EAL 22 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer for the year 1931. 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 and Maternity Hospitals. EALING: Francis A. Perry, Ltd., 4, Kirchen Road. . ; -• EAL 22 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer for the year 1931. 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 and Maternity Hospitals. EALING : Francis A. Perry, Lid.. 4, Kirchen Road. Annual Report of the Medical Officer of Health 1931. INDEX. page Acts, Byelaws and Regulations 25 Ambulances 28 Bacteriological Examinations 24 Births 12 Blind, Deaf, etc., Children 98, 105 Children Act, 1908 (Part I) 35 Clinics and Treatment Centres 29 Dairies, Cowsheds and Milkshops 44 Deaths 13, 18 Defects found by Medical Inspection 103 Dental Defects 76, 87, 110 Diphtheria 55 Disinfection 45 Drainage and Sewerage 39 Employment of Children and Young Persons 100 Factories and Workshops 45, 46 Health Centres 7, 37 Health Education 61, 100 Health Visiting 37 Hospitals in the District 26 Housing 48 Infant Deaths 13 Infectious Diseases 51, 77 Maternal Mortality 34 Maternity and Child Welfare 30 Maternity and Nursing Homes 23 Meat and Other Foods 43 Medical Inspection of School Children 69, 102 Medical Treatment of School Children 78, 108 Mentally Defective Children 98, 105 Midwives 19 Milk 42 Nursing Arrangements 19 Offensive Trades 41, 45 Orthopaedic Treatment 90 Population 10 Provision of Meals 96 Puerperal Fever and Puerperal Pyrexia 57 Sanitary Inspection of the Borough 44 Scarlet Fever 56 Scavenging and Disposal of Refuse 40 School Hygiene 68 Slaughterhouses 45 Smoke Abatement 40 Social Conditions 9 Speech, Defective 93 Staff 6, 65 Statistics, Vital and General 8 Tuberculosis 58, 74, 79 Uncleanliness 72, 110 Vision, Defective 75, 79, 109 Water Supply 38 5 PUBLIC HEALTH COMMITTEE, 1930-31. Councillor A. H. Chilton, J.P. (Chairman). (Died 8th Sept., 1931). Councillor Mrs. F. M. Baker, J.P. ( Vice-Chairman). Aldermen Col. R. R. Kimmitt, O.B.E., and H. W. Peal, J.P. Councillors W. J. S. Cox, Willoughby Garner, C D. Grant, P. G. Holmes, J. Mansel Lewis, H. M. Sayers, Mrs. E. S. Taylor, J.P., H. Telfer, L. T. Watters and W. T. White. MATERNITY AND CHILD WELFARE COMMITTEE, 1930-31. Alderman Col. R. R. Kimmitt, O.B.E. (Chairman). Councillor Mrs. E. S. Taylor, J.P. ( Vice-Chair man). Alderman H. W. Peal, J.P., Councillors Mrs. F. M. Baker, J.P., A. H. Chilton, J.P., W. J. S. Cox, Willoughby Garner, C. D. Grant, F. G. Holmes, J. Mansel Lewis, H. M. Sayers, H. Telfer, L. J. Watters, and W. T. White. Mesdames Girdlestone, Haddon, Holman, Ludlow, Parry and Scrutton. 6 STAFF. Medical Officer of Health and Superintendent of Isolation and Maternity Hospitals— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant Medical Officers of Health-— Thomas H. Bingham, M.D., D.P.H. (resigned 31st March, 1931). John Petrie, M.B., Ch.B., D.P.H. Ai,astair A. Douglas, M.D., D.P.H., B.Sc. (appointed 1st June, 1931). Assistant Medical Officers, Maternity and Child Welfare— Edna I. Langston, M.B., B.S., F.R.C.P., M.R.C.S. (resigned 23rd May, 1931). Marguerite M. Fenn, M.B., B.S., M.R.C.S., L.R.C.P. (appointed 13th July, 1931). Florence Whitrow, M.B., Ch.B., M.R.C.S., L.R.C.P. (appointed 1st Oct., 1931). Ante-Natal Consultant—Part-time— John W. Bell, Iy.R.C.P.I. & L.M., L.R.C.S.I. & L.M. Chief Sanitary Inspector— George W. Stevens, 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. C. P. H. Meadows, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. G. T. H. Bi.ackie, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods. Ernest Belfield, Cert. R.S.I., and Cert. Inspector of Meat and Other Foods (appointed 1st May, 1931). 7 Supervising Health Visitor— Eleanor Evans, Cert. R.S.I., Cert. C.M.B. Health Visitors— Marguerite Farrow, Cert. R.S.I, and Trained Nurse. Mildred Adeline Rice, Cert. R.S.I., Cert. C.M.B., and Trained Nurse. Ritbie G. B. Dugger, Health Visitor's Cert., Cert. C.M.B., and Trained Nurse. Freda de i.a Hoyde, Health Visitor's Cert., Cert. C.M.B., and Trained Nurse. Ruby N. M. S. Field, Health Visitor's Cert., Cert. C.M.B., and Trained Nurse. Chief Clerk and Committee Clerk— Harry Birrell. Clerks— * William A. J. Turner *George W. Stephens *Herbert J. Reed *Gregory Reynolds *Robert S. Leggatt *Elsie M. Wiseman Olive Levasseur Barbara M. Martin Grace M. Jones Evelyn Craighill HEALTH CENTRES. Mattock Lane, Ealing. Cherington House, Hanwell. Ravenor Park, Greenford. Islips Manor, Northolt. 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, 1931. Area (in Acres) 9,135 Population (Census, 1931) 117,688 Population (Estimated) Middle of 1931 117,900 Number of Inhabited Houses (Census, 1921) 18,642 Number of Inhabited Houses (end of 1931) according to Rate Books 29,473 Number of Families or separate Occupiers (Census, 1921) 21,955 Rateable Value (30th Sept., 1931) £1,137,109 Net Produce of a Penny Rate £4,400 SUMMARY OF VITAL STATISTICS, 1931. Live Births:— Legitimate Males, 879 Females, 822 Total, 1,701 1,766 Illegitimate Males, 39 Females, 26 Total, 65 Birth-Rate per 1,000 of Estimated Population 15.0 Still-births Males, 28 Females, 23 Total 51 Rate per 1,000 total Births (Live and Still-births) 27 Deaths: Males, 580 Females, 612 Total 1,192 Death Rate per 1,000 of Estimated Population 10.1 Deaths of Infants under one year of age:— Legitimate : Males, 46 Females, 33 Total 79 84 Illegitimate : Males, 3 Females, 2 Total 5 Death Rate of Infants under one year of age:— All Infants per 1,000 Live Births 47 Legitimate Infants per 1,000 Legitimate Live Births 46 Illegitimate Infants per 1,000 Illegitimate Live Births 77 Deaths from Diseases and Accidents of Pregnancy and Childbirth:— From Sepsis 1 Death Rate per 1,000 Total Births 0.55 From Other Causes 6 „ 3.30 Total 7 „ 3.85 9 Total Deaths Death-Rate per 1,000 Population Measles 0 0.00 Whooping Cough 4 0.03 Diphtheria 5 0.04 Scarlet Fever 1 0.01 Influenza 36 0.31 Tuberculosis of Lung 74 0.63 Other Forms of Tuberculosis 7 0.06 Death-Rate per 1,000 live Births Diarrhoea (under two years of age) 6 3.4 TABLE I. Comparison of Vital Statistics of Ealing with those of England and Wales, Etc., 1931. England and Wales 117 Great Towns (including London) London Ealing Birth-Rate 15.8 16.0 15.0 15.0 Death-Rate 12.3 12.3 12.4 10.1 Infant Death-Rate 66 71 65 47 Measles Death-Rate 0.08 0.10 0.03 0.00 Whooping Cough Death-Rate 0.06 0.07 0.07 0.03 Diphtheria Death-Rate 0.07 0.08 0.06 0.04 Scarlet Fever Death-Rate 0.01 0.01 0.02 0.01 Influenza Death-Rate 0.36 0.33 0.26 0.31 Diarrhoea (under two years per 1,000 Births) 6.0 8.4 9.7 3.4 SOCIAL CONDITIONS. Ealing is classified as one of the 117 great towns of England and Wales, in fact, it is the fourth largest non-county borough. By rail it is about eight miles from the City of London and to this feature it owes its rapid growth for there are few large industries carried on in the area. As a very large proportion of the inhabitants work within the County of London it may be described as one of 10 the dormitories of the Metropolis. Less than a generation ago open fields constituted a considerable part of the older portion of the Borough and in the Greenford and Northolt wards, the districts added to the Borough in recent years, rural conditions obtained until the last few years. Owing to this recent growth and the fact that such a large proportion of the houses have been built to the requirements of modern bye-laws on wide roadways there is an almost total absence of slum areas. The district is almost entirely residential, the factories being small in number. The large up-to-date factories newly erected represent industries such as the making of confectionery, vacuum cleaners, glass bottles, wallpaper, oil lamps, etc. Many of the employees live in new houses in the vicinity of the factories and therefore live and work under good conditions. In fact, the residents of the Borough are generally well-being and appreciate of the value of health. The large attendance of mothers at the Health Centres indicates their desire to do their best to assist in the healthy upbringing of their families. In the development of the Borough the Town Council have given special attention to the provision of open spaces for public use and altogether 574 acres have been secured for this purpose, with a further 187 acres just over the Borough boundary owned jointly with other neighbouring local authorities. STATISTICS. Population.—The provisional figures of the 1931 Census give the population of the Borough as 117,688. This population is 13,688 above the population estimated by the Registrar-General for the middle of 1929, which was employed for calculating the various rates for the year 1930. With our knowledge of the rapid building operations going on in the Greenford ward the population of 104,000 for 1929 was considered to be an underestimate. The Census returns as given in the Table demonstrate that in ten years the population of Ealing has increased from 67,755 in 1921, to 117,688 in 1931, 11 Census 1881 5,764 1891 23,965 1901 33,040 1911 61,222 1921 67,755 1931 117,688 But it must be borne in mind in considering the increase in population that there have been added as a result of the extension of boundaries the areas of Hanwell, Greenford and Northolt which had at the Census of 1921 populations respectively of 20,481, 1,461 and 904. In effect the population of what is now the Borough of Ealing was 90,601 in 1921. This means an intercensal increase of 30 per cent. The populations in the various wards at the 1931 Census are shown by the following provisional figures supplied by the Registrar-General. Since the last Census several of the wards have had their boundaries altered so that the Census populations of 1921 cannot properly be compared with those of 1931, but those of Greenford and Northolt remain practically the same and it is interesting to note that the population of the former has increased from 1,461 to 15,244 and of the latter from 904 to 3,048 in ten years. 12 Census, 1931. Population of the Borough in Wards. (Provisional Figures). Wards M ales Females Persons Castlebar 4,167 5,939 10,106 Drayton 4,603 5,715 10,318 Grange 6,621 8,413 15,034 Mount Park 3,408 5,645 9,053 Lammas 6,307 6,971 13,278 Manor 4,809 6,198 11,007 Grosvenor 5,420 6,032 11,452 Hanwell South 4,386 4,492 8,878 Greenford 7,626 7,618 15,244 Hanwell North 4,841 5,429 10,270 Northolt 1,537 1,511 3,048 Total 53,725 63,963 117,688 It will be interesting in the future to compare the vital statistics of the Greenford ward, the inhabitants of which generally are on the same level in the social scale and are living under the best housing conditions, with the most modern type of schools for the children and in surroundings of the most healthy character, with those of other wards of the Borough. The area of the Borough is 9,135 acres, which makes the density of population or the number of persons per acre 13. Birth-Rate.—The birth-rate in the Borough for the year is 15.0 per thousand of population. This is the same as that for London but 1.0 less than that for the Great Towns and 0.8 less than that for the whole of England and Wales. For the previous year the birth-rate was stated to be 15.7 but that rate was calculated on a population of 104,000, which figure is much less than the actual population as ascertained by the Census in 1931. The 13 Registrar-General has now estimated the population in the middle of 1930 at 111,800, which gives an amended birth-rate for that year of 14.6 per 1,000 of population. This makes the birth-rate for 1931 just a little more, 0.4, than that for 1930 and 0.3 more than that for 1929. Death-Rate.—The death-rate for the year is 10.1 per thousand of the population. As with the birth-rate, the death-rate for the year 1930 was calculated on an under-estimated population and was represented as 11.0 in the Annual Report for 1930, but on the amended estimated population the death-rate is found to be 10.2, which makes it just 0.1 more than the death-rate for 1931. In Table I it will be seen that while the death-rate for Ealing in 1931 was 10.1, that for England and Wales was 12.3 and that for London 12.4. Infant Death-Rate.—The infant death-rate for Ealing is still maintained at a low level. It is 47 per thousand births for 1931. This is a little higher than that for 1930 but lower than that for 1929. It is lower than the average for the previous five years which is 49. The rate however is distinctly lower than those for England and Wales, for the Great Towns, and for London, which are respectively 66, 71 and 65, as indicated in Table I. In Table II a very instructive indication of the steady decline in the infant death-rate is given by comparing the rates for successive five-year periods since 1911, the average rates for these periods being 76, 62, 55 and 49. Table III gives the deaths of infants from the various causes. It will be noted that the greatest number of deaths from any separate cause is from premature birth, 19, and that 17 of these occurred within the first week and 18 within four weeks after birth. Atrophy, debility and marasmus come next with eleven deaths, eight of which occurred within a week and ten within four weeks after birth. Thus, of the total 84 infant deaths at least 30 resulted from conditions operating previous to the birth of the child, in all probability ill-health or disturbance of function in the mother arising from varied causes. Pneumonia and bronchitis, essentially preventable diseases, accounted for 13 deaths, 14 all except one of which occurred after the children were four weeks old. A study of these figures indicate the lines along which preventive measures can be directed, in the first place in building up the health of the expectant mother by ante-natal care and secondly by careful nurture of the child and so increasing its resistance to disease from birth onwards. In this Table it will be noted that of the 84 deaths 44 occurred before the children were four weeks old. These figures give what is called a neo-natal death-rate of 25 per thousand births. Still-births.—The number of still-births registered in the Borough was 51, which gives a rate of 0.43 per thousand of population. This rate is less than that for England and Wales and that for London, which are respectively 0.67 and 0.50. The Illegitimate Infant Death-rate is 77 per thousand illegitimate births compared with the Legitimate Infant Death-rate of 46 per thousand legitimate births. 15 TABLE II. Showing Birth-Rate, Death-Rate and Infant Death-Rate for Ealing for the Years 1911-1931. 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 49 1927 14.1 10.5 56 1928 14.9 9.6 41 1929 14.7 11.3 48 1930 14.6 10.2 44 1931 15.0 10.1 47 16 TABLE III. Causes of Infant Deaths, 1922 to 1931. 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 Diarrhæal Diseases 5 2 4 1 4 3 5 4 3 5 Premature Birth 5 11 7 9 23 20 14 25 14 19 Congenital Defects 6 8 — 10 5 9 6 4 9 9 Atrophy, Debility, Marasmus 10 9 6 8 13 11 6 10 11 Tuberculous Disease 2 1 3 — — — 2 1 2 1 Syphilis — — — 1 1 — — — — 1 Rickets — — — — — — — — — — Meningitis (not Tuberculous) — 1 2 1 1 — 1 3 1 4 Convulsions 2 2 2 — 1 2 3 3 6 5 Bronchitis 5 5 1 4 7 5 7 2 4 2 Pneumonia (all forms) 1 10 3 5 5 7 — 8 10 11 Gastritis 2 1 — — 1 — 1 1 — — Common Infectious Diseases 4 2 3 3 1 2 — 6 2 1 Other Causes 15 10 11 12 9 15 12 6 11 15 Totals 57 62 46 54 71 74 61 73 71 84 17 TABLE IIIA. Infant Mortality during the Year 1931. Deaths at various Ages under One Year of Age. Cause of Death Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks Total under 4 weeks 4 weeks and under 3 months 3 months and under 6 months 6 months and under 9 months 9 months and under 12 months Total deaths under 1 year Causes—Certified 36 4 1 3 44 15 12 8 5 84 Uncertified — — — — — — — — — — Small-pox — — — — — —_— — — — — — Chicken pox — — — — — — — — — — measles — — — — — — — — — — Scarlet fever — — — — — — — — — — Whooping cough — — — — — 1 — — — 1 Diphtheria and croup — — — — — — — — — — Erysipelas — — — — — — — — — — Tuberculous Meningitis — — — — — — — — — — Abdominal Tuberculosis — — — — — — — — — — Other Tuberculous diseases — — — — — 1 — — — 1 Meningitis (not Tuberculous) — — — — — — 2 1 1 4 Convulsions 1 — — — 1 1 2 1 — 5 Laryngitis — — — — — — — — — — Bronchitis — — 2 2 Pneumonia (all forms) — 1 — — 1 2 4 3 1 11 diarrhoea — — 1 — 1 2 1 1 — 5 Enteritis — — — — — — — 1 1 2 Gastritis — — — — — — — — — — Syphilis — — 1 1 — — — — 1 Rickets — — — — — — — — — — Suffocation, overlying — — — — — 1 — 1 Injury at Birth 1 — — — 1 — — — — 1 Atelecatasis — — — — — — — — — Premature Birth 17 1 — — 18 1 — — — 19 Congenital Malformations 4 1 1 6 1 — 1 1 9 Atrophy, Depility and Marsmus 8 1 — 1 10 — 1 — — 11 Other causes 5 — — — 5 5 — — 1 11 Total 36 4 1 3 44 15 12 8 5 84 18 The total deaths from the various causes are indicated in Table IV. It will be seen that heart disease was responsible for the greatest number of deaths, namely, 241, giving a death-rate of 2.04 per thousand of population; the next was cancer with 173 deaths, giving a death-rate of 1.47; and bronchitis and pneumonia accounted for 120 deaths, giving a death-rate of 1.02. Of the infectious diseases, scarlet fever caused one death, giving a death-rate of 0.01 per thousand of population ; diphtheria caused five deaths, giving a death-rate of 0.04 ; whooping cough four deaths, giving a death-rate of 0.03; influenza 36 deaths, giving a death-rate of 0.31; and tuberculosis 81 deaths, giving a death-rate of 0.69. TABLE IV. Causes of Death, 1931. Cause of Death Male Female Total Typhoid and Paratyphoid Fevers — — Measles — — — Scarlet Fever 1 1 Whooping Cough 1 3 4 Diphtheria 4 1 5 lnfluenza 15 21 36 Encephalitis Lethargica — — — Cerebro-Spinal Fever 2 3 5 Tuberculosis of Respiratory System 49 25 74 Other Tuberculous Diseases 5 2 7 Syphilis 4 1 5 General Paralysis of the Insane, Tabes Dorsalis 2 2 4 Cancer, Malignant Disease 77 96 173 Diabetes 5 11 16 Cerebral Haemorrhage, etc. 21 34 55 Heart Disease 116 125 241 Aneurysm 4 1 5 Other Circulatory Diseases 37 33 70 Bronchitis 19 30 49 Pneumonia (all forms) 35 36 71 Other Respiratory Diseases 8 9 17 Peptic Ulcer 11 3 14 Diarrhoea, etc. (Under two years) 4 2 6 Appendicitis 3 3 6 Cirrhosis of Liver 2 1 3 Other Diseases of Liver, etc. 6 6 12 Other Digestive Diseases 13 17 30 Acute and Chronic Nephritis 17 21 38 Puerperal Sepsis — 1 1 Other Puerperal Causes — 6 6 Congenital Debility, Premature Birth, Malformations, etc. 30 16 46 Senility 11 23 34 Suicide 7 6 13 Other Violence 23 21 44 Other Defined Diseases 49 52 101 Causes ill-defined or unknown — — — Total 580 612 1,192 19 GENERAL PROVISION OF HEALTH SERVICES FOR THE BOROUGH. NURSING IN THE HOME. (1) General Diseases.—The Greater Ealing Nursing Association through its five nurses performs admirable work in quite an unostentatious manner in supplying nursing assistance to patients at their own homes. The Northolt Nursing Association provides a nurse for the Northolt ward. The nurses of both these Associations co-operate in every possible way with the Maternity and Child Welfare and School Medical Services. The Town Council makes a grant towards each Association for nursing services rendered in connection with children under five years of age and expectant mothers. The nurses also assist at the Health Centres in weighing the children and in preparing them for examination by the medical officers. During the year the nurses made 16,971 visits and had under their care 775 patients. In connection with Maternity and Child Welfare Service the nurses made 1,030 visits to mothers and children. (2) Infectious Diseases.—The nurses of the two Nursing Associations give nursing assistance when required for children under five years of age who are suffering from ophthalmia neonatorum, measles, whooping cough, poliomyelitis, and diarrhoea. They also, when called upon to do so, attend cases of puerperal sepsis or puerperal pyrexia when the patient is not removed to an institution and is under the care of a doctor. ADMINISTRATION OF MIDWIVES ACTS, 1902 to 1926. By virtue of an Order under Section 62 of the Local Government Act, 1929, the Town Council is the local supervising authority under the Midwives Acts. During the year 43 midwives notified their intention to practise within the Borough, this number including seven midwives residing outside the district. Of the 36 midwives resident in Ealing, 16 were engaged in private practice, 13 were engaged in nursing homes and seven were engaged at the Chiswick and Ealing Maternity Hospital. All of the midwives practising in the Borough possess the certificate of the Central Midwives Board. 