EAL 18 Borough of Ealing. ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE YEAR 1927. THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law, Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation, Maternity and Smallpox Hospitals. BAILING: Francis A.Perry, Ltd., 4, Kirchen Road. EAL Borough of Ealing. ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE YEAR 1927. THOMAS ORR, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law, Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation, Maternity and Smallpox Hospitals. EALING : Francis A. Perry, Ltd., 4, Kirchen Road. ANNUAL REPORT OF THE Medical Officer of Health, 1927. 4 INDEX. page Acts, Byelaws and Regulations 18 Ambulances 16 Bacteriological Examinations 41 Births 9 Blind, Deaf, &c., Children 69, 80 Clinics and Treatment Centres 17 Dairies, Cowsheds and Milkshops 24 Day Nursery 46 Deaths 13 Dental Defects 58, 61, 84 Dental Treatment of Mothers 43 Diphtheria 32 Disinfection 25, 42 Factories and Workshops 25, 27 Food 29 Health Centres 7, 49 Health Centres, Work of 45 Health Visiting 44 Hospitals in the District 14 Housing 28 Infant Deaths 11 Infectious Diseases 32, 59 Institutions in the District 14 Maternity and Child Welfare 42 Medical Inspection of School Children 51 Medical Treatment of School Children 60 Mentally Defective Children 70 Midwives 18 Milk 29 Notifiable Diseases 32 Nursing Arrangements 17 Offensive Trades 25 Population 9 Sanitary Inspection of District 24 Scarlet Fever 35 Sewage Disposal 21 Slaughterhouses 25 Staff 6, 49 Statistics, Vital 8 Statistics, General 8 Tuberculosis 40, 61 Uncleanliness 55 5 PUBLIC HEALTH COMMITTEE, 1926-27. Councillor W. T. White [Chairman). Alderman H. Armriding (Vice-Chairman). Alderman H. W. Peal, J.P., Councillors E. H. Atkinson, A. H. Chilton, J.P., J. C. Fuller, D. Howell-Jones, Lt.-Col. R. R. Kimmitt, O.B.E., J. J. Lynch, W. D. Pocock, H. M. Sayers, J. Smith, Mrs. E. S. Taylor and G. C. Wilcox. MATERNITY AND CHILD WELFARE COMMITTEE, 1926-27. Councillor Lt.-Col. R. R. Kimmitt, O.B.E. (Chairman). Councillor Mrs. E. S. Taylor (Vice-Chairman). Aldermen H. Armriding and H. W. Peal, J.P., Councillors E. H. Atkinson, A. H. Chilton, J.P., J. C. Fuller, D. Howell-Jones, J. J. Lynch, W. D. Pocock, H. M. Sayers, J. Smith, W. T. White, and G. C. Wilcox, Mesdames Cocker, Girdlestone, Ludlow, Morris, Parry and Wilcox. 6 STAFF. Medical Off icer of Health and Superintendent of Isolation, Maternity and Smallpox Hospitals— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant Medical Officer of Health and Medical Attendant of Isolation Hospital— Harold Eujs, M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Assistant Medical Officer, Maternity and Child Welfare— Edna I. Ivangston, M.B., B.S., L.R.C.P., M.R.C.S. Consultant, Health Centres (Ante- Natal Consultation)—Part-time— John W. BEU,, L.R.C.P.I. & L.M., L.R.C.S.I. & L.M. Chief Sanitary Inspector— Thomas Hill, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. Sanitary Inspectors— James Stubbs, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. George W. Stevens, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. C. P. H. Meadows, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. 7 Health Visitors— Eleanor Evans, Cert. R.S.I., Cert. C.M.B. (Senior). Marguerite Farrow, Cert. R.S.I., and Trained Nurse. Mildred Adeline Rice, Cert. R.S.I., Cert C.M.B., and Trained Nurse. Rubie G. B. Dugger, Health Visitors' Cert., Cert. C.M.B., and Trained Nurse. Matron, Day Nursery— Alice M. Exon, Trained Nurse. Chief Clerk and Committee Clerk— Harry Birrell. Clerk and Laboratory Assistant— *Ernest W. Hill. Clerks— *William A. J. Turner. Olive Levasseur. *George W. Stephens. Winifred Rivers. *Herbert J. Reed. Peggy Gostage. HEALTH CENTRES. 13, Mattock L,ane, Ealing. Cherington House, Hanwell. Aberdeen House, Greenford. Note.—To the salaries of all the above officials, excepting those marked with an asterisk, contribution is made under the Public Health Acts or by Exchequer Grants. 8 SUMMARY OF GENERAL STATISTICS, 1927. Population (Estimated, 1927) 93,220 Population (Census, 1921) 89,697 Population (Census, 1911) 81,415 Area of Borough in Acres 7,055 Number of Structurally Separate Dwellings (1921) 18,497 Assessable Value (District Rate), October, 1927 £737,058 Net Produce of a Penny Rate £3,000 SUMMARY OF VITAL STATISTICS, 1927. Births:- Legitimate Males, 625 Females, 643 Total, 1,268 Illegitimate Males, 28 Females, 25 Total, 53 1,321 Birth-rate 14.1 Deaths: Males, 486 Females, 593 Total 1,079 Death-rate (Crude) 11.5 Death-rate (Standardised) 10.5 Deaths of Infants under 1 year:- Legitimate : Males, 35 Females, 31 Total, 66 Illegitimate: Males, 4 Females, 4 Total, 8 74 Infant Death-rate per 1,000 Births:- Legitimate, 52 Illegitimate, 151 Total 56 Death-rate Total per 1,000 Deaths Population Measles - - Whooping Cough 6 0.06 Diphtheria 3 0.03 Scarlet Fever - - Influenza 44 0.47 Tuberculosis of Lung 66 0.70 Other Forms of Tuberculosis 10 0.10 All Forms of Tuberculosis 76 0.80 Death-rate per 1,000 births Diarrhoea (under 2 years of age) 5 3.7 Number of Women dying in or in consequence of Childbirth:— From Sepsis 2 1.5 Other causes 1 0.7 9 TABLE I. Comparison of Vital Statistics of Ealing with those of England and Wales, Etc., 1927. England and Wales 107 Great Towns (including London) London Ealing Birth-rate 16.7 17.1 16.1 14.1 Death-rate 12.3 12.2 11.9 10.5 Infant Death-rate 69 71 59 56 Measles Death-rate 0.09 0.12 0.04 0.00 Whooping Cough Death-rate 0.09 0.10 0.12 0.06 Diarrhoea (under 2 years per 1,000 Births) 6.3 8.3 7.5 3.7 Diphtheria Death-rate 0.07 0.08 0.09 0.03 Scarlet Fever Death-rate 0.01 0.01 0.01 0.00 Influenza Death-rate 0.57 0.49 0.39 0.47 VITAL STATISTICS. Population. The population of the whole area in the middle of 1927, as estimated by the Registrar-General, was 93,220. During the year the natural increase in the population, which is the excess of births over deaths, was 242. At the Census of 1921 the total population for the area was 89,697. The Census returns for 1921 indicate that there were 18,497 structurally separate dwellings occupied in the area now included in the Borough, that there were 111,282 rooms occupied and that there were 1.24 rooms per person. The area of the Borough is 7,055 acres, and the density of population, or number of persons per acre, is therefore 13.2. The Birth-rate is low compared with the rates for England and Wales and for London, which are 16.7 and 16.1 respectively. The number of births assigned to the whole of the area was 1,321, which gives a birth-rate of 14.1 per thousand of population. This is just slightly over the rate recorded for the Borough in the previous year. 10 The Death-rate is slightly higher than in the previous year, 10.5, compared with 10.1. Nevertheless, it compares favourably with that for England and Wales, which is 12.3, and that for London, which is 11.9 per thousand of population. The Infant Death-rate of 56 is just one point higher than the rate for Ealing in the previous year, when it was 55 per thousand births. The rate compares well with the rates for England and Wales, for the Great Towns and for London, which are respectively 69, 71 and 59 per thousand births. In Table II the rate for 1927 is compared with the rates for the previous sixteen years. The illegitimate infant death-rate is 151 per thousand illegitimate births. table ii. Showing Birth-rate, Death-rate and Infant Death-rate for Ealing for the Years 1911-1927. Year Birth-rate Death-rate Infant Death-rate 1911 20.2 11.5 121 76 1912 20.6 9.7 67 1913 18.2 8.9 72 1914 17.5 9.4 59 1915 16.6 10.2 63 1916 17.0 11.1 58 62 1917 14.8 10.5 63 1918 13.0 13.6 76 1919 13.3 10.8 65 1920 17.8 8.8 47 1921 16.9 10.6 63 55 1922 16.2 11.0 52 1923 15.6 10.6 58 1924 14.3 11.1 47 1925 14.0 9.1 56 1926 14.0 10.1 55 1927 14.1 10.5 56 11 The causes of deaths of infants in 1927 are indicated in Table III, in which the causes of deaths in 1927 are compared with those in the preceding eight years. In Table III a the causes of death, and the ages at which death occurred "amongst children under twelve months old, are indicated. It is noteworthy that 47, or 63 per cent, of the total 74 infant deaths occurred under four weeks old, and 40, or 54 per cent. of the total, under one week old. table III. Causes of Infant Deaths, 1919 to 1927. 1919 1920 1921 1922 1923 1924 1925 1926 1927 Diarrhoeal Diseases 3 9 9 5 2 4 1 4 3 Premature Birth 13 15 10 5 11 7 9 23 20 Congenital Defects 6 4 4 6 8 4 10 5 9 Atrophy, Debility, Marasmus 14 14 12 10 9 6 8 13 11 Tuberculous Disease 3 3 - 2 1 3 - - - Syphilis - 3 2 - - - 1 1 - Rickets - - - - - - - - - Meningitis (not Tuberculous) 2 - 1 - 1 2 1 1 - Convulsions 1 2 2 2 2 2 - 1 2 Bronchitis 3 1 6 5 5 1 4 7 5 Pneumonia (all forms) 4 4 9 1 10 3 5 5 7 Gastritis - 2 1 2 1 - - 1 - Common Infectious Diseases 1 7 4 2 3 3 1 2 Other Causes 17 7 9 15 10 11 12 9 15 Totals 67 64 72 57 62 46 54 71 74 12 TABLE IIIA. Infant Mortality during the Year 1927. Deaths at various ages under One Year of Age. Cause of Death Under 1 week 1—2 weeks 1 j—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 40 3 2 2 47 10 9 6 2 74 Uncertified - - - - - - - - - - Small-pox - - - - - - - - - - Chicken-pox - - - - - - - - - - Measles - - - - - - - - - - Scarlet Fever - - - - - - - - - - Whooping-Cough - 1 - - 1 1 - - - 2 Diphtheria and Croup - - - - - - - - - - Erysipelas - - - - - - - - - - Tuberculous Meningitis - - - - - - - - - - Abdominal Tuberculosis - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - Meningitis (not Tuberculous) - - - - - - - - - - Convulsions 1 - - - 1 1 - - - 2 Laryngitis - - - - - - - - - - Bronchitis 2 - - - 2 - 1 1 1 5 Pneumonia (all forms) - - 1 - 1 - 2 3 1 7 Diarrhoea - - - - - - 1 - - 1 Enteritis - - 1 - 1 - 1 - - 2 Gastritis - - - - - - - - - - Syphilis - - - - - - - - - - Rickets - - - - - - - - - - Suffocation, Overlying 1 - - - 1 1 - - - 2 Injury at Birth - - - - - - - - - Atalectasis 4 - - - 4 - - - - 4 Congenital Malformations 3 - - - 3 2 - - - 5 Premature Birth 16 1 - - 17 - 1 2 - 20 Atrophy, Debility and Marasmus 4 - - 1 5 4 2 - - 11 Other Causes 9 1 - 1 11 1 1 - - 13 Totals 40 3 2 2 47 10 9 6 2 74 13 In Table IV are indicated the total deaths from the various diseases. It will be seen that cancer was responsible for 156 deaths, giving a cancer death-rate of 1.67; that heart disease caused 174 deaths, giving a death-rate of 1.86 and that bronchitis and pneumonia accounted for 130 deaths, or a death rate of 1.39. Of the infectious diseases, whooping cough caused six deaths, giving a death-rate of 0.06 per 1,000 of population; diphtheria three deaths, giving a death-rate of 0.03; influenza 44 deaths, giving a death-rate of 0.47; tuberculosis 86 deaths, giving a death-rate of 0.80 per 1,000 of population. There were no deaths from measles or scarlet fever. TABLE IV. Causes of Death, 1927. Cause of Death. Male Female Total Enteric Fever - - - Smallpox - - - Measles - - - Scarlet Fever - - - Whooping Cough 3 3 6 Diphtheria - 3 3 Influenza 15 29 44 Encephalitis Lethargica 1 2 3 Meningococcal Meningitis 1 1 2 Tuberculosis of Respiratory System 34 32 66 Other Tuberculous Diseases 2 8 10 Cancer, Malignant Disease 59 97 156 Rheumatic Fever - 1 1 Diabetes 4 8 12 Cerebral Haemorrhage, etc. 19 36 55 Heart Disease 77 97 174 Arterio-Sclerosis 31 30 61 Bronchitis 25 51 76 Pneumonia (all forms) 32 22 54 Other Respiratory Diseases 10 5 15 Ulcer of Stomach or Duodenum 12 3 15 Diarrhoea, etc. (Under 2 years) 3 2 5 Appendicitis and Typhlitis 6 3 9 Cirrhosis of Liver 4 3 7 Acute and Chronic Nephritis 16 16 32 Puerperal Sepsis - 2 2 Other Accidents and Diseases of Pregnancy and Parturition - 1 1 Congenital Debility and Malformation, Premature Birth 26 22 48 Suicide 6 2 8 Other Deaths from Violence 15 7 22 Other Defined Diseases 85 107 192 Causes ill-defined or unknown - - - Total 486 593 1079 14 GENERAL PROVISION OF HEALTH SERVICES FOR THE AREA. Public Hospitals Situated In or Serving the District. (1) Isolation Hospital.—Cases of infectious disease are isolated at the Joint Hospital, which is managed by the Chiswick and Haling Hospitals Committee. At this hospital, which is situated conveniently just within the southern boundary of the Borough, cases from the Urban District of Brentford and Chiswick are also dealt with. In order to provide sufficient land for extending the hospital to meet the future needs of the two districts served, the Ealing Town Council, who own the hospital, entered into negotiations with, and ultimately purchased from, the Ealing and Old Brentford Burial Board, one and a half acres of land conveniently situated on the north of the hospital site. The acquisition of this land will allow the isolation accommodation to be doubled in the future by the erection of three pavilions of two wards each. It was necessary to take this step as the Burial Board were about to lay out the land and use it for burials. This would have prevented any possible extension of the hospital in the future. (2) Smallpox Hospital.—The Smallpox Hospital for the Borough is situated in the northern part of the district on the north bank of the Brent and about a quarter of a mile from the northern Sewage Works. The buildings consist of a small administrative block and an isolation block of two wards with five beds each. Two acres of land are enclosed with the buildings, but there are in the ownership of the Council 27 acres of land adjoining which can more than meet all possible needs for extension. (3) Tuberculosis Hospitals.—There are no hospitals for tuberculosis in the Borough. The Middlesex County Council make provision for the treatment of cases of tuberculosis at Harefield Sanatorium and at Clare Hall Hospital. (4) Maternity Hospital.—The Chiswick and Ealing Hospitals Committee manage the Maternity Hospital, which was formerly the Chiswick Isolation Hospital. It serves the needs of the Borough and of the Urban District of Brentford and Chiswick, and consists 15 of 22 beds. Improvements are projected at this hospital by providing sufficient accommodation for the staff, by making a new Labour Ward, which will be easy of access, by installing new hot water and heating arrangements and by overhauling and extending the laundry. In these extensions or improvements the possibility of adding to the bed accommodation to meet future needs has been kept in mind. (5) Hospital Provision for Children.—At the King Edward Hospital there is a Children's Ward of 12 beds, where children under 5 years of age can be referred for treatment from the Health Centres. There is also a small Children's Ward of three beds at the Hanwell Cottage Hospital. (6) Other Hospitals.