Journal Rebind Co. Ltd. Unit 4. Prer Wharf Grays Esses EAL 24 AC.439 (1) EALINT Borough of Ealing. ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer 1933 INCLUDING Report on the Isolation and Maternity Hospitals, 1933-34. thomas orr, m.d., d.se., 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. 68578 EAL 24 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer 1933 including Report on the Isolation and Maternity Hospitals, 1933-34. 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. Annual Report OF THE Medical Officer of Health 1933 INDEX. page Ambulances 17 Births 11 Blind, Deaf, Defective and Epileptic Children 90, 110 Clinics and Treatment Centres 19 Deaths 12, 16 Defects found by Medical Inspection 70, 108 Dental Defects and Treatment 27, 87, 115 Diphtheria 48, 52 Disinfection 40 Drainage and Sewerage 32 Employment of Children and Young Persons 94 Factories and Workshops 39,42 Health Centres 7, 19, 24 Health Education 59, 93 Health Visiting 23 Hospitals in the District 20 Housing 44 Infant Deaths 12, 14, 15 Infant Life Protection (Children Acts) 26 Infectious Diseases 47, 74 Legal Proceedings 41 Maternal Mortality 12 Maternity and Child Welfare 22 Maternity and Nursing Homes 30 Meat and Other Foods 37 Medical Inspection of School Children 66, 107 Medical Treatment of School Children 75, 113 Midwives, Supervision of 28 Milk 35, 39 Mortuary 42 Nursing Arrangements 18 Offensive Trades 34, 40 Ophthalmia Neonatorum 29, 56 Orthopaedic Treatment 27, 72, 85, 115 Pathological Laboratory 17 Population 9 Provision of Meals 91 Puerperal Fever and Puerperal Pyrexia 55 Sanitary Inspection of the Borough 38 Scarlet Fever 48, 51, 53 School Hygiene 65 Smoke Abatement 34 Social Conditions 9 Special Clinic 19 Speech, Defective 83 Staff 6, 63 Statistics, Vital and General 9, 10 Tonsillectomy in School Children (Special Enquiry) 95 Tuberculosis 57, 84 Uncleanliness 73, 116 Vision, Defective 71, 76, 114 Water Supply 32 APPENDIX. Report of the Medical Superintendent, Isolation and Maternity Hospitals, 1933-4. 5 PUBLIC HEALTH COMMITTEE. 1932-33. Councillor Mrs. F. M. Baker, J.P. [Chairman). Councillor C. D. Grant ( Vice-Chairman). Aldermen Colonel R. R. Kimmitt, O.B.E., T.D., H. W. Peal, J.P., and W. T. White, J.P. Councillors W. J. S. Cox, T. E. Fowler, Willoughby Garner, F. G. Holmes, J. Mansel Lewis, H. M. Sayers, W. A. Scott, Mrs. E. S. Taylor, J.P., and H. Telfer. MATERNITY AND CHILD WELFARE COMMITTEE. 1932-33. * Alderman Colonel R. R. Kimmitt, O.B.E., T.D. [Chairman), Councillor Mrs. E. S. Taylor, J.P. ( Vice-Chairman), Aldermen H. W. Peal, J.P., and W. T. White, J.P., Councillors Mrs. F. M. Baker, J.P., W. J. S. Cox, T. E. Fowler, Willoughby Garner, C. D. Grant, F. G. Holmes, J. Mansel Lewis, H. M. Sayers, W. A. Scott and H. Telfer. Mesdames Haddon, Holman, Ludlow, Parry, Scrutton and Weeks. 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— John Petrie, M.B., Ch.B., D.P.H. John D. Kershaw, M.B., B.S., D.P.H. Marguerite M. Fenn, M.B., B.S., M.R.C.S., L.R.C.P. (resigned 28th February, 1933). Florence Whitrow, M.B., Ch.B., M.R.C.S., L.R.C.P. (resigned 19th February, 1933). Helen R. B. Buck, M.B., B.S., M.R.C.S., L.R.C.P. (appointed 20th February, 1933). Dorothy Taylor, M.B., B.S., M.R.C.S., L.R.C.P. (appointed 1st March, 1933). Ante- Natal Consultant—Part-time— John W. Rait Bell, L.R.C.P.I. & L.M., L.R.C.S.I. & L.M. Special Clinic—Part-time— Toan G. Malleson, M.B., B.S., M.R.C.S., L.R.C.P. 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. Blackie, 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. 7 Supervising Health Visitor— Eleanor Evans, Cert. R.S.I., Cert. C.M.B. 4 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. Rubie G. B. Dugger, Health Visitor's Cert., Cert. C.M.B., and Trained Nurse. Freda de la 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 Administrative Clerk— Harry Birrell. Clerks— * William A. J. Turner. *George W. Stephens. *Herbert J. Reed. *Gregory E. A. 