EAL12 Borough of Ealing. REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE YEAR 1920. THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law, Medical Officer of Health, School Medical Officer and Medical Superintendant of the Infectious and Smallpox Hospitals. EALING: Francis A. Perry, 4, Kirchen Road REPORT of the Medical Officer of Health, 1920. INDEX. Acts 75 Ante-Natal Clinic 54 Bacteriological Examinations 75 Bakehouses 28 Births 18 Blind, Deaf, etc. Children 133 Cerebro Spinal Fever 43 Closet Accommodation 24 Consumption 45 Cowsheds 30 Crippled Children 111 Dairies 30 Day Nursery 63 Deaths 19 Denta' Treatment for Mothers 56 Diphtheria 38,74 Disinfection 26 Drainage and Sewerage 24 Dysentery 44 Education General Purposes Sub-Committee, 97 Encephalitis Lethargica 43 Expectant Mothers 53 Factories and Workshops 27 Food and Drugs Acts 33 Food Inspection 30 Health Visiting 59,64 Home Helps 54 Home Work 29 Hospital (Isolation) 72 Hospitals, Combination of 66 Housing 77 Hygienic Condition of Schools 100 Illegitimate Births 18 Infant Deaths 20 Infant Visiting 59 Infectious Diseases 34, 117 Malaria 44 Maternity and Child Welfare 50 Maternity and Child Welfare Committee 6 Maternity Aid 54 Index. Measles 48, 61 Medical Aid 55 Medical Inspection of School Children 101 Medical Treatment of School Children 119 Medical Treatment of Children under 5 years 62 Midwives, Supervision of 53 Milk (Mothers and Children) Order 31, 57 Milk Supply 30 Natural Conditions of District 13 Nursery, Day 63 Ophthalmia Neonatorum 61 Pediculosis 106 Phthisis 45 Physical Features of District 13 Pneumonia 44 Population 16 Puerperal Fever 56 Public Health Committee 6 Rivers and Streams 23 Sanitary Circumstances of District 22 Sanitary Inspection of District 25 Scavenging 24 Scarlet Fever 40,73 Social Conditions of District 13 Staff 7. 65, 96 Statistics, Summary of 12 Treatment, Medical, of School Children 119 Tuberculosis 45 Typhoid Fever 43 Unmarried Mothers, Hostel for 63 Water Supply 22 Welfare Centre 59 Whooping Cough 49 Workshops 27 Public Health Committee. Councillor E. J. Morgan (Chairman). Councillor H. Armriding ( Vice-Chairman). Aldermen G. C. Farr and H. W. Peal, J.P., Councillors A. W. Bradford, J.P., J. C. Fuller, W. Hutchings and W. F. Piper. Maternity and Child Welfare Committee. Councillor A. W. Bradford, J.P. (Chairman). Councillor W. F. Piper ( Vice-Chairman). Aldermen G. C. Farr and H. W. Peal, J.P., Councillors H. Armriding, J. C. Fuller, W. Hutchings and E. J. Morgan. Mesdames Chapman, Sharp, Travers Humphreys and Wilson. 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. Assistant Medical Officer of Health— R. P. Garrow, M.D., D.P.H. Consultant, Maternity and Child Welfare Centre (Ante- Natal Clinic)— John w. Bell, L.R.C.P.I. & L.m., L.R.C.S.I. & L.M. Medical Officer, Maternity and Child Welfare Centre (Infant Consultations)— S. Grace Banham, B.Sc. M.B. Chief Sanitary Inspector— Thomas Hill, A.R.San. I., M.S.I.a., Cert. Inspector of Meat and Other Foods. Sanitary Inspectors— Harry Sharpe, Cert. R.S.I., Cert. Inspector of Meat and Other Foods. James Stubbs, Cert. R.S.I., Cert. Inspector of Meat and Other Foods. 8 StaffHealth Visitors— Eleanor Evans, Cert. R.S.I., Cert. C.M.B., (Senior). Gertrude Dowsett, Cert. R.S.I., Cert. C.M.B. Katherine Christain, Cert. R.S.I. (Resigned 2nd December, 1920). Agnes Lainton, Cert. R.S.I. (Commenced duties December 23rd, 1920). Chief Clerk and Committee Clerk— Harry Birrell. Clerk and Laboratory Assistant— Ernest W. Hill. Clerks— Albert C. Groom. Grace Such. Matron, Isolation Hospital— Emily Whittle. Matron, Day Nursery— Mildred A. Benson. Matron, Hostel for Unmarried Mothers— M. E. Donaldson. Maternity and Child Welfare Centre— 13, Mattock Lane, Ealing. Public Health Department, Town Hall. Ealing, W. 5. 18th July, 1921. To the Mayor, Aldermen and Councillors of the Borough of Ealing. Mr. Mayor and Gentlemen, I have the honour to submit to you the Annual Report for the year 1920 on the health of the Borough, and on the work of the Public Health Department. In submitting the Report I take the opportunity of drawing attention to two matters: the first is the splendid position as regards health statistics which Ealing holds compared with other districts, and the second is the actual annual cost of the Public Health Department. As regards the first I shall refer to the Quarterly Report of the Registrar-General dated the 31st January, 1921, in which are given statistics for the year 1920 relating to the health of the 96 Great Towns in which Ealing is included. It is shown that of the Great Towns Ealing has the lowest death-rate except one, having a general death-rate of 8.9 per 1,000 of population, Wimbledon having the lowest with a rate of 8.8, Ilford having the same as that of Ealing, the average for the whole of the Great Towns being 12.5. Ealing is also shown as having the third lowest infant death-rate, the rate being 49, compared with the average for the Great Towns of 85. The rates for Ealing, however, have been lowered by the recent corrected figures to 8.8 and 47 respectively, making the general death-rate the lowest, equal with Wimbledon, but keeping the infant death-rate in the third position relative to the others. These figures indicate a health record of which the Council and the community may justly be proud, manifesting as they do on the one hand foresight in municipal administration and on the other an appreciation of those conditions which make for good health. As regards the second matter the cost of the Public Health Department it seems desirable to discuss it in view of the frequent and insistent call for economy in all branches of municipal administration. The figures for the year ending the 31st March, 1920, are taken so that they can be compared with those for other towns quoted in the Report of the Ministry of Health on "The Amount of the Local Rates." The nett cost to the ratepayers of the Maternity and Child Welfare Scheme was £1,272 19s. 11d., of the Hospital £4,777 14s. Id., and of the general public health scheme, devoted to preventive medicine £2,063 0s. 7d. These figures mean rates respectively of ½d., 2¼d., and 1d. in the £1, which compare well with those for the towns quoted in the Report referred to:— Maternity and Child Welfare Haling Bristol Ipswich Leeds Portsmouth Sunderland ½d. ½d. ½d. 1d. ½d. l½d. Hospitals for Infectious Diseases 2¼ 2¾. 5½. 7½. 3½. 3½. Prevention of Disease 1. 2d. 2¼d 2d. 1. ½. Total 3¾d. 5¼d. 8¼d. 10¼d 5d. 5½d. These rates for Ealing afford a valuable comparison with the health statistics already quoted. In presenting this report I take the opportunity of expressing to the whole of the staff my gratitude for the excellent manner in which they have assisted me during the year. I am, Mr. Mayor and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Officer of Health. 12 SUMMARY OF STATISTICS FOR 1920. Population, 1920 For Birth-rate 76,299 For Death-rate 76,129 (Estimated by the Registrar-General). Population (Census, 1911) 61,222 Area of Borough in Acres 2,947 Inhabited Houses (Census, 1911) 13,776 Births 1,361 Birth-rate per 1,000 of Population 17.8 Deaths 673 Death-rate per 1,000 of Population (Estimated 1920) 8.8 Infant Mortality per 1,000 Births 47 -Phthisis Death-rate per 1,000 of Population .55 Death-rate from other forms of Tuberculosis per 1,000 of Population .19 Death-rate from all forms of Tuberculosis .74 Rateable Value of Borough £543,370 Assessable Value of Borough £522,514 Nett Proceeds of a Penny Rate £2,135 Natural and Social Conditions. 13 NATURAL AND SOCIAL CONDITIONS OF THE DISTRICT. Physical Features and General Character of the District. The Borough of Ealing extends to 2,947 acres, and forms roughly a rectangular area one mile and a half east to west and two miles north to south. It is bounded on the north by the sparsely populated district of Greenford, from which it is separated by the River Brent, and on the south adjoins Brentford. On its east and west boundaries it has Acton and Hanwell respectively. The district is divided into two almost equal areas by the Uxbridge Road, which also divides the district roughly into two parts geologically, the northern composed of London clay, and the southern of alluvial gravel. Prom the southern boundary the surface slopes gradually upwards from 50 feet above sea level, to the highest point at Hanger Hill two miles due north, 200 feet above sea level, from which point it slopes downwards towards the River Brent, the lowest point at which houses are built in this region being 75 feet above sea level. The Great Western Railway main line to Reading passes through the centre of the district, running near to and almost parallel witH Uxbridge Road. The District Railway (Underground) also traverses the district, there being no fewer than five stations within the boundaries. The Great Western Railway (Bicester line) passes just within the northern boundary. 14 Natural and Social Conditions. The Borough is divided into six wards, three north of Uxbridge Road and three south of it, all the former touching the northern boundary and all the latter touching the southern boundary. The district is almost entirely residential, factories being very small and unimportant from the occupational aspect. The factories consist of an optical instrument manufactory, a foundry, a surgical instrument factory, proprietary drugs factory, and seven steam laundries. The lay-out of the town is well designed to give plenty of space between the houses and to preserve the residential character of the district, most of the roads being planted with trees, which add greatly to the appearance, and temper the air in the hot summer months. The public parks are a feature of the district, there being four large parks, consisting of 155 acres in extent, and five open spaces or playing grounds of 34 acres; so that altogether the Council provide an extent of 189 acres as public open spaces. A hundred and seventy four acres of land are used as allotments, of which 63 acres are permanent. The King Edward Memorial Hospital, consisting of 50 beds, 19 for men, 19 for women, and 12 for children, supplies to a certain extent the needs of the district, although many patients find their way to the London hospitals, and some to the West Middlesex Hospital, which is under the Brentford Board of Guardians, the local authority for Poor Law purposes in this area. There is also a Dispensary in connection with the King Edward Memorial Hospital, at which women and children of the working class community can obtain medical treatment in return for a small monthly contribution. Natural and Social Conditions. 15 A dozen private nursing homes supply not only the needs of Ealing, but help to meet the demands of other districts. There are no real slums in the district, although there are three islets of houses of a low standard, some of which have been reduced by the occupiers to slum-like conditions by over-crowding or mal-treatment. The amount of Poor Law Relief distributed in the area during the year, according to information received from the Clerk to the Board of Guardians, was £1,654 6s. 1d. The Central Aid Society and the Ealing Philanthropic Institution do good work in the district by rendering assistance in many needy cases. In the Annual Report for 1919 attention was drawn to the need for a regular nursing service by which nursing aid could be provided for the poorer inhabitants. During the year under review steps were taken to provide such a service. A Nursing Association was formed and a District Nurse appointed, the intention being to increase the nursing provision as funds allow. One nurse is certainly not sufficient to meet the needs of the whole district, but it is hoped that her appointment will lead to an extension of the service in the future, when the demands of the district can be accurately gauged and when voluntary funds are available. The Council maintains an ambulance, kindly placed at their disposal by the Ambulance Committee of the County of Middlesex Division, for the transport of sick and injured persons to hospital or to private nursing 16 Population. homes. Where the removal is of an Ealing resident to the King Edward Hospital or a private nursing home in Ealing there is no charge, but when the removal is to a hospital or a nursing home out of Ealing, a charge of a guinea is made. There can be no doubt that the ambulance has met a great need, and that it is greatly appreciated by the inhabitants, for expressions of appreciation are constantly being received. During the year the ambulance was requisitioned on 470 occasions, involving the travelling of approximately 3,349 miles. VITAL STATISTICS. Population. The population of the Borough in the middle of 1920, as estimated by the Registrar-General, was 76,299 for calculating the birth-rate, and 76,129 for calculating the death-rate. Owing to various circumstances it is difficult to give even an approximately accurate estimate of the population, but these figures have been calculated by the Registrar-General in accordance with certain general principles which apply to all parts of the country. The Census to be made in 1921 should furnish accurate information which will enable us to prepare statistics which can be considered to be nearer the truth. Population. 17 The population at the Census of 1911 was 61,222 and was distributed in the Wards as follows:— Ward. Families or separate occupiers Population. Males Females Total No. 1 or Drayton 1755 3475 | 4146 7621 No. 2 or Castlebar 2130 3324 6192 9516 No. 3 or Mount Park 1572 2549 5164 7713 No. 4 or Lammas 3315 6965 7663 14628 No. 5 or Manor 2882 5334 7106 12440 No. 6 or Grange 2122 3791 5513 9304 Totai. 13776 25438 35784 61222 During the year the natural increase in the population, which is the difference between the number of births and deaths, was 688. The following Census figures indicate the increase in the population of Ealing during successive decades. Census, 1881 15,764 Census, 1891 23,965 Census, 1901 33,040 Census, 1911 61,222 Estimated Population, 1920 76,299 As the area of the Borough extends to 2,947 acres, the density of population, or persons per acre, is 25.9 18 Births. Births. The number of births registered as belonging to the district during the year was 1,361, consisting of 702 males and 659 females. From this number the birthrate is calculated as 17.8 per 1,000 of population, the population on which this calculation is made being that supplied by the Registrar-General of 76,299. The birth-rate, as will be seen in a subsequent Table, is the highest since the year 1913. Ealing has shared with other parts of the country in a marked increase of births compared with previous years. In the following Table the birth-rate of Ealing is compared with that for England and Wales, and with those of the 96 Great Towns and of London:— birth-rate. Ealing 17.8 per 1,000 of population. England and Wales 25.4 „ „ 96 Great Towns 26.2 „ „ London 26.5 „ „ Illegitimate Births.—The illegitimate births were 75 in number, giving an illegitimate birth-rate of .97 per 1,000 of population, and a percentage of 5.5 of the total births. The following Table represents the illegitimate birthrate for the last six years:— illegitimate birth-rate. 1915 54 per 1,000 of population. 1916 40 „ „ 1917 80 „ „ 1918 91 „ „ 1919 97 „ „ 1920 97 „ „ Deaths. 19 Deaths. During the year there were 673 deaths assignable to the district. These give, calculated on the RegistrarGeneral's population of 76,129, a death-rate of 8.8 per 1,000 of population. In the following Table the corrected death-rate for Ealing is compared with the rates for England and Wales and for the 96 Great Towns:— general death-rate. Ealing 8.8 per 1,000 of population. England and Wales 12.4 „ „ 96 Great Towns 12.5 „ „ London 12.4 „ „ This Table indicates the very enviable position which Ealing holds as regards the death-rate, for the rate is no less than 3.6 per 1,000 below the rate for England and Wales or that for London. The following Table indicates the birth-rate and death-rate for each of the last ten years:— Year. Birth-rate. Death-rate. 1910 23.4 9.8 1911 20.2 11.5 1912 20.6 9.7 1913 18.2 8.9 1914 17.5 9.4 1915 16.6 10.2 1916 17.0 11.1 1917 14.8 10.5 1918 13.0 13.6 1919 13.3 10.8 1920 17.8 8.8 20 Infant Deaths. An analysis of the causes of death is to be found in Table III at the end of the Report. Inquests.—Inquests were held in 31 cases. One was of a child under one year, three of children between one andl5 years, and 27 of persons over 15 year:- of age. Infant Deaths. There were 64 deaths of infants under one year, giving an infant death-rate of 47 per 1,000 births. The following Table indicates the infant death-rate for Ealing with the rates for England and Wales, London, and 96 Great Towns:— infant death-rate. Ealing 47 per 1,000 births. England and Wales 80 „ 96 Great Towns 85 „ London 75 „ It will be seen that Ealing has a rate which is 33 less than the rate for England and Wales, and 28 less than that for London, and even 38 less than the average for the 96 Great Towns with which Ealing is comparable. The following Table gives the infant death-rates for Ealing for the last 20 years compared with those for England and Wales:— 21 Infant Deaths. Ealing. England and Wales 1901 114 114 151 138 1902 112 133 1903 136 132 1904 105 145 1905 101 128 1906 129 87 132 117 1907 91 118 1908 80 120 1909 70 109 1910 65 106 1911 121 76 130 110 1912 67 95 1913 72 109 1914 59 105 1915 63 110 1916 58 62 91 91 1917 63 97 1918 76 97 1919 65 89 1920 47 80 On comparing the averages for the five-year periods, a good idea is obtained of the great reduction in the nfant death-rate which has occurred in recent years. The following Table gives the principal causes of death amongst infants under one year of age during the year 1920, and compared with those during the previous five years :— 22 Infant Deaths. 1915 1916 1917 1918 1919 1920 Diarrhoeal Diseases 8 7 10 14 3 9 Premature Birth 11 20 7 12 13 15 Congenital Defects 4 3 5 — 6 4 Want of Breast Milk (Starvation) — — — — — — Atrophy, Debility, Marasmus 1 11 6 11 14 14 Tuberculous Disease 1 2 2 — 3 3 Syphilis 1 — 1 — — 3 Rickets — — — — — — Meningitis (not Tuberculous) 1 5 1 — 2 — Convulsions 3 4 4 4 1 2 Bronchitis 2 2 5 5 3 1 Pneumonia (all forms) 7 4 17 6 4 4 Gastritis 5 1 — — — 2 Common Infectious Diseases 9 5 2 7 1 — Other Causes 22 6 7 13 17 7 75 70 67 72 67 64 SANITARY CIRCUMSTANCES OF THE DISTRICT. Water Supply. Ealing is supplied with water by the Metropolitan Water Board. A supply reservoir for supplying a portion of the town by gravitation during the night is situated at the highest point in the Borough on the top of Hanger Hill. Water Supply, Rivers and Streams, Drainage, and. Sewerage. 23 Rivers and Streams. The Brent forms the northern boundary of the district, and here it receives the effluents from the Wembley Sewage Works and Ealing Northern Sewage Works. In the middle of the year complaints were received regarding the polluted condition of the River Brent. As a result of a report from the Medical Officer of Health, representations were made to the County Council. The County Council thereupon served a Notice upon, the Wembley Urban District Council calling upon them to stop the pollution within a period of three months. Later in the year the District Council made application, under Section 13 of the Middlesex County Council Act, 1898, for an extension of time within which to comply with the statutory notice, and stated that everything possible was being done to hasten the carrying out of the permanent works, and that the arrangements then in hand were such that a definite commencement should be made after December. There can be no doubt of the urgent necessity of some steps being taken to deal with the gross pollution which takes place from the sewage effluent coming from the Wembley Sewage Works, which are quite incapable in their present condition of producing a satisfactory effluent. The times may be difficult, but the pollution has been going on for so long a period, and the discomfort to the inhabitants in Ealing is so great that immediate steps are necessary. 24 Drainage and Sewerage. Drainage and Sewerage. Ealing, being a town of comparatively recent development, is almost completely supplied with modern drainage. The sewerage is suitable to the needs of the whole district and consists of two systems, one taking by far the larger proportion of the sewage and discharging approximately 11 million gallons per day into the Southern Sewage Works on the southern boundary, and the other discharging approximately 240,000 gallons per day into the Northern Sewage Works on the northern boundary. The Sewage Works perform their functions admirably, the process at both places being precipitation by means of sulphate of iron followed by intermittent downward filtration or treatment on contact beds. At the Northern Works, the effluent also passes through a humus tank before being discharged into the river. Closet Accommodation. The whole town is supplied by water closets, there being no earth closets and no privies. Practically everywhere there is one closet for each family and where there is less than this provision it means that difficult housing conditions have compelled two or more families to occupy a house originally designed for one. Scavenging. The Ealing Corporation Act requires the provision of a sanitray dust-bin for each house in the district, and this requirement has been consistently enforced, so that apart from isolated instances which are dealt with on discovery the town is completely supplied with dust-bins. Sanitarv Inspections of the District. 