—To meet the general medical and surgical needs of the Borough there is the King Edward Memorial Hospital, situated at Mattock Lane, which has 94 beds, including eight private wards of one bed each, in addition to the Children's Ward of 12 beds already mentioned. The West Middlesex Hospital, situated at Isleworth, is the Poor Law Hospital of the Brentford Board of Guardians of whose area Ealing forms a part. Although there still exists a prejudice against this hospital because it is a Poor Law Hospital, the people are beginning to get over this to some extent and to recognise that they have for their use a hospital which is well equipped and well managed and in which they can receive every care and attention. There is a definite call, however, for the more extended use of this hospital by the people living in the area served, but this call cannot be answered until the Ministry of Health relax their restrictions with regard to the class of the community who may take advantage of it or until the law determines the policy which has to be pursued in adapting the use of the poor law hospitals throughout the country to the needs of the general community. The promise of new legislation seems to hang like a cloud over these hospitals, to preserve the prejudice against them and prevent their development and full utilisation. As it is, there is duplication of hospital provision, with the general hospitals providing for all the community, and the poor law hospitals for the restricted class of the necessitous poor who unfortunately are so strictly defined in law. We hear of schemes and modified schemes for dealing with the whole problem, but the time has come for a bold move which will result in establishing our hospitals on a proper 16 basis when public and voluntary hospitals will co-operate with one another and not act independently in serving the needs of the community. An entire lack of co-operation is strikingly evident between the King Edward Memorial Hospital and the Hanwell Cottage Hospital, which consists of 12 beds with the three beds for children already mentioned. It is a striking anomaly to have a hospital of the dimensions of a cottage hospital being run in the same district alongside a large voluntary general hospital. There is division of effort not only in the management but in the collection of funds. One hospital is sure to interfere with the other in the collection of funds. Were the resources combined there could be economies in management. Besides, the undivided interest of the people in one hospital or combination of hospitals would result in a better response in the whole of the Borough to an appeal for support. It can be quite readily understood that those who have carefully nurtured the smaller institution and tended it during its early years will be loth to part with control, but there is the broader aspect to consider, the hospital provision for the whole district. A combination of resources need not mean the discontinuance of the Hanwell Hospital or the dispensing with the capable men who have managed its affairs or with the staff. The valuable experience and services of all could be of value to a larger governing body for both hospitals. One has in mind the possibility of utilising the Hanwell Hospital entirely as a Children's Hospital, where the small wards are eminently suitable for treating children, where isolation can be carried out when necessary and where open-air treatment could be conducted in a way that is not practicable at the King Edward Hospital and the utilisation of the children's ward at the King Edward Hospital for adults, for whom beds are so much needed. Surely some means can be found of bringing these two hospitals together for the benefit of the sick of the whole of the Borough. Ambulance Facilities. (1) For Cases of Infectious Disease.—The Chiswick and Ealing Hospitals Committee provide a motor ambulance in which cases of infectious disease are removed from the Borough of Ealing and the Urban District of Brentford and Chiswick to the Isolation Hospital. 17 (2) Non- Infectious and Accident Cases.—The Town Council has two ambulances for the conveyance of accident and noninfectious cases of illness to Hospitals or Nursing Homes. J ourneys within the Borough are made free of charge, those outside are charged a fee of one guinea. During the year the ambulances were called out on 1,169 occasions; 365 calls were for cases of accidents and 804 were for cases of illness. The journeys made outside the Borough were 205, and the total number of miles travelled was 6,329. Clinics and Treatment Centres. Name Address Provided by Health Centre 13, Mattock Lane, Ealing. Ealing Town Council Health Centre Cherington House, Hanwell. Ealing Town Council Health Centre (temporary (School Children) )Betham's School, Greenford. Ealing Town Council Health Centre (temporary) (Mothers and Babies) Aberdeen House, Greenford. Ealing Town Council Day Nursery Uxbridge Road, Hanwell. Ealing Town Council Tuberculosis Dispensary Green Man Lane, West Ealing. Middlesex County Council. Treatment Centres for Venereal Disease Certain Hospitals in London. Middlesex County Council. Professional Nursing in the Home. (1) General.—During the year the amalgamation of the Ealing and the Hanwell District Nursing Associations took place, the new body being called the Greater Ealing Nursing Association, and its activities were extended to embrace the whole of the Borough. Four nurses are now employed, one being stationed in Greenford. At the Health Centres arrangements have been made for the nurses to utilise a cupboard for the storage of dressings, etc., and for them to receive messages requesting their services. They also give some assistance at the Health Centres. The attendance of the nurses at the Centres is an excellent way of securing co-operation between the District Nurses and the Health Visitors, and of introducing the nurses to the mothers who are encouraged to join the provident scheme of the Nursing Association. 18 (2) Infectious Disease.—For a yearly grant by the Town Council to the funds of the Nursing Association the nurses are expected to nurse children under five years of age suffering from ophthalmia neonatorum, measles, whooping cough, poliomyelitis and diarrhoea. (3) Midwives.—In the Borough there are in practice 31 midwives, seven of whom are in the Maternity Hospital. The supervision of midwives comes within the province of the Middlesex County Council. The Town Council, in its scheme of Maternity and Child Welfare does not employ any particular midwife when supplying maternity aid for women in necessitous circumstances. The midwife nearest the patient's residence is engaged and paid by the Council. As the work of all the midwives in the district has been found to be very satisfactory there is no difficulty in engaging any one of them with confidence. Legislation in Force. In the following list are noted all the Local Acts, Adoptive Acts, Byelaws, and Regulations in force in the Borough:- The Ealing Corporation Act, 1905, confers additional powers on the Council with respect to certain sanitary matters, the provision of dustbins, the drainage of houses by combined operation, etc. Adoptive Acts. Public Health Acts (Amendment) Act, 1890. 20th November, 1890 Infectious Disease (Prevention) Act, 1890. 18th December, 1890 Public Health Acts (Amendment) Act, 1907. 21st December, 1908 Notification of Births Act, 1907. 9th May, 1912 Public Health Act, 1925. Parts II, III, IV and V. Byelaws, with date of making, with respect to:- (1) Prevention of nuisances arising from sewage, filth, etc., keeping of animals, and (2) Cleansing of earth closets, privies, ashpits and cesspools, October 15th, 1880. Common Lodging Houses, February 4th, 1881. 19 Slaughter Houses, March 6th, 1884. (Added: Humane Slaughtering of Animals, 1922). New Streets and Buildings, 23rd July, 1925. Byelaws under Section 26 (1) of the Public Health Acts (Amendment) Act, 1890. June 20th, 1907. Tents, Vans, Sheds, etc., under the Housing of the Working Classes Act, 1885. July 2nd, 1907. Prevention of keeping Animals on any premises so as to be injurious to Health. July 15th, 1910. Regulations. Communications between Drains and Sewers, Section 21, Public Heath Act, 1875. October 8tli, 1908. SANITARY CIRCUMSTANCES OF THE AREA. Water.—The Greenford Ward is supplied with water by the Rickmansworth and Uxbridge Valley Water Company, while the rest is supplied by the Metropolitan Water Board. A complaint was received with regard to the condition of the water supplied to a range of houses in Greenford Ward, but this was found to be due to a length of piping which formed a dead end in which the water became stagnant and got coloured with rust from the pipes. On the extension of this pipe to supply other houses in course of erection the cause of the complaint disappeared. Rivers and Streams.—When the extension of the Borough took place in October, 1926, numerous complaints were received regarding the condition of the ditches and streams in the Greenford Ward. Since then as a result of energetic action, which resulted in a large amount of new drainage works involving the abolition of cesspools which overflowed into the ditches and streams, such a marked improvement has been effected that not a single complaint was received during the year. The chief source of pollution of the main stream, which runs through the ward and which was formerly a stinking stream of almost inky blackness, was from the washings of the tallow factory. These washings were diverted into the main sewer in the early part of the year and since then the water has returned to something approaching reasonable purity. 20 In the months of November and December, like many parts of the country and particularly of the Thames Valley, owing to unusually heavy rain, a portion of the Greenford Ward was flooded. The flooding involved two areas, one in Oldfield Lane, with its centre at Betham's School, the floors of all the rooms of the Infants' Department being covered with water, and the other in Coston's Avenue, where some of the new houses were so flooded as to prevent the ground floor rooms being occupied. It is essential that every step should be taken to prevent flooding in the future, for not only does the flooding cause extreme inconvenience to the occupants of the houses, but also becomes a danger to health owing to the dampness of the walls and especially of the floors. The danger consists in the lowering of vitality, which a cold damp atmosphere is liable to bring about, especially in the winter, and in the increased susceptibility to disease. It is most unfortunate that it has been possible to build houses at such a level as renders them liable to flooding, but now that they are built every protection should be offered to the occupiers. Drainage and Sewerage.—Excepting in the Greenford Ward and in the most northerly portion of the Mount Park Ward, both of which areas are still mostly rural in character, the houses in the Borough are supplied with water closets and are drained into the main sewerage system. In the areas mentioned a large amount of work has been carried out during the year in improving the drainage of houses. Sixteen houses have had pail-closets replaced by water closets and the drains of these, and those of eleven other houses at which cesspools have been abolished, have been connected with the sewer. The connecting of the drains of four other houses with the sewer was in progress, though not completed, at the end of the year. There are fifteen houses situated within 100 feet of a sewer which still drain to cesspools and concerning which notices have been served requiring them to be connected with the sewer. In the sparsely inhabited parts of the Greenford Ward there are 57 cesspools where no sewers are at present available. 21 Sewage Disposal.—There are four separate sewage works in the Borough, situated at North Ealing, South Ealing, Greenford and Hanwell. The first two are very efficient works which never occasion any complaints. As regards the Hanwell works, during the year there were complaints from inhabitants of the houses in the vicinity that at certain times during the summer months, particularly in the evening, the smell was so intense as to be almost unbearable. Perhaps the complaints were to some extent justified and may be put down to the fact that the summer season was a very wet one, with the consequence that the drying of the sludge was difficult and there was of necessity a larger surface of land covered with wet sludge. The remedy of this condition consists in the installation of sludge pressing plant as at the North Ealing and South Ealing Works, a proposal for which is in the course of preparation by the Borough Surveyor. Complaints have been numerous with regard to the Greenford Works. These complaints have certainly been justified for the smell in the early part of the year was not only extremely unpleasant, but very persistant. Apparently the smell has been due to sulphuretted hydrogen generated in the tanks and especially set free in the air by the sprinklers on the filter beds. Confirmation of the fact that the smell is due to sulphuretted hydrogen is given by the blackening of the white paint in the vicinity. This heavy gas clings, when liberated from the sewage, to the surface of the land. The smell, therefore, has been particularly evident in the valley down which it has spread long distances, persisting with great tenacity except in the presence of high winds which brings about its dispersal. In the course of the year the works were extended so as to double their capacity, but it need not be anticipated that the extension will of itself eliminate the production of offensive gas. No doubt the works were previously greatly overloaded, but the overloading alone has not caused the production of sulphuretted hydrogen, though it may have had a tendency to increase its production. The special quality of the sewage to be dealt with has been the main cause. A particularly strong sewage is received from large works employing over 3,000 persons, and a sewage of peculiar character conies from tallow works in the same neighbourhood. The former 22 is rich in sulphates and the latter in the products obtained from the washings of the fumes from boiling tallow. The splitting up of the sulphur compounds by the action of bacteria in the tanks at the sewage works appears to bring about the production of sulphuretted hydrogen, and the consequent annoyance of the residents in the district. Experiments have been carried out over many months by adding chlorine in the form of" chloros" to the sewage. Chlorine may act first of all by retarding the action of the bacteria producing the sulphuretted hydrogen, out it may also act by splitting up the sulphuretted hydrogen before it is liberated on the surface of the sewage. Various proportions of chlorine have been added, but it has been found that not less than fifteen parts per million is effective in reducing smell. Half of that quantity does lessen the smell, but fifteen parts gives a marked improvement of which there is good evidence by the absence of complaints during the last months of the year. It might be expected that the addition of such an active antiseptic in such a quantity might act adversely on the sewage purification process, which depends for its success on the action of bacteria, but it has been found that the addition of this quantity of chlorine has not adversely affected the character of the effluent. Experiments were carried out by varying the point of application of the chlorine, for example by adding half the quantity at the point of entrance of the crude sewage into the tanks and half at the point where the sewage passes from the tanks to the filter beds, and by adding all of the chlorine as the sewage is proceeding, after treatment in the tanks, to the filter beds, but it was found beyond doubt that the best results were obtained by adding the whole quantity of chlorine to the crude sewage as it enters the works. As this treatment will have to be continued, the best method of adding chlorine will have to be evolved, but it seems the most economical method is by adding chlorine gas, as is being done in the treatment of the water in the swimming baths, where it has been proved easy to work, very economical, and most efficient. Closet Accommodation.—Except in the Greenford Ward and the most northerly part of the Mount Park Ward the whole of the houses are supplied with water closets, there being as a rule 23 one water closet for each house, or part of a house let as a separate tenement. In the Greenford and Mount Park Wards there are 49 houses with water closets drained to cesspools and 38 with pail closets. Two of the houses with pail closets are within 100 feet of a sewer and notices have been served requiring them to be replaced by water closets drained to the public sewer. Scavenging.—Excepting in the Greenford Ward scavenging is carried out directly by the Council, the house refuse being transported to the two destructors at South Haling and Hanwell. The Hanwell destructor is in course of extension so that it can deal adequately with all the refuse from the area previously imperfectly served by it. Scavenging at Greenford is being carried out by a contractor, the refuse being conveyed to a disused gravel pit outside the Borough. Sanitary dustbins are provided throughout the Borough, the Greenford Ward having in this respect come into line with the rest of the district. Smoke Abatement.—As there are very few factories in the Borough it is seldom that any action is called for in abating nuisance from smoke. During the year representations had to be made on four occasions regarding the abatement of nuisance from smoke : from a bakery, from two laundries and from a carriage works. At all four carelessness in stoking was the cause of the complaint. This was quickly remedied by the management in each case. Premises and Occupations which can be Controlled by Byelaws and Regulations.