitor. Miss B. G. Sorlie, s.r.n., Certificate of Royal Sanitary Institute, C.m.b., H.V. Diploma, Health Visitor and School Nurse. Miss A. Woosnam, s.r.n., c.m.b., Health Visitor and School Nurse. Miss B. C. Broughton, s.r.n., c.m.b., H.V. Diploma, Health Visitor and School Nurse. W. Goodfellow,* A.R.San.I., Cert, of Royal Sanitary Institute ; holds Meat Certificate, Cert. Bacteriology; Chief Clerk. Miss G. Overall,* Clerk. Miss V. E. Arnold,* Clerk. Miss D. E. Beacon, Clerk. 4 —————— Miss M.J. Gilfillan,* s.r.n., c.m.b.. Matron, Isolation Hospital. Miss F. A. Cavendish, Matron, Day Nursery. G. Baker,* Disinfector. Note—To the salaries of all the above officials excepting those marked with an asterisk, contribution is made under the Local Government Act, 1929. I wish to express my appreciation and thanks to all the members of the Public Health Department for their excellent cooperation during the year. I am, Your obedient Servant, D. J. THOMAS, Medical Officer of Health. 73 ANNUAL REPORT OF THE School Medical Officer FOR THE YEAR, 1932 Municipal Offices, Acton, W.3. To the Chairman and Members of the Education Committee. Ladies and Gentlemen, Wc beg to submit the following report upon the schools and school children of the Education Authority for the year 1932. During the year, changes have occurred in the personnel of the School Medical Service. Dr. N. G. Howell was appointed and Commenced duties on March 1st. The medical inspections for the months of January and February were carried out by Dr. L. S. Farquharson. In July, Nurse James resigned under Heage limit after 23 years faithful and conscientious service, and Nurse Broughton was appointed to take her place. Advantage was taken of this change to rearrange and to co-ordinate still further the work of the Maternity and Child Welfare and the School Medical Services. The Infant Welfare Conlre at St. Gabriel's Hall, Noel Road, is now under the charge of Nurse Broughton and the entire work of home visiting is done by one person. Miss Broughton does the home visiting for Acton school, and the area for which she also does the Welfare werle coincides. 74 PUBLIC ELEMENTARY SCHOOLS WITHIN THE DISTRICT WITH ACCOMMODATION. Same of School. Dept. Accommodation Average monthly So. on Register during 1932. Average attendance for Autumn term 1932. Acton Wells Senior 320 252 229 Junior 364 376 343 Infants' 364 336 285 Beaumont Park Senior Girls' 450 254 220 Junior Girls' 450 292 250 Infants' 400 256 198 Berrymede Junior Boys' 640 506 446 Junior Girls' 542 512 450 Infants' 450 319 270 Central 480 402 363 Derwent water Junior Mixed 441 460 422 Infants' 350 271 225 John Perryn Senior 360 275 236 Junior 288 332 294 Infants' 336 345 286 Priory Senior Boys' 500 417 374 Senior Girls' 499 405 342 Infants' 400 297 235 Rothschild Junior Boys' 450 296 262 Infants' 400 281 224 Southfield Senior Boys' 415 273 236 Junior Mixed 382 400 355 Infants' 350 227 179 Turnham Green R.C. 327 277 223 Acton Council Special 68 47 39 10026 8108 6986 A comparison of this Table with that of the year 1931, will show a slight reduction in the number of children on the register and a more marked reduction in the number in average attendance. The reduction in the number of children on the register is due to the continued reduction in the birth rate. This matter has been referred to on several occasions and it is unnecessary to make any detailed observations on this aspect in the present report. The reduction in the average attendance has been due to the outbreaks of Scarlet Fever and Diphtheria in the Autumn, and this matter will be referred to in a subsequent paragraph. 75 AVERAGE HEIGHT without shoes and AVERAGE WEIGHT withoUt Clothes. Anthropometric Committee, 1929. MALES. FEMALES. Age last Height in Weight in Height in Weight in birthday ins. lbs. ins. lbs. 3 36.9 32.9 36.6 31.5 4 39.2 35.9 38.4 33.7 5 41.4 38.7 41.1 37.5 6 43. 41.3 42.8 40.1 7 45.4 45.4 45.1 44.1 8 47.8 51. 47.5 49.4 9 49.2 54.8 48.9 52.6 10 51.3 59.6 51.2 59.8 11 52.7 64.6 52.8 63.9 12 55. 71.6 55.6 73.9 13 . 56.2 76.5 56.9 79. 14 58. 86.1 58.9 88.2 15 61.8 99.3 62.3 106.8 TABLE SHOWING HEIGHTS AND WEIGHTS AT DIFFERENT AGES. ENTRANTS (GIRLS). No. Examined. Years of Age. 3—4 4—5 5—6 6—7 No. Height ins. Weight lbs. No. Height ins. Weight lbs. No. Height ins. Weight lbs. No. Height ins. Weight lbs. Acton Junior Mixed 9 ... ... ... 3 40.1 36.2 3 41.9 37 3 45.8 46.3 Acton Wells Infants' 58 ... ... ... 23 40.8 39.2 30 42.9 41.2 5 44.8 4S.5 Beaumont Park Infants' 56 15 36.7 31.8 10 39.7 35 28 42.6 39.3 3 45.5 41.6 Berrymede Infants' 56 ... ... ... 29 40.1 35.8 19 43.2 42.2 8 44.7 44.9 Derwent water Infants' 60 ... ... ... 26 39.9 38.6 25 43.4 42.8 9 45.4 46 John Perryn Infants' 49 ... ... ... 18 40.4 36.4 22 42.5 39.7 9 45.1 45.6 Priory Infants' 52 ... ... ... 24 40.4 36.6 23 41.9 38.2 5 43.8 38.5 Rothschild Infants' 42 12 38.4 34.8 13 40.2 37.4 11 40.2 37.5 6 44.9 45.1 Southfield Road Infants' 37 ... ... ... 10 40.3 36.2 22 42.5 40.1 5 46.9 59.9 Turnham Green R.C. 8 ... ... ... 5 40.9 38 1 41 34 2 47.7 46 427 27 161 184 55 (BOYS). Acton Junior Mixed 11 ... ... ... 4 41.1 38.8 6 44.6 44.6 1 46.3 44.3 Acton Wells Infants' 57 ... ... ... 19 41.2 37.8 28 43.7 42.7 10 45.4 46.5 Beaumont Park Infants' 51 10 37.4 31.6 15 41.3 38.3 24 42.9 41.2 2 44.9 42.8 Berrymede Infants' 61 ... ... ... 33 40.4 38.6 26 42.6 39.7 2 42.7 46 Derwentwater Infants' 56 ... ... ... 20 41.1 40.6 25 44 44.3 11 45.8 48.1 John Perryn Infants' 58 ... ... ... 17 41.5 38.3 36 43.7 41.9 5 45 44.6 Priory Infants' 57 2 40.2 36.4 34 40.8 37.7 12 43.2 40.5 9 45.9 45.5 Rothschild Infants' 46 13 38.5 36.4 13 40.6 38.1 15 42.7 40.9 5 45.9 47.4 Southfield Road Infants' 47 ... ... ... 17 41.4 40.5 23 44.7 46.1 7 46.6 50.6 Turnham Green R.C 9 ... ... ... 5 39.6 38 3 43.4 42.1 1 43 37 453 25 177 198 53 76 77 TABLE SHOWING HEIGHTS AND WEIGHTS AT DIFFERENT AGES. INTERMEDIATES. (BOYS). No. Examined. No. Years of Age. 7—8 8—9 9-10 Height ins. Weight lbs. No. Height ins. Weight lbs. No. Height ins. Weight lbs. Action Junior Mixed 12 6 49.6 54.3 6 49.8 52.9 ... ... ... Action Wells Junior 30 6 49.9 55.1 24 51 59.1 ... ... ... Action Wells Infants' 25 11 49.8 56.3 14 49.8 55.5 ... ... ... Beaumont Park Infants' 3 3 49.6 55.6 ... ... ... ... ... ... Berrvmede Junior Boys' 122 70 48.4 52.2 52 49.1 52.7 ... ... ... Berrymede Infants' 2 2 47.6 49.1 ... ... ... ... ... ,... Berwentwater Junior 50 38 49.5 56.6 12 49.8 58.1 ... ... ... Derwent water Infants' 1 1 51 52.8 ... ... ... ... ... ... John Perryn Junior 4 .... ... ... 4 51.4 60.7 ... ... ... John Perryn Infants' 56 25 49 53.3 31 49.7 55.2 ... ... ... Priory Infants' 6 6 50.5 57.9 ... ... ... ... ... ... Rothschild Junior 72 27 49.1 54 45 49.4 55 ... ... ... Rothschild Infants' 2 2 49.2 52.6 ... ... ... South field Junior 32 16 50.1 57.7 16 50.8 58.5 ... ... ... South field Infants' 5 5 47.8 54.5 ... ... ... ... ... ... Turnham Green R.c. 12 4 48.2 52.7 6 49.8 55.6 2 52 63.5 434 222 210 2 (GIRLS). Action Junior Mixed 20 7 47.7 49.5 11 49.8 53.2 2 53 59.6 Action well Junior 80 9 49 51.9 20 49.4 53.1 1 55.3 65.5 Action Wells Infants' 23 13 48.5 51.5 10 48.8 51.3 .... ... ... Beaum'nt Pk. Jnr. Girls' 80 56 49.2 51.2 24 49.9 52.9 ... ... ... Beaumont Park -Infants' 6 6 48.5 49.5 ... ... ... ... .... ... Berrymede Junior Girls. 96 57 48.1 51.8 39 46 51.7 ... ... ... Berrymede Infants' 6 6 48.7 51.8 ... ... ... ... ... ... Derwent water Junior 53 40 49.7 55.3 13 50.6 57.9 ... ... ... Derwet water Infants' . 8 8 47.7 49.4 ... ... ... ... ... ... .Jhon Perryn Infants' 49 21 49.7 55.9 28 48.8 51.5 ... ... ... Priory Infants' 22 15 48.4 50.5 7 48.8 50.5 ... ... ... Rothschild Infants' 2 2 48.1 48.5 ... ... ... ... .... ... Southfield Junior 42 17 49.2 52.1 25 49.5 55 .... ... ... Southfield Infants' 4 4 47.3 54 ... ... ... ... .... ... Turnham Green R.C 15 7 48.4 52.4 6 53.4 68.2 2 54.7 62.4 456 268 183 5 78 TABLE SHOWING HEIGHTS AND WEIGHTS AT DIFFERENT AGES. LEAVER (BOYS) No. Examined. Years of Age. 12—13 13—14 14—15 No. Height ins. Weight lbs. No. Height ins. Weight lbs. NoT . Height ins. Weight lbs. Acton Wells Senior 53 50 58.2 80.6 3 60.3 86.1 .... .... .... Central 56 56 57.9 81.5 .... .... .... .... .... .... John Perryn Snr. 56 56 58.4 81.4 .... .... .... .... .... .... Priory Boys' 190 189 57 72.3 1 57 83 .... .... .... Southfi'd Sr. Boys' 119 118 57.2 79.9 1 67.5 115.8 .... .... .... Turnham Gn. R.C. 21 19 57.2 78.4 2 55 73.2 .... .... .... 