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. I slips 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 Public Health Department, Town Hall, Ealing, W.5. To the Mayor, Aldermen and Councillors of the Borough of Ealing. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit the Annual Report for the Year 1933 on the health of the Borough and on the work of the Public Health Department. The Report includes the usual statistical tables and information regarding the work performed and deals in detail with matters which have been of special importance during the year or on which special comment has been requested in the Circular issued by the Ministry of Health regarding the contents and arrangement of the Annual Report of the Medical Officer of Health. Particular attention may be drawn to the birth-rate of 12.7 per thousand of population, which is the lowest on record for the Borough, and to the unusual prevalence of scarlet fever. Three developments of outstanding importance, which will greatly improve the Council's public health service, were approved during the year—the erection of a new Health Centre for the North Greenford Ward, the extension of the Isolation Hospital, and the provision of a new Maternity Hospital. In submitting this Report I wish to take the opportunity of expressing my appreciation of the excellent work performed by the staff of the Public Health Department, who have shown a deep and sustained interest in the municipal activities evolved for the protection and improvement of the health of the community. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Officer of Health. 10th July, 1934. 9 SUMMARY OF GENERAL STATISTICS 1933. Area (in Acres) 9,135 Population (Census, 1931) 117,707 Population (Estimated), Middle of 1933 128,800 Number of Inhabited Houses (Census, 1931) 26,717 Number of Inhabited Houses (1st April, 1933) according to Rate Books 32,471 Number of Families or separate Occupiers (Census, 1931) 31,412 Rateable Value (14th Nov., 1933) £1,208,618 Net Produce of a Penny Rate £4,950 Population.—The Registrar-General has estimated the population of the Borough at the middle of 1933 to be 128,800, which constitutes an increase of 6,100 compared with his estimate of the population at the middle of 1932. The birth-rates and death-rates that are contained in this Report are calculated on this estimated population. The Registrar-General has taken into account the rapid growth of the Borough in recent years in estimating that within two years of the last census of population, which was made in April, 1931, the population of the Borough has increased by 9.4 per cent, from 117,707 to 128,800. A summary of the report of the 1931 Census as regards the Borough of Ealing was contained in the Annual Report for last year. Social Conditions.—The suffering occasioned by the serious trade depression throughout the country has only lightly been experienced in Ealing. There have, of course, been numerous cases of hardship through prolonged unemployment, but there has not been the widespread poverty and distress found in the unfortunate industrial communities. The numbers of unemployed men of 21 years and over, resident in the Borough, on the registers of the local Employment Exchanges provide proof of the decrease which took place in unemployment during 1933. Returns furnished by the Managers of the local Employment Exchanges to the Borough Surveyor show that in January 2,535 men were on the registers April 1,891 ditto September 1,317 ditto December 1,298 ditto 10 It is even more satisfactory to record that by May of this year the number of unemployed men had decreased to 1,022. The majority of the working population are engaged in employment outside of the district, mainly in London. In recent years several large factories of a modern character, manufacturing articles of a varied nature, have been erected in the Greenford Ward, but the areas