ACT 41 Borough of Acton ANNUAL REPORT OF THE Medical Officer of Health TOGETHER WITH THE Report on the Medical Inspection of Schools FOR THE YEAR 1938 4 The incidence of Diphtheria is low, and this is undoubtedly due our successful efforts to secure immunization against the disease Although not so successful as we could wish it to be, and carried out at a comparatively small expenditure, immunization has been one of the most marked preventive measures which have been launched in the district. Compared' with the money spent on isolation and treatment, the expense is trifling, but immunization has achieved far more in preventing Diphtheria than hospital isolation has done since its inception. The survey under the Housing Act was concluded, and a report upon the work is appended. Owing to the introduction of outside work in connection with Air Raid Precautions and other activities, the staff of the Department has had to work under great pressure, but the ser vices of all of them have been rendered ungrudgingly as unsparingly. In conclusion, I should like to express my thanks to the members of the Council for their courtesy and support, not only during the past year, but throughout the period I have served by Medical Officer of Health. I remain, Your obedient servant, D. J. THOMAS. Medical Officer of SECTION A—STATISTICS AND SOCIAL CONDITIONS OF THE BOROUGH. Area—2,317 acres. There has been no change in the boundries Population.—The Registrar-General's estimate of the population in the middle of 1938 was 68,670, compared with 69,100 in 1937. The population at the Census of 1931 was 7510 but a re-arrangement of the boundaries occurred since the date of the Census, and the Census population of the district as now constituted was 70,008. 5 The number of new houses erected since the Census is as follows:— 1931-32 — 257 1932-33 — 188 1933-34 — 224 1934-35 — 134 1935-36 — 380 1936-37 — 201 1937-38 — 273 The number of Parliamentary electors on the Register for the past four years was as follows :— 1935 — 48,258 1936 — 48,813 1937 — 49,255 1938 — 48,961 The Number of Inhabited Houses according to the Rate Books on March 31st, 1938, was 17,041, compared with 16,861 on March 31st, 1937. Rateable Value.—The rateable value of the Borough on April 1st, 1938, was £799,502, and the sum represented by a penny rate was £3,154. Social Conditions.—Two years ago I reported fully upon the social conditions, and the changes which had occurred in recent years. The factors then noticed still operate, and there has been to drastic or sudden change. On December 31st, 1938, the total numbers of persons (18—65) resident in Acton and registered as wholly unemployed were as follows :— Men. Women. Total. 1,416 356 1,772 The total amount of out-relief and in kind disbursed by the Public Assistance Committee was £19,485. Extracts from Vital Statistics. POPULATION: 69,100. Total. M. F. Live Births. Birth-rate per 1,000 of Legitimate 829 422 407 estimated resident pop- Illegitimate 34 18 16 ulation—12.8 863 410 423 6 Still Births. Legitimate 38 20 18 Rate per 1,000 total Illegitimate 2 1 1 (live & still) births 37 40 21 19 Deaths 682 Death-rate per 1,000 inhabitants 10.0. Deaths from Puerperal causes (Headings 29 and 30 of the Regitrar General's short list). Rate per 1,000 total Deaths (live & still) births No. 29 Puerperal Sepsis 0 — No. 30 Other Puerperal causes 2 2.2 Death-rate of Infants under 1 year of age. All infants per 1,000 live births 56 Legitimate infants per 1,000 legitimate live births 55 Illegitimate infants per 1,000 illegitimate live births 88 Deaths from Cancer (all ages) 107 Deaths from Measles (all ages) 5 Deaths from Whooping Cough (all ages) 1 Deaths from Diarrhoea (under 2 years of age) —2 SECTION B.—GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. Staff. A list of the staff of the Public Health Department: will be found at the end of the report. Laboratory Facilities.—There has been no change in the arrangements. Ambulance Facilities.—There has been no change export in the management of the ambulance for infectious diseases. on April 1st, the Isolation Hospital became the Joint Action and Wembley Isolation Hospital, and the ambulance for the removel of infectious diseases belongs to that Committee. The ambulance is available for both districts. The two ambulances for accident 7 and non-infectious cases are housed at the Fire Station and are available at hours. Last year the ambulance was called out to 591 street accidents and on 388 occasions for private cases. free amounting to £172 12s. 6d. were paid for the use of the ambulance for private cases. — Nursing in the Home.—On April 1st, 1938, a new General District Nursing- Committee for Acton came into being-. it will be recollected that formerly the District Nursing was Carried on as part of the activities of the Acton General Hospital, but as the necessity for home nursing increased it was felt that it could be carried out by a Committee specially set up for the purpose. Even before the erection of the Hospital there was a home nursing scheme in connection with the old provident medical dispensary, and when the activities of the dispensary were absorbed in the work of the hospital, home nursing became a past of the work of the hospital. The work gradually increased, in 1937, negotiations were entered into between the Hospital Council and the Health Committee in order to widen the scope of home nursing. As a result of these negotiations a Standing Committee was set up consisting of five members appointed by the Hospital Council and five members appointed by the Borough Council. This joint Committee took over on April 1st, 1938, the management of the district nursing service which had hitherto been provided by the Acton Hospital Council. The Borough Council contributed £125 per annum towards the expenses, and the Joint Committee appointed an additional nurse, making a total of four nurses. Application for the services of the nurses is made through medical practitioner or at the Acton Hospital. The charges from 1s. 6d. a visit to 10s. 6d., but old age pensioners and persons in receipt of Public Assistance are nursed free of charge, Daring the nine months from April to December inclusive last year 334 sick persons were nursed and the nurses paid 7,080 visits to the homes of patients. The work done by the district nurses is not very well known, and this is unfortunate, because they fulfil a very useful purpose and supply a very urgent need in case of illness in many families. Hospital Provision.—The only change in the Hospital Provision is in that of the Isolation Hospital management. On 1st it became the property of the Acton and Wembley Joint Committee. 8 The following figures regarding the work of the Action General Hospital will be of interest:— Accommodation is provided in the Hospital for 72 patient —62 beds in General Wards and 10 for private patients. During 1938, 1,171 patients were admitted, an increase of 20 on the previous year, and the average number of patients resident daily was 59.83. 9,607 Out-Patients were treated during the year, theattendances numbering 51,768, showing that the recently enlarged Out-Patients Department is still well used. The Education Committee has continued its agreement with the Hospital for the treatment of tonsils and adenoids, and for artificial light. There is no change from last year in the following:— Laboratory facilities. Small-pox Hospitals. Tuberculosis. School Clinic. Child Welfare Clinic. Ante-natal Clinics. Treatment Centres for Venereal Diseases. LEGISLATION IN FORCE. The following local Acts, special local orders, general a cea tive Acts and byelaws relating to Public Health are in force in the district. Adopted Public Health (Amendment) Act, 1890 1890 Infectious Diseases Prevention Act. 1890 1899 Notification of Births Act, 1907 1907 Public Health Act, 1907 (Clause 50) (Part VI) 1921 Public Health Act, 1925 (Parts 2, 3, 4 and 5) 1926 The Acton Improvement Act, 1904- Nuisances, &c. 1974 New Streets and Buildings 1925 Smoke Abatement 1930 Middlesex County Council Act, 1930, Part IV (Regulation of Street Trading) Employment of Children Wireless Loudspeakers, Gramophones, &c. 1935 9 Fouling of Footpaths by Dogs 1937 Hairdressers' and Barbers' Shops 1937 Baths 1938 Houses let in Lodgings 1938 Houses for the Working Classes 1938 Cemetery 1938 Sanitary Conveniences 1938 Removal of Offensive or Noxious Matter or Liquid 1938 Mortuary 1938 Slaughterhouses 1938 Common Lodging Houses 1938 Tents, Vans and Sheds 1938 Offensive Trades 1938 MATERNITY AND CHILD WELFARE. Infantile Mortality. 49 deaths occurred in infants under one year of age, Corresponding to an infantile mortality of 56 per 1,000 births. The infantile mortality is slightly lower than that of 1937, 1936 and 1935, but higher than that of 1934 and 1933. 31 of the deaths or 63% of the total were due to developmental conditions including injury at birth, prematurity, malformations, etc. This group includes many vague and ill-defined Conditions in which the cause of death is most difficult to ascertain, and they also include those conditions least amenable of Improvement. Health visiting in the strict sense is not likely to affect or reduce the so-called neo-natal mortality, and the best results will probably accrue from the establishment of an efficient midwifery service including ante-natal supervision. It will be Served from another section of the report that our ante-natal clinics were much better patronised and appreciated last year, and 29 to this aspect of the question that we may hope for a reduction in the mortality from developmental conditions. There was a very gratifying reduction in the number of deaths from Diarrhœa; only two deaths were registered as due to this disease compared with 11 in 1937. The climatic conditions were favourable, but so were those of 1937. In the table at the end of the report are given the figures of visit paid to the names and the attendances at the Child Welfare Clinics. 10 Dr. Mann has kindly sent the following report upon the special Toddlers' Clinic at Steele Road. The Toddlers' Clinic has been held on the last Friday in each month, and as in the previous year, children from two to four years of age were examined. The number of children invited to attend throughout the year was 287, while the actual number of attendances was 132 or 46%, giving an average attendance of 11 per session. and showing a satisfactory increase over the two previous years. Many of the children were examined for the third time and will now leave the supervision of the centre and will come under the school medical service. We thus have, for the for time, a complete record of children from birth to school age The general health of the children was good, and mothers were most anxious to accept advice given on matters of feeding hygiene and general management. No serious abnormalities were met with, but several children were found to need treatment for carious teeth, in fedew tonsils and genu valgum. Three children who had made no progress for many months were referred to London Hospitals for removal of tonsils and adenoids, and have since shown marked improvement in growth. Four were referred to an Orthopaedic Hospital for corres tion of genu valgum and these are .all progressing steadily The following table gives the attandances of the expectant and nursing mothers, and of the pre-school children at the Dental Clinics. Mothers examined 174 Children examined 82 ,, referred 173 ,, referred 95 „ treated 99 „ treated 74 Number of attendances for treatment 386 ,, ,, Permanent fillings 40 ,, ,, Temporary fillings 12 ,, ,, Permanent extractions 793 ,, ,, Temporary extractions 233 ,, ,, Permanent dressings 74 ,, ,, Temporary dressings 35 ,, ,, Dentures supplied 27 11 No case of severe malnutrition or anæmia was seen, dough a small percentage of the children was actually under standard weight for the age. During the winter months a few were found to have boachial catarrh which responded to treatment. It is satisfactory to note that of the children examined 75% had been inoculated against diphtheria. The parents of the examining 25% were strongly advised to have the inoculation done and it is hoped that this will be done in the near future. Day Nursery. The Nursery is situated in Bollo Bridge Road and is open on five days a week. It has accommodation for 28 children and last year it was open on 229 occasions. The total number of attendances was 5,739. The present building is not owned by the Council but is noted and is only held on a short lease. It is the intention of the Council to include a Day Nursery in the new Health Centre in Aveaue Road, and I was asked to report upon the suitability of the position as well as the accommodation which would be necessary under the conditions which now obtain in the district. Since the great War the northern part of the district has been developed on industrial lines, and a large part has been covered with factories which varied industries are carried on, and which employ a large number of women. North Acton is a vague term, and has no definite gev>Sraphinal limits. Possibly for our present purpose the main bridge Road may be a desirable boundary; because esf the the main road forms a kind of barrier which is di rtiCttlf for A mother to cross with a small child or a perambulator. This is not strictly true, of course, because we find that occasionally mothers living north of the Uxbridge Road use the Day Nursery, but in only two instances, or rather two children from the same Family.Where the mother lived north of the main road were the Children being minded in South Acton. In no instance did we had a mother living south of the Uxbridge Road who took her could to be minded by someone north of the main road. As the Council will soon be considering the erection of a the Day Nursery, it may be advisable to review the question as it effects also the southern area and an investigation was made under she circumstances of all the children who are known to be daily minded. As far as the information in our possession goes. 12 there are 84 who are being daily minded, 18 north of the Uxbridge Road and 66 south of it. The addresses of the 18 children who are placed out to be minded during the day are scattered through out the northern area and were distributed as follows : Shake speare Road, Alfred Road, Nemoure Road, York Road, exsiActon, two each; one each in Steyne Road, Hereford Road, Home Lane, Twyford Crescent, Acorn Gardens, Wells House Road Canada Crescent and Canada Road. Four of the children were over 3 years of age and the others were probably under 2 years of age, but the exact age of five of them was not available. Four of the mothers were engaged in a laundry, five in factories, three in daily household work, and one each in office cleaning, school cleaning and clerical work. Three of the children were minded by relatives. some were minded by near neighbours, but two were taken from Shakespeare Road to Stanley Road, and in some instances the address where the baby was being minded was not available. In the southern part of the district, there were ascertained to be 66 children who are being minded. The mothers of the majority of these children work in laundries—48, out of the 66 possibly more. A fairly large number work for less than days a week—3£, 4 and days. 18 of the children were over 3 years old. It is natural that the percentage of the mothers employes in laundries would be higher in the southern part of the district than it is in the northern part. The majority of these mothers live fairly near to the Day Nursery and also to a nursery school A certain proportion of these children are minded by near relatives, generally grandmothers, who live conveniently near sometimes even in the same house, but in a separate tenement As many as 15 of these children were being minded by then grandmothers. Some are minded by the member of another family living in the same house, and in most of the other cases they are being minded by a person who lives conveniently near. We have six women who always have children to mind and who can almost be called professional baby-minders; these always have children but the numbers vary and the children change. Although I have designated these as almost professional baby-minders, the standred which thev observe is not lower, nor is it appreciably higher that the majority of those who mind an occasional baby. Of the 66, 33 are under 2 years of age, 17 between 2 and 3 years, and 16 over 3 years of age. 13 There were 10 from Stanley Road, nine from Colville Road five from Osborne Road, four from Stirling Road, three each from Hanbury Road, Bridgman Road, Berrymede Road and Ramsay Road, two each from Palmerston Road, Mill Hill Grove, Somerset Road, Beaumont Road, and one each from 18 other roads. These numbers are a fair average of the total children who are being daily minded, but they vary at different times of the year. In addition to the rush periods at the laundries and other factories, some mothers do work outside the home at this time of the year in order to augment the family income for Holiday purposes, but an exact record cannot be kept of these children. The daily minder is unregistered and uncontrolled. Eiaborate regulations have been framed to guard the foster child and the adopted child, and to restrict the use of unsatislectory foster homes, but the daily minder can live anywhere, under almost any conditions and supposedly caring for an indefiade number of young children. In most of the cases, the conditions are unsatisfactory. In some big cities it is stated that baby-minding is appalling and a problem; the conditions here the far from satisfactory, but they are in advance of those which obtained before the establishment of the Dav Nursery. Possibly the most fortunate children on the whole are those left with natives, though many of the grandmothers are difficult and brain impervious to the instructions given by the Health visitors. The less fortunate are those who are left with elderly persons and with those who are unable from some disability to under take extra domestic duties. In most cases the feeding is haphazard, but possiblv one of the most objectionable features baby-minding is the want of facilities in the minder's home so that the baby can have a reasonable amount of time in the open-air and sunshine when the conditions are suitable. The children are necessarily kept indoors for most of the time even when weather is warm and fine. The Council is probably more interested in ascertaining another or all of these mothers would accept facilities which might be offered to them in the shape of accommodation in a day Nursery conveniently situated. A small proportion probably would and as the benefits which a Day Nursery undoubtedly contact become appreciated this number would increase. Except when it is done by a near relative, " daily including" is more expensive than the Day Nursery. Tenpence or 2 shilling a day is the usual charge exclusive of the baby's food. 14 It might be assumed that a mother, even on the score of expense only, would prefer to have the baby at the Day Nursery. During most of the year there is a waiting list at the Day Nursery bed the difficulty of admission is not the only or even the primary reason why some of the mothers pr'efer the daily minder to the Day Nursery. Possibly, comparative inaccessibility is one reason, but the majority of the children come from strorck adjacent to the Nursery, and the mothers of these children not appreciate the necessary restrictions and precautions which have to be observed by those who use the Nursery. These regul- lations are essential for the protection of the clean children, but some mothers are unwilling' to conform with the necessary restrictions. We are not now discussing the relative advantages and disadvantages of the Day Nursery to those which obtain in the home. The Day Nursery may be only second best compared with a good home. It is a moot point if mothers should be encourraged to go into factories; is it a disadvantage to the children and also the mother benefit from factory life? The extra money is 2 temptation, but the home of the outdoor worker under the best of conditions presents a serious social problem. In some industrial encouragement is given to young married women to return to factories; they are the more experienced and expert workers, and requests are frequently made for their return, especially at rush periods. This is especially true of the laundry industry, but far as our figures go, the same conditions do not apply in the factories in North Acton. In the southern part of the district especially, in spite the Day Nursery and the eight nursery classes, there are children who are being minded in private houses, and on account of the conditions mentioned, this state of affairs is likely to cen for some time. For the younger children the alternative to the Day Nursery is the baby-minder. The only serious disadvantage of the Day Nursery as compared with the baby-minder is the possibility of exposure to certain epidemic infectious diseases such as Measles and Whooping Cough. Our Nursery is an adapted house, and is not ideal for the purpose, and there is not sufficient provision for isolation purposes. A Day Nursery should be something more than a dumping ground for infants and young children whose mothers have been absorbed into modern industand life. It is now a safe and hygienic playground and nursery.with proper food and suitable management and training, and instration tion is given to the mothers about the care of the children bed they return at night and for the week-ends. The children 15 in outdoor life when the weather is five and warm and suitable for outdoor purposes. In spite of these advantages we have the evidence that many mothers do prefer the baby minder, even if there were Sufficient accommodation at the Nurse These advantages may take some time to be appreciated, bathe mothers are gradually becoming aware of them, and appreiaring their value in the scheme for bettering the health of the children. Nurse Children. At the end of the year there went 1b. children on the register compared with 53 in 1937, and 39e on 1936. The reduction is due to the removal of a school from the district in which there Were several pupils who were on the register. Maternal Mortality. There were two maternal deaths but for the second year in succession there was no death from puerperal sepsis. The uses of death were Toxaemia of pregnancy and Pulmonary Embolism respectively. It is generally held that many of the deaths from Toxaemia of Pregnancy are avoidable; in any case, cause of the Toxaemia is usually enable to treatment, but is essential that the early symptoms. the so-called danger Signals, should be ascertained. It is a the early stages that dietetic and other treatment is successful. and to attain success, Regular ante-natal care is important- In this case, the patient and not attend the clinic. In last year's Annual Report the arrangements for the domiciliary service of midwives were mentioned. It was then slated that the local supervising authority had to submit to the Minister of Health proposals for carrying out its duties under the Midwives Act, 1936, within a period of six months from the commencement of the Act (July 3lsl-1936 or such longer period as the Minister might in any particular case allow. In our area, the Middlesex County Council is the local ( supervising authority, the arrangements did not come in to force until October 1st, The Middlesex County Counal made an agreement with the authorities of Queen Charlotte Hospital for the provision of a domiciliary service of midwives but although these arrange- have now been in force for eighteen months, a copy of the agreement between the County council and the Hospital authorities is not yet available. 