—There are no common lodging-houses in the Borough and there are no Byelaws with respect to houses let-in-lodgings. There are only two offensive trades carried on in the Borough' that of fish-frying which is conducted in 19 separate premises and that of tallow melter, which is carried on at a factory in the Greenford Ward. The tallow factory has been completely reconstructed during the year, and the whole of the machinery or apparatus is of such construction and the trade is conducted in such a manner as to reduce offensive odours to a minimum. The fish-frying premises are all fitted with suitable frying apparatus and there was no occasion for action with regard to any of them during the year. 24 Schools.— The Sanitary Inspectors make a thorough examination each year, during the vacation, of all public elementary and private schools and on their reports steps are taken to remedy any defects found. In the control of infectious disease the routine weekly reports of the absentees on account of non-notifiable infectious diseases' supplied by the head-teachers to the Medical Officer of Health, prove invaluable. These reports enable the Health Visitors to visit the homes and to give the mothers advice regarding the prevention of the spread of infection and the prevention of. complications, particularly in measles and whooping cough. Sanitary Inspection of the Area.— The following tabular statement shows the extent of the work carried out by the Sanitary Inspectors during the year:— General. Number of Premises inspected on Complaint 555 Number of Nuisances observed by Inspectors 112 Number of Premises inspected in connection with Infectious Disease 358 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, Etc.) 985 Number of Houses inspected under House -to- House Survey 353 Food Inspections 3,334 Total number of Re-inspections 9,789 Canal Boats inspected 6 Other Inspections 726 Total number of Inspections and Re-inspections 16,217 Number of Intimation Notices given 569 Number of other Letters written 332 Number of Statutory Notices served 132 Proceedings before Magistrates 7 Dairies, Cowsheds and Milkshops. Number of Cowsheds on Register 6 Number of Inspections made of Cowsheds 18 Contraventions of Regulations — Number of Retail Purveyors of Milk on Register 75 25 Number of Inspections of Retail Purveyors' Premises 127 Contraventions of Regulations — Proceedings before Magistrates — Slaughterhouses. Number of Registered or Licensed Slaughterhouses 6 Number of Inspections made 208 Contraventions of Regulations - Proceedings before Magistrates - Factories and Workshops. Registered Workshops 135 Factories 76 Number of Inspections of Factories and Workshops and Workplaces 210 Number of Defects concerning which Notices were sent 2 Proceedings before Magistrates — Offensive Trades. Fried Fish Shops 19 Other Offensive Trades 1 Number of Inspections 94 Contraventions — Disinfection. Rooms Disinfected by Spray:— (a) Ordinary Infectious Disease 352 (b) Tuberculosis 124 Rooms stripped and cleansed 140 Articles disinfected by steam at Disinfector:— (a) Ordinary Infectious Disease 1,127 (b) Tuberculosis 320 • Articles voluntarily destroyed 133 26 Particulars of the Sanitary Defects referred to in Notices Served and Letters Written. Water Closets repaired or supplied with water or otherwise improved 389 Drains cleared and cleansed 112 Defects in Drains repaired 212 Drains reconstructed 77 Dust-bins provided 131 Overcrowding remedied 3 Accumulations of refuse removed 70 Nuisance from fowls and other animals abated 28 Damp-proof courses inserted in walls 111 Ventilation under floors provided 37 Other forms of dampness remedied 108 Yards paved and repaired 218 Floors repaired 149 Roofs, Gutters, and Rain Water Pipes repaired 443 New Soil and Ventilating Pipes provided 135 Sinks and Waste-pipes repaired or renewed 348 Draw Taps fixed to main supply 39 Dirty Walls and Ceilings stripped and cleansed 1,252 Other Defects or Nuisances remedied 569 Cisterns cleansed and covered 13 Legal proceedings were taken in the following cases, with the results as indicated:— (1) Fowls so kept as to be a nuisance or injurious to health. Order to remove fowls and costs granted. (2) Failure to vacate dwelling-house after Closing Order had become operative. Order to vacate dwelling-house. (3) Pigs so kept as to be a nuisance or injurious to health, also ditch so foul, etc. Order to remedy nuisance and costs granted. (4) House without sufficient water supply. Fine of £10 and costs. (5) Dwelling-house in such a condition as to be a nuisance or injurious to health. Adjourned for a week to enable work to be done. (6) Dwelling-house in such a condition as to be a nuisance or injurious to health. Work ordered to be carried out in 14 days. Costs granted. (7) Dwelling-house in such a condition as to be a nuisance or injurious to health. Fine of £5 and order to complete the work in 14 days. 27 FACTORIES, WORKSHOPS AND WORKPLACES 1.—Inspection of Factories, Workshops and Workplaces. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises (1) Number of Inspections (2) Written Notices (3) Prosecutions (4) — _ Factories (Including Factory Laundries) 73 2 - Workshops (Including Workshop Laundries) 210 — — Workplaces (Other than Outworkers' premises) 20 — — Total 303 2 — 2.—Defects found in Factories, Workshops and Workplaces. Particulars (1) Number of Defects. Number of Prosecutions (5) Found (2) Remedied (3) Referred to H.M. Inspector. (4) Nuisances under the Public Health Acts— Want of Cleanliness 72 72 - - Want of Ventilation 2 2 — — Overcrowding — - — — Want of drainage of floors 2 2 - — Other Nuisances 28 28 — Sanitary accommodation insufficient — — - — unsuitable or defective 2 2 — — not separate for sexes 1 — - — Offences under the Factory and Workshop Acts Illegal occupation of underground bakehouse (s 101) - - - - Other Offences (Excluding offences relating to outwork and offences under the Sections mentione 1 in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921.) - - - - Total 107 106 - - 28 Outwork in Unwholesome Premises, Sec. 108. Nature of Work Instances Notices Served Prosecution Wearing Apparel Making, Etc. — — — Others — — — HOUSING STATISTICS FOR THE YEAR. Number of New Houses erected during the Year. (a) Total 904 (b) As part of a Municipal Housing Scheme 414 1.—Unfit Dwelling Houses. Inspection. (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 1,978 (2) Number of dwelling houses which were inspected and recorded under the Housing (Consolidated) Regulations, 1925 353 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 16 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 1,282 2.—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 1,207 3.—Action under Statutory Powers. A.—Proceedings under Section 3 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which notices were served requiring repairs None 29 (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 the Public Health Acts:— (1) Number of dwelling houses in respect of which Notices were served requiring defects to be remedied 132 (2) Number of dwelling houses in which defects were remedied:— (a) By Owners or Occupiers 116 (b) By Local Authority in default of Owners 2 C.—Proceedings under Sections 11, 14, and 15, of the Housing Act, 1925:— (1) Number of representations made with a view to the making of Closing Orders 16 (2) Number of dwelling houses in respect of which Closing Orders were made 16 (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit None (4) Number of dwelling houses in respect of which Demolition Orders were made 2 (5) Number of dwelling houses demolished in suance of Demolition Order 2 (6) Number of dwelling houses demolished without Orders being made (Orders for Closure previously made) 3 INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—In the Borough there are only six occupiers of cowsheds who are producers of milk. One of these cowsheds is being discontinued as the land has been sold as building sites. Of the remaining five cowsheds one is managed in a capable way and produces milk of a high quality, one has been 30 largely reconstructed and fitted with modern dairy apparatus, the third is well managed, but is capable of much improvement, while the fourth has been the subject of notices under the Milk and Dairies Order, and is now in the process of changing its tenancy, after which it is hoped there will be a decided improvement in the construction of the dairy and in the management of the business of milk production. As regards the fifth much has to be done to make the cowshed and milk store suitable, but this may not be necessary as negotiations are at present going on for the purchase of the land and buildings to be used for another purpose than the production of milk. At the end of the year there were 75 retail purveyors of milk registered in the Borough. Twenty-one of these registrations were in respect of premises owned by one Company and used simply as places for distributing milk which is pasteurised and bottled in a large central depot in the western area of the County of London. During the year three retail purveyors of milk occupying entirely new premises, and seven, who had purchased premises already used for the purpose, were placed on the register. In those premises which are not simply distributing centres for bottled milk, a high standard of equipment and management is gradually becoming the rule. What is aimed at is the provision of a steam boiler, galvanised washing troughs and bottle washing apparatus, where bottles are employed, a separate milk treatment room, where pasteurisation is carried out, and a milk storage room. During the year three of the old premises have been brought up-to-date by installing a steam boiler, fixing galvanised iron washing troughs and providing a separate milk store. New buildings have had to be erected to effect these improvements. The three new premises already mentioned have been similarly arranged and equipped. Milk (Special Designations) Order, 1923.—Under this Order 70 licences were granted during the year, 28 with respect to Certified Milk, 24 Grade A (Tuberculin Tested) Milk, and 18 with respect to Pasteurised Milk. Eleven samples of Certified Milk, one of Grade A (Tuberculin Tested) Milk and three of Pasteurised Milk were taken for bacteriological examination. In all of them the results came within the 31 standards laid down by the Order. Four samples of ordinary market milk were also examined for bacteriological content, but none of these was found to have an excessive number of bacteria. Eight samples were taken for bacteriological examination for the tubercle bacillus. One of these, taken in the middle of December, was found to be tuberculous. This fact was reported to the County Medical Officer in whose administrative district the milk was produced. Immediate steps were taken by the County Veterinary Officer to isolate suspicious cows and to discover the offending animal. (b) Meat, Etc.—There were no infringements of the Public Health (Meat) Regulations. As has been previously stated all shop fronts have been provided with glass protection. In the Borough of Ealing there is no meat sold from stalls or vehicles. Seven private slaughterhouses exist in the district, but very little slaughtering is done. In twelve months there have been slaughtered in them 7 cattle, 114 sheep, 387 pigs and 42 calves. All of these were stunned before slaughter by means of the Cash Captive-bolt pistol which, now that the butchers have got accustomed to it, is much preferred to the old poleaxe. There is no public slaughterhouse in the Borough. Bakehouses and places where food is cooked or prepared have been regularly inspected. In connection with the inspection of meat and other foods, the following were found to be diseased or unsound and were voluntarily surrendered for destruction:— Food Quantity Beef 251½ lb. Pork 111¾ lb. Fish 218 lb. Shellfish (Scallops) 5 dozen Rabbits 96 lb. Fruit 296 lb. Vegetables (bunches of celery) 12 dozen 32 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASES. The numbers of the various infectious diseases notified in the whole of the extended Borough are indicated in Table V and are compared with those of the Borough for the previous ten years:— Disease TABLE V. 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 Diphtheria 66 36 46 56 186 282 56 61 40 72 53 Scarlet Fever 91 61 201 171 665 487 142 123 107 156 136 Enteric Fever (including Paratyphoid) 3 6 5 6 8 3 5 9 5 4 14 Puerperal Fever — 2 3 5 9 3 9 3 6 1 6 Puerperal Pyrexia — — — — — — — - — 3 15 Pneumonia : Primary — - 30 38 21 33 32 47 57 47 66 Influenzal — - 33 27 17 22 7 27 22 17 38 Acute Poliomyelitis 2 1 — — 1 — — 3 — 1 — Cerebro-Spinal Fever 1 — 3 4 1 — 1 — — — 2 Malaria — — 40 27 3 4 2 — 2 5 6 Dysentery — — 5 2 1 1 — — — — — Erysipelas 33 24 22 30 27 22 17 25 17 15 18 Encephalitis Lethargica — — 3 1 1 3 1 6 4 2 6 Tuberculosis:— (a) Pulmonary 92 110 83 63 80 69 92 74 90 93 89 (b) Non-Pulmonary 17 22 25 17 23 16 26 31 25 21 16 Ophthalmia Neonatorum 4 3 4 8 13 10 3 3 6 5 4 Total 309 265 503 455 1036 955 393 412 381 442 469 Diphtheria.—There were only 53 cases of diphtheria notified in the whole Borough. The cases were distributed throughout the year as indicated in Table VI. It will be seen that the month of March provided the largest number in any month, whereas the month of December provided no cases. 33 table vi. Scarlet Fever. Diphtheria. January 5 3 February 5 7 March 5 13 April 6 1 May 11 4 June 18 2 July 21 9 August 9 6 September 6 2 October 20 5 November 14 1 December 16 — Total 136 53 Of the 13 cases occurring in March 4 were in the Hanwell South Ward and 4 in the Grosvenor Ward, the rest being in various other parts of the district. Of the eight cases in the Hanwell South and Grosvenor Wards, five were children attending Oaklands Road Infants' School. There was apparently some common source of infection in the School but the infective child was never discovered. Eight of the nine cases which occurred in July were of children residing in the Greenford Ward. Although the number was not large, the outbreak was alarming because the first two children attacked were so severely affected that they died. In the table of cases which follows it will be seen that the first case in the Greenford Ward was notified on the 22nd July and the second on the 23rd July. During the week commencing the 25th July very active steps were taken and all the children who had attended the School were visited to ascertain their condition and to take swabs in suspected cases. 34 The notification of E. drew attention to her brother F., and particularly to her sister G., who was found from the School Register to have been absent from the 30th June to the 7th July, the mother stating that she had had a cold. G., who was in the same class as A. and C., had a seropurulent discharge from the nose with scabbing and excoriation which one usually associates with nasal diphtheria. Swabs which were taken gave typical diphtheria bacilli. B. and D. played with G. at school and at home, their homes being in close proximity. In all probability, therefore, G. was the cause of all the cases. As regards the last case on the list, H., it was impossible to get definite information from the parents as to the onset. It can only be assumed that she developed nasal diphtheria at about the same time as A. and B. became ill. H. was running about with other children and had a condition of the nose similar to that of G., and gave a positive result as regards the diphtheria bacillus. She had not been away from school previous to the 20th July. The school re-opened after the vacation of four weeks on the 22nd August but no further cases occurred in the Greenford Ward. Particulars of Causes. No. Age Date of onset. Doctor called in Notified A. 10 years 21/7/27 21/7/27 22/7/27 B. 7 years 21/7/27 23/7/27 23/7/27 C. 11 years 21/7/27 22/7/27 25/7/27 D. 6½ years 23/7/27 23/7/27 25/7/27 E.* 8 months 23/7/27 27/7/27 27/7/27 F.* 1½ years 25/7/27 27/7127 27/7/27 (M.o.h.) G* 10 years 30/6/27 27/7/27 27/7/27 (m.o.h) H. 5 years —?— 30/7/27 30/7/27 (m.o.h.) * In same family. In the year there were three deaths from diphtheria, giving a death-rate of 0.03 per 1,000 of population and a mortality rate of 5.9 per cent. of cases. 