495 488 7 (GIRLS) Acton Wells Senior 55 49 59.2 86.6 5 58.8 80 1 63.8 122 B'm't Pk. Sn. Girls' 118 117 58.7 78.8 1 66 115.3 .... .... .... Central 55 55 59 87.7 .... .... .... .... .... .... John Perryn Snr. 79 77 58.8 83.3 2 59.1 82.5 .... .... .... Priory Girls' 193 192 57.7 80.3 1 56 70 .... ... .... Turnham Gn. R.C. 11 11 59 88.6 .... .... .... .... .... .... 510 501 9 1 During the year, 2,754 children were examined in the various age groups prescribed by the Board of Education. Table 2 includes a return of defects found at medical inspection. In Table 2b the number of individual children is given who were found at routine medical inspection to require treatment, excluding uncleanliness and dental defects. A comparison of this table with that for the year 1931, will show that the percentage of children found to require treatment during 1932 is much lower than that for the previous year. A cursory examination of the figures, and a comparison with those of former years, would make it appear that changes have occurred in the conditions which obtain among school children. This is not quite correct. It is true that small variations 79 Do occur, but these are not so marked as the diversity of views by the different persons who are responsible for the inspection. This becomes apparent when a comparison is made between the fjgures of neighbouring areas. A few years ago we published certain figures culled from the annual reports of school medical officers of districts around London it was interesting to note to what extent the personal factor just have entered. Some might say that there is need of accepted standards, but it is difficult to set up any standards which will be accepted by all. The widest variation was noticed in the number cf children who were stated to be suffering from enlarged tonsils and adenoids and required tonsillectomy. Tonsils and Adenoids. During 1932, 58 children were operated on for removal of lonsils and adenoids under the Authority's scheme, as compared with 160 cases during 1931. This great difference in the numbers needs some explanation and the time seems ripe to enunciate the principles which have guided us in the selection of cases during the present year. It is also well to look back on some of our past cases, and try to assess the value which the children have received from the operation. 108 cases which had been operated on under the Authority's scheme were followed up. A large number of these children were generated on at the request of the family doctor, or on the advice of one of the hospitals. The reason why the operation was considered necessary was sought, and the parents were asked whether there was any improvement in the condition for which the operation performed. Of the 108 cases, 37 were improved, 41 were definitely no better, 6 were worse, and in the remaining cases the parents were so that in these cases there was evidently no outstanding benefit from the operation. The first thing that strikes us in the investigation is the diversity of symptoms for which the operation was performed. For instance, 34 children were operated on because they were subject to colds. Only 14 of these were improved in any way. 14 were operated on for tonsillitis, many of them after one back only. 7 only, showed definite improvement and all of these were in the 11-12 age group. 80 11 cases were operated on for enlargement of tonsils alone, without any symptoms. In 2 of these cases the child was said to be brighter, in 7 cases no change was noticed by the parents, and the last child was definitely worse as he had frequent colds after the operation, whereas he had not suffered from colds previously. This child was found on examination to have very wide anterior nares and thus a larger air way than normal. Removal of lymphoid tissue from the post nasal space would be expected to aggravate the condition. In 9 cases, tonsils and adenoids were removed for mouth breathing and in only 2 of these cases was any improvement seen. An interesting point in this connection is that the children in whom improvement occurred were 12 and 7 years of age respectively while the ages of the children in whom there was no improvement ranged from 5 years down to 3 years. In the 2 older children breathing exercises had been carried out after operation, and the benefit was probably largely due to this. 3 cases were operated on for tonsillitis and discharging ears. All were improved. 1 child had suffered from rheumatism and was better after the operation. 4 children were operated on for deafness and 2 of these were definitely better. Other reasons given for operation were, nerves, stomach trouble, and general irritability. None of the children in this group showed any improvement. The number of cases in this investigation was not large, but the reasonable conclusion which one draws from a consideration of the cases is that removal of tonsils and adenoids without definite evidence that they are doing harm is obviously not worth the risk and unpleasantness which the child has to suffer. Comment on the cases quoted is almost unnecessary. In many of the cases we have no proof that the tonsils and adenoids were the cause of the child's ill health and in these cases no improvement resulted. Unfortunately, the operation has now come to be regarded by parents as almost a normal proceeding in the life of a child so that we frequently have difficulty in persuading parents that the operation is unnecessary for some trifling ill. 81 This year each child referred to us for operation has had a thorough examination of nose, throat and nasopharynx, and the general health, and home conditions as well have all been gone into. Infection of the upper respiratory tract in children is extremely common, and the burden of this invasion by microbes is borne by the lymphoid or adenoid tissue, which becomes swollen temporarily. The swelling is a sign that the lymphoid tissue is needed and that it is dealing with the infection. When the infection is removed, the swelling of the adenoids will abate. The condition usually occurs in children living under bad hygienic conditions, generally associated with overcrowding. An operation for removal of tonsils and adenoids in this type of child is obviously not going to do any good, because the enlargement is nature's attempt to deal with massive infection. It is wiser to attempt to deal with the environmental conditions of the child. Broadly speaking, operative interference with the lymphoid tissue of the nose and throat will do good in cases where:— (1) It is causing difficulty in breathing through the nose, (2) It is definitely causing deafness, (3) The tonsils are diseased. Difficulty in breathing through the nose, or mouth breathing, is one of the commonest symptoms for which children are brought along to the throat clinic. In a large number of these children there is no sign of nasal Obstruction and the condition is found to be associated with a general lack of tone. Here again operation is useless and it is our custom to suggest measures for improving the general condition together with regular breathing exercises. Difficulty in breathing through the nose is very commonly associated with swelling of the mucous membrane lining the nasal fossae with puddling of muco pus due to defective nasal hygiene, in older school children. It is surprising how many of these children have never learnt to blow the nose properly, and what a hemendous improvement results when regular and effective nose blowing, followed by breathing exercises, is established as a daily routine. Children who are put on this treatment are asked to return at the end of a month for further examination. 