EAL 10 Borough of Ealing. REPORT OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1918. THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law, Medical Officer of Health, and School Medical Officer. EALING : Francis A."Perry, 4, Kirchen Road. REPORT OF THE Medical Officer of Health, 1918. PUBLIC HEALTH DEPARTMENT. STAFF. Medical Officer of Health and Superintendent of Isolation Hospital: Thomas Orr, M.D., D.Sc. (Of the Middle Temple, Barrister-at-Law). Chief Sanitary Inspector: Thomas Hill, A.R.San.I., M.S.I.A., Cert. Insp. of Meat and Other Foods. Sanitary Inspectors : Harry SharpE, C.R. San.I., Cert. Insp. of Meat and Other Foods. James Stubbs, C.R. San. I. Health Visitors: Miss Eleanor Evans, Miss Gertrude Dowsett. Miss K. Christain. Chief Clerk: Harry Birrell. Junior Clerks : Ernest W. Hill. Albert C. Groom. ISOLATION HOSPITAL. Medical Attendant: L. D. Brown, L.RCP. M atron : Miss A. Whittle. DAY NURSERY. Matron: Miss Dorothy Gammon. Public Health Department, Town Hall, Ealing, W. 5. 29th September, 1919. Mr. Mayor, and Gentlemen, I have the honour to submit to you the Annual Report for the year 1918 on the Vital Statistics of the Borough, and on the work of the Public Health Department. The Report has still been kept within the reasonable limits demanded by the need for economy, but I have found it desirable to deal more fully, comparatively speaking, with the subjects of Maternity and Child Welfare and Control of Influenza, which have demanded so much attention during the past year. The account of these I commend to your consideration. In the report I desire to draw your attention to the small number of cases of scarlet fever and of diphtheria compared with previous years, the numbers in both instances being the lowest for at least ten years, and to the low Infant Death-rate compared with that for England and Wales. I wish to take the opportunity in submitting this Report to express my deep appreciation of the work performed during the year of the whole of my staff. I am, Mr. Mayor and Gentlemen, Your obedient Servant, THOMAS ORR. To the Mayor, Aldermen and Burgesses of the Borough of Ealing. SUMMARY OF STATISTICS FOR 1918. Population for 1918 (Estimated by Registrar-General) 64,480 Population (Census 1911) 61,723 Area of Borough in acres 2,947 Inhabited Houses (Census, 1911) 13,776 Births 942 Birth-rate per 1,000 of population 13.0 Deaths 880 Death-rate per 1,000 of population (Estimated 1918) 13.6 Infant Mortality per 1,000 births 76 Phthisis death-rate per 1,000 of population .94 Death-rate from the other forms of Tuberculosis per 1,000 of population .12 Death-rate from all forms of Tuberculosis 1.07 Rateable Value of Borough £543,135 Assessable Value of Borough £522,494 Nett proceeds of a Penny Rate £2,100 7 SANITARY CIRCUMSTANCES OF THE DISTRICT. Sanitary Inspections of the District. The following is a summary of the work done by the Inspectors during the year:— Number of Premises Inspected on Complaint 257 Number of Premises Inspected in connection with Infectious Disease 103 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, etc) 284 Number of Houses inspected under House to House Survey — Food Inspections 3,169 Total number of Inspections and Re-inspections 7,361 Number of Intimation Notices given 248 Number of other letters written 503 Number of Statutory Notices served 20 Daisies, Cowsheds, and Milkshops. Number of Cowsheds on Register 4 Number of Inspections made of Cowsheds 13 Contraventions of Regulations Nil Number of Dairies and Milkshops on Register 43 Number of Inspections of Dairies and Milkshops 90 Contraventions of Regulations 4 Proceedings before Magistrates Nil 8 Particulars of the Sanitary Defects referred to in Notices served and Letters written :— Water Closets Repaired or supplied with water or otherwise improved 176 Defects in Drains 51 Drains reconstructed 8 Dust-bins provided 71 Overcrowding 1 Accumulations of Refuse 25 Fowls and other Animals 12 Dampness 8 Yards paved and repaired 14 Other Defects or Nuisances remedied 446 Disinfection. Rooms disinfected: Ordinary Infectious Disease 246 „ „ Phthisis 59 Rooms Stripped and Cleansed 189 Articles disinfected : Ordinary Infectious Diseases 1,712 „ „ Phthisis 215 INSPECTION OF MEAT AND OTHER FOODS. The year has been a difficult one in so far as the inspection of meat and other foods have been concerned, due almost entirely to the unusual conditions occasioned by the war. Owing to delays in transport as well as to the insufficiency of cold storage, much meat and fish had to be condemned as unfit for human food. Assistance was given to the Food Control Committee by the Chief Inspector in dealing with meat of bad keeping quality, which during the early days of the year was delivered to the butchers in the town. The Chief Inspector was able to advise when rapid sale was necessary in order to avoid waste. 9 The following tables gives the quantity of food surrendered for destruction on account of unfitness for human food:— food. quantity. Meat 1,172 lbs. Fish 2,035 lbs. Bacon 216 lbs. Cheese 137 lbs. Butter 30 lbs. Rabbits 263 lbs. Rice 278 lbs. Dates 40 lbs. Condensed Milk 50 lbs. The following table supplied by the Chief Officer, County Food and Drugs Department, indicates the samples of food and drugs purchased in the Borough during the year 1918, together with the results of action taken:— Article No. of samples taken. Adulterated. Milk 254 68 Miscellaneous 6 — Total 260 68 Number of Prosecutions 10 Number of Convictions 8 Number of Cautions given 2 The figures given for adulterated samples include some adulterated informal samples in respect of which no proceedings could be taken. SANITARY ADMINISTRATION OF THE DISTRICT. Hospital for Infectious Diseases. The following table gives the number of cases treated in the hospital during the year and the number remaining in hospital at the end of the year:— Disease Remaining in Hospital Dec. 31st, 1917 Admitted to Hospital during 1918 No. of Deaths Scarlet Fever 7 52 - Diphtheria 6 35 4 Enteric Fever 1 5 1 Meningitis - 1 1 Measles - 9 — Puerperal Septicaemia — 1 — Abscess of Breast - 1 - 10 Scarlet Fever.—During the year 52 cases of Scarlet Fever were admitted to the hospital The ages of the patients were as follows :— 1—5yrs. 5—15yrs. 15—25yrs. 25—35yrs. 35—45yrs. 11 31 7 2 1 The following complications were noted amongst the patients :— Rhinitis 3 cases Otitis 2 ,, Albuminuria 1 case Abscess 1 „ The average stay in hospital was 41 days. No deaths occurred. No return cases have to be recorded. Diphtheria.—-Of the 35 cases admitted to hospital as diphtheria seven were found to be cases of tonsillitis. The ages of the patients were as follows:— 1—-5yrs. 5—15yrs. 15—25yrs. 25—35yrs. 35—45yrs. 15 16 3 1 — The complications noted were :— Albuminuria 3 cases. Paralysis of palate 2 „ Epistaxis 3 „ Otitis 1 case Four deaths took place from this disease. No return cases arose from the patients discharged from the hospital. The average stay in hospital was 32 days. Enteric Fever :—Five cases were admitted as enteric fever, but one case was found on blood examination not to be enteric fever. One death occurred. Other Diseases :—One case was admitted as acute poliomyelitis, but proved to be tubercular meningitis. This child died. Nine cases of measles, one of puerperal fever, and one of abscess of the breast in a nursing mother were treated, all with a favourtable result. 11 Workshops, Workplaces, etc. The following tables show the extent of the work done with respect to Factories and Workshops:— 1.—Inspection of Factories, Workshops and Workplaces, including inspections made by Sanitary Inspectors. Premises. No. of Inspections Written Notices. Prosecutioni. Factories (including Factory Laundries) 28 - Workshops (including Workshop Laundries) 123 11 nil Workplaces 25 3 Total 176 14 nil 2.—Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects No. of Prosecutions Found Remed'd Referred to H.M. Inspect'r Nuisances under the Public Health Acts:— nil nil W ant of Cleanliness 21 21 Want of Ventilation — — Overcrowding — — Want of Drainage of Floors 1 1 Other Nuisances 8 8 Sanitary Accommodation:— - Insufficient — — Unsuitable or Defective 9 9 Not separate for sexes — — Offences under the Factory and Workshops Acts:— Illegal occupation of underground bakehouses (s.101) - - Breach of Special Sanitary requirements for bakehouses (ss.97 to 100) - - Other Offences (excluding offences relating to outwork which are inincluded in part 3 of this report) - — Total 39 39 nil nil Bakehouses.—All the bakehouses in the Borough, 24 in number, were kept under supervision. Contraventions of the Factory and Workshop Acts were found in 5 instances, remedial measures being promptly carried out. 12 3.—Home Work. Outworkers Lists, Section 107 Nature of Work Sending twice in a year. Sending once in a year. Lists Contracts Workmen Lists Contracts Workmen Wearing Apparel making, etc. 16 16 22 21 21 27 Household Linen — — — 1 1 1 Stuffed Toys — — - 2 2 5 Artificial Flowers — — — 1 1 1 Total 16 16 22 25 25 34 There were no failures to send lists of outworkers nor were there any infringements of the Acts. 4.—The Registered Workshops in the District are as follows:— Bakehouses 24 Laundries 10 Dressmakers 25 Tailors 17 Millinery 5 Miscellaneous 55 Total 136 5.—Other Matters, nil. 13 PREVALENCE OF AND CONTROL OVER ACUTE INFECTIOUS DISEASES. The death-rates from the principal infectious diseases are represented in the following table, together with those for England and Wales:— Enteric Fever Small-pox Measles Scarlet Fever Whooping Cough Diphtheria England and Wales 0.03 0.00 0.28 0.03 0.29 0.14 96 Great Towns 0.02 0.00 0.36 0.04 0.34 0.15 148 Smaller Towns 0.03 0.00 0.25 0.02 0.25 0.14 London... 