35 The death-rate from diphtheria is low compared with that for England and Wales and with that for London, which are respectively 0.07 and 0.09 per 1,000 of population. Facilities for the bacteriological diagnosis of diphtheria are offered at the Public Health Laboratory which is situated at the Town Hall and is readily accessible from the whole area. Medical men are repeatedly advised not to wait for the bacteriological results if diphtheria is suspected but to give the specific anti-toxin treatment at once. In order to facilitate the early administration of anti-toxin, and thus reduce the mortality from the disease, anti-toxin is provided free for administration to the children of parents who are not in good financial circumstances. Doctors may obtain the anti-toxin either at the Town Hall, Ealing, or at Cherington House, Hanwell, at any time of the day or night. During the year 146,000 units of anti-toxin were issued to doctors for use in this way. Scarlet Fever.—There were 136 cases of scarlet fever notified during the year. This is the fifth successive year in which the district has been free from an outbreak of epidemic proportions, the last epidemic having been experienced in the years 1921, when there were 665 cases, and 1922, when there were 487 cases. In Table VI it will be seen that the highest number of cases occurred in June, July and October, the smallest number in January, February and March. Little association could be discerned between many of the cases which were widely scattered throughout the Borough. The disease was very mild in character and there were no deaths. This is the second year in succession in which there have been no deaths from scarlet fever. It is worth noting for comparison that the death-rate from scarlet fever for England and Wales was 0.01 per 1,000 of population. Enteric or Typhoid Fever.—During 1927 there were 14 cases notified under this heading. This is the highest number since the year 1903 and included 12 cases of Paratyphoid B, one of Paratyphoid A, and one of Typhoid fever. The cases of paratyphoid were distributed throughout the year, two cases occurring n May and three in June, the other seven occurring in different 36 months. Three of the cases were, without doubt, infected outside the Borough. One of the cases occurring in June was the wife of a case notified in January. Beyond this there was no relationship between the cases and there was no ascertainable source of infection. Cress had been eaten in only two cases. The ages of the patients ranged from 1 year and 7 months to 64 years, as seen in Table VII. The disease was mild in all the cases and there were no deaths. Cerebro-Spinal Fever.—Two cases of cerebro-spinal fever occurred during the year, one in March and the other in July. One was a child 6 months old, who gave typical signs of the disease and who died after 19 days of illness ; the other was a girl 1\ years of age who suffered from a fulminating attack of the disease, becoming unconscious within 24 hours and dying within 48 hours. Both cases were confirmed by bacteriological examination of the spinal fluid. Encephalitis Lethargica.—Six cases of encephalitis lethargica occurred in the Borough. One other case, which at first was notified as encephalitis, proved to be tuberculous meningitis. The six cases consisted of four females, 17, 47, 59 and 68 years of age and two males, 43 and 47 years of age. Three deaths occurred, two females, 17 and 59 years of age, and a male, 43 years. Of the three other cases, one is in a Mental Institution and the other two are now normal both mentally and physically. Puerperal Fever and Pyrexia.—Six cases of puerperal fever were notified during the year. Two of the cases were attended by a midwife who later had to call in a doctor to render assistance. Both were removed to the West Middlesex Hospital, where one died. The four other cases were attended by a doctor from the first, and in each some operative procedure was called for during the confinement. Three of these cases were admitted for treatment to the West Middlesex Hospital, where one died. There were thus two deaths from puerperal sepsis. Fifteen cases of puerperal pyrexia were notified. In no case was the rise in temperature found subsequently to be due to puerperal sepsis. The conditions noted in individual cases were cystitis, pyelitis, otitis media, nasal catarrh, femoral thrombosis, and mastitis, while in nine other cases no definite cause could be assigned. 37 Pneumonia, Acute Poliomyelitis, Malaria and Dysentery.— During the year there were notified 66 cases of primary pneumonia and 38 of influenzal pneumonia. Of the former, 34 occurred in the first three months of the year and 11 in the last month, and of the latter 29 in the first three months and 5 in December. The ages of those notified are indicated in Table VII. There were six cases of malaria all of which had been acquired abroad and there were no cases of dysentery. No cases of acute poliomyelitis were notified during the year. Whooping Cough and Measles.—Information regarding the prevalence of these two non-notifiable infectious diseases is obtained from the weekly returns of absentees made by the head-teachers to the Medical Officer of Health. There were only 21 cases of absence due to measles but there were 319 due to whooping cough which was prevalent in the early part of the year. No deaths are to be recorded from measles but six are to be noted from whooping cough. These give a whooping cough death-rate of .06 per 1,000 of population, which is less than the rates for the Great Towns and for London which were respectively 0.10 and 0.12 per 1,000 of population. 38 table vii. Cases of Infectious Disease notified during the year 1927. Disease Ages of Cases Notified. Totals Total cases removed to Hospital Under One Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and upwards Diphtheria 1 2 — 4 4 27 6 2 6 1 53 52 Scarlet Fever — 2 9 11 10 67 24 9 8 1 2 — 136 108 Enteric Fever (including Paratyphoid) — 1 — - — 1 2 2 4 1 3 .— 14 7 Puerperal Fever — - - - - - - - 5 1 — — 6 5 Puerperal Pyrexia — — — — — — — — 12 3 — — 15 3 Pneumonia : Primary 3 1 3 5 1 8 2 1 12 7 11 12 66 4 Influenzal — 1 — 2 1 2 1 1 5 6 10 9 38 3 Acute Poliomyelitis — - - - - - - - - - - — — — Cerebro-Spinal Fever 1 — — — — 1 - - - - - — 2 2 Malaria — - - - - - - - 2 3 1 6 Dysentery — — — — — — — — — — — — — — Erysipelas — - - - - - - - - 4 9 5 18 — Encephalitis Lethargica — - - - - - - 1 1 1 2 1 6 5 Tuberculosis : (a) Pulmonary Male — — — — - 1 — 2 21 9 19 — 52 — Female - - - - - 2 2 6 16 8 2 1 37 (b) Non-Pulmonary Male — — — — — — 1 — 1 — 1 — 3 — Female — 1 — 1 3 1 1 2 2 1 1 — 13 Ophthalmia Neonatorum 4 - - - - - - - - - - — 4 — Total 9 8 5 23 19 110 39 26 95 46 61 28 469 — 39 TABLE VIII. AGES AT DEATH FROM NOTIFIABLE INFECTIOUS DISEASES. Disease Under One Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and upwards Totals Diphtheria — — — 1 - 2 — — — — — — 3 Scarlet Fever — — — — — — — — — — — — — Enteric Fever (including Paratyphoid) — — — — — — — — — — — — — Puerperal Sepsis — — — — — — — — 1 1 — — 2 Pneumonia : Primary — 1 4 2 — 1 — 1 2 5 7 28 51 Influenzal — — — — — — — — — — 1 2 3 Acute Poliomyelitis — — — — — — — — — — — — — Cerebro-vSpinal Fever 1 — — — — 1 — — — — — — 2 Malaria — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — Erysipelas — — — — — — — — — — — 1 1 Encephalitis Lethargica — — — — — — — 1 1 — 1 — 3 Tuberculosis (a) Pulmonarv Male — — 1 — — — — 2 12 8 10 1 34 Female — — — — — — — 4 17 5 6 — 32 (b) Non-Pulmonary Male — — — — — — — 1 1 — — — 2 Female — 1 — 1 1 — — 1 3 1 — — 8 Ophthalmia Neonatorum — — — — — — — — — — — — — Totals 1 2 5 4 1 4 — 10 37 20 25 32 141 40 Ophthalmia Neonatorum.—There were 4 cases of ophthalmia neonatorum notified during the year. The following table show that favourable results occurred in all the cases. Number of Cases Notified No. Treated Vision unimpaired Vision impaired Total Blindness Deaths At Home In Hospital 4 4 — 4 — — — Tuberculosis.—In Table IX is indicated the number of new cases of pulmonary and non-pulmonary tuberculosis notified during the year in the whole of the Borough, together with the number of deaths in the various age-groups. There were 66 deaths from pulmonary and 10 deaths from non-pulmonary tuberculosis, which give death-rates of 0.70 and 0.10 respectively, and a total tuberculosis death-rate of 0.80 per 1,000 population. There were 5 deaths from pulmonary tuberculosis in persons who had not been previously notified : three were of persons dying outside the district, the deaths being transferred to Ealing, and two occurred in the King Edward Memorial Hospital. TABLE IX. TUBERCULOSIS. Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 - - - - - - - - 1—5 — — — 5 1 — — 3 5—10 1 2 — 1 — — — — 10—15 — 2 1 1 — — — - 15—20 2 6 — 2 2 4 1 1 20—25 7 5 — — 5 9 1 3 25—35 14 11 1 2 7 8 — — 35—45 9 8 — 1 8 5 — 1 45—55 12 1 1 5 5 — — 55—65 7 1 - — 5 1 _ 65 upwards - 1 - - 1 - — — Total 52 37 3 13 34 32 2 8 41 The Tuberculosis Officer has very kindly supplied the following information with respect to cases of tuberculosis from the district which have been under treatment by him:— Number of persons examined for the first time by the Tuberculosis Officer:— (a) Tuberculosis of Lungs 47 (b) Other forms of Tuberculosis 5 Number of persons transferred from other areas:— (a) Tuberculosis of Lungs 9 (b) Other forms of Tuberculosis 3 Number of persons kept under treatment at the County Council Dispensary, Ealing 110 Number sent to Sanatoria 38 Number sent to Hospital 8 No action has been called for, either under the Public Health (Prevention of Tuberculosis) Regulations, 1925, or under Section 62 of the Public Health Act, 1925. Laboratory Work.—At the public health laboratory the following specimens were examined in connection with the diagnosis and control of infectious disease:— Positive Negative Total Diphtheria: From the Borough 21 772 793 Isolation Hospital 68 1,195 1,263 Tuberculosis: From the Borough 39 238 277 Miscellaneous: From the Borough 11 36 47 Isolation Hospital 4 16 20 Total 143 2,257 2,400 Disinfection.—Besides the steam disinfector at the Isolation Hospital, which is chiefly used for the disinfection of articles in the hospital itself, there is a steam disinfector at North Ealing. The steam disinfector at Hanwell was dismantled as with motor transport it was found to be unnecessary and the site was required for the extension of the refuse destructor. 42 The amount of disinfection carried out in connection with infectious disease was as follows:— Rooms disinfected by formalin spray:— (a) Tuberculosis 124 (b) Other Infectious Disease 352 Articles disinfected in Steam Disinfector:— (ia) Tuberculosis 320 (b) Other Infectious Disease 1,127 In connection with the disinfection 01 homes alter infectious disease 133 articles of clothing were destroyed. To render disinfection more thorough 140 rooms were stripped and cleansed by the owners after notices were served on account of dirty condition. MATERNITY AND CHILD WELFARE. In the Annual Report of the previous year the Special Report on the steps necessary to extend the scheme of Maternity and Child Welfare to the newly added areas of Hanwell and Greenford was printed. The recommendations contained in this Report were put into effect during the year and the new Centres were opened at Cherington House, Hanwell, and at Aberdeen House, Greenford. Both of these Centres have met with great success and are being resorted to by the mothers in the areas served to a much greater extent than was ever anticipated. It has been the policy of the Council to arrange for Maternity and Child Welfare work being carried on in the same building as School Medical work, and as far as practicable to offer to children under 5 years of age whatever form of treatment is available for those of school age. In fact, these two forms of public health work go hand in hand in a thoroughly co-ordinated manner, and combined with the care of the expectant and nursing mother, form a complete scheme of medical supervision, the direct object of which is to ensure the rearing of robust children and thus a healthy race. Such being the object of these Centres in the widest sense, the Council have decided to discard the name "Maternity and Child Welfare Centre and School Clinic," applied to each building where the work is conducted, and to apply the name simply "Health Centre," the term connoting the prevention of disease and the fostering of good health as much by health education as by preventive treatment. 43 In the work of these Centres great assistance has been given by the Welfare Working Party, who, under the leadership of Mrs. Kimmitt, continue to make for children suitable approved garments which are sold to mothers at cost price or given free to those who are in necessitous circumstances, and by Mrs. Cocker, Mrs. Morris and Mrs. Bowthorpe, in giving instructions to the mothers in the cutting out and sewing of suitable clothing for children. Two new additions to the scheme of Maternity and Child Welfare were made during the year, first by the provision of ultraviolet ray, or what is commonly called artificial sunshine treatment, at the King Edward Memorial Hospital for children suffering from rickets and such other conditions which are sometimes benefited by this form of treatment, and secondly by the provision of an improved scheme of dental treatment for expectant and nursing mothers. The appended report indicates the scope of the latter which will make for the better health of many of the poorer mothers attending the Centres who find it very difficult to obtain dental treatment otherwise. REPORT TO MATERNITY AND CHILD WELFARE COMMITTEE. Dental Treatment of Nursing and Expectant Mothers. I have to report that I have gone into the question of the provision of dentistry for expectant and nursing mothers attending the Welfare Centres. The provision of a complete scheme has been facilitated by the appointment of a whole-time school dentist, who will devote one session a week, and more if required, to this special work. The scheme will consist of the school dentist performing all fillings and necessary extractions. He will prepare the mouths of those mothers who require artificial dentures, take impressions of the mouths for submission to the dental mechanic and then fit the dentures on their receipt from the latter. A mechanic doing work for the dental profession has been found locally and his charges, a list of which have been supplied to me, appear reasonable. By the adoption of this scheme it will be possible not only to extend the work of dentistry amongst the mothers, but to carry it out at a less cost than formerly for each mother treated. A small initial expenditure of £4 10s. 6d. is required for apparatus in connection with the taking of impressions of the mouths by the school dentist. The other costs are £50 which the Council have already decided to contribute towards the school dentist's salary and the payments to the dental mechanic. It is very difficult to estimate the cost of this last item, but it should not, for the present, exceed what the artificial dentures have cost the Council in each of the past three years even with an increase in the number of mothers treated. 44 I submit the following as the maximum charges to be made for treatment. Scale of Charges. Extractions.— Under gas or local anaesthetic, Is. per tooth, with a maximum of 10s., irrespective of number of teeth or number of visits. Fillings.— Is. per tooth. Artificial Dentures.