16 As far as domiciliary midwifery is concerned, this want of information is not serious, but unfortunately, we are not aware of the conditions under which midwifery nurses can be obtained and utilised by general practitioners.. Other instances of dilataness on the part either of the Ministry of Health or of the Middlesex County Council might be given. At the Maternity and Child Welfare Committee in October, 1938, a resolution was passed asking the Middlesex County Council to take steps to putinto force Section 6 of the Midwives Act, 1936, which would prohibit any person other than a registered midwife or registered nurse from receiving any remuneration as a nurse for attending on a woman in childbirth. It was pointed out that in this area the midwifery service was efficient and capable of dealing with ill conditions and emergencies, and that a considerable amount of unqualified midwifery practice was carried on here. Neighbouring districts had already put this section into force. The Committee's resolution was sent to the Middles County Council, and a reply was received that the Middles County Council decided in April, 1938, to ask the Minister of Health to make an order applying the Section to the whole area for which the County Council is the local supervising authorihty Although this resolution was passed by the County Council in April, no decision had been arrived at in October, and as as we are concerned, nothing had been done in March, 1939, when the matter was brought up again to the notice of the local Maternity and Child Welfare Committee. The domiciliary midwifery scheme is working satisfactorily but its usefulness will probably be extended when the work of ante-natal clinics is extended and amplified. Throughout 1938, all the expectant mothers who booked the Queen Charlotte's midwives attended our ante-natal clinic at Avenue Road. The midwives attend the clinic which once weekly, and usually book their cases there. Unless Some abnormal condition exists, the expectant mothers continue, to attend our clinic until the 36th week of pregnancy, when they attend the ante-natal clinic at Ravenscourt Park. They are their examined by the doctor who would be called out by the midwife should any emergency arise at the confinement. The authorities at the Central Middlesex County Hospital would prefer a similar arrangement for the expectant mothers who are to be confined at that institution, and for those mothers who live in the southern part of the district this procedure is followed, but some of the mothers who live in the northern part of the borough attend the Hospital's clinic throughout their pregnancy 17 This arrangement was the only possible one until a second clinic had been established; the second weekly clinic was opened in March, 1939, at St. Gabriel's Hall, Noel Road. We could not possibly cope with an increased attendance at the clinic Avenue Road. During 1938 the attendances increased considerably. In 1938, 501 expectant mothers attended the clinic compared with 209 in 1937 and these made 1,051 attendances compared with 448 attendances in 1937. It will be seen that the Average attendance at each session of the clinic was over 20; but the average attendance does not give a correct idea of the conwhich obtained there. On some mornings the attendance was so great as to make it almost impossible to carry out the examinations properly, and the inconvenience from overcrowding was very considerable. A second weekly clinic thus became inevitable, and the only question was its location. Owing to the congestion of other work in Avenue Road, it was difficult to fit in another session on any day of the week. There were also either reasons in favour of holding the second clinic in the northern part of the borough if a suitable building could be secured. It is true that very few mothers north of the Great Western Railway attend our present clinic, but that is probably due to the comparative inaccessibility of the clinic. This also may account for comparatively small number from that area who have availed themselves of the domiciliary midwifery scheme. It is, of course, 2 piatitude to say that the utilisation of any facility is dependent upon its convenience and accessibility as well as its need and service, but if the comparative inaccessibility of the clinic is a factor in the non-utilisation of the domiciliary service, then the in habitants of the northern area have a grievance. In the area worth of the Great Western Railway and east of the North London Railway, north of the Uxbridge Road, only 15 mothers out of 207 availed themselves of the Municipal midwifery service in 1938, while 65 out of 330 mothers confined in the Central Middlesex County Hospital came from the same area. North of the Uxbridge Road, 47 mothers availed themselves of the domimidwifery service and 160 south of the Uxbridge Road, ojhilst-157 out of 330 confined in Central Middlesex County Hospital came from the district north of the Uxbridge Road. One other important fact has to be taken into consideration :apart from maternity nursing, private domiciliary midwifery as doomed. In 1937, the number of births notified by private midwives amounted to 273; in 1938, the number was 19, and 15 of these were notified by midwives who lived outside but practised in the district; three out of the four were notified by a midwife 18 who has left the district to take up an appointment under the Middlesex County Council domiciliary midwifery scheme. In 1938, 207 births were notified by Queen Charlo He's Hospital midwives under the domiciliary midwifery scheme, 330 births occurred in the Central Middlesex County Hospital, 11 in the West Middlesex County Hospital and 75 in Queen Charlo He's Hospital. In addition, the maternity hospitals and the maternity departments of the London voluntary hospitals were utilised by numbers of expectant mothers. For these mothers, a consultant service is available, either at Ravenscourt Park, or at the antenatal clinics attached to the respective hospitals. The only mothers for whom the Council is directly respensible for a consultant ante-natal service are those attended by private midwives, those attended by private doctors and these who are confined in nursing homes. Of these 19 were attended by private midwives, and 178 births were notified by general practitioners. The numbers confined in outside nursing homes are not available, but in local nursing homes the number was When the Council discontinued its own consulting ante-natal clinic it was decided to arrange for the private cases to attend the. Gynaecology clinic at the Acton Hospital under Dr. Bell. The numbers referred by doctors were too small to justify the Count's continuing the consulting clinic at Avenue Road. During the year the Health Visitors paid 526 visits to the homes of 318 expectant mothers. As stated on a previous page. 209 expectant mothers attended the ante-natal clinics. Section C. SANITARY CIRCUMSTANCES OF THE AREA. Water Supply. The Borough is supplied with water by the Metropolien Water Board. Drainage and Sewerage. All the dwelling houses are provided with water closets and are drained into the main sewerage system. By arrangement with the London County Council the is discharged into the London Sewers. Storm water is filtered and emptied into the Thames. Public Cleansing. The house refuse is collected by the Council and burnt in the Destructor. Last year 20,961 tons of refuse were collected and butal- 19 Sanitary Inspection of the Area, The following table includes the tabular statement furnished by the Sanitary Inspector under Article 27 (18) of the Sanitary others (Outside London) Regulations, 1935. tabular statement of inspections and 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) 2524 (1) Dealt with by service of Informal Notice 1291 (2) Dealt with by service of Statutory Notice under Section 17, Housing Act, 1930 88 (3) Dealt with by service of Statutory Notice under Public Health Acts 45 Premises (other than defective dwelling-houses) inspected for nuisances and miscellaneous defects 683 (1) Dealt with by service of Informal Notice 390 (2) Dealt with by service of Statutory Notice under Public Health Act, &c. 32 Reinspections subsequent to service of Notice 7812 Inspection after notification of Infectious Disease 202 Number of Premises under Periodical Inspection. Bakehouses 35 Slaughterhouses 2 Public House Urinals 37 Common Lodging Houses 1 Batches' Shops 39 Fish Shops 33 Premises where food is manufactured or prepared 68 Dries 17 Cowsheds Nil Piggeries Nil Rag and Bone Dealers 7 Was Nil Schools (12 Elementary, 1 County, 1 Technical, 7 private) 21 Carvan Grounds 2 Their dressers 50 Rent Restriction Act. Number of Certificates granted 4 20 Detail of Work carried out. Sanitary Dustbins provided 401 Yards paved or yard paving repaired 117 Insanitary forecourts remedied 38 Defective drains repaired or reconstructed 92 Defective soil pipes and ventilating shafts repaired or renewed 61 Defective fresh air inlets repaired or renewed 93 Defective gullies removed and replaced by new 88 Rain water downpipes disconnected from drain17 Dishing and curb to gullies repaired and new gratings fixed 99 Defective W.C. pan and traps removed and replaced by new 117 Defective W.C. flushing apparatus repaired or new fixed 304 Defective W.C. seats repaired or new fixed 264 Defective flush pipe connections repaired 46 Insanitary sinks removed or new fixed 44 Sink waste pipes repaired or trapped 170 Insanitary wall surface over sinks remedied 54 Ventilated food cupboards provided 11 Drinking water cisterns cleansed 109 Defective covers to drinking water cisterns repaired or new fixed 95 Insanitary sites beneath floors concreted 32 Spaces beneath floors ventilated 98 Dampness in walls from defective damp-proof course remedied 233 Dampness from defective roof, rain water gutterings, etc., remedied 766 Defective plastering repaired (number of rooms)553 Rooms where dirty walls and ceilings have been cleansed and redecorated 2615 Defective floors repaired 143 Defective or dangerous stairs repaired 43 Defective doors and windows repaired 307 Defective kitchen ranges and fire grates repaired 223 Defective washing coppers repaired 42 Coal cupboards provided or repaired 9 New W.C. apartments provided 8 Accumulations of offensive matter removed 41 Drains unstopped and cleansed 139 Drains tested, exposed for examination, etc 77 Smoke observations taken 338 Smoke nuisances abated on service of notice 89 Miscellaneous nuisances abated 153 Notifications of waste of water sent to Metropolitan Water Board 176 21 SMOKE. During the year 338 observations were made of factory climneys in the district. 20 Abatement Notices were served in respect of the emission of black smoke, and five for emitting grit; 53 Intimation Notices were also served in connection with these Csses. — Welsh coal is superior in smokelessness to that mined in England, and in Cardiff, where I am informed no other than Welsh is burned, the City is practically free from smoke pollution; the buildings are as a consequence clean, and there is a total absence of smoke haze over the City. The majority of English coals are of a bituminous type, and there fore smoke producing, but if something could be done in the way of grading, so as to ensure that those coals which produce little smoke in domestic grates and boiler furnaces were burned in towns, much inconvenience, and many of the ill effects burning raw coal would disappear. The burning of any coal in its raw state is uneconomic, by reason of the destruction of the valuable bi-products. To an econoimist, smoke means inefficiency and waste; it entails much Work for housewives, expense to all who live in towns, and a definite loss of sunlight. Also, it means dirtier streets and bulldings, and fouler air. We are constantly impressing on all ow'ners and managers the advantages financially to themselves and to the amenities of the district, of burning a good grade steam coal of a size suitable for their particular type of boiler, also the employment of a wholetime stoker who would have the time to fire at regular intervals, instead of employing a handyman to fire when he can, 2nd who shovels on the coal until there is a firebed of anything from 5 to 12 inches in thickness. These are the cases which five us the most trouble. There have been instances when the omission by the stoker to admit secondary air immediately after a charge of fuel was found to be the sole cause of the emission of smoke. In some cases, with a view to reducing costs, mechanical Stokers have been fitted to furnaces, but we have found on occasions that their efficiency has been reduced by the use of a very cheap coal, or through their being tended by untrained 22 The nuisance from the emission of grit from chimneys nearly always follows attempts to reduce the emission of smoke by the installation of- mechanical forced draught. Unless such appliance is carefully regulated, small particles of flue grit 2nd coal dust are blown unconsumed through the furnace and up the chimney, and are deposited at varying distances according to the velocity of the wind and the size of the particles, arresters to small plants are rather expensive, and not altogether satisfactory. Careful hand-firing with good grade fuels, without mechanical forced draught or steam jets, has satisfactorily abated several nuisances from grit. The Council has become a. member of the "Greater London Advisory Council for Smoke Abatement," which was recently formed under the Chairmanship of M. H. Keeling, Esq M.P., M.C. At a meeting held at the Home Office on March 29th last: Mr. M. W. Kinch, the Chief Sanitary Inspector, was elected to serve on the Executive Committee. Burning in the Open. 17 Complaints were received of nuisances from the burning of refuse in the open. Under the present state of the law, the Council has no power to deal with such cases, but if burning is continuous, and such a nuisance as to interfere with any person's ordinary rights, he can take action against the offender. when complaints of this nature are received, we usually write to the person responsible for the burning, and suggest that they should send such refuse to the Council's Destructor, and thus avoid 2 day annoyance to their neighbours. Section D.—HOUSING. 1. Inspection of Dwelling-houses during the Year 1938: — (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2529 (6) Number of inspections made for the purpose 8779 (2) (a) Number of dwelling-houses (included under sub-head (1) above), which were inspected and recorded under the Housing Consolidated Regulations, 1925 1731 (6) Number of inspections made for the purpose 5901 23 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 2 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subhead) found not to be in all respects reasonably fit for human habitation 2136 2. Remedy of Defects during the Year without Service of formal Notices: — Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 2008 3. Action under Statutory Powers during the Year: — A.—Proceedings under sections 9, 10 and 16 of the Housing Act, 1936: — (1) Number of dwelling-houses in respect of which notices were served requiring repairs 83 (2) Number of dwelling-houses which were rendered fit after service of formal notice:— (a) By owners 83 (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 45 (2) Number of dwelling-houses in which defects were remedied after service of formal notices: — (а) By owners 45 (b) By local authority in default of owners Nil 24 C.—Proceedings under sections 11 and 13 of the Housing Act, 1936: — (1) Number of dwelling-houses in respect of which Demolition Orders were made 2 (2) Number of dwelling-houses demolished in 1938, in pursuance of Demolition Orders Nil D Proceedings under section 12 (1) of the Housing Act, 1936: — (1) Number of separate tenements or ground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or ground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — Nil In previous Annual Reports the details of the work done under the Housing Act of 1935 have been given. Two Survey had to be made. Under Survey A, or the preliminary enumeration, 16,942 dwellings were inspected and 316 lettings were found to be definitely overcrowded, and 1,352 possibly overcrowded Survey A was completed in January, 1936. Survey B, which included the measurement of the 1,352 lettings, was completed in April, 1936, and of these 174 were definitely overcrowded, but' in the meantime 60 of the 316 overcrowded under Survey A had become uncrowded, which left a total of 430 lettings over crowded. When the results of the Survey were considered by the Special Committee appointed by the Council, it was decided that further information should be obtained concerning the over crowded families, more especially as to the rent paid, whether the lettings were controlled or decontrolled, and the presence of lodgers. This further inquiry was carried out in August, 1986 approximately less than six months since the survey for form B had been made, but in that interval it was found that 89 of the 430 lettings had become uncrowded. On December 22nd, 1936, an order was made for fixings January 1st, 1937, as the appointed day for the purpose of Section 6 of the Act, and the appointed day for the purpose of Sections 3 and 8 was fixed for July 1st, 1937. 25 In order to ascertain the permitted numbers for each working class dwelling and for the furnishing of this information to landlords in the prescribed form of notice in the rent-books, all working class dwellings had to be measured. On December 31st, 1937, 9,960 tenements had been measured, and "29 new cases of overcrowding were reported during the year. Included in the 9.560 lettings measured up to December 31st, 1937, were the 1,868 lettings which had been inspected or measured under Survey B. Owing to a slight omission in the forms which were Supplied for the purpose of Survey A and Survey B the different lettings in the houses could not be distinguished; the floors on which the rooms were situated were not indicated. These lettings had to be revisited in order to obtain the necessary particulars. of the 430 lettings overcrowded in Surveys A and B, "246 had become uncrowded when they were again inspected in 1937. On December 31st, 1937, there were, therefore, 213 lettings overcrowded. Particulars of these premises, the size of the tenements 2nd their distribution in the district were given in pages 26 and 27 of the Annual Report of 1937. The measurement of the remaining houses was continued in 1938 and concluded by the end of August. Altogether 17,550 lettings were measured. Tables were constructed each week to show the amount of overcrowding, and these show that the number of lettings known to be overcrowded varied from 288 in the week ending February 3rd to 221 in all the weeks from the middle of July to the end of August. With the completion of He measurements in August, the position had to a certain extent become stabilised, or more correctly, the amount of overcrowding would not materially increase after that date. A certain number of lettings which were on the borderland of overcrowding on the appointed day may become overcrowded merely by the lapse of time; namely, those families in which there were infants under five months, and children under ten years of age. When the reached the age of one year, they would count as half A_unit, and when those under ten reached the age of ten years, they would count as one unit and not as half a unit. Apart from over owding from these causes, it will be illegal on the part of the landlord to allow a larger number of persons to occupy the houses which have now been measured; the number allowed in each letting has to be entered in the rent books. The following table gives the number of lettings overCrowded on August 31st, i938, when the measurements were completed. 26 Cases of Overcrowding Before "The Appointed Day." Number of tenements overcrowded on completion of Survey B 430 Number of tenements under Survey B uncrowded to August 31st, 1938 276 154 Number of additional tenements found to be overcrowded under the present Survey, but occupied before " The Appointed Day " 132 Number of tenements under latest (1937-8) Survey uncrowded to August 31st, 1938 69 63 Total cases of overcrowding 217 Cases of Overcrowding After "The Appointed Day." Number of tenements found to be overcrowded under the present Survey, but occupied since " The Appointed Day " 10 Number of above abated to August 31st, 1938 6 Total 4 The causes of this fall in the number of dwellings which are overcrowded are many and varied. In the Annual Report for 1936 figures were given which showed the amount of over crowding at the four Censuses, 1901, 1911, 1921 and 1931. crowding slightly increased in each of the intercensal periods 1901—1911 and 1911—1921, but there was a sharp decrease with intercensal period 1921—1931. The percentages of families over crowded under the Registrar General's standard of more than two persons per room were as follows :— 1901 6.0 1911 6.3 1921 6.6 1931 4.3 27 The standards used for the surveys under the Housing Act, 1935, were slightly higher than those of the Registrar General, but in spite of this, the percentage of overcrowding in the Iettings inspected under Surveys A and B was only 2.5, which'showed that the decline in overcrowding which had been noticed in the intercensal period 1921—1931, had continued and even become accentuated in the period 1931—1936. Throughout the kingdom, one of the main causes in the dtcline of overcrowding (apart, of course, from the provision of dwellings has been the consistent and continuous decrease in the average size of families, and since 1911 Acton has had a Similar experience to that of the rest of England and Wales. The average size of the family did not decrease much in the intereensal period 1901—1911, but in the 20 years, 1911—1931, the average size was nearly one person per family less in the latter khan in the former year. The birth rate fell gradually but continuously until 1933, and though since there has been a very Sight rise, it is not sufficient to affect materially the average yu of the families. The fall of the birth rate has been observed ??? the wards of the district, and though the birth rate is still highest in the south-west ward, the relative fall has been greater in that ward than in the rest of the district. Both controlled and decontrolled houses have become ???rowded and in August, 1938, 276 of the overcrowded Iettings had become uncrowded. The cause of the uncrowding had been different in the two kinds of houses. The tenants of controlled house hesitate to forego the advantages of a controlled letting, and would not be prepared always to accept alternative accommodation if offered by the Council. Where it was possible to abate the overcrowding by a rearrangement of the sleeping accommodation or even by arranging for one or more of the family to deep elsewhere, this was frequently done. In the case of the decontrolled house, overcrowding was ???haed by moving into more commodious premises either in this ares or in a neighbouring area. Transport facilities have so improved that employees of the large factories in the north of the district are not compelled to live within the boundaries of the district in which the factory is situated, though in order to save rail and bus fares, people would prefer to live close to their place of employment. Within recent years, a very large number of houses have been built in neighbouring boroughs and some of those employed in the district have taken advantage of these opportunities to obtain better accommodation. •28 Although the presence of lodgers was not a very impor??? factor in the overcrowding of houses when the Surveys made, some of the lettings have become uncrowded because the lodgers have left and the rooms are occupied exclusively by the members of the family. In addition to these causes which have contributed towards the abatement of overcrowding, the whole trend of housing affairs and the changed attitude of local authorities in respect of housing since the War, have materially affected and are still affecting the question of overcrowding. In this connection the history of Action is fairly typical of most authorities in Greater London, and though the efforts made by the local authority here would not grealty affect the question, taken in conjunction with similar efforts by surrounding authorities, they have been effective in materially reducing overcrowding. As far as Acton is concerned the public authority owne no dwelling