0.02 0.00 0.42 0.03 0.43 0.17 EALING 0.01 0.00 0.17 0.00 0.20 0.06 Notifiable Infectious Diseases. During the year 1918, the cases of infectious disease notified were 1324 in number and were distributed during the year as follows:— Diphtheria Scarlet Fever Erysipelas Enteric Fever Poliomyelitis Puerperal Fever. Ophthalmia Neonatorum German Measles Measles January 3 6 5 - - - - 16 157 February 3 4 2 - - - 1 21 208 March 5 9 4 - 1 - - 36 205 April 2 6 1 - - - 1 93 204 May 1 - 4 1 - - - - - June 4 2 2 - - - - - - July 2 - 2 - - - - - 99 August 4 4 1 2 - 1 - 4 9 September 4 7 1 3 - - - 5 3 October 4 11 2 - - - - - - November 1 8 - - - 1 1 1 3 - December 3 4 — — 1 — - 6 1 36 61 24 6 1 - 3 143 1018 14 The following table indicates the infectious cases in accordance with the wards in which they occurred:— Drayton Castlebar Mount Park Lammas Manor Grange Total Diphtheria 6 6 3 8 9 4 36 Scarlet Fever 6 9 5 14 18 9 61 Erysipelas 4 2 1 7 7 3 24 Enteric Fever 1 - 1 — 1 3 6 Puerperal Fever 1 1 — — — — 2 Cerebro-Spinal Fever — - — — — — — Ophthalmia Neonatorum 1 — — — 1 1 3 German Measles 17 39 28 27 12 20 143 Measles 117 191 177 195 218 150 1048 Poliomyelitis — — — 1 — - 1 Totals 153 248 215 252 266 190 1324 The following table shows the number of cases of the principal infectious diseases notified in each of the last ten years: Disease 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 Smallpox - 2 - - - - - - - - Diphtheria 48 55 95 56 57 82 56 37 66 36 Scarlet Fever 160 148 125 187 326 511 458 146 91 61 Erysipelas 35 47 31 31 45 39 39 19 33 24 Enteric Fever 6 7 4 4 5 7 11 5 3 6 Puerperal Fever 4 — 3 — — 2 1 1 — 2 Cerebro-Spinal Fever - - - - - 1 2 2 1 — Poliomyelitis — — — 2 3 — 2 — 2 1 Ophthalmia Neonatorum - - - - - 9 5 8 3 3 Total 253 259 258 280 611 763 574 218 199 133 In this table it will be seen that the number of cases of diphtheria is lower by one than that for 1916, which was the lowest for the preceding ten years, and that the number of cases of scar let fever is lower by 30 than that for 1917, which had the lowest number of cases for ten years. The total number of the principal infectious diseases for 1918 is easily the lowest for ten years. Encephalitis Lethargica.—This disease, which was at first believed to be " Botulism," a form of food poisioning, but which was later recognised as a new disease of quite a different nature, was made notifiable by the Public Health (Acute Encephalitis Lethargica and Acute Poiio-Encephalitis) Regulations, of the 15 17th December, 1918. Before this date two cases were voluntarily notified to the Medical Officer of Health. The first case was notified on the 2nd May, the patient being a man 34 years of age, and the symptoms being typical, and the second on the 20th June, the patient being a man 68 years of age. In the latter case the diagnosis was not free from doubt. Recovery took place in the former case, but an early fatal termination in the latter. Influenza. Influenza became epidemic in Ealing in the beginning of July, an idea of the prevalence of the disease being given by the Weekly Returns of children absent from school. During July 959 children were noted as being absent on account of Influenza, though most of the cases occurred during the first half of the month. The disease was of a mild character, the children recovering with remarkable rapidity. Adults also were affected, but enquiries led one to the belief that the outbreak owed its spread to the schools, children being affected more than adults. In the month of June no deaths from Influenza were registered in the Borough, but in July four were registered in the week ending the 15th, and two in the week ending the 31st July. Thus, although the disease was very prevalent during this month among the school children, no deaths occurred amongst them, and only six occurred amongst adults. Towards the end of July the outbreak subsided and few cases occurred until October. In August only one death, a female, 33 years of age, was recorded, and in September, none. From the 1st June to September 30th seven deaths occurred altogether. A recrudescence of the epidemic was experienced in the second week of October in the Northfields Area, Northfields School being chiefly affected. From here it quickly spread during the following week to Lammas School and to Little Ealing and Junction Road Schools, taking in the whole of the south-western area of the Borough. In the next week the schools, as a whole, became affected to such an extent that the closure of all was recommended for ten days. At the time of closure the children absent from school numbered 2,777 out of 7,642 on the rolls, or 35 per cent of the elementary school population. 16 It must not be assumed that all absentees were cases of Influenza, but it may be stated, as a result of particular enquiries, that about 80 per cent of those absent from school were actually victims of the disease. The general population was affected at the same time as the school children, but as the disease was not notfiable it was difficult to gauge the extent of the prevalence amongst adults. A great number of families, however, were severely affected, whole households being completely incapacitated at the same time. In the absence of statutory notification the returns of absentees from the schools gave a general idea of the prevalence of the disease. During the week ending the 7th October one death occurred from Influenza, the week ending 14th October none, the week ending the 21st October two, the week ending 28th October 9, but during the week ending the 4th November, 30 deaths, making a total for the month of 42. During the first week in November the disease reached its maximum, the deaths for the weeks following showing a distinct decrease. Deaths for week ending 11th November 37 Deaths for week ending 18th November 15 Deaths for week ending 25th November 20 Deaths for week ending 2nd December 15 Total for the month 87 The deaths from Influenza during December were as follows:— Deaths for week ending 9th December 11 Deaths for week ending 16th December 8 Deaths for week ending 23rd December 1 Deaths for week ending 31st December 2 Total deaths for month 22 Thus from the 1st June to the end of the year there were 158 deaths from Influenza. 17 The age distribution of the deaths were as follows:— 0—5 yrs. 5—15 yrs. 15—25 yrs. 25—35 yrs. 35—45 yrs. 45—65 yrs. 65 and upwards yrs. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 6 8 3 10 7 23 15 26 13 10 9 10 7 11 Of the 158 deaths, 60 were of males and 98 of females. Between the ages of 5 and 35 the deaths of females greatly exceeded the males, 59 female deaths compared with 25 male deaths. The total deaths for the year, 161, give the high death rate for Influenza of 2.5 per 1000 population. measures adopted to deal with epidemic. The measures taken to prevent the spread of the influenza were of little avail, in the first place on account of the great infectivity of the disease, and in the second place on account of the want of assistance on the part of the public, who failed to take the necessary steps to prevent the spread of infection, with a dis interestedness, or even it might be said callousness, which brought disaster to many families. In the early stages of the outbreak the schools were visited and the teachers instructed regarding the isolation of affected children, the exclusion of children from invaded households and regarding the ventilation of the classrooms. Instructions based on those issued by the L.G.B. were issued by posters and leaflets throughout the town, the latter especially by means of the school. The aid of the local press was invoked at the same time to assist in the spread of information. As it seemed that to have the Cinema Halls kept open while the schools were closed, the whole object of closure would be defeated, the managers of these places were approached. One promptly promised to exclude school children so long as the schools were closed, one stated that children under 12 years were always excluded except when accompanied by their parents, one pro mised to communicate with his Directors, but no reply was received, the fourth approved of the suggestion but his Directors disapproved. 18 As so little could be done to lessen the prevalence of the scourge efforts were directed towards reducing the mortality by providing nursing and hospital accommodation. The Health Visitors did excellent work in visiting affected households, giving advice whenever necessary, and in nursing serious cases, but the help they were able to render was small compared with what was required, and many of the stricken families had to depend almost entirely on neighbourly assistance, which the Health Visitors were often successful in securing. The question of isolating serious cases in the Isolation Hospital was considered, but the insufficient staff and the impossibility of securing further nursing assistance caused the project to be abandoned. The Board of Guardians, through their Secretry, came to our assistance and many of the more serious cases were removed to the Infirmary for care and treatment. There can be no doubt that the absence of efficient nursing and medical attention, due to the demands made by the War Office on the medical and nursing profession for our forces engaged in the war, was responsible for a large number of deaths. Again, the severe mental and physical strain resulting from four anxious years of war accompanied by restrictions in diet probably redered the community more susceptable to infection and more liable to the complications when attacked. 