25 Removal of household refuse is carried out regularly and efficiently, a collection once a week being the rule. A destructor comprising ten cells, at South Ealing adjoining the Sewage Works, receives the refuse from the whole of the town. 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 287 Number of Nuisances observed by Inspectors 47 Number of Premises Inspected in connection with Infectious Disease 328 Number of Premises Visited by Periodical Inspection (Cowsheds, Dairies, Slaughter houses, Workshops, etc.) 328 Number of Houses Inspected under House-to- House Survey 269 Pood Inspections 4,071 Total number of Re-inspections 6,825 Total number of Inspections and Re-inspections 12,155 Number of Intimation Notices given 697 Number of other Letters written 239 Number of Statutory Notices served 87 dairies, cowsheds and milkshops. Number of Cowsheds on Register 3 Number of Inspections made of Cowsheds 14 Contraventions of Regulations Nil. Number of Dairies and Milkshops on Register 32 Number of Inspections of Dairies and Milkshops 138 Contraventions of Regulations 8 Proceedings before Magistrates Nil. 26 Sanitary Inspections of the District. particulars of the sanitary defects referred to in notices served and letters written : — Water Closets repaired or supplied with water or otherwise improved 217 Drains cleared or cleansed 74 Defects in drains repaired 47 Drains reconstructed 24 Dust-bins provided 172 Overcrowding 2 Accumulations of refuse 44 Fowls and other animals 36 Damp-proof courses inserted in walls 22 Ventilation under floors provided 11 Other forms of dampness 14 Yards paved and repaired 48 Floors repaired 73 Roofs, gutters, and rain water pipes repaired 247 New soil and ventilating pipes 52 Sinks and waste pipes repaired or renewed 44 Draw taps fixed to main supply 8 Other defects or nuisances remedied 310 disinfection. Rooms disinfected :— Ordinary Infectious Disease 355 Phthisis 41 Rooms stripped and cleansed 129 Articles disinfected :— Ordinary Infectious Disease 1,748 Phthisis 230 Articles voluntarily destroyed 142 Sanitary Inspections of the District. 27 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 . Writ'n N'tices Prosecu tions. Factories (including Factory Laundries) 77 7 Workshops (including Workshop Laundries) 182 43 — Workplaces — — — Total 259 50 — 28 Sanitary Inspections of the District. 2.—Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects No. of Prosecutns Found Round Referred to H.M.'r Inspect Nuisances under the Public Health Acts :— nil nil Want of Cleanliness 43 43 Want of Ventilation — — Overcrowding — — Want of Drainage of Floors — — Other Nuisances 42 42 Sanitary Accommodation:— Insufficient — — Unsuitable or Defective 26 26 Not separate for sexes 1 1 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) 25 25 Other Offences (excluding offences relating to outwork which are included in part 3 of this report) 3 3 Total 140 140 nil nil Bakehouses.—There are 27 bakehouses in the Borough, of which three are underground. Of the total number there are 17 where machinery has been installed. Two of the five underground bakehouses noted last year have been abolished. Sanitary Inspection of the District. 29 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. 36 18 32 20 20 24 Cardboard Boxes — — — 1 1 1 Hand Bags 2 1 1 1 1 1 Artificial Flowers — — — 1 1 1 Brush Making — — — 1 1 1 Total 38 19 33 24 24 28 There were no failures to send lists of outworkers nor were there any infringements of the Acts. The . premises were found in all instances to be satisfactory. There were no cases of infectious disease at the premises 4.—The Registered Workshops in the District are as follows :— Bakehouses 10 Laundries 2 Dressmakers 33 Tailors 17 Milliners 15 Upholsterers 8 Miscellaneous 67 Total 152 30 Food. 5.-Other Matters :— Factories in District:— Laundries 5 Bakehouses 17 Boot Factories 2 Optical Instruments 2 26 Premises and Occupations Controlled by Bye-laws or Regulations. There are no common lodging houses within the Borough, and there are no Bye-laws with regard to Houses let-in-Lodgings. The only Offensive Trade in the district is that of fish-fryer. This trade is carried on at nine places. One new fried-fish shop was opened during the year. All were inspected regularly and found to be kept in a satisfactory condition. FOOD. Milk Supply. There are three cowsheds registered in the district. During the year 14 visits of inspection were made, but no contraventions of the Regulations were found. The general condition of all three cowsheds was satisfactory. These cowsheds supply but a very small proportion of the needs of the community, the district being dependent on outside sources for its milk supply. The number of Dairies and Milkshops on the Register was 32, and to these 138 visits of inspection were made Food. 31 during the year. Contraventions of the regulations were found in 8 instances, the defects, which consisted of delay in limewashing, and non-removal of manure, being remedied at once when Notices were served. Milk (Mothers and Children) Order, 1918.—Under this Order the Council has made provision by which expectant and nursing mothers and children under five years of age who are in necessitous circumstances can obtain a supply of milk. The practice adopted has been not to supply the milk at a reduced cost but to supplement the milk supply of the household by a certain amount of milk free of charge, in accordance with the circumstances of the parents. In carrying out the scheme an order is sent to the dairyman who usually supplies the house with milk, specifying the length of time for which it is to be supplied, the practice being to order a certain amount per day for a month at a time, the order being repeated at the end of the month according to the financial circumstances of the case. At the end of each month the dairyman renders his account to the Public Health Department. To begin with, the amount of income per head per week coming into the house, less rent, insurances and travelling expenses, which entitle the mother or child to a free supply of milk under the Order, was fixed at seven shillings, but in February, 1920, this amount was raised from 7s. to 8s. 6d. There can be no doubt that this Order, permitting the provision of milk in necessitous cases, has been of great benefit to both mothers and children. Care, however, has had to be exercised to prevent abuse, for there have been striking instances in which application has been made for a supply of milk, and wrong figures of the income given on the application form. 32 Food. Other Foods. There is no Public Abbatoir, but there are five private Slaughter-houses in the district. These, however, have not been used to any large extent during the year, on account of the large amount of imported meat which is being consumed, and on account of the fresh meat being very largely brought from the Smithfield Market. Most of the animals killed in the private slaughterhouses have consisted of sheep and pigs. Arrangements are made by which the Chief Sanitary Inspector inspects all the animals slaughtered in the district. Regular inspections, at least weekly, have been made of all the butchers' shops in the district. In many instances the vendors have notified the Inspector of the need for inspection of meat or food which has come into their possession. The following is a list of the unsound foodstuffs surrendered voluntarily on account of unfitness for human food :— Food. Quantity. Meat 613 lbs. Bacon 12 „ Carcases (4) of Pigs, etc. 763 „ Liver 9½ „ Fish 668 „ Rabbits 387 „ Condensed Milk 72 tins. Tomatoes 26 „ The four carcases of pigs were delivered in Ealing, having been slaughtered in the country, and were found to be affected generally with tuberculosis. The other foods surrendered were in a putrefactive condition. Food. 33 Sale of Food and Drugs Act. The administration of the Sale of Food and Drugs Acts is under the Country Council The following information of the samples taken for analysis and the results of prosecutions in cases of adulteration is given through the kindness of Dr. Young, County Medical Officer. Nature of Sample. No. of Samples taken. No. found Adulterated. Milk 333 21 Separated Milk 13 — Butter 14 1 Cream 5 2 Cream, preserved 2 2 Coffee 3 — Lard 3 Saccharin 3 — Liquid Eggs 1 — Cocoa 1 — Lime Juice 1 — Aerating Powder 1 — Prescription 1 1 381 27 Number of Prosecutions 1 Number of Convictions 1 Fine imposed £2 The twenty-one samples of milk reported against by the County Analyst included fifteen "informal" samples, and five formal samples in which the deficiency of fat or of non-fatty solids was not serious enough to justify legal proceedings. 34 Infectious Diseases. 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 & Wales 0.01 0.00 0.19 0.04 0.11 0.15 96 Great Towns 0.01 0.00 0.22 0.04 0.14 0.16 148 Smaller Towns 0.02 0.00 0.19 0.03 0.10 0.14 London 0.01 0.00 0.22 0.05 0.17 0.22 BALING 0.00 0.00 0.04 0.01 0.01 0.08 Injections Diseases. 35 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 5 6 10 9 14 12 56 Scarlet Fever 11 25 18 58 44 15 171 Erysipelas 2 5 3 12 4 4 30 Enteric Fever 1 2 2 1 — 6 Puerperal Fever — — 1 3 1 — 5 Cerebro-Spinal Fever 1 — — 1 1 1 4 Ophthalmia Neonatorum 2 — — 3 2 1 8 Encephalitis Lethargica — 1 — — — — 1 Malaria 1 2 3 9 7 5 27 Dysentery — 1 — — 1 — 2 Influenzal Pneumonia 3 8 6 2 2 6 27 Primary Pneumonia 5 6 5 7 9 6 38 Totals 31 56 48 105 85 50 375 36 Infectious Diseases. The following Table shows the number of cases of the principal infectious diseases notified in each of the last ten years :— Disease 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Smallpox — — — — — — — — — — Diphtheria 95 56 57 82 56 37 66 36 46 56 Scarlet Fever 125 187 326 511 458 146 91 61 201 171 Erysipelas 31 31 45 39 39 19 33 24 22 30 Enteric Fever 4 4 5 7 11 5 3 6 5 6 Puerperal Fever 3 — — 2 1 1 — 2 3 5 Crebro-Spinal Fever — — — 1 2 2 1 — 3 4 Poliomyelitis — 2 3 2 — 2 1 — — Ohhthalmia Neonatorum — — — 9 5 8 3 3 4 8 Total 258 280 611 763 574 218 189 133 284 280 Infectious Diseases. 37 Notifiable Infectious Diseases. During the year 1920 the cases of Scarlet Fever and Diphtheria were 227 in number, and were distributed during the year as follows :— Scarlet Fever. Diphtheria. January 23 4 February 13 5 March 19 8 April 8 5 May 17 4 June 7 3 July 9 1 August 6 5 September 6 3 October 16 5 November 19 7 December 28 6 171 56 38 Diptheria. Diphtheria. Diphtheria was slightly more prevalent during 1920 than in the previous two years, although the number of cases, 56, was less than in the year 1917, when the number was 66. As will be seen in the Table on page34, the cases were distributed throughout the whole of the year, the smallest number, one, occurring in July, and the highest eight, in March. The cases were not associated with any ward in particular, but occurred irregularly throughout the town, with little or no relationship between them. Three cases occurred in one house and two in another. There were six deaths from diphtheria during the year, giving a diphtheria death-rate of 0.08 per 1,000 of population. This compares favourably with the rate for England and Wales. death-rate from diphtheria. Ealing 0.08 per 1,000 of population. England and Wales 0.15 ,, ,, 96 Great Towns 0.16 „ ,, London 0.22 „ „ The Bacteriological Laboratory opened during the year should prove of inestimable value to the general Diptheria. 39 titioners in the diagnosis of diphtheria. A laboratory situated locally enables the examination of the swab to be made within a much shorter time than formerly, and an earlier report on the diagnosis to be given. The examination of these specimens is free, no matter what the circumstances of the patient may be. To avoid delay in the administration of antitoxin, which holds out the best chance for the patient, medical practitioners can obtain a supply at the Public Health Department whenever it is required. For this antitoxin cost price is charged to the patient, but where the circumstances are necessitous, no charge is made. During the year 18,000 units of antitoxin were supplied. When cases are nursed in the Isolation Hospital, they are not discharged until two successive reports of freedom from diphtheria bacilli have been received from the laboratory. So also in cases nursed at home, disinfection is not carried out until two successive negative results have been obtained to show the patient free from infection. Thus the Council provide the means of assisting the medical practitioners in the early diagnosis of the disease, in the early administration of the specific treatment, and also in determining when the patient may be considered safe to mix with other members of the community without danger of causing infection. 40 Scarlet Fever. Scarlet Fever. Scarlet fever was less prevalent in 1920 than in 1919, 171 cases occurring in the year under review compared with 201 in the previous year. The number for 1920 was higher than the numbers for 1916, 1917, and 1918, which were respectively 146, 91 and 61, but was less than those for the years 1912, 1913, 1914 and 1915, which were respectively 187, 326, 511 and 450. Ealing shared during the year in the prevalence of the disease in Greater London, which was especially affected in the last quarter, although the extent of the prevalence in Ealing was not so marked as in other Metropolitan areas. The disease, as already mentioned, was most prevalent in the last quarter of the year, which accounted for 63 cases, although the first quarter supplied 55 cases, the second and third quarters supplying respectively 32 and 21 cases. In the Table on page 37, the figures indicating the occurrence of the disease in each month are shewn alongside those for diphtheria. The number of cases in each Ward were as follows :— Drayton. Castlebar. Mount Park. Lammas. M anor . Grange 11 25 18 58 44 15 The Lammas and Manor Wards were most affected, the former having 58 and the latter 44 cases during the year. Scarlet Fever. 41 These Wards not only have a larger population than the others, but they have a larger working-class population with large families of susceptible young children, so that one cannot say that the increased prevalence was due to insanitary conditions. A relationship, and that was of a casual nature, could be found between only a very few of these cases, the instances being unimportant and not worth recording. There was no common source of infection, such as contact in school or infection from food which could be blamed for the occurrence or spread of the disease. In 16 instances, two cases occurred in one house, in one instance three cases, and in another instance four cases occurred in one house. Four " Return " cases have to be recorded, as follows : K.S. developed Jan. 9th. Brother discharged from Hospital, Dec. 16th. M.G. developed Jan. 19th. Brother was discharged on Jan. 13th. D.B. developed Jan. 31st. Brother was discharged on Jan. 17th. P.B. developed July 5th. Brother discharged on June 25th. None of the infecting cases showed any nasal or ear affection when discharged from the hospital, and there was no indication that they might be infectious. 42 Scarlet Fever. To prevent " return " cases as far as possible, great care is taken in dismissing cases from the Isolation Hospital, particular attention being paid to the nose, ears and submaxillary glands, enlargement of which seems to indicate active infection. After dismissal from the hospital all cases are visited at their homes by the Health Visitors at least twice during the first fortnight, and if there is any sign of the ears or nose being affected, further isolation is advised and further exclusion from school directed, repeated visits being made until the condition of the nose or ears is such as to warrant the patient being allowed freedom to mix with other children. It often happens that a patient, on reaching home, develops a nasal discharge, and the precautions indicated are desirable to prevent infection, should the nasal secretions be still infective. During the year the Health Visitors made 113 first visits and 111 subsequent visits to scarlet fever convalescents after their return home. Only one death occurred among the 171 cases of the disease, giving a mortality rate of 0.6 per hundred cases, and a scarlet fever death-rate of 0.01 per 1,000 of population. This death-rate is low compared with that for England and Wales and the 96 Great Towns. death-rate from scarlet fever. Ealing 0.01 per 1,000 of population. England and Wales 0.04 „ 96 Great Towns 0.04 „ „ London 0.05 „ „ Typhoid and Para-Typhoid Fever. 43 Typhoid and Para-Typhoid Fever. One case of typhoid and five cases of para-typhoid fever were notified during the year. The case of typhoid fever, which was confirmed by blood examination, occurred in a child 4 years of age, no source of infection being ascertainable. Of the cases of para-typhoid fever all were females, the ages being 16, 19, 28, 30 and 34. There was found to be no evidence of infection between the cases, which occurred in widely separated parts of the town, and at wide intervals of time. All the cases were confirmed by blood test and found to be paratyphoid B. One case might have had its origin on the Continent, from which she had arrived sixteen days before the symptoms developed. No source of infection could be discovered in the other cases. Encephalitis Lethargica. Only one case of encephalitis lethargica was notified during the year. This was the case of a student, 27 years of age, who presented fairly typical symptoms of the disease. He was removed to a general hospital in London, where he made a good recovery. Cerebro-Spinal Fever. Four cases of cerebro-spinal fever were notified during the year. Two occurred in January, one in September and one in December. Those occurring in January were a man, 36 years of age, who died before he could be removed to the Isolation Hospital from the King Edward Hospital where he had been admitted, and a boy of 44 Malaria, Dysentery and, Pneumonia. 10 years of age, who was removed to the Isolation Hospital, but died ten days later. The third case was a man, 68 years of age, who developed a typical attack of the disease, which left him paralysed in the lower limbs and lower part of the body, and rendered him mentally unstable. He died four months later. A fortunate result occurred in the fourth case, a child 8 months old, who was removed to the Isolation Hospital and was ultimately discharged, the only defect remaining being a convergent squint of both eyes. In three of the cases the diagnosis was confirmed by bacteriological examination. Malaria, Dysentery and Pneumonia. The number of cases of these diseases notified under the Public Health (Pneumonia, Malaria, Dysentery, etc.) Regulations, 1918, were 27 of malaria, 2 of dysentery, 27 of influenzal pneumonia, and 38 of primary pneumonia. All the cases notified were investigated by the Sanitary Inspectors. The cases of malaria and dysentery were men who had developed the disease abroad while on military service. To minimise the danger of the spread of malaria from these chronic cases to the civil population, instructions were given to the patients to keep under treatment, and to deal with mosquitoes which may invade their homes. Further, all stagnant pools of water which might serve as breeding places for mosquitoes were sprayed with petroleum. Influenzal pneumonia was notified to the extent of only 27 cases during the year, indicating the absence of influenza in epidemic form. Tuberculosis. 45 Tuberculosis. Under the Public Health (Tuberculosis) Regulations, 1912, the following notifications were received :— 1-6 yrs. 5-15 yrs. 15-25 yrs. 25-45 yrs. 45-65 yrs. 65 and upwards Total Pulmonary Tuberculosis – – 8 18 30 7 63 Other forms of Tuberculosis — — 7 6 1 3 17 Totals — — 15 24 31 10 80 The number of cases of pulmonary tuberculosis is less by 20 than that of the previous year, and the number of other forms of tuberculosis is 8 less. Medical practitioners appear to recognise the necessity of notifying all forms of tuberculosis, and there is no suspicion that they are failing in any part of their duty with respect to the Regulations. Although the supervision and treatment of cases of tuberculosis comes within the province of the County Council, nevertheless every advantage is taken of notification to have the houses visited at least once by the public health staff, in the first place to ascertain if the patient is securing medical attention, and secondly, to discover if the sanitary environment of the house is satisfactory. With respect to the first, where desirable, the case is referred to the Tuberculosis Officer, and with respect to the second, where insanitary conditions prevail, the assistance of the Tublic Health Acts is invoked in having remedial measures taken by those responsible. 