82 Many of the children are referred to the clinic on account of frequent colds. Some of these children are found on examination to have wide anterior nares and a larger airway than usual. Have again, removal of adenoid tissue is particularly apt to aggravate the condition. Deafness is another symptom for which operation on the nose and throat is often demanded, and this again is a condition which may be made worse by indiscriminate removal of tonsilk and adenoids. If the child is deaf, and physical signs such as retraction of the drumhead are present, then a digital examination is necessary in order to find out whether adenoid growth is causes obstruction to the Eustachian tube. If this is found, the condition is usually improved if the otological adenoids only are removed leaving behind any adenoid tissue which is present in the mid line The same consideration must be exercised over the question of the removal of the tonsils. If the tonsils are a source of sepses they must be removed, but working on the principle that swelling of lymphoid tissue is a protective mechanism, tonsils should never be removed for enlargement alone, except in the very rare event of their causing mechanical obstruction. The explanation of the reduction in the number of cases operated on this year therefore, lies in our recognising that enlargement of tonsils and adenoids are due to many different causes that enlargement may be beneficial to the child temporarily, and removal detrimental. The number of cases remaining where the operation is needed are necessarily greatly reduced, as tonsils are only removed when diseased, and thus the lymphoid tissue of the upper respiratory tract is conserved during those years when the child most needs it A return of the defects found at medical inspection will be found on Table 2 at the end of the report. A full report Malnutrition and Otorrhoea appears below. Provision of Meals. Early in the year, the question of feeding necessitous children in. the Borough was considered. A list of children who were considered necessitous was submitted, and the children were examined at the School Clinic. Although only a small percentage of children on the list was found to be malnourished, it was decided to extend the investigation and to consider the question of malnutrition all school children, whether necessitous or not. 83 167 children were reported by the Head Teachers to be in their opinion necessitous or undernourished. A few children who had been seen Ailment Clinic, or during a routine school inspection, were added to the list. Altogether, 175 children were preferred for examination. We used as a basis the relation between the height and weight of the child and singled out for special examination any child who fell below 7% of the standard weight for his height. Of the 175 children who were first reported to us, 127 were weighed and measured at the Clinic, and the weight of each child was compared with the average standard normal weight for height. 48 of the children were absent from school for various reasons, so they were dealt with at the school on their return. 14 of the 127 children were found to be overweight, 7 came up to normal, 46 were less than 7% below weight, and 60 were made than 7% below weight. These 60 children were submitted to a Careful physical examination to determine the cause of malsituation. In most cases they were accompanied by a parent and a family accurate idea of the home conditions could be surmised. Of the 60 children, 5 were obviously suffering from physical defects. One child was suffering from acute rheumatism, another from heart disease, 3 children had threadworms and no attempt had been made to clear up the condition. 12 of the children were well cared for and the food they had was sufficient in quantity. None of them had any physical defect to ccount for the failure to gain in weight. In most of them the malnutrition was undoubtedly due to faulty health and food habits, want of rest, and overfatigue either singly or combined. Many of these children from the age of 6 years onwards never went to bed Unhl 9 or 10 o'clock at night. Faulty food habits were found not only in this group of children but also in many of the others, and they were practically always associated with other factors, such as over fatigue and poor mothering generally. We found that although sufficient money was spent food, it was badly spent and full value was not obtained from the outlay. In several cases both parents were at work, and the child hadto fendfor himself for the mid-day meal, which usually con.sidered of bread and butter. We also found that meals were served regular intervals, but the most important factor was the total disgaurd paid by the mother to food values. 84 One outstanding fact was that the diet of these children consisted almost entirely of articles which required no cooking. Where the mother is employed outside the home, the difficulty of providing properly cooked meals can be appreciated, but in the cases now under review no such excuse could be offered. The cause was either ignorance or laziness. 4 of the children had tea and cake for breakfast and 2 were frequently given cream cakes and custard pies at this meal. 2 others had bread and butter and fish paste habitually for breakfast. Dinner in practically all the cases consisted of either bread and butter alone, or in addition one of the following,—fish paste, tinned salmon, german sausage, or corned beef. Several of the children had bread and butter only for every meal, and this unbalanced diet would be enough to cause malnutrition, but lack of nutriment was enhanced by failure of appetite due to the monotonous dietary. No attempt seems to have been made to vary the diet according to the seasonal supply of a particular food. At the time of year when this enquiry was begun, eggs cost less than Id. each locally, yet in very few cases were they ever included in the diet. Wholesome inexpensive articles of food, such as fresh herrings, were seldom found in the diet, probably because of the necessity of cooking. More than half of the undernourished children had no milk in the diet except when it was taken in tea. In every case, the state of affairs was explained to the parents, and they were asked to co-operate with us in trying to improve the condition of the child. Suggestions were made regarding more rest for the child, the inclusion in the diet of foods of high food value and the correction of faulty food habits, such as irregular meals bolting of food, drinking with meals, etc., and they were urged tc have physical defects, such as carious teeth, dealt with. It was decided to provide morning milk and dinner at school to certain necessitous children, while other malnourished childrern were also provided with milk at school at the expense of their parents. In no case has a child received free milk or meals without the parents being interviewed, and a thorough physical examination being carried out, and physical defects remedied. Carious teeth have been dealt with, mouth-breathers investigated and suitable treatment suggested, in fact what began as an investigation into nutrition has now grown into a nutrition Clinic in the broad sense. 85 In the early days of the enquiry, it was realised that the standard of weight for height could not be used as a hard and fast rule, but that the general physical condition of the child must be taken into account. We therefore began to include children who showed symptoms of fatigue, anaemia, enlarged glands in the neck, and other signs of debility. All the children who are being provided with meals and milk, as well as all the school children who are considered to be undernourished, are weighed and measured at the Clinic once each month. Certain children have been added to those on the list of free meals from time to time, and in certain cases we have had to waive altogether the weight for height standard, and provide meals for the children temporarily, where they were obviously needed owing to lack of money in the home. Six months after the first examination and the commencement of school meals, the children were all examined again and any progress noted. Many of the children on free meals belong to a floating population as they discontinue school meals when home circumstances improve. We have chosen for special mention children who were under our care continuously during the first 6 months after the scheme came into operation. There were 80 such children receiving free meals and milk. In addition 2 received meals only, and 11 received milk only. 67 of these children had gained in weight satisfactorily and were better in every way. During the August holiday, 15 children actually lost weight, but one month after recommencing meals they had all gained weight. 4 of the children had not gained weight at all. One of these suffered from a severe form of heart disease and in spite of his failure to gain there was a definite general improvement. No cause for the stationary condition could be found in the other 3 but they still went to bed far too late and fatigue was probably the cause of the failure to gain. 9 children continued to lose weight, and the reason appeared in most cases. 3 of them were obviously neglected. They small children who were sent to school in a dirty and ragged condition and there was no home care. Another girl who was in general condition was found to return home after her school dinner in order to run errands, and she was kept at home one day weekly for housework. Her mouth and teeth were in a very bad condition, and the mother refused dental treatment. The homes were visited and the children kept under stricter supervision, and wall cases some improvement resulted. 