19 epidemic influenza, 1918. Table of deaths week by week, showing deaths due to (1) Influenza, (2) Broncho-Pneumonia, (3) all other forms of Pneumonia. Influenza. Broncho-Pn. Pneumonia Jan. 1st to July 1st 3 11 18 July 8 (week ended) — — 2 „ 15 4 — — „ 22 — — — „ 29 2 - - Aug. 5 1 - 2 „ 12 — — 1 „ 19 — — — „ 26 — — — Sept. 2 — — — „ 9 — — — „ 16 — — — „ 23 — — — „ 30 — — — Oct. 7 1 1 1 „ 14 - 1 2 „ 21 2 1 2 ,, 28 9 — 1 Nov. 4 30 — 6 „ 11 37 — — „ 18 15 — 4 „ 25 20 — 1 Dec. 2 15 1 2 „ 9 11 — — „ 16 8 — — „ 23 1 — 2 „ 31 2 2 — Total for year 161 17 44 20 Epidemic Influenza, 1918. Table of Deaths in age periods. Under 1 Year 1 to 5 Years 5 to 15 Years 15 to 25 Years 25 to 3S Years 35 to 45 Years 45 to 65 Years Over 65 Years Total. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Influenzen 2 2 4 6 3 10 7 23 15 27 13 10 10 10 8 11 62 99 161 Broncho-Pneumonia 3 2 2 — — — - 1 — 1 — - 3 2 — 3 8 9 17 Pneumonia, all other forms 2 — 1 1 3 — 1 7 4 5 5 - 6 2 4 3 26 18 44 21 Prevalence of and Control over Tuberculosis. Under the Public Health (Tuberculosis) Regulations, 1912, the following notifications were received:— 1-5 yrs. 5-15 yrs. 15-25 yrs. 25-45 yrs. 45-65 yrs. 65 and upwards Total Pulmonary Tuberculosis 1 9 31 50 18 1 110 Other forms of Tuberculosis 4 11 2 4 1 - 22 Totals 5 20 33 54 19 1 132 The following information supplied by Dr. Young, the County Medical Officer, gives a record of the treatment of cases of tuberculosis in the Borough during the year:— Number of persons resident in Ealing examined for the first time in 1918 by the Tuberculosis Officer 137 Number of persons kept under treatment at the County Council Dispensary 84 Number sent to Sanatoria 24 Number sent to Hospital 18 Sanatorium Cases.—Eight were discharged during the year after an average stay in the Sanatorium of 15 weeks 3 days, and then kept under observation at the Dispensary. Sixteen remained in institutions at the end of 1918. Hospital Cases.—Five were discharged during the year after an average stay in Hospital of 12 weeks and 1 day. Five died in Hospital after periods of residence varying from 17 days to 40 weeks and 5 days. Eight remained in institutions at the end of 1918. 22 MEANS FOR PREVENTING MORTALITY IN CHILDBIRTH AND IN INFANCY. There were 72 deaths of infants under one year, which give an infant death-rate of 76 per 1,000 births. The following table gives the infant death-rate for Ealing with that for England and Wales :— Ealing 76 per 1.000 births England and Wales 97 „ „ 96 Great Towns 106 „ „ London 107 ,, ,, The following table gives the infant death-rates for Ealing for the last 18 years compared with those for England and Wales:- Ealing. England and Wales. 1901 114 151 1902 112 133 1903 136 132 1904 105 145 1905 101 128 1906 129 132 1907 91 118 1908 80 120 1909 70 109 1910 65 106 1911 121 130 1912 67 95 1913 72 109 1914 59 105 1915 63 110 1916 58 91 1917 63 97 1918 76 97 Notifications of Births Act, 1907.—There were 39 failures to notify under the Act, compared with 54 for the previous year. In all cases of failure the parent, doctor, and nurse were communicated with and their responsibilities under the Act pointed out. 23 Health Visitors' Work.—The following tables indicate the scope and extent of the work of the Health Visitors:— Visits to Infants :— Number of first visits 910 Number of second visits 1019 Number of third visits 588 Number of fourth visits 306 Number of fifth visits 258 Number of sixth visits 172 Number of seventh visits 120 Number of eighth-fourteenth visits 232 Number of fifteenth to twenty-eighth visits 14 Total number of visits to Infants 3619 Visits to Expectant Mothers:— Number of first visits 53 Number of second visits 26 Number of third visits 12 Total visits to Expectant Mothers 91 Visits to Cases of Tuberculosis Number of first visits 121 Number of second visits 42 Total visits to cases 163 Visits to Cases of Measles & German Measles Number of first visits 992 Number of second visits 74 Total visits 1066 24 Visits to Cases of Scarlet Fever discharged from Isolation Hospital :— Number of first visits 32 Number of second visits 20 Number of third visits 15- Total visits 67 The total visits by the Health Visitors may be summarized as follows:— Visits to Infants 3619 Visits to Expectant Mothers 91 Visits to cases of Tuberculosis 163 Visits to cases of Measles and German Measles 1066 Visits to discharged cases of Scarlet Fever 67 Visits to investigate still-births and infant deaths 80 Visits to cases of ophthalmia neonatorum 9 Other visits 345 Grand total visits 5440 Maternity and Child Welfare Centre. In the table which follows are figures giving the extent of the work carried on at the Centre. Child Welfare. Number of Children on Register 330 Number of Children visiting for the first time 263 Number of Children on Register from previous year 67 Number of Mothers visiting for the first time 257 Total attendances of Children for the year 1699 Total attendances of Mothers for the year 1498: 25 Average attendances at Centre per afternoon— Children 17 Mothers 15 Total 32 Number of Children seen by Doctor at Centre 472 Average number seen by Doctor each day 9 Maternity Welfare— Number of maternity cases attending antenatal clinic. (May 29th to December 31st, 1918) 10 Number of visits paid by cases 32 Medical aid called in by midwife 2 Consultant called in by doctors in complicated maternity cases 4 Provision of Food and Drags.—Under the Milk (Mothers and Children) Order, milk was provided free by the Council in 30 cases. Dried milk at wholesale price was sold to the extent of 2473 lbs. in the year. Cod liver oil, emulsion, liquid paraffin, olive oil, Chymol, and powders, as advised by the Medical Officer, were also supplied at wholesale prices at the Centre. At the first meeting of the Maternity and Child Welfare Committee. formed under the Maternity and Child Welfare Act, 1918, held on the 28th November, 1918, a Report was submitted on the Circular of the Local Government Board of the 9th August, 1918. The suggestions contained in this Report, which is printed below, were adopted by the Committee and later approved by the Council on the 8th December. Towards the end of the year steps were take to acquire a house at 13, Mattock Lane for a combined Maternity and Child Welfare Centre and School Clinic. The combination with the School Clinic should enable the treatment of minor ailments and defects of the eyes, throat, nose and ears in young children to be carried out without delay and with a minimum of trouble, while the dental treatment of nursing and expectant mothers should be facilitated. 26 report to the maternity and child welfare committee. Town Hall, Ealing. November 28th, 1918. Mr. Chairman, Ladies and Gentlemen, It is quite appropriate that I should furnish the Maternity and Child Welfare Committee at its first meeting with a report on the Circular of the Local Government Board on Maternity and Child Welfare, which was issued on the 9th August, after the passing of the Maternity and Child Welfare Act. The circular is so important that I shall deal with it in detail so far as it applies to Ealing, a statement being made at the same time as to what has already been done in the Borough with respect to the matters under consideration. First of all it is pointed out that the Act widens out the powers of Local Authorities in the matter of maternity and child welfare. The Act. enables Local Authorities to make such arrangements as may be sanctioned by the Local Government Board for attending to the health of expectant and nursing mothers, and of children who have not attained the age of five years and are not being educated in schools recognised by the Board of Education. The Act gives very wide powers to Local Authorties. By it the payment of a grant to the Creche and even the establishing of a Creche by the Council is placed on a legal basis. The Circular points out that the additional services for which the grant of 50 per cent is now available, subject to the Board approving the arrangements, are chiefly:— (a) Hospital treatment for children up to five years of age. (b) Lying-in Homes. (c) Home helps. (d) The provision of food for expectant and nursing mothers and for children under five years of age. (e) Creches and day nurseries. (f) Convalescent Homes. (g) Homes for the children of widowed and deserted mothers and for illegitimate children. (h) Experimental work for the health of expectant and nursing mothers and of infants and children under five years of age. 27 Inspection of Midwives. The inspection of the midwives in the Borough is the duty of the Middlesex County Council. Although the County Council has possessed powers under the Midwives Act, 1902, to delegate its duties in this respect to the Local Authorities within its area, it has jealously kept this inspectorial duty in its own hands not trusting these local authorities, however efficient in administration they may have shown themselves. The Midwives Bill before Parliament contains a clause which has for its object the abolition of the power of the County Council to delegate its duties under the previous Midwives Act. As this clause is likely to become law it now lemains for us to accept the inevitable and to try and deal with the disadvantage in the best way possible. It seems however, an extra-ordinary thing that the Ealing Council should take measures for dealing with maternity and child welfare, yet the control of midwives, who might in any scheme become potent factors for good, is within the jurisdiction of another body, to wit the County Council, who have no intimate knowledge of the conditions in or the needs of the district. The Board in their circular state that it is important that the supervising authority should in