46 Tuberculosis. School children suffering or suspected of suffering from tuberculosis, are regularly referred to the Tuberculosis Officer for continued supervision, the School Nurses visiting and advising the parents to obtain medical examination and advice. The following information, supplied by Dr. Young, 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 1920 by the Tuberculosis Officer and found to be suffering from tuberculosis :— Tuberculosis of Lungs 43 Tuberculosis of Bones, Glands, etc. 10 Number of Persons kept under Treatment at the County Council Dispensary 109 Number sent to Sanatoria 31 Number sent to Hospital 19 The number of visits made by the Health Visitors to cases of tuberculosis were as follows :— First Visits 45 Second Visits 5 Third Visits 1 There were 57 deaths from all forms of tuberculosis during the year, giving a tuberculosis death-rate of 0.74 per 1,000 of population. Of these deaths 42 were Tuberculosis. 47 from pulmonary tuberculosis, or phthisis, 9 from tubercular meningitis, and 6 from other forms of tuberculosis. The pulmonary tuberculosis, or phthisis, death-rate, was 0.55 per 1,000 of population. This rate is less than that for the previous year, and may be compared with those for several years :— Pulmonary Tuberculosis Other forms of Tuberculosis All forms of Tuberculosis 1911 0.53 0.30 0.83 1912 0.62 0.17 0.79 1913 0.54 0.17 0.71 1914 0.50 0.15 0.65 1915 0.72 0.16 0.88 1916 0.73 0.13 0.86 1917 0.92 0.23 0.15 1918 0.94 0.12 1.07 1919 0.75 0.26 1.01 1920 0.55 0.19 0.74 The ages of those dying of phthisis were as follows :— 0-5 yrs. 5-15 yrs. 12-25 yrs. 25-45 yrs. 45-65 yrs. 65 yrs. and upwards. — 1 6 22 12 1 The ages of those dying of other forms of tuberculosis were as follows :— 0-5 yrs. 5-15 yrs. 15-25 yrs. 25-45 yrs. 45-65 yrs. 65 yrs. and upwards. 3 5 5 1 1 48 Measles and Whooping Cough Measles and Whooping Cough. By the Public Health (Measles and German Measles) Regulations, 1915, Recision Order, issued in Novenber, 1919, measles ceased to be compulsorily notifiable in January, 1920. The cessation of notifications has not been to the disadvantage of public health efforts to deal with this disease, for by the weekly notifications from the schools of all non-notifiable infectious diseases very accurate information regarding cases is provided. The cases so notified are visited by the health visitors, who give instructions regarding the care of the sick and the protection of the uninfected, and provide in some instances nursing assistance. Measles was epidemic in the town during March, April, May and June, the maximum number of cases occurring in May. The absences recorded from the schools owing to measles in the home was as follows :— Jan. Feb. Mar. April. May. June July. Aug. Sept. Oct. Nov. Dec„ 3 6 95 200 319 100 14 1 — 1 3 — Total 742 These absences were not all actual cases of the disease, some being due to the disease in other members of the house. Nevertheless, they give some idea of the prevalence, and the notifications are sufficient to direct our attention to the individual homes infected. There were only three deaths from measles, giving a measles death-rate of 0.04 per 1,000 of the population. In the following Table the measles death-rate for Ealing is compared with that for England and Wales, etc. :— Measles and Whooping Cough. 49 death-rate from measles, 1920. Ealing 0.04 per 1,000 of population. England and Wales 0.19 ,, ,, 96 Great Towns 0.22 „ „ London. 0.22 ,, ,, The scheme of notification from the schools operates also with regard to whooping cough, all of which cases are also visited by the Health Visitors. While whooping cough was present during the same months as measles, it did not reach the same epidemic proportions. The notifications of absences from^the schools were as follows :— Jan. Feb. March, April. May. June. July. Aug. Sept. Oct. Nov. Dec. 2 2 9 22 24 15 — 1 3 1 6 19 Total 104 The death-rate from whooping cough was also very low and may be compared with the death-rate for England and Wales, etc. death-rate from whooping cough, 1920. Ealing 0.01 per 1,000 of population. England and Wales 0.11 ,, „ 96 Great Towns 0.14 ,, ,, London 0.17 ,, ,, 50 Maternity and Child Welfare. MATERNITY AND CHILD WELFARE. General Arrangements. The comprehensive and more or less complete scheme for attending to the health of expectant and nursing mothers, and of children under 5 years of age, may be summarised as it was in the Annual Report for last year, as follows :— Arrangements for the Care of the Mother. 1. The supervision of midwives. 2. The visiting of expectant mothers by Health Visitors. 3. Consultations for expectant mothers (Ante- Natal Clinic—Dr. Bell). 4. Home helps when necessary. 5. Maternity (midwife) aid when necessary. 6. Medical aid when the midwife requires skilled help. 7. Consultant aid (Dr. Bell) when the medical attendant requires assistance in abnormal or complicated confinements. 8. Hospital provision for normal and abnormal or complicated confinements. 9. Nursing at home of cases of puerperal fever. 10. Treatment at the Isolation Hospital of cases of puerperal fever. 11. Dental treatment and the provision of artificial dentures at the School Clinic for nursing and expectant mothers. Maternity and, Child Welfare. 51 12. The provision of milk free of charge for tous nursing or expectant mothers. 13. The treatment of diseases of women (after effects of abnormal or complicated confinements) at the King Edward Hospital. Arrangements for the Care of the Child up to five years of Age. 1. The visiting of infants and children under 5 years of age by Health Visitors. 2. Consultations for children under 5 years of age at the Welfare Centre (Dr. Grace Banham). 3. Operative treatment for enlarged tonsils and adenoids, dental and ophthalmic treatment, and treatment of minor ailments at the School Clinic. 4. The visiting of all cases of measles and whooping cough notified through the schools. 5. The nursing of serious or complicated cases of measles, whooping cough, infant diarrhoea, and poliomyelitis. 6. The treatment of cases of measles at the Isolation Hospital. 7. The home nursing of cases of ophthalmia torum. 8. The treatment of serious cases of ophthalmia neonatorum at the Isolation Hospital. 9. The treatment of wasting or ailing children at the King Edward Memorial Hospital. (Six beds reserved). 52 Maternity and Child Welfare. 10. Operative treatment for such conditions as phimosis, etc., at the King Edward Hospital. 11. The provision of milk for the children of parents who are in necessitous circumstances. 12. The supply of dried milk, paraffin for internal use, " Chymol," olive oil and umbilical belts at wholesale prices (and in special cases free of charge) to mothers unable to afford the usual cost of such articles. 13. A Day Nursery for children whose mothers have to go out to work. 14. A Hostel for unmarried mothers and their babies. This is the scheme as it was in operation at the end of 1919. No additions were made in 1920. But the work has been continued in the same energetic manner by the staff, with the whole-hearted support of the Maternity and Child Welfare Committee, improvements being made in the details of the administration or management as were demanded by experience. The popularity of the Welfare Centre, situated as it is in a central, convenient and pleasant position, has continued unimpaired, and the co-ordination of the work of the Maternity and Child Welfare Department with the School Medical Service, both of which departments are in the same building, has been, if anything, closer than formerly. This is very desirable if the continuous supervision of the children is to be maintained from birth until the end of school life. Maternity and Child Welfare. 53 Arrangements for the Care of the Mother. 1. The Supervision of Mid-wives.—In the Annual Report for 1919 remarks were made on the anomolous position in which the Borough Council was placed by the legislature putting the supervision of the midwives, who form part of the Maternity and Child Welfare Scheme of any district, entirely under the supervision of the County Council without any power of delegation. Fortunately, the need for the supervision of midwives in Ealing is not so great as it is in large industrial centres, for the great majority of births are attended by doctors who take responsibility for the cases. Midwives may be present, but the responsibility is taken off their shoulders. As the majority of confinements are attended by doctors, it naturally follows that few midwives find the opportunity of gaining a livelihood in the district. There are only nine registered as practising,' and all hold certificates of training. All co-operate in a splendid manner with the Health Visiting Staff, and a good feeling exists between them, The Health Visitors visited 984 of the 1,465 births notified. As those not visited were in the best class of houses in the district, it may be presumed that doctors attended at the confinement in all of them. Of those visited by the Health Visitors it was found that • only 217 were attended by midwives alone, 67 were attended by doctors and midwives, and 580 had doctors and untrained women. Thus out of 1,465, 217, or 15 per cent., were attended by midwives alone—a very small percentage compared with other districts. 2. Visiting of Expectant Mothers.—The Health Visitors made 159 visits to expectant mothers. Of these visits, 89 were first visits, 38 second visits, 15 third 54 Maternity and Child Welfare. visits, and 17 subsequent visits. As so many of themothers are attended at their confinements by doctors who are engaged some time beforehand, the need for home visiting is not so great as in industrial areas. The fact of the midwives all being trained also renders the visiting by the Health Visitors less necessary. 3. Consultations for Expectant Mothers (Ante-Natal Clinic).—The number of expectant mothers coming to the Centre to consult Dr. Bell showed an increase on the previous year. The Ante-Natal Clinic was open on 25 afternoon sessions in the year, and 70 mothers presented themselves for examination and advice, 64 return visits being made by them. Many of these cases were referred to the Clinic by the midwives who were engaged by the women, and some were referred by doctors. The total consultations during the year were 134, or an average of 5 per session. 4. Home Helps.—Home Helps were provided in 15 cases during the year, the circumstances in all being necessitous the whole cost was defrayed by the Council. The Home Helps, who are paid at the rate of £1 1s. per week, are kept under the supervision and are regularly under the instruction of the Health Visitors. Although they have not received a course of training, they receive such individual attention from the Health Visitors that they prove very satisfactory at their work. 5. Maternity Aid.—A midwife was supplied free of charge by the Council in 6 cases in which, through necessitous circumstances, the husband was unable to afford the cost. Maternity and, Child Welfare. 55 6. Medical Aid.—Payment for the doctor called in by the midwife was paid for in only one case. As such a small proportion of confinements are attended by midwives, it necessarily follows that the occasions for calling in medical aid will be few in number, although it must be admitted that one in 217 cases attended by midwives is a small proportion. It can only be assumed that when the midwife has required to call in medical aid, the husband has been able to pay the doctor's fee. 7. Consultant Aid.—Dr. Bell was called in by doctors in seven serious cases of complicated confinement. The provision of a consultant is greatly appreciated by the doctors, who are glad of advice in cases which are apt to cause them a great deal of anxiety. There is no doubt that the early provision of skilled advice and operative interference is the means in these cases of saving the lives, not only of some of the mothers, but of the children. 8. Hospital provision for normal and abnormal confinements.— As noted in the Report for 1919, it has been very difficult to provide for these cases in Dr. Bell's home, owing to the great demands of private paying patients. During the year the Council provided maternity home accommodation for 11 cases, but other cases had to be referred to the Infirmary and to Hospitals in London, on account of the lack of accommodation in Ealing. The amalgamation of the Chiswick and Ealing Isolation Hospitals, and the arrangement by which the former will become the Maternity Hospital and the latter the Isolation Hospital serving the two districts, will 56 Maternity and, Child Welfare. meet the needs of both districts for hospital provision for normal and abnormal confinements. In another part of this Report, the nature of the amalgamation is alluded to in full. The Maternity Hospital, which will provide 16 beds, is expected to be opened on the 1st May, 1921. The Chiswick Hospital consists of excellent modern buildings with well arranged wards and administrative block. There is accommodation for a general ward, a labour ward, a children's ward, and an isolation ward. In the future, at a comparatively small cost, an extension of the hospital can be readily accomplished, so as to make more beds available and to provide an operating theatre. 9 and 10. Nursing and Hospital Treatment of Puerperal Fever.—Five cases of puerperal fever were notified. All the cases were attended by doctors at their confinement. Three of the cases were removed to the Isolation Hospital for treatment, one being subsequently removed to the King Edward Hospital for operation, one was removed to the infirmary, and one was nursed at home. Two of the cases died. The circumstances of all the cases were investigated by the Health Visitors, but there was no occasion for them to give nursing assistance. 11. Dental Treatment and Provision of Artificial Dentures.—Twelve mothers received dental treatment at the School Clinic, nine of these being subsequently supplied with artificial dentures. The cost of the dentures to the Council during the year was £38 1s. 0d. and Maternity and Child Welfare. 57 the amount received from the mothers was £6 13s. 6d. For dental treatment the sum of 15s. 6d. was also received from the mothers. 12. Provision of Milk for Expectant and Nursing Mothers and for Children under 5 years of age.—Under the Milk (Mothers and Children) Order, 1918, milk was supplied in the manner indicated in a previous section of the Report to expectant and nursing mothers in necessitous circumstances. The extent of this provision was as follows :— 39 mothers received 1 pint of milk for 1 month. 29 „ „ 1½ pints „ „ 1 „ 64 „ „ 2 „ „ „ 1 „ 20 „ „ 1 pint „ „ 2 months. 21 „ „ 1½ pints „ ,, 2 35 „ „ 2 „ „ „ 2 „ 3 „1pint „ ,, 3 „ 5 ,, „ l½ pints „ „ 3 „ 12 2„ 3 „ 1 „ 2 „ „ „ 5 „ Total 229 Under the same Order the amount of milk supplied to children under 5 years of age was as follows :— 26 children received 1 pint of milk for 1 month. 21 „ 1½ pints „ „ 1 month. 3 „ 1 pint „ „ 2 months. 2 „ 1½ pints „ „ 2 1 „ 1 pint „ „ 3 2 „ l½ pints „ ,, 3 1 „ 1 pint „ „ 4 Total 56 58 Maternity and Child Welfare. In addition to this supply of milk through the dairyman, dried milk was supplied in nine cases, the amount supplied being two pound packets per week over a period of one month in eight cases, and over a period of two months in one case. Altogether there were 306 applications for a free supply of milk. In 294 cases a free supply was granted, but in 12 the application could not be acceded to on account of the income of the parents being above the amount sanctioned by the Council, viz., 8s. 6d. per head per week, after deducting rent, insurances, and railway fares. The number of cases dealt with shows a great increase over the previous year, which increase is accounted for by unemployment, in which Ealing has shared with the rest of the country. 13. Treatment of Diseases of Women.—Although no definite arrangements have been made between the Council and the King Edward Memorial Hospital with regard to the treatment of women suffering from abnormal conditions resulting from child-birth, four cases were received for treatment from the Welfare Centre, all of which required operative treatment. Arrangements for the Care of the Child. 1. Visiting of Infants and Children under five years of age.—Under the Notification of Births Act, 1907, there were notified during the year 1,465 births, of which 37 were still-births. There were 50 failures to notify, the father, doctor and nurse in each case being informed of the failure to comply with the provisions of the Act. Maternity and Child Welfare. 59 The persons notifying were as follows :— Doctor or Midwife Nurse. Doctor & Midwife. Parent. Parent & Doctor. 958 469 13 21 4 The Health Visitors made the usual visits of instruction in 984 of the 1,465 living births notified and visits of investigation in 12 of the 37 still-births. They also visited 833 children under 5 years of age. The following Table gives the total number of visits made to children under one year and to those between one and five years of age :— TOTAL VISITS OF HEALTH VISITORS. To Infants under 1 year. To Children 1-5 years. Number of first visits 984 833 Number of second visits 874 473 Number of third visits 566 251 Number of fourth visits 345 237 Number of fifth visits 270 86 Number of sixth visits 97 51 Number of seventh visits 48 23 Number of eighth visits 18 14 Number of ninth to twelfth visits 17 15 Total Visits 3,219 1,983 The Health Visitors also investigated 63 of the 64 infant deaths registered during the year. 2. Consultations for Children at the Welfare Centre.— The Welfare Centre continues to do excellent work in encouraging the consultations for children under 5 years of age. The following Table indicates the extent to which the consultations have been taken advantage of:– 60 Malernuy and Child Welfare. WELFARE CENTRE. CHILD CONSULTATIONS. Number of Children on register at end of 1919 929 Number of Children on register at end of 1920 1,067 Children visiting for the first time 671 Mothers visiting for the first time 671 Total attendances made by children 4,818 Total attendances made by mothers 4,178 Average attendance at each afternoon Children 30 Mothers 29 Average total each afternoon 59 Children seen by Doctor during the year 2,189 Average number of children seen by the Doctor each afternoon 16 The Welfare Centre is open for child consultations on three afternoon sessions per week, Dr. Grace Banham being in attendance on these occasions. This number of afternoons appears to meet the demands of the town. There has been during the year no increase in numbers demanding an increase in the number of sessions. In connection with the child consultations, the Health Visitors made 1,492 special visits to the homes, either to see that the treatment advised was being carried out, or to report on the further progress of the child, or to advise regular attendance at the Centre. 3. Operations and Treatment at the School Clinic.— Thirty-two children under 5 years of age were referred to the School Clinic for treatment, 6 being for diseases of the eyes, 8 for diseases of the throat, including enlarged 61 Maternity and Child Welfare. tonsils and adenoids for operation, 13 were for dental caries, and 5 for diseases of the nose. The Health Visitors also carried out a certain amount of treatment for minor ailments at the homes of the children, necessitating 20 special visits during the year. 4 and 5. Visiting of Cases of Measles, etc.—The Health Visitors made 546 visits to cases of measles, 50 to cases of whooping cough, and 7 to cases of influenza, giving advice on the care of the children and assisting in the application of treatment. Information regarding cases of the first two diseases was obtained through the schools, the head-teachers of which notified weekly all cases of non-notifiable infectious disease. Ten cases of measles were admitted to the Isolation Hospital, owing either to bad home conditions and the difficulty of isolating the patients, or to their serious condition. No cases of poliomyelitis were notified during the year. Infant diarrhoea was practically absent. 6. Ophthalmia Neonatorum.—Eight cases of ophthalmia neonatorum were notified during the year. In all the cases a doctor was present at the birth, a trained nurse being with the doctor in one case and an untrained woman, or monthly nurse as she is called, being present with the doctor in seven cases. Five were treated at home by the monthly nurse, under the supervision of the doctor in attendance, two were admitted to the King Edward Hospital, Ealing, and one was treated at an Eye Hospital in London. Six cases recovered completely without any impairment, but a certain amount of permanent damage to the cornea occurred in the remaining two cases. The Health Visitors 62 Maternity and Child Welfare. were not called upon to treat any of the cases, although 27 visits were made to make enquiries and to see that the treatment was being carried out properly by the nurse in attendance. 7. Hospital Treatment forWasting and A iling Children —Six beds in the Children's Ward at the King Edward Memorial Hospital are placed at the disposal of the Council for wasting or ailing children under 5 years of age, the charge made by the Hospital Committee to the Council being £2 2s. each child per week. During the year 23 cases were admitted. The shortest stay of any child in Hospital was one day, the longest stay of any child was 36 and 4-7th weeks, and the average for all the children 7 and 5-7th weeks. 