houses before the War. In the first decade of this century the question of building houses for the working clases was periodically raised in the Council but the motion was not taken seriously, although in common with many other parts of the country, in the years immediately before 1914 working Class houses were being built in decreasing numbers in Acton. The south-west and south-east wards had been almost fully developed before the Census of 1911 and building operations between 1911 and 1914 were confined to the north-east and north-west wards The houses which were being built in these two wards were mostly for sale and were beyond the reach of those included in the ferm " working class." During the War, building operations came practically to a standstill and this led to a shortage and the demand far exceeded the supply of houses. This was particularly true of Acton; a large filling factory had been established by the Government at Park Royal, which gave employment to thousands of munition workers; many of those employed there came here to reside permanently. After the War the Ministry of Pensions offices were erected in the Vale, and the north-western area was developed as a factory area. Houses of all kinds were naturally at a premium here. To meet the demand for more and improved houses, Parliament supplied the necessary machinery in the Housing Act of 1919, which for the first time providedan Exchequer subsidy to local authorities to build houses to meet the general needs of their areas. The Housing Act of 1919 was primarily intended to overcome the shortage of houses left by the War; the shorage 29 was too great to attempt to satisfy it wholly, the cost of production was so high that only the better paid artisans and person of a similar economic status could afford to pay the rents which the local authorities were obliged to charge. Under the ???ising Act of 1919 the Acton Council acquired three flats in Bello Bridge Road, but the main effort was the erection in 1920 of 320 houses in East Acton. The rate of interest for the loans raised varied from 6 to 63/4 per annum and the other costs of erection were correspondingly high. In spite of the subsidy the lowest rent charged was 17s, 17s. 3d. and 18s. for a house with living-room, scullery 2nd three bedrooms; out of 320 houses, 136 were of this type. 172 of the houses consisted of a parlour, living-room, scullery and three bedrooms, and the rents for these varied from 19s. 10d. to 22s. 4d. per week. Twelve of the houses were centrally heated 2nd the rents of these varied from 23s. 2d. to 31s. Id. a week. Central heating has now been discontinued and the charges for the service, which varied from 4s. 6d. to 7s. 6d. a week, have been abolished. These rents compared very favourably with those charged for houses of similar accommmodation in the district, and there was keen competition for the houses. There was always a long waiting list, and the Housing Committee were able to select ??? they considered would be an asset and not a liability. The criterion was the suitability of the tenant from a landlord's Point of view and not any question of overcrowding or unhealthy condition under which the applicant lived. Nearly ten years elapsed before the Council undertook further building operations. In 1930, 28 flats were erected in ??? Acton: in 1931 eight flats were erected in Enfield Road, 2nd in 1932 eight flats were erected in Brouncker Road, and 64 and six houses in Wales Farm Road. These were all ???ected under the Housing Act of 1924. The Housing Acts of 1923 and 1924 had the same objective as that of the Housing Act of 1919, namely, the provision of more and more houses, partly by private enterprise and partly bv local authorities, and there was a subsidy under the Housing Act of 1924 of 10s. for each dwelling. But the costs of production had fallen rapidly; the rate of interest for loans paid by the Council for the houses and flat erected under the Act of 1924 varied from 31/2% to 5% and the other costs of erection were also correspondingly lower. At the time of erection the two-bedroom flats were let at rents ???ing from 10s. Id. a week to 11s 9d.; the three-bedroom flats 30 at rents varying from 11s. 9d. to 13s. 8d. a week, and the three bedroom houses at 13s. lid. a week. Later the Council equalised the rents of the houses erected under the Housing Act, 1919 and the houses and flats erected under the Housing Act, 1924, which effected a lowering of the rents of the former houses and a corresponding raising of the rents of the houses and flats erected under the 1924 Act. In 1934 the Council erected two houses and 52 flats in Canada Crescent under the Housing Act, 1925. Prices had again fallen and the rate of interest for loans varied from 3% to 31/2 per annum. The result was that the two three-bedroom houses without a subsidy, were let at 14s. lid. and las. 2d. a week the two-bedroom flats at 13s. a week. These rents are exactly corrcci for the year 1935-1936. They vary slightly according to the. level of the district rate which is levied in the area, but the variation in the past has been small). The Housing Act of 1930, by which a comprehsive attack upon the slum was begun, was ol minor Importance, to Acton. A survey was made of the district, but less than a score of houses were closed. As the Committee is aware, in one an appeal was made by the owner to the County Court against the demolition order made by the Council, and the County Court judge refused to make the order. There are a few houses still left in the district which are showing signs of age and unless extensive structural work is undertaken to recondition them, they will have to be closed. In the ordinary acceptance of the term, we have no slums in Acton. We have no areas which could be scheduled for clearance purposes; most of the district is comparatively new the streets were planned and the houses erected after Buiding Bye-laws had been in operation. The Housing Act of 1935 was of much more important this Act dealt specifically with overcrowding, and fixed a mimimum standard of overcrowding. Reports upon the results of the survey made under the Act have already been made and the flats erected in the Steyne and the proposed erection of ??? in the Vale is the Council's contribution to relieve overcrowding in the district. Although overcrowding was specifically not dealt With in the Housing Acts before that of 1935, a change in the type of tenant had been setting in for some time before that. The houses and flats built under the Housing Acts of 1924 and 1925 were much chcaper than those built under the Act of 1919. and as shown above, could be let at lower rents. The Council could 31 therefore, draw upon a wider field of applicants. The rents for flats were lower than for tenements of similar accommodation in other parts of the district except for controlled houses ???enements. The question of local housing- finance thus became taks prominent; there was not the same need to discriminate in the process of selection ; a larger number of working class families were able to pay the rent and to enjoy the benefits of municipal housing. Although for these reasons the Housing Committee was able to pick and choose and inquiries were made into the habits and circumstances of the applicants for houses and fiats, synpathetic consideration was given to those with large families found it difficult to find suitable accommodation, elsewhere It is well known that private landlords look askance at ?mnts with large families for various reasons; large families are tenants, and in the nature of things, large familles are the poorest and find it difficult to pay the rent regualy. Although inquiries were made into the circumstances and the applicants, contact with the new tenants was not sufficiently Ovt&xate to prepare them for the new surroundings. Arrangewere not made for cleansing furniture and clothing and fermation was not given on matters connected with the change. During the last summer complaints were made that the Council houses were infested, some of them heavily infested, and the Housing Committee decided to institute inquiries into the cause and the extent of the infestation, and to ask the Public Health Ckp-irtment to undertake the disinfestation. Inquiries were made in all the Council's houses and flats; with first place the tenants were asked if they had seen any bedbugs in the house, and the sanitary inspectors confirmed the P^Scnce of them when reported by the tenants. Inquiries were at 491 houses and flats, and 108 were found to be infested; >c»'ere heavily infested and 78 slightly infested. According to statements made, some of these had been infested for over j®* years, and in one instance as long as sixteen years. It was <5n\ous that in some instances the premises were infested when present tenants entered into possession. In other instances rU.rtnants brought the bed-bugs with them from their'old houses, c^*Cp»>ssibly their belongings might have been infested in the van •H'he furniture removers. The problem of disinfestation had to be attacked along ***»«iain channels; not only had we to deal with the disinfestation tv houses and the belongings of families in transit between dwellings and clean houses, but also the disinfestation already verminous in which the tenants have to remain. 32 The latter aspect of the problem is the more difficult, because we have no chemical disinfectant which is lethal to all stages of the bed-bug and egg, which can be easily applied, if at all, where the tenants are already occupying the houses. Many chemical substances have been applied at different times and two have proved to be entirely successful in eradicating bugs—cyanide 2nd heavy naphtha. For many reasons, the cyanide method cannot be used in the Council houses, and its use was rejected, but it has been adopted for the fumigation of furniture. The Housing Committee decidcd that when a Council house or flat became vacant, where necessary, the building should be treated with heavy naphtha, and in all cases the furniture of the new tenant is collected in vans and fumigated with hydrogen cyanide and the bedding disinfested with steam. Since August 3rd, 1938, this procedure has been ??? out. The fumigation of the furniture in vans is done by the Associated Fumigators, Ltd., and from August to the end of the year the furniture of 32 new tenants was fumigated hydrogen cyanide and the bedding steam disinfested. Eight empty houses were found to be infested and were treated with heavy naphtha. Heavy coal-tar naphtha it ft clear almost colourless liquid which, in air, partially vapor The concentration of vapour obtained is dependent on the ture, and certain conditions must be observed in order to obtain sufficient concentration and vaporisation for it to act both 3S contact insecticide and vapour fumigant. When properly the rooms are charged with the vapour in such a concern form as to penetrate all cracks and crevices, drawing 33 ?? uphtha disappears more quickly when the house is opened up Subfrequently. The rooms are kept sealed for 24 hours; it is (needless to say, of course, that the disinfestors have to wear From the visits we paid to other districts the method Appeared to be very successful; our numbers, so far, are too smal juried out it was entirely successful in the eradication of bugs 3bt tho Disinfestation by naphtha is a fairly expensive process; occlusive of wages, transport, equipment and establishment £kiri,'es, it works out at about 95s. a house. The disinfestation of houses already occupied is far more difficult. From a description of the methods employed with heavy ttjphtha it is obvious that the tenants must vacate the house for or three days and find other accommodation. This was jointed out to the tenants, and in no instance were they able, cx cared, to seek the necessary accommmodation. We thereto* had to resort to other insecticides with varying results. We fcc*ted altogether 100 houses, containing 416 rooms, with different i**jfccticides, most of them with two proprietary fluids. Altogether (00 houses (416 rooms) have been treated with these insecticides A«vl the houses visited on several occasions afterwards; in 16 (48 rooms) it was necessary to sprav a second time, and in Httt cases (nine rooms) a third time. We presume that the till*re was due to the fact that the insecticide was not applied to. or did not reach into every crevice, to the insects or their eggs. t* *ome houses the process is only applied to some of the rooms re-infestation may have occurred from rooms not treated, one instance, weeks after the application of the insecticide picture rail was taken down and behind it there were conquerable numbers of dead bugs. At the end of the year, inquiries were made, and in most the houses, as far as we could ascertain, the bugs had been Eradicated. We cannot forecast the conditions which may arise the advent of warm weather in the coming spring and sumbut with continued vigilance and the changes in administra**• decided upon by the Housing Committee there is every '**e5tation faces us when we try to find the cause and endeavour 34 to prevent the conditions above-mentioned. A percentage of over 20 of the Council houses was found to be infested; so of them so heavily infested that if they had been found on private property, the sanitary authority would have called upon the owner forthwith to abate the nuisance. In some of the houses treated with heavy naphtha the crevices and upper and inner borders of the wallpaper in the bedrooms were thickly clustered with dead bugs and their eggs. In the first place, had the conditions in the Council houses deteriorated in the last ten years; how did these conditions ??? pare with those which obtain in the parts of the district from which the tenants of the Council had been drawn ? We have no exact figures of the amount of infestatation in the Council houses ten years ago; no complete survey was attempted before last year, but from the inquiries made at and the observation of the different officers of the Council, there is little if any, doubt that conditions have deteriorated very considerably Infestation has increased both in the number of houses affected and in the amount of infestation in most of the houses affected On the other hand, the sanitary inspectors and health visotors are of the opinion that in the district as a whole there has been a decided and definite improvement in the last ten years. Even in those streets which have had for years the worst reputation and in which most of the tenements were periodically over crowded, not only is infestation much reduced as compared with ten years ago, but they would compare favourably with the Council houses in the number of rooms which are infested. There is more than one explanation of this ??? state of things. Private property is constantly inspected and the tenants are not averse from complaining to the sanitary inspectors and health visitors; the complaints are investigated and, if nessary notices are served upon the landlords or their agents. Most of these houses are registered as houses let in lodgings, and under the Bye-laws we have power to call upon the owners the nuisance. The owners of the houses also maintain contact with the tenants, and unless the tenants co-operate with them in maintaining cleanliness, pressure is exerted. These conditions have been to a great extent non-existent in the control of the Council houses. The tenants are aware that decoration can ble be carried out at stated intervals and probably imagine that complaints would be useless. Even if inspection was often appeared to them as if it was carried out by agents of the Council. 35 In order to remove some of these difficulties the Housing Committee decided to appoint a Housing Visitor, and Miss Carney commenced her duties on September 1st, 1938. Her duties have not been too strictly defined, and the vale of her work will be enhanced if the tenants will regard her Appointment in its true light. She is not here for the purpose ot interfering in matters affecting their private lives, but to promote their social welfare. A considerable part of her time 4us been spent in visiting applicants for Council houses, and in rttis way it is possible to see the selected tenants in their old arroundings. The four-floor block of flats—Steyne House—was finished in December and occupied in the first week of 1939; the block cosists of 24 flats, and one wing of eight two-bedroom flats is occupied by tenants transferred from the East Acton Estate. It wii be recollected that in the Annual Report of 1936, it was pointed out that although many of the houses there were overCWmded, there were also many which were much under-occupied. erection of these flats in Steyne House enabled the Council to rcctify this anomaly so as to allow the houses in East Acton to be occupied by families living in overcrowded houses. All the new tenants, prior to their removal, are visited by the Housing Visitor and information about their conditions and ffecir circumstances, the urgency of their need and other details Aw obtained by the visit. On the day of removal the Housing 'fteitor is present at the actual loading and unloading of the fumigating vans so as to avoid friction and complaints, and also Censure that all furniture goes into the van. Close touch has Ween kept with the Town Clerk's Department, which manages the fin tings. In the course of her visiting, notes are made of complaints in connection with repairs, etc., and these, in turn, have been Passed on to the Borough Engineer and Housing Foreman. The large majority of the tenants are of a good standard, are less cleanly in their habits, and a small number require a certain amount of supervision. " The degree of need varies from family to family. At one end of the scale all that may be 36 needed is a call to make a friendly enquiry in time of sickness at the other, there may be an occasion for taking some disciplinary action." When necessary, it would be advantageous if the Council would uphold the measures suggested, and not allow any famtfy unreasonably to break the conditions of tenancy, nor allow anvon to disturb others in the peaceful enjoyment of the amenities of life. It is impossible to estimate the difficulties which folow vacillation and hesitancy in dealing with obstinate and truculent tenants. The unfortunate family who have met with unexptected and adverse circumstances always deserve consideration, and the feckless and even apathetic rouse sympathy. When the letter are advised, they do intend to carry out instructions, though they usually fail, but even when they fail the harm they do is frequently limited to the results of their failure and falls mostly upon themselves. But with the obstructive tenant matters 2k different. The repercussions of his refusal are felt when attemple are made to assist others. Section E.—INSPECTION AND SUPERVISION OF FOOf) (a). Milk Supply. There are no cowsheds in the Borough, all the milk ??? produced outside. There are 120 persons or firms retailing milk in the di under the following categories: — There are 120 persons or firms retailing milk in the under the following categories: — Dairymen. Purveyors ol ??? 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 shop from which milk issue in closrd receptacle only 13 15 2 37 Special Designated Milk. The number of persons or firms licensed to sell Special Designated Milk is as follows: — 5 Tuberculin Tested. 1 Tuberculin Tested (Supplementary Licence). 2 Accredited. 13 Pasteurised. 1 Pasteurised (Supplementary Licence). 3 Pasteurised (No licence fee payable by Express Dairy Co. Ltd.)* 25 *The Express Dairy Co. Ltd. have a pasteurising plant at No. 100 Bollo Lane. ft). Meat Inspection. There is no change of conditions. There are two slaughterHouses in the district; in one of these a whole-time meat inspector W i-ngaged on the duties of inspection. Meat Inspection at T. Wall & Sons' Slaughterhouse during the Year 1938. During the past year there has been the very slight increase of .o62 in the number of pigs' carcases inspected, affected with dseseases other than Tuberculosis, and a decrease of .78% in the affected with Tuberculosis. One carcase was found to be affected with cystercircus '"whsae (viz., measly pork). This disease is uncommon in the 38 British Isles, but fairly common on the Continent. In the intermediary host (the pig) the parasite takes the form of a cyst varying in size from a pinshead to a pea, in the muscles or other tissue of the pig. In the host (man) the tapeworm develops and may grom to a length of ten feet. When each segment is mature, it detaches itself from the rest of the worm, and passes out of the intestine, with the faeces. By the decomposition of the segments the are set free, and may be devoured by other food animals in disthek, where the contents of cesspools and privy pits are spread over land, and thus the cycle of events is carried on. There is alway the danger of infection from eating measly pork in an imperfectty cooked condition. Two improvements have been carried out in the slaughtes house during the year, one being the installation of a Gjerotru Black Scraper, which removes the black from the skin of back pigs after they have passed through the singeing machine. This machine can be set at various speeds, and is very thorough in its opera rion. The other improvement, the installation of an Iwel Anew Depilating Plant, is not yet completed, but when it is, sows and large pigs will be immersed in a solution of resin and cotton ??? at a high temperature, and after a short period withdrawn, and cooled with water. The film of resin and oil is then stripped off removing any hairs by the roots. The strippings are afterward re-melted, filtered, and returned to the dipping tank. This process follows the scalding tank and de-hairer. and is really a finishing machine, removing all hairs which the de has failed to do. The plant is an American invention, and is the only one of its kind in Europe. The other slaughterhouse deals almost entirely with Kesher meat. 39 CAUCASES INSPECTED AND CONDEMNED. Cattle, excluding Cows Cows Calves Sheep & Lambs Pigs 1. Number killed 13 5 13,264 2,526 40,691 2. Number inspected 13 5 13,264 2,526 40,691 3. All diseases EXCEPT TUBERCULOSIS— Whole carcases condemned — — 76 3 1 Carcases of which some part or organ was condemned 6 1 174 730 60 Percentage of the number inspected affected with disease other than Tuberculosis 46.1% 20% 1.13% 29% 0.15% 4. TUBERCULOSIS ONLY— Whole carcases condemned — 2 22 — 39 Carcases of which some part or organ was condemned 3 — 112 — 1,870 Percentage of the number inspected affected with Tuberculosis 23.0% 40% 1.01% — 4.7% 4* O NUMBER OF PIGS' CARCASES INSPECTED FROM 1st JANUARY TO 31st DECEMBER, 1938 WITH ANALYSIS OF SURRENDERS ON ACCOUNT OF DISEASE. 1938. 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 3192 15'2 7 1 — 2 — — 148 803 lbs — February 3447 118 3 — 1 — 91 310 ,, — March 3292 109 3 — 1 1 — 125 393 ,, 1 April 2956 151 5 — — 2 — 107 344 2 May 8084 174 1 — 2 186 292 ,, — June 8114 155 4 — — 153 287 „ 2 July 3928 1'21 1 . 1 1 158 317 .. 2 August 8088 105 3 1 1 — — 88 191 1 September 8084 198 4 — 1 88 189 „ 3 October 3774 187 7 2 1 205 322 ,, 1 November 3877 214 3 __ ____ 1 291 357 ,, 2 December 3143 128 — — 1 1 — — 179 395 „ 1 Total 40593 1710 40 3 3 8 7 1 1819 3700 ,, 16 41 (C) Adulteration. List of samples taken during the year ended 31 st December, 1938. Article. Taken. Adulterated. Milk 123 — Ammoniated Quinine Tablets 2 1 Boracic Acid Ointment 1 — Brandy 1 — Butter 2 — Chocolate Milk 1 — Cream Pastries 2 — Gin 3 — Mercury Ointment 1 — Minced Beef 8 2 Red Currant Dressing 1 — Rum 1 — Sausages 28 7 Vinegar 10 6 Whisky 5 1 189 18 Number of Prosecutions 3 — Number of Convictions 3 — SECTION F.—PREVALENCE AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. At the end of the Report a Table is given showing the incidence of the compulsory notifiable diseases, and the following •ceived special attention during the year. MEASLES. In previous Annual Reports it has been shown that since WflO Measles has occurred in Acton regularly every two years and, 42 as was anticipated, it made its appearance in the late autumn at1937, and continued into the summer of 1938. From 1918 to1930, the interepidemic period was slightly over 104 weeks, the result that the deaths from the disease were entirely confined to the even years, as the following figures show:— Year. Deaths. Year. Deaths. 