86 3 children had lost weight slightly and we could not account for the loss. The parents were very poor, but were doing their almost for the children and were most anxious to co-operate with us. We managed to send one of these children to the sea for a fortnight during the summer and he began to improve from that time. One child was frequently absent from school and we had some difficulty in securing a record of his weight. The last child was a girl who was receiving meals and milk and was gaining until the summer holidays. The parents refused to allow the meals when the schools re-opened. All the children who have failed to gain, or who have lost weight, have been re-examined at intervals, and the parents interviewed at the Clinic or the home visited. 11 of the children were having milk only, as their parents were able to provide dinner. 9 of these were putting on weight, one was losing, and the weight of the other was stationary. The parents of the last 2 cases were told of this, and urged to allow the children to remain for dinner. In 2 cases meals only were supplied, as the children could not be persuaded to drink milk at school. Both gained well Another child was considered to be necessitous, but the mother refused the offer of meals and milk when the scheme was started. This child however was found to have gained in weigh each month, and the mother was providing meals of higher food value. 12 children were considered undernourished, but were not necessitous. The parents were interviewed individually, and the diet, food habits, and health habits of the child discussed. In mam cases; diets of higher food value were suggested, defects wen corrected, and more rest at home, and sometimes also at schooi was advised. Our efforts were evidently responded to, for all these children gained weight steadily and were better in every way. During the year, 155 children received milk and dinners 3 children received dinners only, and 12 received milk only. Each malnourished child is weighed monthly and a record kept. Any loss of weight, or failure to gain is noted, and the child is brought up for review again. 87 The meals are prepared at the various Cookery Centres at the schools by the Domestic Science Mistresses and their pupils, and our acknowledgements and thanks are due to these Mistresses for their interest, enthusiasm, and very hard work, without which the working of the scheme would have been impossible. Below we give a list of the Centres at which meals are provided, together with the number of meals and the number of bottles of milk supplied during the year. Number of Free Meals supplied at the Various Centres—January to December, 193'2. Acton Wells 644 Priory 1869 Beaumont Park 2647 Southfield 880 Central 761 John Perryn 2568 Total 9369 Number of bottles of Milk supplied at the Schools. Acton Wells Senior 81 John Perryn Junior 797 Acton Wells Junior 242 John Perryn Infants 1100 Acton Wells Infants 438 Priory Boys 327 Beaumont Pk. Senr. Girls 223 Priory Girls 304 Beaumont Pk. Junr. Girls 219 Priory Infants 270 Beaumont Pk. Infants 308 Rothschild Junior 90 Berrymede Junior Boys 626 Rothschild Infants 350 Berrymede Junior Girls 1344 Southfield Infants 5 Berrymede Infants 2094 Turnham Green R.C. 425 Central 104 Derwentwater Junior 111 Derwentwater Infants 186 Total 10,353 John Perryn Senior 709 Otorrhoea. During the year, 77 children were examined at the Clinic account of ear disease. In the majority of cases the children sent up to the Clinic on account of discharging ears, the & large being due to disease of the middle ear. j An analysis of the figures will give a clear idea of the conns found, and the treatment which was considered appropriate. 88 5 of the cases were acutely ill with middle ear disease at the first attendance. In 2 of these cases the infection had already spread to the mastoid and an immediate operation was necessary. These cases were referred to the family Doctor, and through him to Hospital, where they were operated on. The other 3 cases were sent home, and the parents advised to call in a doctor. All these cases were cured. The remaining cases were all cases of middle ear disease and there was a perforation in the drum head. Our method of dealing with these cases needs a little explanation. We are convinced that the most important point in the treatment of these ear conditions is the attention given to the external auditory meatus during the first week of the discharge. The influence that care of the external auditory meatus has upon the middle ear is indirect. (1) The removal of discharge from the meatus leaves room for fresh discharge to take its place. (2) The toilet of the meatus prevents the secondary infection of the middle ear by the organisms present in the external ear. Inflammation of the middle ear becomes chronic when a second microbe gets in, and the most frequent source of this secondary infection is from the skin of tthe external ear. The organisms require moisture in which to grow, and their growth is prevented by keeping the skin of the external ear dry and free from discharge. This part of the treatment then, depends on getting the ear dry and keeping it so. It was decided to make each child over 7 years of age take a part in the treatment of his ear disease. It was uphill work and occasionally disheartening, but the results have justified our faith in the intelligence of the school child, and confirmed our views on the cause of the chronicity, in many cases, of middle ear disease. 58 cases were referred to the Clinic for treatment. Each child over 7 years was taught to make mops for himself by twiddling pieces of cotton wool firmly round special sticks, and then by means of these mops to dry his ear thoroughly. He was also told to do this at home at least 4 times a day, scrubbing his hands before and after dealing with his ears, and burning the mops after they had been used. There was a little difficulty in getting the scheme to work at first, chiefly because the children did not want to be bothered, and in some cases because the parents were afraid of the child doing some damage to his ears. 89 At first, the ears of these children were examined with each week at the Clinic, and very soon they understood that they were ixpected to come up with no discharge in their ears at all A few children who were rather refractory were made to come daily and in '2 or 3 cases we had to ask one of the parents to come along in order to explain the matter to them and insist on the treatment being carried out. Finally the scheme was firmly established 58 cases attended the Clinic for treatment. 5 caves were acute-as mentioned above and were referred elsewhere. It were fresh cases of transient ear discharge which cleared up very quickly on routine treatment. In 32 cases the ear discharge had been present from a week to 3 months. In 5 of these cases there was a considerable degree of external otitis and the ear disease ceased very soon after this condition had been cured. The method of dealing with these cases was as follows. On the first attendance at the Clinic, the ear was cleaned out with a little peroxide of hydrogen for the purpose of examining the drum head. The condition of the drum head was noted on the medical card. The ear was then dried out with a little methylated spirit and the external meatus lightly coated with Ung.Hyd.Ox.Flav B.P. The child was.then instructed in mopping his ear and was given Mime of the special sticks to take home. This procedure was fllowed on each subsequent visit of the child to the Clinic and them provement noted until finally the child was discharged. The 32 cases were cured. There were 11 old cases in whom the discharge had been present for over 6 months. These in turn were made to come up daily for a week, some of them for longer until they were well on the way to recovery and were carrying out the treatment faithfully 3 of the children were too young to treat themselves and were done by their parents. One child had a large polyous protruding through the perforation in the drum head and was preferred to Hospital for currettage. 4 of the cases had a severe and offensive external optics which appeared to be chiefly responsible for the discharge and they cleared up on the routine treatment of dry mopping but with the ox Fla.v. applied 4 times daily. In one child who was very resistant and had a large old Perforation, we instilled silver nitrate once daily for 3 day and then carried on with the routine treatment. The discharge cased and the perforation is practically healed. 