— £ s. d. Upper and lower dentures of 20 teeth or more, including extractions, gas, etc. 4 00 One denture of 10 teeth or more, including extractions, gas, etc. 2 0 0 Dentures of 2 to 9 teeth, including extractions, gas, etc., per tooth 4 0 Dentures of one tooth 6 0 Remodelling of Denture 12 6 Additions of one tooth 4 0 For other teeth, more than one at the same time, per tooth 2 6 Repairs—Fracture 3 6 16ct. gold wire (if required) 2 0 16ct. gold band (if required) 2 6 These charges should be reduced in accordance with the financial position of the patients. Taking the scale of income for the benefits given at the Child Welfare Centre and School Clinic as a basis I would recommend the following :— Where the average income of the family per head per week is :— 15/- to 20/- Full charge 12/6 to 15/- Half 10/- to 12/6 One-third 8/6 to 10/- One-fourth 7/- to 8/6 One-eighth Under 7/- No charge Where the income is over 20/- per head per week treatment should be obtained from a private dentist. THOMAS ORR, Medical Officer. Town Hall, Eaijng, W.5. May 31s/, 1927. The following is a Summary of the Work of the Health Visitors during the year :— Total Visits to children under 12 months :— First Visits 1,141 Return Visits 2,507 Visits to children 1 to 5 years of age 3,916 Visits to children or mothers attending the Welfare Centres 2,097 Visits to expectant mothers 298 Visits to investigate infant deaths and still-births 67 Special visits or investigations 351 Visits to cases of Ophthalmia Neonatorum 31 45 Visits to cases of Puerperal Fever 10 Visits to cases of Measles and Whooping Cough 123 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 108 Other Visits 149 Total Visits 10,798 Interviews, etc. 3,295 The following is Summary of the Work of the Health Centres during the year :— Matlock Cherington Aberdeen Lane House House Number of children on register at the end of year 1,403 549 100 Mothers visiting Centre for the first time 746 336 79 Children visiting Centre for the first time 746 392 100 Total attendance made by mothers 6,119 3,945 596 Total attendances made by children 6,886 4,589 680 Average attendance of children each afternoon 45 44 18 Number of Consultations by Medical Officer 2,744 1,261 333 Average number of children seen by Medical Officer on each session 19 19 9 Total Children referred to School Clinic for treatment:— Nose and Throat 21 Eves 11 Teeth 44 Orthopaedic 43 Mothers receiving dental treatment 42 Mothers supplied with artificial dentures 8 Children referred to King Edward Hospital for minor operations 41 Children admitted to King Edward Hospital as indoor patients 1 46 Children referred to other Hospitals 41 Mothers attending Ante-Natal Clinic :— First visits 342 Re-visits 557 Number of Consultations by Consultant at Centre 837 Mothers referred to Hospital 34 Aid provided for mothers at confinement:— Consultant aid—cases 16 Medical aid-cases 6 Midwives—cases 43 Home Helps—cases 44 Dried Milk supplied at cost priceValue £495 4s. Id. Virol supplied at cost price Value £143 Is. Od. Cod Liver Oil supplied at cost price Value £228 3s. lOd. Number of cases admitted to the Chiswick and Ealing Maternity Hospital 176 Amount received for treatment at Maternity Hospital £921 10s. 3d. Expectant or Nursing Mothers receiving a supply of milk free of charge for one month 591 Children under 5 years of age receiving a supply of milk free of charge for one month 800 Day Nursery. Whole day attendances 3,743 Half day attendances 115 Amounts received from Parents £147 13s. 8d. THOMAS ORR, Medical Officer of Health. Town Hall, Ealing, W.5 April 24th, 1928. Borough of Ealing. EDUCATION COMMITTEE. REPORT of the School Medical Officer for the Year ended 31st December, 1927. 48 EDUCATION GENERAL PURPOSES SUB-COMMITTEE, 1926-27. (Which deals with the School Medical Service). Chairman— Councillor G. R. Weeks. V ice- Chairman— Mr. L. Marsh, M.A. Alderman H. Armriding. Alderman H. J. Baker. Councillor E. H. Atkinson. Councillor W. J. S. Cox. Councillor H. M. Sayers. Councillor the Rev. T. B. Scrutton, M.A. Councillor W. J. Sturgess. Miss F. M. Coombe. Miss C. G. Wilson, L.L.A. Mr. M. C. Humbert, J.P. The Rev. C J. Sharp, M.A. 49 STAFF. School Medical Officer— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant School Medical Officers— Harold Ellis, M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Edna i. Langston, M.B., B.S., L.R.C.P., M.R.C.S. School Nnrses— *†‡ Hilda Bailey (Senior). * ‡Annie Johnson. *Mary McGann. *†May P. Dorkins. Clerks— †mercie Richardson. Grace Such. Winifred Rivers. Peggy Gostage. Surgeon (part time)— Cecil I. Graham, M.R.C.S., L.R.C.P., F.R.C.S. (Eng.). Anaesthetist (part time)— S. M. Banham, M.B., M.R.C.S., L.R.C.P. Dentist— C. E. Mainwaring, L.D.S. (Birm.). HEALTH CENTRES— 13, Mattock Lane, Ealing, W.5. Cherington House, Hanwell, W.7. Betham's School, Greenford (temporary). * Certificate as Trained Nurse. †Certificate of Royal Sanitary Institute, School Nurse and Health Visitor. ‡Certificate of Central Midwives Board. 50 CO-ORDINATION. On previous occasions the close association and complete co-ordination of Maternity and Child Welfare work with the School Medical Service have been remarked upon. This co-ordination has been rendered practicable by the adoption of the general policy that these two branches of public health work should be conducted in close touch in the same building, and it has been further assisted by the appointment of a whole-time assistant whose activities embrace the whole of the Maternity and Child Welfare work in the Borough, together with part of the School Medical work. As if to indicate the desirability of complete co-ordination and the need for developing as health educational centres in the widest sense with regard to mothers and children, the Town Council and the Education Committee have decided to employ the term "Health Centre" for what was formerly known as a "Maternity and Child Welfare Centre and School Clinic." The new Health Centre at Cherington House has proved a great success not only on account of its excellent arrangements, but because of the manner in which its facilities have been utilised by the mothers and children in the area served. At Greenford the temporary arrangements are rapidly proving insufficient and it may be necessary sooner than was expected to proceed with the erection of a new Health Centre to serve the needs of Greenford, and also of Northolt, whose addition to the Borough is expected in the course of the year. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC HEALTH. School Hygiene. Under the control of the Local Education Authority at the end of the year there were 17 public elementary schools, embracing 32 departments. In June, 1927, the new Grange School for Juniors was opened and the Good Shepherd Hall temporary school was closed. A new school, which is urgently required, is being built at Greenford to meet the ever increasing demands for accommodation resulting from the occupation of many new houses in that Ward. Betham's School had to overflow into the Village Hall, 51 which occupies a position on the opposite side of the road, and now this temporary school is so overcrowded as to make the completion of the new school a matter of great urgency. Twice during the year the Infants' Department of Betham's School was flooded, once when the school was open and once during the Christmas vacation, but apart from the inconvenience caused to the teachers and children on the first occasion, no injury to health resulted. The floors, made with concrete and surfaced with wood blocks, very quickly dried. This site has proved an unsatisfactory one, not only on account of its liability to flooding, which may to a large extent be obviated by the works which are being carried out to widen the ditches and main water course, but also by reason of the high trees which on the closely adjoining property obscure the main windows and prevent the access of direct sunlight throughout the whole year. Medical Inspection. The inspections carried out at the schools in the Borough included the following groups :— 1.— Routine inspections as required by the Board of Education as follows:— (a) Entrants— All children admitted to school for the first time during the year. (b) Intermediates— All children eight years of age or reaching that age before the end of the year. (c) Leavers— Children who are twelve or who will be twelve before the end of the year, together with those over that age not previously examined. 2.— Non-routine inspections as follows :— (a) Children, not in the aforementioned routine groups, who are presented by the head-teachers for examination for some defect or suspected defect. (b) Children requiring supervision on account of some defect found at a previous routine or non-routine examination. 52 3.— Annual Inspections at the schools or at the Health Centies of (a) Physically defective or crippled children. (b) Mentally defective children. The following tables indicate the total number of children medically inspected in a routine manner. The children included 1,316 entrants, 1,086 intermediates, and 1,238 leavers, making the total children inspected in a routine manner 3,640, or 38.4 per cent, of the children on the school registers. Number of Children Inspected. School Entrants Total Boys Girls Provided. Drayton 75 43 118 Grange - - - Greenford Avenue 44 50 94 Lammas 70 54 124 Little Ealing 99 77 176 North Ealing 38 29 67 Northfields 63 41 104 Oaklands Road 93 116 209 St. Ann's 53 30 83 St. Mark's 39 33 72 Good Shepherd Hall (temporary) 26 34 60 Non- Provided. Betham's 20 17 37 St. John's 34 32 66 St. Joseph's 10 11 21 St. Mary's 39 23 62 vSt. Saviour's 7 16 23 Total 710 606 1,316 53 Number of Children Inspected. School Intermediates. \ Leavers. Boys Girls Total Boys Girls Total Provided. Drayton 46 31 77 35 45 80 Ealing Central - - - 66 110 176 Grange 28 26 54 41 38 79 Greenford Avenue 29 26 55 12 18 30 Lammas 41 33 74 - - - Little Ealing 74 51 125 44 58 102 North Ealing 18 28 46 7 26 33 Northfields 34 42 76 82 55 137 Oaklands Road 71 79 150 88 64 152 St. Ann's 53 63 116 118 86 204 St. Mark's 34 36 70 - - - Good Shepherd Hall (temporary) 9 11 20 - - - Non- Provided. Betham's 19 19 38 27 30 57 Christ Church 23 20 43 23 41 64 St. John's 20 19 39 40 58 98 St. Joseph's 19 16 35 10 14 24 St. Mary's 20 18 38 - 2 2 Total 552 534 1086 593 645 1238 The non-routine inspections consisted of 253 children who were re-examined on account of some defect previously found, and 20 children who were submitted by the head-teachers for examination at school on account of some defect or suspected defect. At the Health Centres there were examined 2,331 children, who were submitted by the head-teachers, school enquiry officers and the school nurses. Of this number 1,092 children attended for further examination. 54 The total number of children attending public elementary schools who were examined once at least during the year was 5,991. The number of children on the school registers was 9,480, and the average attendance was 87.1 per cent. Taking the number of children medically examined as 5,991, it means that 63 percent, of the children on the registers were medically examined at least once during the year. The number of parents present at the routine inspections was 2,786, or 76.5 per cent, of the total children examined. Findings of School Medical Inspection. In Table II are indicated the defects noted on inspection at the schools during medical inspection and at the special inspections. Among the 3,640 routine children examined there were 1,423 defects requiring treatment and 727 requiring to be kept under observation without treatment; and among 2,351 children specially examined there were found 1,818 defects requiring treatment and 68 requiring to be kept under observation. Out of a total of 5,991 children there were altogether 3,241 defects requiring treatment and 795 requiring to be kept under observation. Of the 3,640 children examined at the routine inspections, 679, or 18.6 per cent, were found to require treatment for defective conditions other than uncleanliness and dental disease. (a) Uncleanliness.— The heads of all the girls attending public elementary schools were inspected three times in the year after the usual school holidays. Of 16,326 children examined, 410, or 2.5 per cent, were excluded on account of verminous condition. There were 62 other children in a verminous condition found at the routine medical inspection in the schools, and 24 found at special inspections after being referred for examination by the head-teachers. During the year two summonses were issued under the School Attendance Byelaws for non-attendance owing to exclusion for verminous condition. A fine of 5s. was imposed by the Court in each case. 55 The following table demonstrates that there has been a continued improvement in the cleanliness of the children from 1923 to 1926. In 1927 the percentage of exclusions rose owing to the larger number of uncleanly children in the schools in the recently added areas. In the course of the year, however, these schools showed a marked improvement as a result of the periodical inspections and exclusions. Uncleanliness. Year Number of Children Examined for Verminous Condition Number of Children Excluded Percentage Summonses Issued 1923 8,247 418 5.0 33 1924 9,591 329 3.4 2 1925 9,387 245 2.6 1 1926 9,826 209 2.1 7 1927 16,326 410 2.5 2 (b) Minor Ailments.— The minor ailments found at routine and non-routine inspections were as follows :— Ringworm of Head 6 Ringworm of Body 20 Scabies 13 Impetigo 414 Minor Injuries 63 Other Skin Diseases 29 Ear Disease (including Otorrhoea) 123 Eye Disease (including Blepharitis and Conjunctivitis) 115 Miscellaneous (Sores, Chilblains, etc.) 240 Total 1,023 56 It is noteworthy that only six cases of ringworm of the head were discovered during the year. (c) Enlarged Tonsils and Adenoids.— At the routine inspections 74 children were found with enlarged tonsils, 18 with adenoids, 61 with enlarged tonsils and adenoids, and 13 with other conditions of the nose and throat requiring treatment. Children with these conditions that required to be kept under observation numbered 309. In addition, 29 cases of enlarged tonsils, 25 of adenoids, 36 of enlarged tonsils and adenoids, and 37 of other conditions requiring treatment, and 11 cases of similar diseases of the nose and throat requiring to be kept under observation were found on special inspections. (d) Tuberculosis.— One suspected case of pulmonary tuberculosis in which treatment was considered advisable and one needing to be kept under observation were found on routine medical inspection. In addition three cases for treatment and eight others for observation were discovered on special examination. Four cases of glandular tuberculosis were found. Three other cases of tuberculosis, one of the spine, one of the hip and one of the skin, were met with as a result of special examination. (e) Diseases of the Skin.— At the routine inspection there were found nine cases of impetigo and 19 of other conditions of the skin. The cases met with at non-routine examinations, to which they had been specially referred, were as follows :— Ringworm of Head 6 Ringworm of Body 20 Scabies 13 Impetigo 414 Other Conditions 251 Total 704 These conditions have already been enumerated under the heading "Minor Ailments." 57 (f) External Eye Disease.—Twenty-four cases of blepharitis, 8 of conjunctivitis, 26 of squint and 16 of other conditions of the eye were observed at routine medical inspection ; and 25 cases of blepharitis, 25 of conjunctivitis, 10 of squint and 34 of other conditions were found in children referred for special examination. Of these cases 149 were advised treatment and 19 were recommended to be kept under observation. (g) Defective Vision.—During routine inspection 199 children were found with defective vision and referred for examination by an Oculist. As a result of special inspection 108 were also referred to an Oculist. (h) Ear Disease and Defective Hearing.—Four cases of defective hearing, 17 of otitis media and 16 of other conditions were found at medical inspection ; special inspections revealed 15 cases of defective hearing, 67 of otitis media and 23 cases of other conditions of the ear, all requiring treatment. (i) Dental Defects.—The first table which follows classifies the dental defects found at routine medical inspection. In this table it will be seen that of the entrants 42.4 per cent, had sound teeth, of the intermediate group 46.5 per cent., and of the leavers 70.8 had sound teeth. Dental Inspection, 1927. Entrants Intermediates Leavers Total All teeth sound— No. of Children . ... 558 506 877 1,941 Percentage 42.4 46.5 70.8 53.3 Less than 4 teeth decayed— No. of Children ... 378 369 291 1,038 Percentage 28.7 33.9 23.5 28.5 Four and more than 4 teeth decayed— No. of Children ... 