all cases secure co-operation between the midwives and the local organisation for maternity and child welfare work. What I would suggest to bring about this co-operation is that lectures should be given by the Maternity and Child Welfare staff to the midwives in the Borough, the County Council being asked to assist the Borough Council in bringing them to the notice of the midwives, and in advising their attendance and co-operation. The lectures I suggest should include ante-natal hygiene, post-natal hygiene, and the feeding and care of infants. Provision of Midwifery. In a previous report I have shown that the great majority of maternity cases are attended by doctors. The midwives in the Borough, most of whom are trained, appear to be sufficient in number to meet the needs of the district. The Council has already made provision by which a midwife can be provided in cases where the people are unable through impoverished circumstances to engage one. 28 Doctors' Fees. The Council has also arranged to pay the fees of doctors when called in by midwives during the period of confinement. The cost is remitted by the Council in the case of persons in necessitous circumstances, those able to afford it being expected to repay the outlay. Health Visitors. The function of a Health Visitor the circular states, should comprise the visiting and supervision of all children under school age in the district needing this attention ; the visiting of expectant mothers who have attended at an Ante-natal Centre, or for whom visits are desirable; inquiry into still-births and the deaths of young children; and attendance at the Centre to which women and children, including those whom she has visited in their homes, come for medical and hygienic advice. Where these duties are fully performed it appears to the Board that a district with about 400 births a year will be as much as one Health Visitor can undertake, unless the district is very compact, or is of such a class that many infants do not need visiting. In Ealing there are two visitors and their duties include, not only those mentioned in the Circular, but the visiting of cases of tuberculosis, the visiting of cases of infectious disease after leaving the hospital, and the visiting of cases of measles, Ophthalmia Neonatorum and Epidemic Diarrhoea. To these duties has to be added the management of the Maternity and Child Welfare Centre. Ail this work together means more than two Health Visitors can properly cope with. Qualifications of Health Visitors. The circular discusses the qualifications necessary where Health Visitors are employed by Local Authorities. It also states that the salary of a whole time officer acting as Health Visitor should as a rule not be less than £120 a year. Unfortunately our two Health Visitors are not paid on this scale. They are both efficient officers and I must point out that unless the salary paid is on this scale recommended by the Local Government Board, we cannot hope to retain their services. In 29 maternity and child welfare work continuity is essential. The mothers get accustomed to the same person, and if a change is made it acts detrimentally on the progress of the work. It is with a view to preventing changes and with a view to preserving continuity that I recommend that the salaries of these two officers should now be considered by the Committee. Appointment of Health Visitors as Infant Protection Visitors under the Children Act, 1908. The Local Authority under the Children Act, 1908 is the Board of Guardians. The circular states that it appears desirable that, where practicable, the Health Visitor and the Infant Protection Visitor should be the same person, and it is suggested that the Local Authority appointing Health Visitors should consult the Local Authority appointing the Infant Protection Visitors in their areas with a view of securing this. In my view this expression of opinion by the Local Government Board is a very proper one. It is essential to reduce as far as possible the number of visitors or inspectors, especially in these days when there are inspectors for many purposes. Besides, it is desirable that the supervision of children and their health should be centred in one person. I suggest that the Board of Guardians be asked to consider the appointment of the Senior Health Visitor as Infant Protection Visitor. Nursing. The home nursing services in respect of which the grant is now available are nursing needed for expectant mothers, maternity nursing, the nursing of puerperal fever and the nursing of measles, whooping cough and epidemic diarrhoea in young children, and of ophthalmia neonatorum. The Council has already made provision by which in necessitous cases midwives may be employed at the cost of the Council. Any midwife may be selected for this purpose, it being left to the Medical Officer of Health to engage the midwife for each case. With regard to the nursing of measles I was authorised by the Council to engage a nurse when necessary. The engaging 30 of a temporary nurse for measles is always a difficult matter and in the end is likely to be extravagant on account of the special remuneration to be paid for temporary service. As the Board recommend the home nursing of puerperal fever, the nursing of whooping cough and epidemic diarrhoea, and the nursing of expectant mothers, I would recommend that a whole-time nurse be appointed. Most of her time would be devoted to nursing these diseases, but, except during an epidemic, she would be able to give assistance to the other two Health Visitors,, especially at the Maternity and Child Welfare Centre. Centres. As the result of a representation by me to the Council, a house has been taken at 13, Mattock Lane, where the work of the Maternity and Child Welfare Centre and School Clinic will be conducted. The Centre is to provide medical and hygienic advice to the mothers bringing their children to be weighed by the Health Visitors and to be examined by the Medical Officer. For three years I have myself carried out the examination of the children attending our Centre, but the time has now come when, on account of the pressure of other duties, I must give up this work. The work does not fall within my duties as Medical Officer of Health, in fact, the Circular states that the Medical Officer (of the Centre) if an Officer of the Local Authority should be paid a separate salary for this work. I suggest that a part-time Medical Officer, preferably a lady, be appointed to examine the children at the Centre under my general supervision, the remuneration to be paid to this officer being at the rate of £1 for an afternoon session of 2 hours, together with a war bonus of 5s., making 25s. per session. The Centre is open on two afternoons each week so that the cost to the Council would be £125 per annum. The Board state that it is an advantage for the Centre to be combined with the School Clinic so that Ophthalmic and dental cases may be treated through the, agency of the School Clinic. They state that the Dental Clinic should, whenever practicable. 31 be available for expectant and nursing mothers and their children under five years. When the new School Clinic is completed it will be possible to arrange for cases from the Maternity and Child Welfare Centre being treated there. The Board's grant is available for this treatment, and it is stated that a charge should ordinarily be made for new dentures for women and for spectacles for children, but the Board are willing that the charge should be reduced below the cost price or remitted entirely where the circumstances of the woman or of the child's parents are such as to justify this course. I would suggest that arrangements be made later for treatment as suggested by the Board. Instruction in Hygiene. The Board state that the extension of the grant to this purpose has been made in order to make it available in aid of reasonable expenditure on literature, exhibitions, and on collective instruction to expectant and nursing mothers, and also to voluntary and salaried workers where the Medical Officer considers that the instruction is likely to improve their competency to undertake the Maternity and Child Welfare work assigned to them. The expenses of salaried workers engaged in such work may be included in the application for grant under this heading. Provision for Confinements. The Council has already made provision for the care of abnormal confinements in an institution, Dr. Bell's Home at Old Court, Hanger Hill. There is also need to provide for normal cases which cannot, through unusual circumstances, be dealt with at their own homes. During the last six months, although the necessity did not arise for the admission to hospital of any abnormal or complicated confinements, the necessity did arise with regard to three normal cases, one of which was ultimately admitted to a hospital in London, the other two to the Infirmary at Isleworth. A normal case may require institutional care for three main reasons, firstly, where there is insufficient accommodation at home ; secondly, where the condition of the home is likely to endanger the health 32 of the mother; and thirdly, where there is a large family and it is desirable for the sake of the mother to remove her from domestic worries during the period of her confinement and convalescence. For such cases it is desirable that provision should be made, and I would suggest that the Committee of the King Edward Memorial Hospital be approached with a view to their considering whether they could make provision in the near future, not only for normal cases of confinements, but also abnormal cases. Failing this I would advise that separate provision