90 In one child removal of Tonsils and Aednoids was considered necessary in view of their unhealthy nature. All these cases are now well. 10 cases still continue to have ear discharge. 6 of these cases are probably due wholly to neglect. They are very young children and attend the Clinic only occasionally and always have to be fetched. Their ears are always in an extremely dirty condition. The parents have been visited time and again, but improvement only results for a short time. In 3 cases the perforation in the drum head is small and there is insufficient drainage from the middle ear. A secondary paracentesis would probably help in clearing these cases, and in one of them removal of Tonsils and Adenoids has also been suggested but the parents refused the operation. We do not feel justified in suggesting further operative measures until secondary paracentesis has been performed. The last case is a small boy who is now nearly well. He is a child whom we had difficulty in getting along to the Clinic. On examination he was found to have a piece of paper firmly wedged against the drum head causing irritation and infection. On the whole these results are satisfactory considering the short time that the scheme has been in operation. We were helped of course, to a very large extent, by the fine summer. Th parent of every child attending the Ear Clinic was asked to send the child out into the sunshine as much as possible, and to see that the child ran about, in order to improve the circulation. Many of them responded by allowing sun bathing. Our thanks are due to the teaching staff who have given us every assistance. We realise how trying it must be to allow a child to miss a class daily for a week in order to come to the Clinic, but we believe that in treating these cases intensively from the beginning we are preventing the chronic ear case which is a constant source of offence in a classroom. RETURN OF EXCEPTIONAL CHILDREN. On Table 3 is given a return of all exceptional children in the area. The figures in many instances are the same as those given in last year's report, but the following notes give further information on the cases. 91 Multiple Defects. One boy who is mentally defective and is also suffering from tuberculosis of the bones of foot and hand, is resident in the Stanmore branch of the Royal National Orthopaedic Hospital. The second boy, who is also a mental defective, suffers from deformity of the spine and chest, and birth palsy. He is in attendance at the Acton Special (M.D.) School. The third case, a girl, is blind and mentally defective. She was at Swiss Cottage Blind School, but was discharged from there on account of her mental defect and an increasing tendency to fits. She has been notified to the Board of Education, and is now awaiting admission to a suitable school or home. Blind. Two boys attend schools maintained by the London County Council. One boy suffering from a high degree of myopia attends a private school, another boy suffering from optic atrophy attends Southfield Senior Boys' School, while a third partially blind child, 3 girl, is being taught at home. all 1 .,■■■• v " ■■■: f Deaf. One girl is at Oak Lodge Residential School, and 2 others attend the Ackmar Road Special School. Two boys who have recently attained the age of 7 years, are still in attendance at elementary schools but are awaiting admission to a special school. Epileptics. One boy was in December at the Lingfield Colony for Epileptics. This child has given us a great deal of trouble, and one month after admission to Lingfield his mother removed him and refused to allow him to return. Arrangements have now been made for the child to be taught at home. Another severe case, a girl, is at home awaiting admission to the Colony. Two mild cases, a boy and a girl, are in attendance at the ordinary elementary schools. Tuberculosis. Two children, a boy and a girl, suffering from active Pulmonary tuberculosis are respectively at Harefield and at 92 i Brompton. Two boys suffering from tubercular glands are at public elementary schools. One boy suffering from abdominal tuberculosis is at a sanitorium at Lymington, while three boys suffering from tuberculosis of bones and joints, are at certified Hospital schools at Margate. One girl who has been at the Treloar Cripples' Home at Alton is now at home. Crippled Children. One girl is at St. Mary's Home, Dover. Two boys and one girl attend Physically Defective Schools maintained by the London County Council. Seven boys and three girls with a minor degree of deformity attend the public elementary schools, and 1 girl with severe birth palsy is being retained in an Infants' department until a transfer can be arranged to a P.D. School. Heart Disease. Two boys and two girls are at Certified Hospital Schools. One girl is at home, under the care of the family doctor. DEFECTS TREATED. Report of the. School Oculist. The work of the Ophthalmic Clinic has been carried on regularly during the year. Last year the Board of Education circulated a report of the Committee of Inquiry into problems connected with the prevention of defective eyesight in school children. As an initial attempt to deal with the large amount of work involved, we suggested that a more thorough and searching eye test at the routine medical inspection should be made, and that the younger children should have their vision tested more regularly. These recommendations have resulted in a considerable increase of work at the Ophthalmic Clinic. Over 100 more children have been examined than in the previous year, the parents advised as to the care of their eyes, and, where necessary, glasses prescribed. These extra examinations have been mainly among the younger children and the parents have been asked to return with the children to the Clinic for re-examination sooner than formerly. Treatment at any early age is most necessary in the prevention of serious defects of vision in later life. 93 In addition, 7 cases of external eye disease have been continuously treated at the Clinic, one being sent into the West Middlesex Hospital for more thorough treatment than was possible at home. Two mothers from the Welfare Centres have been examined and glasses provided, and 13 babies from centres have been treated, mainly for early squint. (,Sd.) G. BANHAM. REPORT OF THE SCHOOL DENTAL SURGEON. 8,261 school children were examined during the year, and 5.036 of these were referred for treatment. These figures show an increase on last year. The number of cases actually treated has, however, decreased. Probably the chief factor governing this decrease was a change in the scale of charges which increased the payment for the bulk of our patients, with the effect of slightly raising the number of refusals, although these are fewer than in 1930. I understand that steps are being taken to remedy this. The epidemics of Scarlet Fever and Diphtheria had also an unfortunate influence on the attendance for treatment. In spite of this however, the number of permanent fillings has increased, showing that more conservative work is being done on the permanent dentition. The average number of extractions per child remains about the same. It is gratifying to note that the percentage of children who do not require treatment, shows an increase of about 2% on 1931. The number of parents present at inspections is increasing, and in some districts the general condition of the childrens mouths is improving considerably. Treatment for mothers and infants from the Welfare Centres has been continued throughout the year, and there is a slight increase in the number of mothers and a decrease in the number of infants dealt with. 94 The following are the figures for the Welfare work:— Number of mothers examined 39 ,,,,,, referred for treatment 39 „,,„ treated 49 infants examined 171 ,,,,,,referred for treatment 114 ,,,,,, treated 147 ,,,,Temporary Fillings 25 ,,,,,,Extraction 360 ,,,, Permanent Fillings 21 ,,,,,,Extractions 296 ,,,,Dressings—Permanent teeth 13 „„,,Temporary teeth 28 ,,,, Scalings and Gum Treatment 9 „,,Anaesthetics (N20) 191 ,,,,Dentures supplied 14 „,,Attendances 281 The usual lectures have been given at the Welfare Centres, and the attendances were better than in the previous year. I should like to add a word of warm appreciation of the indispensable help and co-operation of the Head Teachers and the Clinic staff. (Sd.) P. H. SLATER CONTROL OF INFECTIOUS DISEASES. There was a marked increase in the incidence of most of the infectious diseases. A fuller report upon these diseases will be found in the report of the Medical Officer of Health, but certain details which concern the attendance at the schools more directly, are given here. It is disappointing that so little progress can be reported in the prevention of outbreaks of infectious diseases in schools, it is true that we have modified our methods, and by such means we have reduced the mortality from the diseases but with the possible exception of Diphtheria and Small-pox, we have not discovered the means of preventing the spread of the principal infectious disease in the schools. 