developed for factories do not seriously affect the amenities of the residential areas adjoining. The many public open spaces situated in various parts of the Borough, comprising in all no less than 581 acres, do much to preserve the residential character of the district. In addition, Gunnersbury Park, 186 acres in extent, adjoins the boundaries of the Borough and is partly maintained by the Council. SUMMARY OF VITAL STATISTICS, 1933. Live Births :— Legitimate Males, 831 Females, 750 Total, 1,581— Illegitimate Males, 22 Females, 35 Total, 57— 1,638 Birth-Rate per 1,000 of Estimated Population 12.7 Still-Births:— Males, 44 Females, 37 Total 81 Rate per 1,000 total Births (Live and Still-Births) 47 Deaths : Males, 622 Females, 674 Total 1,296 Death-Rate per 1,000 of Estimated Population 10.1 Deaths of Infants under one year of age:— Legitimate Males, 42 Females, 37 Total, 79— Illegitimate Males, 1 Females, 2 Total, 3— 82 Death-Rate of Infants under one year of age:— All Infants per 1,000 Live Births 50 Legitimate Infants per 1,000 Legitimate Live Births 50 Illegimate Infants per 1,000 Illegitimate Live Births 53 Deaths from Diseases and Accidents of Pregnancy and Childbirth:— From Sepsis 1 Death-Rate per 1,000 Total Births 0.58 From Other Causes 4 „ „ 2.33 Total 5 „ „ 2.91 11  Total Deaths Death-Rate per 1,000 Population Measles — — Whooping Cough 7 0.05 Diphtheria 7 0.05 Scarlet Fever 7 0.05 Influenza 71 0.55 Tuberculosis of Lung 63 0.49 Other Forms of Tuberculosis 17 0.13 Death-Rate per 1,000 Live-Births Diarrhoea (under two years of age) 5 3.1 table I. Comparison of Vital Statistics of Ealing with those of England and Wales, Etc., 1933. England and Wales 118 Great Towns (including London) London Ealing Birth-Rate 14.4 14.4 13.2 12.7 Death-Rate 12.3 12.2 12.2 10.1 Infant Death-Rate 64 67 59 50 Measles Death-Rate 0.05 0.06 0.02 — Whooping Cough Death-Rate 0.05 0.06 0.08 0.05 Diphtheria Death-Rate 0.06 0.08 0.08 0.05 Scarlet Fever Death-Rate 0.02 0.02 0.02 0.05 Influenza Death-Rate 0.57 0.55 0.51 0.55 Diarrhoea under two years per 1,000 Births) 7.1 9.4 11.6 3.1 Birth-Rate.—The birth-rate of 12.7 per thousand of population shows a marked decrease on previous years and is the lowest on record for the Borough, being even less than the abnormally low rate recorded in 1918 at the end of the period of the War. The extent of the decrease in the birth-rate can be seen in Table II and the decrease is particularly noticeable as the birth-rate for the Borough has fluctuated only slightly during the past nine years. The birth-rates for England and Wales (14.4), for the 118 Great Towns (14.4), and for London (13.2) are all higher than the birth-rate for Ealing. 12 Death-Rate.—The number of deaths assigned to the Borough is 1,296, this total being slightly less than in 1932, when there were 1,326 deaths. The death-rate for the Borough is 10.1 per thousand of population, compared with the rate of 10.8 recorded in the previous year. Table I indicates that the death-rate for the Borough (10.1) is well below the rates for England and Wales (12.3), the 118 Great Towns (12.2), and London (12.2). Infant Death-Rate.—The death-rate of infants under one year of age of 50 per thousand live births is higher than the rate for 1932, when a rate of 45 per thousand live births was recorded. Table II shows the infant death-rate for the year under review to be the highest since 1927, this being due to an increase in the number of deaths from premature birth of the infant. The infant death-rate for the Borough still compares very favourably with those for England and Wales, the 118 Great Towns and for London, which are respectively 64, 67 and 59. The causes of infant deaths are indicated in Tables III and IIIa, which show the total number of deaths to be 82. Premature birth accounted for no less than 35 of these deaths, while 13 were due to congenital malformations and six to pneumonia. Table IIIa shows that 40 of the 82 deaths occurred before the infant was one week of age, while 52 deaths occurred before the infant was four weeks of age. This latter figure gives a neo-natal death-rate of 32 per thousand live births. Maternal Mortality.