1919 — 1929 — 1920 9 1930 9 1921 — 1931 3 1922 5 1932 12 1923 — 1933 1 1924 16 1934 11 1925 — 1935 — 1926 12 1936 10 1927 — 1937 o 1928 12 1938 5 In 1932 the interepidemic period became slightly less and cases made their appearance in the late autumn of 1931. The same phenomenon occurred in the 193-4 epidemic, but, the epidemic of 1936 again made its appearance at little more : the 104 weeks after that of 1931-32, and no deaths occurred in Last year's epidemic made its appearance in less than 109 weeks, and two of the deaths occurred in 1937. It was reported in last year's Report that a limited outbreak occurred in West Acton in the summer of 1937, but no deaths occurred. general epidemic which was due, made its appearance in October 1937, and one death occurred in the last week of November, and one death in the last week of December. The epidemic, like the two preceding ones, was slow in developing. There was a lull during the Christmas holiday and the schools in the southern area of the district were not much affected until late in January, 1938. The epidemic rcaehed its peak in March, 1938. One death occurred in the first quarter of 1938, and four in the second quarter. With the exception of the epidemic of 1922 the number of deaths was less than that in any of the other epidemics, but if we take two epidemic periods, although 43 In improvement recently, there were three more deaths than in the two epidemic periods of 1919-1922, as the following figures Show:— Years. ... ... ... Deaths. 1919-1922 ... ... ... 14 1923-1926 ... ... ... 28 1927-1930 ... ... ... 21 1931-1934 ... ... ... 27 1935-1938 ... ... ... 17 There was no change in our administrative methods. Measles in Acton is almost entirely a disease of pre-school children and children attending Infants' Departments. Exclusion of confacts in the Junior and Senior Departments is unnecessary, and it doubtful if exclusion is of any use, even in the Infants' Departments. Most of the deaths occur in children of pre-school age, Ami it is desirable to avoid infection among them as much as possible. If, therefore, contacts of school age are permitted to attend school, they are less likely to infect their younger brothers And sisters. Reference may again be made to the researches of Or. Stocks, that a temporary immunity is conferred in a large number of children by sub-clinical infections. Under such conditions it is possible that the attendance in schools of contacts may Sexell the numbers of their fellow-pupils who become temporarily Viwnune by sub-clinical doses of infection. Our usual procedure of admission into hospital was adopted. Our accommodation at Fever Hospital would not possibly allow the admission of all cases, even if that were desirable. A selection has to be made, those cases in which a complication of Measles had occurred Of where the home conditions were unsatisfactory were admitted. Suring the year 32 cases were admitted to Hospital, with three deaths. SCARLET FEVER. One hundred and sixty cases of Scarlet Fever were notified Wsvyeaj, but there was no death from the disease. This is the consecutive year in which no death has occurred from leaflet Fever. This fact alone is sufficient evidence to show that here has in recent years been of a very mild character, but the change in the incidence of the disease has not corresponded with the mortality from it. In the early part of this Coutury and in the latter part of the last, Scarlet Fever 44 was a formidable disease, but even the older generation of doctors distinguished between Scarlet Fever, which was a dangerous and deadly disease, and Scarlatina, a similar but much milder ??? of infection, which hardly ever causes a death. The death returns in these earlier periods showed the loss of several members of the same family, when the disease was prevalent in a locality. The throat symptoms were especially severe in these cases, and doubt is sometimes cast upon the diagnosis; that some of these cases may have been due to the virulent type of Diphtheria, similar to that which occurred in the district in 1932 and 1933. We know that in the gravis type of the Diphtheria bacillus death does occur within 48 hours or less of the onset; the membrane which appears does not assume the characteristic appearance of the mild or moderately severe type of the . disease, and before the rise of bacteriology it is suggested toilsome of the deaths attributed to Scarlet Fever may have been due to the virulent type of Diphtheria. It is not necessary assume that a mistake in.diagnosis was made. In the early years of this century we experienced these severe cases of Scarlet Fever and in 1908 15 deaths occurred from the disease in Acton, and in 1909, 16 deaths. Various reasons have been given for the change of type in the disease, such as the influence of isolation, improved methods of treatment, etc. These may have had an influence, but it is very doubtful. We find that in the four consecutive years, 1917—1920 in Acton not a death occurred from due disease, and in that period treatment by a specific serum and chemo-therapy had not been introduced. Figures from Acton are not available before 1881, some of these are not too reliable, and earlier figures woould probably be less reliable. A study of the history of Scarlet Fever shows that in different countries long periods, during which the disease proved extremely virulent, were followed by other long periods in which the disease was very benign. The history of the disease in Acton shows that virulent cases occurred fairly the quently up to the War, but since the Great War virulent cases are rare, and a death from uncomplicated Scarlet Fever occurs, unless the victim was originally in unsound health or otherwise debilitated. In the 25 years 1889 to 1913 there were 104 deaths, and in only two years, 1892 and 1897, was there no death from the disease. In the 25 years, 1914 to 1938, there only 21 deaths, and in 12 of these years there was no death from the disease. 45 Although the mortality of Scarlet Fever has in recent years reduced here to very small proportions, the number of cases still remains fairly high, and we have to admit that hospital isolation has not succeeded in controlling the spread of the disease. Recent researches into the cause and mode of spread of Scarlet Fever partly explain the cause of the failure. We are still bound by the idea that Scarlet Fever is a separate entity, the diagnostic criterion being a train of symptoms, which included (ever, sore throat, and more especially a rash. These are the usual reactions of a young person to the invasion of the germ which causes Scarlet Fever. But we now know that in any outbreak the symptoms range in severity from almost nil to the severe, and that the symptom which is usually taken as the most important, the rash, may be absent. Some persons possess a partial or complete resistance to the poison, but the resistance may be insufficient to protect them from some of the symptoms. Moreover, some of the strains of hemolytic streptococci differ in their capacity to produce a rash; in some it is so high that 90 per cent of those infected develop clinical Scarlet Fever; in others it is so low that onlv one out of 10, or even 20, exhibit the charac??? istic rash. Scarlet Fever is really only one manifestation of a Very large group of allied conditions, which include tonsillitis, colds, erysipelas and other conditions. With these facts in mind it is not difficult to understand why hospital isolation has had apparently no influence in lowering incidence of the disease. Only those cases which exhibit the principal symptoms are notified; these cases alone are, in many istricts, systematically removed to hospital, leaving unisolated many cases of infection with kindred organisms, which are a source of danger to the community. To remove all patients exhibiting clinical symptoms of streptococcal infection is obviously impossible and unnecessary, and the Ministry of Health now deprecate the indiscriminate removal of all cases of Scarlet Fever to the hospital. Whenever possible, uncomplicated cases of -Siarlet Fever should be treated at home and thus removed from the danger of cross-infection, which are at present inseparable from the routine system of isolation hospital treatment as commonly practised. Unfortunately, a large number of Scarlet Fever cases have to be removed to hospital for social and economic reasons they cannot be isolated or properly treated in their homes, and even if these conditions can be observed the occupation of the other members of the household might make it extremely inconvenient to treat the cases in their own homes. 46 We do not desire that the public should in any way underestimate the infectiousness of Scarlet Fever, but rather appreciate the infectiousness of other conditions which are allied to itMedical practitioners are becoming alive to the different manifev tations of infections with the haemolytic streptococci, but there I* need for the education of the general public in regard to th» infectious nature of tonsillitis and feverish sore throats, although they may be unaccompanied by a rash. DIPHTHERIA. Nineteen cases of Diphtheria were notified and there two deaths. Both the deaths were in children who had not been artificially immunised. Two children who had been immunised contracted Diphtheria. Both cases were mild. The first had received three doses of Formol Toxoid in 1933, and when Schick tested in 1935 was found to be negative. The second one was one of those unusual cases who are extremely difficult to render immune. He received three doses of Formol Toxoid in 1935, and two doses of Alum Precipitated Toxoid when he went to school 1937. He contracted Diphtheria in February, 1938; in October 1938, he was Schick-tested and was found to be positive. It his been repeatedly stated that a negative Schick reaction does not always indicate ability to withstand a virulent infection, especially of the " gravis " type. Moreover, two doses of Alum Precially tated Toxoid or three doses of Formol Toxoid or Toxoid Floccules are not always sufficient to bring about a negative Schick reaction To overcome these difficulties, Doctors Parish and \Vr inland Doctors Schwartz and Janney consider that, as a routine, measure, a re-test at school entry or a dose of prophylactic & desirable. We have anticipated these recommendations, and for time we have advised the parents to allow their children to haveas a routine measure, a dose of prophylactic when they enter the Infants and Junior Departments. In the school report figures given to show the extent to which this practice has been carried out and last year 370 school children were re-inoculated after a three years' interval. Whatever may be the theoretical limitations ofartificial immunisation, from a practical point of view it has been an outstanding success in our district. Since we commenced the practice, nearly seven years ago, no death has occurred in ??? immunised person. An occasional clinical case of Diphtheria occurred amongst these. No attempt has been made to hide these; the number has been published in every Annual Report. but no fatal case of Diphtheria has occurred in an immuinsed person. 47 The deaths from Diphtheria for the past seven years were as follows:— 1938 2 1937 6 1936 2 1935 8 1934 7 1933 23 1932 21 As we did not start artificial immunisation until the autumn of 1932, possibly it would not be fair to introduce that year into the comparison, but it is fair to include it in order to show the danger of Diphtheria. Excluding 1932, in the last six years we fcave had 48 deaths from Diphtheria, all in persons who had f«fused or neglected to take the simple precaution of being immunised. It might be assumed that these facts would be a Sufficient inducement for parents to have their children immunised, but we find it extremely difficult to keep up the herd immunity. Last year, the figures for pre-school children were worse than those of 1937, though the number of school children immunised ims higher. In 1938, only 249 pre-school children received the first dose of A.P.T., and 232 the second dose, compared with 353 and 292 respectively in 1937. The same difficulties are probably encountered in other districts; from the Annual Report of the Chiet Medical Officer of the Ministry of Health for 1937, Acton was the best immunised district in Greater London, with over per cent, of its child population protected. There has been some change in the procedure. For reasons technical for discussion in this Report, we give two doses of S.c.c. of A.P.T., instead of a first dose of .1 c.c. and a second dose of .5 c.c. The process of the manufacture of the Alum Precipitated Toxoid has been so improved that reactions, general or local, are most rare. 48 TUBERCULOSIS. 8*2 cases of Pulmonary Tuberculosis, and 16 cases of otl«w forms of Tuberculosis were notified during the year. There were 34 deaths from Pulmonary Tuberculosis anA k deaths from other forms of Tuberculosis. The notification death interval of the 34 patients who died from Pulmonary Tuberculosis in 1938 was: — Information from Death Returns 5 Died within l jnouih after notification 4 Died between 1 and 3 months after notification 5 ,, 3 and 6,, 5 ,, 6 and 12,, 4 1 and 2 years ,, 3 ,, 2 and 3 ,, 3 Died over 3 years after notification 5 The following Table gives the age incidence of new cases of tuberculosis in 1938 and of the deaths from the disease in the area in 1938. CO Age Periods. New Cases. Deaths. Respiratory. Non-Respiratory Respiratory. Non-Respiratory M. F. M. F. M. F. M. F. 0 — — — — — — — 1 1 — 2 — — — — 1 5 1 3 4 1 — — — — 15 10 12 1 4 5 4 2 1 25 14 13 1 1 8 2 — — 35 10 4 — — 6 1 — — 45 5 1 — 1 5 1 — — 55 2 3 — — 1 — — — 65 and upwards 2 — 1 2 1 — — — Totals 44 38 7 9 26 8 3 3 50 The following is a statement of the particulars appearing in the Register of cases of Tuberculosis on 31st December, 1938; Pulmonary. Non- Pulmonary. Total Number of Cases on the Register at the Commencement of the year 189 males 47 males 178 females 32 females 444 Number of Cases notified for the first time during the year 39 males 5 males 30 females 6 females ??? Number of Cases previously removed from the Register which have been restored thereto during the year 1 male — males — females 1 female Number of Cases added to the Register other than by notification 4 males 1 male 8 females 2 females 15 Number of Cases removed from the Register during the year 31 males 6 males 21 females 2 females bo Number of Cases remaining on the Register at the end of the year 20*2 males 47 males 195 females 39 females In 1938, the Tuberculosis Officer examined 40 new cases of pulmonary tuberculosis, and 5 new cases of non-pulmorary tuberculosis. 44 patients were admitted to Sanatoria under the County Scheme, and 3 were admitted to hospitals. 51 BACTERIOLOGICAL EXAMINATIONS. For Diphtheria. -fatal Examinations, 2030 Positive. 235 Negative. 1795 Sent by Medical Practitioners 8 243 do. (re-examinations) 7 49 from Isolation Hospital 145 986 do. (re-examination) 60 206 Convalescents (1st Swabs) — 19 Contacts (1st Swab) 7 131 do. (re-examinations) 4 42 do. (2nd examinations) 2 19 do. (re-examinations) 1 6 $ecautionary Swabs — 81 do. (re-examinations) — 11 School Sore Throats 1 2 (ty For Haemolytic Streptococcus. Total examinations—73 Positive. Negative. 73 (c) For Vincent's Angina. Total examinations— Positive. 1 Negative. (d) For Ringworm. Total examinations—1 Positive. Negative. 1 (e) For Tubercle. Total examinations—123 Positive. 22 Negative. 101 52 BIRTHS. In former reports it has been explained that at the end of the year, the Registrar-General sends the total number of births belonging to Acton which have been registered both inside and outside the district. This number has always exceeded that of the number of notified births, the excess number varying in different years. The difference depends on two factors; in the first price although the figures in both instances refer to those which belong to the calendar year, births have to be notified within 36 hours whilst a period of six weeks is allowed before a birth must be registered. As births occur fairly regularly throughout all the months of the year, little variation is observed in the notified and registered births in any given period. The higher number of registered births, as given by the Registrar-General at the end of the year, compared with the number of notifications received by us was due to the fact that all local authorities did not trouble to transfer the "outside births" which occurred in their areas to the authority to which they properly belong. Curiously, our number of notified live births last year exceeded the figure of total registered live births as supplied by the Registrar-General. The number given by him was 863, while the total number of births notified was 873. As we have to accept the Registrar-General's figure, the birth rate is 12.5 per 1,000 inhabitants. The number of still births registered was 40, which corresponds to an annual rate of .58 per 1,000 inhabitants, or 4.6 per cent. of the total births. The number of still births notified was 36. The ward distribution of the live births notified was:- North-East. North-West. South-East. South-West. 302 188 148 235 The ward distribution of the still births notified was:North-East. North-West. South-East-. South-West. 9 7 6 14 Of the 873 live births notified, 402 occurred inside the district and 471 occurred outside the district. 53 DEATHS. The methods by which inward and outward transfers are arranged have been explained in former Annual Reports. Three hundred and sixty deaths were registered in the district; of these 37 did not belong to Acton, and were transferred to the respective authorities in whose area they had resided. Three hundred and fifty-nine deaths of Acton residents accurred outside the district and have been included in our returns. The total number of deaths belonging to the Borough is, therefore, 682, which corresponds to an annual rate of 9.9 per 1,000 inhabitants. The number of deaths is considerably lower than in recent proceeding years; in fact, it is the lowest number since. 1926, and the death rate is, with the exception of that of 1923, the lowest on- record for the district. It has been explained in other Reports that the age-distribution of the population of the district is changing, and that the average age of the inhabitants is becoming greater, with the result that the death rate is gradually becoming higher. In order to adjust the local death rate to make it comparable with other districts, the Registrar-General issues a figure, called the comparability factor, which is based upon the age distribution and sex incidence at the Census, 1931. The comparability factor for Acton is 1.08, and when the death rate is multiplied by this factor the standardised death rate is obtained. The standard death rate of Acton is, therefore, 10.7 per 1,000 inhabitants. 54 TABLE 1. BIRTH-RATE, DEATH-RATE AND ANALYSIS OK MORTALITY DURING THE YEAR 1938. The Mortality rates for England and Wales refer to the whole population, but for London and the towns to civilians only. Rate per 1,000 Total Population Annual Death-rate per 1,000 Population. Rate per 1,000 Live Births All Causes Enteric Fever Small Pox Measles Scarlet Fever Whooping Cough Diphtheria Influenza Diarrhoea and Enteritis (under 2 yrs.) Total deaths under 1 year Live Births. StillBirths. England and Wales 15.1 0.60 11.6 0.00 0.00 0.04 001 0.03 0.07 0.11 5.5 53 122 County Boroughs and Great Towns, including London 15.0 0.65 11.7 0.00 0.00 0.05 0.01 0.03 0.07 0.11 7.8 57 148 Smaller Towns Estimated Populations, 25,000-50,000 15.4 0.60 11.0 0.00 0.00 0.03 0.01 0.02 0.06 1.1 3.6 51 London 13.4 0.48 11.4 0.00 0.00 0.06 0.01 0.03 0.05 0.06 13.1 57 Acton 12.5 0.6 10.0 0.00 0.00 0.07 0.00 0.02 0.03 0.04 12.4 57 The maternal mortality rates for England and Wales are as follows:— Puerperal Sepsis. Others. Total. Per 1,000 Total Births 0.86 2.11 2.97 „ „ „ (Acton) 0 2.2 2.2 55 TABLE 2. VITAL STATISTICS FOR THE WHOLE DISTRICT DURING 1938 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 Rate Number Rate of Non-Resi- dents Registered in the District of Residents Registered outside Dist. Number Rate per 1,000 Births Number Rate per 1,000 inhabitants 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 13.70 486 6.88 29 302 60 62 786 11.11 1933 70,300 886 12.60 492 6.99 31 329 41 46 788 11.20 1934 69,472 943 13.57 454 6.50 24 297 39 41 727 10.46 1935 68,900 868 12.60 417 6.04 41 328 51 60 704 10.20 1936 69,140 881 12.7 431 6.2 42 405 60 68 794 11.5 1937 69,100 886 12.7 396 5.7 26 378 51 57 748 10.8 1938 68,670 863 12.5 360 5.2 37 359 49 56 682 9.9 56 TABLE 3. AGES AT DEATH, AND WARD DISTRIBUTION OF DEATHS IN 1938. Causes of Death. Ace in Years. Ward Distribution. Total 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 North East North West South East South West Measles 5 — - 4 1 — — — — 1 1 2 1 Whooping Cough 1 1 — - — - — - — 1 — — Diphtheria 2 1 - — 1 — — — 1 1 — — Encephalitis Lethargica 1 - - — — — - — 1 — — 1 — Cerebro-Spinal Fever 1 1 — — — — - — — — 1 Influenza 3 - — — — — 3 - 1 2 — Pulmonary Tuberculosis 34 - - — — 9 17 7 1 9 9 7 9 Other t.b. 6 1 - 1 - 3 — 1 — 1 1 2 2 Syphilis 1 - — - — — 1 — 1 — - — Diabetes 9 - — — 1 — 4 4 3 3 2 1 Cancer 107 1 — - 1 8 30 61 40 28 23 16 Rheumatic Fever 2 - — 1 — — 1 1 1 - — Cerebral Hæmorrhage 59 - - — — — 1 19 39 17 16 18 8 Heart Disease 129 — 1 1 11 29 87 38 38 31 22 Other circulatory diseases 27 - — — - — - 6 22 9 11 2 5 Bronchitis 24 — — — 1 7 16 7 8 1 8 Pneumonia 54 7 3 1 — — 4 11 28 24 10 7 13 Other respiratory diseases 6 — — — - 1 — 2 3 2 — — 4 Peptic Ulcer 12 - - - - - 1 8 3 4 2 2 4 Diarrhœa 2 2 - - - - - - - - 1 — 1 Appendicitis 3 — — — - - 1 — 2 1 1 — 1 Cirrhosis of Liver 4 — — — — — 3 1 2 2 — — Other diseases of Liver 5 — — — - — 3 2 1 — 2 2 Nephritis 20 — — — - 1 2 8 9 5 10 1 4 Other diseases and accident of Parturition 2 — — — - 2 — - 1 - — 1 Senility 45 — — — - — — 45 23 11 2 9 Cong. Debility and Prematurity 31 31 — — - - — — — 10 6 7 8 Suicide 5 — — — — 2 2 1 1 1 2 1 Other deaths from Violence 20 - — 1 1 2 5 7 4 5 4 8 3 Other defined diseases 69 5 - 2 - 3 17 16 19 17 19 14 22 TOTALS 682 50 3 9 4 23 72 169 352 224 186 136 135 57i TABLE 4. INFANTILE MORTALITY 1938. Disease. Ages. Wards. Total Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks 1—3 months 3—6 months 6—9 months 9—12 months North East North West South East South West Diphtheria 1 - - - - - - - 1 - 1 - - Tubercular Meningitis 1 — - — - - — 1 — — - 1 - Menigococcal Meningitis 1 — - — - 1 — — — - - - 1 Pneumococcal Meningitis 1 — — — - 1 — - — 1 — - - Pneumonia 7 — - — - 2 2 1 2 2 — 1 4 Oedema of Lungs 1 1 - — - — - — — - 1 - - Asphyxia 1 1 - — - — — — — — - 1 — Intracranial Haemorrhage 4 3 - — - 1 — - — 1 1 2 — Haemorrhagic Disease of New Born 1 1 - - - - - - - 1 - - - Diarrhoea 2 - - — - 1 1 — - - - 1 1 Congenital Defects 8 1 1 - 1 5 — — - 3 1 2 2 Prematurity 11 8 - — — 3 — — — 2 2 1 6 Atelectasis 3 2 - 1 - — — — — 1 1 1 — Hydrocephalus 2 — - — - — 1 1 — 1 1 - — Inhalation of Vomit 1 — - — - — 1 — — — 1 — — Acute Sinusitis 1 - - - - - 1 - - - - 1 — Cystic Hygroma 1 — - — - — 1 — — 1 - - — Erysipelas 1 — - — - — — 1 — — 1 — — Jaundice 1 1 - — - — — — — — 1 — — TOTALS 49 18 1 1 1 14 7 4 3 13 11 11 14 58 TABLE 5. CASES OF INFECTIOUS DISEASE NOTIFIED DURING THE YEAR 1938. 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 Scarlet Fever 160 - 40 98 9 12 1 - M 29 31 47 Diphtheria 19 1 5 9 2 1 1 — 5 3 4 7 Pneumonia 42 5 11 8 1 13 2 2 10 7 11 14 Erysipelas 23 - 2 2 1 9 7 2 1 9 4 9 Puerperal Pyrexia 2 — — — 1 1 - - 1 - - 1 Ophthalmia Neonatorum 4 4 — — — — — — 1 - 4 1 Poliomyelitis 1 — — — 1 — — — — 1 — - Cerebro-Spinal Fever .... 1 — 1 — - - — — — — - 1 Dysentery 3 1 1 1 — — — — 1 1 - 1 Tuberculosis (reap.) 82 — 2 4 22 41 11 2 32 12 17 21 Tuberculosis (other) 16 - - 5 5 2 1 3 4 2 7 3 TOTALS 355 11 62 127 42 79 23 9 105 63 79 105 59 OPHTHALMIA NEONATORUM. Cases. Vision unimpaired. Vision impaired. Total Blindness. Deaths. Notified. Treated. At home. In hospital. 