20 Uncertificated Women.—During the year the Town Council instituted proceedings against a woman who, not being a certified midwife, was alleged to have attended upon a woman at her confinement contrary to the provisions of the Midwives and Maternity Homes Act, 1902 to 1926. The case was dismissed, the Court being of the opinion that the case was one in which the attention was given in consequence of sudden and urgent necessity. In another case in which a woman, not being certified as a midwife, had attended upon a woman in childbirth otherwise than under the direct and personal supervision of a duly qualified medical practitioner, the Town Council gave her a serious warning as to her conduct in the future. Number of Births attended by Midwives.—From the usual returns furnished by the midwives at the end of the year it was found that 1,009 births in Ealing were attended by certified midwives acting in the capacity of midwife, and that in 369 cases attended by doctors, midwives acted as maternity nurses. The number of births attended by midwives acting in the capacity of midwife is equal to 52.7 per cent. of all births notified, while certified midwives acted as maternity nurses in a further 19.3 per cent. of the cases. Notifications.—The notifications received from midwives, in accordance with the Rules of the Central Midwives Board, were as follows:- Notifications of : Sending for medical assistance- On account of a complication of pregnancy 24 On account of a complication during labour 74 On account of a complication during the puerperium 9 On account of the health of the child 28 * 135 Still-birth 8 Laying Out of a Dead Body 3 Artificial Feeding of Infant 5 Liability of Midwife to be a source of Infection 5 Total 156 21 The three notifications in respect of the laying-out of a dead body were received from midwives engaged in nursing homes and in each case the midwife had been acting in the capacity of a maternity nurse. Ophthalmia Neonatorum.—Among the 28 notifications of sending for medical assistance on account of the health of the child were included seven on account of inflammation of, or discharge from, the eyes. In four of these the medical practitioner called in by the midwife notified the case as being one of ophthalmia neonatorum. Visits to Midwives.—The number of visits made by the Assistant Medical Officer, who acts as Inspector of Midwives, to midwives outside the Maternity Hospital was as follows:— Routine Visits of Inspection 44 Special Visits of Enquiry 9 The routine visits of inspection have shown that with few exceptions the midwives practising in the Borough maintain a very satisfactory standard. The visits of enquiry in connection with special cases were as follows:- Ophthalmia Neonatorum 4 Puerperal Pyrexia 2 Puerperal Fever 1 Other Visits 2 In one case it was found that a midwife had failed to call in medical aid to an infant suffering from a slight discharge from the eyes. The attention of this midwife was drawn to the necessity of calling in medical aid to any infant suffering from inflammation of, or discharge from, the eyes, however slight, and she was cautioned as to her conduct in the future. Payment of Fees.—The Town Council are responsible for the payment of the fees of medical practitioners when called in by midwives and during the year under review fees amounting to £105 15s. 6d. were paid in respect of 87 claims sent in by medical practitioners. The Council has power to recover from the patient, 22 or her husband, the amount of the fee paid or such proportion of it as the financial circumstances of the family justify. The amount of fees reclaimed during 1931 was £38 1s. 0d. Compensation to Midwife.—During the year it was found necessary to suspend one midwife from practice to prevent the spread of infection. In accordance with Section 2 (1) of the Midwives and Maternity Homes Act, 1926, compensation for loss of practice was paid to her amounting to £3 10s. 0d. Post-Certificate Instruction of Midwives.—At the invitation of the London County Council arrangements were made with them for midwives resident in the Borough to attend courses of post-certificate lectures and demonstrations on general midwifery held under the joint auspices of the London and Middlesex County Councils. Later in the year arrangements were also made for midwives to attend courses of practical ante-natal and post-natal demonstrations conducted at various hospitals in London. On the whole, midwives do not realise sufficiently the importance of ante-natal work. Their appreciation of the importance of dental treatment during pregnancy, is perhaps increasing, but routine ante-natal supervision is not carried out by more than a quarter of the midwives engaged in private practice, in spite of the fact that attention is being constantly directed to the need for ante-natal care. Their omission in this respect is in large measure due to lack of special training but one would have expected them, if this were the only reason, to take advantage of the lectures and demonstrations which have been arranged for their benefit. Midwives must recognise that it is just as important that the mother should receive skilled attention before as during the confinement. In fact it is in this period that much can be done to prevent mortality and disability occurring as a result of labour. The quality of a midwife's work will in the future be judged to a large extent by the occasions on which she sends for medical help during the ante-natal period. 23 MATERNITY AND NURSING HOMES. The powers and duties under the Nursing Homes Registration Act, 1927, as regards the Borough were delegated to the Town Council by the Middlesex County Council as from the 1st October, 1930. During 1931 one application was received for registration. The premises were found to be suitable in every way and ware therefore registered. In accordance with Section 6 of the Act, four applications for renewal of Certificates of Exemption were granted. These were in respect of the King Edward Memorial Hospital, Hanwell Cottage Hospital, St. David's Home and the Twyford Abbey Convalescent Home. The following table gives information regarding the nursing homes within the Borough:- No. of Homes No. of Beds Number of Nursing Homes on Register at beginning of Year 26 (16) 201 (84) Number of Applications for Registration 1 — Number of Nursing Homes Registered for the first time 1 - Number of Nursing Homes Discontinued 3(1) — Number of Nursing Homes remaining on Register at end of Year 24 (15) 190 (79) (The figures shown in brackets indicate the number of Homes and Beds devoted wholly or partly to the reception of Maternity Cases). The visits made to the Nursing Homes during the year were as follows:- By the Assistant Medical Officer acting as Inspector of Midwives and Nursing Homes 56 By the Medical Officer of Health 2 24 In connection with the inspection of Nursing Homes the Chief Sanitary Inspector visited two Homes to advise on the sanitary arrangements and the Chief Officer of the Fire Brigade visited one Home to make suggestions regarding the precautions in case of fire. A circular regarding the standards required with respect to the supervision, staffing, accommodation, equipment and general arrangements in nursing homes was approved by the Council and issued to the keepers of registered nursing homes in the Borough. In several of the homes it has been necessary to request the keeper to provide suitable precautions against an outbreak of fire, or to carry out necessary decorations or repairs. In all instances except one the request was complied with immediately, but in the one case it was only after the keeper of the nursing home had been requested to attend before the Committee to show reason why an order should not be made cancelling the registration of the premises as a nursing home, that the necessary work was carried out and the home put into good condition. On the whole the nursing homes in the Borough are maintained in a very satisfactory manner. 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 51 601 652 Isolation Hospital 80 1,257 1,337 Tuberculosis : From the Borough 90 329 419 Miscellaneous : From the Borough 40 48 88 Isolation Hospital 4 2 6 Total 265 2,237 2,502 25 Specimens indicated in the above table as coming from the Borough are sent by medical practitioners for whom they are examined free of charge. Any special examinations such as those of material from cases of puerperal sepsis or of milk for the bacillus of tuberculosis, etc., are made at the Lister Institute, the cost being defrayed by the Town Council. LEGISLATION IN FORCE IN BOROUGH. 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 Act (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 New Streets and Buildings, 23rd July, 1925. Smoke Abatement, 17th June, 1930. Registration of Nursing Homes, 9th December, 1930. In January, 1929, Byelaws were made by the Town Council, with the approval of the Minister of Health, making certain amendments in the Byelaws with respect to nuisances, in the Byelaws with regard to tents, vans and sheds, repealing certain Byelaws and extending the Byelaws mentioned below to the whole of the extended Borough 26 (1) Prevention of nuisance 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. Slaughter Houses, March 6th, 1884. (added : Humane Slaughtering of Animals, 1922). 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. The provision of means of escape in case of fire in certain factories and workshops, 22nd March, 1922. Regulations. Communications between Drains and Sewers, Section 21, Public Health Act, 1875. October 8th, 1908. HOSPITALS. (1) Isolation Hospital.—The hospital for the treatment of cases of infectious disease is under the control of the Chiswick and Ealing Hospitals Committee and this also serves the needs of the Urban District of Brentford and Chiswick. On account of the large increase of population, particularly in the Borough of Ealing, the Hospitals Committee decided to extend the hospital. The extension suggested is an additional diphtheria block and a new cubicle block consisting of single bedded wards as well as necessary additions to the administrative block. Unfortunately the financial difficulties from which the Nation suffered in the middle of the year brought about the postponement of the steps to be taken for extension. The Middlesex County Council have considered the needs for isolation hospital accommodation in the whole of the County and have made suggestions with regard to the grouping and utilisation of the existing hospitals. The original suggestions, however, as a result of consideration by the local authorities concerned, have 27 undergone material modification and are likely to undergo still greater changes before they are finally adopted. On account of the negotiations and conferences which are still taking place it seems unwise to go into the report on this occasion or make criticisms of it or even make suggestions. There is no doubt that greater efficiency and greater economy can be obtained as a result not only of a combination of some of the hospitals but also of cooperation between all of them. Every step should therefore be taken to bring about such combination and co-operation provided the control of the local authorities concerned is not unduly lessened or interfered with. (2) Smallpox Hospital.—The provision for the isolation and treatment of cases of smallpox remains the same. This consists in the London County Council receiving into their smallpox hospitals any cases occurring in the County of Middlesex, the arrangements having been made by the Middlesex County Council at the request of the local authorities in the County. (3) Tuberculosis Hospitals.—Hospital accommodation for cases of tuberculosis occurring in the Borough or in any part of Middlesex is provided by the Middlesex County Council at Harefield Sanatorium and at Clare Hall Hospital. (4) Maternity Hospital. The Maternity Hospital for the Borough, which also serves the Urban District of Brentford and Chiswick, is managed by the Chiswick and Ealing Hospitals Committee. During the year the Hospitals Committee decided to extend the hospital to make provision for 16 more beds and to erect a new Labour Block. Unfortunately, in the same way as with the Isolation Hospital, the progress was stopped on account of the financial crisis. So great is the demand for hospital accommodation for maternity cases which are of a suitable kind to require this treatment that the beds at the Hospital are usually booked completely three or four months in advance. One advantage of booking so early is that expectant mothers are impressed with the need for attending the Ante-Natal Centre early, but the unfortunate thing is that sometimes a mother who is greatly in need of this special provision and who has been unfortunate enough 28 not to book early is precluded from being admitted. Additional accommodation is pressingly required and the work in the way of providing for it will be resumed whenever possible. (5) Hospital Provision for Children.—At the King Edward Memorial Hospital a children's ward provides 12 beds for children and to this ward children under five years of age can be referred for indoor treatment from the Health Centres. At the Hanwell Cottage Hospital there is also a small children's ward with three beds. (6) Other Hospitals.—The King Edward Memorial Hospital, which is a voluntary hospital, has, in addition to the children's ward previously mentioned, 94 beds for the treatment of general, medical and surgical cases. Twelve beds are also provided for surgical or medical cases at the Hanwell Cottage Hospital. The West Middlesex Hospital which is situated at Isleworth, a mile and a half from the Borough boundary, is under the control of the Middlesex County Council and makes provision for persons coming under the Poor Law in the southern section of Middlesex, of which Ealing forms a part. AMBULANCE FACILITIES. (1) For Cases of Infectious Disease.—The Chiswick and Ealing Hospitals Committee maintain a motor ambulance for removing cases of infectious disease to the Isolation Hospital from the Borough of Ealing and from the Urban District of Brentford and Chiswick. (2) For Non- Infectious and Accident Cases.—The Town Council have two motor ambulances for the purpose of conveying cases, other than those of infectious disease, to hospitals and nursing homes within the Borough or in the London area. No charge is made for runs within the Borough. Charges ranging from 7s. 6d. to one guinea are made if the ambulance has to go outside the Borough. The service is one which is in operation both during the day and the night with a double service available between 1 p.m. and 4 p.m., when most calls are made for the use of the ambulances. The demands on the ambulance service are 29 extending every year as is shown in the following table, which indicates that in four years the number of cases conveyed has increased from 1,169 to 1,985, while the number of miles travelled has increased from 6,329 to 12,301, in other words has nearly doubled. General Ambulance Service. 1927 1928 1929 1930 1931 Accident Cases Conveyed 365 520 530 546 729 Illness Cases Conveyed 804 1,098 1,070 1,211 1,256 Total Cases Conveyed 1,169 1,618 1,600 1,757 1,985 Number of Journeys outside the Borough (included in above) 205 253 215 226 268 Total Number of Miles Travelled 6,329 8,379 7,988 11,111 12,301 CLINICS AND TREATMENT CENTRES. Name Address ded by Health Centre 13, Mattock Lane, Ealing. Ealing Town Council Health Centre Cherington House, Hanwell. Ealing Town Council Health Centre Ravenor Park, Greenford. Ealing Town Council Health Centre Islips Manor, Northolt. Ealing Town Council Orthopaedic Clinic 13, Mattock Lane, Ealing. 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 30 MATERNITY AND CHILD WELFARE. The general scheme of maternity and child welfare is the same as has been noted in previous reports. The following is a summary of the whole Scheme for the care of mothers and children:— For the Mothers. (1) Ante-Natal Care of Expectant Mothers. (а) Visits to homes by Health Visitor to give advice. (b) Ante-Natal Examination by Medical Officer at Centre. (c) Admission to Maternity Hospital for treatment of Ante-Natal Complications or Abnormalities. (d) Midwife can call in Doctor in abnormal ante-natal case at cost of Council. (e) Doctor can call in Consultant in abnormal ante-natal case at cost of Council. (f) Milk free of charge in necessitous cases. (g) Dental treatment, including provision of artificial dentures at reduced charges according to the family income. (2) Intra-Natae Care. (a) Provision of a Midwife free of charge in necessitous cases. (b) Midwife can call in Doctor free of cost or at reduced cost, depending on circumstances. (c) Doctor can call in Consultant, free of cost, or at reduced cost. (d) Admission to Maternity Hospital for confinement at fees according to circumstances. (e) Home Helps provided free of cost in necessitous cases. (f) Supply of aseptic maternity outfits free of charge in necessitous cases. (3) Post-Natal Care. (a) Medical aid in complications after confinement, free or at reduced cost. (b) Consultant aid when Doctor calls in further help in complications during the puerperium. 31 (c) Investigation of cases of puerperal sepsis or pyrexia. (d) Treatment of puerperal sepsis or pyrexia in hospital free of charge. (e) Visits by Health Visitor after Midwife and Doctor leave patient. (f) Consultations at Health Centre by Medical Officer. (g) Supply of milk free to nursing mothers in necessitous circumstances. (h) Investigation of maternal deaths. For the Children. (1) Medical attendance for four weeks after birth when Doctor called in by Midwife. (2) Visiting by Health Visitors at homes to give advice on feeding and care of infants. (3) Infant consultations at Health Centre by Medical Officer. (4) Treatment of defects in children up to five years of age at Health Centre:- (a) Minor ailments. (b) Teeth. (c) Enlarged tonsils and adenoids. (d) Orthopaedic treatment. (e) External eye disease. (5) Nursing at home of cases of measles, whooping cough, ophthalmia neonatorum, etc. (6) Hospital treatment of severe or complicated cases of measles. The summary of the work of the Health Visitors and of the activities of the Health Centres gives an idea of the extent to which the Maternity and Child Welfare Services are utilised by the parents. Medical Examination of Children 1-5 years.