8. Operative Treatment, Circumcision, etc.—The King Edward Hospital undertakes to carry out small operations such as circumcision at a charge to the Council of 7s. 6d. per case, the parents paying the amount to the Council, the cost being remitted where the parents are in necessitous circumstances. During the year 36 of these cases were referred to the hospital for operative treatment, at a cost to the Council of £13 10s., the amount repaid by the mothers being £10 1s. 3d. 9. Provision of Milk for Children under five years of age.—This has been considered in a previous paragraph when dealing with the supply of milk to expectant and nursing mothers. 10. Supply of Dried Milk, etc.—At the Welfare Centre dried milk can be obtained at cost price by mothers who cannot strictly be called necessitous, but who cannot afford to pay the usual retail price. 63 Maternity and Child Welfare. Those supplied are only mothers who are known to the Health Visitors and who attend the Welfare Centre regularly to seek advice and to give an account of the progress of their children. During the year 7,507 pound packets of dried milk, representing in money value £849 3s. 4d., were sold at the Centre. Chymoll Virol, cod-liver oil emulsion, paraffin oil for interna, use, olive oil and malt, were also sold at cost price under similar circumstances, the sales of these articles amounting to £103 15s. 3d. 11. Day Nursery.— There was a distinct falling off in the use of the Day Nursery. The total attendances during the year were 5,365, compared with 6,244 during the previous year, the average attendauce being 21, compared with 24 for the previous year. The new cases admitted were 49 compared with 54 for 1919. The decrease in number was most evident during the last quarter of the year, and was apparently due to a number of the women who formerly sent their children being thrown out of employment by trade depression, the trade in which the mothers are most interested in Ealing being laundrying. 12. Hostel for Unmarried Mothers and their Babies.— The history of the inception of this institution was noted in the Annual Report for last year, and was brought up to the formation of a voluntary committee with the four women members of the Maternity and Child Welfare Committee as a nucleus. This voluntary committee found they could not undertake to collect voluntary subscriptions, and it was ultimately disbanded. The Maternity and Child Welfare Committee then took over 64 Maternity and Child Welfare. the full responsibility, and appointed the four women members of their Committee as a Management SubCommittee. The Hostel has been open under the authority of the Council since June, 1920. There is accommodation for 11 unmarried mothers and their babies, and during the whole of the time it has been open there have been not less than ten mothers present. Summary of the Work of the Health Visitors. It is appropriate that all the visits of the Health Visitors should be summarised at the end of the account of the Maternity and Child Welfare work, so as to give an idea of the extent of their activities. Visits to infants and children under 5 years of age 5,005 Visits to expectant mothers 159 Visits to children or mothers attending the Welfare Centre 1,266 Visits to investigate infant deaths and still-births 75 Special visits or investigations 226 Visits to cases of ophthalmia neonatorum 27 Visits to cases of pueperal fever 8 Visits to cases of measles 546 Visits to cases of tuberculosis 51 Visits to cases of scarlet fever discharged from the Isolation Hospital 224 Other visits 81 Total Visits 7,668 Interviews, etc. 653 65 Maternity and Child Welfare. This table shows a considerable increase in the work during the year, 7,668 visits in 1920 compared with 4,226 in 1919 and 653 interviews in 1920, compared with 320 in the previous year. It is desirable to draw attention to the number of interviews recorded. They take place at the Welfare Centre and arise when the mothers desire to consult the Health Visitors urgently, at other than the regular times of medical consultations, concerning their own or their children's health, or when they are seeking information regarding medical or other aid for themselves or their children. These interviews, which have proved most useful, have shown the desirability of having the Centre open all day, and of having there some responsible person who can give advice of a hygienic nature and at the same time answer enquiries. SANITARY ADMINISTRATION OF THE DISTRICT. Staff. The inspectorial staff consists of the Chief Sanitary Inspector and two District Inspectors. The Chief Inspector deals particularly with the inspection of meat and other foods, and the inspection of dairies, cowsheds and milkshops, and also supervises the work of the District Inspectors, whom he assists or advises and from whom he takes over any work which he or the Medical Officer of Health considers of such importance as to require his own personal attention. All the general sanitary work of the district is divided between the two District Inspectors, the one dealing with the Northern and the other the Southern half of the Borough. 66 Sanitary Administration of the District Three Health Visitors are employed in the Public Health Department, one acting as Senior, who has supervisory and other special duties, the other two acting as District Health Visitors, their areas being similar to those of the District Inspectors. Hospital for Infectious Diseases. The Isolation Hospital for Infectious Diseases is situated on the southern boundary, the breadth of a road separating it from Chiswick Hospital and the breadth of another road separating Chiswick from Brentford Hospital. A suggestion put forward in 1919 that thesn three hospitals should be combined with a view te saving expenditure resulted in a conference betweeo representatives of the three District Councils. Ultimately the Brentford Council withdrew from the discussion, declining to consent to any amalgamation, but the Chiswick and Ealing Councils were able to come to an agreement by which the hospitals will be managed by a Joint Committee, the Ealing Hospital, with the Medical Officer of Health of Ealing as Superintendent, as at present, to be the Isolation Hospital, and the Chiswick Hospital, with the Medical Officer of Health of Chiswick as Superintendent, to be the Maternity Hospital for the two districts. The proposals are best understood by reference to the report which was submitted by the Medical Officer of Health, and to the report of the conference between the representatives of the Borough of Ealing and of the Urban District of Chiswick. It was further decided that the Joint Committee should take over the control of the Hospitals on the 1st April, 1921. 67 Sanitary Administration of the District, REPORT TO THE PUBLIC HEALTH COMMITTEE. 31 st May, 1921. " Suggested Combination of Brentford, Chiswick, and Ealing Isolation Hospitals." "I beg to submit, as requested, some suggestions with regard to the proposal, which has already been discussed by representatives of the three districts concerned, for a combination of the three Isolation Hospitals supplying the needs of Brentford, Chiswick, and Ealing, which are situated in close proximity to each other in South Ealing. "Brentford Hospital possesses 29 beds for a population of 17,000, Chiswick 20 beds for a population of 43,500, and Ealing 100 beds for a population of 64,480. Together the accommodation is 149 beds for a total population of 124,980, or one bed for 838 of the population. The outstanding debts for the three Hospitals are respectively £324, £8,168 and £11,506, but it has to be noted that Brentford Hospital has a large portion of its buildings of a temporary character, Chiswick and Ealing Hospitals being modern and substantially built institutions. "The desirability of a combination is evident when one considers that since the end of 1915 the Ealing Hospital could have accommodated at any time all the infectious cases from the other districts, without being taxed beyond its ordinary resources and when one considers that at times each hospital has had to retain its staff over long periods with but a few patients in each. 68 Sanitary Administration of the District, "It is well known that the smaller the hospital the greater is the average cost per patient, and also, though it is not a corollary, that the more patients to be dealt with within one institution the smaller the average cost, so that we have here other arguments in favour of a collection of the cases in one hospital. "The average cost of maintenance per patient (excluding capital charges) in the three hospitals, during the years ending 1917-18-19 was respectively for Brentford £38 15s. 5d., for Chiswick £42 11s. 7d., and for Ealing £19 5s. 0d. "The Brentford Council is in a favourable position as regards capital charges, which are so low as £191, compared with £836 for Chiswick and £1,018 for Ealing, but on the other hand the annual maintenance expenses for Brentford are high, on the average £1,045 (population 17,000), compared with £1,859 for Chiswick (population 43,500) and £2,457 for Ealing (population 64,480) for the average of the three years 1917-18-19. Considering the capital charges and the maintenance together, the annual costs, taking the oapital charges for 1919 and the average of three years' maintenance work out at £1,236 for Brentford, £2,695 for Chiswick, and £3,476 for Ealing. If we take this average total outlay and calculate it according to rateable value, we find that Brentford would have to pay an annual amount of £884 compared with £2,245 for Chiswick and £4,278 for Ealing. Brentford would gain substantially and Ealing would be penalised on account of its high rateable value. "If there is to be a combination of hospitals, the only prarticable method would be by means of a Joint 69 Sanitary Administration of the District. Committee or Board, each district being represented according to rateable value. "The three hospitals could be combined, or two only. If all three were combined, Ealing Hospital could be set aside as an Infectious Hospital for all the three districts, there being 100 beds available normally and 150 in epidemic times, Brentford Hospital being kept available as an overflow hospital, to be staffed and used only when the emergency necessitates its use. Chiswick Hospital would thus be freed, and could be used as a Maternity Hospital, which is so much needed in Ealing, and, I believe, needed in Chiswick and possibly Brentford. "If Brentford is unwilling to come in, and one is led to consider this on account of the attitude of the representatives at the Conference, then the Ealing Hospital could easily deal with infectious cases from Chiswick and Ealing, the Chiswick Hospital being freed to take in maternity cases from both Ealing and Chiswick. "In a combination, one must consider the possible displacement of the staff. As to the first combination, the Matrons of the Ealing and Chiswick Hospitals could remain as they are and the Matron of the Brentford Hospital could be appointed Deputy Matron of either the Ealing or Chiswick Hospital. "With regard to the Medical Staff, Brentford has Dr. Bott, M.O.H., as superintendent and medical attendant, Chiswick has Dr. Brebner, M.O.H., as superintendent and medical attendant, and Ealing has the M.O.H. as superintendent and his assistant as medical attendant. If Chiswick and Ealing Hospitals were combined, the medical staffing could remain the 70 Sanitary Administration of the District. same but if Brentford, Chiswick and Ealing were all three combined, a more difficult position arises to consider for one hospital (Brentford) would be abolished, and would cause the displacement of Dr. Bott, and the consequent loss to him of £100 a year unless another position be found for him. "In such a combination a medical superintendent over all three hospitals would be the ideal arrangement, for then they could be administered impartially so as to meet the needs of all districts, the staffs could be so managed that there would be some arrangement between them in unusual times when nursing help could be sent from one to the other, and lastly the stores could be supplied to all three from a central stores department under the same superintendence. "If such a medical superintendent were appointed he would be purely an administrative officer, and a medical attendant would be appointed for the Ealing Hospital and one for the Chiswick Hospital. "However, such an arrangement is not practicable when the positions of Dr. Bott and Dr. Brebner are considered. In my view two arrangements are practicable. Dr. Brebner could retain his position as medical superintendent of Chiswick Hospital should it be made into a Maternity Hospital. As to Ealing Hospital, either I could retain the position of medical superintendent, with Dr. Bott as medical attendant, or Dr. Bott could become medical superintendent with Dr. Garrow, Assistant Medical Officer for Ealing, as medical attendant as he is at present. "Either of these two arrangements would provide for the three districts being represented on the medical staff at the initial stage. "THOMAS ORR, "Medical Officer. 71 Sanitary Administration of the District. "REPORT OF CONFERENCE "between Representatives of the Borough of Ealing and "the Urban District of Chiswick, relative to the Isolation "Hospitals of the two Authorities, held at the Town "Hall, Ealing, on the 25th October, 1920. "Combination of Isolation Hospitals.—The Chairman briefly outlined the proposals which had been discussed by Committees of the two Local Authorities (hereinafter referred to as The Authorities') relative to the formation of a Joint Committee to manage in combination the Ealing and Chiswick Isolation Hospitals, in order that the former may be used for the isolation of infectious cases, and the latter for maternity cases, from both districts. "After giving the matter full consideration, it was unanimously resolved to recommend the respective Councils:— "That in exercise of the powers conferred by Section 57 of the Local Government Act, 1894, and of any other powers conferred by statute, a Joint Committee be formed as aforesaid, to be constituted by the appointment by the Ealing Town Council of five representatives from that body, and by the appointment by the Chiswick Urban District Council of three representatives from the Urban District of Chiswick. "That the apportionment of expenditure be based upon the rateable values of the two districts. "That the powers of the Committee be limited to the payment of all ordinary expenses of maintenance, upkeep and general repairs. 72 Sanitary Administration of the District. ''That capital expenditure to be shared by both the Authorities, shall not be incurred in respect of either building, without the sanction of the said Authorities. "That the period of such management as aforesaid shall be twenty-one years terminable at the end of the 7th or 14th year by two years' previous notice in writing, given by either authority to the other, the terms of dissolution at the expiration thereof failing agreement to be settled by arbitration; and "That the Corporate and Common Seals of the respective Authorities be impressed upon a Deed, to be entered into embodying the foregoing terms. "The question relative to the appointment of Chairman, Treasurer, Clerk, the place of meeting, and other minor details to be left for settlement by the Joint Committee when formed. "It was also resolved to recommend that the Medical Officers of Health and Surveyors of the Authorities be requested to report as to the cost of the adaptation of each hospital for use as aforesaid." These recommendations were approved by the Chiswick Urban District Council and by the Ealing Town Coupcil. Treatment for Infectious Cases at the Isolation Hospital. The following Table gives the number of cases treated in the Isolation Hospital during the year and the number remaining in the Hospital at the end of the year:— 73 Sanitary Administration of the District. 7i Disease. Remaining in Hospital Dec. 31st, 1919. Admitted to Hospital during 1920. Remaining in Hospital Dec. 31st, 1920. No. of Deaths Scarlet Fever 28 144 28 1 Diphtheria 6 68 4 5 Enteric Fever — 2 — — Paratyphoid Fever — 1 — — Puerperal Fever — 3 — — Erysipelas — 1 — — Measles — 10 — 1 Chicken Pox — 2 2 – Cerebro-Spinal Fever — 2 1 1 Meningitis — 1 — 1 Pneumonia — 1 — — Cellulitis — 1 — 1 Total 34 236 35 10 Scarlet Fever.—The number of cases of scarlet fever admitted to hospital was 144. Four of these were from the Greenford Urban District. The ages of the patients were as follows:— Age No. 1-5 yrs. 46 5-15 yrs. 81 5-25 yrs. 13 25-35 yrs. 3 35-45 yrs. 1 74 Sanitary Administration of the District. Amongst the patients treated the following complications were recorded Rhinitis 7 Otitis 5 Albuminuria 4 Rheumatism 2 Measles 6 Chicken-pox 3 Herpes Zoster 1 Only one death occurred from scarlet fever during the year. The average period of residence in the hospital was 40 days. Four "return" cases occurred. These have been recorded in dealing with scarlet fever elsewhere in the Report. Diphtheria.—The number of cases admitted as diph theria was 68, ten of which were found not to be suffering from the disease. Fourteen of the cases were admitted from the Chiswick Urban District. The ages of the patients were as follows:— Age No. 0-1 yrs. 1 1-5 yrs. 23 5-15 yrs. 33 15-25 yrs. 5 25-35 yrs. 1 35-45 yrs. 2 45-50 yrs. 3 Tracheotomy was performed in three cases. Ten other cases suffered from complications, six from albuminuria and four from paralysis of the palate. Five deaths occurred. The average duration of residence in hospital was 24 days. The other cases of infectious disease treated in the Isolation Hospital call for little comment. They consisted of two cases of typhoid fever, one of para-typhoid fever, one of erysipelas, one of cellulitis, three of 75 Sanitary Administration of the District. puerperal fever, two of cerebro-spinal fever, one of tubercular meningitis, one of pneumonia admitted as cerebro-spinal fever, two of chicken-pox, and ten of measles. Amongst these there were four deaths, one of tubercular meningitis, one of cerebro-spinal fever, one of cellulitis, and one of measles complicated with broncho-pneumonia. The total cost of the hospital for the year April, 1920, to March, 1921, was £6,112 4s. 6d., or an average cost for each patient for food, medical and nursing attendance of 12s. 6d. per day. As the food alone cost £1,204 3s. 9d. in the same time, the average cost of food for each patient, or each member of the staff, was 1s. 7d. per day. This figure indicates very economical management. On the northern boundary are the Small-pox Hospital and Reception House. There has been no occasion to use either of these for some years. Local Acts, Adoptive Acts, etc. The Ealing Corporation Act, 1905, confers additional powers on the Council with respect to certain sanitary matters, the provision of dust-bins, the drainage of houses by combined operation, the control of tuberculous milk, etc. Other Acts which have been adopted by the Council are Public Health Acts (Amendment Act,) 1890. Infectious Disease (Prevention) Act, 1890. Public Health Acts (Amendment) Act, 1907. Bacteriological Laboratory. On the 1st July a laboratory was opened in the Public Health Department for the examination of 76 Sanitary Administration of the District logical specimens submitted by general practitioners and by members of the Public Health Staff. The presence of a laboratory in the district is a decided acquisition not only to the practitioners in the nieghbourhood but to the Department, for it enables a diagnosis to be carried out with the least possible delay and with the least possible trouble in the transmission of the specimens. Besides, the laboratory will effect a considerable saving in expenditure for the cost of the examination of specimens at the commercial laboratories has been going up with the cost of other services. The following is a summary of the examinations carried out during the year:— At Lister Institute (until June 30th): Positive. Negative. Total. Diphtheria 19 47 66 Tuberculosis 2 3 5 Others — 3 3 21 53 74 At Public Health Laboratory (after July 1st): Positive. Negative. Total. Diphtheria Hospital 41 93 134 Private 18 81 99 Tuberculosis 5 23 28 Others 4 6 10 68 203 271 77 Housing. HOUSING. General Housing Conditions In the District. The general housing conditions are good, most of the town being of modern growth, the houses being arranged with plenty of space between them. Large expanses of public recreation ground have been provided by the Local Authority. Like other districts, and for the same reasons, Ealing is suffering from a dearth, not only of the working-class, but of the better class houses, although perhaps the difficulties are not so acute as in many industrial areas. It is difficult to gauge the extent of the shortage, but the figure given last year of 500 may be roughly correct. To meet this shortage private enterprise is only coming forward to a very limited extent, but the Town Council, by its Housing Scheme inaugurated in 1919, is making provision for 245 working-class dwellings. During 1920 private enterprise completed 30 houses, of which 5 were working-class dwellings, and the Council completed 72, all of which were houses designed