4 2 2 4 — — - 60 TABLE 6. CASES REMOVED TO HOSPITAL. Total Notified. Scarlet Fever 135 160 Diphtheria 19 19 Pneumonia 21 42 Puerperal Pyrexia 1 2 Erysipelas 15 23 Ophthalmia Neonatorum 2 4 Cerebro-Spinal Fever 1 1 Dysentery 3 3 Poliomyelitis 1 1 BIRTHS. TABLE 7. Live Births. Male. Female. . Total 440 423 863 Legitimate 422 407 829 Illegitimate 18 16 34 Still Births. Total 21 19 40 Illegitimate 1 1 2 Legitimate 20 18 38 Notified Live Births. Ward Distribution. Total. N. East. N. West. S. East. S. West. Total Births notified in the district 416 136 74 66 140 Notifications received from other districts 493 175 121 88 109 Notified Still Births. Inside 14 Outside 22 Total 36 Notifications were received from:— Doctors and Parents 666 Midwives 243 61 TABLE 8. INFANT WELFARE CENTRES, 1938. 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 11,757 (b) by children between 1 and 5 years of age 6,809 Average attendance of children per session 43 Number of children who attended for the first time during the year:— (a) under 1 year of age 720 (b) between 1 and 5 years of age 191 Percentage of notified live births represented by number of children who attended a centre for the first time during the year 83% Children treated at Dental Clinic 78 Children treated at Ophthalmic Clinic 22 Mothers treated at Ophthalmic Clinic 1 Children operated on for enlarged tonsils and adenoids — Children operated on with X-Ray for Ringworm — TABLE 9. ANTE-NATAL CLINIC. Number of Expectant Mothers who attended 501 Number of attendances made by Expectant Mothers 1,051 Mothers referred for Dental treatment at the Clinic 174 Mohers supplied with Dentures 28 Expectant Mothers to whom Dried Milk was supplied free 21 Number of packets of Dried Milk supplied free 1,133 62 INQUESTS. Suicide 5 Accidental Fall 3 Run over by Motor Lorry 3 Run over by Motor Bus 2 Motor Car Accident 2 Jumping off a moving Bus 1 Knocked down by a Steam Train 1 Collision between Cycle and Motor Car 1 Found Drowned 2 Accidentally Drowned 1 Striking Head against Door 1 Inhalation of Vomit 1 Pneumonia 1 Accidental Burns 1 Total 25 POST-MORTEM WITHOUT INQUEST. Heart Disease 13 Pneumonia 4 Cerebral Haemorrhage 3 Meningitis 2 Cancer 1 Pyleonephritis 1 Gastric Ulcer 1 Arterio-sclerosis 1 Diabetes 1 Pernicious Anaemia 1 Perforated Caecum 1 Asthma 1 Bronchitis 1 Peritonitis 1 Total 32 63 FACTORIES ACT, 1937. 1.-Inspection of Factories, including Inspections made by Sanitary Inspectors. Premises. Inspections. Written Notices. (1) (2) (3) Factories with mechanical power 219 27 Factories without mechanical power 134 14 Other Premises under the Act 37 5 Total 390 46 2.—Defects found in Factories. Particulars. Found. Remedied. (1) (2) (3) Want of Cleanliness (S.1) 8 8 Inadequate Ventilation (S.4) Nil Nil Overcrowding (S.2) Nil Nil Ineffective drainage of Floors (S.6) 2 2 Other Offences 2 2 Unreasonable Temperature (S.3) Nil Nil Sanitary Accommodation:— Insufficient 2 2 Unsuitable or defective 31 31 Not separate for sexes 4 4 Total 51 51 3—Outwork in unwholesome premises, Section III. Nil 64 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). Elsie Madeley, m.b., ch.b., 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; Chief Sanitary Inspector (Inspector under Diseases of Animals Acts and the Rag Flock Act). J. J. Jenkins, M.R.San.I., Cert. of Royal Sanitary Institute; holds Meat and Smoke Certificates, Deputy Chief 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 and Smoke Certificates, Sanitary Inspector. A. H. G. Johnson, Cert. of Royal Sanitary Institute; holds Meat Certificate; Meat Inspector. Miss B. G. Sorlie, s.r.n., Certificate of Royal Sanitary Institute, c.m.b., H.V. Diploma, Health and School Nurse. Miss W. E. Bennett, s.r.n., Health Visitor's Certificate of Royal Sanitary Inst., c.m.b., Health Visitor School Nurse. Miss W. L. Orfeur, s.r.n., Health Visitor's Certificate of Royal Sanitary Institute, c.m.b., Health Visitor and School Nurse. 65 Miss A. Woosnam, s.r.n., c.m.b., Health Visitor and School Nurse. Miss N. Lapham, s.r.n., Certificate of Royal Sanitary Inst., c.m.b., Health Visitor and School Nurse. A. S. M. Pratt,* Barrister-at-Law, Chief Clerk. Miss A. Kent,* Clerk. Miss J. Warburton, b.a. (hons.), Clerk. Miss V. Slack,* a.c.t.s. Clerk. Miss J. Wood,* Clerk. Miss M. G. Hester, Clerk. Miss F. A. Cavendish, Matron, Day Nursery. C. Baker,* Disinfector. T W. Mason,* Mortuary Keeper. 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 am, Your obedient Servant, D. J. THOMAS, Medical Officer of Health. 66 ISOLATION HOSPITAL. On April 1st, 1938, the Isolation Hospital was taken over by the Acton and Wembley Joint Hospital Committee. The following is a copy of the Report submitted to that Committee. SCARLET FEVER. 454 case of Scarlet Fever were admitted, but 23 of these were diagnosed as not suffering from the disease. With the changing views concerning the nature of Scarlet Fever, it is frequenlty very difficult to decide whether the case can be accepted or not as Scarlet Fever. The vast majority of the cases admitted have a definite train of signs and symptoms. The earliest symptom is usually a sore throat, accompanied by a temperature which frequently reaches 103, 104 and 105 degrees. The throat is congested and the soft palate may be uniformly injected or it may have the appearance of a punctate rash, which may be regarded as the enan them of the disease. The tongue, at first furred, afterwards assumes the typical strawbeny appearance. When these signs are present there is no difficulty in the diagnosis, but the conditions may be modified to an extraordinary degree. Clinical Scarlet Fever is now regarded as a manifestation of an infection with a haemolytic streptococcus in a person who is susceptible to the effects of the poison produced by it. Some persons possess a partial or complete resistance to the poison, but the resistance may be insufficient to protect them against local or general tissue invasion by the streptococcus itself. More over streptococcal strains differ in their capacity to produce rashes; in some it is so high that most of those infected develop them: on others it is so low that only a small proportion of those infcetal exhibit the characteristic rash. It will thus be appreciated that frequently the difficulty of the diagnosis is fundamental, and not due to want of skill. The conditions are so variable as to warrant the assumption that the disease we call Scarlet Fever is not a Speciticentity but caused by different strains of the streptococcus. The conditions are too variable to be explained only by the resistance of the individual, but also that they are due to different degress of virulence in the different strains. Only one death occurred from the disease, and this Fact is sufficient to indicate that the type of disease was mild. A study of the history of Scarlet Fever shows that throughout some centance it has varied greatly in its severity. A mild type would be followed by one of extreme malignancy, and mild and severe epidemics have alternated throughout the ages. For some years now, thf cases admitted have been of a mild character, and last year there was no evidence to show that the disease is at the present time assuming a more severe character. 67 There were 14 return cases from 13 infecting cases. Return cases have been defined by the Society of Medical Officers of Health 26 "cases occurring in the same house or elsewhere and apparently traceable to the person released within a period of not less than 24 hours, or not more than 28 days, after his return from release from isolation." The patient released from isolation and the cause of the "return" case is called the "infecting" case. The period of one month is an arbitrary one, but useful, because it is presumed that a Scarlet Fever patient is not usually infectious for more than one month. Although this is true of the vast majority of cases, there is evidence that Scarlet Fever patients may remain intermittently infectious for very long periods. We had many such cases last year and Lne following are given as instances. Mrs. L. was admitted on April 8th, 1938, suffering from Scarlet Fever. Her son had been in Hospital from October 18th, 1937, to February 2nd, 1938. His prolonged stay in the Hospital was due to Otorrhoea and subsequent Mastoidectomy. The boy was quite tree from symptoms 5 or 6 weeks after leaving Hospital, when he developed a "cold in the head," with a marked nasal discharge. Another case occurred in the same house after a period of more than 4 months since the release of the infecting case. M. J. was admitted suffering from Scarlet Fever on May 23rd, 1938. His brother had been in Hospital from December 28th, 1937, to January 18th, 1938. The first case had been "clean" and without complications in Hospital. A third case occurred after 5 months. G. C. was admitted on October 14th, 1938. His sister had been in Hospital from April 10th to May 14th, 1938. The first one was a straightforward, uncomplicated case. These cases occur too frequently to be mere coincidence; they are more likely to be instances of prolonged intermittent infection. From an administrative point of view, these possible instances of possible prolonged infection are of less importance than those which are included as " return " cases. It is suggested that sence of the return cases can be avoided, and it may therefore be profitable to examine more closely the conditions under which they occurred. "Return" cases are not entirely a phenomenon of hospital isolation, as they occur also after the release of a patient from quarantine when the case has been nursed at home. The Medical officer of Health of Brighton published some figures of return cases there. In 5 years, out of 892 patients nursed at home there were 34 return cases, or a percentage of 4, and out of 725 hospital patients, there were 41 return cases, or a percentage of 5.5. 68 The report of the Medical Officer of Health of Manchester for 1936 contains particulars of that year's return cases in his area. The number of patients discharged from the Manchester Isolation hospitals after treatment for Scarlet Fever was 2,114 and the number of true return cases was 71, a return case rate of 3.4 per cent. It is sometimes stated that the number of return cases bears no relation to season, but with us 7 return cases occurred in the first quarter of the year. The number admitted in the first quarter was 92 compared with 362 in the remaining three quarters. It is possible that the enhanced number in the first quanter had some relation to the climatic conditions, and consequently to the over-use of the wards. The wards were not overcrowded in the first quarter, but for some years the first quarter has suffered mostseverely from climatic conditions, and the convalescent patients do not spend so much of their time in the open air as they do in the warmer months. It is known, of course, that overcrowding of the wards will result in an increased percentage of return cases. This is partly if not mainly, due to the greater liability to complications when the wards are overcrowded, and to the possibility of infection by other strains of streptococci to those with which they were originally infected. Our wards were not overcrowded in the stpict sense, and at no time was there less than 144 square feet or less than 12 feet between the centre of the beds during the year. Some authorities state that the number of return cases bears an inverse ratio to the length of the quarantine period, but a lengthened stay in the hospital does not guarantee freedom from return cases. In recent years, there is a growing tendency to reduce the duration of Scarlet Fever patients' stay in hospital. A recommendation was made in the Annual Report of the Chief Medical Officer of the Ministry of Health for 1927, which is now adopted at most hospitals, that in an uncomplicated case, isolation for four weeks is quite sufficient. This does not appear to be known to all medical practitioners, much less to the laity, as letters are received expressing surprise or annoyance from parents and employers when patients are discharged in about four weeks from hospital. The average length of stay in the hospital of the infecting cast would 69 convey no useful infomation and the actual stay of each infecting patient is given, and it was as follows:— 1. 27 days. 2. 30 „ 3. 31 „ 4. 32 „ 5. 32 „ 6. 33 „ 7. 34 „ 8. 39 „ 9. 48 „ 10. 55 „ 11. 61 „ 12. 68 „ 13. 99 „ Nos. 1—7 were clean cases, without any complications while in hospital, but No. 5 had a nasal discharge after going home. Nos. 9, 12 and 13 had Otorrhoea in hospital and on No. 13 a Mastoidectomy was done. The ears had been quite clear for some time before the patient left hospital. The others had a nasal discharge whilst in hospital and this complication accounted for the extra length of stay in the hospital. It has sometimes been urged that the return case is dependent upon some abnormal condition of the mucous membrane of the nasopharynx but in seven of our cases, no rhinorhoea or nasal discharge had been noticed in the children during their stay in hospital. In one of the cases, there was a nasal discharge which developed a few days after the patient had reached home. It has been suggested that the return case may be caused rot by a continuance of the original infection, but by another germ picked up in the hospital by the patient. Dr. Griffith, in the ministry of Health's Laboratory, has shown that there are many 70 strains of the haemolytic streptococcus which can be differentiated by certain reactions and identified as they occur in different clinical manifestations. Infection by one strain of haemolytic streptococcus does not protect a patient against infection by another, and the so-called relapse is, probably, a fresh infection by a streptococcus differing serologically from that of the primary infection. Last year we had 10 cases in which a so-called "secondary" rash appeared in most instances after a period of over three weeks after the patiet's admission to hospital. All these cases showed the typical symptoms of Scarlet Fever on admission. Scarlatinal Infection due to different types cannot be differentiated clinically, and it is not possible at present to type all of them bacteriologically on admission. In a Scarlet Fever multiple bed ward it is inevitable that many types of haemolytic streptococci are represented and that therefore cross-infection may occur. Until the extensions to the hospital are completed we can only minimize the risk by ample bed-spacing, and trying to segregate the cases on a Geographical basis in convalescent wards. Although it is possible that some of the "return" cases may be due to a recent infection with a fresh type, it is not likely that this would explain all the cases. When a probable re-infection occurs in hospital there are certain symptoms which presumably are caused by the re-infection. For instance, it is stated that enlarged glands otorrhoea, and even nephritis, occurring for the first time at least two or three weeks after admission are due to a re-infection by to. different strain of streptococcus. When Otorrhoea, Rhinorhoca enlarged glands, etc., occur after arrival home, it is probable that a re-infection had occurred. But many of these "re-infecting" cases do not exhibit any symptoms which would be presumptive evidence of re-infection. I have enlarged on this subject because it is important to us when planning our extension. Theoretically, Scarlet Fever patients should be "warded" in accordance with their types; alternatively, each patient should have his own cubicle. In authoritative quarters, it is held that neither of these remedies is at present deemed to be practicable. A certain number of cubicles are essential but the mostpopular and most highly esteemed block is that in which segregation is based largely on geographical and time considerations. Place of a model ward block so adopted as to enable this to be possible have been drawn up and have been accepted by a number of local 71 authorities, although no block of this type has been erected. Cubicle isolation on this modified plan has been practised by Dr. Lichenstein in Stockholm; he admits to one and the same ward cases coming from a common vicinity or who are infected at approximately the same date, on the assumption that infection may have been with the same strain of organism. A Mastoidectomy was done on 12 patients; on one of these the Mastoid on both sides was operated upon; 6 of the operations were done in the first quarter, 2 in the second, two in the third and two in the fourth quarter of the year. A Paracentesis was done on one patient and the Antrum of Highmore was drained in two patients. DIPHTHERIA. 105 cases of Diphtheria were admitted with 5 deaths. Of the total cases admitted, 18 had no clinical signs of the disease on admission, and all the swabs from the nose and throat of these were found to be negative. Of the deaths, one occurred on the day of admission, three on the second day after admission, and the fifth on the sixth day after admission. The ages of the patients who died were:— 4 months, 10 months, 7 years, 12 years and 22 years. The last had been ill for 12 days on admission. No death occurred in a child who had been previously immunized and as far as could be ascertained only two cases had been previously immunized. MEASLES. 59 cases of Measles were admitted with three deaths. Since the Great War, Measles has appeared in epidemic form in London and most of the district of Greater London every other year, and 1998 was an epidemic year. The epidemic usually makes its appearance in the late autumn months of the "odd" years, reaches its peak in the spring of the "even" and usually continues into the early summer. There will probably be very few cases in 1939, but we may expect some cases towards the end of the year and an epidemic in 1940. 72 CASES ADMITTED TO HOSPITAL. ISOLATION HOSPITAL. On April 1st, 1918, the Isolation Hospital was taken over by the Acton and Wembley Joint Hospital Committee. The following is a copy of the Report submitted to that Committee. Patients admitted, 1937—688. Patients admitted, 1938—633. Sc. Fever. Diph. Measles. Ery. Wh. Cough. Impetigo. C.S.M. C.P. Acton 135 25 36 7 - - - - Wembley 300 79 22 2 2 2 1 2 Ealing 'J - - - - - - - Southall 10 1 — — — — — — 454 105 58 9 2 2 1 2 Total—633. Patients Discharged. Sc. Fever. Diph. Measles. Ery. Wh. Cough. Impetigo. C.S.M. C.P. Acton 143 29 31 7 - - - - Wembley 309 75 26 2 1 2 - 2 Ealing 11 — — — — — - Southall 8 1 — — — — — — 471 105 57 9 1 2 - 2 Total—647. Deaths. Diph. Measles. C.S.M. Wh. Cough. Sc. Fever. Acton 2 3 - - - Wembley 3 — 1 1 1 5 1 1 1 1 Total—11. Patients in Hospital. January 1st 1936-38 Patients in Hospital. January 1st 1939-53 D. J. THOMAS, Medical Superintendent 73 ANNUAL REPORT OF THE School Medical Officer FOR THE YEAR 1938. Town Hall, Acton, W.3. To the Chairman and Members of the Acton Education Committee. Ladies and Gentlemen, We beg to submit the following report upon the schools and school children of Acton for the year 1938. As in former years, the subject matter has been arranged as far as possible in tabular form. The Tables at the end of the report are those issued by the Board of Education. 74 The health of the school children of Acton during 1938 was good. There were few cases of Scarlet Fever and Diphtheria, and the Measles epidemic although it continued for a long time, was mild in character. New cases of Rheumatism and Chorea were slightly less than in 1937. In 1936, it was suggested that the rise which occurred in the number of cases of Acute Rheumatism, was due to the fact that Acton was approaching the crest of a wave of infection. It has been pointed out by some observers that the disease occurs in waves, and the figures of 1937 and 1938 bear this out at present. There was only a small increase in the number of cases in 1937, and actually a decrease in 1938. It is to be hoped that cases are now on a steady decline and it will be interesting to see if 1939 bears this out. One of the most annoying causes of school absence in 1938 was Scabies. In spite of all endeavours, cases of Scabies continue to increase in the Borough and in 1938 there were nearly 3 times as many cases as in 1936. Scabies is not a notifiable infectious disease so the. law gives no power of compulsory disinfection of the home, and it is felt that advice as to how to deal with clothing and bedding is ignored, and cases continue to be reported. The general nutrition of the school children on the whole is satisfactory,—there are of course many cases which have to be helped during the year to attain and maintain a satisfactory standard, but on the whole the average school child is a good specimen. Defects are present, of course, and dental decay is one of the commonest. It is a great pity that as a nation our standard of dental fitness is so poor, and so many adults have false teeth that dental decay is taken by them as a matter of course in the young, instead of being a matter to cause shame and concern. More attention to correct feeding, pre and post natally, would go far to remedy the condition, as dental decay is now regarded by the majority of people, to be in great part a deficiency disease. That so many small children have to attend our dental 75 sessions for extraction of large numbers of their temporary teeth, is disturbing and is a matter which must be tackled first in the person of the ante-natal mother, and continued in the infant and young child. PUBLIC ELEMENTARY SCHOOLS WITHIN THE DISTRICT, WITH ACCOMMODATION. School. Dept. Accommodation. Avge. Monthly No. on Register. Average attendance. Acton Wells Senior 320 207 189 Junior 364 392 353 Infants' 364 190 147 Beaumont Park Senior Girls' 450 133 118 Junior Girls' 450 204 187 Infants' 400 184 156 Berrymede Junior Boys' 640 385 337 Junior Girls' 542 352 317 Infants' 450 281 234 Central 480 379 352 Derwentwater Junior 441 372 340 Infants' 350 339 269 John Perryn Senior 360 169 154 Junior 288 236 215 Infants' 336 259 213 Priory Boys' 500 298 265 Girls' 499 279 239 Infants' 400 275 223 Rothschild Junior 450 209 191 Infants' 400 265 219 Southfield Senior Boys' 415 138 128 Junior 382 314 287 Infants' 350 233 195 Roman Catholic 327 255 220 West Acton 300 240 204 Special (M.D.) 68 41 34 10326 6629 5786 76 AVERAGE HEIGHT without shoes, and AVERAGE WEIGHT without clothes. Anthropometric Committee, 1929. Age last birthday. MALES. FEMALES. Height in inches. Weight in lbs. Height in inches. Weight in 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. LEAVERS (BOYS) No. Examined. Years of Age. 12—13 13—14 14—15 No. Height ins. Weight lbs. No. Height ins. Weight lbs. No. Height ins. Weight lbs. Acton Wells Senior 29 29 58.2 81.9 .... .... .... .... .... Central 49 49 58.7 82.6 .... .... .... .... .... John Perryn Snr. 32 31 57.8 80.9 1 62.3 102.5 .... .... Priory Boys' 120 120 57.9 81.8 .... .... .... .... .... .... Southfi'd Sr. Boys' 48 46 58. 81.1 2 57.6 74.2 .... .... 94..3 Turnham Gn. R.C. 10 8 55.7 77. 1 59.8 84. 1 62.8 288 283 .... .... 4 .... .... 1.... (GIRLS) Acton Wells Senior 29 29 58.3 80.1 .... .... .... .... .... B'm't Pk. Sn. Girls' 55 52 58.6 83.7 3 59.8 92.5 .... .... Central 51 51 58.3 82.3 .... .... .... .... .... John Perryn Snr. 29 29 59.3 84.5 .... .... .... .... .... Priory Girls' 99 98 58.3 85.7 1 59.3 80.8 .... .... Turnham Gn. R.C. 10 7 58. 83.7 3 61.4 84.1 .... .... 273 266 .... .... 7 .... .... .... .... 77 TAble showing heights and weights at different ages. intermediates. (BOYS). No. Examined. Years of Age. 7—8 8—9 9—10 NO. Height ins. Weight lbs. No. Height ins. ■ Weight lbs. No. Height ins. Weight  lbs. (???)Wells Junior 28 18 50.9 57.8 10 50.3 56.3 ... ... ... (???)Wells Infants' 22 11 47.9 51.1 11 49. 54.9 ... ... ... (???)Park Infants' 2 2 51.3 56.2 ... ... ... ... ... ... (???)Junior 97 65 49.1 55. 30 49.5 55.9 2 54.3 72.3 (???)Infants' 6 6 49.2 55. ... ... ... ... ... ... (???)Junior 51 26 49.8 57.1 24 50.6 56.5 ... 58. 70.5 (???)Infants' 9 8 47.9 51. 1 48.8 53.3 ... ... ... (???) Junior 2 ... ... ... 2 52.7 66.7 ... ... ... (???)Infants' 36 20 49.9 56.5 16 50.4 57.1 ... ... ... (???)Infants' 4 3 47.6 48.8 l 47. 