95 During the early part of the year, there was an outbreak of Measles in our districts, and it is doubtful if our efforts were in any way successful in limiting the spread of the epidemic. We have gained considerable knowledge of the epidemiology of the disease, and as a result we have avoided many of the mistakes which were formerly made. We have given up school closure, as we know that such a procedure is useless. Even when it is resorted to, it was more for financial reasons than with any hope of ending an outbreak. An epidemic may be slowed down in its progress, but it cannot be definitely stopped. An epidemic of Measles begins when sufficient children have accumulated who have not previously had the disease. It was formerly thought that the outbreak terminated when this surplus of susceptibles has been depleted, but this is doubtful, or at any rate, it does not follow that the depletion occurs because all the susceptibles have suffered from an attack of Measles. An epidemic of Measles may result in a transient immunization of some of the contacts, which may last about a year, whilst it is known that a clinical attack usually confers immunity for a lifetime. Our methods depend upon an appreciation of the importance of these facts. Most of the children in the Junior and Senior departments have already suffered from an attack of Measles, and we find that the disease does not spread in these departments. Junior and Senior contacts who have had Measles are not excluded from school attendance, and so we are able to concentrate our attention on the Infants' departments. The earlier cases were reported in January, 1932. On the re-opening of the schools after the Christmas holidays three cases were reported, one from Silver Crescent, one front Kingswood Road, and one from Weston Road. All attended the Infants' department of the Rothschild Road School, and had been taken towards the end of December, the rash in one of the cases appearing on December 28th, and in the other two on January 1st. From the distibution of the 3 cases and the history, the source f the infection would probably be in school, but on enquiry no children had been absent with any suspicious symptoms in the week ending December 19th, which would be the period of infection of the 3 cases. In the second week in January two other cases occurred, both children lived in Antrobus Road, and were pupils at Rothsinfants' School. These two cases, though, were not infected in school as the probable date of infection would be the last few 96 days of December, or the early days of January, i.e., during the school holidays. They were instances of home infection and were possibly infected by one of the 3 cases previously mentioned. Although the case was not traced, it appears probable that a mild unrecognised case occurred in the school during the week ending December 19th, and that the 3 cases which occurred in the holidays were the first crop. The first crop thus falling during the vacation, it was hoped that the second crop would not be a heavy one, and that an epidemic would be postponed for a few months. Other cases however were reported in Rothschild Infants department, and in the week ending January 23rd, several cases occurred in Beaumont Park Infants department. During the Spring Term the outbreak spread to other schools, and before the end of the Summer all the schools had been attacked. Whooping Cough was also prevalent during the year, but its greatest incidence was a little later than that of Measles. The serious aspect of the disease is still under-rated by the public, and very little attention has been paid to the disease in the field of public health. At ages 0-5 years, Whooping Cough took fifth place during the decade 1921-30 in the list of causes of mortality. More school time is lost through Whooping Cough than through Measles, but more important than this, is the toll of impaired physique and the cardiac damage which cannot even be estimated. A question of educational interest is the possibility of psychological trauma in severe cases to which attention has recently been drawn. It is possible that the incessant terrifying paroxysms with their sense of impending suffocation may have a lasting effect upon the child. Diphtheria, In the Annual Health Report will be found an. account of the outbreak of Diphtheria which occurred in the Autumn of the year. It is now recognised that Diphtheria is a disease which is largely associated with school life. The usual swabbing of contacts and isolation of the patients was followed, but it was decided to offer immunisation to all those who desired to avail themselves of this method of protection. 97 A start was made in Southfield School and the following tables give the result of the Schick testing in the Southfield Road departments. Southfield Senior Boys. Year la lb lc 2a 2b 3a 3b Total Positive 12 9 8 5 3 9 4 50 Negative 8 15 7 14 7 7 9 67 Total tested 20 24 15 19 10 16 13 117 Age groups of boys tested. Years 11 12 13 14 Positive 23 14 9 4 Negative 24 26 15 2 = 57.2% Negative. Southfield Junior Mixed. Standard 1 lb 2 2a 2b 3 3a 3b 4a Total Positive 27 15 21 23 23 27 21 19 20 196 Negative 3 4 9 8 6 2 5 8 13 58 Total tested 30 19 30 31 29 29 26 27 33 254 Age groups. Years 7 8 9 10 11 Total Positive 38 46 46 60 6 196 Negative 5 15 12 20 6 58 = 22.8% Negative. Southfield Infants. Class 1 2 3 4 5 Total Positive 23 17 14 22 19 95 Negative 7 5 3 1 1 17 Total tested 30 22 17 23 20 112 Age groups. Years 4 5 6 7 Totsl Positive 17 31 41 6 95 Negative 1 2 10 4 17 = 15.1% Negative, 98 The results obtained were very similar to those obtained in other districts. The number of positive re-actors gradually diminished as the ages of the children increased. In the Infants department the percentage of positive re-actors is so high as to render it almost unnecessary to carry out the test. In some districts the preliminary Schick-testing of children under 7 years of age has been abandoned. In spite of the suggestion that the immunisation could be arranged for privately, only 14 took advantage of the opportunity. The first immunisation was given on the 17th October, the second on the 2nd November, and the third on the 30th November. It is satisfactory to note that in no instance did any of the pupils who were immunised in the school suffer any adverse reaction, local or constitutional. Although protection is not expected until a certain period has elapsed after the 3rd immunisation, there have been only 0 cases of Diphtheria notified from the school, and these have all been pupils who were absent at that time or whose parents objected to immunisation. The pupils at the Acton County School were Schiek Tested on November 14th and 16th. It was hoped that the work at the County School would be done by the County Council, but the County Authorities stated that the responsibility was not theirs. The Ministry of Health expressed the opinion that the responsibility lay upon the local sanitary authority. The results in the County School were as follows: — County School. Form 1 lb 2a 2b 3a 3b 4a 4b 5 6 Total Positive 12 12 15 15 13 17 11 15 27 4 141 Negative 14 18 9 9 9 9 13 8 18 9 116 Total tested 26 30 24 24 22 26 24 23 45 13 257 Age groups. Years 11 12 13 14 15 16 17 Total' Positive 11 39 25 31 14 17 4 141 Negative 16 30 15 24 16 11 4 116 = 45.1% neg The next school dealt with was the Derwentwater Infants and Junior departments. Five cases of Diphtheria occurred in October and November in the Infants' department and one in the Junior department. 