280 211 70 661 Percentage 28.8 19.4 5.6 18.1 58 In the next table will be found the percentages of sound teeth in the various groups since 1915. Dental Inspection, 1915 to 1927. Year Entrants Intermediates Leavers Total Percentage with sound Teeth Percentage with sound Teeth Percentage with sound Teeth Percentage with sound Teeth 1915 23.0 26.2 35.7 27.0 1916 15.6 30.2 37.2 25.3 1917 21.7 25.9 41.1 28.8 1918 28.8 25.8 44.1 32.8 1919 36.9 32.2 60.6 42.7 1920 48.6 46.4 64.2 53.1 1921 58.4 64.0 76.5 66.6 1922 45.7 50.2 72.8 56.3 1923 55.2 52.5 80.5 63.9 1924 55.0 58.5 78.0 65.0 1925 47.8 44.3 74.0 53.4 1926 35.5 39.0 64.2 43.8 1927 41.6 46.5 70.8 53.3 (j) Crippling Defects.—At the end of the year there were 56 children classified as suffering from some form of crippling. Three of these children were so defective that they had to be sent to Special Residential Schools and 53 were able to attend public elementary schools. There were no crippled children not attending school. The list of crippled children represents fairly accurately all those in attendance at, or who would, if they were normal, attend, a public elementary school. Crippled children are ascertained through the head-teachers, school enquiry officers, school nurses and particularly through the Health Centres which the children attend until they reach five years of age and enter school. Since the scheme of orthopaedic treatment has been made to apply to children under 5 years of age the Health Centres have proved to be most important sources of information regarding crippled children newly admitted to school. 59 All crippled school children are seen at least once in each year in order that a record may be made of their progress. INFECTIOUS DISEASE. By means of the returns of non-notifiable infectious disease, supplied at the end of each week by the head-teachers, it was ascertained that during the year the numbers of children absent from school on account of these diseases were as follows :— Measles ... ... ... ... 21 Whooping Cough ... ... ... 319 Chicken Pox ... ... ... ... 357 Mumps ... ... ... ... 162 The reduction of the attendance below 60 per cent, was attributable to the prevalence of influenza at the following schools and certificates were supplied by the vSchool Medical Officer to that effect under Schedule IV, Rule 23 of the Code :— Good Shepherd Hall Infants', week ending June 21st. Little Ealing Infants', week ending June 28th. Northfields Infants', weeks ending June 21st and 28th. Oaklands Road Infants', weeks ending June 21st and 28th. Children to the number of 420 were excluded during the year under Article 53 of the Education Code for the following conditions :— Conjunctivitis ... ... ... 9 Impetigo ... ... ... ... 364 Ringworm of Head ... ... ... 6 Ringworm of Body ... ... ... 9 Scabies ... ... ... ... 13 Other Skin Diseases ... ... 19 Total ... 420 In the diagnosis of infectious conditions in school children use is freely made of the facilities offered by the bacteriological laboratory of the Public Health Department. 60 FOLLOWING-UP. Special lists are made of all children requiring treatment, which can be provided at the Health Centre, for defects of the teeth, eyes, nose and throat. All these cases are visited at once by the School Nurses, who advise the parents to obtain treatment, and put those who cannot afford treatment by a private doctor in the way of securing it at the Health Centre. All other cases, in which treatment is advisable or in which observation is required, are visited in rotation by the School Nurses, who advise parent.", to obtain treatment or give directions regarding the hygienic supervision already recommended by the Medical Officer at the inspection. During the year the School Nurses made 1,438 visits to the schools and to the homes of the children. MEDICAL TREATMENT. (a) Minor Ailments.—In Table IV are tabulated the number and the nature of the minor ailments which received treatment during the year. It will be noted that 739 of the 1,083 children suffering from minor ailments, or 72.2 per cent., were treated at the Health Centres, and 284, or 27.7 per cent, were treated by private practitioners or at hospitals. The total attendances at the Health Centres for the daily treatment of minor ailments were as follows:— Ear Cases ... ... ... ... 1,740 Eye Cases 1,233 Ringworm 232 Impetigo ... ... ... ... 6,459 Scabies ... ... ... ... 16 Eczema ... ... ... ... 181 Minor Injuries 200 Others 3,220 Total ... 13,281 (b) Tonsils and Adenoids.—It is indicated in Table IV that 74 cases of enlarged tonsils or adenoids were submitted to operation at the Mattock Lane Health Centre, and that 19 cases were dealt with at hospitals or by private practitioners, 61 (c) Tuberculosis.— Nine children were referred to the Tuberculosis Officer for supervision, eight being suspected of tuberculosis of the lungs and one of the cervical glands. The cases of tuberculosis of the hip and of the spine had become quiescent and were submitted for orthopaedic supervision. (d) Skin Diseases.—The cases of diseases of the skin which were treated are included in Table IV. There were 785 children referred for treatment, 589 of whom were treated at the Health Centres and 196 otherwise. During the year four cases of ringworm of the head were treated by means of X-Rays by Dr. Arthur, the results being satisfactory in all cases. Of the 414 cases of impetigo, 340 were treated at the Health Centres. During the year 13 cases of scabies were found, and 11 of these were treated at the Mattock Tvane Centre. (e) External Eye Disease.—The children referred for treatment of external eye disease numbered 115, of whom 70 were treated at the Health Centres. (/) D :i«ective Vision.—During the year 308 children were referred for the testing of refraction. The School Oculist examined 280 children and 28 were examined by private practitioners or at hospitals. Glasses were prescribed in 234 cases and supplied in 232 cases. (g) Ear Disease and Hearing.—Of 123 children with ear defects who received treatment, 80 were treated at the Health Centres. (h) Dental Defects.—The following is the report of the School Dentist:— I assumed my duties as the first whole-time school deutal officer to the enlarged Borough of Ealing on the 14th April, 1927. Previously, two local practitioners had given part-time services to the original Borough. An examination of the children's teeth soon revealed what an excellent scheme of dental inspection and treatment was in existence. During the year 1927 all the elementary school children in the old Ealing area had their teeth examined ; 5,257 were inspected and 2,100 did not require treatment. In the Hanwell and Greenford areas only those children in the entrant, intermediate and leaving groups 62 were examined, totalling 1,254, of whom 424 required no treatment. In these areas in 1928 the new entrant and intermediate groups will be seen, together with those already examined. Thus in about four years' time the annual inspection of all children will be undertaken in the Hanwell and Greenford areas in the same way as in the old Ealing area. Altogether, as seen in Table IV, Group IV, 6,515 children, or 68 per cent, of the children on the school registers have been inspected, of whom 2,524 required no treatment, a percentage of 38.8. There were actually treated 2,261 children, 1,180 receiving further treatment during the year. The extractions numbered 1,133 permanent and 4,915 temporary teeth. Both nitrous oxide and a local anaesthetic were employed, the former being administered at 64 sessions. Fillings were applied to 1,739 permanent teeth and to 14 temporary teeth. One case of dental deformity was referred to the Royal Dental Hospital for special treatment. As a result of school dental inspection and treatment, the teeth of school children generally show a satisfactory improvement from year to year. One exception to this is found in the case of the children in the entrant group—those who have not been previously examined. The condition of these children's teeth has steadily become worse since the war, and the matter is engaging the attention of public health officers and others throughout the country. In the absence of any official pronouncement on the subject, one must be permitted a certain amount of conjecture in assigning a cause. During the war and in the period immediately following, the fact that the population had to depend upon plainer food and that certain starchy articles of diet were not obtainable seems to account for the temporary improvement in the children's teeth. Subsequently, the release of certain of these foods and the enormous increase in the consumption of sweets, undoubtedly have had a very detrimental effect upon the teeth. With a view to improving the condition of the teeth of younger children, a scheme for the treatment of children of pre-school age has been inaugurated, and mothers are encouraged to bring their toddlers for advice, and where necessary, treatment. Forty-four of these children have been referred, 68 attendances made; 167 temporary teeth have been extracted by gas for 28 children, and 17 fillings have been applied to temporary teeth. Lectures in Dental Hygiene have now become a routine part of the work. Half-hour talks are given in the schools on the occasion of the dental inspection, to all children over the age of 7, instructing them in the proper use of the tooth brush, and explaining in a simple way the process of decay and how it can be prevented and remedied. A special point is made of attempting to eliminate that element of fear which is frequently so prevalent regarding a "visit to the dentist"; the danger of over-indulgence in sweets and the desirability of eating more fruit are also emphasised. A great deal has yet to be accomplished in overcoming the ignorance of the parents and breaking down the prejudice against accepting dental treatment for their children, but the result of these lectures has been most encouraging. They will be repeated each year, as the success of any propaganda depends upon its constant repetition. Systematic dental treatment has now been begun for expectant and nursing mothers, and all forms of conservative and prosthetic treatment are undertaken. One session a week is devoted to this work and 49 mothers have been referred for examination. Attendances to the number of 156 were made. Nitrous oxide was administered to 29 and a local anaesthetic to 7 for the extraction of 204 teeth. Twenty fillings and ten dressings were applied and eight mothers had their teeth scaled. 63 Eight mothers have been fitted with artificial dentures and nine more are at present under treatment. C. E. MAINWARING, School Dentist. (i) Orthopaedic Treatment.— This form of treatment is the most successful and encouraging embarked upon by the Education Committee. The benefits are threefold. In the first place most satisfactory results accrue to the children who in many instances show a very remarkable improvement in their condition, to such an extent is the crippling of most of them remedied that there is now no need for a Special School for Cripples, and the feeling is gaining ground that anything in the nature of severe crippling in a school child will in the future be a rarity; secondly the mothers gain greatly in time and monetary cost by having the treatment so readily accessible at the Health Centre and thirdly the Education Committee secure an advantage in the uninterrupted attendance of the children at school, except when they have to undergo an operation at the hospital, where, however, the education of the children is continued. In securing these striking results the outlay is comparatively small, not only in initial cost of apparatus, but in the cost of attendance of the surgeon once a month and of the masseuse four times a week. During the year the surgeon saw on the occasion of his monthly visits 78 school children for the first time. Only 21 of these can be classed as cripples, the remainder being cases of round shoulders, lateral curvature of not too marked an extent and flat-feet. There were 158 re-inspections of these or other children already undergoing treatment. Three children were advised operative treatment which they received at the National Orthopaedic Hospital at Stanmore, and 40 were advised massage. The attendances for massage numbered 1,029. Two school children were supplied with surgical boots and four with other surgical apparatus. In addition to the school children, 43 children under 5 years of age were submitted for a first examination by the surgeon, 48 re-inspections being necessary. The attendanoes of those requiring massage numbered 230. No operations were required for the children under school age. 64 The attendance of so many children under school age will not only assure better results through the early treatment, but they will save the greater cost of treatment at a later period when, in the absence of such early treatment, the deformity is more firmly established and less easily rectified. (j) Heart Disease.— In previous reports the importance of the prevention of rheumatism, which is the most common cause of heart disease, was emphasised and attention was drawn to the need for care in the upbringing of children in whose families there is a susceptibility to the disease. At the same time attention was drawn to the need for proper treatment and medical supervision of those suffering from rheumatism to avoid severe heart involvement and of those affected with valvular disease of the heart to prevent serious results from strain. A list is kept of all children suffering from heart affection. Each child is examined at least once a year to determine his condition and appropriate advice is given to the parents or head-teachers. During the year there were found in the course of routine and special inspections 65 children suffering from organic, and 49 from functional disease of the heart. The latter condition, which is often found in anaemic children, usually disappears as the general condition of the child improves. (k) Payments for Treatment.— The following amounts were received during the year for the treatment of children at the Health Centres :— £. s. a. Dental Treatment 88 19 0 Throat Operations 16 7 6 Spectacles 63 19 7 Treatment at the Royal Dental Hospital 18 0 Treatment at National Orthopaedic Hospital 5 8 0 Surgical Appliances 7 17 6 Massage Treatment 21 17 0 Other Payments from Maternity and Child Welfare Committee, etc. 33 7 3 £238 13 10 65 OPEN-AIR EDUCATION. Whenever the weather is favourable playground classes are developed and encouraged. Much can be done in the way of open-air classes when the head-teacher is interested and the teachers are encouraged. Open-air classes are an object lesson to the children and whilst favouring good health they also foster in the children a love of open-air conditions and an appreciation of its value in the prevention of ill-health. The Grange Schools, constructed on open-air lines so that the classrooms can at any time, when the weather permits, have the whole of one side completely open, are perhaps now being better appreciated and the special facilities for open-air education are being utilised to a greater extent. A greater use can be made of them but the extent of this use depends on the enthusiasm of the head-teachers. If the head-teachers lead the others are sure to follow. The new school at Greenford is being constructed on similar lines. When this is in use it might be practicable, and it certainly would be interesting, to compare the health of the children, possibly as shown by the incidence of infectious disease, in open-air schools and in those of the old type. PHYSICAL TRAINING. Organised games are being developed more and more every year. During the year a larger number of pitches in the public parks were allotted to school children for the playing of such games as cricket, football, netball, etc., during school hours, and further grants for playing equipment were made. The school children are taught swimming with great enthusiasm by the two teachers of swimming and every encouragement is given by the Education Committee to enable each boy or girl to be a proficient swimmer before leaving school. The result is that a large number of children each year receive certificates of proficiency. This number, however, could be much increased if the school teachers instilled into the children an interest in the art. In addition to swimming being a means of saving life, there is no finer exercise. Much discussion has taken place among those