be made for them by the Council. It seems to me, however, that it would be unwise for the Council to establish an independent institution when there is within its area a hospital which could be adapted, with the support of the Council, to the many needs of the community. Until permanent provision is made I would advise that arrangements be made with Dr. Bell to admit into his Home normal, as well as abnormal cases. For this institutional care a charge would have to be made according to the financial condition of the people, the charge being remitted in cases of impoverished circumstances. The Council has also made arrangements by which Dr. Bell can be called in as a consultant by medical men in cases of complicated confinement. Should operative interference be necessary and should removal to a hospital be desirable the patient can, as already indicated, be removed to Dr. Bell's Home. Home Helps and other Assistance. The circular states that in many cases a woman is unwilling to leave her home even if its conditions are unsuitable for her confinement, and that if the difficulty arises from the number of children, arrangements may sometimes be made for the children to be boarded out during the mother's lying-in period; but if it is due to the need for a person to look after the house during this period, whether the confinement takes place at home or elsewhere a home help may be supplied for the purpose. The grant is available for assistance of this character where the Board's general consent has been previously obtained to the local arrangements. 33 Home helps must, of course, be persons of suitable character. Where the confinement takes place at home they should undertake the necessary duties under the direction of the nurse or midwife in attendance. The duties of a Home help would be the ordinary domestic duties usually undertaken by the mother, including cleaning, cooking, washing, care of children, mending and marketing. She should not undertake any work which properly belongs to the sphere of the trained nurse or midwife, nor assist at a confinement unless a doctor or midwife is in attendance. If the Board's suggestion of Home helps were adopted a great need would be met. Recently I have come across several cases where the home has been managed with great difficulty during the confinement of the mother who has been exposed to great mental anxiety on account of her household affairs. In on case the results were serious for the mother and the child. These home helps, if properly chosen and trained at the Maternity and Child Welfare Centre, would not only be of assistance to the mother, but would be a means of educating the mothers under their care in the general principles of hygiene and child welfare. Usually the scale of fees paid home helps is 12s. 6d. to 15s. per week. For people in necessitous circumstances the charge would be remitted by the Council, but when there is ability to pay a charge in accordance with their circumstances would be made. Hospitals for Infants. Now that hostilities have ceased there is a reasonable prospect that in the near future the children's ward at the King Edward Memorial Hospital will revert to its original use. The time, therefore, seems opportune for the adoption of the suggestion put forward in my report of the 2nd April last, that negotiations be opened with the Hospital Committee for securing a certain number of beds for children under 5 years of age. It appears desirable that six beds should be allotted for this purpose, three beds for purely medical cases, which would be under the care of the Hospital staff, and three beds for cases which are not thriving in the normal way and which should be kept under 34 the care of the Medical Officer of the Welfare Centre. These last cases are placed in hospital so as to keep close observation on the progress of the child from day to day the feeding being charged in accordance with the progress or otherwise, a proceeding which cannot be carried out at the home of the child for the very obvious reasons that the mother cannot give the necessary attention to the child and that the Medical Officer cannot be in attendance there. Food. Under the Milk (Mother and Children) Order, 1918, milk or food is provided by the Council to nursing or expectant mothers and to children under 5 years of age where the financial circumstances warrant it. Usually milk is provided, this being supplied to the mother or parent through her usual dairyman on an order issued by the Public Health Department. Sometimes food is provided through the National Kitchens, but usually milk is easier to provide and more acceptable. An application form is filled in by each applicant, who has to state the total income and family circumstances. If the amount of income does not exceed 7s. per head per week the milk or food is given free. If the income is between 7s. and 10s. per head, dried milk is supplied from the Welfare Centre at wholesale price. I find this scale works well. It seeem to meet the cases equitably. Creches, Etc. The Board's grant is available in respect of expenditure by Local Authorities on providing or aiding creches and day nurseries, and on placing children in the care of foster-mothers who are under supervision by the Medical Officer of Health. The grant is also available for aiding homes where children can remain through the night as well as the day, and is especially intended for the children of mothers who go out to work. A scale of charges should be fixed for these services, but a charge may be remitted or reduced in individual cases where the circumstances justify the adoption of this course. The South Ealing Crcche or Day Nursery, which has been managed by the Creche Society has met a decided need in the 35 Borough. So long as the Council could not legally establish and maintain a Creche, the Society continued its beneficent work. However, now that the Council can legally carry on this work, the Society anticipates that subscriptions will not be forthcoming for its support, and it feels that it is the duty of the Council to carry on the work which has been so far conducted by voluntary effort. There can be no doubt about the necessity of a Creche in the South Ealing district. The question for the Council to consider is the advisability of taking it over. I should advise that this be done. The next question to be considered is whether there is need for another Creche in Ealing. This can be answered in the affirmative. I have evidence of the need of one at West Ealing, in a list of at least 28 mothers who go out to work, and whose children would be better cared for in a Creche. These are all mothers who must work for their living, being widows, unmarried mothers or mothers who have difficulty in sustaining the household on account of the small wages of the father. A Creche should not be the means of encouraging mothers to work and leave their children to the care of others unless they are compelled to do so. The best place for the mother is at home looking after her children, giving them proper home nurture and preserving the family life as it should be. It is a question whether it would not be more profitable for the State to pay these mothers to stay at home and look after their children in the proper way, rather than that the children should be cared for by a neighbour or in an institution. The best person to take care of a child is its own mother, and the best life for the child is that which it enjoys in its own family under constant care and discipline. Convalescent Homes. It is stated in the Board's circular that a stay in a Convalescent Home is especially important for recovery after certain cases of confinement and for some conditions in young children, especially after measles and whooping cough, and that it is desirable, therefore, that Local Authorities should either themselves or through a voluntary agency arrange for beds in convalescent homes to be available as part of their schemes. 36 At the present time the provision of such convalescent homes is a difficult matter. It is not possible even to guess at the amount of accommodation to be provided, and until the Maternity and Child Welfare scheme has been working for some time it is improbable that an estimate of the needs of the district can be given. A home of the character suggested would have to be situated in open country. Further, it might be more convenient and more economical to join with other Focal Authorities in establishing and maintaining such institutions. Homes for Children. The Board in their Circular refer under this heading only to Homes for illegitimate children. At present there is in Ealing one such home where not only the children, but also the mothers, who go out to work during the day, are cared for. This Home is situated in Sutherland Road, and has accommodation for twelve mothers with their infants. The mothers are usually servants, clerks, or shop assistants, night workers not being catered for. Another Home in Madeley Road, which admitted 16 mothers, who were engaged in munition work, and their children, has recently been closed. It is impossible to say at present what are the needs of the district, and to what extent they are met by the Home in Sutherland Road, for it is difficult to get exact information. Summary of Suggestions. 1. Lectures should be arranged for midwives and the assistance of the County Council should be asked in encouraging the attendance of the midwives at the Lectures. 2. The salaries of the Health Visitors should be considered. 3. Representations should be made to the Board of Guardians with a view to the Senior Health Visitor being appointed Infant Protection Visitor for the Ealing District. 