for the working-classes. No unusual changes in population have been experienced during the year, and none are contemplated in the future, to affect the housing problem. Overcrowding. Overcrowding undoubtedly exists owing to the difficulty in obtaining houses. Two, and in some cases three, families are housed in dwellings originally designed for one family. In last year's Report the number of houses occupied by more than one family, although only de signed for one, was estimated at 481;. This number 78 Housing. can only have been reduced to a small extent by the 77 working-class dwellings completed during the year. It is difficult, if not impossible, to deal with overcrowding while the demand for houses is so acute. What can be done, however, is to alleviate the conditions by a re-arrangement of the rooms of each house so that one part is not more crowded than another, and so that sleeping accommodation is not too much restricted, or, in other words, that undue overcrowding in bedrooms s prevented. Fitness of Houses. The general standard of fitness in the houses in the town is high. In only three small areas can the houses be said to approach slum conditions, and these conditions are to a slight extent due to the old construction of the houses, but to a large extent due to the carelessness of the tenants. Those houses considered to be unfit for human habitation are very small in number, not more than thirty. Then condition is due to dampness want of through ventilation and general dilapidation, the defects being of such a serious character that it is not profitable for the owners to remedy them, and the re-housing difficulties being so great that it is unwise to order closure. In many of the houses defective conditions have been allowed to persist and to get worse owing to the unwillingness of the agents and owners to expend a large amount of money on their improvement, the high cost of the work being the usual excuse when remedial measures are demanded by the Inspectors. Much good work, however, has been done during the year, in spite 79 Housing. of the unwillingness of those responsible to expend large sums of money on improvements. Whatever improvements have been carried out have been done thoroughly and with the view of permanent and not temporary amelioration. All action has been taken under the Public Health Acts, the Housing Acts not having been resorted to. Although it was necessary to have 87 statutory notices under Section 91-94 of the Public Health Act, 1875, in no case were court proceedings necessary to enforce compliance. Unhealthy Areas. No unhealthy areas were represented during the year, and none are contemplated. It would be difficult to point out any area in the town which could be represented as an unhealthy area. Bye-laws. No difficulty has been experienced in the working of the Building Bye-laws. Houses not complying with the Building Bye laws to the number of 88 were erected during the year with the consent of the Local Authority under Section 25 ot the Housing, Town Planning, etc., Act, 1919. Although there are Bye-laws with respect to Tents, Vans, Sheds, etc., they are scarcely required, as it is seldom that inhabited tents, vans or sheds come into the district, and then their stay is but of short duration. There are no common lodging houses in the town, and there are therefore no Bye-laws with respect to such places ; neither are there any Bye-laws with respect to houses let-in-lodgings. 80 Housing. General and Miscellaneous. It might be appropriate at this juncture to outline the scheme of housing which has been adopted and is being undertaken by the Council. In 1919 the Council purchased, at a cost of £600 per acre, land to the extent of 20 acres at Village Park, South Ealing, for the purpose of erecting houses for the working classes. The site is an ideal one, with an easy gradient towards the south and east, facilitating planning. The site is open, being free to the north, east and south, houses existing only on its western boundary, and these are of a good working-class, artisan or residential type. The subsoil consists of gravel to the depth of many feet, the presence of gravel on the site effecting a saving in the cost of building. The Borough Surveyor presented several schemes of lay-out, and that adopted by the Council provides for the erection of 245 tenements, 64 being flats. In the scheme adopted very few have a direct northerly aspect. A good feature of the lay-out is the provision of two open spaces, one centrally situated, in extent 2 acres 3 roods and 28 poles, and one towards the south-east for use as garden plots, in extent 1 acre 1 rood 3 poles. A better idea of the arrangement of the houses on the site can be obtained from the photograph which is reproduced. The scheme includes six types of cottages and flats as follows:— 1.—Parlour, living room, scullery, bathroom, and four bedrooms. 2 and 3.—Parlour, living room, scullery, bathroom and three bedrooms. (Two types for different aspects). Housing. 81 4 and 5.—Living room, scullery, bathroom, and three bedrooms. (Two types for different aspects). 6—Flats with living room, scullery, bathroom and two bedrooms. Each cottage and flat is provided with a larder, water-closet and coal-store. The sculleries are provided with a copper, with draw-off top and gas-cooker. Hot water is provided in all houses, a gas circulator being fixed in conjunction with the hot water system. All the rooms are wired for electric light. The plans of the various types of houses are illustrated in the second photograph. The third photograph of the completed houses facing Pope's Lane give an idea of the pleasing elevation. The rents fixed, with the approval of the Ministry of Health, are for the parlour-houses 24s. a week, including rates, rent of meter and circulator; for the non-parlour houses 20s. a week; and for the flats 16s. 6d. a week. Seventy-two of these houses were completed by the end of the year. The Council have also provided six flats, to relieve overcrowding, by the temporary conversion of a large house on the Village Park site. Two other flats have been made by the erection and conversion of an Army hut on the ground belonging to the Council in Bramley Road. While considering this new scheme, it must be remembered that as long ago as 1901 the Council inaugurated a Housing Scheme in South and North Roads, South Ealing, where 139 tenements were erected. 82 83 84 Housing. 85 Appendices. HOUSING CONDITIONS. Statistics Year ended 31st December, 1920. 1.—General. (1) Estimated population 76,129 (2) General Death-rate 8.8 (3) Death-rate from tuberculosis 0.74 (4) Infantile mortality 47 (5) Number of dwelling houses of all classes 15,346 (6) Number of working-class dwelling houses 9,911 (7) Number of new working-class houses erected 77 (8) Number of other new houses erected 25 2.—Unfit Dweli.ing Houses. I.— Inspection. (1) Total number of dwelling houses spected for housing defects (under Public Health or Housing Acts) ... 931 (2) Number of dwelling houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 269 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation None (4) Number of dwelling houses (exclusive of those referred to under the preceding subheading) in which defects were found 827 86 Housing. II.—Remedy of Defects without Service of formal Notices. Number of defective dwelling houses rendered fit in consequence of informal action. by the Local Authority or their officers 471 III.— Action under Statutory Powers. (a) Proceedings under Section 28 of the Housing, Town Planning, etc., Act, 1919 : (1) Number of dwelling houses in respect of which Notices were served requiring repairs None- (2) Number of dwelling houses which were rendered fit:— (a) By Owners None (b) By Local Authority in default of Owners None (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by Owners of intention to close None (b) Proceedings under Public Health Acts. (1) Number of dwelling houses in respect of w'hich Notices were served requiring defects to be remedied : Informal Notices 740 Statutory Notices 87 (2) Number of dwelling houses in which defects were remedied :— (a) By Owners or Occupiers 553 (b) By Local Authority in default of Owners None (c) Proceedings under Section 17 and 18 of the Housing, Town Planning, etc., Act, 1909: Housing. 87 (1) Number of representations made with a view to the making of Closing Orders None (2) Number of dwelling houses in respect of which Closing Orders were made None (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been ren- deied fit None (4) Number of dwelling houses in respect of which Demolition Orders were made None (5) Number of dwelling houses demolished in pursuance of Demolition Orders None 3.—Unhealthy Areas. Areas represented to the Local Authority with a view to Improvement Schemes under la) Part I. or (b) Part II. of the Act of 1890 None (1) Name of area — (2) Acreage — (3) Number of working class houses in area — (4) Number of working class persons to be displaced — 4.—Number of houses not complying with the building bye-laws erected with consent of Local Authority under Section 25 of the Housing, Town Planning, etc., Act, 1919 88 5.—Staff engaged on housing work with, briefly, the duties of each Officer :— :— The Borough Surveyor and his Staff (part time). TheM.O.H. and his three Inspectors ipart time). Housing work is included with their other duties 88 Table 1.- Vital statistics of whoe district during 1920 and previos years. 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. No. Rate. of NonResidents registered in the District. of Residents not registered in the District. Under 1 year of age. At all Ages. No. Rate. No. Rate per 1000 Nett. Births. No. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1915 66181 1160 1184 166 550 8.3 16 142 75 63.0 676 102 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 1919 73212 1111 1018 13.3 666 9.1 37 173 67 65.8 802 10.8 1920 76299 1463 1361 17.8 606 8.0 79 146 64 47.0 673 8.8 Area of District in acres (land and inland water)—2947. Total population at all ages 61723 Number of inhabited houses 13515 At Census of 1911. Average number of persons per house 4.5 Infant Mortality. 90 91 TABLE II.—Cases of Infectious DiseasiNotified during the Year, 1920. Notifiable Disease Number of Cases Notifi 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. Grange 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) 56 — 14 32 5 3 2 — 5 6 10 9 14 12 41 Erysipelas 30 — — 1 4 10 12 3 2 5 3 12 4 4 1 Scarlet Fever 171 — 30 118 16 6 1 — 11 25 18 58 44 15 135 Enteric Fever 6 — 1 1 1 3 — — 1 2 2 1 — — 2 Puerperal Fever 5 — — — 2 3 — — — 1 3 1 — 3 Cerebro-Spinal Meningitis 4 1 — 1 — 1 — 1 1 — — 1 1 1 3 EncephalitisLethargica 1 - - - - 1 - - - 1 - - — — 1 Ophthalmia Neonatorum 8 8 — — - - - - 2 — — 3 2 1 — Pulmonary Tuberculosis 63 — — 8 18 30 7 — 10 7 5 14 18 9 — Other form of Tuberculosis 17 — — 7 6 1 3 — — 3 — 7 4 3 — Malaria 27 — — — 6 18 3 — 1 2 3 9 7 5 — Dysentery 2 — — — — 2 — — — 1 — — 1 — — Influenzal-Pneumonia 27 — 2 — 3 16 6 — 3 8 6 2 2 6 — Primary-Pneumonia 38 2 3 4 4 12 8 5 5 6 5 7 9 6 — Totals 455 11 50 172 65 106 42 9 41 66 53 126 107 62 186 Ealing Isolation Bpital, South Ealing. 92 TABLE III. Deaths registered during the Calendar Year 1920 classified by age and cause. Causes or Death. Nett Deaths at the subjoined ages or " residents," whether occurring within or without the district. Total Deaths whether of 1' Residents'' or" NonResidents "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 1 2 3 4 5 6 7 8 9 10 11 All causes: Certified 673 64 4 15 25 30 82 172 281 126 Uncertified — — — — — — — — - Enteric Fever - Small-Pox — - Measles 3 1 2 1 Scarlet Fever 1 1 2 Whooping Cough ... 1 — 1 - Diphtheria and Croup 6 — 1 2 3 17 Influenza 28 — 4 1 10 7 6 1 Erysipelas — — - — — - Phthisis (Pulmonary Tuberculosis) 42 1 6 22 12 1 - Tuberculous Meningitis 9 1 - — 5 3 3 Other Tuberculous diseases 6 2 2 1 1 4 Cancer, malignant disease... 74 — 1 — 1 5 33 34 16 Rheumatic Fever 6 — 1 3 1 1 1 Meningitis 3 — - — 2 1 2 Organic Heart Disease 82 — — — 1 7 29 45 6 Bronchitis 40 1 2 — 1 10 26 - Pneumonia (all forms) 48 4 1 4 3 3 9 13 11 6 Other disease of Respiratory Organs) 6 3 3 1 Diarrhoea and Enteritis 9 9 2 Appendicitis and Typhlitis 8 — 2 - 3 3 5 Cirrhosis of Liver 1 - - - - - - 1 - Alcoholism 1 - - - - - - 1 - - Nephritis and Bright's Disease 18 — 1 10 7 3 Puerperal Fever 4 — - — - 2 2 - - 1 Other accidents and diseases of Pregnancy and turition 3 — 1 2 3 Congential Debility and Malformation, including Premature Births 29 27 2 11 Violent Deaths, excluding Suicide 12 - - 1 1 - 1 4 5 7 Suicide 6 2 3 1 3 Other Defined Diseases 225 20 1 2 10 15 39 138 31 Diseases ill-defined or unknown 2 - - - - - - 2 - - Totals 673 64 4 15 25 30 82 172 281 126 93 TABLE IV. 93 Infant Mortality during the Year 1920. Nett Deaths from stated causes at various ages under One Year of Age. Cause of Death. Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks Total under 4 weeks 4 weeks and under 3 months 3 months and under 6 months. 6 months and under 9 months. 9 months and under 12 months. | Total deaths under 1 year. All Causes Certified 28 7 2 37 6 15 3 3 64 Uncertified — — - — — — — — — Small-pox - - - - - - - - - - Chicken-pox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Whooping-Cough - - - - - - - - - Diphtheria and Croup - - - - -- - - - - - Erysipelas - - - - - - - - - - Tuberculous Meningitis - - - - - - - - 1 1 Abdominal Tuberculosis - - - - - - 1 — 1 2 Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tubgrculous) - - - - - - - - - - -Convulsions 1 — — - 1 — — 1 — 2 Laryngitis - - - - - - - - - - Bronchitis — — — - — — 1 — — 1 Pneumonia (all forms) — 1 — - 1 1 1 — 1 4 Diarrhoea — — — - — — 3 — — 3 Enteritis - - - - - 2 2 2 — 6 Gastritis 1 1 1 — 2 Syphilis — 1 — - 1 1 1 — — 3 Rickets — — - — . — — Suffocation, overlying - - - - - - - - - - Injury at Birth — — — — — — — — Atelectasis — o - - 2 - - - - 2 Congenital Malformations 3 — — — 3 1 — — — 4 Premature Birth 12 2 1 - 15 — — — — 15 Atrophy, Debility & Marasmus 9 — 1 - 10 1 3 — — 14 Other Causes 3 — — - 3 — 2 — — 5 Totals 28 7 2 — 37 15 3 3 64 Nett Births in the year:— Nett Deaths in the year of :— Legitimate 1286 Legitimate Infants 58 Illegitimate 75 Illegitimate Infants 6 Borough of Ealing. EDUCATION COMMITTEE. REPORT of the School Medical Officer, For the Year ended 31st December, 1920. STAFF. School Medical Officer— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant School Medical Officer and School Oculist— R. P. Garrow, M.D., D.P.H. School Nurses— Clerk— Adela Dickens. Surgeon— E. A. Chill, M.D., C.M. A naesthetist— S. M. Banham, M.B., M.R.C.S., L-R.C.P. L. Brown,, L.D.S., R.C.S., (Eng.) I. Cohen, L.D.S., (Eng.) Hilda Bailey (Senior) Alice Gough, Mercie Richardson, Frances Fuller. Dentists— School Clinic. 13, Mattock Lane, Ealing, W. EDUCATION GENERAL PURPOSES SUBCOMMITTEE, 1919-1920. (Which deals with the School Medical Service). Chairman— Councillor W. Hutchings. V ice-Chairman— Councillor E. Newson. Alderman G. C. Farr, J.P., C.C. Alderman E. C. Sayers, J.P., Councillor H. Armriding, Councillor W. J. S. Cox, Councillor W. F. Piper, Miss A. D. Hawkin, Dr. Stanley I,. Box, Mr. M. C. Hulbert, J.P., Rev. C. J. Sharp, M.A., Mr. W. T. White. Town Hall, Ealing, W. 5. June 28th, 1921. To the Chairman and Members of the Education Committee. Mr. Chairman, Ladies and Gentlemen, I beg to submit my Annual Report for 1920 on the work of the School Medical Department. The general scope of the work remains the same as in 1919, except that it has been extended to include a better supervision of mentally and physically defective children, of whom regular examinations are made and complete records are kept. In various directions the work has increased, but chiefly in dental and ophthalmic treatment, and in the inspection of defective children referred by the Head-teachers to the Inspection Clinic. An idea of the increase of school medical work may be obtained by the consideration of the attendances made by children at the School Clinic in successive years. In 1914 there were 4,989 attendances ; in 1915, 4,259 ; in 1916, 7,218; in 1917, 9,315; in 1918, 8,827; in 1919, 10,316 ; and in 1920 no less than 12,267 attendances. The two great needs in connection with school medical work, as you are well aware, are the provision of a school for mentally defective children, and an open-air school for physically defective, anaemic, and poorly nourished children. While the provision of these may not be opportune at the present time they should not be lost sight of as necessary developments whenever circumstances are favourable. Recently it has become a fashion to level at municipal Services the general criticism of extravagance without actual figures or facts being put forward as evidence. It seems desirable, therefore, to place before the public actual figures relating to the cost of the service which it is my duty to supervise, especially as these figures can be compared with those for certain other districts. As this report deals with the year 1920, and as exact figures are available for the year ending 31st March, 1920, for Ealing as well as for some other towns which are noted in a recent report of the Ministry of Health on " The Amount of Local Rates," I propose to quote the figures for that year. The total cost of the whole of the School Medical Service for the year ending 31st March, 1920, was £1,880 15s. 5d., and the receipts £72 19s. 0d., making a nett cost of £1,807 16s. 5d. for the whole of the medical supervision of all the children in the elementary schools. As half of this cost is repaid by the Board of Education, the nett cost to the ratepayers is £903 18s. 2d., or a rate of 2-5ths of a penny— a very low proportion of the whole rate. This rate compares favourably with the rate for similar purposes in other towns which are quoted in the Report referred to. Ipswich for that year had a rate of 2d. in the £, Leeds 3d., Portsmouth 2d., and Sunderland fd. for the school medical service. These figures require no further comment by me. I take this opportunity of expressing my great appreciation of the work of all the members of the staff, but particularly that of Dr. Garrow, who was recently appointed Medical Officer of Health for Chesterfield and that of the Senior School Nurse, Miss Bailey. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR. 100 General Review: Co-ordination. There is complete co-ordination between the work of the School Medical Service and that of the Infant and Child Welfare Department. To secure this co-ordination the School Clinic and the Welfare Centre have been arranged in the same building where the whole of the work is carried on by the respective staffs. This arrangement facilitates information regarding children under school age being conveyed by the School Nurses to the Health Visitors and information regarding school children being conveyed from the Health Visitors to the School Nurses ; it also facilitates the transference to the School Medical Service of medical history cards of children after they reach the age of five. The treatment of minor ailments of children under school age at the School Clinic also tends towards intimate cooperation between the two departments. Debilitated and crippled children under school age are treated at the King Edward Memorial Hospital under the Maternity and Child Welfare Scheme, every effort being made to deal with such children as early as possible in their lives and before they proceed to school. The treatment or supervision of such children is automatically transferred to the School Medical Service when the child passes into an elementary school. The School Medical Service in Relation to Public School Hygiene. There are twelve public elementary schools under the control of the Local Education Authority. Six of these are of modern construction, dating from 1905 to 1911, five are old with recent adaptations while one is a temporary school. In the first group the general General Review. 101 hygienic conditions are satisfactory and no comment is required upon them, but in the second group special reports were made regarding the defective sanitary arrangments at St. John's Schools and the defective flooring at the temporary school, Good Shepherd Hall. The result of these reports was immediate remedial action on the part of the Education Committee. A survey was made of the sanitary arrangements of the non-provided schools all of which come into the second group of schools already mentioned, when it was found that there were no serious defects demanding immediate attention, but that eight out of the eleven departments had trough closets operated automatically by a cistern for each section of closets. These trough closets require the closest attention on the part of the caretaker to keep them in a sanitary condition and, although every care appears to be taken, it is desirable that they should be replaced by pedestal closets as early as economic conditions will allow of the expenditure of money on them. Medical Inspection. (a) The children medically examined were those in the three groups required by the Code of the Board of Education. They included (1) all the children admitted to school during the year, (2) all children between 12 and 13 years of age, together with children over 13 years who have not already been examined, and (3) all children between 8 and 9 years of age. In addition there were examined in the course of routine school medical inspection children outside these groups who were submitted by the head-teachers on account of some defect or suspected defect, these 102 General Statement. being called non-routine cases, and also re-inspection cases submitted for re-examination on account of their having been found on a previous inspection to have some defective condition requiring supervision. In the twelve public elementary schools under the Local Education Authority there are twenty-six departments, eight for boys, seven for girls, eight for infants, two for boys, girls and infants (mixed), and one for girls and infants. The following tables indicate the number of children in each group inspected in the various schools:— Number of Children Inspected. School. — Entrants. Total Boys Girls Provided. Drayton 58 48 106 Joseph Lancaster 26 23 49 Lammas 99 70 169 Little Ealing 67 76 143 North Ealing 50 48 98 Northfields 98 97 195 Good Shepherd Hall (temp.) 30 10 40 Non-Provided. Christ Church 23 36 59 St. John's 50 42 92 St. Mary's 25 24 49 St. Stephen's — — — Wesleyan — — — Total 526 474 1000 General Statement. 