—Five maternal deaths were recorded during the year, only one of them being from puerperal sepsis. The maternal death-rate is 2.91 per thousand total births, compared with 4.23 for England and Wales. Still-Births.—The number of still-births assigned to the Borough was 81, which gives a rate of 47 per thousand of all births. The incidence of still-births again shows an increase compared with rates for previous years, which were 40, 27 and 33 for the years 1932, 1931 and 1930 respectively. 13 table ii. Showing Birth-Rate, Death-Rate and Infant Death-Rate for Ealing for the Years 1911-1933. 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 15.4 12.1 65 1920 20.5 10.2 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 1932 14.4 10.8 45 1933 12.7 10.1 50 14 TABLE III. Causes of Infant Deaths, 1924 to 1933. 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Diarrhoea and Enteritis 4 1 4 3 5 4 3 5 9 4 Premature Birth 7 9 23 20 14 25 14 19 24 35 Congenital Malformations — 10 5 9 6 4 9 9 11 13 Congenital Debility 6 8 13 11 6 10 9 11 4 4 Tuberculous Disease 3 — — — 2 1 2 1 — 1 Syphilis — 1 1 — — — — 1 1 — Meningitis (not Tuberculous) 2 1 1 — 1 3 1 4 — — Convulsions 2 — 1 2 3 3 6 5 4 3 Bronchitis 1 4 7 5 7 2 4 2 — 3 Pneumonia (all forms) 3 5 5 7 4 8 10 11 6 6 Gastritis — — 1 — 1 1 — — — — Common Infectious Diseases 3 3 1 2 — 6 2 1 2 3 Other Causes 11 12 9 15 12 6 11 15 18 10 Totals 46 54 71 74 61 73 71 84 79 82 15 table iiia. Infant Mortality during the Year 1933. 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 All Causes 40 6 4 2 52 11 8 7 4 82 Measles — — — — — — — — — — Whooping Cough — — — — — 1 — 1 1 3 Diphtheria — — Influenza 1 — — — 1 1 — 1 — 3 Tuberculosis of Nervous System — — — — — — — 1 — 1 Tuberculosis of Intestines and Peritoneum — — — — — — — — — — Other Tuberculous Diseases — — — — — — — — — — Syphilis — — — — — — — — — — Meningitis — — — — — — — — — — Convulsions 2 1 — — 3 — — — — 3 Bronchitis — — — — — 2 — 1 — 3 Pneumonia — 1 1 — 2 — 1 1 2 6 Other Respiratory Diseases — — — — — — 1 — — 1 Inflammation of the Stomach — — — — — — — — — — Diarrhoea and Enteritis — — — — — 1 2 1 — 4 Hernia, Intestinal Obstruction — — — — — — — — — — Congenital Malformations 5 — 1 — 6 3 2 1 1 13 Congenital Debility 1 1 — — 2 1 1 — — 4 Premature Birth 28 3 2 1 34 1 — — — 35 Injury at Birth 3 — — — 3 1 — — — 4 Other Diseases Peculiar to Early Infancy — — — — — — — — — — Suffocation—in bed or not stated how — — — — — — 1 — — 1 Inattention at Birth — — — — — — — — — — Other Causes — — — 1 1 — — — — 1 16 Table IV indicates the causes of the 1,296 deaths which have been assigned to the Borough. The three causes accounting for the greatest number of deaths are again shown to be, first, heart disease with 266 deaths, giving a death-rate of 2.07 per thousand of population; second, cancer with 192 deaths, giving a deathrate of 1.49 ; and third, bronchitis and pneumonia with 128 deaths, giving a death-rate of 0.99. The next highest number of deaths was due to influenza from which there were 71 deaths, compared with 40 in the previous year. Of the infectious diseases, scarlet fever, whooping cough and diphtheria were each the cause of seven deaths, giving a deathrate of 0.05 for each disease. As previously mentioned, there were 71 deaths due to influenza, giving a death-rate of 0.55, while 79 deaths were due to tuberculosis, giving a death-rate of 0.62. TABLE IV. Causes of Death, 1933. Cause of Death Male Female Total Typhoid and Paratyphoid Fevers — — — Measles — — — Scarlet Fever 5 2 7 Whooping Cough 1 6 7 Diphtheria — 7 7 Influenza 28 43 71 Encephalitis Lethargica — 1 1 Cerebro-Spinal Fever 1 — 1 Tuberculosis of Respiratory System 28 35 63 Other Tuberculous Diseases 10 7 17 