56. ... ... ... (???)Junior 47 27 50. 58.2 20 49.7 56.7 ... ... ... (???)Infants' 8 8 47.9 53. .... ... ... ... ... ... (???)Junior 45 13 49.3 55. 32 49.5 57.1 ... ... ... (???) Infants' 9 9 50.5 57.7 ... ... ... .. ... ... (???)Green R.C 21 5 52.1 61.3 13 49.4 53.9 3 52.5 56.6 (???)Acton 30 8 49.5 52.4 22 49.9 56.3 ... ... ... 417 229 ... ... 182 ... ... 6 ... ... (GIRLS). (???) Wells Junior 13 10 48.1 51.1 3 49. 50.3 ... ... ... (???)Wel!s Infants' 17 9 48.7 49.9 8 49. 53.1 ... ... .... (???) Pk. Inr. 46 25 48.6 53.2 21 49.9 57.6 ... ... ... (???) Park Infants' (???) lunior 1 1 51.8 66.5 ... ... ... ... ... ... 77 41 48.6 54.2 34 48.9 53.4 ... 51.2 73.4 (???)Infants' 2 2 47.5 51.3 ... ... ... ... ... ... (???)Junior 48 21 49.6 55.1 27 49.5 53.5 ... ... ... (???)Infants' 6 6 47.8 52.7 ... ... ... ... ... .... (???)Perryn Junior 3 ... ... ... 3 50.4 58.3 ... ... ... (???)Infants' 36 12 50.9 54.9 24 50.1 56.2 ... ... ... (???)Infants' 4 4 48.6 47. ... ... ... ... ... .... (???) Infants' ... ... ... ... ... ... ... ... ... ... (???)Junior 39 15 47.5 52.6 24 50.7 55.7 ... ... ... (???)infants' 9 9 45. 56.2 ... ... ... ... ... ... (???)Green R.C. 15 5 47.3 48.6 7 50. 53.6 3 52.9 61.6 We Action 21 5 48.9 50.5 16 49.2 54.7 ... .... ... 337 165 ... ... 167 .... ... 5 .... ... 78 TABLE SHOWING HEIGHTS AND WEIGHTS AT DIFFERENT AGES. ENTRANTS (HOYS). No. Examined. Years op Age. 3—1 4—5 5—6 0—7 No. Height ins. Weight lbs. No. Height ins. Weight lbs. No. Height ins. Weight lbs. No. Height ins. Weight lbs. Acton Wells Infants' 30 3 38.2 35.5 13 41.3 40.3 13 44.5 43.6 1 47.8 48.3 Heaumont Park Infants' 41 19 37.7 34.9 5 41.9 41.2 13 42.7 41.5 4 46.5 49.7 Berrymede Infants' 62 25 37.9 36. 20 40.6 38.4 12 44.1 45.4 5 45.4 50.2 Derwentwater Infants' 68 .... ... .... 40 41.1 38.9 21 43.8 40.3 7 46.6 48.3 John Perryn Infants' 17 ... ... ... 4 41.2 37.9 11 44.1 43.5 2 45.6 45.8 Priory Infants' 64 20 37.9 33.7 20 41.2 40.7 16 43.8 44. 8 46.7 47.5 Rothschild Infants' 49 20 37.6 35.3 12 39.9 39.8 13 42.2 41.4 4 46.1 49.5 Sou fh field Road Infants' 39 .... ... .... 19 40.6 37.8 15 44. 42.4 5 45.9 47.2 Turnham Green R.C. 18 .... .... .... 5 41.6 38.9 8 43.5 40.3 5 46.2 46.5 West Acton 30 8 30.2 34.0 12 42.1 40.8 9 44.7 40.9 1 43. 38.8 418 95 ... 150 131 42 (GIRLS). Acton Wells Infants' 28 4 37.7 33.0 5 40.6 38.8 16 42.1 41.1 3 44.5 43.8 Heaumont Park Infants' 23 10 36.2 32.0 6 41.2 38.8 6 42.3 41.1 1 43. 41.3 Berrymede Infants' 55 24 37. 32.9 14 40.4 39.2 13 41.9 40.1 4 46.2 49. Derwentwater Infants' 68 .. ... ... 24 41.4 38.0 38 43. 42.7 6 45.8 46.1 John Perryn Infants' 34 ... ... ... 10 40.9 38. 10 43.6 41.6 8 47. 49.2 Priory Infants' 48 10 37. 33.1 13 40.2 37.4 14 42.9 41.1 5 44.5 45.3 Rothschild Infants' 48 23 37.6 33.0 11 40.8 39.7 10 42.9 43.8 4 45.G 50.3 Southfield Road Infants' 45 ... .... ... 17 41.2 38.8 21 43.5 41.1 7 45.8 40.5 Turnham Green R.C. 24 ... ... ... 8 40.0 37. 9 43.1 40.7 7 44.8 45.1 West Action 29 7 37.8 32.3 7 40.3 32. 1 11 43.2 41.8 4 46.8 46.9 202 84 115 154 1 79 TONSILS AND ADENOIDS. In 1938 much discussion took place in various medical papers on the subject of Tonsillectomy in children. Dr. Glover, in a paper given before the Royal Society of Medicine, gave most startling finures for the incidence of the operation in different parts of the country. He pointed out that the operation was a comparatively rare one before the present century, although it is difficult to get reliable figures for tonsillectomy in children before the onset of the School Medical Service with its subsequent grants for treatment, and therefore available statistics. The number of school children operated upon for the removal of tonsils and adenoids, rose rapidly to reach its maximum in 1931. It then fell from 1932 to 1935 and is now rising again. The figures for tonsillectomy in Acton at these periods is given at the end of this article. It is difficult to find an explanation for the spectacular rise in the rate of operation, and equally difficult to explain the different percentages of children operated upon in various parts of the country. It was pointed out that a child living in one Borough was 20 times more likely to be tonsillectomised than one living in a neighbouring Borough, and that two suburbs of London with comparable child populations differed enormously in the numbers of their children who had their tonsils removed. It was not observed that the children in the suburb where few operations were performed, suffered in comparison with their neighbours from what might have been expected as a result of non-operation, i.e. otitis media, deafness, enlarged glands in the neck, or rheumatism. These facts require some explanation, but until definite criteria are laid down as to what constitutes disease of the tonsils, the question of their removal will always remain a matter of opinion, and as such, divergent results will always be obtained. It has been said that three attacks of tonsillitis in one year, or two attacks accompanied by growing pains, are indications for operation. It has also been said that gross enlargement accom(???) by interference with hearing and marked nasal obstruction indications. Removal of tonsils is also necessary should the child ever have suffered from quinzy. These factors must, however, be correlated with observations and notes made at the time examination, i.e., 1—The age of the child must be taken into consideration. At certain ages, 5 to 8, there is a physiological enlargement of the tonsil consequent upon rapid growth and the meeting of "herd" 80 infections at school as against the ordinary home infections. Is the enlargement so often met with at those ages due to the rapid growth of all the bodily structures of the child, or is it due to a protective activity of the body in putting up a defence to the new infections the child is meeting? It has been pointed out that the majority of tonsillectomies are performed between the ages 5 to ft, and it is possible that many tonsils are removed which might be left in situ without detriment to their owner, and which would subside as a natural development in the next few years of life. 2—The oral and nasal hygiene of the child. It is possible to have enlargement of the tonsillar gland or of the glands of the neck from sepsis in the child's teeth or in its nasopharynx. If a child has very badly decayed or septic teeth, if it has a persistent post-nasal discharge from badly infected nasal sinuses, it is conceivable that an attack might be made on the overworked and overloaded tonsil as the culprit, while the causal factor escaped observation. It is not possible at routine school medical inspections to examine exhaustively all a child's nasal sinuses, and it is equally difficult to ensure that advice given to a parent to enable such sinuses to clear themselves is followed, and the position is thus made no easier at a subsequent examination if the advised treatment has not been followed, and the source of the infection may still remain in doubt. 3.—The history obtained from the parent. These are by no means always reliable, and many people have no idea what really is meant by an attack of tonsillitis. To accept their statements sometimes means believing that a child has had 20 to 30 attacks of tonsillitis in an incredibly short space of time. There is also (???). difficulty so often met that someone has told the mother that the child's tonsils are bad, and from that idea she will not move. the mother who is determined by hook or by crook to have her child § tonsils out, is not uncommon, and it is preferable for her to believe that something spectacular in the way of operation is needed, than to credit that ordinary nasal hygiene and some dental attention will be sufficient. The mother who will not countenance operative measures at all is also met with, and it is a fact that events often prove her to be right in refusing. At puberty there is a normal natural shrinking of such structures as the tonsil, and if operation caij be avoided until then, it is often the case that there are no indications for operation left. If every case put forward for tonsillectomy were considered carefully from all these points of view, and none were operated upon immediately, but only after a considered period-say 3 81 months—during which local treatment to the nose and its accessory sinuses and to the teeth, were persisted in, it is possible that tonsillectomy would again take its place as a rare operation. It is proposed in Acton to pursue for the future the regime outlined above wherever it is possible. A Nose Clinic is being established in which all cases for operation will be treated, and no case will be allowed to go for operation until its teeth have been attended to. A certain number of cases which are operated upon through our School Medical Service are referred to that service for operation by various hospitals, etc. but unless a special reason is alleged, these will be treated in similar manner. The practice advocated by Mr. T. B. Layton of Guy's Hospital, will also be adopted in refusing all Tonsillectomies during the winter. It is naturally in the winter that enlargement may be present which is due merely to the common cold, and sore throat from common cold is not synonymous with tonsillitis although many mothers find it difficult to distinguish the two. Common colds have never yet been prevented by the removal of tonsils, and it is better that a child should recuperate at a time of year when common colds and other more serious infectious diseases are less prevalent. During 1938 in Acton, 41 operations for Tonsillectomy were performed and 3 cases were operated on for removal of Adenoids only. Of these cases, 23 were referred through the school medical service in the first instance, and 21 referred for operation through our service by various hospitals, i.e., Mr. Griffiths, Ear Consultant at the Acton Hospital, referred 12 cases, Dr. Nicol Roe the Tuberculosis Officer referred 3 cases, Brompton Hospital referred 3 cases, Golden Square Hospital referred 2, and the Princess Louise Hospital referred one case. 30 cases had their tonsils and adenoids removed because of repeated attacks of tonsillitis accompanied by enlargement of the cervical glands, 5 cases were operated on because of their chest conditions and cervical gland enlargement, 1 case was operated upon because of persistent ear discharge, one child who suffered from rheumatism was recommended for removal of septic tonsils, 3 children were operated on because of excessive enlargement of the tonsils with mouth breathing and slight deafness, one child was operated on following an attack of tonsillitis with quinzy. 2 children had adenoids removed because of slight deafness, and improvement followed the operation. One child was operated on for the removal of a large lump of adenoids which had been Partially detached at a previous operation and which was blocking the child's nasopharynx. 82 Figures for Tonsillectomy in Acton. Aural Surgeon appointed in September, 1918. Operated, on through the Authority's Scheme. Operated on Privately. 1919 189 11 1920 279 36 1921 120 15 1922 67 31 1923 35 15 1924 — 31 1925 118 25 1926 173 13 1927 196 13 1928 183 20 1929 202 37 1930 232 17 1931 160 26 1932 59 5 1933 47 4 1934 38 2 1935 77 6 1936 47 5 1937 43 3 1938 44 RHEUMATISM. Acute Rheumatism in childhood continues to be a potent source of ill health both at the time of infection and in its subsequent effects on the heart. In 1938 Acton again had its quota of children suffering from acute rheumatism or chorea to be noted, and a number of relapses to record in children who had previously suffered from acute rheumatism. Rheumatism in its first attack may not damage the heart, but each subsequent attack renders the patient more liable to injury and permanent damage may be done. As pointed out in previous annual reports, it has been held by some specialists in dealing with acute rheumatism in childhood that a period of convalescence in a heart home of at least one year after the initial attack may lessen the risk of subsequent attacks and so lessen the risk of permanent heart damage. It has also been 83 held that with adolescence the risk of relapse becomes less and that if rheumatism can only be held in check until then, there is a fair chance of the child growing into a healthy adult. The child who then develops acute rheumatism or chorea when 5 years old has more years of anxious watching to meet than the child who has its initial attack when 9 to 11 years old. All children who had, or have had, rheumatism will have to be watched for the rest of their school days, and for this purpose local authorities have established rheumatic clinics. Here, these children are examined periodically and all necessary steps for safeguarding them are undertaken. Our rheumatic clinic is attached to the Princess Louise Hospital for Children, where Dr. Aitken sees our cases and advises on treatment. During 1938, 12 new cases of • rheumatism came under observation, 7 cases of acute rheumatism, and 5 cases of chorea. Of these 12, 2 were treated for the original acute attack in the Central Middlesex Hospital, 1 in the Ealing General Hospital, and 2 by their own doctors at home. 3 cases were discovered at school inspections to be attending the Princess Louise Hospital Rheumatic Clinic and the remaining 4 were discovered by the School Medical Officers and referred to the Princess Louise rheumatic clinic. The ages of these 12 new cases ranged from 5 to 11 years and in no case except 1 was there permanent heart damage as a result. The one case mentioned is still in Hospital so it is too soon to tell. 28 old cases of rheumatism were kept under observation in 1938, 21 of these went through 1938 with no relapses and are attending school in a satisfactory condition. 7 cases however showed relapses of varying degrees of severity. One of these cases was in hospital at the end of the year, one is in the Edgar Lee Heart Home, one is in the Heart Home at Lancing. 2 children were discharged from the West Wickham Heart Home after a period of convalescence following the relapse and one was discharged in a similar manner from the Heart Home at Lancing. One child whose relapse is very slight, is attending the Princess Louise Hospital regularly and being kept under observation. In 2 of these cases, last year's was the third attack of acute rheumatism and one of these children is now only 8 years of age. it will be some time before adolescence comes to his rescue with its lessened tendency to relapse. He is fortunate in that the damage to his heart up to date is negligible, and should he escape further damage will in no way lessen his efficiency as a worker when he grows up. It was pointed out by Dr. Schlesinger in the work he did at the West Wickham Heart Home, that attacks of tonsilitis 84 tended to cause relapses, and as this boy has now had his tonsils removed it is to be hoped that the future will hold for him a greater resistance to infection. 2 cases were referred to the rheumatic clinic as being suspect cases of rheumatism, 1 child was suspected of chorea and the other of a mild attack of rheumatism. Both children had rheumatic family histories and therefore were suspect, but the attacks were abortive and the children are meantime well and in a satisfactory condition. ASTHMA. 8 cases of Asthma came under observation in the year 1938 and 3cases of Asthma were associated with Eczema of the skin Of these cases, one has been in a Home at Broadstairs for 6 months and is still there, one was in a Home at Worthing from February until September when he came home as being much improved As soon as he came back to London his Asthma restarted and he is meantime awaiting admission to the same home. 3 other cases of Asthma are waiting admission to convalescent homes. 3 children are attending ordinary elementary schools, 2 of these are now having very slight and infrequent attacks, and 1 after a pro longed holiday in Somerset is now fairly free from attacks. Of the 3 cases suffering from Asthma and Eczema, 2 are time fairly well, with skins rough but healed, and very little Asthma. The third suffers less from Asthma but his skin is not yet healed. Attempts were made to get the latter boy to(???) in Switzerland through the Queen Alexandra Fund, but there was no vacancy and not likely to be one for some time. The boy' name has been taken by the Secretary but there is not much hope of getting him to Switzerland. Asthma is a disease due to a hypersensitivity on the part of the sufferer to something in his environment or diet .the tendency is hereditary, and in the same family are often found other sensitisation diseases such as Hay Fever or Urticaria. the cause may be anything from the dust in the air the person breai(???) to the food eaten at any meal. Cure is often wrought by(???) to a different environment, by tracing the articles in the dret which bring on attacks, or by desensitising injections given over 2 long period. In Cardiff there exists a special Asthma clinic whose immense trouble is taken to investigate each patient and to fiend out to what substances he is sensitive. Breathing exercises are also taught and the results of these exercises show that clinically cured and another 50% improved. It is a 85 fact that breathing, which is a most vital function of our bodies, is so often performed badly, and that perhaps for days, weeks or months the lungs of a person living a sedentary life may never be fully expanded or air drawn into all the air spaces of the lungs. The figures of the Cardiff clinic of improvement and cure in Asthma from regular breathing exercises are most impressive, and the Medical Superintendent of the Clinic reports that the majority of patients, having learned to breathe properly can prevent an attack of Asthma progressing, by using the exercises. SCARLET FEVER. There were fewer cases of Scarlet Fever in the school population in 1938 than in 1937, there being 108 cases as against 134. The usual autumn rise in the numbers of Scarlet Fever cases did not materialise, in fact towards the end of the year there were fewer cases of Scarlet Fever about than during the summer (so-called) and the cases which did occur were of a very mild type. Few complications occurred and fewer cases of otorrhoea were noted generally, both in hospital and in the school population. When there is Scarlet Fever about, there will always be a certain number of cases who do not develop a Scarlet Fever rash, but in whose throats the causative organism may be found. These cases are not suspected by their families, are not reported, and are the cause of the regular cropping up of cases of Scarlet Fever throughout the year. It is not practicable to isolate every child whose throat condition on examination is such that it may be harbouring temporarily the organism of Scarlet Fever, and it is only after a case or two has occurred in a classroom that steps are taken to try to isolate the possible carrier. The organism of Scarlet Fever is so ubiquitous and may find a temporary lodgement in so many throats without giving rise to symptoms of the disease, that to try to stamp it out in that way is an impossibility, at any rate in a town. Immunisation against Scarlet Fever in the same way that it is performed for Diphheria is not a practicable solution either. The immunity conferred does not last more than a few months and protection would mean continual re-inoculation. The distribution of the cases in the schools was as follows: — Acton Wells 13 Beaumont Park 27 Berrymede 10 Central 2 Derwentwater 16 John Perryn 7 Priory 7 Rothschild 11 Southfield 7 West Acton 8 Roman Catholic — 86 In 6 schools the numbers had fallen and this decrease was particularly noticeable in South Acton. In Berrymede and Priory Schools in 1937 there were 36 cases. In 1938, only 17. In Rothschild and Beaumont Park Schools, on the other hand, the number rose from 30 in 1937 to 38 in 1938. John Perryn School in 1938 had 7 cases against only 1 in 1937. Acton Wells School had exactly the same number as in 1937, but West Acton School showed a drop from 14 to 8. Derwentwater and Central Schools had 18 cases in 1938 as against 20 cases in 1937. There were no cases at all reported from the Roman Catholic School in 1938 and there were 3 in 1937. Southfield School had 15 in 1937 but only 7 in 1938. 103 Scarlet Fever patients and 135 contacts were examined at the Town Hall before resuming school attendance. Contacts are allowed to attend school if found to be alright and are kept under observation. The exclusion of contacts was formerly done on the assumption that they were incubating the disease and wencapable of infecting others. It is the exception rather- than the rule to have another case in the family as the child, if ill, has probably been kept apart. It is after the return of the patient from hospital that the danger arises, for it is then that the child, convalesceni and allowed to mix with the others as much as it wants, is mort likely to pass on the organism to its brothers and sisters. It is impossible to guarantee that any child discharged from hospital after Scarlet Fever has not got some of the organisms still in its nose and throat. As mentioned before, the organism is ubiquitous and the advice given to parents to keep the patient apart for atleast a fortnight, is seldom carried out. Fortunately, for many years now, Scarlet Fever has been of a very mild type, and is an infectious disease which at the present time gives rise to little anxiety. DIPHTHERIA. 1938 was a year nearly free from Diphtheria in the school population. There were only 9 cases during the whole year Unfortunately, one of these 9 cases died, a little girl—an only child who had not been immunised against the disease. It is unfortt that it seems impossible to convince people that immunisation vC a good thing, and it is not until it is too late that some means awake to a sense of their responsibilities, and regret, with unavar ing bitterness, their obstinacy and carelessness. 87 It is gratifying to be able to report however, that in our infant schools, the percentage of children inoculated has risen, and that in two schools it is over 60%. The figures are given below and the percentages for 1936 are given for comparison. 1938. 1936. Acton Wells 52.6% 43.5% Beaumont Park __ 61.9% 42.6% Berrymede 26.1% 33.7% Derwentwater __ 44.4% 45% John Perryn 59.8% 40% Priory 43.2% 37% Rothschild 56.6% 31% Southfield 50.2% 37% West Acton 67.9% It will be noted that in nearly every case the percentage has risen, and this augurs well for the possibility of freedom from Diphtheria in the next year. It will be seen from the above table that Berrymede School which serves the most crowded part of the Borough, i.e. South Acton, is the school with the poorest percentage of immunised children. It is also the school from which 4 out of the total 9 notified cases of Diphtheria were drawn. It is the most difficult school from which to get consent from the parents for inoculation to be performed. At medical inspections it is waste of time to try to reason or explain the dangers which might so easily be avoided by simple injections. The parents "don't hold with it" and that is that, no argument is of any avail against blind assertion unbacked by any facts or knowledge. The schools at which Diphtheria occurred during the year were:— Acton Wells 1 Beaumont Park 1 Berrymede 4 Rothschild 1 Southfield 1 (died) Roman Catholic 1 88 Two of the children who developed Diphtheria had been immunised, one 5 years previously, and one the year before. Both had mild attacks and their condition never gave rise to anxiety. Our immunisation scheme against Diphtheria was conducted on similar lines to former years. Immunisation is offered to children in their pre-school years at Infant Welfare Centres, and again to all school entrants. The necessary injections are carried out, and after an interval of 6 months the children are Schick tested and those found. to be positive are re-inoculated. It was not found that any child required more than one injection after the Schick test, to turn a positive reactor into a negative one, and therefore in future it is proposed to drop the Schick test altogether and substitute for it, in each case, another injection of immunising material. The Schick test is not a reliable test of the level of immunity created in the blood, and it is a much greater ordeal for the child than an injection. It is not thought, therefore, that any child will suffer by the substitution, but that the immunity in a great many cases will be heightened. The immunity so conferred can be reckoned as lasting approximately three years, so it is our custom to offer to all immunised children another injection every three years during their school days. This stirs up the waning immunity in the blood and keeps the child reasonably safe from contracting Diphtheria. It is claimed by those who oppose Diphtheria Immunisation, that to be immunised may prevent a child succumbing to the disease, but will not prevent him from harbouring the germ in nose or throat. Each such child, or carrier, is a potential source of danger to others, and each immunised child may be looked upon as suitable soil for becoming a carrier. We thus are, by immunisation, enormously enlarging the field of potential Diphtheria carriets and laying the whole unprotected population open to catching the disease from such people. There is no proof that this actually happens, and ample proof to those who care to look, that immunisation must have saved the lives of thousands of children Since immunisation started in Acton, there has not been one death in a fully immunised child—the statement must be expressed thus, as it may take anything up to 6 months after the last injection before the immunity in the blood has reached a satisfactory level 10 Diphheria patients and 22 contacts were seen at the office before returning to school. 