103 Number of Children Inspected. School. Age 8 Group Total Age 12 Group Total Boys Girls Boys Girls Provided. Drayton 50 52 102 39 61 100 Joseph Lancaster 17 23 40 28 16 44 Lammas 75 64 139 84 76 160 Little Ealin 72 83 155 66 70 136 North Ealing — 44 44 — 29 29 Northfields 6S 63 131 60 83 143 'Good Shepherd Hall (temp.) Non-Provided Christ Church 10 14 24 25 23 48 St. John's 48 46 94 63 59 122 St. Mary's 28 14 42 26 26 52 St. Stephen's 33 — 33 22 22 Wesleyan 9 10 19 30 27 57 Total 410 413 823 443 470 913 There were medically examined at school, 1,000 entrants, 823 in the age-8 group and 913 in the age-12 group, making a grand total of 2,736 children. In addition to the routine inspections there were 1,198 children re-examined in school (624 boys and 574 girls), and 2,164 special cases (1,065 boys and 1,099 girls) dealt with at the Inspection Clinic. The total number of individual children examined during the year whether by routine or non routine examinations, was 4,900. 104 General Statement. The total number of children on the school registers was 7,492, and the average attendance 6,643, thus making an average attendance 88.6 per cent. As 4900 children were medically examined out of a total average attendance of 6,643 it means that 74 per cent. of the children in attendance were medically examined during the year. (b) The Board's Schedule of Medical Inspection has been adhered to in every respect. (c) To secure the early ascertainment of children suffering from crippling defects particular steps are taken in routine manner. In the first place, all crippled children under the supervision of the Child Welfare Staff are transferred as they reach school age to the School Medical Department, their record cards being passed on in a routine way ; in the second place, it is the duty of the School Attendance Officers to give immediate information to the School Medical Officer of all crippled children coming to their knowledge; thirdly, the head-teachers have to notify to the School Medical Officer any additions to the official list, supplied by the School Medical Officer each year, of crippled children attending each school ; and lastly, a particular medical survey of all crippled children, whether attending or not attending school, is made each year to ascertain their progress and to determine the need for treatment, the official list of crippled children being then checked and each school being supplied with its corrected list. Special Record Cards of all crippled children are kept in a separate file, a note being made of each medical examination and of the progress of the child. General Statement. 105 (d) The extent to which disturbance of school arrangements was involved by school medical inspection may be taken as negligible, if at all noticeable. In 18 school departments medical inspection was conducted either in a special medical inspection room or in a teachers' room. In one school the children were •examined in the medical inspection room of an adjoining school, and in the remaining seven medical inspection was conducted in a classroom, which had been vacated by a class engaged at physical exercise or by a class which was temporarily joined up with another, with little disturbance of the ordinary school arrangements. Findings of Medical Inspection. Review of the Facts Disclosed. In Table II (which is appended) a list is given of all the defects discovered during school medical inspection, whether routine or non-routine. Of those children examined, 1,366 were found to have one or more defects requiring treatment or supervision. The total defects found were 1,547 amongst children examined in a routine manner and 1,824 amongst those specially examined, or a total of 3,371. Of the defects in the former group 990 were referred for treatment and 557 for observation and of those in the latter group 1,783 for treatment and 41 for observation. Verbal notices to the number of 387 and written notices to the number of 394, or a total of 781, were given to the parents. To the teachers 24 verbal and 36 written notices were given respecting defective children requiring special supervision. Some of the defects found demand some comment or particular notice. 106 General Statement, (a) Uncleanliness.—During routine inspection only 18children were excluded for uncleanliness of the head and two for uncleanliness of the body. But one can expect this small number when the parents have hadi notice of the inspection. The periodic inspections which are made without notice give a better idea of the prevalence of verminousconditions among the children attending the elementary schools. These inspections are made immediately after the Easter holidays, after the Summer holidays and after the Christmas holidays, as it is during the holidays that the children are apt to be neglected. The School Nurses made 36 visits to school departments for the purpose of making inspections of heads. Thirty-three of these were made after the holidays, mentioned, but three were made at the particular request of the head-tea,chers who discovered some verminous cases in school. No boys' schools were inspected since bo3rs are seldom found to be affected and when they are affected the condition is readily apparent to the teacher who can refer them for special examination at the Inspection Clinic to which any child can be sent by a teacher for medical examination in the morning of any school day. At these inspections mentioned, 5,691 girls were examined by the nurse, 686 being referred for medicaL examination, and 339 being excluded as a result. In addition, 25 other children were submitted to the Inspection Clinic by the teachers for medical examination and excluded. Thus there were altogether 364 school children excluded during the year for verminouS, conditions. These children excluded for verminouS General Statement. 107 conditions necessitated 1,236 examinations at the Inspection Clinic. In dealing with verminous cases excluded from school, in fact in dealing with any excluded cases, an exclusion certificate is supplied to the parents and at the same time a circular giving directions how to treat the children. The teachers receive copies of all exclusion certificates and no children are re-admitted until certificates of re-admission are given by the School Medical Officer. A complete list of all excluded children is also given to the woman attendance officer whose duty it is to see that the children receive proper attention at home and that they attend the Clinic for reinspection. When, in the case of verminous children, the parents fail to cleanse them within a fortnight, or when children are repeatedly excluded for uncleanliness, the School Medical Officer is authorised by the Education Committee to request the attendance officer to issue a summons against the parents. This procedure has, since its initiation, certainly reduced the excluded period and given rise to a greater degree of cleanliness. But no matter what one does the " old offenders " always turn up : it is the old offender who constitutes the great difficulty in controlling verminous conditions. Summonses were issued under the Attendance Byelaws with regard to ten cases who were not cleansed in a reasonable time. A fine of 20s. was imposed by the Justices in two cases, 10s. in one case, and 5s. in five cases. In two other cases cautions were given by the Justices. No provision has been made for the official cleansing of school children, the reason put forward being that it is the duty of the parents to cleanse the children and 108 General Statement. to keep them clean, and that if the children were cleansed by the Local Education Authority simply to assist the parents it would not act as a deterrent in the future. If, however, the cleansing were performed so that suitable legal action may be taken under the Children Act, it might be argued that action is easier and just as effective under the Attendance Bye-laws. (b) Minor Ailments.—It is difficult to define what a minor ailment is, but commonly the term is applied to conditions such as blepharitis, conjunctivitis, ringworm, impetigo, scabies, otorrhoea, septic sores, etc., which can be, and usually are, treated at the School Clinic. The extent of these conditions is dealt with either under their respective headings or under work done at the Inspection Clinic, and is summarized in Table IVa. (c) Adenoids.—On routine inspection there were found 129 cases of enlarged tonsils, 7 cases of adenoids, and 9 cases of adenoids with enlarged tonsils. Thus of a total 2,736 children examined in the routine way, 5 per cent. required operation for enlarged tonsils or adenoids, or both. Twenty-eight other cases were found on special examination to require operation. (d) Tuberculosis.—On routine inspection no cases of pulmonary tuberculosis were noted during the year. Two cases of tubercular glands, and two cases of tuberculosis of the hip were found. At the Inspection Clinic one definite and seven suspected cases of pulmonary tuberculosis came under notice. (e) Skin Disease.—Seven cases of scabies, 22 of impetigo, and 15 of non-infectious disease of the skin were General Statement. 109 found on routine inspection. The cases of scabies thus constituted .2 per cent., and those of impetigo .8 per cent. of the children examined. At the Inspection Clinic on reference by the teachers or attendance officers 62 cases of scabies, 464 cases of impetigo, and 4 cases of non-infectious disease of the skin were discovered. (f) External Eye Diseases.—At routine inspection four children were found to be suffering from conjuctivitis, 19 from blepharitis, 22 from squint, 3 from corneal opacity, and six from other conditions, such as hordeolum or stye, making a total of 54. At the Inspection Clinic the cases of these diseases found were four of conjunctivitis, five of blepharitis, two of keratitis, two of corneal ulcer, two of corneal opacity, fourteen of squint, and one of hordeolum, or a total of 30 cases of external eye disease. (g) Vision.—Defective vision is one of the most common and at the same time one of the most important defects found amongst the school children. No fewer than 198, or 7 per cent. of the children examined at the routine inspection were found to have such defects as to require attention. Besides, 27 children were examined specially and found to have defective eyesight requiring correction. (h) Ear Disease and Hearing.—On routine inspection 27 children gave evidence of defective hearing, 19 suffered from otitis media, and one had eczema of the ear; while on non-routine inspection five had defective hearing and two otitis media. In addition to these cases 139 of otitis media were found at the Inspection Clinic. 110 General Statement. (i) Dental Defects.—The following are the results of the inspection of the three routine groups of children for dental defects :— Entrants. Age 8 Group. Leavers. Total. Teeth sound- No. 486 380 585 1,451 Per cent. 48.6 46.4 64.2 53.0 Less than 4 cayed teeth—- No. 242 261 278 781 Percent. 24.2 31.7 30.4 28.2 More than 4 teeth decayed— No. 272 180 49 501 Per cent. 27.2 21.7 5.3 18.7 Sepsis- No. 2 1 3 Per cent. .2 .1 .1 This Table indicates that 27.2 per cent. of the infants,. 21.7 per cent. of the children age- 9, and 5.3 of the leavers had four or more teeth decayed, and points prominently to the need for early inspection and treatment of children on admission to school. (j) Crippling Defects.—During the year an enquiry was made regarding the extent and nature of crippling amongst school children, the results of which enquiry together with an account of the provision made in Ealing for dealing with them were submitted in a report to the Board of Education in June, 1920. This report is here reproduced. Crippled Children. 111 Borough of Ealing Report on Crippled Children. 1.—The following is a complete list of school children who have been discovered to be physically defective to such an extent as to be called cripples. These children have been discovered either by means of school medical inspection or through the Teachers, Attendance Officers, and School Nurses. As a special survey was made last year and checked this year, this list may be deemed to include practically all the crippled children who are attending public elementary schools or whowould attend if it were not for their crippled condition. 112 Crippled Children. Table of Crippled School Children. No. Ages. Part affected. Date of Onset. Male. Female. Tuberculosis 15 15, 14, 12 10, 9, 9, 9 7 13. 12, 12, 9,8,7,6 Hip—7 Spine—4 Knee—2 Heel—2 1 yr. 2 yrs. 4 yrs. 6 yrs. 10 yrs. 11 yrs. II yrs. 11 yrs. 13 yrs. Others doubtful Poliomyelitis 19 12, 12, 11 11, 7, 7, 5 12, 11, 11, 10, 10, 9, 9, 8,8,8,8,6 Both legs—4 Rt. leg—7 Left leg—6 Rt. arm and leg-2 4 mths. 8 mths. 10 mths. 1 yr. 2 yr. 2 yr. 2 yr. 2 yr. 2 yr. 2 yr. 2 yr. 3 yr. 3 yr. 4 yr. 4 yr. 5 yr. 6 yr. Two doubtful Rickets 3 7 7, 13 B oth tibia Genu valgum Genu varum 18 mths. Infancy Trauma 3 12, 7, 7 Ankylosis of elbow Left elbow fixed Left leg amputated 6 yrs. Congenital Deformities 16 14, 12, 12, 12, 10, 7, 6 6 13. 12, 11, 10, 10,10, 9, 7 Right arm—3 Right leg—3 Left shoulder 2 AT Birth. Talipes—2 T orticollis 2 Hand—1 Left arm—1 Spina bifida — 1 Heart cases 5 10 13. 11,7, 6 Epispadias (incontintence)—1 61 All five heart cases are either unable to attend or are very irregular in attendance at school. Crippled Children. 113 The following is a list of the crippled children under five years of age who have been discovered by the Health Visitors through home-visiting or through the Welfare Centre. Crippled Children under School age. No. Ages. Part affected. Date of onset. Male. Female. Tuberculosis — — — — — Poliomyelitis 4 2,3,4 3 Legs One at three yrs. Other doubtful Rickets 6 2 2 4, 3, 2.1½ Legs Congenital and Traumatic Deformities 4 5, 4, 1 3 Leg Shoulder Torticollis Femur fractured at birth Serious Heart Disease 1 1 yr — Congenital systolic murmur 15 2.—The Central Aid Society has been of great assistance in obtaining treatment for crippled children of all ages. This treatment has included sanatorium, hospital, or convalescent home treatment, no matter what the cause of the crippling may have been. The help of this Society, however, has been sufficient to meet the needs of but a few of the cases, and the necessary treatment has in many cases been too long deferred or insufficient. The Middlesex County Council is now dealing with the treatment of tuberculosis by sanatorium or hospital treatment. 114 Crippled Children. Children under five years of age are being dealt with by the Maternity and Child Welfare Committee, those requiring treatment being sent to the Ealing King Edward Memorial Hospital, which has placed six beds at the disposal of the Committee for all children under five years of age requiring medical or surgical treatment. It is hoped that arrangements may be made by which such cases as require massage and electrical treatment may be treated as outdoor cases. In this way many of the cases of paralysis resulting from poliomyelitis may receive suitable treatment so as to prevent wasting of the muscles and to correct deformities before structural changes occur in the bones and other tissues. The Education Committee has just completed arrangements with the King Edward Memorial Hospital by which crippled school children, tuberculous, paralytic, or other cases, may receive indoor treatment, embracing surgical measures if necessary, and outdoor treatment by means of massage, special exercises or electrical treatment. It has been estimated, in the first year of the experiment, that ten cases shall receive indoor treatment for three weeks each, and ten cases outdoor treatment once a week for twelve weeks. As the demand for treatment at the local hospital increases greater provision will be made. Of the 44 cases of crippling due to tuberculosis or poliomyelitis, all except two are receiving treatment, and that at London hospitals. The treatment so far away from their homes is apt to make it less continuous and less thorough, especially as regards remedial exercises, massage and electrical treatment, than it ought to be, but the provision of treatment near their homes may be the means of securing continuous treatment and Crippled Chilren. 115 consequently better results. Earlier treatment should certainly be one result of a local treatment centre. 3.—The table of cases indicates that poliomyelitis is the chief cause of crippling, congenital deformities come next, and tuberculosis almost as much as congenital deformities. As regards poliomyelitis, the age of onset is in most cases under three years of age. Of the 19 cases, ten occurred under two years of age, two at three years, two at four years, one at five years, and one at six years, the onset of the others not being ascertainable. As to tuberculosis, the age at onset varied from one year to 13 years, no particular age appearing to be specially affected. 4.—Most of the children have been accustomed to receive treatment at London hospitals. It is proposed to provide medical and surgical treatment for them at the Ealing King Edward Memorial Hospital. Here also it is proposed to develop for children the treatment by massage, remedial exercises, electricity, etc., which was carried out there for the military patients during the period of the War. 5.—The Education Committee is most anxious to provide special educational facilities for such children as require them, and efforts have been made to secure a suitable site, with or without buildings, for an openair school, but without success up to the present. There will be no relaxation of effort to secure an openair school in the near future. It may be noted that of all the cases in the Table only nine cripples are unable at present to attend the ordinary public elementary school. 116 Crippled Children. 6.—The facilities for detecting cases in the district may be considered satisfactory. The teachers send information to the School Medical Officer of all crippled cases newly admitted or developing during attendance at school, the School Attendance Officers and School Nurses give information regarding cases reaching the age of five and not attending school, as well as cases which develop during attendance at school, and, lastly, the Health Visitors put forward cases which they find under school age. A card index file has been arranged by which a complete record is kept of all cases, and steps will be taken, now that treatment is about to be provided locally, to see that each child receives appropriate and continuous treatment. 7.—If the treatment arranged for at the King Edward Memorial Hospital develops along the proper lines, and if an open-air school is established to deal with all the children requiring special educational facilities, the proper care of crippled children should be secured. 8.—As already indicated, crippled cases and the circumstances of their crippling are ascertained by the Health Visitors either at their homes or through the Welfare Centre, by the Teachers, School Nurses and Attendance Officers, by the routine medical inspection at the schools and at the Inspection Clinic, records of all cases being kept for reference and such supervision as may be deemed necessary. 0 Thomas Orr, Medical Officer. Town Hall, Ealing, W. 5. 8th June, 1920. Infectious Disease. 117 Infectious Disease. In dealing with infectious disease in the schools much assistance is obtained from the weekly returns of absences due to infectious disease furnished by the head-teachers. Valuable information is provided of the occurrence of cases of non-notifiable diseases, the extent of the prevalence can be fairly accurately gauged and the children can be visited at their homes either by the School Nurses or by the Health Visitors. Measles was prevalent in the early summer, especially in three infants' schools, Drayton, Northfields and Christ Church, all of which were closed on the recommendation of the School Medical Officer under Article 45b of the Code, the first two from the 14th to the 21st May, for seven days, which with the week's holiday at Whitsuntide meant a period of closure of 14 days, and the third for 14 days from the 21st June to the 5th J uly. Under Article 53 no fewer than 645 children were excluded during the year. The conditions necessitating exclusion were as follows : Impetigo 464 Ringworm of Head 50 Ringworm of Body 29 Scabies 62 Other Skin Diseases 40 645 When children are excluded they are not re-admitted until submitted for examination by the School Medical Officer and a certificate of re-admission granted. This is a rule which is strictly kept by the teachers. 