Syphilis 2 — 2 General Paralysis of the Insane, Tabes Dorsalis 3 — 3 Cancer, Malignant Disease 85 107 192 Diabetes 9 10 19 Cerebral Haemorrhage, etc. 28 41 69 Heart Disease 120 146 266 Aneurysm 2 2 4 Other Circulatory Diseases 27 28 55 Bronchitis 32 21 53 Pneumonia (all forms) 43 32 75 Other Respiratory Diseases 11 6 17 Peptic Ulcer 11 3 14 Diarrhoea, etc. (Under two years) 3 2 5 Appendicitis 1 3 4 Cirrhosis of Liver 3 1 4 Other Diseases of Liver, etc. 2 4 6 Other Digestive Diseases 14 13 27 Acute and Chronic Nephritis 20 25 45 Puerperal Sepsis — 1 1 Other Puerperal Causes — 4 4 Congenital Debility, Premature Birth Malformations, etc. 33 24 57 Senility 11 24 35 Suicide 11 4 15 Other Violence 29 9 38 Other Defined Diseases 49 63 112 Causes ill-defined or unknown — — — Total 622 674 1,296 17 GENERAL PROVISION OF HEALTH SERVICES. PATHOLOGICAL LABORATORY. The following table indicates the number of specimens which were examined in the Council's Pathological Laboratory during the year:— Positive Negative Total Diphtheria: From Practitioners in the Borough 49 657 706 From the Isolation Hospital 328 1,994 2,322 Tuberculosis 104 264 368 Miscellaneous 22 274 296 Total 503 3,189 3,692 AMBULANCE FACILITIES. 1. For Cases of Infectious Disease.—Cases of infectious disease requiring removal to the Chiswick and Ealing Isolation Hospital are conveyed in the motor ambulance maintained by the Hospitals Committee. 2. For Non-Infectious and Accident Cases.—The Council has three well-equipped motor ambulances and a day and night service is provided. Following the removal of the Fire Brigade to new quarters at St. Leonard's Road the old Fire Station was taken over and adapted for use as an Ambulance Station. Two ambulances, one of which was purchased during 1933, are housed at this new Ambulance Station, while the third ambulance is kept at the new Fire Station and whenever the regular ambulance drivers are not available the Fire Brigade are able to answer urgent calls. Details of the runs carried out during the past six years are given in the following table:— 18 General Ambulance Service. 1928 1929 1930 1931 1932 1933 Accident Cases Conveyed 520 530 546 729 711 772 Illness Cases Conveyed 1,098 1,070 1,211 1,256 1,322 1,149 Total Cases Conveyed 1,618 1,600 1,757 1,985 2,033 1,921 Number of Journeys outside the Borough (included in above) 253 215 226 268 444 365 Total Number of Miles Travelled 8,379 7,988 11,111 12,301 13,626 13,265 NURSING IN THE HOME. 1. General Diseases-The Greater Ealing Nursing Association and the Northolt Nursing Association provide an admirable home nursing service by means of which persons requiring nursing in their own homes may receive trained assistance at a small cost or, in the case of poor persons, free of cost. The Greater Ealing Nursing Association has a staff of six nurses, while the Northolt Nursing Association, which deals with the Northolt Ward only, has one nurse. The two Associations are closely connected with the Council's Public Health Service and receive financial support from the Council on this account. The nurses render certain nursing services with regard to children under five years of age and expectant and nursing mothers. The District Nurses also assist on certain afternoons at the Health Centres, when they assist in the weighing of the children and in preparing them for examination by the medical officers. During the year they made a total of 1,176 visits to the homes of 137 cases referred to them by the staff at the Health Centres. 19 2. Infectious Diseases.