99 The Schick test results at John Perryn Junior are given below:- John Perryn Junior. Standards la lb 2a 2b 2c 3a 3b 3c Total Positive 18 11 13 9 5 15 5 6 82 Negative 5 10 4 6 9 10 11 9 64 Total tested 23 21 17 15 14 25 16 15 146 Age Groups 8 9 10 11 Total Positive 27 26 27 2 82 Negative 13 20 25 6 64 = 43.8% Negative. In the Derwentwater Infants' department, it was not considered necessary to Schick test the children, and 109 pupils received the first imunising dose on November loth. The second imunisation took place on November 27th, and the third on December 20th. The Derwentwater Junior department was Schick tested on 26th November and the immunisations were given on December 6th,. and 20th, and January 26th, 1933. The following is the table of the Derwentwater Junior results of Schick testing:— Derwentwater Junior. Standards la lb 2a 2b 3a 3b 4a 4b 5a 5b Total Positive 15 11 12 14 9 14 11 13 14 15 128 Negative 7 9 10 11 12 9 9 12 9 8 96 Total tested 22 20 22 25 21 23 20 25 23 23 224 Age Groups. Years 7 8 9 10 11 Total Positive 26 28 42 25 7 128 Negative 17 20 30 21 8 96 =42.8% Negative. The next school dealt with was the John Perryn. In vptember 2 cases occurred in the John Perryn Infants', in October one, and one in the Senior department. In November 2 cases occurred in the Infants', 1 in the Junior, and 3 in the Senior. In December 2 cases occuned in the Senior department. The first inoculation took place on the 19th December, the second on the 27th January, 1933, and the third on the 24th February, 1933. Since December we have only had one case from the John Perryn School. This was in a child who had received one inoculation. The disease was mild and the patient was soon out of hospital. 100 In the Rothschild Infants' School the children were not immunised at the School, but about 50 of them came to the Clinic and were immunised there before the Christmas holidays. 4 cases of Diphtheria had occurred there in October, 7 in November, and one in December. 4 cases which occurred in Rothschild Infants' department during February, 1933, were among children whose parents had refused immunisation in the Autumn. 2 of these proved fatal. One case occurred in this school in November in which the child had received one immunisation. The case was a very severe one but the child recovered. Immunisation was again offered at Rothschild Infants' department in February 1933, and larger numbers of parents took advantage of this offer. At the same time Schick testing and immunisation took place in the Junior department. In Beaumont Park, 2 cases occurred in September, 1 in October, and 1 in November. In January 1933, 3 cases occurred, and Schick testing and immunisation commenced on the 6th February. In Turnham Green R.C. School, one case occurred in October, one in November, and 2 cases early in the New Year. Schick testing and immunisation took place in March. In the Junior departments of Berrymede School, one case occurred in October and one in November, and in the Infants' department, one case in November, and one in January, 1933. Schick testing and inoculation was commenced at this school in February. It was not possible in 1932 to arrange for the work in all the schools, but many requests were received from parents that their children should be Schick tested and immunised. It was therefore decided to carry out the work for these, and also children from the Welfare Centres, on Saturday mornings at the School Clinic, and at these sessions 228 children were Schick tested, and 800 immunisations were given. 101 The following table gives the school distribution of Schick testing and immunisation. It has not been possible to tabulate the results as they stood on the 31st December, but these figures show the amount of work done up to mid-February. School. Schick Schick tested. Positive re-actors. Number of attendances for 1st Inoc. 2nd Inoc. 3rd Inoc. Acton Wells Senior 3 1 1 1 1 Acton Wells Infants 2 2 7 7 5 Beaumont Pk. Senr. Girls 9 6 7 6 4 Beaumont Pk. Junr. Girls 122 52 52 10 6 Beaumont Pk. Infants 3 1 77 11 8 Berrymede Junior Boys 195 90 72 5 5 Berrymede Junior Girls 182 83 80 5 5 Berrymede Infants 1 1 107 1 — Central 5 4 5 3 3 Derwentwater Junior 242 135 136 130 121 Derwentwater Infants 1 — 130 128 122 John Perryn Senior 2 2 3 1 1 John Perryn Junior 166 93 86 69 2 John Perryn Infants 4 2 202 147 4 Priory Girls 4 3 3 2 2 Priory Infants 4 4 7 6 6 Rothschild Junior 137 63 61 8 8 Rothschild Infants 32 23 77 45 33 Southfield Senior Boys 129 56 55 55 52 Southfield Junior 264 206 198 195 188 Southfield Infants 121 104 107 102 86 Turnham Green R.C. 1 — 1 1 — Acton County 269 151 138 133 126 Chiswick County 4 3 3 2 2 Other Schools 19 18 6 4 4 Welfare Children 1 — 142 107 83 Scarlet Fever Patients in Isolation Hospital — — 146 128 103 1922 1102 1909 1312 980 It will therefore be seen that up to the 18th February, 1922 children had been Schick tested. Of these 1102 were positive, and 820 were negative re-actors. Of these 1102,—36 refused inoculation or went to their own doctors, leaving 1066 whom we immunised. 21 refused the second inoculation, and 16 refused the third. In addition, 843 children were immunised without the preliminary Schick testing. 102 Distribution of Diphtheria. The school distribution of cases of Diphtheria was as follows : Acton Wells 3 Beaumont Park 11 Central 2 Derwentwater 7 John Perryn 12 Priory 3 Rothschild 15 Berrymede 6 Southfield 24 Turnham Gn. R.C. 6 89 55 Diphtheria patients, and 225 contacts were examined before their return to school. Scarlet Fever. There was a considerable increase in the incidence of Scarlet Fever during the year. The cases were distributed as follows:— Acton Wells Mixed 2 Acton Wells 9 Beaumont Park 87 Central 15 Derwentwater 31 John Perryn 24 Priory 35 Rothschild 55 Berrymede 56 Southfield 30 Turnham Gn.R.C. 16 Acton Special 1 361 274 Scarlet Fever convalescent patients, and 795 contacts were examined before returning to school. EMPLOYMENT OF CHILDREN. The following Tables give the number of children employed in the various registered occupations. 103 TABLE SHOWING THE NUMBER OF CHILDREN ATTENDING ACTON SCHOOLS EMPLOYED IN THE VARIOUS REGISTERED OCCUPATIONS AS ON THE 31st DECEMBER, 1932. SCHOOL. Delivering Goods or Parcels Delivering Newspapers Delivering Milk Totals Boys Girls Boys Girls Boys Girls Boys Girls Acton Wells 1 .... 13 .... 2 .... 16 .... John Perryn 3 .... 2 .... 1 .... 6 .... Central 5 .... 15 .... 6 .... 26 .... Acton County 3 .... 5 .... 4 .... 12 .... Roman Catholic .... 2 .... .... .... 2 .... Southfield 16 .... 20 .... 1 .... 37 .... Beaumont Park .... 1 .... .... .... 1 Priory 29 .... 28 .... 13 .... 70 .... Totals 57 .... 85 1 27 .... 169 1 104 TABLE SHOWING THE NUMBER OF CHILDREN EMPLOYED OUTSIDE SCHOOL HOURS AS ON 31st DECEEMBER, 1932. SCHOOL. Registered Occupations in Acton. Ages. 12 — 13 Ages. 13 — 14 Totals 12 — 14 Acton Wells 6 10 16 John Perryn 1 5 6 Central 10 16 26 Acton County 2 10 12 Roman Catholic 1 1 2 Southfield 13 24 37 Beaumont Park 1 — 1 Priory 24 46 70 Totals 58 112 170 105 TABLE SHOWING THE DISTRIHUTION OF ALL CHILDREN EMPLOYED DURING THE PERIOD 1st JANUARY 1932, TO 31st DECEMBER, 1032. SCHOOL. BOYS GIRLS John Perryn Acton Wells Central Priory Southfield Roman Catholic Acton County Others Special Totals Beaumont Park Totals (1)—Registered Occupations :— (a) Carrying or delivering goods or parcels 5 3 12 53 31 1 6 5 .... 116 .... .... (b) Delivering newspapers 3 19 32 50 35 5 8 10 .... 162 1 1 (c) Delivering Milk 3 3 7 18 5 .... 6 3 1 46 .... .... (2)—Employed in Other Areas:— .... .... .... .... .... .... .... .... .... .... .... .... Totals 11 25 51 121 71 6 20 18 1 324 1 1 Corresponding Figures for 1931 9 25 57 142 93 8 16 16 .... 366 .... .... 108 EXAMINATION OF TEACHERS AND OFFICE STAFF. 7 Candidates were examined during 1932. CONVALESCENT HOMES AND COUNTRY HOLIDAYS. 14 children (of whom 2 were granted free places), were sent to the Middlesex Edward VII. Memorial Hostel, Bexhill. MOTHERCRAFT CLASSES. The schools which sent classes to the Day Nursery were as follows:— Acton Wells 6 Priory 5 Beaumont Park 6 Turnham Green R.C. 2 Central 5 John Perryn 5 Total 29 MEDICAL INSPECTION RETURNS. A.—Routine Medical Inspections. Number of Code Group Inspections:— Entrants 858 Second Age Group 890 Third Age Group 1006 Total 2754 Number of other Routine Inspections 22 B.—Other Inspections. Number of Special Inspections 2479 Number of Re-Inspections 2297 Total 4776 109 Pages 106-107 blank TABLE II. 4 —Return of Defects found by Medical Inspection in the Year ended 31st December, 1932. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment. (1) (2) (3) (4) (5) Malnutrition 26 85 176 4 Skin:— Ringworm: Scalp 1 — 9 — Body 1 — 28 — Scabies 6 — 32 — Impetigo 6 — 401 — Other Diseases (Non-Tuberculous) 10 — 103 — Eye:— Blepharitis 15 — 86 — Conjunctivitis 2 — 34 — Keratitis — — 1 — Corneal Opacities — — 1 — Infective Vision (excluding Squint) 108 — 78 — Squint 9 — 10 — Other Conditions 2 — 56 — Ear:— Defective Hearing 9 — .... .... Otitis Media 11 — 5 — Other Ear Diseases 7 1 91 10 Nose and Throat:— Enlarged Tonsils only — — — 8 Adenoids only — — — 4 Enlarged Tonsils and Adenoids 42 3 15 4 Other Conditions 2 — 16 201 Cervical Glands NonTuberculous) — 89 — 5 Defective Speech 4 — — — Heart and Circulation :— Heart Disease: Organic — 8 — — Functional — 37 — — Anaemia — 9 — 1 Rangs:— Bronchitis — 3 — 1 Other Non-Tuberculous Diseases — 8 — — 110 TABLE II.