37 4. A whole-time Health Visitor with nursing training should be appointed to nurse cases of measles, whooping cough, epidemic diarrhoea, ophthalmia neonatorum, etc., and at the same time to assist at the Maternity and Child Welfare Centre. 5. A part-time Medical Officer should be appointed for the Maternity and Child Welfare Centre. 6. The Committee of the King Edward Memorial Hospital should be approached with a view to certain cases of normal and abnormal confinements being provided for. 7. Home helps should be provided in cases of confinements, in which assistance is deemed by the Medical Officer of Health to be necessary. 8. The Committee of the King Edward Memorial Hospital should be approached with a view to their allotting six beds for children under 5 years of age. 9. The South Ealing Creche should be taken over and managed by the Council. A second Creche should be considered at West Ealing. I am, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR. 38 VITAL STATISTICS. Births. The birth-rate for 1918 was 13.0. This rate is calculated on a population estimated by the Registrar-General, and is based on the assumption that the ratio between total and civilian population is the same in the district as in England and Wales as a whole. With a view to approximation to the population amongst which the births have occurred the total population of England and Wales has for this purpose been calculated by adding to the published estimate for 1914 the natural increase up to the middle of the year 1917. The population estimated is 72,247. The births registered numbered 942, consisting of 499 males and 443 females. Illegitimate Births.—The illegitimate births numbered 66 which give an illegitimate birth-rate of .91 per 1,000 of population and a percentage of 7.0 of the total births. Deaths. The population in the middle of 1918 estimated by the Registrar General was 64,480. This population is less by 304 than that estimated by the Food Executive Officer of the Borough from the number of Ration-books issued in July, 1918. On the population estimated by the Registrar General the death-rate was 13.6. The following table gives the population, number of deaths, and death-rate for each of the last twelve years:— Year Population No. of deaths Death-rate. 1906 48,316 622 12.8 1907 49,588 596 12.0 1908 51,000 573 11.2 1909 52,550 632 12.0 1910 54,259 533 9.8 1911 61,723 714 11.5 1912 64,500 630 9.7 1913 68,500 616 8.9 1914 71,300 672 9.4 1915 66,181 676 10.2 1916 65,566 728 11.1 1917 64,128 679 10.5 1918 64,480 880 13.6 39 In the following table the death-rate for Ealing is compared with that for England and Wales and that for the 96 Great Towns:— Ealing 13.6 per 1,000 population. England and Wales 17.6 „ „ 96 Great Towns 18.2 „ „ London 18.9 „ „ Inquests.—The Coroner held 23 inquests on deaths occurring in the Borough. Two were of children under one year, and 21 were of persons over 15 years of age. TABLE I. Vital Statistics of Whole District during 1918 and Previous Years. BOROUGH OF EALING. Year. Population estimated to Middle of each Year. Births. Total, Deaths Registered in the District. Transferable Deaths. Nett Deaths belonging to the District. Uncorrected Number. Nett. Number. Rate. of Nonresidents registered in the District. of Residents not registered in the District. Under 1 yr. of age At all Ages. Number. Rate. Number, Rate per 1000 Nett Births. Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1913 68500 1214 1249 18.2 506 7.3 14 110 90 72.0 616 8.9 1914 71300 1234 1253 17.5 566 7.9 17 123 74 59.0 672 9.4 1915 66181 1160 1184 16.6 550 8.3 16 142 75 63.0 676 10.2 1916 65566 1189 1213 17.0 595 9.0 19 152 70 58.0 728 11.1 1917 64128 1001 1064 14.8 549 8.5 18 148 67 63.0 679 10.5 1918 64480 981 942 13.0 709 11.0 32 203 72 76.0 880 13.6 Area of District in acres (land and inland water)—2947 Total population at all ages 61723 Number of inhabited houses 13515 Average number of persons per house 4.5 Census of 1911 TABLE II. Cases of Infectious Disease Notified during the Year 1918. BOROUGH OF EALING. Notifiable Disease. Number of Cases Notified. Total Cases Notified in Each Ward. Total cases removed to Hospital. At all ages. At Ages—Years. Drayton Ward. Castlebar Ward. Mount Park Ward. Lammas Ward. Manor Ward. Orange Ward. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 45. 45 to 65. 65 and upwards Diphtheria (including Membranous croup) 36 1 12 16 3 4 — — 6 6 3 8 9 4 28 Erysipelas 24 — — — 11 8 5 — 4 2 1 7 7 3 Scarlet Fever 61 — 11 41 6 3 — 6 9 5 14 18 9 43 Enteric Fever 6 — — 3 1 1 1 — 1 — i 1 3 2 Puerperal Fever 2 — — — 1 1 — 1 1 — — — — 1 Cerebro-Spinal Meningitis — — — — — — — — — — — — — — — Poliomyelitis 1 — — 1 — — — — — — — 1 - — 1 Ophthalmia Neonatorum 3 3 — — — — — — 1 — — — 1 1 — Pulmonary Tuberculosis 110 — 1 9 31 50 18 1 15 10 4 32 34 15 — Other form of Tuberculosis 22 — 4 11 2 4 1 1 6 1 9 3 2 — Measles 1048 16 389 566 51 24 1 1 117 191 177 195 218 150 9 German Measles 143 4 25 79 23 9 3 — 17 39 28 27 12 20 — Totals 1456 24 442 726 129 104 29 2 169 264 220 293 303 207 84 Ealing Isolation Hospital, South Ealing. TABLE 111. Deaths registered during the Calendar Year 1918 classified by age and cause. BOROUGH OF EALING. Causes or Death. Nett Deaths at the Subjoined Ages of " Residents," whether occurring within or without the district. Total Deaths whether of Residents or "Non-Residents" in Institutions in the District. All ages. Under 1 year. 1 and under 2. 2 and under 5. 5 and under 15 15 and under25 25 and under45 45 and under65 65 and upwards. Enteric fever 1 - - - 1 - - - — 1 Measles 11 2 3 6 — — — — — — Scarlet fever — — — — — — — — — — Whooping cough 13 5 4 2 2 — — — — — Diphtheria and croup 4 — — 1 3 — — — — 5 Influenza 161 4 4 6 13 30 65 20 9 16 Erysipelas — — — — — — — — — — Phthisis (Pul. Tuberculosis) 61 — — 2 1 15 25 13 — 2 Tuberculous Meningitis 4 — — 1 2 — 1 — — 2 Other tuberculous diseases 4 — — — 2 — — 2 — 2 Cancer, malignant disease 83 — — - — 1 11 24 47 6 Rheumatic fever 2 — — — — — - 1 1 — Meningitis 3 — 1 — 2 — — — — — Organic Heart Disease 72 — — — 1 1 9 18 43 — Bronchitis 49 5 1 2 — — 2 11 28 — Pneumonia (all forms) 66 6 3 4 3 12 14 12 12 15 Other Diseases of the Respiratory Organs 17 — — — 2 1 5 4 5 3 Diarrhoea and Enteritis 16 14 2 — — — — — — — Appendicitis and Typhlitis 3 — — — — — — 2 1 3 Cirrhosis of Liver 2 — — — — — — 1 1 1 Alcoholism 1 — — — — — — 1 — — Nephritis and Bright's Disease 19 — — — 2 — 2 7 8 4 Puerperal Fever 1 — — — — 1 — — — — Other accidents and diseases of pregnancy and parturition 4 — — — — 1 3 — — — Congenital debility and Malformation, including Premature Birth 25 25 — — — — — — — 4 Violent Deaths, excluding Suicide 15 2 — 1 1 2 6 — 3 7 Suicide 6 — — — — — 3 2 1 1 Other defined diseases 136 9 2 2 8 7 34 40 134 19 Poliomyelitis 1 — — — 1 — — — — — Totals 880 72 20 27 44 71 180 163 303 91 43 TABLE IV. Infant Mortality during the Year 1918. Nett Deaths from stated causes at various ages under One Year of Age. BOROUGH OF EALING. Causes op Death. Under 1 Week 1-2 Weeks. 2-3 Weeks. 3-4 Weeks. Total under 4 weeks. 1-3 Months. 3-6 Months 6-9 Months. 9-12 Months. Total Deaths under One Year. All Causes Certified 13 4 11 3 31 15 9 9 8 72 Uncertified — — — — — — — — — — Small-pox — — — — — — — — - — Chicken-pox — — — — — — — — — — Measles — — — — — — 1 1 2 Scarlet Fever — — — — — — — — — — Whooping Cough — — 1 — 1 1 — 2 1 5 Diphtheria and Croup — — — — — — — — — — Erysipelas — — — — — — — — — — Tuberculous Meningitis — — — — — — — — — — Abdominal Tuberculosis — — — — — — — — — — Other Tuberculous Diseases — — — — — — — — — — Meningitis (not Tuberculous) — — — — — — — — — — Convulsions — 1 — — 1 2 1 — — 4 Laryngitis — — — — — — — — — — Bronchitis — — 1 — 1 2 — — 2 5 Pneumonia (all forms) — — — — 1 — 1 2 — 6 Diarrhoea — — 1 1 — 1 — — 2 Enteritis — — 1 2 3 2 4 2 1 12 Gastritis — — — — — — — — — — Syphilis — — — — — — — — — — Rickets — — — — — — — — — — Suffocation, Overlying — — — — — — — — — — Injury at Birth — — — — — — — — — Atelectasis — — — — — — — — — — Congenital Malformations — — — — — 1 1 — — 2 Premature Birth 9 1 2 — 12 — — — — 12 Atrophy, Debility, and Marasmus 3 2 1 1 7 4 — — — 11 Other Causes 1 — 3 — 4 3 1 2 1 11 13 4 11 3 31 15 9 9 8 72 Nett Births in the year legitimate 876 illegitimate 66. Nett Deaths in the year of legitimate infants 61. illegitimate infants 11. Borough of Ealing EDUCATION COMMITTEE. REPORT of the School Medical Officer, For the Year ended 31st December, 1918. 47 staff. School Medical Officer: Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister at-Law. School Nurses: Miss A. Gough. Miss M. Richardson. Miss A. Clark. Clerk: Miss Grace Massie. Surgeon: E. A. Chill, M.D., C.M. (Edin.) Anaesthetist: S. M. Banham, M.B. (Lond.), M.R.C.S., L.R.C.P. Oculist: Margaret B. A. Dobson, M.D. (Lond.) Dentists: L. Brown, L.D.S., R.C.S. (Fng.) I. Cohen, L.D.S. (Eng.) School Clinic: 13, Mattock Lane, Ealing. Town Hai.l, Ealing, W 5. September, 1919. TO the Education Committee. Mr. Chairman, Ladies and Gentlemen, I have the honour to submit to you the Annual Report on the work of the School Medical Department for the year 1918. The scheme of medical inspection and treatment of school children, as the Report will demonstrate, has not suffered in any way during the year. As a matter of fact, the administrative machinery has been improved in many details, making for expedition in the treatment of the children and for the keeping of "better records. Towards the end of the year the acquirement of premises at 13, Mattock Lane, to which the School Clinic and the whole of the School Medical Staff were transferred, was an excellent step forward, placing as it did the whole of the staff in the same building, and enabling complete co-ordination of the work to be effected, and proper supervision to be established. In presenting this Report, I desire to take the opportunity of expressing my deep gratitude to my staff, who have carried out their work in an admirable manner, and have loyally supported me in my efforts to carry out the work of the department efficiently. I am, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR. 49 General Statement of the Extent and Scope of the Medical Inspection carried out during the Year. The following tables indicate the number of children in each group inspected in the various schools:— School Entrants Total Boys Girls Provided. Drayton 59 59 118 Joseph Lancaster 27 32 59 Lammas 94 82 176 Little Ealing 97 110 207 North Ealing 30 46 76 Northfields 58 68 126 Junction Road (temporary) Non-Provided. 