—The staff of the two Nursing Associations give nursing assistance when required to children under five years of age who are suffering from measles, whooping cough, poliomyelitis, otorrhoea or ophthalmia neonatorum. They also attend cases of puerperal fever or puerperal pyrexia, which are being nursed at home, when the doctor in attendance requires their services. CLINICS AND TREATMENT CENTRES. Name. Address. Provided by Health Centre 13, Mattock Lane, Ealing Ealing Town Council Health Centre Cherington House, Han well 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 Special Clinic 13, Mattock Lane, Ealing Ealing Town Council Tuberculosis Dispensary Green Man Passage, West Ealing Middlesex County Council Treatment Centres for Certain Hospitals Middlesex County Venereal Disease in London Council Special Clinic.—Early in the year the Council decided to provide a Special Clinic at which advice on birth control could be given to mothers who are married women and who have been regularly attending one of the Health Centres. Cases are only referred to this Clinic by the Council's Medical Officers and no case is referred unless the Medical Officer is of opinion that further pregnancy would be detrimental to the woman's health. Arrangements have been made for a medical woman experienced in this work to attend at one of the Health Centres on one afternoon in each month and for a Health Visitor, who has been specially instructed in the work, to be in attendance on one afternoon in each week. The first session was held on the 21st April and by 20 the end of the year 46 mothers had received advice. The mothers who are referred to the Clinic are naturally limited in number but the provision of this service is of great importance as it must be realised that each woman attending the Clinic has been specially recommended by a Medical Officer as being in need of advice on the subject on grounds of health. HOSPITALS. 1. Isolation Hospital.—Hospital accommodation for the treatment of cases of infectious disease, other than smallpox, is provided at the Chiswick and Ealing Isolation Hospital, which is situated on the southern borders of the Borough. For some years the accommodation of this hospital has been quite incapable of providing for the ever increasing needs of the Boroughs of Ealing and of Brentford and Chiswick, which in 1921 combined for the provision of this hospital service for both districts. Three years ago the extension of the hospital was proposed by the Hospitals Committee but the matter had to be held in abeyance on account of the serious financial position at the time. Towards the end of 1933, however, the necessity for the extension of the hospital became so pressing that the matter was brought forward again and a definite scheme for the extension of the hospitals was put forward by the Hospitals Committee. The recommendations of the Hospitals Committee (see Appendix to Medical Superintendent's Report) were ultimately approved by the two Councils concerned. These recommendations set out clearly the extent of the proposed extensions :— (1) That the Isolation and Maternity Hospitals be amalgamated to form an enlarged Isolation Hospital. (2) That a Diphtheria Block of 22 beds be erected at an estimated cost of £7,360. (3) That a Cubicle Block of 12 beds be erected at an estimated cost of £4,560. (4) That extensions to the Administrative Block, Laundry, etc., of the Isolation Hospital be carried out at an estimated cost of £7,000. (5) That a new Maternity Hospital be erected on a site in Ealing at an estimated cost of £35,000. 21 When these extensions have been completed the accommodation of the isolation hospital will be increased to 140 beds and the new cubicle block will provide such accommodation as is essential for the efficient isolation and treatment of different diseases such as enteric fever, cerebro-spinal fever, complicated cases of measles and whooping cough, and for dealing with cross-infected cases. 2. Maternity Hospital.—A hospital of 22 beds is provided for the use of residents of the Borough of Brentford and Chiswick and of the Borough of Ealing and is managed by the Chiswick and Ealing Hospitals Committee. The scheme for the extension of the Isolation Hospital, previously mentioned, provides for the amalgamation of the present Maternity Hospital with the adjoining Isolation Hospital. Recommendations regarding the provision of an entirely new maternity hospital of 42 beds on a site at Perivale have been approved by the two Councils and detailed plans are now in the course of preparation. 