—A special effort was made during the year to encourage more mothers to bring their children aged 1 to 5 years for regular medical examination. Accordingly, a circular letter was sent pointing out to parents the value of advice in the care of young children and the importance of early treatment of defects which, if neglected, may lead to disease 32 and deformity. The letter suggested regular medical examination after each birthday by the family doctor or at the Health Centre. One hundred copies were sent out, but only four children were brought to the Centre as a direct result of these letters, proving beyond doubt that printed information and advice is of very little value. Following on the visits of the Health Visitors, however, and their advice and suggestions to the mothers to take advantage of the regular medical supervision of young children provided by the Health Centre, the number of children examined from 1 to 5 years of age increased considerably. A new record card was adopted whereby a complete account of the child's family and personal medical history could be kept, examinations being recorded on five occasions between one and five years old, the first between one year and one-and-a-half years old, the second from one-and-a-half years to two years, the third two years to three years, the fourth three years to four years, and the fifth between four and five years, this card being handed over to the School Medical Department on the child reaching the age of five years. It is hoped that in this way many defects will be prevented and others will receive the necessary treatment at the earliest stage, thus reducing the number of defects found on school medical inspection. From June, when the new arrangements began, until December, 1,745 children from one to five years of age were specially examined and the facts ascertained on examination duly recorded, treatment being advised as with school children when defects were found. From this beginning of regular medical inspection it is hoped to develop a scheme of medical inspection of children under school age similar in all respects in the way of recording, treatment and supervision to that for school children. In addition to the work above-mentioned there are also important activities of a non-medical or educative character carried on by the Health Visitors, and certain voluntary Workers, notably Mrs. Adnams, Mrs. Ludlow, Mrs. Parry and Miss Peal, to whom the thanks of the Council are due; 33 the former in giving regular talks to the mothers regarding their own and their children's health and the latter in giving valuable instruction and guidance to the mothers in the making and use of suitable garments for the mothers themselves or their children. The Welfare Working Party also performs valuable services in knitting suitable garments for babies and young children to be sold at cost price or given free of charge to those who are in necessitous circumstances, and gratitude must be expressed to them for their continued assistance. DENTAL TREATMENT OF EXPECTANT AND NURSING MOTHERS. Dental treatment for expectant and nursing mothers was begun five years ago. Great difficulty was experienced in persuading mothers to undergo the necessary treatment and very few were treated during the first three years. As a result of educative work and also as a result of pressure on the part of the medical officers, who have it in their power to refuse to accept applications for admission to the maternity hospital if the mothers do not act on their advice, more are accepting treatment. In the first year of treatment 36 mothers were dealt with, in the next two years 73 and 87 respectively, in 1930 there were 149 and in 1931 no fewer than 270. The mouths of most of these mothers were in an appalling condition with extensive caries and severe sepsis of the gums. Treatment of such conditions must make for not only safety for the mother at her confinement and better health of the baby but greatly improved health of the mother afterwards. Only a nominal charge is made for extractions, scaling and filling of the teeth, and payment for artificial dentures is requested according to the family income. Unfortunately for some of the mothers, after extractions have been carried out, their husbands selfishly put every step in the way of their receiving their artificial dentures by refusing to pay anything towards their cost even though they are in a position to make some contribution. In the year under review, of the 270 mothers dentally treated, 203 were expectant and 67 nursing. The number of attendances of these mothers for dental treatment amounted to 1,026. 34 The actual dental work accomplished consisted of permanent fillings to 281 teeth, scaling of the teeth in 65 cases, extractions of 1,877 teeth and other treatments 103. Full or partial artificial dentures were supplied to 108 mothers. This work may be comparatively small in extent but it is growing not only in amount but in acceptance by the mothers. It is work of first importance not only from the aspect of immediate personal health but from its relation to health education. MATERNAL MORTALITY. Seven deaths due to or consequent upon childbirth occurred during the year. The following are the causes of maternal deaths:- 1. Cerebral embolism. 2. Cerebral haemorrhage. 3. Pulmonary embolism (P.M.). 4. Septicaemia—acute nephritis—empyema (P.M.). 5. Puerperal fever—pelvic cellulitis—perineal laceration. 6. Eclampsia—haemorrhage and shock—rigid cervix— breech delivery. 7. Haemorrhage—placenta praevia. Detailed enquiry of the first four cases show that death was unavoidable. In three cases sudden death occurred from embolism or cerebral haemorrhage, and in the fourth case, death was due to septicaemia following on empyema, the condition being aggravated by pregnancy and premature labour. Of the remaining three cases, details are known of two. The case of death from eclampsia was seen several times at the ante-natal clinic, and the last time within a fortnight of delivery. Although the patient suffered from minor discomforts, there had been no cause for alarm, so it appears probable that the eclampsia was of the unexpected, fulminating type. The death from puerperal fever was preventable. This was in all probability due to infection from the septic finger of a friend, who slept with the patient during the puerperium. 35 Six of the cases had been admitted to Hospital for treatment before they died. Enquiries are made regarding all cases of puerperal pyrexia and puerperal fever occurring within the Borough. The doctor in charge of the case is asked to complete a form giving all details, and further investigation is made where necessary. Where a case occurs in the practice of a midwife, or in a nursing home, the medical inspector visits in order to ascertain if adequate precautions are being taken, and if any further steps are necessary in the interests of the patient. Children Act, 1908 (Part I). The work of supervising children placed in the care of fostermothers is carried out by the Health Visitors, who have been designated Infant Protection Visitors. On receipt of a notification that a foster-mother has undertaken the care of a child, a visit is made to the house and a report furnished to the Medical Officer regarding the home conditions, etc. Frequent re-visits are made by the Health Visitor to ensure that the conditions remain satisfactory and that the children are properly cared for. In addition, the foster-mothers are urged to bring the children to the Health Centres to be seen by the Medical Officer in attendance and to enable the progress of the child to be adequately noted. The following Table gives information regarding the number of foster-children who have been registered in the Borough:— Number of children on register at beginning of year 77 (Actual number of foster-mothers having care of the above children, 62). Number of children registered during the year 105 Number of children removed from the register during the year:— Removed by parents from care of the foster-mother 53 Removed for adoption through a Society 9 Removed to Hospital 3 Child attained seven years of age 3 Child legally adopted by foster-mother 1 Child died 2 36 Foster-mother died 1 Foster-mother left district, taking child with her 4 Child removed from care of foster-mother at request of Medical Officer 1 — 82 Number of children on register at end of year 100 (Actual number of foster-mothers having care of the above children, 68). Number of visits made by Infant Protection Visitors 602 In one case where the child was not being cared for in a satisfactory manner it was considered desirable to request the fostermother, who had three children of her own in addition to being expectant, to make arrangements for the foster-child to be removed from her care. In a second case in which the foster-child had been removed to hospital suffering from burns, the foster-mother was interviewed by the Medical Officer of Health and agreed that as she had a family of five children it was not desirable for her to take the foster-child back when discharged from hospital. The following is a Summary of the Work of the Health Visitors during the year:- Visits to children under 12 months:- Total First visits 1,809 Return visits 4,155 Visits to children 1 to 5 years of age 6,528 Visits to expectant mothers 518 Visits to investigate infant deaths and still-births 96 Special visits or investigations 154 Visits to cases of Ophthalmia Neonatorum 15 Visits to cases of Puerperal Fever and Pyrexia — Visits to cases of Measles and Whooping Cough 97 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 138 Inspections of Women's Lavatories 93 Visits to children under care of foster-mothers 602 Other visits 4 Total Visits 14,209 Interviews, etc., at Centres 3,543 37 The following is a Summary of the Work of the Health Centres during the year:— Mattock Lane Cherington House Ravenor Park Islips Manor Total Number of children on register at the end of year 1,625 1,292 930 162 4,009 Mothers visiting Centre for the first time 554 581 529 87 1,751 Children visiting Centre for the first time 654 689 625 94 2,062 Total attendances made by mothers 7,136 7,042 5,565 1,135 20,878 Total attendances made by children 8,536 8,254 6,711 1,422 24,923 Average attendance of children each afternoon 55 55 59 27 - Number of Examinations of children by Medical Officer 2,652 3,034 2,236 569 8,491 Average number of children seen by Medical Officer on each Session 17 20 20 11 - Children referred to School Clinic for treatment:- For Nose and Throat 38 For Eyes 19 For Teeth 288 Orthopaedic Treatment 112 Children undergoing Ultra-Violet Ray treatment at King Edward Hospital 9 Mothers receiving dental treatment 270 Mothers supplied with artificial dentures 108 Children referred to King Edward Hospital for minor operations 21 Children admitted to King Edward Hospital as indoor patients 4 Children referred to other Hospitals 29 38 Expectant mothers attending Ante-Natal Clinic:- First Visits 669 Re-Visits 2,013 Number of Consultations by Consultant at Centre 27 Mothers referred to Hospitals 20 Aid provided for mothers at confinement:— Consultant aid—cases 20 Medical aid—cases 87 Midwives—cases 51 Home Helps—cases 11 Dried Milk supplied at cost price Value £527 11 9 Virol supplied at cost price Value £129 16 9 Cod Liver Oil supplied at cost price Value £270 7 7 Number of Cases admitted to the Chiswick and Ealing Maternity Hospital 347 Amount received for treatment at Maternity Hospital £1,570 4 6 Expectant or Nursing Mothers receiving a supply of milk free of charge for one month at a time 731 Children under 5 years of age receiving a supply of milk free of charge for one month at a time 621 SANITARY CIRCUMSTANCES OF THE BOROUGH. Water.—The Greenford and Northolt Wards are supplied with water by the Rickmansworth and Uxbridge Valley Water Company, while the rest of the Borough is supplied by the Metropolitan Water Board. During the year samples of water were taken from four wells at premises where they were the only source of supply for drinking water. In two instances the analyst reported the water to be unfit for dietetic purposes and notices were served upon the owners of the premises to provide a proper water supply. These notices were complied with ultimately by connecting the houses with the Metropolitan Water Board's mains. Rivers and Streams.—There has been no occasion during the year to complain of the pollution of any stream in the district. 39 Drainage and Sewerage.—Excepting in the undeveloped portions of the Borough, namely, the most northerly part of the Mount Park Ward and in the Greenford and Northolt Wards, the whole of the houses are supplied with water closets and are drained to the sewerage system. The few houses still unconnected to the sewers in the Greenford Ward received attention. Nine were connected during the year and the remainder will be dealt with as circumstances permit. Six houses in the Northolt Ward were connected up and this practically completes the work until there is an extension of the sewers. Work is in progress towards the construction of an automatic pumping station to receive the drainage from 36 bungalows, which will shortly be passed for occupation, and also from ten other houses. The sewage will be pumped through a rising main to the head of the existing sewer in Church Road. There are five separate sewage disposal works in the Borough, situated at North Ealing (Perivale), South Ealing, Hanwell, Greenford and Northolt. In view of the West Middlesex Sewerage Scheme, extensions to the existing works were restricted as far as possible. The work on the additional filter beds at Greenford was completed in the early part of the year and an extension of the filter beds at Northolt is in progress. Closet Accommodation.—Excepting in the undeveloped portions of the Borough already alluded to, the whole of the houses are supplied with water closets, there being one or more water closets for each house or part of a house let as a separate tenement. The following Table gives the number of pail closets, the number of cesspools and the number of water closets connected therewith, etc., in the areas mentioned, at the end of 1931 :— 40 Wards Cesspools Water Closets PailClosets Houses within 100 feet of Sewer No. of Houses Northolt 89 93 39 6 119 Greenford 22 25 10 8 30 Hanwell North 2 2 – – 2 Mount Park and Drayton 14 17 16 – 33 127 137 65 14 184 Scavenging and Disposal of Refuse.— The whole of the Borough is scavenged directly by the Council, the refuse being transported to the two destructors at South Ealing and Hanwell, which deal adequately with the work they are called upon to perform. The refuse dump belonging to the St. Marylebone Borough Council and situated in the Northolt Ward continues to be conducted in a satisfactory manner. All refuse is covered with ashes or earth shortly after dumping. The use of the large dump at Yeading, to which refuse from the Borough of Paddington and other districts was brought, was discontinued in the early part of the year and the nuisance from smoke caused by the burning of the dump has considerably decreased. A new dump conducted on a system of controlled tipping was commenced on a site near the old dump. By this method refuse is deposited in layers of eight feet with a layer of soil on the top. This has, so far, proved satisfactory ; the covering of the refuse with earth almost immediately after dumping has been effectual in keeping down any nuisance from smell and there has been no trouble from fire. Periodical inspections of these dumps are made to see that the dumping is conducted in such a manner as to prevent nuisance. Smoke Abatement.—There are comparatively few factories in the Borough with steam-raising plants, but eighteen observations were made on chimneys during the year. In three 41 instances representations were made regarding the emission of black smoke for a longer period than that allowed by the Byelaw made under Section 2 of the Public Health (Smoke Abatement) Act, 192(S. In two of these cases the nuisance was caused by improper stoking and advice given to the stokers was effectual in causing an abatement; in the other case the excessive smoke was remedied by the repair of a defective flue. Premises and Occupations which can be Controlled by Byelaws and Regulations.—There are no common lodging houses in the Borough and no Byelaws have been made with respect to houses let-in-lodgings. There are only two offensive trades carried on in the Borough, namely, fish-frying which is conducted in nineteen separate premises and that of a tallow melting which is carried on at Greenford. During the year eight applications were received for permission to establish fish-frying businesses but in no case was permission granted. Some success has been met in persuading fish friers using oldfashioned apparatus to bring their premises up-to-date, four new cooking ranges of the enclosed type being installed. Schools.— At least once a year the Sanitary Inspectors make a routine visit to all public elementary and private schools to inspect the sanitary conveniences and drainage and take steps to have remedied any defects which may be found. This year a special survey was made of the private schools and all rooms used as classrooms were measured. Very little overcrowding was discovered as out of 177 classrooms dealt with only six were found to be overcrowded and in three of these cases ample space was available in other rooms. In the control of non-notifiable infectious diseases routine reports of absentees continue to be furnished weekly by the head teachers of public elementary schools to the public health department. These give a general idea of the prevalence of these diseases at any particular time and enable the Health Visitors to visit the homes affected, 42 It was not found necessary to close any school in order to check the prevalence of infectious disease. Rag Flock Acts, 1911 and 1928.—It is very doubtful if any rag flock is. used in the Borough. Inspections have been made of all the upholsterers' workshops and in all instances where bedding is made or re-made it was found that wool flock was used. This flock is purchased from the wholesaler under a guarantee that it conforms to the Government standard of purity. No samples were taken. INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—There are now only six cowkeepers on the register as producers of milk, one having been discontinued during the past year. At the end of the year there were on the register 90 retail purveyors of milk. Twenty of these registrations were in respect of premises owned by one company and used as places for distributing bottled pasteurised milk received from the Central Depot in another district. During the year six purveyors of milk opened new premises for the purpose of selling milk, seven were registered at premises they were already occupying to retail milk in sealed receptacles only, six new purveyors of milk were registered who had purchased premises from others who were on the register and one with premises in another district was registered to retail milk within the Borough. Three purveyors of milk transferred their businesses to other premises. There are 36 purveyors of milk with dairies attached to their premises and considerable attention has been paid in recent years to the bringing of these dairies up to a reasonable standard of equipment and management. Milk (Special Designations) Order, 1923.—Under this Order 58 licences were granted during the year, 14 for the sale of Certified Milk, 16 for Grade A (Tuberculin Tested) Milk and 28 for Pasteurised Milk. One licence for bottling Grade A (Tuberculin Tested) Milk was granted. 43 One sample 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 were considerably below the standard laid down by the Order. Seventeen samples of ordinary unclassified milk were examined for general bacterial content. Three of these were found to contain 427,500, 387,000 and 277,500 bacteria per cubic centimetre. The attention of the vendors was drawn to the condition of the milk and suggestions made to exercise more care in the sterilisation of the milk utensils. The advice apparently proved of value, for further samples contained only 56,666, 58,000 and 66,666 bacteria per cubic centimetre respectively. The remainder of the samples all contained less than 200,000 bacteria per cubic centimetre, one being as low as 24,433. Fourteen samples of ordinary milk were examined by biological test at the Lister Institute for the presence of tubercle bacilli. In one sample these organisms were found. This was reported to the Middlesex County Council and measures to segregate the offending cow were still in progress at the end of the year. Meat and Other Foods.—There were no infringements of the Public Health (Meat) Regulations. No meat is sold from stalls or vehicles in the Borough. There are four private slaughterhouses but the bulk of the killing is done in two. During the year 188 cattle, 1,097 sheep, 1,158 pigs and 251 calves were slaughtered in these private slaughterhouses. All these animals were stunned by means of a humane implement. There is no public slaughterhouse in the Borough. The appointment of an additional Sanitary Inspector in May made possible a more thorough inspection of bakehouses, butchers' and fishmongers' premises, and other places where food is prepared for or stored before human consumption. These businesses were found generally to be conducted in a satisfactory manner. 44 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 542 lbs. Pork 633 lbs. Mutton127 lbs. Fish 733 lbs. Rabbits 31 lbs. Fruit 264 lbs. Sanitary Inspection of the Borough.—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 768 Number of Nuisances observed by Inspectors 171 Number of Premises inspected in connection with Infectious Disease 446 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, Etc.) 3,338 Number of Houses inspected under House-to-House Survey 539 Food Inspections 2,544 Total Number of Re-inspections 8,874 Canal Boats Inspected – Other Inspections 1,399 Total Number of Inspections and Re-inspections 18,079 Number of Intimation Notices given 511 Number of other Letters written 598 Number of Statutory Notices served 61 Proceedings before Magistrates – Milk and Dairies Act, Etc. Number of Cowsheds on Register 6 Number of Inspections made of Cowsheds 18 Contraventions of Act or Orders 1 Number of Retail Purveyors of Milk on Register 90 Number of Inspections of Retail Purveyors' Premises 203 Contraventions of Act or Orders 3 Proceedings before Magistrates – 45 Slaughterhouses. Number of Registered or Licensed Slaughterhouses ... 