89 (???) school. Positive Negative 1st. 2nd 3rd 1st. 2nd after 3year Acton Wells Senior __ 10 Acton Wells Junior 6 4 — 1 3 6 10 66 Acton Wells Infants — — — — l 49 40 16 Beaumont Pk. Senior Girls 4 3 1 1 l 1 — 1 Beaumont Pk. Junior Girls 1 — — — — 1 — 10 Beaumont Park Infants — — — — — 30 34 9 Berrymede Junior Boys — — — — 2 5 7 22 Berrymede Junior Girls — — — — — 2 2 16 Berrymede Infants — — — — 1 30 22 1 Central 1 — — — — 1 — 12 Derwentwater Junior — — — — — 3 2 27 Derwentwater Infants — — — — — 40 37 17 John Perryn Senior — — _ — — — — 5 John Perryn Junior — — — — — — — 31 John Perryn Infants — — — — — 25 23 25 Priory Boys — — — — — — — 2 Priory Girls — — — — — 2 1 3 Priory Infants — — — — 1 63 48 12 Rothschild Junior — — — — — — — 17 Rothschild Infants — — — — 2 48 42 4 Southfield Senior Boys — — — — — — — 1 Southfield Junior 3 — — 1 1 28 24 30 Southfield Infants — — — — — 51 42 5 Roman Catholic — — — — — 25 20 2 West Acton 1 — — — — 64 60 24 , Hospital — — — — — 46 41 Welfare — — — — — 249 232 — Others 1 — — — — 1 1 2 Total 17 7 1 3 12 766 700 370 In addition 604 were Schick tested after inoculation, and of this number 129 were Positive and were given another dose. 90 MEASLES. 1938 was an epidemic year for Measles, but the (???) although long drawn out, was mild in character and did not present the number of ear complications,—otitis media and mastoi(???) that the 1936 epidemic did. On the whole, the disease was mid and although several deaths occurred, there was no death in a child over 5 years of age. It is in the early years of life that Measles is such a deadly children's disease, and if a child can escape catching it until he has reached the age of 7, there is less danger to life and much more likelihood of the child's escaping with a mild atrack of the disease. Measles has occurred in Acton with regularity every two years for the last 30 years. It is an interesting epidemiologcal problem to consider the why and wherefore of this. It has been suggested that in addition to those who contract measles and thereby develop a life long immunity to the disease, there are three who develop a temporaiy immunity by getting subclinical dosen of infection during an epidemic. The epidemic dies down when the percentage of children who have not got either a temporary or a permanent imi(???) falls below 20%, and breaks out again when the percentage has risen again above 25%. The causative organism of measles (???) far unidentified, and the only preventive treatment at our (???) consists in the administration of serum from human beings who have had in the past, or who are at present convalescing from the disease. Exclusion of contacts from the Infants Departments only is practised. It is, as has been said, in the early years of like measles is a serious complaint, and a large proportion of children in the junior and senior departments of our schools wil allready have developed an immunity to the disease. EXCEPTIONAL CHILDREN. Blind and Partially Sighted. 1 child attends a certified school for the Blind to which the ^ was transferred last year. 1 child attends the Kingwood rood School for Partially Sighted, and 1 child is at present(???) an ordinary elementary school because he is not yet old enough to attend a special school for the partially sighted. 91 Deaf. 4 children are attending special schools for the deaf. attend Ackmar Road School, 1 is at Oak Lodge, and 1 is at Anerley Residential School. 2 children, both deaf and dumb are at present attending ordinary elementary schools until they are old enough to go to special schools for the deaf. Mentally Defective Children. There are 42 children at present attending our Special School {or Mental Defectives. During the year 10 new admissions were made, 2 were sent to Ealing Occupation Centre as ineducable. Epileptic Children. 2 children are in epileptic colonies, one at Lingfield and one at Chalfont St. Peter's. 1 child is being allowed to attend an ordinary elementary school as she suffers from petit mal and the Attacks are very slight and infrequent, and one child, recently moved to Acton, is waiting admission to an epileptic colony. Tubercular Children. 2 children are suffering from Tuberculosis of the lungs. One in Brompton Hospital and the other in Harefield Sanatorium. children suffer from non-pulmonary tuberculosis. One is in the Treloar Home at Alton and one, after being operated upon in the Central Middlesex Hospital, is at present in a convalescent home if Worthing. delicate Children. 14 children are included under this heading. 3 of these children are attending the Wood Lane Open Air School and 2 are waiting admission to the school. 3 children are attending ordinary mentary schools and are being kept under supervision. 1 child is waiting admission to a residential heart home, he has been away before and recently has been losing ground and is to go away again meantime he is attending the ordinary elementary school. children are in Homes at Broadstairs, 2 boys suffering from Asthma are waiting admission to residential convalescent homes, and one child is at home waiting admission to a residential con- ascent home as a result of repeated chest trouble. 92 Crippled Children. 1 child is at a certified P. D. School (Queensmill Road School), 1 child is in hospital having had repeated operations on her leg, and 1 child is at home. She has been recommended to attend a school for physically defective children later on. She has had bone grafting operations performed on one of her legs and ft not considered suitable for an ordinary elementary school. Children with Heart Disease. 2 children are at special heart homes, one at Lancing, and one at the Edgar Lee Heart Home. 2 children whose hearts were affected by Rheumatism are attending ordinary schools but are being kept under observation at the rheumatic clinic, and 1 child . is being treated by his own doctor for heart disease following rheumatism. Multiple Defects. There is one child who has recently moved into Acton who is deaf and dumb, partially paralysed, is said to suffer from fits and possibly is feeble-minded. She is meantime in Acton Hospital undergoing an operation, but has been recommended for a residential school under the L.C.C. REPORT OF THE EAR CLINIC. 73 cases attended the Ear Clinic during 1938. 61 were treated for Otorrhoea (ear discharge). 4 had earache,—3 due to inflammation of the middle car and subsided, and 1 due to a boil in the ear. 2 were deaf. 2 had wax in the ears. 1 nothing wrong with ears. 3 had external otitis, were treated and cured. 61 cases of Otorrhoea. 44 of these cases suffered from acute attacks of otorr(???) and 3 of those 44 suffered from two attacks during 1938. 47 cases of acute ear discharge treated at the Clinic. 17 of these cases cleared up in a week from the beginning of treatment. and 15 more had cleared by the end of the second week. 4 cases 93 three weeks to clear up and 3 cases took a month. 1 case took six weeks in which to clear up but attendance here was very irregular. In 1 case the time could not be determined as the holidays intervened, and the child did not attend during holidays. The ear was, however, better when school reopened. One child refused to attend our clinic, one preferred to attend her own doctor, ind one had to be referred to hospital for operation on her mastoid process. The remaining three cases were all recent cases and were still attending the Clinic at the end of the year. The person who suffers from chronic ear discharge is much more difficult to treat and responds much less readily to local treatment. It is often difficult to decide whether the ears will clear up with local treatment or whether resort to operation will be necessary. There are children who, whenever they get a cold in the head, develop ear discharge which ceases as the cold clears away. Each attack, of course, makes the condition of the ear just a little worse as regards hearing, but there is no guarantee that, even after operation, these children will not get ear discharge just the same with each head cold. There is one case attending our Ear Clinic at intervals with discharge from both ears, and this child had, in order to clear up her original attacks of otorrhoea, both mastoid processes operated upon. Still, with every head cold, this child gets from both ears discharge which is most obstinate and difficult to treat. She has now been referred to our new Nose Clinic and her nose and nasopharynx are to be subjected to regular courses of treatment to try to prevent the child developing colds and so getting further attacks of otorrhoea. There are 17 cases of chronic otorrhoea who have been treated in 1938, a fair proportion of these (9) were treated for otorrhoea in 1937 and one has been treated each year since 1935 for otorrhoea,—a perfect example of ear discharge following a winter cold in the head. 4 cases were very resistant to treatment and the ear discharge continued for weeks before clearing up. 1 case was referred to the Ear Specialist at Acton Hospital as he resisted treatment (he also had previously been operated on) and - cases were still attending the Ear Clinic at the end of the year. 5 cases of Earache. 3 of these were due to inflammation of the ear, 1 was due to a boil in the ear, 1 was due to a slightly inflamed throat. All subsided with treatment. 94 4 cases of deafness. 2 cases were due to wax in the ears and cleared up after its removal. 1 was due to a foreign body in the ear and cleared up after its removal, and 1 was due to a slight inflammation d the ear during the course of a head cold, and disappeared with the cure of the cold. 3 cases of External Otitis. It was difficult at first to tell what was the extent of the trouble, and swelling and scabs of Impetigo made it impossible to see into the ear, but on treatment to the outside Condition, the drum was found to be unaffected in each case. 1938 has been fortunate in being a year with comparatively little Scarlet Fever. The usual expected Autumnal rise did not materialise to any extent, although during the summer cases Scarlet Fever were cropping up in unexpectedly large numbers the time of year. With the absence of the Autumn rise ho there was absence of those sore throats, etc., which do not bec clinical Scarlet Fever. We are inclined to attribute the ease which so many of our cases of otorrhoea cleared up, to the that the organism of Scarlet Fever was not so ubiquitous as and it is notoriously those cases due to the organism of Scar Fever which are so difficult to clear up. In comparing the number of cases of otorrhoea in 1938 those of the previous year, i.e., 61 with 63, there is very difference, but it was found much less difficult to clear up the of otorrhoea in 1938 than it was" in 1937. The Ear Clinic has been conducted along the same as before. Each case has been seen each school day by the Medical Officer or the nurse, and appropriate undertaken. SCABIES. Scabies continued to infect the school population in 1935 even greater numbers than in 1937. There were in all 121 cases of Scabies in school children and 80 families were affected. 95 Treatment was carried out at home in the first instance, r^-ed instruction and sufficient ointment being given to the utffei'r to enable her to carry out the necessary applications. In fa vast majority of cases a cure was effected in less than a hi°ht, and it was easy to pick out the mothers who would not j^could not do the treatment efficiently. In those cases it was ^.issary to send the children to the -Kensington Cleansing Station ^treatment, and even then in some cases it was weeks before jare was effected. The Acarus Scabei, the cause of Scabies, will live for a time Jprt from the human body if conditions are favourable and he /i kept warm. It is therefore perfectly understandable that any teount of treatment at public baths will be ineffective if infected Clothes and articles of clothing are kept in the home. Instructs were given to the parents of infected children to boil their Skets and pillow cases, and their bedding and clothing which cctii not be so treated were removed and disinfected. It only an infected pair of gloves to be overlooked for the treatment rendered null and void,- and in some of the infected persons fw idea of ordinary personal cleanliness was most elementary and homes, according to reports after visits, dirty and untidy in extreme. Unexpected and inexplicable opposition was often «MG0untered also to the idea of having mattresses and clothing in a disinfector, and in every case from those whose failure fa clear up the infection was most apparent. Scabies is not a wfcfiable disease, and so the law gives no power of compulsory ^infection. Sometimes success was attained by threat of report to the "S.P.C.C., but the position is not satisfactory and Scabies conhates to spread in the Borough. Several families became infected more than once during the i families had Scabies three times during the year, and 5 wlies had it twice. It will be evident from the tables below **ving the number of cases and the schools and departments '■^fcted, how widespread was the infection and how persistent "®ugh the whole year. The majority of cases occurred in South pfcn and the schools which serve that area. In the lists of "'"'•lies affected, the same family is sometimes noted under both "^nj'mede and Priory Schools and in some cases also an elder attends the Central School. 96 School. Department. Cases. Families Priory All 30 '20 Berrymede All 25 17 Derwentwater & Central All 15 13 Acton Wells All 15 8 Rothschild All 11 7 Beaumont Park All 10 8 John Perryn Junior & Senior 5 4 Special (M.D.) 4 4 Southfield Infants & Junior 2 2 West Acton 2 2 Roman Catholic - 2 2 121 87 The times of the year during which these schools were infected are shown below. (2 January. Priory, Berrymede, Derwentwater, Central, Rothschiw, mont Park, John Perryn, Special, Roman Catholic. February. Priory, Berrymede, Derwentwater, Acton Wells, Beaumont" Park. March. Priory, Derwentwater, Acton Wells, Rothschild, Park, Southfield, Roman Catholic. April. Priory, Berrymede, Derwentwater, Beaumont Park, May. John Perryn. June. Priory, Berrymede, Beaumont Park. July. Priory. August. Berrymede, Acton Wells. September. Priory, Berrymede, Derwentwater, Acton Wells, John Perryn, Southfield, West Acton. October. Priory, Berrymede, Derwentwater, Rothschild, West Acton. November. Berrymede, Acton Wells, Beaumont Park, John December. Berrymede, Acton Wells. 97 Parents are always asked when a child is found to be suffering from Scabies, if any member of the family who does not attend school is suffering from a similar complaint. If so, treatment is offered for infants or for adults as the case may be. It is also advised that if the infected person has been sleeping in the same bed as any other member of the family who is not infected, that treatment should be given to the apparently clear child also, in case the statement that the child is clear is erroneous and all effort wasted by clearing one and not the others. REPORT OF THE SCHOOL DENTAL SURGEON. There has been an all round rise in the number of school children treated this year. The acceptance rate for elementary Schools was maintained at about 70%, while for the secondary Schools the percentage of acceptances has risen from 66.5 to 72%. Actually, though the amount of treatment carried out for the secondary schools was considerably more, this does not mean that the condition of the mouths was not so good. The number treated in 1938 was 328, as against 241 in the previous year, the fillings rose from 385 in 1937 to 529 in 1938, while extractions fell from 165 in 1937 to 112 in 1938. Thus it will be seen that as well as a rise in the percentage of acceptances there was 'a rise in the proportion of conservative work over extractions. This result has been made possible by the introduction of extra assistance to the full capacity of our present premises. Almost double the number of expectant and nursing mothers 36 sent from the Welfare and Ante-natal Centres for oral examination, but this did not result in much increase in the number heated. The reason is, I think, that most of the extra ones were rot in need of such urgent treatment, and perhaps naturally, are not inclined to have anything done at such a time. Just before Christmas the most up-to-date apparatus for the administration of gas and oxygen was purchased for the clinic. This is proving a great advantage in giving a better and quieter (???)esthesia and is also very much more economical in the use of gas than the old type. The amount of oxygen used is, of course, small. 98 Below are given the figures for work done for the secondary schools and for the welfare clinics, as these are not included in the returns to the Board of Education at the end of the report. Secondary Schools. Number of children examined — 618 Referred for treatment 459 Treated — — 328 Attendances for treatment 610 Permanent Fillings 529 ,, . Extractions 84 ,, Dressings 51 Temporary Extractions _ . 28 Welfare Cases. Mothers examined 174 Referred for treatment 173 Treated 99 Dentures supplied 27 Permanent Fillings 40 ,, Extractions 793 ,, Dressings 74 Attendances (Mothers and children) . 386 Anaesthetics given (Mothers and children) 264 Children examined _ 82 Referred for treatment 75 Treated 74 Temporary Fillings 12 „ Extractions 233 ,, Dressings 35 P. H. SlatfR REPORT OF THE SCHOOL OCULIST. The work of the Clinic has been carried on interruption during the past 12 months. During the year 337 school children were referred for examination. Of these, 226 were provided with glasses, 7 were treated privately, and 34 refused treatment. 70 children were found not to require glasses,and there were 14 cases of external disease of the eye. 99 22 children and 1 mother were referred from the Welfare Centres. 18 of the children and the 1 mother did not require treatment, 7 were supplied with spectacles and 2 cases refused treatment. There were 3 cases of external eye disease. 28 boys were referred from the County and Technical Schools. Of this number 23 were provided with spectacles, 1 went to Hospital and 4 did not require treatment. Two cases of defective colour were examined at hospital and proved to be cases of partial red-green blindness. A few cases have been referred to hospital for orthoptic treatment and these are the cases in the Clinic which would benefit from a course of treatment. Children undergoing treatment have to attend two or three times a week and the course of training may extend over many weeks. In quite a number of cases, parents, though willing for their children to have the benefit of a course of training, have stated that they cannot afford either the time involved or the cost of the fares to and from town. There is no doubt that the acquisition of the necessary apparatus and the services of a trained orthoptist for two sessions a week would prove 2 great asset to the Clinic. F. Clifton. PROVISION OF ME.ALS. Free meals and milk continue to be provided at 7 Feeding Centres in Acton. These meals and milk are granted on medical grounds to children certified by the School Medical Officer to be Suffering from malnutrition and to be medically in need of the extra nourishment. When assessing the nutrition of a child, is the case to be considered from the standpoint of the present physical State of the child, or is it to be assessed from the evidences present of faulty nutrition post or pre natally? When considering a child's Qualifications for the granting of free meals and milk it is probably fetter to take the present state of the child, its weight, height, lack of muscular tone, flabby skin lacking that polish (which is ore of childhood's greatest charms), lacklustre eyes and hair, and poor posture indicating fatigue. The weight for height measure, as a means of assessing nutrition has been abandoned for some time, for it is perfectly possible to have an overweight child who is flabby and whose nutrition leaves much to be desired. . To assess nutrition, from the national point of view, requires a different standard. We come then to consider the 100 ravages made permanently in the human frame before birth, affo birth and at the present time. Lack of proper nutrition of the mother during pregnancy may result in a poorly developed skeletol in the child with teeth liable to early decay. Lack of sufficent protective substances in the diet in infancy will produce deformities in the bony skeleton due to rickets and the want of adequate diet later may cause lack of muscular tone, with resulting bad posture and deformities. It must not be forgotten however, that diet is not the beginning and end of the question of nutrition. Environmental factors must be considered. Overcrowding with its resulting lack of proper rest, continual noise in home surroundings with its lack of repose, lack of sunlight and fresh air, lack of proper exercise irritability of parents and neighbours because of their being herded together or worried by financial matters,—all these play their part in the production of the final result, the child suffering from na nutrition as we call it for want of a better name. Any child, it might be said, who is not suffering from a disease may be stated to be suffering from malnutrition it its present condition is capable of improvement. There remains much to be done, very much in the way at educating the general spending public on what foods are essential what foods are good, and what foods do not repay in food value the money spent on them. It is unfortunate that, as a naton we are not milk drinkers. It is by no means unusual to find that mothers do not give the children milk, because " they don't like it." That is naturally a sufficient reason to someone who does not understand the value of milk as a food nor how necessary it is to the growing child. It has been held by some that children who do not like milk are sensitive to it, and that it will do harm make them drink it, but the child to whom milk is poisonous very rare indeed. In an experiment carried out in America in over 5,000 children, only 147 were found to be made ill by it a very small percentage. At the end of the report will be found the Tables of figure for provision of free meals and milk during 1938. During the Summer holidays all the children on free meals and milk were reviewed and those children who had attained satisfactory level of nutrition were taken off free meals and given only milk twice daily at school instead. Watch was kept on these children and in only four cases was it