36 31 67 Christ Church 17 25 42 St. John's 53 56 109 St. Mary's 33 18 51 St. Stephen's — — — Wesleyan — — — Total 504 527 1031 50 Number of Children Inspected. School. Age 9 Group Total Leavers Total Boys Girls Boys Girls Provided. Drayton 48 54 102 41 56 97 Joseph Lancaster 23 17 40 23 25 48 Lammas 83 50 133 79 73 152 Little Ealing 74 86 160 68 91 159 North Ealing — 27 27 — 30 30 Northfields 78 58 136 81 47 128 Junction Road (temporary) — — - — — — Non-Provided. Christ Church 28 20 48 29 33 62 St. John's 60 50 110 54 66 120 St. Mary's 20 15 35 18 15 33 St. Stephen's 24 — 24 22 — 22 Wesleyan 11 11 22 12 10 22 Total 449 388 837 427 446 873 51 Statement of number of Children concerning whom notices were sent to the Parents. The following is a classified list of the defects found, concerning which notices were given to the parents advising treatment:— Defect Entrants Age 9 Leavers Total Boys Girls Boys Girls Boys Girls Teeth 225 221 129 97 42 32 746 Tonsils 110 95 46 37 31 32 351 Adenoids 6 10 2 1 2 — 21 Mouth Breathers 9 15 5 5 5 1 40 Eyesight 6 5 27 22 15 19 94 External Eye Disease 13 9 14 4 8 5 53 Ear Disease 3 4 4 1 2 2 16 Deafness 3 2 3 — 3 8 19 Nasal Discharge 14 4 1 5 3 2 29 Heart Disease 12 8 11 4 11 6 52 Anaemia 8 21 15 24 13 48 129 Suspected Phthisis 1 2 — — — 1 4 Bronchitis 6 6 1 1 1 — 15 Ringworm 1 1 — — — 2 Impetigo 6 1 1 1 5 — 14 Scabies 5 6 4 3 2 3 23 Verminous Head 1 8 — 7 — 4 20 Verminous Body — 1 — — — 1 Talipes — — 2 — 1 1 4 Spinal Curvature 1 1 — — 3 5 Round Shoulders 3 8 4 14 25 37 91 Others 20 10 24 6 25 11 96 Total Defects 453 437 294 232 194 215 1825 52 Total Notices to Parents: Verbal 416 Written 559 975 Total Notices to Teachers; Verbal 31 Written 50 81 These figures represent defects and not defective children. The number of notices given to the parents indicate children. More than one defect may be present in a child, hence the former number is greater than the latter. When notices are given to the parents, treatment by a doctor may not be necessary, for the treatment advised may simply be hygienic or home treatment to be given by the parents. General View of the Facts Disclosed by Medical Inspection. A summary of the facts disclosed on School Medical Inspection is given in Table II. One condition found amongst the children, and almost entirely amongst the girls, demands some consideration, and that is verminous condition of the head, or pediculosis capitis. Pediculosis. Systematic inspections of the heads of the children in certain schools were carried out by the School Nurse on three occasions during the year, the first after the Christmas holidays, the second after the Easter holidays, the third after the Summer holidays. The results were as follows:— Number of Number children examined, found with pediculosis 1839 106 1913 50 1869 222 All those found with pediculosis were submitted to the School Medical Officer, as a result 55, 39, and 150 children being excluded respectively on those occasions. 53 In addition to those inspected at school by the School Nurse, 62 other children were sent by the teachers for examination by the School Medical Officer. All of these were excluded as affected with pediculosis. The total number of exclusions for verminous condition during the year was 306. Summonses were issued by the Attendance Officers with respect to six of these cases which were not cleansed within a reasonable time, a fine of 5s. being imposed by the Justices in two cases, and a fine of 10s. in four cases. In dealing with these verminous cases, great assistance has been obtained from Mrs. Byles, the Woman Attendance Officer, who was appointed in February, 1918. Although her appointment was in the nature of an experiment, the results of her work have amply justified the appointment. At the suggestion of the School Medical Officer, the work allotted to Mrs. Byles consisted of the general supervision of the attendance of two schools, and of the supervision of all the cases excluded from all the schools in the Borough on account of verminous conditions of the head or body, impetigo, scabies and ringworm. After the exclusion of such children, there has always been a great difficulty in getting them submitted for re-examination, resulting in the children remaining out of school for an unreasonable length of time. Since the advent of the Woman Attendance Officer, these children have come up for examination with remarkable regularity, even in cases where the parents have been loud in their expostulations and vehement in their assertions that the children would not be brought for examination, showing that by the exercise of tact and the adoption of a reasoning attitude much can be done to make the mother realise what she has to do. In cases of verminous condition, the Woman Attendance Officer can give instructions how to clean the child and how to keep her clean, instructions which are more acceptable when given by a woman than by a man, while in cases of impetigo, scabies or ringworm. she can see whether treatment is being properly carried out at home, or she can persuade the mother to submit the child tor treatment at the School Clinic. 54 As indicating the value of the work of the Woman Attendance Officer, the following figures may be quoted:— Total children excluded for verminous condition in 1917, before the appointment of Mrs. Byles 242 Total summonses for non-attendance owing to verminous condition in 1917 37 Total children excluded for verminous condition in 1918, after Mrs. Byles' appointment 306 Total summonses for non-attendance owing to verminous condition in 1918 6 So that, although the number of excluded cases was larger in 1918 than in 1917, due to a noticeable increased neglect on the part of the mothers, the children were cleansed so quickly after the visits of the Woman Attendance Officer that only six summonses were issued, as against 37 in the previous year. In dealing with such children, as well as in the ordinary work of school attendance, there is much in favour of the appointment of women. Given some strength of character, a tactful manner and some suasive power, women are sure to succeed in this class of work, where the parent who has usually to be reckoned with is the mother, and not the father. Medical Treatment. The following is a summary of the work of treatment carried out at the School Clinic during the year. Throat, Nose, and Ear Department. Number of children advised during 1918 to have operation for enlarged tonsils, adenoids and nasal obstruction 354 Number of children operated on for enlarged tonsils or adenoids and nasal obstruction 116 Number of children treated by own doctor or at a general hospital 32 Number of children whose parents objected or who left the District 26 58 These children came within the routine medical inspection groups examined during 1918, but in addition there were also treated at the Clinic 13 non-routine cases. The total operations performed at the Clinic during 1918 were 125 for excision of the tonsils or adenoids, and 4 for nasal obstruction arising from other causes. The total number of attendances of children for treatment was 474, which number included cases visiting the Clinic regularly for the treatment of otorrhoea. After operation the cases were re-inspected by the Schoo Medical Officer in the course of the following twelve months The number of children re-inspected was 139, the result of the operation being found to be satisfactory in all cases. Eye Department. Number of children found by the School Medical Officer to have defective eyesight or eye disease 154 Number of children treated at the Clinic 148 Number treated by own doctor or at a hospital 6 In addition to the 148 routine cases there were 62 non-routine cases who attended the Clinic for treatment. The number of children treated for external eye disease was 41. Through the agency of the School Attendance Aid Committee spectacles were provided during the year in 153 cases. In the majority of cases the parents paid the whole or part of the cost, but in 12, on account of the necessitous circumstances of the parents, spectacles were provided free. The total outlay on spectacles during the year was £27 7s. 3d., and the amount paid back by the parents £24 17s. 0d. As formerly, cases of defective eyesight previously treated were kept under supervision by re inspections at periodic intervals by the School Oculist. The total re-inspections during the year numbered 614. 