4 Number of Inspections made 516 Contraventions of Regulations – Proceedings before Magistrates – Factories and Workshops. Registered Workshops 163 Factories 88 Number of Inspections of Factories and Workshops and Workplaces 387 Number of Defects concerning which Notices were sent 70 Proceedings before Magistrates Offensive Trades. Fried Fish Shops 19 Other Offensive Trades 1 Number of Inspections 147 Contraventions – Disinfection. Rooms Disinfected by Spray:— (a) Ordinary Infectious Disease 393 (b) Tuberculosis 158 Rooms stripped and cleansed 80 Articles disinfected by Steam at Disinfector:— (a) Ordinary Infectious Disease 1,259 (b) Tuberculosis 349 Articles voluntarily destroyed 107 Particulars of the Sanitary Defects referred to in Notices Served and Letters Written. Water Closets repaired or supplied with water or otherwise improved 313 Drains cleared and cleansed 111 Defects in drains repaired 109 Drains reconstructed 58 Dust-bins provided 74 46 Overcrowding remedied 2 Accumulations of refuse removed 106 Nuisance from fowls and other animals abated 10 Damp-proof courses inserted in walls 48 Ventilation under floors provided 11 Other forms of dampness remedied 138 Yards paved and repaired 80 Floors repaired 62 Roofs, gutters and rain water pipes repaired 330 New soil and ventilating pipes provided 84 Sinks and waste-pipes repaired or renewed 159 Draw taps fixed to main supply 60 Dirty walls and ceilings stripped and cleansed 740 Other defects or nuisances remedied 497 Cisterns cleansed, renewed and covered 24 Houses connected to Sewer 15 Water supply re-instated 30 FACTORIES, WORKSHOPS AND WORKPLACES. 1.—Inspection of Factories, Workshops and Workplaces. Including Inspections made by Sanitary Inspector or Inspectors of Nuisances. Premises (1) Number of Inspections (2) Written Notices (3) Prosecutions (4) Factories (Including Factory Laundries) 108 13 – Workshops (Including Workshop Laundries) 279 23 – Workplaces (Other than Outworkers' Premises) – – – Total 387 36 – 47 2.—Defects found in Factories, Workshops and Workplaces. Particulars (1) Number of Defects Found (2) Remedied (3) Referred to H.M. Inspector (4) Number of Prosecutions (5) Nuisances under the Public Health Acts— Want of Cleanliness 8 8 – – Want of Ventilation 1 1 – – Overcrowding – – – – Want of drainage of floors – – – – Other Nuisances 15 15 – – Sanitary accommo dation insufficient 1 1 – – unsuitable or defective 13 13 – – not separate for sexes 2 2 – – 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 mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921.) 30 30 – – Total 70 70 – – Outwork in Unwholesome Premises, Sec. 108. Nature of Work Instances Notices Served Prosecution Wearing Apparel Making, Etc. – – – Others – – – 48 HOUSING STATISTICS. 1.—Inspection of Dwelling Houses during the Year:— (1) (a) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 1,443 (b) Number of inspections made for the purpose 1,443 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected under the Housing Consolidated Regulations, 1925 539 (b) Number of inspections made for the purpose 539 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 34 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 855 2.—Remedy of Defects during the Year without Service of Formal Notices:— Number of defective dwelling houses rendered fit in consequence of informal action by the Local Authority or their Officers 797 3.—Action under Statutory Powers during the Year:— A.—Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which notices were served requiring repairs – (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) by Owners – (b) By Local Authority in default of Owners – 49 B.—Proceedings under Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 46 (2) Number of dwelling houses in which defects were remedied after service of formal notice:— (а) By Owners 41 (b) By Local Authority in default of Owners – C.—Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which Demolition Orders were made – (2) Number of dwelling houses demolished in ance of Demolition Orders – (3) Number of houses concerning which action has been taken by the Local Authority under Section 19, and with respect to which owners have given an undertaking that they will not be used for human habitation 13 D.—Proceedings under Section 20 of the Housing Act, 1930:— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made – (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit – E.—Proceedings under Section 3 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which notices were served requiring repairs – 50 (2) Number of dwelling houses which were rendered fit after service of formal notices :— (a) By Owners – (b) By Local Authority in default of Owners – (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close – F.—Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which Closing Orders were made (2) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit – (3) Number of dwelling houses in respect of which Demolition Orders were made – (4) Number of dwelling houses demolished in ance of Demolition Orders 6 During the year 1,073 houses were built in the Borough by private enterprise. None of these could be deemed as houses for the working classes being intended for purchase by the occupiers. No new houses were completed by the Town Council, although at the end of the year there were in course of construction 67 nonpar lour houses in different parts of the Borough. 51 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASES. The numbers of the various infectious diseases notified in the Borough are indicated in Table V and are compared with those for the previous ten years:— TABLE v. Disease 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 Smallpox – – – – – – – 1 1 1 – Diphtheria 186 282 56 61 40 72 53 68 90 129 83 Scarlet Fever 665 487 142 123 107 156 136 313 231 264 154 Enteric Fever (including Paratyphoid) 8 3 5 9 5 4 14 12 1 4 1 Puerperal Fever 9 3 9 3 6 1 6 2 2 7 6 Puerperal Pyrexia – – – – – 3 15 16 13 26 18 Pneumonia: Primary 21 33 32 47 57 47 66 73 100 78 96 Influenzal 17 22 7 27 22 17 38 13 59 12 18 Acute Poliomyelitis 1 – – 3 – 1 – – 1 – 2 Cerebro-Spinal Fever 1 – 1 – – – 2 – 1 – – Malaria 3 4 2 – 2 5 6 4 4 2 1 Dysentery 1 1 – – – – – 1 – – – Erysipelas 27 22 17 25 17 15 18 23 24 34 20 Encephalitis Lethargica 1 3 1 6 4 2 6 3 3 1 1 Tuberculosis:— (a) Pulmonary 80 69 92 74 90 93 89 99 109 111 141 (6) Non-Pulmonary 23 16 26 31 25 21 16 24 27 22 27 Ophthalmia Neonatorum 13 10 3 3 6 5 4 8 9 9 9 Total 1036 955 393 412 381 442 469 665 675 700 577 52 table vi. Diphtheria. Scarlet Fever. January 9 15 February 3 10 March 12 11 April 10 15 May 7 17 June 5 4 July 5 4 August 5 14 September 10 12 October 4 13 November 3 11 December 10 28 Total 83 154 53 TABLE VII. Cases of Infectious Disease notified during the Year 1931 in Age Groups. 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 Smallpox – _ _ _ _ – – – – – – – – – Diphtheria – 1 3 4 5 39 18 4 8 1 – – 83 82 Scarlet Fever – 6 4 5 6 81 99 8 14 4 4 – 154 134 Enteric Fever (including Paratyphoid) – – – – – -– – 1 – – – – 1 1 Puerperal Fever – 5 1 – – 6 4 Puerperal Pyrexia – - – – – – – – 15 3 – – 18 10 Pneumonia : Primary 7 4 – 7 4 12 4 3 16 8 14 17 96 15 Influenzal – 2 1 – – – – 9 1 5 6 1 18 2 Acute Poliomyelitis – – – – – 2 – – – –- – – 2 1 Cerebro-Spinal Fever – – – – – – – – – – – – – Malaria – – – – – – – – 1 – – – 1 1 Dysentery – – – – – – – – – – – – – Erysipelas – – – – – – – – 2 6 7 5 20 3 Encephalitis Lethargica – – – – – 1 – – – – – – 1 1 Tuberculosis : – (a) Pulmonary Male – – – – – 1 2 6 35 10 33 3 90 – Female – – – – – – – 5 21 12 10 3 51 – (b) Non-Pulmonary Male – – 2 1 – 2 3 3 2 3 4 – 17 – Female – – 1 1 – 3 – – 5 – – – 10 – Ophthalmia Neonatorum 9 – – – – – – – – – – – 9 1 Total 16 13 11 18 15 141 49 32 125 53 75 29 577 – 54 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 – 3 1 – – – – – 5 Scarlet Fever – – – – – 1 – – – – – – 1 Enteric Fever (including Paratyphoid) – – – – – – – – – – – – – Puerperal Sepsis – – – – – – – – 1 – – – 1 Pneumonia: Primary – 2 1 1 – 2 – – 2 2 24 36 70 Influenzal – – – – – – – – – – 1 – 1 Acute Poliomyelitis –– – – – – – – – – – – – Cerebro-Spinal Fever 2 – – – 1 – – – – – 1 – 5 Malaria – – – – – – – – – – – – – Dysentery – – – – – – – – – – – – – Erysipelas – – – – – – – – – – – – – Encephalitis Lethargica – – – – – – – – – – – – – Tuberculosis: (a) Pulmonary Male – 1 1 – – – – 3 16 5 21 2 49 Female – – – – – – – 1 13 3 4 4 25 (b) Non-Pulmonary Male 1 – – – – – – 3 – – 1 – 5 Female – – – 1 – – – – 1 – – – 2 Ophthalmia Neonatorum – – – – – – – – – – – – – Totals 3 3 2 3 1 6 2 7 33 10 52 42 164 55 Diphtheria;—The number of cases of diphtheria was less than in the previous year, only 83 cases being notified, compared with 129. The diphtheria case-rate for Ealing was 0.72 per thousand of population, this rate being well below the case-rate for England and Wales, which was 1.27. As will be seen from Table VI, diphtheria was not very prevalent at any time of the year, the greatest number of cases notified in any month being 12, in March. The least number of cases occurred in the months of February and November, in each of which only three were notified. There were five deaths from the disease, giving a death-rate of 0.04 per thousand of population and a mortality-rate of 6.0 per cent. of cases notified. The death-rate is below those for England and Wales, the 117 Great Towns, and London, which are respectively 0.07, 0.08 and 0.06. Recovery from diphtheria depends mainly on the promptitude with which the specific remedy, diphtheria anti-toxin, is administered. A study of the circumstances attending the five deaths which occurred last year suggests that anti-toxin was not administered sufficiently early in the majority of them. Two main reasons are usually responsible for delay, the principal being the failure on the part of parents or guardians to realise that their child is seriously ill and requiring medical attention. Consequently a doctor is not called in until the disease is too far advanced for successful treatment. Although the lesion in diphtheria is most frequently situated in the throat it is by no mean; always accompanied by pain, and the attention of the parent may not be directed to the cause of illness. The throat of an ailing child should always be examined and where there is the slightest doubt about the cause of the illness, medical aid should be sought at once. The recognition of the disease is not always easy, even to the skilled physician, and the second main reason for delay in administering serum is the failure of the doctor to do so until he has had bacteriological confirmation of the diagnosis, or until the diagnosis is obvious. Where there is the slightest suspicion of diphtheria anti-toxin should be administered at once. The possibility of untoward results from the administration of anti-toxin, should the case prove not to be one of diphtheria, is very remote, while the immediate benefit to the patient if it is one of diphtheria may be vital. 56 To enable medical practitioners to administer anti-toxin to suspicious cases without any delay a supply of anti-toxin is available at the Town Hall at all hours of the day and night. In cases where the parents of the patient are too poor to be able to pay for the anti-toxin, no charge is made. During the year 146,000 units of anti-toxin for 26 cases were supplied free of charge. Scarlet. Fever.— The number of cases of scarlet fever occurring during the year under review was 154, this number showing a great reduction compared with the total of 264 cases notified in 1930. The scarlet fever case-rate for the Borough is 1.31 per thousand of population, this being the lowest case-rate since 1918. The rate compares well with that for England and Wales, which is 2.05. The cases occurred during the months of the year as indicated in Table VI. As will be seen, the greatest number of. cases occurred in December, when 28 cases were notified, while the lowest number occurred in June and July in each of which months only four cases were notified. The large number of cases notified during December was mainly accounted for by an outbreak of the disease in South Ealing associated with Little Ealing and Grange Infants' Schools, 14 cases occurring within a week. With the exception of this outbreak very little connection was discovered between any of the cases, which were more or less evenly distributed in the various parts of the Borough. Only one death occurred from the disease, this being a girl, five years of age, who died in the Isolation Hospital as a result of a complication of the disease after a stay of 74 days. This gives a scarlet fever death-rate of 0.01 per thousand of population. The deathrate is the same as that for England and Wales and is less than that for London, which is 0.02 per thousand of population. Enteric and Para-Typhoid Fever.— One case of enteric fever was notified. This was a young man 19 years of age. A possible source of infection in this case was suggested by the fact that the patient was reported to have been drinking unboiled river water when camping beside the River Thames. The case did not prove fatal. One case was notified as para-typhoid fever but proved later not to be a case of this disease. 57 Puerperal Fever and Puerperal Pyrexia.— Six cases of puerperal fever were notified during the year. One occurred in the Chiswick and Faling Maternity Hospital, one at a Nursing Home and four in private practice. In two cases the septic condition arose after a miscarriage and the doctor was not called in until some days after. In the only case which died the labour was prolonged and operative interference was necessary. The case-rate for Ealing is 3.24 per thousand births, compared with 3.55 for England and Wales. There were 18 cases of puerperal pyrexia notified. Nine of these were notified from the Chiswick and Ealing Maternity Hospital, three from Nursing Homes and six from private practice. The case-rate for Ealing is 9.40 per thousand births, compared with 8.71 for England and Wales. The higher number of cases occurring at the Maternity Hospital than in general practice does not indicate a higher morbidity rate at the hospital but is in all probability due to the scrupulous care with which notification is carried out. The same may be said of the case-rate for Ealing as compared with that for England and Wales. All cases of puerperal fever and pyrexia are investigated with the help of the doctors in attendance to determine if possible the exact cause and to discover if any action might have prevented the condition. Help in the way of the provision of the services of a consultant or in securing admission to hospital is also offered when necessary. Primary and Influenzal Pneumonia.—Notifications of primary pneumonia and influenzal pneumonia showed an increase over the previous year, 96 cases of primary pneumonia and 18 of influenzal pneumonia being notified, compared with 78 and 12 cases respectively. As in the previous year the greater proportion of the cases occurred during the first three months, when 41 cases of primary pneumonia and 10 cases of influenzal pneumonia were notified. Acute Poliomyelitis.—Two cases of acute poliomyelitis were notified during the year. One was a girl five years of age who was admitted to the King Edward Hospital six days after the onset of the illness and was notified six days later. The second case was that of a girl seven years of age who was attended by a 58 doctor but was not recognised as suffering from acute poliomyelitis until three weeks later. Both children had some paralysis of the legs on recovering from the acute symptons. Cerebrospinal Fever.— Five deaths were certified from this disease during the year, all occurring in institutions outside the Borough. None had previously been notified as suffering from the disease, and presumably the diagnosis was not made until the patient was admitted to a general hospital. The cases occurred in widely separated districts and at different times during the year and were apparently unconnected. Malaria and Dysentery.— One case of malaria was notified. This was a man 25 years of age who had been discharged from the Army nine months previously. He had been stationed in India, but this was said to be his first attack of the disease. There were no cases of dysentery. Encephalitis Lethargica. — Only one case coming under this heading was notified. This was a boy seven years of age who came from South Wales on holiday. He developed pneumonia and was removed to the King Edward Hospital. A week later he was notified as suffering from acute encephalomyelitis and the following day he died. Ophthalmia Neonatorum.—There were nine cases of ophthalmia neonatorum notified during the year. The following Table gives a summary of the cases and the results of treatment:—- Number of Cases Notified No. Treated Vision unimpaired Vision impaired Total Blindness Deaths At Home In Hospital 9 8 1 9 — – – Tuberculosis.— Table IX indicates the number of cases of pulmonary and non-pulmonary tuberculosis notified during the year, together with the number of deaths, in the various agegroups. The notifications of pulmonary tuberculosis were greater than in 1930, 141 compared with 111 cases. 59 There were 74 deaths from pulmonary and seven from nonpulmonary tuberculosis, which give death-rates of 0.63 and 0.06 respectively, or a total tuberculosis death-rate of 0.69 per thousand of population. This rate is less than that for the previous year, which was 0.83 per thousand of population, and is the lowest death-rate from the disease in the last ten years. Nine persons were certified as dying from pulmonary tuberculosis although they had not been notified as suffering from the disease ; two died outside the district and seven were attended by local doctors. Of the three deaths from non-pulmonary tuberculosis which had not been notified, two were persons dying outside the district and one was attended by a local doctor. In each case where a local medical practitioner had failed to notify a case previous to the death, a communication was sent drawing his attention to the requirements of the Public Health (Notification of Infectious Disease) Regulations, 1918. At the end of the year there were 457 cases remaining on the tuberculosis register, 357 being cases of pulmonary tuberculosis and 100 being cases of non-pulmonary tuberculosis. The register is revised periodically, the Sanitary Inspector visiting the homes, where necessary, and the Tuberculosis Officer giving information regarding cases in attendance at the Dispensary. This total of 457 cases indicates that one out of even' 259 persons resident in Ealing is suffering from tuberculosis. Tuberculosis. Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male Female Male Female Male Female Male Female 0—1 — — — — — — 1 — 1—5 — — 3 2 2 — — 1 5—10 1 — 2 3 — — — — 10—15 2 — 3 — — — — — 15—20 6 5 3 — 3 1 3 — 20—25 8 9 2 1 5 4 — — 25 —35 27 12 — 4 11 9 — 1 35—45 10 12 3 — 5 3 — — 45—55 17 8 1 — 12 3 — — 55—65 16 9 — — 9 1 1 — 65 upwards 3 3 — — 2 4 — — Total 90 51 17 10 49 25 5 2 60 The Tuberculosis Officer has been good enough to supply 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 89 (b) Other forms of Tuberculosis 14 Number of persons in Institutions:— (a) Tuberculosis of Lungs 32 (b) Other forms of Tuberculosis 16 Number of persons kept under treatment at the County Council Dispensary, Ealing 106 Number sent to Sanatoria 72 Number sent to Hospital 24 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. Whooping Cough and Measles. Information regarding the prevalence of these two non-notifiable infectious diseases is obtained from the weekly returns regarding infectious disease made by the head-teachers to the School Medical Officer. There were 280 absentees from school due to whooping cough and 38 due to measles. The number of cases of whooping cough shows an increase compared with the previous year, when there were only 108 cases recorded, but the number of cases of measles was very small considering there were 1,116 cases recorded during 1930. Four deaths occurred from whooping cough, the death-rate being 0.03 per thousand of population. This rate is below those for England and Wales, the 117 Great Towns, and London, which are respectively 0.06, 0.07 and 0.07. There were no deaths from measles, whereas the death-rates from this disease for England and Wales, the 117 Great Towns, and London are, respectively, 0.08, 0.10 and 0.03, 61 HEALTH EDUCATION. The education of the public in matters pertaining to health has become one of the duties of a local authority. There are two ways in which this can be carried out, firstly by the efficient discharge of the public health services in the area and secondly by supplementary methods of teaching and propaganda. Undoubtedly the soundest form of health education is in the efficient conduct of the public health services. No series of health lectures, posters, pamphlets, etc., can be of such value as the gradual improvement of the sanitary conditions in the district and no health exhibition can compete with an efficiently equipped and managed health centre. No organised lectures can be so effective as the personal advice given by medical officers, health visitors and school nurses in the course of visits to homes or by consultations at the health centres. Health Education in Ealing is based on these principles and every effort is made to keep the Health Centres up to a high standard of efficiency and to concentrate largely on individual advice to parents and children. Other supplementary methods of propaganda are not lost sight of, however, and although organised " Health Weeks" or "Health Exhibitions" are not held there are numerous ways in which knowledge on health topics is broadcast to the public. It is to the young that most of our educative efforts have to be directed, as instruction and advice given before the mode of life has become definitely fixed is of the greatest value. The foundation of all such instruction is laid in the schools and the Education Committee have given every encouragement to the teachers in the public elementary schools to devote sufficient time to education in health matters. Every teacher has a copy of the Board of Education's " Handbook of Suggestions on Health Education" as a guide. They are also supplied with a copy of "Better Health" each month. All children about to leave school are given a copy of either "Keep Fit" for boys or" Health for Beauty "for girls, two of the many excellent publications of the Health and Cleanliness Council. 62 Leaflets of advice are issued to expectant mothers and copies of the booklets, "To Mothers and Fathers "and" The Mothers' Cookery Book "published by the National League for Health, Maternity and Child Welfare and the booklet," Hints for the Busy Housewife "issued by the Health and Cleanliness Council are freely distributed. In addition various leaflets and booklets issued by the Health and Cleanliness Council, the National Milk Publicity Council and the Dental Board of the United Kingdom are circulated and posters issued by these bodies are exhibited at the Health Centres and in the schools. The general public are approached by means of the monthly periodical called "Better Health," in which are given informative articles on all subjects relating to general and personal health. In this publication, 2,000 copies of which are distributed each month, there is an entire absence of stunt-mongering and fadpushing so that the reader can depend on information which is of undoubted authority. A booklet entitled " The Public Health Service of the Town Council"is also issued, the object of which is to give information about the public health services and to set out the facilities that are offered to residents in the Borough. Lastly, one must mention the local Press who are always very ready and willing to draw the attention of their readers to any developments in the public health service or to publish informative and authoritative notes on some matter or another relating to health. THOMAS ORR. May 31s/, 1932. Borough of Ealing. EDUCATION COMMITTEE. REPORT of the School Medical Officer fob the Year ended 31st December, 1931. 64 EDUCATION GENERAL PURPOSES SUB-COMMITTEE, 1930-31 (Which deals with the School Medical Service). Chairman— Councillor H. M. Sayers. Vice- Chairman— Councillor J. C. Fuller. The Rev. C. J. Sharp, M.A. (Ex-officio, Chairman of the Education Committee). Alderman H. J. Baker, J.P. (Ex-officio, Vice-Chairman of the Education Committee). Councillor E. H. Atkinson. Councillor E. H. Brooks. Councillor A. H. Chilton, J.P. Councillor W. Jennings. Councillor Mrs. E. S. Taylor, J.P. Councillor G. R. Weeks, J.P. Councillor W. T. White. Miss D. B. Beck, M.A. Miss C. G. Wilson, L.L.A. Mr. E. Heaton. Rev. T. B. Scrutton, M.A. 65 STAFF. School Medical Officer— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant School Medical Officers— Thomas H. Bingham, M.D., D.P.H. (resigned 31st March, 1931). John Petrie, M.B., Ch.B., D.P.H. Alastair A. Douglas, B.Sc., M.D., D.P.H. (appointed 1st June, 1931). Edna I. Langston, M.B., B.S., L.R.C.P., M.R.C.S. (resigned 23rd May, 1931). Florence Whitrow, M.B., Ch.B., M.R.C.S., L.R.C.P. (appointed 1st October, 1931). Surgeons (part-time)— Herbert J. Seddon, F.R.C.S. (Eng.), M.B., B.S., M.R.C.S., L.R.C.P. (Orthopaedic Clinic). Cecil I. Graham, M.R.C.S., L.R.C.P., F.R.C.S. (Eng.). (Throat Operations). Dentists— C. Colenso, L.D.S. (Liver.). Winifred M. Hunt, L.D.S. (Glas.). John V. Houlton, L.D.S., R.C.S. (Eng.) (part-time) (appointed 16th April, 1931). Supervising School Nurse— *†‡Hilda Bailey. 66 School Nurses— *‡Annie Johnson. *†‡Vera C. Lawes. *Mary McGann. * †‡ Mar jorie Coslett. *†may P. Dorkins. Clerks— Ivie L. Parker. Edith F. Miles. Winifred Rivers. Mollie E. Reeve. Winifred I. Sharp. Noreen M. Morrison. Masseuse (part-time)— Florence Hepburn, C.S.m.m.G. Teacher of Class for Stammering Children (part-time)Honor M. S. Baines. HEALTH CENTRES— Mattock Lane, Ealing. Cherington House, Hanwell. Ravenor Park, Greenford. Islips Manor, Northolt. *Certified as Trained Nurse. †Certificate of Royal Sanitary Institute, School Nurse and Health Visitor. ‡Certificate of Central Midwives Board. 67 CO-ORDINATION. In previous reports an impression was given of the way in which the work of the Child Welfare Department is co-ordinated with that of the School Medical Department by both activities being conducted in four joint Health Centres, Mattock Lane, Cherington House, Ravenor Park and Islips Manor, situated at convenient parts of the town, and by the work of the one service being dovetailed into the other in such a way as to make practically one complete service dealing with children from birth until they leave school. One great difficulty experienced has been in keeping under supervision the child between one year and five years old, the toddler or pre-school child as he has been called. While the child is under one year old the mother, as a rule, brings him regularly to the Centre, but after that the Health Visitors experience great difficulty, unless another child arrives, in persuading the mother to continue to attend the Health Centre. In many cases therefore a gap occurs in the supervision and defects of a serious character develop and remain untreated until the child goes to school. An effort was made during the year to encourage the mothers to bring their children regularly up to 5 years of age for a complete medical examination. A beginning was made by circularising the parents of many of the children emphasising the need for regular medical inspection and suggesting a visit to the Health Centre. It was found that this circular letter signally failed in accomplishing its object. Then followed visits by the Health Visitors, the result of which was a good response whether a circular letter was received by the parent or not; in fact it was felt that the letter was useless alone and that it did not assist to any extent the Health Visitor on the occasion of her visit. A new record of medical inspection based on the school medical schedule was adopted and since June, 1931, a complete examination of each child from 1 to 5 years attending the Centres was made. Altogether in the six months 1,745 children underwent the complete medical examination, advice being given to the mothers regarding any defects found and treatment being offered for certain defects in the same way as for school children. Many of the mothers when they have had the purpose of the examination explained to them have expressed appreciation and 68 have promised to continue to submit their children for examination as suggested at one to one-and-a-half years, one-and-a-half to two years, two to three years, three to four years and four to five years old. If the scheme develops, as it is hoped it will, one more strong link will be forged in the co-ordination of the Child Welfare and School Medical Services. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC HEALTH. School Hygiene. Under the control of the Ealing Education Authority there were at the end of the year 22 public elementary schools embracing 40 departments. The year under review was one of great building activity. Five new schools and additional departments to older schools were being constructed : Horsenden School to accommodate 800 children, Wood End to accommodate 380, Grange Infants' to accommodate 400, Coston Junior Mixed to accommodate 400, and Bordeston Senior Boys' School to accommodate 400 children. Two of these schools, Grange Infants' and Coston Junior, were opened during the year, while three, Horsenden, Wood End and Bordeston, have since been officially opened. Horsenden, Wood End and Grange Infants' are of the Derbyshire open-air type which was described in the Annual Report for 1930 in connection with Stanhope School. Coston Junior Mixed Department was built on a similar plan to the older part of that School, while Bordeston on account of special provision having to be made for science, handicraft, art and practical rooms, had to be constructed of a different type to prevent the work going on in one classroom interfering with that in another. 69 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 not inspected in the previous year or reaching that age before the end of the current year. (c) Leavers.— Children twelve years of age not inspected. in the previous or attaining twelve before the end of the current year, together with those over that age not previously inspected. 2.—Non-routine inspections as follows:— (a) Children, not in the previously named routine groups, presented by the head-teachers, school nurses, etc., 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 3.— Annual Inspections at the schools or at the Health Centres of:— (a) Physically defective and (b) Mentally defective children. 70 The following tables indicate the total number of children in the various schools who were examined at routine medical inspection. The children included 1,821 entrants, 2,030 intermediates, and 1,084 leavers, making 4,935 as the total number of children inspected in a routine manner. Number of Children Inspected. School. Entrants Total Boys Girls Provided. Coston 1 2 3 Drayton 50 50 100 Grange 62 58 120 Hobbayne 50 43 93 Lammas 39 41 80 Little Ealing 95 84 179 North Ealing 55 42 97 Northfields 40 68 108 Northolt 40 27 67 Oaklands 63 52 115 St. Ann's 15 21 36 St. Mark's 36 32 68 Stanhope 85 104 189 Horsenden 84 80 164 Wood End 17 18 35 Non-Provided. Betham's 66 74 140 St. John's 26 26 52 St. Joseph's 16 13 29 St. Mary's 27 25 52 St. Saviour's 54 40 94 Total 921 900 1,821 71 Number of Children Inspected. School. Intermediates Total Leavers Total Boys Girls Boys Girls Provided. Central — — — 49 33 82 Coston 68 71 139 50 42 92 Drayton 49 44 93 35 27 62 Grange 65 66 131 34 36 70 Hobbayne 27 38 65 20 14 34 Lammas 49 31 80 — — — Little Ealing 74 68 142 57 52 109 North Ealing 55 63 118 14 14 28 Northfields 63 51 114 47 50 97 Northolt 40 33 73 19 23 42 Oaklands 57 55 112 47 38 85 St. Ann's 28 34 62 49 43 92 St. Mark's 39 34 73 2 2 4 Stanhope 160 179 339 53 58 111 Horsenden 89 80 169 24 29 53 Wood End 15 17 32 2 4 6 Non-Provided. Betham's 18 20 38 — — — Christchurch 39 31 70 29 21 50 St. John's 24 25 49 19 14 33 St. Joseph's 23 10 33 14 11 25 St. Mary's 23 28 51 7 2 9 St. Saviour's 22 25 47 — — — Total 1027 1003 2030 571 513 1084 72 At the Health Centres there were 2,592 non-routine inspections of children who were submitted by the head-teachers, school enquiry officers or school nurses on account of some defect or suspected defect, and of whom 1,057 attended for re-inspection. Owing to a defect being found on a previous routine or non-routine inspection 830 children were submitted to a re-examination. There were, therefore, 4,479 special inspections or re-inspections of children. Included in these numbers are the physically and mentally defective children kept under supervision and re-examined each year. The total number of children attending public elementary schools who were examined once at least during the year was 7,527. The average number of children on the school registers was 11,769. This means that 64 per cent, of the children on the registers were medically examined during the year. The average attendance at the schools was 88.5 per cent. Findings of School Medical Inspection. The number of defects noted on routine medical inspection at the schools and on the special inspections or re-inspections are given in Table II. Among the 4,935 children examined in a routine manner there were 2,063 defects requiring treatment and 1,775 requiring to be kept under observation without treatment; and among 2,592 children specially examined there were found 2,025 defects requiring treatment and 325 requiring to be kept under observation. Of the 4,935 children examined at the routine inspections, 873, or 17.7 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 the 23,094 children examined, 310, or 1.3 per cent., were excluded on account of verminous condition. There were 99 other children with verminous heads found at the routine medical inspection in the schools, and 52 found at special inspections after being referred for examination by the head-teachers. 73 During the year one summons was 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 the report for 1930 the view was expressed that the percentage of verminous children excluded from school was so low that further reduction was too much to expect. Nevertheless, a further reduction has with much satisfaction to be recorded for 1931, as during the year the percentage was 1.3 compared with 1.7 in the previous year. Such a result is an incentive to further efforts to attain an ideal condition of cleanliness in our schools. The following table shows the progressive improvement over a period of nine years :— Uncleanliness, 1923—1931. 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 1928 17,391 389 2.2 — 1929 19,276 342 1.7 — 1930 20,720 382 1.8 4 1931 23,094 310 1.3 1 74 (b) Minor Ailments.—The minor ailments found at routine and non routine inspections were as follows:- Ringworm of Head 28 Ringworm of Body 24 Scabies 37 Impetigo 301 Other Skin Diseases 115 Minor Injuries 156 Ear Diseases (including Otorrhoea) 184 Eye Diseases (including Blepharitis, Conjunctivitis, etc., but excluding defective vision and squint) 212 Miscellaneous (Sores, Chilblains, etc.) 441 1,498 (c) Enlarged Tonsils and Adenoids.—At the routine inspection 232 children were found with enlarged tonsils, 15 with adenoids, 152 with enlarged tonsils and adenoids, and two with other conditions of the nose and throat requiring treatment. Children with these conditions who had to be kept under observation numbered 946. In addition, 59 cases of enlarged tonsils, 7 of adenoids, 54 of enlarged tonsils and adenoids, and 26 of other conditions requiring treatment, and 69 cases of similar diseases of the nose and throat requiring to be kept under observation were found on special inspection. (d) Tuberculosis.— One definite case of pulmonary tuberculosis requiring treatment was found on special examination. Five suspected cases of pulmonary tuberculosis requiring to be kept under observation were found at routine medical inspection and four who needed to be kept under observation were discovered on special examination. One suspected case of tuberculosis of the glands, one of the knee joint, and two other forms of tuberculosis requiring to be kept under observation were found at routine medical inspection. One case of glandular tuberculosis to be kept under observation was found on special examination. 75 (e) Disease of the Skin.— At the routine inspection there were found five cases of ringworm, one of the head and four of the body, five of impetigo, six of scabies and six cases of other conditions of the skin. The cases met with at non-routine examinations, for which they had been specially referred by the teachers or school nurses were as follows:— Ringworm of Head 27 Ringworm of Body 20 Scabies 31 Impetigo 296 Other Skin Conditions 109 483 (/) External Eye Disease.— Thirty-five cases of blepharitis, 25 of conjunctivitis, 53 of squint and 16 of other abnormal conditions of the eyes were observed at routine medical inspection, and 43 cases of blepharitis, 42 of conjunctivitis, 27 of squint and 51 of other conditions were found in children referred for special examination. Of these cases, 256 were advised to have treatment and 36 were recommended to be kept under observation. (g) Defective Vision.— During routine inspection 261 children were found with defective vision and referred for examination by an Oculist. As a result of special inspection 111 were also referred to an Oculist. (h) Ear Disease and Defective Hearing.—Two cases of defective hearing, 20 of otitis media and three other conditions of the ears requiring treatment and eight cases of defective hearing, five of otitis media, and two other conditions requiring to be kept under observation were found at routine medical inspection. Special inspections discovered nine cases of defective hearing, 57 of otitis media, and 67 of other conditions of the ear requiring treatment, and four cases of defective hearing, one of otitis media, and six of other conditions to be kept under observation, 76 (i) Dental Defects.—The table which follows classifies the dental defects found at routine medical inspection. In this table it will be seen that of the entrants 41.7 per cent, had sound teeth, of the intermediate group 52.7 per cent, and of the leavers 67.0 per cent, had sound teeth. Entrants Intermediates Leavers Total All sound teeth — No. of children 760 1,070 727 2,557 Percentage 41.7 52.7 67.0 51.8 Less than four teeth decayed— No. of children 461 624 296 1,381 Percentage 25.3 30.7 27.4 28.0 Four and more than four teeth decayed — No. of children, 600 336 61 997 Percentage 33.0 16.6 5.6 20.2 The percentage of entrants having sound mouths is higher than in previous years. Comments on this improvement are better deferred until it is ascertained if the improvement is maintained in subsequent years. The condition of the mouths of the children actually leaving school is not correctly indicated by the percentage in the Table because dental inspection and treatment of children in the group took place after the medical inspection of the group. Hence as is noted in the Report of the School Dentist the dental condition of the children on leaving school is much better than this figure represents it. (j) Crippling Defects.—The crippled children under supervision at the end of the year numbered 35. Of these one was so 77 severely affected that he was unable to attend an ordinary elementary school and was maintained at a Special School and one was kept at home. The list of crippled children of school age is practically a complete one and is compiled from information received from the health visitors, who transfer to the school medical department records of such children as attain five years of age, from the teachers, the school nurses, and the school enquiry officers, all of whom immediately supply particulars regarding crippled children whom they find in the course of their duties. Each crippled child newly admitted to school is examined at the earliest possible opportunity and all crippled children are examined at least once a year to determine their exact condition, or to estimate their progress and put them forward for any treatment required under the Committee's Orthopaedic Scheme. INFECTIOUS DISEASE. Through 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 38 Whooping Cough 280 Chicken Pox 643 Mumps 88 On no occasion was it found necessary to give a certificate under Schedule IV, Rule 23, of the Code. Children to the number of 392 were excluded during the year under the Education Code for the following conditions:— Conjunctivitis 1 Eye Condition 1 Impetigo 300 Ringworm of Head 28 Ringworm of Body 9 Scabies 37 Other Skin Diseases 16 Total 392 78 FOLLOWING UP. As years go on the appreciation of the parents of medical inspection and the response to advice given either at the actual inspection or on the occasion of the visit of the school nurse becomes greater. There is in effect a better recognition of the value of the steps taken to prevent or detect ill-health in the children. On the whole parents very readily accept advice and submit their children for treatment. Sometimes objection is made to dental treatment of the children but this objection, mostly due to want of knowledge of the need for proper dental care, is gradually being worn down. During the year persistent refusal on the part of a number of parents to accept dental treatment for their children at the Health Centre was met by letters threatening action under the Children Act. These letters had the desired effect of securing the attendance of the children for treatment. MEDICAL TREATMENT. (a) Minor Ailments.