—Continued. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defect. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment. Tuberculosis:— Pulmonary: Definite — — 3 — Suspected — 3 — — Non-Pulmonary: Glands — — 2 — Spine — 2 — — Hip — — 1 — Other Bones and Joints — — — — Skin — — — — Other Forms — — 1 — Nervous System:— Epilepsy — 2 — — Chorea 2 1 — — Other Conditions — 1 — — Deformities:— Rickets — 13 — — Spinal Curvature — 3 — — Other Forms — 11 — — Other Defects and Diseases (excluding Uncleanliness and Dental Diseases 6 35 998 — B.—Number of Individual Children found at Routine Medical Inspection to Require Treatment (excluding Uncleanliness and Dental Diseases). Group Number of Children Percentage of Children found to require Treatment Inspected Found to require Treatment. 1 2 (3) (*) - Code Groups:— Entrants 858 55 6.4% Second Age Group 890 86 9.6% Third Age Group 1006 79 7.8% Total (Code Groups) 2754 220 7.9% Other Routine Inspections 22 — — 111 table III. Return of all Exceptional Children in the Area. Boys. Girls Total. Multiple Defects 2 1 3 Blind—(including partially blind): Suitable for training in a School for the totally blind: At Certified Schools for the Blind 2 — 2 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Suitable for training in. a School for the partially Blind: At Certified Schools for the Blind or Partially Blind — — — At Public Elementary School 1 — 1 At other Institutions 1 — 1 At no School or Institution — 1 1 Deaf—(including deaf and dumb and partially deaf): Suitable for training in a School for the totally deaf or deaf and dumb: At Certified Schools for the Deaf — 3 3 At Public Elementary Schools 2 — 2 At other Institutions — — — At no School or Institution — — — Suitable for training in a School for the partially deaf: At Certified Schools for the Deaf or Partially Deaf — — — At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Mentally Defective: Feebleminded : At Certified Schools for Mentally Defective Children 26 16 42 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Notified to the Local Mental Deficiency Authority during the year — — — Epileptics: Suffering from severe epilepsy: At Certified Schools for Epileptics 1 — 1 At Certified Residential Open Air Schools — — — At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — 1 1 Suffering from epilepsy which is not severe: At Public Elementary Schools 1 1 2 At no School or Institution — — — Physically Defective : Active pulmonary tuberculosis (including pleura and intrathoracic glands): At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 1 2 At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — 112 Quiescent or arrested pulmonary tuberculosis (including pleura and intrathoracic glands): An Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools 1 3 4 At other Institutions 1 — 1 At no School or Institution — — — Tuberculosis of the peripheral glands: At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board — — — At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools 2 — 2 At other Institutions — — — At no School or Institution — — — Abdominal tuberculosis: At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 — 1 At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Tuberculosis of bones and joints (not including deformities due to old tuberculosis): At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 4 1 5 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — 1 1 Tuberculosis or other organs (skin, etc.): At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board — — — At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Delicate Children, i.e., all children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an Open Air School: At Certified Residential Cripple Schools — — — At Certified Day Cripple Schools — — — At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools 6 11 17 At other Institutions — — — At no School or Institution — — — 113 Physically Defective (continued): Crippled Children (other than those with active tuberculous disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life: : At Certified Hospital Schools — — — At Certified Residential Cripple Schools — 1 1 At Certified Day Cripple Schools 2 1 3 At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At Public Elementary Schools 7 4(1) 11(1) At other Institutions — — — At no School or Institution 1 2 3 Children with heart disease, i.e., children whose defect is so severe as to necessitate the provision of educational facilities other than those of the public elementary school: At Certified Hospital Schools 2 2 4 At Certified Residential Cripple Schools — — — At Certified Day Cripple Schools — — — At Certified Residential Open Air Schools — — — At Certified Day Open Air Schools — — — At other Institutions — — — At no School or Institution — 1 1 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1932. Treatment Table. Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V.) Disease or Defect. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme Otherwise Total (1) (2) (3) (4) Ringworm-Scalp 4 — 4 Ringworm-Body 22 6 28 Scabies 29 3 32 Impetigo 378 15 393 Other skin disease 94 6 100 (External and other, but excluding cases falling in Group II) Minor Eve Defecs 177 2 179 Minor Ear Defects 105 2 107 Miscellaneops (e.g., minor injuries, bruises, sores, chilblains, etc.). 948 50 998 Total 1757 84 1841 114 Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease. No. of Defects dealt with. Under the Authority's Scheme Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme Otherwise Total (1) (2) (3) (4) (5) Errors of Refraction (including Squint) (Operations for squint should be recorded separately in the body of the Report) 426 11 — 437 Other Defect or Disease of the Eyes (excluding those recorded in Group I-). 7 — — 7 Total 433 11 — 444 Total number of children for whom spectacles were prescribed— (a) Under the Authority's Scheme 323 (ft) Otherwise 11 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme 323 (b) Otherwise 11 Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment. Received other forms of Treatment Total number treated Under the Authority's Scheme, in Clinic or Hospital By Private Practitioner or Hospital, apart from the Authority's Scheme Total (1) (2) (3) (4) (5) 59 5 64 — 64 115 TABLE IV.—Continued. Group IV.—Dental Defects. 1)Number of Children who were :— (2) Half-days devoted to:— (a) Inspected by the Dentist: Inspection 36 Treatment 421 Aged: Total 477 5— 673 6— 818 (3) Attendances made by children for treatment 3822 7— 768 8— 891 9— 976 (4) Fillings:— Coutine Age Group 10—974 Permanent teeth 1703 11—1029 Temporary teeth 59 12— 963 Total 1762 13— 610 14— 193 (5) Extractions:— Total 7895 Permanent teeth 770 Specials 366 Temporary teeth 4018 Grand Total 8261 Total 4788 (b) Found to require treatment 5036 (6) Administrations of general anaesthetics for extractions 2178 (7) Other operations:— Actually treated 2811 Permanent teeth 136 Temporary teeth 133 Total 269 Group V.—Uncleanliness and Verminous Conditions. Average number of visits per school made during the year by the School Nurses 12 Total number of examinations of children in the Schools by School Nurses 18301 Number of individual children found unclean :— Vermin and Nits86 Slightly infested 597 Number of children cleansed under arrangements made by the Local Education Authority 2 Number of cases in which legal proceedings were taken:— (a) Unnder the Education Act, 1921. — (b) Under School Attendance Byelaws — 116 STATEMENT OF THE NUMBER OF CHILDREN" NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1932, BY THE LOCAL AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY Total number of children notified 11 Analysis of the above Total. Diagnosis. Boys. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots 2 1 (b) Imbeciles 2 1 (c) Others — — (ii) Children unable to be instructed in a Special School without detriment to the interests of other children : (а) Moral defectives — — (B) Others — — 2 Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 1 — 3. Feeble-minded children notified under Article 3, i.e., "special circumstances" cases — — 4. Children who in addition to being mentally defective were blind or deaf — 1 Grand Tota 5 6 We are, Your obedient servants, D. J. THOMAS, N. G. HOWELL. wi 69