118 Infectious Disease. No action was taken during the year under Article 57 of the Code. Following Up. When medical inspection in a school has been completed, forms are made out, giving a list of children found to have adenoids or enlarged tonsils, defective eyesight and defective teeth, all children suffering from one class of defect being entered on a form distinguishingly coloured. These forms are passed over to the Clinic Nurses, who visit the houses and advise treatment, which is subsequently arranged for if the parents consent to treatment at the School Clinic. Repeated visits may be necessary before treatment is ultimately carried out. When treatment is given record cards are made out indicating its nature and the progress of the child. Children found at medical inspection to have defects requiring hygienic care, and perhaps medical attention, are placed in a separate group, which is kept under the supervision of the nurse who assists at the inspection in the school. She visits the homes and gives the parents advice on the care of the children, recommending medical attention when considered necessary or desirable. The children in this group are usually those suffering from anaemia, heart disease, suspected tuberculosis, and malnutrition. Record cards are made out for all these children, notes being kept of the nurse's visits and of the children's condition, and the results of subsequent special medical examinations. The School Nurses in this way are able to keep all defective children under supervision. Medical Treatment. 119 Medical Treatment. Review of the methods employed or available for the treatment of defects and a statement of the ascertained residts of treatment. (a) Minor Ailments.—Table IVa. gives the total number of minor ailments referred for treatment as 856, the number treated at the School Clinic as 372, and those treated privately or at hospitals as 484. The largest number of cases was due to impetigo, a condition which has been prevalent in several schools and which has caused a great loss of attendance. Energetic treatment for this condition at the School Clinic certainly shortens the period of absence. (b) Tonsils and Adenoids.—In Table IVc. an account is given of the 190 cases referred for treatment, 148 being operated on at the Clinic and 14 by general practitioners. Eight nasal cases were dealt with by means of the cautery. (c) Tuberculosis.—No cases of definite or suspected pulmonary tuberculosis were found on routine school medical inspection. At the Inspection Clinic one definite and seven suspected cases were dealt with. All of these were referred to the Tuberculosis Officer. Two cases of glandular tuberculosis and two of hip-joint disease were found on routine medical inspection. All four cases were under the supervision of private practitioners. (d) Skin Diseases.—In Table IVa. the treatment of skin disease is dealt with. Of 50 cases of ringworm of the head, 44 were treated by Dr. Arthur with X-rays, the treatment in all cases being successful. Six cases 120 Medical Treatment. were treated and cured by drugs. Twenty-nine cases of ringworm of the body were found during the year. Fifteen were treated at the School Clinic and fourteen at home. Scabies supplied 62 cases, 12 being treated by baths at the School Clinic necessitating 19 separate bath and 50 being treated at home in accordance with printed directions supplied at the time of exclusion. Of 464 cases of impetigo 215 were treated at the School Clinic. (e) External Eye Diseases.—Five cases were treated at the School Clinic and 32 by private medical practitioners. During the year a proposal was put forward for the provision of operative treatment at the King Edward Hospital for certain eye defects which cannot be dealt with at the School Clinic. This proposal was adopted by the Education Committee, and later sanctioned by the Board of Education. In the course of the Oculist's work, he occasionally comes across an extreme case of squint which can be benefited, at least from the aesthetic point of view, by operation, or a case of total blindness of an eye, the removal of which would be better for the child. Such cases it is intended to send to the hospital, where operative treatment can be obtained, and for which a charge of £2 2s. per week for each patient during residence will be paid by the Committee. Since this proposal Was sanctioned, only two cases have been dealt with; one was a case of extreme squint and the other a case of complete blindness n one eye due to ophthalmia in infancy. Medical Treatment. 121 (/) Vision.—In Table IVb. an account of the work of the School Oculist is given. Of 246 children referred for examination, 169 were submitted to refraction at the School Clinic, and 29 were dealt with by a private practitioner or at a hospital. Glasses were prescribed in 151 cases and supplied in 147. Other forms of treatment were given in 55 cases. No treatment was required in eleven cases. There was a considerable and necessary extension of the work of the School Oculist during the year. Whereas in 1919 the Oculist devoted only one session to the work, in January, 1920 (after Dr. Garrow was appointed), two sessions were allotted to it, and later, in April, three. Dr. Garrow furnishes a report on this branch of clinic work, indicating the lines on which he considers uture work should be developed:— School Oculist's Work. Report for year 1920. The School Oculist's work was extended from one session per week to two sessions per week in J anuary, 1920, and as it was still found impossible to cope with the work, to three sessions per week in April, 1920. The total number of consultations—that is, visits made by children (usually accompanied by a parent) to the Clinic for examination by the School Oculist— was 1,053. This, together with 1,150 attendances for treatment by the School Nurses under the supervision of the School Oculist, makes a total of 2,203 attendances in 1920, as compared with 877 in 1919. 122 Medical Treatment. New cases are referred to the School Oculist from routine school medical inspection, from the Inspection Clinic, from the Maternity and Child Welfare Centre, and from the teachers at the request of parents. In addition to the new cases, systematic re-examination of old cases is carried on. During 1920 there were 813 such re-inspections made in following up children previously examined in 1918 and 1919. The re-inspections include all the children examined and treated in 1918 and 1919. The work has thus been brought well up to date. External Eye Diseases.—External diseases of the eye, including inflammation of the eyelids, are very rare amongst the school children of Ealing. Only eight new cases were treated during the year and 45 old cases re-inspected. This relative immunity from external eye diseases is in keeping with the general good health and hygienic conditions of the children. Defective Vision.—The great bulk of the work consists in investigating cases of defective vision depending upon errors of refraction, and correcting these errors by prescribing suitable glasses. In order to get the best results, each child with defective vision pays four visits to the School Oculist. At the first visit the vision is tested in the ordinary way and noted. Atropine drops to dilate the pupils are then instilled into the eyes for four days, and at the second visit an examination is made of the interior of the eyes, and the error of refraction is estimated accurately by the shadow test, or retinoscopy. At the third visit the vision is tested with various lenses guided by the result of the previous examination and the appropriate glasses to correct the defect are prescribed, and at the fourth or final visit Medical Treatment. 123 the glasses received from the makers are tested to see that they correspond exactly with the prescription and that they fit the child's face comfortably. In the majority of cases the results are highly satisfactory, and there is perhaps no department of school medical work in which the parents appreciate more keenly the value of what is being done for their children. Suggestion for future development of the School Oculist's work.—There is, however, a certain proportion of cases in which the correction of errors of refraction does not appear to result in any great improvement in the visual defect. For example, a child aged 10 years on being tested is found to have only one quarter of the normal vision—in technical terms its vision is stated to be 6/24 instead of 6/6. For all practical purposes the child is three-quarters blind. On further examination he is found to have three degrees of astigmatism— a common error of refraction. The appropriate glasses for the correction of this error are supplied and the child's vision is still defective to practically the same extent. Careful examination of the eyes fails to reveal any other cause of defective vision. Cases of this kind—and they are fairly common— seem to me to point the direction in which the work of the School Oculist must be developed in the future, that is, in the direction of the earlier investigation and correction of defective vision. To prevent these cases of partial blindness there should be a systematic examination by the method of retinoscopy of every child's eyes when it enters school. This system is already in use in the Glasgow schools and is giving highly satisfactory results, and I would suggest that in Ealing 124 Medical Treatment. one session per week of the School Oculist's time be devoted to this work. It would undoubtedly help to diminish the number of cases of permanently defective vision, and it must not be forgotten that even in the case of a child of, say, 10 years with one quarter normal vision brought up to normal vision by spectacles, that child has already spent five years of its school life three-quarters blind. The Chief Medical Officer to the Board of Education in his annual report for 1919 says that "prevention rather than cure is the guiding principle and fundamental purpose of school medical inspection." So far as the vision of the school children is concerned, this ideal can never be attained until the School Oculist turns his attention to the Infants' Department and examines the eyes of every infant on commencing school life. R. P. Garrow. (g) Ear Disease and Hearing.—Of the 159 cases of ear disease 56 were treated at the School Clinic, and 103 treated at home under the supervision of private medical practitioners. (h) Dental Defects.—The School Dentists devote four sessions a week to actual treatment of dental defects and roughly one session to inspection of the children preliminary to treatment. Mr. Brown takes one regular session and Mr. Cohen the three other regular sessions each week, so that roughly three-fourths of the work is in Mr. Cohen's hands. In the beginning of the year the group dentally inspected was changed. Instead of the children 6 to 8 years old coming up for inspection the "entrants" were dealt with. This change was made because it was found that a large amount of dental disease was present in these young children Medical Treatment. 125 and because it was felt that they ought to be treated as early as possible after admission to school and so avoid the disability arising in the period between their admission and the time of dental inspection at 6 to 8 years old. In the present system the intention is to inspect and treat all children on admission to school each year, all children when once treated being inspected each subsequent year, and treated if necessary. In this way dental supervision and treatment will be extended until all school children, no matter what their age may be, are dealt with. Urgent cases of sepsis or toothache in the older children not coming within the immediate purview of the dentists at present are treated as occasion arises. The arrangement of making a dental inspection of the "entrants" lessens the administration work for the Dentists follow the school medical inspection of the same group of children, and the list for the one is the same for the other. Table IVdI gives an idea of the extent of the Dentists' work. The children inspected numbered 3,746, embracing 3,554 routine cases or re-inspections and 192 special or urgent cases. Of the former 2,014, and all the latter were referred for treatment. In all 2,430 children were treated. The particulars of the time devoted to dental treatment and the operations undertaken are indicated in Table IVd2. It will be seen that 25 sessions or half-days were devoted to inspection, and 208 to treatment. The number of permanent teeth extracted was 147, and filled, 1912 ; the number of temporary teeth extracted 2738, and filled, 21. The total number of fillings was thus 1,933. A general anaesthetic was administered for extractions in 292 cases. 126 Open-Air Treatment. The Education Committee in 1919 entered into an arrangement with the Royal Dental Hospital for the treatment of school children presenting dental abnormalities which could not be dealt with at the School Clinic. These abnormalities consist of irregular dentures, which interfere with proper mastication, which tend to early caries and sometimes bring about an abnormal facial expression. They are susceptible to orthodontic treatment, which is sometimes both lengthy and difficult. Twenty cases were put forward for treatment during the year, but as most of them did not receive treatment until the end of the year reports on all the cases cannot be given. At the end of December four had completed treatment, with, according to Mr. Cohen, very satisfactory results ; the others were still under treatment. (i) Crippling Defects and Orthopaedics.—The treatment of crippling defects has already been considered in a previous section when considering the extent of crippling in school children in Ealing and nothing need be added here. Open-Air Education. The provision of an open-air school for physically defective, anaemic, and badly nourished children was discussed by the Education Committee, and a Special Sub-Committee was appointed to consider the question and to recommend a suitable site. Two sites, the only suitable sites available, were particularly considered, but the high purchase prices of both caused the whole question to be postponed. The Education Committee have always been sympathetic towards the proposal to provide an open-air school, and there is no doubt that whenever economic conditions become normal, and the Physical Training. 127 ban of the Board of Education against new institutions has been raised, efforts will again be made to obtain a suitable site and provide an open-air school. Whenever possible, the teachers in the schools arrange for open-air classes in the school playgrounds. This practice, which deserves every encouragement, affects the children to a limited extent, for usually only one class can be dealt with at a time, and the open-air period can therefore be of limited duration. Physical Training, The only way in which the school medical service is associated with the work of physical training in the schools is when the School Medical Officer makes a recommendation with regard to the nature and amount of physical exercise which a particular defective child should have. During the year the Education Committee adopted a. proposal that the Director of Physical Exercises in the employment of the Baths Committee of the Council, who is also instructor of swimming under the Education Committee, should be appointed Organiser of Physical Training for the public elementary schools. This proposal was not approved by the Board of Education, on the grounds that the man proposed as instructor had not had special training for the position. It is unfortunate that the Board have never at any time laid down the qualifications for such a position, and have given no guidance in the choice of Organisers. The Board, however, have adopted some arbitrary standard unknown to Local Education Authorities, who are liable to be disconcerted at the last moment after the appointment is made by the refusal of the Board to give their sanction. 128 Provision of Meals. The action of the Board in this case in refusing to sanction the appointment months after it had been made caused the whole question of the appointment of an organiser to be abandoned indefinitely. At the same time it made an end to the proposal of remedial physical treatment for certain school children, since part of the proposal was that the Organiser should supervise this form of a special physical instruction. Provision of Meals. In the beginning of March an opinion was expressed by a member of the Committee that there were many children in our elementary schools for whom meals should be provided, under the Education (Provision of Meals) Act, by the Local Education Authority. As a result of this expression of opinion, enquiries were made by Dr. Garrow at all the schools. He reported that with the exception of a few isolated instances the teachers were unanimous in their opinion that there was no evidence of underfeeding amongst the children in their schools, and there was no call for the provision of meals in school. He further stated that every teacher expressed the opinion that the children were better fed and better clothed now than they have ever been, and that the conditions amongst the poorer people were much better than before the war. These opinions were in accord with his own observations in the routine medical inspection of the school children, the children being as a general rule well covered both with flesh and clothing, and a high average level of physical fitness being displayed. The children whose names were given by the teachers as being badly nourished and in need of food belonged Provision of Meals. 129 to nine families, and were 29 in number. On further enquiry it was found that in the case of three families, embracing eight children, the malnutrition was not due to the want of food, of which they apparently received sufficient, but due to some weakness of constitution To provide for the other 21, who were certainly in need of help, was the problem. A communication was sent by the Town Clerk to the Board of Education, suggesting that, in these cases, which were so few in number, the Local Education Authority might supply food by means of coupons available at eating houses. The Board expressed disapproval of the suggestion, and stated that they considered that special care should be taken by the authority to see that the meals were provided under as satisfactory conditions as possible, and that careful supervision over the dietary and the service and conduct of the meals was exercised by the Authority's officials. To make provision for 21 children coming from widely separate parts of the town by the usual method suggested by the Board would not only be difficult, but expensive. For such cases it appears to me that the provision of a milk meal, without the usual formalities of a formal meal, with its service and attendance, would meet the need if the Board would only sanction the procedure under the Education (Provision of Meals) Acts. Perhaps after all, it might be still more advisable in such necessitous cases to provide the milk for consumption by the children at home under the supervision of their mothers, and under a certain amount of supervision by the School Nurses, who could see that the children requiring milk receive it. 130 School Baths. School Baths. There are no baths provided at any of the schools, but a swimming bath, adjoining the public swimming baths, with a man and a woman as instructors, is maintained for school children. All children, boys and girls, are given the opportunity during school hours, of learning to swim before they leave school, and the opportunity appears to be taken advantage of by the children who are encouraged in every possible way to become proficient in the art of swimming and of saving life from drowning. Co-operation of Parents. Parents are encouraged to attend the medical inspection of their children, a special request being made on the notice of inspection which is sent to the parents. At the inspection of the infants 85 per cent, were accompanied by at least one parent, at the inspection of the boys age—8 22 per cent., of the girls age—8.77 per cent., of the boy—leavers, 54 per cent., and of the girl—leavers, 74 per cent. These high percentages for the groups of children inspected indicate the great interest of the parents in the inspections. There can be no doubt that as years go on the parents are becoming more and more interested in school medical inspection. This interest is due to the fact that they receive general advice regarding the care of the children and that they are assisted in obtaining treatment for certain defects. Whereas many parents used to be opposed to any form of inspection, now it is welcomed and expected, and even demanded. Such a feeling is all to the good, for it shows a much keener interest in the health of the children and a greater appreciation of preventive measures of treatment. Co-operation of Teachers. 