—In Table IV are indicated the number and the nature of the minor ailments which received treatment during the year. It will be noted that 1,181 of the 1,360 children suffering from minor ailments, or 86.9 per cent., were treated at the Health Centres and 179, or 13.1 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:— Impetigo 3,987 Ear Cases 1,854 Eye Cases 2,818 Ringworm 408 Scabies 118 Eczema 55 Minor Injuries 1,131 Others 4,279 Total 14,650 79 (6) Tonsils and Adenoids.—It is indicated in Table IV, Group III, that 166 cases of enlarged tonsils or adenoids were submitted for operation at the Mattock Lane Health Centre, and that 71 cases were dealt with at hospitals or by private practitioners. (c) Tuberculosis.—Fourteen children were referred to the Tuberculosis Officer for supervision, nine being suspected of having tuberculosis of the lungs, two of glands, one tuberculosis of the knee and two of other organs. (d) Skin Disease.—The cases of diseases of the skin which were treated are included in Table IV, Group 1. There were 500 referred for treatment, 467 of whom were treated at the Health Centres and 33 otherwise. In this table are indicated under the term " Miscellaneous " 524 cases of such conditions as minor injuries, sores, chilblains, etc., and of these, 503 were treated at the Health Centres and 21 otherwise. During the year 25 cases of ringworm of the head were treated and cured by means of X-rays by Dr. Arthur. All the 301 cases of impetigo received treatment at the Health Centres. During the year 37 cases of scabies were found and 29 of these were treated at the Health Centres. (e) External Eye Disease.—The children referred for treatment of external eye diseases numbered 189, of whom 118 were treated at the Health Centres. (f) Defective Vision.—The Report of the School Oculist Dr. A. A. Douglas, which follows, gives an indication of the care and thoroughness with which the refractive examination of the eyes of the school children has been carried out. This report, as those submitted on the same subject in previous years, shows the need for " myope classes," the formation of which, but for the financial crisis, would have been provided for in the estimates for the current year. 80 Report on the Eyesight of School Children. "During the year 1931 a full examination of the eyes of 491 school children has been carried out, and 80 other examinations. The conditions found in the former group are shown in the following table. The classification adopted is that used by the Committee of Inquiry into Problems connected with Defective Vision in School Children. No child, however, is included in two groups, cases of astigmatism with anisometropia being included only under the former head. New Re- Cases Inspections Total Myopia 57 49 106 Emmetropia 30 5 35 Hypermetropia 124 66 190 Myopic astigmatism 9 7 16 Hypermetropic astigmatism 58 15 73 Mixed astigmatism 25 10 35 Anisometropia 18 10 28 Other Conditions 8 — 8 329 162 491 Included in this total of 491 are 58 children who were seen for the first time towards the end of 1930, but whose examination was not completed until 1931. "In all, the examination of the children involved some 1,280 attendances. Spectacles to the number of 426 pairs were prescribed. "Eight children were referred to hospital because of defects unsuitable for treatment at the Health Centre. "Method of detecting Visual Defects.—At present the method used to detect visual defects in school children is a test of visual acuity; children who read 6/6 or 6/9 are passed as normal, others are referred for testing by refraction. In addition a certain number of children are tested by refraction because of squint (42 during 1931) or because of such symptoms as migraine, blepharitis, conjunctivitis, headache, etc. (36 during 1931). 81 "It has come to be realised that this method has certain drawbacks, the chief of which is that many cases of defective vision are not detected by it. Thus certainly many children with hypermetropia, even high hypermetropia, go uncorrected. Perhaps this is not very important, but unfortunately it is becoming obvious that cases of early myopia and myopic astigmatism, and also of hypermetropic astigmatism, are not submitted for refraction, until, of course, eventually the acuity of vision becomes so diminished that attention is called to the need of it. Accurate records are now available of the condition of refraction of a large group of unselected children in the Report of the Committee already mentioned. From this the cases of children of school age have been extracted and the proportionate distribution of the various refractive conditions calculated with the following result:— Number Per Cent. Simple Myopia 38 2.4 Emmetropia 90 5.8 Simple Hypermetropia 1,000 64.2 Myopic Astigmatism 12 .8 Hypermetropic Astigmatism 217 13.9 Mixed Astigmatism 19 1.2 Anisometropia 182 11.7 1,558 100.0 "If the percentages thus arrived at are applied to the total number of school children in Ealing the expected number of children in each of the seven groups can be arrived at and this can then be compared with the actual number of cases on the records of the School Oculist. These records have been carefully scrutinised, and the results classified after the method used in the report. Since it is estimated that 10 per cent. of children receive ophthalmic treatment privately a correction has been applied for this. The total number of school children in Ealing has been taken as 12,100, and the expected numbers of the more important abnormal refractive conditions are seen contrasted with the actual numbers under observation in the table below :— 82 Expected Actual Simple Myopia 298 118 Myopic Astigmatism 94 45 Hypermetropic Astigmatism 1,696 235 Mixed Astigmatism 100 75 "It is surprising and rather disturbing that the actual numbers of children with myopia and myopic astigmatism fall so far short of those expected. That this is so is because of two factors. Firstly many of the undetected cases are doubtless early and the error slight. But these are just the cases it is important to detect. Secondly some belong to the group of children under eight years of age who have not been subjected to a test of vision chiefly because they did not know the letters at the first routine examination. Although the number of undetected cases of hypermetropic astigmatism would seem to be very large this is not such a serious matter, though it is probable that uncorrected hypermetropic astigmatism predisposes to, or aggravates, such conditions as tiredness, lassitude, and ' nervousness,' especially in children whose general health is not of the most robust. That such a large proportion (75 per cent.) of the cases of mixed astigmatism came for refraction accords with the diminution in visual acuity usually found in this complaint. "The conclusion of the Committee, that ' there appears to be a strong argument in favour of modifying the practice which governs ophthalmic work in schools' is undoubtedly supported by these findings, but to decide what would constitute a suitable reform is difficult. The ideal is obviously that every child should be examined by refraction instead of by vision testing, but this would involve administrative reforms of such magnitude, and such increase in expenditure that it cannot be contemplated for the present. It seems probable however that the efficiency of the routine visual examination could be improved by such simple procedures as are mentioned in the report, such as testing acuity with a convex lens of one dioptre. Furthermore the eyes of children entering school might be tested by these means as soon as they know the letters, by someone—doctor or nurse—specially instructed in the methods of vision testing. And lastly, if possible to a 83 greater extent than heretofore, all children with symptoms which might be traced to an uncorrected refractive error should be examined by refraction. "Myopia.—From the point of view of school ophthalmology myopia undoubtedly constitutes the most difficult clinical and administrative problem, so a careful inquiry has again been undertaken into its prevalence in Ealing. At present there are 158 children with myopia or myopic astigmatism under observation by the School Oculist. These are examined frequently, usually annually, but oftener should it be thought advisable, and every care is taken to ensure that vision, with correcting glasses, is as good as possible. That no small measure of success attends this effort is shown by the following graphical representation of the state of vision of the children before and after suitable correction by spectacles. "(Visual acuities of 6/6 and 6/9 with the better eye are included for this purpose as good, 6/12 and 6/18 as fair, and 6/24 and severe degrees as poor). 84 "It will be seen that the proportion of children whose vision is really bad after correction is small (5.8 per cent.). In several other cases, however, of children whose vision is as yet good or fair, there is a risk of rapid progression of the morbid process. "Dr. Bingham in his report for 1930 discussed the groups into which myopic children may be graded. A small number (estimated in London as only 1—1,800 of myopic children) must be accommodated in special " myope schools " since their visual acuity is so bad that they must perforce be taught by special methods. These are extreme cases. "In Ealing at present all the others are accommodated in the ordinary elementary schools, and these may be divided into three groups as follows :— "Group 1.—This group includes those children who have good vision with either eye, and cannot be looked upon as severe or rapidly progressive cases. In Ealing 109 of the total 158 belong to it. Such children can adopt the usual curriculum both as regards games and lessons, and are hardly handicapped in any way. "Group 2.—Those children who have a serious defect in one eye only, or a moderate one in both, are included in this group and number 32. With reasonable care, school work should not damage their vision, but all fine and close work is prohibited, and the children are encouraged to write in a large bold hand, preferably on a millboard. This is called ' easy treatment.' "Groups.—Into this group fall those children who suffer from myopia of a severe or rapidly progressive type. Some of these have poor visual acuity and cannot read small type. There are 17 on the records in Ealing. "The divisions of these three groups are shown on the following table :— 85 table ii. Boys Girls Total Group 1— (Observation Cases) 51 58 109 Group 2— (Easy Treatment) 11 21 32 Group 3— (Severe Cases) 8 9 17 70 88 158 "The first group constitutes a relatively simple administrative problem, but it is far otherwise with the second and third, especially, of course, the last, and the position is still further complicated by the fact that scientific opinion is divided as to the value of the procedure which is usually adopted to attempt to check the progress of the condition (avoidance of reading, homework, sewing, etc.). "Briefly there are two schools of thought. The majority of ophthalmologists in this country believe that the progress of the morbid process is accelerated by ordinary school work such as reading and writing, and advocate that all homework should be prohibited and only oral teaching adopted in school. The opposing school, on the other hand, holds that these factors are of little importance in these severe cases, and that the progress of the disease depends on hereditary and constitutional factors. If this latter view is correct, as it may well be, administrators who prohibit such children from reading take a very serious responsibility. It is well known that very many eminent men in the literary and scientific worlds are high myopes, indeed myopes are traditionally studious, and to deprive an intelligent child of twelve of books at the time when normally he starts to acquire those habits of curiosity and study upon which so much depends later, seems grossly unfair, and may well be resented by the parent who wishes his child to do well. In addition myopes are often unfitted by their general physique, even by the very defect itself, from any but a studious or sedentary life. They cannot excel at games or sports, and to 86 deprive them of their traditional consolation, and path to a healthy self esteem—to excel in studies—will often pave the way to unhappiness and a sense of inferiority. "Perhaps the best course to adopt is to allow such children to attend the ordinary schools for part of the time, but to devote the rest to special instruction in the methods which may be adopted to overcome their disability and prevent its progress so far as this is possible. "There are in Ealing 17 children who would benefit from constant instruction of this kind, for a few hours daily, and 32 others who might attend intermittently as occasion arose. These would form a convenient number for a myope class. "Hypermetropia.—It is well known that hypermetropia is the normal state of the eye of the savage and the young child, and the inquiry into problems connected with defective vision in school children showed that it is by far the commonest refractive condition met with in normal children of school age, though it gradually decreases in frequency from about 85 per cent. at the age of two years to 50 per cent. at the age of fourteen. The eye of the child is in a constant state of descent down the hypermetropic scale, and if emmetropia is reached during the early school years the probability is that it will pass on to myopia. This change was observed in four cases during 1931. "It is obvious that hypermetropia is nearly always symptomless, and yet a fairly large number of children with this condition are presented for examination annually, and spectacles prescribed with apparent benefit. When the hypermetropia is of three or more dioptres and there is some diminution of visual acuity this result is not surprising, but examination of the records shows that such a high degree of hypermetropia is by no means the rule in the cases referred for examination. Thus during 1931 of 87 new cases of hypermetropia only 16 were of three or more dioptres. (Cases of squint are excluded from these figures for obvious reasons). 87 "The reasons for performing refraction were different in these two groups. Thus in Group 1 (three or more dioptres) these were as follows :— Diminished Visual Acuity 15 ' Blinking ' 1 "In the second group there was a variety of reasons :— Diminished Visual Acuity 39 Headache 12 Styes 6 Conjunctivitis 5 Blepharitis 4 Diplopia 2 Watering 2 Migraine 1 71 "It is an interesting question why children whose eyes are in the normal condition for their years should suffer from such symptoms which are often rapidly relieved by the wearing of glasses. Careful examination of the records suggests that in many cases degrees of hypermetropic astigmatism, too slight to be revealed by the method of classification used, are the real source of trouble." (g) Ear Disease and Hearing.—Of 147 children with ear defects who received treatment, 93 were treated at the Health Centres. (h) Dental Defects.—As will be gleaned from the following report of the School Dentist, Mr. C. Colenso, L.D.S., most satisfactory work was performed during the year ; in fact, it was the first year in which all the work which had to be done in dentally inspecting and treating the children was accomplished. 88 "The dental inspection and treatment of all the school children has been completed within the year. This satisfactory condition has not been accomplished before, owing to the fact that on account of the rapidly increasing school population there were always more children needing treatment than one dentist, latterly two dentists, could possibly manage. Now there are two whole-time dentists and one part-time to inspect and treat over 11,000 children. "The part-time dentist has two schools with roughly 900 children to inspect and treat and devotes two sessions weekly to the work, six of the sessions being allowed during the year for the inspection of the children and the rest for treatment. "The treatment given at the Ravenor Park and Islips Manor Centres was very extensive, as the children attending the new schools in the Greenford and Northolt wards apparently had had very little dental treatment before. The work during the current year at these centres should be much more conservative. "Most of the leavers, these are children of 14 years of age and upwards, who left school during the year showed a very good dental condition; in fact, out of 473 who left, 376 or 79.5 per cent. had been treated and therefore on leaving school had sound mouths. Those children leaving and not receiving complete treatment totalled 97 or 20.5 per cent. "The actual work carried out at the various centres shows a big increase over each of the last three years. In 1931 11,261 children were inspected and of this number 7,634 were found to require treatment. Those actually treated numbered 5,571 and of these 617 re-visited for further treatment, making a total of 6,188 attendances in the year. For these children various forms of treatment were carried out; 8,185 fillings were put into permanent teeth and 1,012 temporary fillings were inserted in the first dentition. Dressings of silver nitrate were applied to 420 temporary and permanent teeth and 131 children had their teeth scaled. Treatment of ulcerative stomatitis was given in two cases and root 89 treatment for incisor teeth was done for six children. One case of hypertrophied gum tissue was successfully treated by incision. Twenty children were referred for special treatment to dental hospitals in London. "It is satisfactory to note that the extractions of permanent teeth have been considerably reduced this year : 924 were removed as against 1,814 in the year 1930, and 1,637 in the year 1928. A large number were removed for the purpose of regulating irregularities of the permanent dentition. "In the younger children, those five to eight years old, a great number of temporary teeth were removed. Still, the number is smaller than that of the previous year, which seems to indicate that decay is not so extensive as formerly. But taking it all round, from general observation, there has been a slight decrease in the percentage of decay in the temporary teeth and a slight increase in the percentage of decay in the permanent dentition. The number of temporary teeth extracted totalled 11,200 as against 12,205 in the year 1930. "Dental treatment for the pre-school child was commenced in the year 1927 and during that year 68 of these children were referred to the dentist. The number actually treated was 30. Since that time there has been a steady increase in the number of children treated. It appears that the majority of mothers came on their own initiative specially to seek advice and treatment and the others were advised by the Medical Officers at the Health Centres to avail themselves of treatment. In time a greater number still will be treated. Altogether 249 of these children were treated in the year. Fillings to the number of 431 were applied and the number of extractions totalled 724. To complete this work 421 attendances were made during the year. "The dental treatment of expectant and nursing mothers was inaugurated five years ago. In the first year 36 attended, in the second and third years 73 and 87 respectively received treatment, and in 1930 the number had increased to 149. In the year under review 270 cases were treated, 203 of these being expectant and 67 nursing mothers. The number of attendances made by these mothers during the year amounted to 1,026. 