interested in swimming regarding the merits and demerits of the 66 crawl stroke and whether, as in the United States of America, this stroke should be taught in preference to the other strokes. In this country the tendency is to develop from the breast and back strokes to the trudgeon and the crawl, but the view is growing that the crawl should be taught earlier in life and earlier in the course of instruction. With suitable instruction the crawl is not so difficult when taught early in life and it is not so strenuous as was once thought to be, for it has been shown that the stroke can be a fast or a slow one as the swimmer wishes. It is undoubtedly the fastest sprinting stroke, but Americans have shown that it is also applicable to long distance swimming. Our swimming instructors appreciate the value of this stroke and are now devoting more attention to it. By suitable apparatus, which has recently been devised by a swimming instructor in London, the principles of the crawl stroke can be inculcated out of the water. The Education Committee has provided two sets of this apparatus for the use of school children. During the year the school children in the added areas of Hanwell and Greenford schools have for the first time been given facilities for learning to swim in the same way as the children in the schools in the original Borough. PROVISION OF MEALS. Meals are not provided for school children under Sections 82 and 85 of the Education Act. On the infrequent occasions on which children are found to be insufficiently fed, the teachers provide out of voluntary funds supplementary food in the form of biscuits and milk or cocoa and milk. The numbers of such children are not sufficiently large to call for organised methods of providing meals in school. CO-OPERATION OF OTHERS IN THE SCHOOL MEDICAL SERVICE. A marked change has taken place in the attitude of the parents since school medical inspection began. It is very rarely that an objection is made to medical inspection. The rule is that the parents welcome it and are most anxious to get advice regarding the care of 67 their children and to receive treatment at the Health Centre, which has grown in the estimation of the parents. The high percentage of parents attending the inspection is indicative of the great interest taken in the work. The teachers are an immense help in the scheme of medical inspection and treatment. On all occasions the teachers offer every assistance and look upon medical inspection and treatment as part of the educational machine. They recognise that the development of the mind must go hand-in-hand with the cultivation of a healthy body, the one being complementary to the other, and that as teachers, they have almost as much responsibility with regard to the one as with the other aspect of the development of the child. In early life the teacher can inculcate healthy habits in the receptive young mind and in the older children can instil the general principles of hygiene in the course of the child's general education. "The Handbook of Suggestions on Health Education" just recently issued by the Board of Education, is an admirable guide to the teacher and should be the means of effecting a proper recognition in the minds of the young of the value of hygiene in the prevention of ill-health and consequently of assisting in the general improvement of the health of the community. All teachers in the schools in the Borough are being supplied with copies of this Handbook and the head-teachers are being asked to submit their proposals for the carrying out of the suggestions contained therein. In this way it is hoped that there will be some uniformity in the adoption of the suggestions, and a sufficient amount of time devoted to the instruction. In the course of the year the School Dentist on the occasion of his dental inspections of the schools gave to the children a short lecture on the care of the teeth. These lectures were given to the children in the upper schools, who were brought together in the assembly hall for the purpose. The head-teachers enthusiastically entered into the arrangement. The lectures, coming from an experienced dental officer, are likely to be of value to the teachers themselves in giving instruction to the children. To assist the teachers in giving instruction in the care of the teeth the Education Committee issued to them copies of the excellent booklet, “Hygiene of the Mouth and Teeth," gratuitously supplied by the Dental Board. 68 The School Enquiry Officers continue to give the same valuable assistance as was noted in previous annual reports. They act in close co-operation with the school medical staff to whom they supply useful information regarding defective children and from whom they can often obtain much help in their school attendance work. The three officers fully recognise how closely school medical and school attendance work are necessarily associated. Certain voluntary bodies give valuable assistance in school medical work. The Central Aid Society gives help in obtaining special Hospital and Convalescent Home treatment for anaemic or badly nourished children; the National Society for the Prevention of Cruelty to Children in bringing pressure to bear on neglectful parents; the School Attendance Aid Committee in providing boots for children of necessitous parents and the Middlesex King Edward Memorial Committee in giving holidays, at their Holiday Home at Heme Bay, for anaemic or weakly children. NURSERY SCHOOLS. There are no Nursery Schools within the Borough, but children between 4 and 5 years of age are admitted to the Infants' Departments whenever the School Attendance Committee is of opinion that it is to their advantage, on account of special home circumstances such as the occupation of the mother or the overcrowded or unsuitable conditions, to be admitted. Each case is considered on its merits by the Committee on an application being made by the parents. Very few married women in the district are engaged in regular employment, so that there has at no time been any insistent demand for Nursery Schools. SECONDARY SCHOOLS. Medical inspection at the two Secondary Schools, provided by the Middlesex Education Committee, is carried out by the Ealing School Medical Staff. This arrangement is very convenient as the great majority of the boys and girls attending these schools come from Ealing Public Elementary Schools, where they have already been under medical supervision. 69 BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. Specially defective children are ascertained through the School Enquiry Officers, who report all such cases not attending school, through the head-teachers who are expected to notify all defective children immediately on admission to school, through the School Nurses as a result of visiting the homes and though the Health Visitors who discover the defective children before they are of school age on being brought to the Health Centres by their mothers. In these ways a fairly complete list of all specially defective children can be kept. On discovery, blind and deaf children are sent to Special Residential Schools. Three blind girls and five blind boys were being maintained at Certified Schools for the Blind at the end of the year. Five boys and five girls, considered to be partially blind on account of myopia, attended public elementary schools under particular supervision, which consists in a special examination even- three months or even oftener. Particular instructions are given to the teachers and to the parents regarding the proper care of these children, so as to avoid any excessive use of the eyes or any severe physical exertion which might adversely affect the condition of the eyes. Eleven deaf-mutes, two boys and nine girls, were maintained at Special Residential Schools. Two boys were found to be suffering from severe epilepsy and were kept at home. One has so far recovered that on the earnest entreaty of the parents he has been allowed back to the elementary school on trial. The other has been so ill that he cannot even be sent to a Special Residential School. Seven children, three boys and four girls, suffering from epilepsy of a mild nature, were attending public elementary schools. Ten feeble-minded children, seven girls and three boys, were maintained at Special Residential Schools. There were also in attendance at the public elementary schools 18 feeble-minded children and one was kept at home. This child who was kept at home was awaiting a vacancy in a Special School. All feeble-minded children who are troublesome in school or at home, or whose home circumstances are so unsatisfactory that they cannot be properly cared for, are sent to Special Residential 70 Schools. The others attend the ordinary school, where they make more or less progress depending on their mental capacity and the attention or particular care which the teachers are able to devote to them in the class with normal children. Perhaps the total number stated, 28, is too low an estimate of the elementary school children who should be specially cared for on account of their feeble-minded condition. The number depends much on the observer who is apt, when no special provision is made for the education of such children, to classify as border-line cases those who might otherwise be classified as feeble-minded. A definite classification however is not essential under the present circumstances for all border-line children are kept under medical supervision in the same way as feeble-minded children, and are specially examined each year to ascertain their mental progress. The question of the special education of feeble-minded children was considered by the Education Committee on account of the offer by the Acton Education Committee to accept a certain number of defective children from Ealing into their Special School. A report on the subject was submitted to the Education Committee as a result of which it was decided to adopt the principle of establishing Craft Classes as recommended in the Report. The Report was as follows:— REPORT TO THE EDUCATION GENERAL PURPOSES SUB-COMMITTEE. Mentally Defective Children. In view of the offer of the Acton Education Committee to accept ten children from Ealing into their school for mentally defective children, it seems desirable that the Committee should have in writing not only a short account of what is at present the exact procedure in Ealing with regard to mentally defective children, but also my suggestions for dealing with the education of those who still remain in our schools and are not receiving any special education. A complete record is kept of all mentally defective children who would, if they were normal, attend a public elementary school. The head-teachers inform me at once of any suspected mentally defective children who are admitted, and the school attendance officers bring to my notice any children over 5 years of age who are suspected of being mentally defective and who are not attending school. All these children are specially examined as soon after as possible. In addition to these children, all who are backward at school to the extent of two or more years are examined to determine if they are mentally defective. 71 As a result of these examinations mentally defective children are classified into four groups:— (1) Idiots. (2) Imbeciles. (3) Moral Imbeciles. (4) (a) Feeble-minded who are troublesome at home or at school, or whose home circumstances are bad; (b) Feeble-minded children who are capable of some education and who are amenable to discipline. The children coming under the headings (1), (2) and (3) (Idiots. Imbeciles and Moral Imbeciles) are reported to the Local Control Authority (The Middlesex County Council), under whose care the Law places them. Children coming under (4) (a) are sent to Residential Special Schools, where they remain until they are 16 years of age. The last group, (4) (b) have so far been allowed to attend the ordinary schools where their educational progress is variable, depending on their mental capacity, the interest taken in them by the teachers, and the home circumstances. This group consists of the highest grade mental defectives, some of whom appear to the casual observer to be quite normal children, and some of whom are able to earn their own livelihood in certain classes of unskilled work. These, together with very backward children, are medically inspected each year and have their intelligence assessed by mental tests to determine their mental progress. As regards the suggestion that ten of this group of children should be sent to the Acton School for Mentally Defective Children, I wish to offer some criticisms. The school is not a mentally defective school in the true sense of the phrase, because in a mentally defective school the beginnings of certain specified trades or occupations, suitable for such abnormal children, are usually taught. The education provided is that which is usually given in a school or class for backward children. Proper classification of the children according to mental capacity is quite impracticable in a school where there are so few children. Only the highest grade of children is desired and insisted upon by the Acton Education Authority, so that we should still be left with the more difficult cases. It would require a great and disproportionate effort to secure the attendance at Acton of simply ten children from Ealing. I should, myself, find difficulty in saying which cases ought to go and I should always be opposed by the parents who would strongly resent their children being sorted out and sent to a mentally defective school while other children worse than theirs would not undergo this form of treatment. Many of the parents of the children, and particularly of those of the higher grade, believe them to be only backward, and strongly resent my calling them mentally defective. In securing the compulsory attendance of these children at Acton we should be constantly experiencing difficulty. If it is suggested that the number to be sent to Acton be extended to twenty the strongest argument is then provided for dealing with all our mentally defective children, between 40 and 45 in number, in Ealing itself. After considering the whole question thoroughly I am going to put forward the suggestion, the same as I put before the General Purposes Sub-Committee a little over two years ago, that a certain number of backward classes should be established in connection with our schools to deal not only with all mentally defective children, but with the most backward children. My proposal on that occasion did not meet with sufficient support, but T take the opportunity of putting it forward again on this occasion. 