56 The total attendances of children during the year was 920,. which number included children attending for daily treatment of the eyes under the supervision of the Oculist. Daily Treatment. The Clinic is open on school days for such cases as otorrhoea, external eye disease, impetigo, ringworm, etc., requiring treatment by the Clinic Nurse. Ear Cases: Number of Children treated 34 Number of Attendances 564 Eye Cases: Number of Children treated 148 Number of Attendances 877 Impetigo, Ringworm, etc.: Number of Children treated 175 Number of Attendances 1353 The total number of children treated was 357 and the total number of attendances 2,794. In connection with the general scheme of treatment at the School Clinic 1,301 visits were paid by the School Nurses to the schools or homes of the children. Dental Department. During the year eight school departments (four schools) were visited by one or other of the School Dentists, and the children between the ages of 6 and 8 years were examined. Of the total 959 children examined, 682 or 80 per cent, were found to require dental treatment. The following indicates the extent of dental treatment administered during the year:— Number of Children treated for the first time 389 Number of extractions under general anaesthetic (nitrous- oxide gas) 930 Number of extractions under local anaesthetic 3 57 Number of extractions without anaesthetic 821 Number of Dressings 40 Number of Fillings 1,196 Number in which scaling performed 21 Number of children to whom gas was administered 179 Number of children re-inspected 954 The total number of children dealt with by the dentists at the School Clinic was 1,499, which included 51 non-routine cases requiring immediate treatment. Dental Inspection and Treatment. The Board of Education have been accustomed to recommend that children between 6 and 8 years of age should receive first consideration in any scheme for dental treatment. This age-group appears to have been chosen having regard to the physiological development of the teeth and the period of greatest activity, and not particularly having regard to what are the conditions actually found in the mouths of school children before the age of six years. Between the age of 6 and 8 years would be a suitable time if children at other ages could not be treated and especially if there was not so much advanced caries and sepsis in the children when they enter school at the age of 5 years. In Ealing, the age-group treated by the dentists is 6 to 8 years, all children treated being afterwards kept under dental supervision during their school days, but so many children between 5 and 6 years of age have shown markedly septic mouths,accompanied by poor nutrition, that they have been treated as non-routine and urgent cases. The treatment of so many non-routine and urgent cases has tended to upset the general arrangements for the routine cases to such an extent that one has been impressed with the importance of dealing with the children at 5 years, in other words, all entrants, in place of the 6 to 8 years group; not only from the necessity to the child, but from the administrative aspect. Further, as regards the administrative aspect, it has to be noted that in the course of routine school medical inspection the teachers have to supply a list of all the entrants during the year since the last inspection and of dental inspection a list of all the children between the ages of 6 and 8 years of age. 58 If for dental inspection and treatment the entrants were dealt with instead of the 6 to 8 years group only, one list only would be necessary in the year, thus saving a considerable amount of labour, not only for the teachers, but for the School Medical Staff. Again, it seems only logical that dental treatment should begin as early as possible when the child comes within the scope of school medical inspection, its dental treatment being pursued throughout its school life, the scheme being widened as the work increases amongst the older children and the demand for treatment being met as the need arises. Treatment of Ringworm of the Head.—During the year 51 cases of ringworm of the head were treated by X-rays by Dr. Arthur. All of the cases were certified by the School Medical -Officer to be cured. Blind, Deaf, Mentally and Physically Defective and Epileptic Children. The Local Education Authority maintains one child at the Fitzroy Square Institution for the Oral Instruction of the Deaf, and three children at the Training School for the Blind at Swiss Cottage. Five mentally defective children were reported during the year to the County Council as being non-educable and unsuitable for a Special School. Miscellaneous Work. Under this heading are included cases referred to the School Medical Officer for examination at the instance of the Teachers, School Attendance Officers, or Education Committee. Each morning of the week, except Monday, cases may be referred for examination at 10 o'clock. The children are usually those suspected of having verminous heads or bodies, those affected with ringworm, scabies, or impetigo contagiosa, or those whose examir.ation is desirable on account of some defect, such as defective eyesight and eye or ear disease requiring treatment. 50 The examinations for the year may be tabulated as follows:— Verminous Children 1,116 Impetigo 1,039 Ringworm 256 Miscellaneous 729 The total number of children examined was 1,409, and the total number of attendances 3,140. THOMAS ORR, M.D., D.Sc. TABLE 1 Number of Children Inspected January 1st to December 31st, 1918. A—" Code " Groups. Age. Entrants. \ 3 4 5 6 Other Ages. Total. Boys 37 273 145 49 504 Girls 35 247 151 94 527 Totals 72 520 296 143 1031 Age Intermediate Group. Leavers. Grand Total. 8 12 13 14 Other Ages. Total. Boys Girls Totals 449 388 418 437 9 9 876 834 837 855 18 1710 2741 B—Groups other than "Code." Intermediate Group (other than 8 years) Special cases. Re- Examinations (i.e., No. of Children Re-Exmd. (1) (2) (3) (4) Boys 11 129 Girls — 5 104 Totals — 16 233 TABLE II. Return of Defects Found in the Course of Medical Inspection. defect OR disease. Code Groups. Specials. No. referred for treatment. No. to be kept under observation but not referred for treatment. No. referred for treatment. No. to be kept under observation but not referred for treatment. Skin Malnutrition 3 183 Uncleanliness Head 20 53 — — Body 1 57 — — Skin. Ringworm, Head 1 — — — Ringworm, Body 1 — — — Scabies 23 — — — Impetigo 14 — 2 — Other Disease — 7 — — Eye. Defective Vision and Squint 143 — 2 — External Eye Disease 53 — — — Ear. Defective Hearing 19 — — Ear Disease 16 — — Teeth. Dental Disease 746 — 2 — Nose and Throat. Enlarged Tonsils 351 1 — Adenoids 21 6 1 — Enlarged Tonsils and Adenoids 21 — — Defective Speech 7 — 2 Heart and Circulation. Heart Disease—Organic 52 — — — Functional — 44 — — Anaemia — 129 1 — Lungs. Pulmonary Tuberculosis Definite — — — — Suspected 4 2 Chronic Bronchitis 15 — Other Disease — — — Nervous System. Epilepsy 4 — — Chorea — — — — Other Disease — — — — Non-Pulmonary Tuberculosis. Glands 1 — Bones and Joints — — — Other Forms — — — Rickets — Deformities — 196 — — Other Defects or Diseases — 37 3 3 TABLE III. Numerical Return of All Exceptional Children in thk Area in 1918. boys girls T TAL. Blind. (including partially blind) Attending Public Elementary Schools 2 2 Attending Certified Schools for the Blind 2 1 3 Not at School 1 1 Deaf and Dumb. (including partially deaf) Attending Public Elementary Schools Attending Certified Schools for the Deaf 1 1 Not at School 1 15 15 1 30 Attending Public Elementary Schools Mentally Feeble Minded Attending Certified Schools for Mentally Defective Children 1 1 Deficient Notified to the Local (Control) Authority during the Year 4 1 5 Not at School 4 5 9 Imbeciles At School Not at School 4 1 5 Idiots Attending Public Elementary Schools Epileptics. Attending Certified Schools for Epileptics Not at School Pulmonary Attending Public Elementary Schools Tuberculosis Attending Certified Schools for Physically Defective Children Not at School 3 3 Attending Public Elementary Schools Physically Other forms of Tuberculosis Attending Certified Schools for Physically Defective Children Defective Not at School 1 7 2 4 3 11 Cripples other than Attending Public Elementary Schools T ubercular Attending Certified Schools for Physically Defective Children Not at School 3 69 3 93 6 162 Dull or Backward Retarded 2 years Retarded 3 years TABLE IV. Treatment of Defects of Children during 1918. Condition. No. of defects found for which treatment was considered sary. No. of defects for which no report is available. No. of defects treated. Results of Treatment. No. of defects not treated. Percentage of defects treated. From previous year ! New. Total. Remedied. Improved. Unchanged Clothing 17 17 - 17 17 - - 100 Footgear — 6 6 — 6 6 - - 100 Cleanliness of Head — 379 379 — 379 379 - - 100 Cleanliness of Body — 58 58 — 58 58 - - 100 Nutrition — — — — - - Nose and Throat 27 390 417 241 176 176 - 42 External Eye Disease — 40 40 18 22 22 - 55 Ear Disease — 16 16 4 12 10 2 75 Teeth — 747 747 - - Heart and Circulation 18 52 70 - 70 - 30 40 100 Lungs 8 4 12 — 12 - 7 5 100 Nervous System — 4 4 — — - - - Skin — 46 46 — 46 46 - - 100 Rickets — — — — — - - - Deformities — 196 196 — - - - - Tubiroulosis Speech ary) — 1 1 - - - - - — 7 7 — — - - - Mental Condition — 110 110 — — - - - Vision and Squint 17 188 205 63 142 142 - - 70 Hearing 19 19 5 14 — 12 2 74 Miscellaneous — — — — — — — — Totai. 70 2280 2350 331 1054 946 59 49 — 45 64 TABLE V. Inspection, Treatment, etc., of Children, during 1918. (1)—The total number of children medically inspected (whether Code Group, special, or ailing child) 2741 (2)—The number of children in (1) suffering from defects (other than uncleanliness or defective clothing or footgear), who require to be kept under observation, but not referred for treatment. 532 (3)—The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) 1227 (4)—The number of children in (3) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) 1115