90 "The work accomplished during the year included permanent fillings to 281 teeth, 1,877 extractions and scaling of the teeth in 65 cases. Full or partial artificial dentures were supplied to 108 mothers. Repairs to old dentures were carried out in seven cases ; subsequent easing after fitting dentures in 37 cases. Fibromas attached to the gum were removed in two mothers. Plugging of sockets in post extraction haemorrhage was required in two cases. Operations for the removal of pockets around the teeth, where acute pyorrhoea was present, and dressings in combination with this treatment were done for 99 expectant or nursing mothers." (i) Orthopaedic Treatment.—During the year the Orthopaedic Surgeon saw for the first time, on the occasion of his fortnightly visits, 106 school children suffering from crippled conditions, lateral curvature and round shoulders. There were 252 re-inspections of these children and of others already undergoing treatment. Some of the cases of lateral curvature and round shoulders were only mildly affected and were completely cured after treatment of but a few months' duration. Four children received operative treatment at the National Orthopaedic Hospital and 76 were advised massage and special exercises. The attendances for massage or special exercises numbered 1,318. Four children were supplied with surgical appliances which were ordered by the Surgeon. In addition to the school children, 105 children under five years of age were submitted for a first examination by the Surgeon, 238 re-inspections being necessary. The attendances of those requiring massage numbered 818. Five operations were performed at the Hospital on children under school age. Five were supplied with special boots or surgical appliances. 91 The following two tables show the children of school age and those under five years of age who were kept under the supervision of the Orthopaedic Clinic during the year :— Orthopaedic Cases—School Children. Boys Girls Total Flat Feet 17 5 22 Genu Valgum (Knock-knees) 14 11 25 Genu Varum (Bow-legs) 5 1 6 Spine:— Scoliosis (Lateral Curvature) 18 18 36 Kyphosis (Round Shoulders) 17 12 29 Lordosis (Curvature) 2 2 4 Torticollis (Wry Neck) 1 1 2 Paralytic Conditions :— Hemiplegia 1 3 4 Diplegia — 1 1 Paraplegia 1 — 1 Infantile Paralysis 4 5 9 Talipes (Club Foot) 2 2 4 Myopathy 1 — 1 Tuberculous Knee 1* — 1 Tuberculous Hip 1* — 1 Birth Palsy 1 3 4 Spina Bifida 1 1 Total 87 64 151 * Quiescent. 92 Orthopaedic Cases—under Five Years of Age. Boys Girls Total Flat Feet 6 2 8 Genu Valgum 21 17 38 Genu Varum 29 18 47 Scoliosis 1 3 4 Torticollis 1 1 2 Congenital Dislocation of Hip — 2 2 Talipes 7 5 12 Contracted Finger — 1 1 Congenital Deformity of Foot 1 — 1 Rickets 3 2 5 Hammer Toe 1 3 4 Total 70 54 124 (j) Heart Disease and Rheumatism.—During the year there were found in the course of routine and special inspections 19 children suffering from organic and 56 from functional disease of the heart and 44 cases of rheumatism. All children suffering from organic disease of the heart, or who have a history of having suffered from rheumatism, which is the main cause of heart disease, are kept under particular supervision. They attend the Health Centre for examination at frequent intervals, the length of which depend on their condition, and parents are advised as to treatment. A report on the home conditions in each case is made by the Sanitary Inspector, 49 such reports being made during the past year. When children require treatment in a general hospital when suffering from an acute attack of rheumatism they are referred there, and those children for whom residence at a hospital school for heart cases is desirable are sent to such an institution at the cost of the Education Committee. 93 (k) Defective Speech.—At the end of the year there were in the schools 36 children who had defective speech, mainly stammering, 30 boys and 6 girls. The class for stammering children which had been contemplated for some time started work on April 14th, 1931, being housed in the accessory building at 13, Mattock Lane, which is also used for orthopaedic treatment and remedial exercises. Here twelve children, the usual number in such a class, can be readily accommodated. An important part of the treatment is to teach the children to cultivate complete mental and physical relaxation, an end which is not easy to attain if even a slight degree of congestion is present. The number of cases so far treated has been small, but already our experience corroborates that of other local authorities who have been undertaking the work for some time, namely, that the expense and additional work entailed are repaid by encouraging results. Few realise how severe a handicap a stammer is, and only those who have heard the experiences of stammerers told by themselves can appreciate the degree of mental anguish for which it is sometimes responsible, so that it is not surprising that the rapid improvement which often results from treatment is followed by a corresponding measure of gratitude from children and parents. Numbers.—In all 18 children attended the class during the year and 20 are now awaiting admission. The results of treatment at the end of the year can briefly be indicated as follows :— Cured 3 Very much improved 5 Left school, much improved 3 Definitely improved 5 Condition unchanged 2 18 94 Causation.—The number of cases is so small that little can be said under this head as yet. The term "nervous" as applied to children covers a variety of indefinitely related conditions, and it has often been applied to stammerers, in whose case the underlying cause of the condition is usually an excessive tendency to nervous discharge. Stammering children are restless. Indeed it only needs a visit to the class while it is in progress to realise that their dispositions are the reverse of placid. In ten cases a hereditary factor was traced and in two others the correction of unsuspected visual defects led to general improvement. Lefthandedness was only found in one case, and is, as has been stated of others, of no significance. Length of Treatment.— The length of treatment which is necessary to produce a cure naturally varies much in the different cases. Intelligent children who co-operate by practicing and carrying out the necessary exercises at home improve in a short time, and can be trusted to maintain the improvement by perseverance when they cease to attend the class. Others, less intelligent and more apathetic, while they improve considerably while under treatment, tend to relapse when this is discontinued. The duration of treatment of the cases at the end of the year is shown below :— Three months 2 Six months 2 Eight months 2 Nine months 4 Still under instruction 8 The eight cases still under instruction were greatly improved in the majority of instances but either because of age, or the nature of their affliction, it was thought advisable to keep them under observation for a more prolonged period. (I) Payments for Treatment.—The following amounts were received during the year for the treatment of children in the Health Centres:— 95 £ s. d. Dental Treatment 240 16 0 Throat Operations 33 9 6 Spectacles 83 5 9 Treatment at National Orthopaedic Hospital 17 8 0 X-ray Treatment for Ringworm of Head 7 2 6 Surgical Appliances 10 6 Massage Treatment 35 5 0 Other Payments, from Maternity and Child Welfare Committee, Etc. 219 2 3 £636 19 6 OPEN AIR EDUCATION. Nothing need be added to what has been stated in previous reports regarding the action taken by the teachers to conduct classes as far as possible in the open air. Reference was made in last year's report to the Derbyshire type of open air school on the model of which the new Stanhope School at Greenford was based. Three other schools of this type have been completed: Horsenden at Greenford, Wood End at Northolt and Grange Infants' School, a new department added to Grange School. The special characteristics of this type of school seem to be appreciated and to be utilised by the teachers. It is possible to have one side of each classroom open in all states of the weather, in winter or summer, provided consideration is given to the direction of the wind, and to have the children at all times taught under open air conditions. PHYSICAL TRAINING. There is nothing to be added to what has already been said in previous annual reports with reference to the provision made for physical exercises and organised games. One obtains an idea of the extent to which the facilities for instruction in swimming provided by the Education Committee are made use of by the school children from the fact that after the summer season last year 446 certificates of proficiency were gained by boys and 387 by girls. These results certainly redound to the credit of the teachers. 96 PROVISION OF MEALS. The teachers have continued to encourage the parents and children to support the scheme of the National Milk Publicity Council by which, at a cost of a penny a day to the parents, the children can have one-third of a pint of milk daily. The arrangements are simplicity itself. On the parents expressing their willingness to pay for the milk the head-teacher sees that the milk is supplied. The dairyman to whom the order is given by the head-teacher delivers the requisite number of bottles of milk (capacity one-third of a pint) in readiness for the mid-morning interval. At the interval the bottles are distributed along with straws through which the children partake of the milk slowly. After use the bottles are collected by the dairyman and the only labour entailed by the teacher is the collection of fivepence a week from each child participating in the scheme. On all sides there is appreciation of the benefit of the daily supply of milk to the children and the benefit is not only in health but indirectly in education. When the scheme was begun in 1929 the total number of children receiving milk in this way each day was 2,949. In March, 1931, the number was reduced to 2,245, possibly because the novelty had somewhat worn off, but more recently the total supplied each day has increased to 2,605. The Education Committee in 1930 adopted this method for supplying milk free of charge to necessitous children under Sections 82—85 of the Education Act, 1921, and at the end of the year 409 children were being so supplied. The following tabular statement indicates the number of children being supplied with milk free of charge and the cost:— 97 Free Supply of Milk to School Children. (Sections 82—85 Education Act, 1921). Scheme for supply of milk to necessitous children commenced on the 1st April, 1930. Number of children for whom a supply of milk was approved, 1st January, 1931 340 Number of children whose addition to the lists was approved during the year 213 Number of children to whom supply was discontinued 144 Number of children being supplied at the end of the year 409 Total number of children who received milk during the year 553 Daily average number of children who received a supply of milk 321 Total number of bottles of milk supplied 68,311 Cost of milk supplied £2 £284 12s. 7d. CO-OPERATION OF OTHERS IN THE SCHOOL MEDICAL SERVICE. In previous reports recognition was made of the great assistance rendered by the teachers and by the school enquiry officers in the work of school medical inspection and treatment. Through their agency the parents are being encouraged more and more to appreciate school medical inspection and to obtain treatment for defects found or to carry out instructions regarding the care of those children whose continuous supervision is necessary in the prevention of disease. As in former years acknowledgment must be made of the very real help obtained from the Central Aid Society, from the National Society for the Prevention of Cruelty to Children, from the School Attendance Aid Committee in supplying boots to needy children and from the Middlesex King Edward Memorial Committee in giving holidays at their Holiday Home at Bexhill to anaemic or badly nourished children. 98 NURSERY SCHOOLS. There are no Nursery Schools and there are no nursery classes in the ordinary schools in the Borough. Children under five years of age are admitted to some of the schools when in the opinion of the School Attendance Sub-Committee the home circumstances justify their being admitted. Altogether there were in the schools at the end of the year about 160 children under five years of age, chiefly in St. John's, Little Ealing, Betham's, Drayton and Grange Schools. Where the numbers render it practicable classes are conducted on kindergarten lines. SECONDARY SCHOOLS. Medical inspection of children in the three County Schools in Ealing is carried out on behalf of the Middlesex County Council by the Ealing School Medical Staff. Proposals were put forward by the County Council by which dental inspection and treatment and the treatment of defective vision would also be carried out by the local staff but these proposals, which were agreed to by the Ealing Education Committee, had to be postponed in consequence of the national financial crisis. Medical inspection of children and adults attending the Occupation Centre for Mental Defectives is carried out on behalf of the Mental Deficiency Authority. Medical treatment is given where this is possible at the Health Centre. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. All blind and deaf children of school age are sent to Special Residential Schools. Five blind girls and five blind boys were being maintained at Certified Schools for the Blind at the end of the year. Thirteen deaf mutes, seven girls and six boys, were at the end of the year being maintained at Special Residential Schools One boy suffering from severe epilepsy was maintained at a Special Residential School. 99 Seven girls and five boys who were suffering from mild attacks of epilepsy, occurring at night and never in the day, were attending public elementary schools and one girl was kept at home where she was undergoing treatment by her regular medical attendant. One crippled boy, who was unable to attend the ordinary school was maintained at a Special Residential School. All the other children suffering from crippling conditions, except one boy who was kept at home, were able to attend the public elementary schools like normal children—a very satisfactory state of things which has been mainly due to the marked improvement in their condition resulting from continuous and effective orthopaedic treatment. One boy and two girls suffering from heart disease were maintained at a Special Hospital School. Four feeble-minded children, three girls and one boy, were maintained at Special Residential Schools. There were 59 feebleminded children, 31 girls and 28 boys, in attendance at public elementary schools. Twelve children were notified during the year to the Local Mental Deficiency Authority: one idiot girl, five imbecile boys, and four imbecile girls; one feeble-minded boy and one feebleminded girl on leaving a special school after attaining the age of 16 years. The ascertainment of all the mentally defective children in the public elementary schools was completed early in the year and those deemed to be non-educable were duly notified to the Local Mental Deficiency Authority. As the Hadow Re-organisation Scheme proceeds in the schools parallel classes are being formed and retarded children are being dealt with in these. When the re-organisation has been completed it is expected that all retarded children will be accommodated in such classes and that such records of their educational progress will be available as will assist in determining what is the next best step to take in providing for their special education. 100 In the course of the year four boys and four girls requiring convalescent treatment were maintained for six weeks each at the King Edward Memorial Convalescent Home at Bexhill at the cost of the Education Committee. These periods of convalescent treatment have markedly beneficial results and if the facilities could be extended to many more children the expenditure would be met with a good return in the way of improved health of the children concerned. HEALTH EDUCATION. In the Annual Report for 1929 an account was given of the extent of the health education given in the schools and the steps taken by the Education Committee to encourage this essential kind of instruction. Since that report was made no changes have taken place in the scheme. 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. Girls. Errand Boys 97 Milk Round 11 Newspaper Round 21 Baker's Round 25 Helping in Shop 1 None. General Help 1 Order Boy 6 Yard Boy 1 Apprentice 1 Collecting Accounts 1 Total 165 One hundred and eighty-two children were examined in connexion with employment and out of this number 17 were found to be in such a condition of health that their employment was not allowed. 101 At the routine medical inspection of employed children at school five were found to be suffering in health and their employment was discontinued. Sixteen children were found to be employed without being registered under the Byelaws and one girl was found to be under age. MISCELLANEOUS. All medical examinations made at the Health Centres, including those of children referred by the Education Committee, Headteachers, School Enquiry Officers and School Nurses are included under this term. Children may be submitted for examination at the Health Centres at 9.30 a.m. on certain days of the week. Those submitted are usually children suspected of having verminous heads or bodies, of having ringworm, scabies or impetigo, or those whose examination is desirable on account of some defect, such as defective eyesight, disease of the eye, ear, nose and throat, which may require treatment. In fact, any child with an actual or suspected defect and not under medical care may be submitted by the headteachers for examination. The examinations carried out during the year were as follows:— Verminous Children 765 Impetigo 666 Scabies 117 Ringworm 135 Eczema 10 Minor Injuries 199 Teachers on Appointment 47 Miscellaneous 2,937 Total 4,876 THOMAS ORR. May, 1932. 102 STATISTICAL TABLES. The Statistical Tables required by the Board of Education are as follows:— TABLE I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections:— Entrants 1,821 Intermediates 2,030 Leavers 1,084 Total 4,935 Number of other Routine Inspections - B.—Other Inspections. Number of Special Inspections 2,592 Number of Re-Inspections 1,887 Total 4,479 103 TABLE II. A—RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1931. DEFECT OR DISEASE Routine Inspections Special Inspections No. of Defects No. of Defects. Requiring Treatment Requiring to be kept under observation, but not requiring Treatment Requiring Treatment Requiring to be kept under observation, but not requiring Treatment (1) (2) (3) (4) (5) Malnutrition 1 52 - - Uncleanliness (See Table IV, Group V) 99 — 52 — Skin Ringworm, Scalp 1 — 27 — „ Body 4 — 20 — Scabies 6 - 31 — Impetigo 5 — 296 — Other Diseases (Non-Tuberculous) 3 3 107 2 Eye Blepharitis 31 4 40 3 Conjunctivitis 23 2 41 1 Keratitis 1 2 — Corneal Opacities — 1 — — Defective Vision (exluding Squint) 261 — 111 12 Squint 44 9 21 6 Other Conditions 8 6 46 3 Ear Defective Hearing 2 8 9 4 Otitis Media 20 5 57 1 Other Ear Diseases 3 2 67 6 Nose and Throat Enlarged Tonsils only 232 787 59 35 Adenoids only 15 5 7 6 Enlarged Tonsils and Adenoids 152 4 54 14 Other Conditions 2 150 26 14 Enlarged Cervical Glands (Non-Tuberculous) 3 280 5 23 Defective Speech — 25 — 11 Teeth—Dental Diseases (See Table IV, Group IV) 997 - 48 - Heart and Circulation Heart Disease: Organic — 14 4 1 Functional — 54 — 2 Anaemia 7 25 1 12 Lungs Bronchitis 2 67 15 26 Other Non-Tuberculous Diseases — 8 — 4 Pulmonary: Tuberculosis Definite — - 1 — Suspected — 5 — 4 Non-Pulmonary: Glands — 1 — 1 Spine — — — — Hip — — — — Other Bones and Joints — 1 — — Skin — — — — Other Forms — 2 — — Nervous System Epilepsy — 2 2 3 Chorea — 7 3 10 Other Conditions — 2 — — Deformities Rickets — 1 — — Spinal Curvature 15 2 2 — Other Forms 105 200 13 7 Other Defects and Diseases 21 27 856 86 Rheumatism (apart from Heart Disease) 1 13 2 28 104 B.