necessary to put the children back on free meals again. In every other case the nutrition was 101 (???)intained. This is a slight indication that in the majority of cases children will be given an adequate meal at home and that what is lacking in their diet to improve their condition, is the milk and other protective foods which are present to such a much greater extent in the dietaries of the well-to-do. Advice is given by the School Medical Officer to those in charge of the feeding centres on the need of dishes which should be supplied, brown bread to be substituted for white, fresh fruit for dessert whenever possible, and cheese dishes to be offered. The children clamour for white bread, refuse cheese and cheese dishes, and do not like herrings so we are told, and if that is the case it shows how much needed is education in the home as to which foods are best for children, and which commodities have good food value. Children will eat what they are in the habit of seeing eaten, and resent innovations, and if these articles were seen on the home table more often they would not be refused at the feeding centre. As before, meals were supplied at the feeding centres during. the school holidays, and the attendance of children justified their being kept open. Heals supplied at the different Centres. Avenue Road 24321 Beaumont Park 6994 Central 2687 John Perryn 4353 Priory 4882 Southfield 996 West Acton 569 Acton Wells 393 (ceased at Mid-summer) 45195 Heals supplied during the Quarter ending: — March 11388 June _ _ 10409 September 12659 December 10739 45195 102 Numbers of bottles of milk supplied, Quarter ending: — March 32758 June 30034 September 29648 December 38169 * 130609 Number of children on feeding list: — Meals and Milk. Milk only. March 210 144 June 220 162 September 200 163 December 204 183 CHILDREN'S COUNTRY HOLIDAYS. In 1938 the number of children in Acton who took advantage of the arrangements for having a country holiday was greater than ever. The numbers for the last 4 years are as follows: — In 1935 the total was 294 1936 359 1937 387 1938 420 The number of boys in 1938 was 224 and girls 196. As in previous years there were many more applicants than could be sent away by the money available, but the necessary amount was made up in various miraculous ways. The children themselves collected over 70,000 "Daily Mirror" Coupons, which brought in £28 10s. Od. There was still a probable deficit of about £56. The Mayor of Acton, Councillor A. P. Grundy, issued public appeal in the "Acton Gazette" which brought in £46. MrB. Whiting generously promised to make up any deficit. Before it was known exacdy what the deficit would be, an excellent response to Mr. A. A. Milne's appeal in "The Times" and "Punhc enabled Headquarters to allow Acton an extra grant of money. There were 57 different parties sent away. Most of thew went to the West Country and to Wales, some to Warwickshive Lincolnshire, Berkshire and Kent. 103 The behaviour of the children was excellent this year, and their health on the whole very good. One little girl was sent home after one week with severe ear trouble, one had to stay an extra week as a result of tonsillitis. A boy at Kenilworth broke his arm, mother injured his finger in a machine. One of eight boys on a form near Worcester developed a rash which the Doctor suspected was Scarlet Fever. It proved to be a false alarm, but all eight boys had to remain at the farm in quarantine for an extra nine days. The weather had made the haymaking season later than usual, and this fact added very much to the children's enjoyment. On the actual days of departure and return, the children were conducted to and from the London Stations by the teaching staffs, municipal office staff, and many other friends. Head Teachers report that the holidays undoubtedly did thechildren good, and that the holidays are popular is shown by the steadily increasing number of applications for children to go away. The amount of work required to organise holidays for these children is enormous, and Miss Stevens, the Headmistress of Berrymede Infant School, is to be congratulated on the efficiency with which all the arrangements were carried out. It is owing to Miss Stevens that the Acton branch of the Children's Country Holidays Fund was started, and it is through her energy and unselfish work as Secretary that the branch has been so successful. It is unfortunate that she has found it impossible to continue to act as Secretary any longer, but those children, who have had such good holidays through her efforts, will always owe her a debt of gratitude. THE ORGANISATION OF PHYSICAL TRAINING. Routine visits have been made to all the schools in Acton and the majority of teachers who take physical training have been seen at work. In the course of discussions, various suggestions have been made and in most schools demonstrations of teaching methods have been given. The question of time-table arrangements, use of playgrounds and halls, playing fields, storage and changing facilities, have been discussed with Head Teachers. Teachers have been encouraged to develop and extend the scope of the organised games period to provide a well constructed lesson with a variety of games and practices. Most senior schools and several junior schools have been able to arrange a games period 104 for each class once a week on a grass pitch at least during the summer months. This development is most marked in many girls schools which hitherto had not left the school premises for games. Small apparatus has been supplied to all schools in the area and use of it is being made during the physical training and games period. The supply of apparatus has been much appreciated bv teachers and children. Schemes are now in hand for the supph of portable gymnastic apparatus to senior schools where conditions are favourable. The problem of storage has presented certain difficulties, but as conditions vary at each school it is felt that the problem can best be solved as it arises at individual schools. Gym shoes have been supplied to schools for Head Teachers to distribute to necessitous cases. At the same time, those children who can afford to supply their own shoes have been further encouraged to do so, and an increasing percentage of children are keeping a pair of shoes permanently at school for physical training purposes. As it is unhygienic, it is hoped that the use of a communal supply of gym shoes is only a temporary expedient and that each child will ultimately possess a pair of shoes. A noticeable development during the year, has been a growing tendency for children voluntarily to remove all superfluous clothing for the physical training lesson. This is especially so where the lessons have become fuller, more active and more interesting to the children. The problem of storage of gym shoes presents a certain amount of difficulty, and the possibility of supplying storage lockers for all schools is being explored. It is hoped that in new school buildings adequate storage for shoes, etc., will be incorporated. The permanent marking of playgrounds has been successfully effected at several schools, and in the light of experience gained as to the expense and usefulness of the marking, it is hoped that all playgrounds will shortly have the marking out required. Though it is expected that the playground will be used for physical training whenever possible, it is essential for a school to have indoor accommodation available. During weather unsuitable for work out of doors, it is hoped that school halls will be used equally by all departments, in such cases where sharing is necessary. The supply of gym shoes, and in senior school the supply of portable apparatus, should make possible work of con siderable scope, variety and benefit in the school hall. 105 A programme for the building of gymnasia at senior schools has been submitted to the authorities, and plans for a gymnasium it the Central School are being drafted. Athletics have been encouraged during the summer months, and in Acton the value of the schools' playing field has been amply demonstrated by the increasing use of the Bromyard Avenue field (or athletic sports meetings. Athletic meetings on the whole are well organised though almost invariably teachers err in attempting too long a programme. A course in the teaching of swimming would be valuable before the next season commences. A number of school and interschool swimming galas have been attended in the area which have produced a number of fast swimmers, but style in swimming seems often to have been neglected. Early in the year, a series of Gaumont British Instructional Films on Physical Training were shown to all Senior and Junior schools in the area. Separate showings were given for teachers. The films were much appreciated and appear to have been of material benefit. The work of organising physical training in elementary schools has been considerably facilitated by the whole-hearted co-operation of the Head Teachers of the area, who have helped in the arrangement of demonstrations and have given helpful suggestions and advice in solving the problems of the storage of shoes and apparatus. In conclusion, the class teachers have responded well to the provision of training courses, and this fact combined with the supply by the local authorities of gym shoes and small apparatus, has given a valuable stimulus to the development of physical training in schools. E. L. M. Watteeu. O. Hailstone. SWIMMING INSTRUCTION, SEASON 1938. The Swimming Season opened on Monday, "2nd May, 1038 and provision was made for 53 classes at the Public Baths, 33 for hoys and 20 for girls. Of these, 50 classes were held in school hours, whilst one class for girls and two clasess for boys were held in periods immediately following normal school hours (4.30 to 5-0, and i2.0 to 12.30 p.m.). All the instruction was given by 'he teaching staff of the schools. 106 The Season normally closes on the 30th September, but as in previous years, one or two small classes continue to attend.] the Baths during the winter months for instruction and practice in life-saving. The Acton Education Committee continues to award certificates to boys and girls who can swim twenty-five yards down the length of the bath, without interruption, pause or rest, and Acton scholars also compete for the certificates of the London Schools' Swimming Association and the Royal Life Saving Association, as under: — Swimming: 1st class—100 yards. (Conditions as for Acton certificates). 2nd class—50 yards. ,, ,, „ Life Saving: Elementary, Intermediate, Advanced and Medallion. There are in the schools at the present time, 1246 scholars (629 boys and 617 girls) who can swim, as against 1134 at the end of last season, and 276 boys and 254 girls now in the schock learned to swim during the 1938 season (against 540 in 1937). it should be bome in mind, however, that a great number of the. scholars who left the Elementary schools at the summer vacation to enter Secondary schools had learned to swim by that date. The following is a statistical return relating to the season's work, with comparative figures for last year. Year 1938. Year Boys. Girls. Total. Boys. Girls. Total No. of classes per week allocated 33 20 53 32 21 53 Total attendances made 11436 7699 19135 10972 7730 18702 Certificates gained. Acton Education Committee 218 171 389 224 219 443 L.S.S.A.: 1st class 143 99 242 119 132 251 2nd class 197 119 316 176 174 350 Life Saving. Elementary — 13 13 Intermediate — — — — — Advanced — — — Medallion — — — — — — TABLE SHOWING THE NUMBER OF CHILDREN ATTENDING ACTON SCHOOLS EMPLOYED in THE VARIOUS REGISTERED OCCUPATIONS AS ON 31st DECEMBER, 1938. SCHOOL. Delivering Newspapers Delivering Milk Delivering Goods or Parcels Totals Boys. Boys. Boys. Acton Wells 4 3 2 9 Central 2 1 3 6 County 5 — 3 8 John Perryn — — — — Priory 10 — 15 25 Roman Catholic — — — — Southfield 4 2 6 12 Technical — — — — Others — 1 1 2 Totals 25 7 30 62 107 TABLE SHOWING THE DISTRIBUTION OF ALL CHILDREN EMPLOYED DURING THE PERIOD 1st JANUARY—31st DECEMBER, 1938. School. Acton Wells Central County John Perryn Priory Roman Catholic Southfield Technical Others Total Registered Occupation :— Delivering Newspapers 10 7 9 — 27 — 7 1 — 61 Delivering Milk 4 1 1 — — — 4 1 1 12 Delivering Goods 5 4 5 2 39 — 10 1 3 69 Total 19 12 15 2 66 — 21 3 4 142 Corresponding figures for 1937 14 12 12 9 78 1 22 4 3 155 108 109 Uncleanliness Table. Sch. Date. No. examd. Very few Nits. A. Few Nits B. Many Nits. C. Vermin. D. Total Unclean. % % %' % % 1 July 62 — 1.6 — — 1.6 Sept. 99 1.0 — — — 1.0 2. July. 83 — — — — — Sept. 113 — 1.7 — — 1.7 3. July 165 .6 — — — .6 Sept. 187 1.06 — — .53 1.6 4. July 164 .6 1.2 — — 1.8 Sept. 165 .6 — — 2.4 3. 5. July 164 .6 1.8 — 1.2 3.6 Sept. 144 — .7 — .7 1.4 6. July 105 7.6 3.8 3.8 — 15.2 Sept. 134 8.06 3.2 — 1.6 12.9 7. July 194 9.2 5.1 1.3 1.5 17.01 Sept. 191 11.5 3.6 1.5 3.1 19.8 8. July 193 6.7 1.5 1.03 1.5 10.8 Sept. 157 4.4 1.9 — — 6.3 9. July 362 2.7 .27 .27 3.3 Sept. 333 2.7 .3 — — 3. 10. July 350 5.7 .8 — .8 7.4 Sept. 298 11. 2.3 — 1. 14.4 11. July 213 4.2 .9 — 1.8 7. Sept. 206 7.2 .9 — .4 8.7 12. July 122 — — — — — Sept. 123 — — — — — 13. July 155 3.8 .6 — — 4.5 Sept. 133 4.5 — — — 4.5 14. July 167 1.19 — .59 .59 2.3 Sept. 204 3.4 1.4 — .4 5.3 13. July 167 9.5 1.2 .5 .5 11.9 Sept. 177 13. 3.3 .5 2.2 19.2 16. July 280 3.5 1.07 — 1.07 5.7 Sept. 255 4.3 1.1 .39 1.5 7.4 17. July 86 — Sept. 81 1.2 — — — 1.2 18. July 94 2.1 — — — 2.1 Sept. 92 3.2 — — — 3.2 13. July 117 .8 — — — .8 Sept. 114 — — — — — 20. July 127 5.5 .7 — .7 7. Sept. 126 5.5 .7 — — 6.3 21. July 242 2.4 — .8 3.3 Sept. 215 3.2 .4 — .9 4.6 110 Sch. Date. No. examd. Very few Nits. A. Few Nits. B. Many Nits. C. Vermin. D. Total unclean % % % % % 22. July 284 — — — — — Sept. 259 .7 — — — .7 23. July 197 1.5 2.5 — — 4. Sept. 274 6.9 — — — 6.9 24. July 243 2.8 — — .4 3.2 Sept. 202 1.4 — — .9 24 25. July 173 1.1 — — — 1.1 Sept. 205 .9 — — — .9 26. July 265 3. .3 — — 3.4 Sept. 190 5.2 — — — 5.2 27. July 113 .8 .8 — — 1.7 Sept. 138 — 1.4 — — 1.4 28. July 147 — 1.3 — — 1.3 Sept. 153 .6 — — — .6 29. July 141 1.4 .7 — — 2.1 Sept. 146 .6 1.3 — .6 2.7 30. July 215 .4 1.3 — .4 2.3 Sept. 160 .6 — — .6 1.2 31. July 134 1.4 .7 — — 2.2 Sept. 102 .9 .9 — — 1.9 32. July 75 6.6 2.6 1.3 1.3 12 Sept. 110 10. 2.7 .9 — 13.6 33. July 40 2.5 — — — 2.5 Sept. 46 10.8 — — — 10.8 34. July 247 — .4 — — .4 Sept. 188 —' .5 — — .5 VISITS PAID BY SCHOOL NURSES. The following are the number of home visits paid by the Nurses during the year. The visits have been divided into school distribution. Acton Wells 69 Rothschild 223 Beaumont Park 121 Southfield 190 Berrymede 262 Roman Catholic 14 Central 14 West Acton 29 Derwentwater 178 Total 1494 John Perryn 182 Priory 212 111 CONVALESCENT HOMES & COUNTRY HOLIDAYS. One boy and one girl were sent to the Winter School of Recovery, Bexhill, for 3 months each. Two boys, and two girls were given a fortnight's free holiday during the Summer at Bexhill. MEDICAL INSPECTION RETURNS. TABLE I. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups:— Entrants 820 Second Age Group 754 Third Age Group 561 Total 2135 Number of other Routine Inspections Grand Total 2135 B.—Other Inspections. Number of Special Inspections Number of Re-Inspections 2126 1155 Total 3281 MOTHERCRAFT CLASSES. The following Table gives the number of classes sent from each school to the Day Nursery. Beaumont Park 5 Roman Catholic 2 Acton Wells 5 28 Central 6 John Perryn 3 Priory 7 112 C.—Children found to Require Treatment. Group For defective vision (excluding squint) hor all other conditions recorded in Table II A. Total (1) (2) (3) (4) Entrants 1 34 34 Second Age Group 52 45 95 Third Age Group 33 18 51 Total (Prescribed Groups) 86 97 180 Other Routine Inspections — — — Grand Total 86 97 180 113 table II. A—Return of Defects found by Medical Inspection in tot Year ended 31st December, 1938. 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) Skin:— Ringworm—Scalp — — 2 — „ Body — — 20 — Scabies 7 — 142 — Impetigo 8 — 301 — Other Diseases (Non-Tuberculous) 20 5 139 — Total 35 5 604 — Eye:— Blepharitis 14 — 10 — Conjunctivitis 3 — 47 — Keratitis — — 1 — Corneal Opacities — — 2 — Other Conditions (excluding Defective Vision and Squint) 1 — 56 — Total 18 — 116 — Defective Vision (excluding Squint) 86 _ 45 Squint 13 — 11 — far:— Defective Hearing 2 9 2 — Otitis Media 3 — 65 — Other Ear Diseases 3 — 6 — Nose and Throat:— Chronic Tonsillitis only 1 — 4 — Adenoids only — — 1 — Chronic Tonsillitis and Adenoids 6 — 24 — Other Conditions — 3 2 143 Enlarged Cervical Glands (Non-Tuberculous) — 122 — 41 Defective Speech — 2 — 1 114 TABLE II.—Continued. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment. Requiring Treatment Requiring to be kept under observation, but not requiring Trentment. (1) (2) (3) (4) (5) Heart and Circulation ;— Heart Disease: Organic 1 1 — — Functional — 12 — 1 Anaemia 1 2 — 2 Lungs:— Bronchitis — 2 — Other Non-Tuberculous Diseases 3 — 5 — Tuberculosis— , Pulmonary: Definite — 2 — Suspected — — 4 — Non-Pulmonary: Glands — — 2 — Bones and Joints — — — — Skin Other Forms — — 1 — Nervous System :— Epilepsy — — 2 — Chorea — — 1 — Other Conditions — 1 — — Deformities :— 1 Rickets — — Spinal Curvature 5 1 — — Other Forms 6 12 1 — Other Defects and Diseases (excluding Defects of Nutrition, Uncleanliness and Dental Diseases) 8 12 659 35 Total number of defects 191 182 1559 224 115 B.-Classification of the Nutrition of Children Inspected during tiir Year in the Routine Age Groups. Age-groups. Number of Children Inspected A (Excellent) B (Normal) C (Slightly (subnormal) D (Bad) No. % No. % No. % No % Entrants 820 307 37.43 487 59.4 25 3.04 1 .12 Second Age-group 754 315 41.77 416 55.17 23 3.05 — — Third Age-group 561 149 26.55 387 68.98 25 4.43 — — Other Routine Inspections — — — — — — — — — Total 2135 771 36.11 1290 60.42 73 3.41 1 .04 TABLE III. Return of all Exceptional Children in the Area. BLIND CHILDREN. At Certified Schools for the Btind At Public Elemenrarv Schools At other Institutions At no School of Institution Total 1 — — — 1 116 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind At Certified Schools for the Partially Sighted At Public Elementary Schools At other Institutions At no School or Institution Total — 1 1 — — 2 DEAF CHILDREN. At Certified Schools for the Deaf At Public Elementary Schools At other Institutions At no School or Institution Total 4 2 — — 6 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf At Certified Schools for the Partially Deaf At Public Elementary Schools other Institutions At no School or Institution Total — — — — — — MENT ALLY DEFECTIVE CHILDREN. FEEBLE-MINDED CHILDREN. At Certified Schools for Mentally Defective Children At Public Elementary Schools At other Ins'itutions At no School or Institution Total 42 — — — 42 117 EPILEPTIC CHILDREN. CHILDREN SUFFERING FROM SEVERE EPILEPSY. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 2 1 — 1 4 PHYSICALLY DEFECTIVE CHILDREN. A.—TUBERCULOUS CHILDREN. 1-CHILDREN SUFFERING FROM PULMONARY TUBERCULOSIS. (Including pleura and intra-thoracic glands). At Certified Special Schools At Public Elementary Schtols At other Institutions At no School or Institution Total — — 2 — 2 II.—CHILDREN SUFFERING FROM NON-PULMONARY TUBERCULOSIS. At Certified Special Schools At Public Elcment.ity Schools At other Institutions At no School or Institution Total — — 2 — 2 118 B.—DELICATE CHILDREN. (i.e.) Those whose general health renders it desirable that they should be specially selected for admission to an Open Air School. At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 3 5 2 4 14 D.—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 Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 2 2 —— 1 5 C.—CRIPPLED CHILDREN. (i.e.) (Other than those diagnosed as tuberculous and in ntei treatment for that disease) who are suffering from a degree of crippfi*^ sufficiently severe to interfere materially with a child's normal mode of At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total 1 — 1 1 3 119 CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Combination of Defect At Certified Special Schools At Public Elementary Schools At other Institutions At no School or Institution Total Deaf, Crippled & Feble- rinded. — — 1 — 1 TABLE IV. Return of Defects Treated during the Year ended 31st December, 1937. Treatment Table. group I.—Minor Ailments (excluding Uncleanliness, for which see Table VI.) Disease or Defect Number of Defects treated, or under treatment during the year Under the Authority's Scheme Otherwise Total (1) (2) (3) (4) skin— Ringworm-Scalp— (i). X-Ray Treatment 2 — 2 (ii). Other Treatment — — — Ringworm-Body 20 — 20 Scabies 137 5 142 Impetigo 301 — 301 Other skin disease 138 — 138 Minor Eye Defects— (External and other, but excluding cases falling in Group II.) 115 1 116 Minor Ear Defects— 73 — 73 Miicellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 802 — 802 Total 1588 6 1594 120 Group II.—Defective Vision and Squint (excluding Minor Eye Defou treated as Minor Ailments—Group I). Defect or Disease. No. of defects dealt with. Under the Authority's Scheme Otherwise Total (1) (2) (3) (4) Errors of Refraction (including squint) 337 6 343 Other defect or disease of the eyes (excluding those recorded in Group I) 14 1 15 Total 351 7 358 No. of Children for whom spectacles were— (a) Prescribed 228 2 230 (b) Obtained 226 2 228 Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment Under the Authority's scheme, in Clinic or Hospital By Private Practitioner or Hospital, apart from the Authority's Scheme Total Received other forms of Treatment total Number Treted (1) (2) (3) (4) (5) 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4. — 3 41 — — — — — — 3 41 — — 46 (1)—Tonsils only. (2)—Adenoids only. (3)—Tonsils and adenoids (4)—Other defects of the nose and throat. Group IV.—Orthopaedic and Postural Defects. Under the Authority's Scheme. (1) Otherwise. (2) Total number treated Residential treatment with education Residential treatment without education N onKesidenlial treatment at an orthopaedic clinic Residential treatment with education Residential treatment without, education NonResidential treatment at an orthopaedic clinic (i) (ii) (iii) (i) (ii) (iii) No. of children treated — — — —• 2 2 121 122 Table V.—Dental Inspection and Treatment. (1) Number of children who were:— (4) Attendances made by children for- treatment 4696 (a) Inspected by the Dentist: (5) Half-days devoted to: Aged: Inspection 41 Routine Age Groups. . 5— 592 Treatment 561 6— 714 Total 602 7— 677 8— 640 (6) Killings: 9— 640 Permanent Teeth 2215 10— 637 Temporary Teeth 84 11— 634 12— 569 Total 2299 13— 544 (7) Extractions: 14— 128 Permanent leeth 931 5775 Temporary Teeth 4184 (6) Specials 496 Total 5115 (c) Grand Total 6271 (8) Administrations of general anaesthetics for extractions 2216 (2) Number found to require treatment 4507 (9) Other Operations: Permanent Teeth 206 Temporary Teeth 66 (3) Number actually treated. .. 2994 Total 272 Table VI.—Uncleanliness and Verminous Conditions. Average number of visits per school made during the year by the School Nurses 6 Total number of examinations of children in the Schools by School Nurses 27392 Number of individual children found unclean :— Vermin and Nits 66 Slightly infested 405 Number of individual children cleansed under Section 87 (2) and (3) of the Education Act, 1921 9 Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 (b) Under School Attendance Byelaws 123 STATEMENT OF THE NUMBER OF CHILDREN' NOTIFIED DURING THE YEAR ENDED 31ST DECEMBER, 1938, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total number of children notified 7. Analysis of the above Total. Diagnosis. Boys. Girls. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots (b) Imbeciles 1 1 (c) Others (ii) Children unable to be instructed in a Special School without detriment to the interests of other children : (a) Moral defectives (b) Others 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 1 4 3. Feeble-minded children notified under Article 3, i.e. "special circumstances" cases i. Children who in addition to being mentally defective were blind or deaf Grand Total 2 5 We are, Your Obedient Servants, D. J. THOMAS. E. MADELEY.