72 I feel convinced that with backward classes, which could be called Handicraft Classes, we should get rid of the stigma of the "Silly School," inseparably associated with the mentally defective school, and that we should secure the co-operation of the parents. If these classes could be associated with schools where there are handicraft and domestic centres we should improve greatly on the special education provided at Acton by teaching, when the children reach a certain age, the beginnings of certain occupations suitable for them. The children would be kept under constant supervision, mentally and physically, and we should be able to deal with all of them in a thorough manner and not with a few in a partial and tentative fashion. The establishment of a Mentally Defective School must receive the sanction of the Board of Education, and I am led to understand that this sanction cannot be obtained from the Board at the present time. No such sanction is required for backward classes and they can be established whenever it is practicable for the Director of Education to organise them. It comes within the province of the Director to deal with the establishment of these backward classes, it being an educational matter. As School Medical Officer it is simply my duty to recommend the form of education desirable. Definite suggestions with regard to where the backward classes could be established will be put forward by the Director, with whom I have carefully discussed the matter, and I can only conclude by saying that if the classes are established I am prepared to co-operate in every possible way with the Director of Education to make these classes a success not only from the children's but from the Committee's point of view. THOMAS ORR, Medical Officer. \lth February, 1927. Nevertheless, when details of the scheme indicating the schools where the classes would be held were put forward by the Director of Education, the Committee reversed its decision. Consequently another Report was submitted as follows:— BOROUGH OF EALING—EDUCATION COMMITTEE. Review of the Present Position as regards the Education of Mentally Defective Children in the Borough. It is the duty of the Local Education Authority to ascertain (a) what children between 7 and 16 years of age within their area are mentally defective, (b) to ascertain which of these children are capable of being educated in a Special School, and (c) to notify to the Local Authority under the Mental Deficiency Act (The Middlesex County Council) any children who are not capable of receiving benefit at, or who are unsuitable for, a Special School. In order that these duties may be carried out a complete record is kept of all mentally defective children who would, if they were normal, attend public elementary schools. These children are specially examined and are classified into six groups:— 73 (1) Idiots. (2) Imbeciles. (3) Moral Imbeciles. (4) Feeble-minded, (a) Who are not capable of receiving benefit at, or who are unsuitable for, a Special School; (b) Who are educable but are troublesome at home and at School; (c) Who are capable of some education and who are amenable to discipline. Children coming within groups (1), (2), (3) and (4a) are notified to the County Council, who are required to make provision for them. Groups (4b), children who are educable but who are troublesome at home or at school, and (4c), children who are capable of education and who are amenable to discipline, come within the care of the Education Authority, which is required to make special provision for these particular children On the 31st December, 1926, there were in the former group 19 children, of whom 15 were being maintained in Special Residential Schools by the Education Authority, three were awaiting vacancies in Residential Schools and one was kept under good circumstances at home; and in the latter group 31 children, 28 of whom were at elementary schools and three were allowed to leave school before attaining 16 years because suitable occupations had been offered. Thus it may be considered that at present there arc 31 children for whom a special form of education should be provided. These are the highest grade mental defectives who do not ordinarily show antisocial characters and who are likely to earn their own livelihood and to make, if not good, at least tolerable citizens. On several occasions I have made Special Reports to the Education Committee on the need for Special School accommodation for the mentally defective children who are educable to some extent. In 1919 I suggested the use of Village Park as a Special School but the need for housing families was considered by the Council to be more pressing. The next year I furnished to the Committee a Special Report on defective children. In this I recommended the establishment of a Day School for mentally defective children and a limited number of Special Classes in the ordinary schools for Backward Children. The question was adjourned to enable a suitable site to be found. No suitable site was found and the proposal fell through. In 1924 I suggested the combination of several Local Education Authorities in establishing a Special Day School for a wider area. I took steps to ascertain if this proposal might be entertained, but I could find encouragement in only one quarter. In my Annual Report for 1925 I alluded to the question of the education of mentally defective children as follows:— "The provision of Special Day Schools for mentally defective children, who are at present attending public elementary schools, remains for the future consideration of the Committee. Special Schools are very costly and it would be especially costly to provide for such a small number of children as there is to be dealt with in this area. Moreover, the ultimate advantages of their special education are, relatively speaking, so small that at a time when economy must be exercised, the provision of a costly special school cannot be undertaken lightly. But if a special school must ultimately be provided, it appears that it would be better and more economically provided by a combination of Local Education Authorities in this part of the county." Since I wrote that I have not changed my views. 74 When I reported on the 17th February, the report was called for because I felt that if the Committee were inclined to accept the offer of a limited number of places in the Special School of the Acton Education Authority they might do better by establishing a scheme to deal with all the children in Ealing by means of classes, called Craft Classes, for backward children and mental defectives as a temporary measure until a Special School, as suggested in my Annual Report, could be established. I have still the feeling that such classes, if they could have been quietly established in suitable schools, might have met the difficulty for the present. The initiation of such a scheme, however, was dependent on co-operation all round so that when opposition was made failure was bound to follow. What is to be done now? That is the question to be decided. I feel that I can only refer you again to my Annual Report and recommend you to consider the combination of other Local Authorities in providing a Day School for Mentally Defective Children for a wider area and I would suggest that, if a Conference is called, it should be called by the County Education Committee who might be partners in the scheme. Even if the sanction of the Board of Education may not be obtained for carrying such a scheme into execution at the present time, nevertheless the ground may be explored and, if necessary, tentative arrangements entered into. THOMAS ORR, School Medical Officer. 26th May, 1927. The recommendation contained in this report was accepted by the Education Committee, with the result that the County Education Committee called the Conference at which the representatives unanimously approved of the proposal and decided to approach the Board of Education for its sanction. This is as far as the proposal has gone. 75 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. The number of boys and girls employed out of school hours in accordance with the Byelaws with respect to the Employment of Children is given in the following list, together with the nature of the employment:— Boys. Errands 153 Milk Round 24 Newspaper Round 42 House Work 1 % Delivering Washing 6 Baker's Round 38 Order Boy 14 Bottle Washer 2 Delivering Coal 2 Golf Caddie 1 Shop Cleaning 1 Total 284 Girls. Errands 1 Nurse Maid 1 House Work 4 Piano Playing 1 Newspaper Round 1 Total 8 All these children were medically inspected during the year and 66 were found to be in such a condition of health that their employment was discontinued. Nineteen children on routine medical inspection were found to be employed without being registered under the Byelaws and five were found to be under age. MISCELLANEOUS. Under this heading are noted all examinations carried out at the Health Centres. At the School Clinics are examined all children referred by the Education Committee, Head-Teachers and School Enquiry Officers. Children can be submitted for examination at the Centres on each school-day at 9.30 a.m. Those usually submitted are children suspected of having verminous heads or bodies, or having ringworm, scabies, or impetigo, or those whose examination is desirable on account of some defect or suspected defect, such as 76 defective eyesight, disease of the eye, ear, nose and throat, which may require treatment. In fact, any defective child not under medical care may be submitted by the head-teachers for examination. The examinations carried out during the year may be summarised as follows:— Verminous Children 1,055 Impetigo 844 Scabies 31 Ringworm 74 Eczema 10 Minor Injuries 40 Teachers on Appointment 29 Children for Holiday Home, King Edward Memorial Scheme 9 Miscellaneous 2,036 Total 4,128 THOMAS ORR, April 19th, 1928. School Medical Officer. Town Hall, Ealing, W.5. 77 STATISTICAL TABLES. The Statistical Tables required by the Board of Education are as follows:— TABLE I. A.—Routine Medical Inspections. Number of Code Group Inspections:— Entrants 1,316 Intermediates 1,086 Leavers 1,238 Total 3,640 Number of other Routine Inspections — B.—Other Inspections. Number of Special Inspections 2,351 Number of Re-Inspections 1,345 Total 3,696 78 TABLE II. A.-RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1927. disease or defect. Routine Inspection Special Inspections No. of Defects. No. of Defects. N umber referred for Treatment. Number required to be kept under observation but not referred for Treatment. Number referred for Treatment. Number required to be kept under observation, but not referred for Treatment (1) (2) (3) (4) (5) Malnutrition 1 3 — - Uncleanliness 62 — 4 — Skin Ringworm, Head — — 6 — Body 3 — 17 — Scabies 1 — 12 — Impetigo 9 — 405 — Other Diseases (Non-Tubercular) 15 9 251 4 Eye - Blepharitis 19 5 25 — Conjunctivitis 8 — 25 — Keratitis — — 1 — Corneal Opacities — — - — Defective Vision 199 3 108 4 Squint 24 2 10 — Other Conditions 7 9 30 3 Ear Defective Hearing 4 4 15 — Otitis Media 17 2 67 — Other Ear Diseases 16 5 23 — Nose and Throat Enlarged Tonsils 74 221 29 4 Adenoids 18 4 25 2 Enlarged Tonsils and Adenoids 61 7 36 — Other Conditions 13 77 37 5 Enlarged Cervical Glands culous) 9 124 25 3 Defective Speech 1 7 — — Teeth—Dental Diseases 663 — 304 — Heart and Circulation Heart Disease:— Organic 21 24 9 11 Functional 2 44 — 3 Anaemia 45 31 21 2 Lungs Bronchitis 17 28 5 — Other Non-Tubercular Diseases 9 17 12 1 Tuberculosis Pulmonary:— Definite - - - Suspected 1 1 3 8 Non-Pulmonary:— Glands 1 1 1 1 Spine — — — 1 Hip — — — 1 Other Bones and Joints — — — — Other Forms — — — 1 Nervous System Epilepsy 2 — 7 — Chorea 2 1 6 — Other Conditions 1 5 11 — Rickets — — — — Deformities Spinal Curvature 25 30 13 1 Other Forms 41 38 9 2 Other Diseases and Defects 32 25 266 11 TOTAL 1423 727 1818 68 79 B.—Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Uncleanliness and Dental Diseases). Group (1) Number of Children Percentage of Children found to require Treatment (4) Inspected (2) Found to require Treatment (3) Code Groups:— Entrants 1,316 238 18.0 Intermediates 1,086 223 20.5 Leavers 1,238 218 17.6 Total (Code Groups) 3,640 679 18.6 Other Routine Inspections — — - 80 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Boys Girls Total Blind (including partially blind) (i) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind 5 3 8 Attending Public Elementary Schools - - - At other Institutions — — — At 110 School or Institution — — — (ii) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind - - - Attending Public Elementary Schools 5 5 10 At other Institutions — — — At no School or Institution — — - Deaf (including deaf and dumb and partially deaf) (i) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 2 9 11 Attending Public Elementary Schools - - — At other Institutions — — — At no School or Institution — — — (ii) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf - - - Attending Public Elementary Schools 1 - 1 At other Institutions - - - At no School or Institution — — - Mentally Defective Feebleminded (cases not notifiable to the Local Control Authority). Attending Certified Schools for Mentally Defective Children 3 7 10 Attending Public Elementary Schools 8 10 18 At other Institutions — — — At no School or Institution 1 — 1 Notified to the Local Control Authority Feebleminded - _ - Imbeciles 3 1 4 Idiots — - - 1 Epileptics Suffering from severe epilepsy. Attending Certified Special Schools for Epileptics - - - In Institutions other than Certified Special Schools - - - Attending Public Elementary Schools - - - At no School or Institution 2 — 2 Suffering from epilepsy which is not severe. Attending Public Elementary Schools 3 4 7 At no School or Institution — — — 81  Boys Girls Total Physically Defective Infectious pulmonary and glandular tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 2 3 At other Institutions At no School or Institution — — — Non-infectious but active pulmonary and glandular tuberculosis At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential OpenAir Schools - - - At Certified Day Open-Air Schools - - - At Public Elementary Schools 2 10 12 At other Institutions — — — At no School or Institution — — — Delicate children (e.g., pre- or latent tuberculosis, malnutrition, debility, anaemia, etc.) At Certified Residential OpenAir Schools At Certified Day Open-Air Schools - - - At Public Elementary Schools 133 128 261 At other Institutions — — — At no School or Institution — — — Active non-pulmonary tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board - - - At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — Crippled Children (other than those with active tuberculous disease e.g., children suffering from paralysis, etc., and including those with severe heart disease. At Certified Hospital Schools - - — At Certified Residential Cripple Schools 3 3 At Certified Day Cripple Schools - - - At Public Elementary Schools 28 25 53 At other Institutions — — — At no School or Institution - - - 82 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1927. TREATMENT TABLE. Group 1.—Minor Ailments (excluding Uncleanliness, for which see Group V.) Disease or Defect (1) Number of Defects treated, or under treatment during the year. Under the Authority's Scheme (2) Otherwise (3) Total (4) Skin:— Ringworm—Scalp 4 2 6 Ringworm—Body 14 6 20 Scabies 11 2 13 Impetigo 340 74 414 Other Skin Diseases 18 11 29 Minor Eye Defects (external and other, but excluding cases falling in Group II) 70 45 115 Minor Ear Defects 80 43 123 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 202 101 303 Total 739 284 1023 83 Group 2.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group I.) Defect or Disease (1) No. of Defects dealt with. Total (5) Under the Authority's Scheme (2) Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme (3) Otherwise (4) Errors of Refraction (including Squint) ((Operations for squint should be recorded separately in the body of the Report) 280 28 - 308 Other Defect or Disease of the Eyes (excluding those recorded in Group I) - - - — Total 280 28 - 308 Total number of children for whom Spectacles were prescribed:— (a) Under the Authority's Scheme 234 (b) Otherwise 28 Total number of children who obtained or received Spectacles:— (а) Under the Authority's Scheme 232 (б) Otherwise 28 Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment Received other forms of Treatment (4) Total number treated (5) Under the Author ity's Scheme, in Clinic or Hospital (1) By Private Practitioner or Hospital, apart from the Authority's Scheme (2) Total (3) 74 19 93 - 74 84 Group IV.—Dental Defects. (1) Number of Children who were:— (a) Inspected by the Dentist: Routine Age Groups Aged Total 6,515 5 470 / 6 726 7 760 8 894 9 647 10 509 11 582 12 741 13 676 14 428 15 68 16 14 Specials 304 Grand Total 6,819 (b) Found to require treatment 3,987 (c) Actually treated 2,261 (d) Re-treated during the year as the result of periodical examination 1,180 {2) Half-days devoted to:— Inspection 45 Total 382 Treatment 337 (3) Attendances made by Children for Treatment 3,441 (4) Fillings:— Permanent Teeth 1,739 Total 1,753 Temporary Teeth 14 (5) Extractions:— Permanent Teeth 1,133 Total 6,048 Temporary Teeth 4,915 (6) Administrations of General Anaesthetics for Extractions 881 (7) Other Operations:— Permanent Teeth — Total — Temporary Teeth — Group V.—Uncleanliness and Verminous Conditions. (1) Average number of Visits per School made during the year by the School Nurses 3 (2) Total number of Examinations of Children in the Schools by School Nurses 16,326 (3) Number of individual children found Unclean 410 (4) Number of Children cleansed under arrangements made by the Local Education Authority None (5) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 None (b) Under School Attendance Bye-Laws 2