—NUMBER OF INDIVIDUAL CHILDREN FOUND AT ROUTINE MEDICAL INSPECTION TO REQUIRE TREATMENT. (Excluding Uncleanliness and Dental Diseases). Group Number of Children Percentage of Children found to require Treatment Inspected Found to require Treatment (1) (2) (3) (4) Code Groups:— Entrants 1,821 323 17.7 Intermediates 2,030 365 17.9 Leavers 1,084 185 17.0 Total (Code Groups) 4,935 873 17.7 Other Routine Inspections - - - 105 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Boys Girls Total Blind (including partially blind). (i) Suitable for training in a School for the totally blind. At Certified Schools for the Blind 5 5 10 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — (ii) Suitable for training in a School for the partially blind. At Certified Schools for the Blind or Partially Blind - - - At Public Elementary Schools 7 7 14 At other Institutions — — — At no School or Institution — — — Deaf (including deaf & dumb & partially deaf). (i) Suitable for training in a School for the totally deaf or deaf and dumb. At Certified Schools for the Deaf 6 7 13 At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — — (ii) Suitable for training in a School for the partially deaf. At Certified Schools for the Deaf or Partially Deaf - - - At Public Elementary Schools — — - At other Institutions — — - At no School or Institution — - — Mentally Defective. Feebleminded. At Certified Schools for Mentally Defective Children ... 1 3 4 At Public Elementary Schools 28 31 59 At other Institutions - - - At no School or Institution — — — Notified to the Local Mental Deficiency Authority during the year. 6 6 12 Epileptics. Suffering from severe epilepsy. At Certified Schools for Epileptics 1 - 1 At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools - - - At other Institutions - - - At no School or Institution - — — Suffering from epilepsy which is not severe. At Public Elementary Schools 5 7 12 At no School or Institution — 1 1 106  Boys Girls Total Physically Defective. Active pulmonary tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 - 1 At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools — — — At other Institutions — — — At no School or Institution — — - Quiescent or arrested pulmonary tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools 2 2 4 At other Institutions - - - At no School or Institution — — — Tuberculosis of the peripheral glands. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools - - - At other Institutions - - - At no School or Institution - — — Abdominal tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board - - - At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools — — - At other Institutions - - - At no School or Institution — — — Tuberculosis of bones and joints (not including deformities due to old tuberculosis). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board - - - At Public Elementary Schools 2 1 3 At other Institutions — — - At no School or Institution - — — 107  Boys Girls Total Physically Defective—continued. Tuberculosis of other organs (skin, etc.). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board - - - At Public Elementary Schools — 2 2 At other Institutions — — — At no School or Institution — — — Delicate Children, i.e., all children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an Open Air School. At Certified Residential Cripple Schools - - - At Certified Day Cripple Schools - - - At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools 145 110 255 At other Institutions — — — At no School or Institution — — — Crippled Children (other than those with active tuberculous disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life. At Certified Hospital Schools 1 - 1 At Certified Residential Cripple Schools - - - At Certified Day Cripple - - - Schools — — — At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools 16 17 33 At other Institutions At no School or Institution 1 — 1 Children with heart disease, i.e., children whose defect is so severe as to necessitate the provision of educational facilities other than those of the public elementary school. At Certified Hospital Schools 2 1 3 At Certified Residential Cripple Schools - - - At Certified Day Cripple Schools - - - At Certified Residential Open Air Schools - - - At Certified Day Open Air Schools - - - At Public Elementary Schools 2 2 4 At other Institutions — — — At no School or Institution - — - 108 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR. TREATMENT TABLE. Group 1.—Minor Ailments (excluding Uncleanliness, for which see Group V). Disease or Defect Number of Defects treated, or under treatment during the year. Under the Authority's Scheme Otherwise Total (1) (2) (3) (4) Skin:— Ringworm—Scalp 25 3 28 Ringworm—Body 24 — 24 Scabies 29 8 37 Impetigo 301 — 301 Other Skin Disease 88 22 110 Minor Eye Defects (External and other, but excluding cases falling in Group II) 118 71 189 Minor Ear Defects 93 54 147 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 503 21 524 Total 1,181 179 1,360 109 Group 2.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments—Group 1). Defect or Disease No. of Defects dealt with. Under the Authority's Scheme Submitted to refraction by private practitioner or at hospital, apart from the Authority's Scheme Otherwise Total (1) (2) (3) (4) (5) Errors of Refraction (including Squint) 433 35 - 468 Other Defect or Disease of the Eyes (excluding those recorded in Group I) - - - - Total 433 35 - 468 Total number of children for whom Spectacles were prescribed:— (a) Under the Authority's Scheme 426 (b) Otherwise 35 Total number of children who obtained or received Spectacles:— (a) Under the Authority's Scheme 422 (b) Otherwise 35 Group 3.—Treatment of Defects of Nose and Throat. Number of Defects Received Operative Treatment Received other forms of Treatment Total number Treated Under the Authority's Scheme in Clinic or Hospital By Private Practitioner or Hospital, apart from the Authority's Scheme Total (1) (2) (3) (4) (5) 166 71 237 — 237 110 Group 4.—Dental Defects. (1) Number of Children who were:— (a) Inspected by the Dentist: Aged Routine Age Groups 5 1,112 Total 11,261 6 1,249 7 1,286 8 1,340 9 1,335 10 1,412 11 1,396 12 800 13 662 14 471 15 149 16 49 Specials 48 Grand Total 11,309 (b) Found to require treatment 7,682 (c) Actually treated 5,571 (2) Half-days devoted to:— Inspection 84 Treatment 928 Total 1,012 (3) Attendances made by children for treatment 6,188 (4) Fillings:— Permanent Teeth 8,195 Temporary Teeth 1,012 Total 9,207 (5) Extractions:— Permanent Teeth 924 Temporary Teeth 11,200 Total 12,124 (6) Administrations of General Anaesthetics for Extractions 1,165 (7) Other operations:— Permanent Teeth - Temporary Teeth — Total - Group 5.—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 23,094 (3) Number of individual children found unclean 310 (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 Byelaws 1 Chiswick and Ealing Hospitals Committee. ISOLATION HOSPITAL. MATERNITY HOSPITAL. ANNUAL REPORT of the MEDICAL SUPERINTENDENT for the year ending 31st MARCH, 1932. THOMAS ORR. M.D., D.Sc., Medical Superintendent. 2 CHISWICK AND EALING HOSPITALS COMMITTEE. COMMITTEE. Councillor G. Jenkin (Chairman). Councillor W. T. White ( Vice-Chairman). Alderman A. W. Bradford. Alderman Col. R. R. Kimmitt, O.B.E. Councillor Mrs. F. M. Baker, J.P. Councillor Mrs. E. L. Hill. Councillor F. F. Poole. Councillor Mrs. E. S. Taylor, J.P. STAFF. Medical Superintendent— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Medical Attendant, Isolation Hospital— John Petrie, M.B., Ch.B., D.P.H. Medical Attendant, Maternity Hospital— Marguerite M. Fenn, M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Consulting Surgeon— C. W. Gordon Bryan, F.R.C.S., M.R.C.S., L.R.C.P. Consulting Oto- Laryngologist — Dan McKenzie, F.R.C.S., M.D. Consulting Obstetrician— John W. Rait Bell, L.R.C.P.I. & L.M., L.R.C.S.I. & L.M. Matron, Isolation Hospital— Miss I. Gregory. Matron, Maternity Hospital— Miss E. A. Morton. Clerk to Committee— Harry Birrell. Treasurer— E. C. T. Owen. 3 CHISWICK AND EALING HOSPITALS COMMITTEE. ANNUAL REPORT OF MEDICAL SUPERINTENDENT. Mr. Chairman, Ladies and Gentlemen, I have the honour to submit to you the report on the administration of the Isolation and Maternity Hospitals for the year 1931-1932. ISOLATION HOSPITAL. The number of cases admitted to the hospital was 375, being 130 less than in the previous year, and the lowest since the year 1926-1927. The highest daily number under treatment was 61 on May 28th and the lowest 23 on August 12th. Towards the end of the year as the Committee decided to make further use of the available accommodation cases of measles were admitted to the hospital. The following Table indicates the number of cases of the various diseases treated during the year. Disease. Remaining in Hospital, March 31st, 1932. Admitted during Year 1931-32 Discharged during Year 1931-32 Died 1931-32 Remaining in Hospital March 31st, 1932. Scarlet Fever 17 247 235 - 29 Diphtheria 24 120 135 5 4 Enteric Fever - 2 2 — — Ophthalmia Neonatorum - 1 1 - - Dysentery — 1 — — 1 Measles - 1 — — 1 Erysipelas - 1 1 — — Other Diseases - 2 2 — — 41 375 376 5 35 4 Scarlet Fever.—Of the 247 cases admitted as scarlet fever 174 were from the Borough of Ealing and 73 from the Urban District of Brentford and Chiswick. Nineteen of the total were not suffering from the disease and were ultimately diagnosed as follows: Tonsilitis 6, septic rash 2, drug rash 1, food rash 1, serum rash 1, urticaria 1, impetigo 1, common cold 1, no apparent disease 3. One was admitted so as to have a mastoid wound re-opened and one was a scarlet fever carrier only. Two cases of scarlet fever were found on admission to be suffering at the same time from diphtheria and four others were also suffering from chicken-pox. The incidence of the actual cases of scarlet fever in the various age-groups was as follows: 1-5 yrs. 5-15 yrs. 15-25 yrs. 25-35 yrs. 35-45 yrs. 37 159 17 6 9 The complications observed in the course of the disease were as follows : No. of Cases. Adenitis 49 Rhinorrhoea 54 Otitis media 7 Otorrhoea 18 Supra-orbital neuralgia 1 Arthritis 9 Albuminuria and nephritis 3 Cervical gland abscess 3 Peritonsillar abscess 1 Bradycardia 1 The following major operations were performed during the year: T.A. Male 8 yrs. Mastoid L. 16/4/31 H.R.S. Male 3½ yrs. Mastoid R. 7/5/31 Mastoid L. 12/6/31 K.R. Male 8 yrs. Mastoid L. 16/5/31 Re-opened 4/7/31 J.B. Female 3¼ yrs. Mastoid R. 19/9/31 D.G. Female 8 yrs. Mastoid R. 20/10/31 D.B.S. Male 3½ yrs. Mastoid R. and L. 29/12/31 L.P. Male 6 yrs. Mastoid R. 8/1/32 5 The above operations were performed by Dr. Dan McKenzie, who made 14 visits to the hospital during the year. He also removed tonsils and adenoids in three cases. Cross Infection.—Three cases of scarlet fever became infected with chicken-pox while in the ward and three with measles: all recovered. The source of infection in each was a child admitted with scarlet fever while in the incubation stage of the other disease, which subsequently developed in the ward. Return Cases.—The following five patients gave rise to return cases on discharge: Sex Age Admitted Discharged No. of days in Hospital Return Case Admitted F. 5½ 16/12/30 31/3/31 105 Father 7/4/31 M. 10 23/5/31 19/6/31 27 Sister 12/7/31 M. 6 1/9/31 29/9/31 28 Sister 4/10/31 M. 7 2/2/32 24/2/32 22 Sister 2/3/32 F. 9 19/12/31 27/2/32 70 Mother and Father 20/3/32 7/4/32 The last case was re-admitted to hospital and was found to have a slight nasal discharge and an intermittent vaginal discharge. The average duration of stay in the hospital of the cases of scarlet fever was 40 days. Diphtheria.—The numbers of cases admitted as diphtheria from the two districts were 73 from Ealing and 47 from Brentford and Chiswick, making a total of 120. This total is 80 less than in the previous year. Of this number 39 were ultimately diagnosed 6 as not suffering from diphtheria. The incidence of actual cases in age-groups was as follows: 1-5 yrs. 5-10 yrs. 10-15 yrs. 15-25 yrs. 25-45 yrs. 14 40 14 7 6 The following complications were observed among the cases: No. of Cases. Palatal paresis 12 Ciliary paralysis 3 Neck paralysis 1 Pharyngeal paralysis 2 Cardiac involvement 10 Rhinorrhoea 4 Cervical adenitis 2 Albuminuria 3 Otorrhoea 1 Two cases admitted with diphtheria were also suffering from scarlet fever and one had measles. The diagnoses in the non-diphtheritic cases were as follows: Acute follicular tonsilitis 18 Laryngitis 4 Adenitis 1 Septic pharyngitis and septicaemia 1 Scarlet fever 2 Contact carrier 1 Quinsy 6 Vincent's angina 1 Pneumonia and empyema 1 Broncho-pneumonia 1 Bronchitis 2 No apparent disease 1 There were three cases of laryngeal obstruction, all of which recovered satisfactorily without the operation of tracheotomy. Deaths.—There were three deaths from diphtheria, giving a mortality rate of 3.8 per cent. Two deaths occurred among the non-diphtheritic cases, one of septic pharyngitis and septicaemia and the other of pneumonia and empyema. Particulars of diphtheria deaths are as under : Day of disease when admitted Days in hospital before death Sex Age Male 3 years 3 1 Male 6 years 4 3 Male 7 years 4 1 None of these cases had received anti-toxin before admission There were no cases of cross infection in the diphtheria ward and no return cases. The average duration of stay in hospital for diphtheria cases was 50.3 days. Enteric Fever.—Two cases were admitted with a diagnosis of enteric fever during the year, one as a case of para-typhoid " A " and one para-typhoid " B." The latter proved to be a case of simple gastro-enteritis. Each made an uneventful recovery. Other Diseases.—One case of ophthalmia neonatorum recovered satisfactorily. A girl of 5 years was admitted with a diagnosis of dysentery, but this was not confirmed bacteriologically. One case was admitted with measles and broncho-pneumonia and was still under treatment at the end of the year. There was one case of erysipelas, a woman of 47 years. Illness of Staff.—One nurse developed scarlet fever during the year and one ward maid developed diphtheria. Two nurses had acute tonsilitis, one had influenza and one gastro-enteritis. 7 8 Cost of Maintenance, Etc. £ s. d. Salaries 2,433 16 1 Repairs to buildings 552 17 5 Furniture, fittings and utensils 410 9 0 Maintenance of ambulance 182 8 9 Medical and surgical requisites 433 6 4 Provisions 1,304 16 1 Fuel, light and cleaning 919 2 6 Rates, taxes and insurance 726 17 8 Miscellaneous 146 6 10 Superannuation—employer's contribution 66 16 7 Loan charges 1,618 1 7 8,794 18 10 Administrative charges, proportion 308 15 9 £9,103 14 7 The patients spent 14,345 days in hospital so that the average cost of each patient per day was 12s. 8d. Taking the patientdays 14,345 and the staff-days 10,410, or a total of 24,755, the average cost of food works out at Is. O½d. per person per day. MATERNITY HOSPITAL. The number of patients admitted during the year 1st April, 1931, to 31st March, 1932, was 546. The numbers in the three preceding years were 450, 534 and 561 respectively. Owing to the fact that overcrowding occurred in the hospital from time to time in the previous year, the number of bookings has been purposely limited. The beds are now being booked three or more months ahead, and a considerable number of applicants cannot be accepted ; the need for extension of the hospital, therefore, is becoming still more pressing. The districts from which the patients were admitted are shown in the following Table ; 9 Brentford and Month. Chiswick Ealing Total 1931 April 8 36 44 May 16 26 42 June 13 36 49 July 15 33 48 August 13 39 52 September 23 25 48 October 24 25 49 November 15 25 40 December 18 29 47 1932 January 17 23 40 February 8 27 35 March 21 31 52 191 355 546 There were no cases admitted from outside districts. Mothers.—Emergency Cases.—Twelve cases were admitted at the request of the medical practitioner in attendance on account of the following complications : Placenta praevia—central 1 marginal ... 2 Toxaemia 4 Prolonged labour 2 Delivery of second twin 1 Abortion 1 For investigation and ante-natal care 1 In all cases, the mother made an uninterrupted recovery. The first case, that of central placenta praevia, was delivered by Caesarian Section, and the last case recovered sufficiently to be confined at home. 10 Of the ten viable infants born, seven were discharged in good condition and three were stillborn ; one of these stillborn children was macerated, the second twin already alluded to died during labour, and in one case of prolonged labour, the child failed to breathe after birth. Ante-Natal Cases.—Four of the twenty-six ante-natal cases were discharged with the condition so much improved that they were able to return later as normal cases. The complications so benefited were one case each of pyelitis, toxaemia, heart disease and threatened premature labour. Abnormalities and Complications. The complications were as follows :— Ante- Natal. Toxaemia (requiring surgical induction 2) Total 9 Eclampsia 2 Hydramnios 2 Pyelitis 3 Disproportion (requiring surgical induction) 2 Post-Maturity (requiring medical induction) 1 History of previous stillbirths (surgical induction) 2 Lateral placenta praevia 2 Threatened premature labour 1 Heart disease 1 For investigation 1 Labour. Breech (complete) 6 Breech (extended legs) 6 Persistent occipito-posterior presentation 16 Face presentation 1 Shoulder presentation 1 Twins 7 Conditions requiring forceps delivery 11 11 Caesarian section 5 For contracted pelvis 1 For central placenta praevia 1 Delayed second twin 1 Normal delivery of patient with congenital dislocation of hip 1 Ante-partum haemorrhage-— Toxaemic Placenta praevia—central 1 lateral 5 Post-partum haemorrhage of severe character — Eclampsia 2 Manual removal of placenta 1 Episiotomy 2 Ruptured-perineum (more than one stitch) 45 Abscess of bartholin's gland 1 Gonorrhoea 1 Syphilis 1 Puerperium. Arthritis 1 Post-partum collapse 1 Abscess of thigh 1 Pyelitis 6 Phlebitis 2 In addition to the above cases, nine cases of puerperal pyrexia occurred, all of which made an excellent recovery. The cases were as follows : Pyelitis 1 Sapraemia 2 White-leg of venous origin 1 White-leg of lymphatic origin 1 Parametritis 1 Eclampsia, jaundice and cystitis 1 Pneumonia 1 Cause indefinite 1 Maternal Deaths.—No maternal deaths occurred during the year. 12 Children. Number of Infants born— Males 299 , Females 243 Total 542 Of the 36 premature infants, those of 28 and 32 weeks development and one of 34 weeks development died. Three premature babies were stillborn. Stillbirths.—Total 12. Macerated— Premature 2 Hydrocephalus 1 Others 3 Prematurity 1 Hydramnios and malformations 1 Asphyxia 1 Pre-eclampsia in mother 1 Eclampsia in mother 1 Difficult breech delivery 1 Of these stillbirths only one (the eclamptic case) was a female. Number of cases of Twins 7 Number of cases of Premature Infants— 38 weeks development 23 36/37 do. 8 34/35 do. 3 32 do. 1 28 do. 1 Total 36 13 Infant Deaths.—Total 5. Prematurity 1 Prematurity and ante-partum haemorrhage 2 White asphyxia (eclampsia in mother) 1 Supraenal haemorrhage 1 Abnormalities in Infants. Congenital heart disease 3 Mild hypospadias 2 Mild talipes 2 Generalised oedema 1 Broncho-pneumonia 1 Convulsions 1 The last two cases recovered in hospital and were discharged well. Dr. J. W. Rait-Bell, the Consulting Obstetrician, was called in on eight occasions during the year. 14 Cost of Maintenance, Etc. £ s. d. Salaries— Medical 198 4 0 Nurses 500 5 5 Other staff 947 6 4 District training of probationers 135 0 0 Repairs to buildings 257 0 3 Furniture, fittings and utensils 352 14 7 Medical and surgical requisites 253 6 11 Provisions 1,057 0 10 Fuel, light and cleaning 691 11 1 Rates, taxes and insurance 354 9 4 Miscellaneous 66 15 0 Superannuation—employer's contribution 56 12 8 Doan charges 772 12 7 5,642 19 0 Administrative charges 198 2 6 5,841 1 6 Less Income from patients 2,480 3 0 . £3,360 18 6 The patients spent 8,286 days in hospital so that the gross cost of each patient per day was 14s. Id., or £4 18s. 8d. per week and the net cost, after deducting the amounts paid by the patients, 8s. Id. per day or £2 16s. 8d. per week. Taking the patient-days 8,286 and the staff-day 8,391, or a total of 16,677, the average cost of food for patients and staff works out at Is. 3¼d. each person per day. 15 Year. No. of Patients in Year. Net Cost of each Patient per week. £ s. d. 1921-22 109 14 0 0 1922-23 235 7 11 2 1923-24 284 6 4 6 1924-25 369 4 6 7 1925-26 388 4 1 3 1926-27 358 5 6 9 1927-28 407 4 6 11 1928-29 450 3 1 3 1929-30 534 3 0 8 1930-31 561 3 0 7 1931-32 546 2 16 8 In submitting my report on the year's work an opportunity is afforded me of expressing my appreciation of the work of the medical staff and of the matrons, which has consistently been on a high plane of efficiency. It is quite unnecessary for me to draw your attention to the devoted service of Mr. Birrell, the Clerk to the Committee, but I wish here to express my gratitude for the great assistance he has rendered me as in former years. I am, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Superintendent. Town Hall, Ealing, W.5. 25th May, 1932.