131 Co-operation of Teachers. The co-operation and assistance of the teachers is essential in any well organised scheme of school medical inspection and treatment just as a properly organised scheme of medical supervision is essential for the success of any scheme of education. Undoubtedly the teachers recognise this basic fact, for they show its recognition by their interest in the medical progress of the children. Some perhaps show greater interest than others, this interest being evidenced by excellent private records kept by them of all children found defective on school medical inspection or reported by their parents to be ailing. This record of illness or of physical weakness in the children determines to a large extent the care and supervision required in the education of the child, and is sufficient recognition of the value of medical inspection in the education of the child. To assist the teachers in maintaining this interest in the medical history of each child, a new system has been adopted. After each medical inspection a list of all children found defective is sent to the head-teacher for confidential information, advice in writing being given regarding any special care or attention required on the part of the teacher. These records can be kept and filed by the teachers and referred to when necessary in determining any matters relating to the educational progress of the individual children. As regards the actual medical inspection every assistance is given by the teachers, but as regards following up and treatment no responsibility has been thrown on them, although they have given much assistance in many cases in referring for the special consideration of the School Medical Officer cases not being attended to as quickly as the defective condition demands. 132 Co-operation of School Attendance Officers. The assistance of the teachers, however, is now being solicited in this important work of following up, by asking them to make a note on a form, to be returned within ten weeks to the School Medical Officer, of all the children who have received treatment since school medical inspection. By this means it will be possible to single out children who should be visited at an early date by the School Nurses, who in the ordinary course of events would not discover the facts until the home was visited some time after. Co-operation of School Attendance Officers. The Attendance Officers have continued to give every assistance, especially in providing information regarding children who are absent on account of conditions, such as impetigo, ringworm, etc., without receiving treatment at home or at the School Clinic, or who have been absent either continuously or irregularly without a medical certificate being supplied. But the greatest assistance has been obtained from the woman attendance officer, Mrs. Byles, the value of whose work one cannot estimate too highly. Her appointment was almost in the nature of an experiment, for it was thought by some that a man might be more suitable. But the experiment has been justified in every respect. Whereas the two men attendance officers divide the supervision of the ordinary absences in all the schools except two, the woman deals with the ordinary absences from the two remaining schools, as well as the excluded cases in all the schools, the conditions for which exclusion is called for being verminous conditions, impetigo, ringworm and scabies. There is ample evidence to show that by her visits she has encouraged the mothers to cleanse or treat the Co-operation of Voluntary Bodies. 133 children with greater energy and speed than formerly. She gives advice regarding cleansing, and sees that the children are presented when necessary for treatment at the School Clinic, supervising the treatment at the home when considered desirable. By her tact and strength of character she is able to influence the mothers more than the men with regard to these cases, which is only natural, since in these matters the advice of a woman is more readily accepted than that of a man, and the children return to school at an earlier date than formerly—a great gain to the Education Committee in grant and a great gain to the children in education. Co-operation of Voluntary Bodies. The whole of the following up is carried out by the School Nurses, who refer cases which cannot be dealt with at the School Clinic to Voluntary Societies. To the Central Aid Society are referred children for convalescent treatment, children requiring treatment in a general hospital and those in need of surgical appliances ; to the National Society of the Prevention of Cruelty to Children are referred children requiring supervision; and to the School Attendance Aid Committee children in need of boots which cannot be provided by the parents on account of necessitous circumstances. Blind, Deaf, Defective and Epileptic Children. To ascertain what children are defective within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893, and the Elementary Education (Defective and Epileptic Childien) Act, 1899 and 1916, a particular survey of all the children coming within these Acts is made once in each year, the children being examined and special records kept ot the examination. 134 Blind, Deaf, Defective and Epileptic Children. Any such children newly admitted are immediately reported by the teachers to the School Medical Officer, who causes an examination of the children to be made as early as possible after admission. There are four blind children, all boys, under the care of the Local Education Authority, and all are being maintained at Certified Schools for the Blind. Two partially blind boys are attending elementary schools under special supervision. One deaf and dumb boy is maintained by the Local Education Authority at a Certified School. On the records are 70 feeble-minded children, 53 (26 boys and 27 girls), being in attendance at the elementary schools, eight (3 boys and 5 girls), being at home, and nine (3 boys and 6 girls), being maintained at Special Schools. During the year one girl was notified as an imbecile to the Central Authority. The provision of suitable educational facilities for these feeble-minded children was considered by the Special Sub-Committee at the same time as for physically defective and badly nourished children, but, as already noted, the scheme was abandoned on account of the difficulty of obtaining a suitable site or building at a reasonable price. A Special School for feeble-minded school children is certainly required in or near the district. At present only feeble-minded children whose home circumstances are unsuitable or whose supervision at home is difficult are sent by the Local Authority to Residential Special Schools. Seven epileptic school children are known. Four (3 boys and 1 girl), are so mildly affected as to be able to attend school, but three (2 boys and 1 girl), are in such a condition that attendance at school is undesirable Nursery Schools. 135 Nursery Schools. There are no Nursery Schools in the Borough. Secondary and Continuation Schools. The administration of these schools comes within the control of the County Council, which is represented locally by the Ealing Higher Education Committee. The School Medical Officer of the Borough acts as Medical Officer to the Higher Education Committee, and as such carries out the medical inspection at the Secondary School. In this way the continuity of supervision and treatment of the children is preserved. As over 74 per cent. of the children attending the Secondary School have already been in Public Elementary Schools in Ealing, the medical inspection and treatment of the children is thus kept continuously in the same hands, an arrangement which facilitates administration and at the same time benefits the children. The report on these children is submitted to the County Education Committee, and will be embodied in the report of the County Medical Officer. Employment of Children and Young Persons. Conditions of the employment of children and young persons.—Bye-laws, based on the model set of the Home Office, under the Employment of Children Act, 1903, as amended by the Education Act, 1918, were made by the Local Education Authority on the 14th October, 1920. These bye-laws, which came into force on the 5th January, 1921, prescribe the conditions under which children (persons under 14 years of age) can be employed, and under which young persons (between 14 and 16 years of age) can be employed in Street Trading. 136 Employment of Children and Youug Persons. The chief employments in which children are engaged in Ealing are delivering papers, milk and bread, doing domestic work, and acting as message boys. Those in which young persons are employed are chiefly selling papers and hawking fruit or vegetables. Arrangements have been made by which all employed children will be medically examined at least once a year to determine if they are being adversely affected by the conditions of their employment. The head-teachers have been asked by circular letter to inform the School Medical Officer at once of any children whom they consider are being adversely affected by employment out of school hours. Cases so reported will be medically examined and reported upon. All young persons before being employed in street trading are medically examined and reports are made on the forms relating to them, which are kept by the Shops Inspector, who administers the bye-laws on behalf of the Education Committee. Co-ordination of the work of the School Medical Service with that of the Juvenile Employment Committee and of the Certifying Factory Surgeon.—Reports are furnished to the Juvenile Employment Committee regarding the health or physical condition of any young person of whom records are available and concerning whom such reports are desired. In some cases a medical opinion is also given apart from or in addition to such reports. There is no co-ordination of the work of the Certifying Factory Surgeon and of the School Medical Service. No reference has ever been made by the Surgeon with regard to any person, but this may be due to the fact that no occasion has arisen. There are very few fac- Miscellaneous. 137 lories in Ealing, and those that exist are small in character and do not employ young persons to any extent. Findings of the School Medical Service as regards the physical conditions of Employed Children and Young Persons.—It is only since the passing of the bye-laws in October, 1920, that particular medical examination of all employed children and young persons engaged in street trading has been carried out, and a sufficent amount of material has not been available on which to base a general expression of opinion, but it may be stated that since the examinations began, no child has been found to be adversely affected by the nature or extent of his employment. Special Enquiries A special enquiry was carried out during the year regarding the extent and nature of the crippling of school children, a report on which has been already given when considering Crippling Defects. Enquiries are being made regarding the effects of operation and non-operation on enlarged tonsils, and on the extent and nature of heart disease among school children, but these are not yet complete. Miscellaneous. Under this heading it seems desirable to record all the examinations made at the Inspection Clinic. At the Inspection Clinic are examined all children specially referred by the Head-teachers, School Attendance Officers or Education Committee, and also teachers newly appointed by the various Education Sub-Committees or School Managers. Each morning of the week, at 10 o'clock, children may be referred for medical examination. The children are usually those suspected of having verminous heads 138 Miscellaneous. or bodies, those affected with ringworm, scabies, or impetigo, or those whose examination is desirable on account of some defect or suspected defect, such as defective eyesight, and eye, nose, or ear disease, which may require treatment. Excluded children are also examined regularly until certified as able to return to school. The examinations for the year may be tabulated as follows:— Verminous children 1,236 Impetigo 1,382 Ringworm 274 Scabies 202 Teachers 27 Scholarship children 3 Children to be sent to Convalescent Home, under King Edward Memorial Scheme 12 Miscellaneous 1,258 Total 4,394 Statistical Tables. The six Statistical Tables required by the Board of Education are appended. 139 TABLE I. 139 Number of Children Inspected, 1st January, 1920 to 31st December, 1920. A.-ROUTINE MEDICAL INSPECTION. Age. Entrants. 3 4 5 6 7 8 Total. Boys — 51 264 155 4a 12 526 Girls — 31 199 144 7a 26 474 Totals — 82 463 299 118 38 1000 Age. Intermediate Groups Leavers. Grand Total 8 12 13 14 Oth'r Ages Total Boys 410 399 41 3 — 853 1379 Girls 413 431 38 1 — 883 1357 Totals 823 830 79 4 — 1736 2736 B—SPECIAL INSPECTIONS. Age. Special Cases. Re- Examinations (i.e.,No.of Children Re-examined). Boys 1065 624 Girls 1099 574 Totals 2164 1198 C.—Total number of Individual Children Inspected by the Medical Officer whether as Routine or Special Cases (no child being counted more than once in one year). Number of individual children inspected, 4900. 140 141 TABLE II. Return of Defects Found in the Course of Medical Inspection. 1920. defect or disease. Routine Inspection. Specials. No. referred for treatment. No. requiring to be kept under observation but not referred for treatment. No. referred for treatment. No. requiring to be kept under observation but not referred for treatment. (1) (2) (3) (4) (5) Malnutrition: — 1 106 - Uncleanliness:— - - Head 18 - 707 - Body 2 - 4 - Ringworm:— - - Head — - 50 - Body 2 - 29 - Skin Scabies 7 - 62 - Impetigo 22 - 464 Other Diseases — 15 4 - (Non-Tuburcelar) - Eye Blepharitis 19 5 - Conjunctivitis 4 — 4 - Keratitis — — 2 - Corneal Ulcer — — 1 1 Corneal Opacities — 3 1 1 Defective Vision 198 — 27 - Squint 22 - 7 7 Other Conditions — 6 1 — (Defective Hearing 27 - 5 Ear Otitis Media 19 — 139 — Other Ear Diseases 1 — — — NOTE AND THROAT 'Enlarged Tonsils 129 23 28 Adenoids 7 — — — Enlarged Tonsils and Adenoids 9 — — — Enlarged Cervical Glands NON Tubercular) 3 1 Submaxillary — 68 — — Tonsilary - 3 - - Defective Speech — 4 — — Teeth Dental Diseases 501 — 192* — Heart Disease:— Heart and Circulation Organic 76 4 - Functional — — — — Anaemia — 110 5 — Lungs Bronchitis 17 2 - Other Non-Tubercular Diseases — 12 10 10 Tuberculosis Pulmonary:— Definite — — 1 - Suspected — — — 7 Non-Pulmonary Glands 2 - Spine — — - Hip — 2 — - Other Bones and Joints — — — - Skin - Other forms — — — — Nervous System Epilepsy 2 - 4 Chorea - - 5 5 Other Conditions — 3 — Deformities Rickets Spinal Curvature 2 Other Forms — 102 — — Other Diseases and Defects — — 17 9 Totals 990 557 1783 41 Number of individual children having Defects which required Treatment or to be kept under observation 1366 (*) See also Report on Dental Treatment. 142 143 TABLE III. Numerical Return of All Exceptional Children in the Area in 1920. Blind (including partially blind), within the meaning of the Elementary Education (Blind and Deaf Children Act, 1893) Girls Boys Total Attending Public Elementary Schools - 2 2 Attending Certified School for the Blind - 4 4 Not in School - Deaf and Dumb Attending Public Elementary Schools - - - (including partially deaf), within the meaning of the Elementary Education (Blind and Deaf Children Act, 1893) Attending Certified Schools for the Deaf - 1 1 Mentally deficient Feeble-Minded Attending Public Elementary Schools 27 26 53 Attending Certified Schools for Mentally Defective Children 6 3 9 Notified to Local Control Authority by Local Education Authority during the year 1 - 1 Imbeciles Not in School 5 3 8 At School - — — Idiots Not in School — — — At School — — —- Epileptics Attending Public Elementary Schools 1 3 4 Attending Certified Schools for Epileptics — — — In Institutions other than Certified Schools — — — Not in School 1 2 3 Pulmonary Attending Public Elementary Schools 3 2 5 Tuberculosis Attending Certified Schools for Physically Defective Children — — — In Institutions other than Certified Schools - — - Physically Defective Not in School I — 1 Crippling due to Tuberculosis Attending Public Elementary Schools 8 4 12 Attending Certified Schools for Physically Defective Children — — — Crippling due to Causes other than Tuberculosis, i.e., Paralysis, Rickets, Rheumatism Other Physical Defectives, e.g., Delicate and other Children suitable for admission to Open-air Schools, and Children suffering from severe heart disease In Institutions other than Certified Schools — — —- Not at School 3 2 5 Attending Public Elementary Schools 25 1 56 Attending Certified Schools for Physically Defective Children — — — In Institutions other than Certified Schools - — - Not at School 3 4 6 Attending Public Elementary Schools 7 13 20 Attendiing Open-air Schools — — — Attending Certified Schools for Physically Defective Children other than Open-air Schools — — — Not at School 6 3 9 Dull or Backward:— Retarded 2 years 98. Retarded 3 years—50. 144 TABLE IV. Treatment of Defects of Children during 1920. A.—Treatment of Minor Ailments. Disease or Defect. Referred for Treatment Number of Children Treated. Under Local Education Authority's Scheme. Otherwise. Total. Skin — Ringworm—Head 50 44 6 50 Ringworm—Body 29 15 14 29 Scabies 62 12 50 62 Impetigo 464 215 249 464 Minor injuries 1 1 — 1 Other Skin Diseases 12 2 10 12 Ear Disease 159 56 103 159 Eye Disease (external and other) 37 5 32 37 Miscellaneous 42 22 20 42 Totals 856 372 484 856 145 B.—Treatment oJ Visual Defect. Number of Children. Referred for Refraction Submitted to Refraction. For whom Glasses were prescribed. For whom Glasses were provided. Recommended for Treatment other than by Glasses. Received other forms of Treatment. For whom no Treatment was considered necessary. Under Local Education Authority's Scheme Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 246 169 29 — 198 151 147 7 48 11 Refraction Re-inspections—813. 146 C.—Treatment of Defects of Nose and Throat. Number of Children. Received Operative Treatment. Referred for Treatment. Under Local Education Authority's Scheme Clinic or Hospital. By Private Practitioner or Hospital. Total. Received other forms of Treatment. 190 148 14 162 8 D.—Treatment of Dental Defects. 1.—Number of Children dealt with. (a) Inspected by Dentist Referred (b) treatment for Age Groups. " Specials " Total. 5 6 7 8 9 10 11 12 13 14 48 304 582 440 535 411 416 313 243 262 192 3746 2014 192 2206 (c) Actually treated 2238 192 2430 (d) Re-treated (result of periodical examination 1709 1709 147 2.—Particulars of Time Given and Operations unde rtaken. Number of Half days devoted to Inspection . Number of Half days devoted to Treatment. Total of Number Attendances made by the Children at the Clinic. Number of Permanent Teeth. Number of Temporary Teeth. Total Number of Fillings. Number of Administrations of General Anaesthetics, included in (4) and (6). Number of other Operations Extracted. Filled. Extracted. Filled. Permanent Teeth. Temporary Teeth. (1) (2) (3) | (4) (5) | (6) (7) (8) (9) (10) (11) 25 208 2430 147 1912 2738 21 1933 292 Nil. Nli. 148 E.—Treatment of Uneleanliness. (a) The average number of visits made by the School Nurse to each School 3 (b) The total number of examinations made of Children by School Nurses in a year in the Schools 5691 (c) The number of individual Children found unclean 711 (d) The arrangements made by the Authority for cleansing, and the number of children cleansed Nil (e) The School Attendance Officer issued summonses in ten cases where the children were not cleansed in a reasonable time, a fine of 20s. being imposed by the Justices in two cases, 10s. in one case, 5s. in five cases, and two were cautioned. 149 TABLE V. Summary of Treatment o( Defects as shown in Table IV. (A, B, C, D and F, but excluding E). Number of Children. Referred for Treatment Treated. Local Under Education Authority's Scheme. Otherwise. Total. Minor Ailments 856 372 484 856 Visual Defects 246 169 29 198 Defects of Nose and Throat 190 148 22 170 Dental Defects 2206 2387 — 2387 Other Defects 42 22 20 42 Total 3540 3098 555 3653 150 TABLE VI. Summary Relating to Children Medically Inspected at the Routine Inspection during the Year 1920. (1) The total number of children medically inspected at the routine inspections 2736 (2) The number of children suffering from:— Malnutrition 107 Skin Disease 46 Defective Vision (including Squint) 220 Eye Disease 32 Defective Hearing 27 Ear Disease 20 Nose and Throat Disease 168 Enlarged Cervical Glands (Non-Tubercular) 74 Defective Speech 4 Heart Disease:— Organic 76 Functional — Anaemia 110 Lung Disease (Non-Tubercular) 29 Tuberculosis:— Pulmonary: Definite Suspected — Non-Pulmonary 4 Disease of the Nervous System 5 Deformities — Other Defects and Diseases 104 (3) 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 448 (4) The number of Children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc.) 569 (5) The number of Children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) 562