3. Smallpox Hospital.—The arrangements made for cases of smallpox occurring in the Borough to be treated in the Smallpox Hospitals maintained by the London County Council continue in force. It was not necessary to take advantage of these arrangements during the year. 4. Hospital Provision for Children.—There is a children's ward at the King Edward Memorial Hospital containing 24 beds to which children under five years of age can be admitted when referred for in-patient treatment from the Health Centres. A small children's ward of three beds is also provided at the Hanwell Cottage Hospital. 5. Other Hospitals.—The King Edward Memorial Hospital, a voluntary institution, has accommodation for a total of 130 patients, including the beds for children previously mentioned. The Hanwell Cottage Hospital has accommodation for 16 patients. The Middlesex County Council provide medical, surgical and maternity hospital treatment for persons residing in the Borough at the West Middlesex County Hospital, Isleworth. 22 MATERNITY AND CHILD WELFARE. A detailed summary of the scheme of maternity and child welfare in operation in the Borough has been included in the Annual Reports for the last two years and need not be repeated again on this occasion. The rapid development of the North Greenford Ward has made it necessary for further provision to be made for maternity and child welfare services and the Council has decided to build a new Health Centre to serve this area. Plans for the erection of this new Health Centre have been prepared but some difficulty has been experienced in securing a suitable site. This difficulty has now been overcome and early progress will be made in the construction of this new Centre. The additional work in this rapidly growing area necessitated an increase in the staff of Health Visitors and the Council approved of the appointment of an additional Health Visitor, who commenced duty on the 1st January, 1934. During the year the Middlesex County Council suggested that the provision of a midwife in necessitous cases should be dealt with by one authority. The Town Council had not as a rule provided assistance for cases where the family were receiving assistance from the Public Assistance Authority, but they agreed to accept the responsibility of providing midwives in all necessitous cases, including those receiving relief. In connection with the employment of midwives to attend necessitous cases the Council made a further new decision whereby the fees paid to midwives employed by the Council were increased to £2. 5s. Od. for a primipara and to £2. Os. Od. for a multipara. The summary of the work of the Health Visitors and of the activities of the Health Centres given on the following pages, conveys an idea of the extent to which the maternity and child welfare services are utilised by the mothers. In connection with the work at the Health Centres some extremely valuable assistance is received from a number of voluntary workers who attend regularly and assist at the sessions for children held in the afternoons. Thanks are due to these ladies, prominent among whom are Mrs. Ludlow, Mrs. Narraway, Mrs. 23 Parry and Miss Peal. In addition, the Welfare Working Party meets at the Mattock Lane Centre every fortnight and gives valuable help by making suitable garments for distribution at cost price, or free of charge, to children whose mothers are in necessitous circumstances. The following is a Summary of the Work of the Health Visitors during the year :— Visits to children under 12 months— Total First visits 1,644 Return visits 2,856 Visits to children 1 to 5 years of age 6,455 Visits to expectant mothers 856 Visits to investigate infant deaths and still-births 96 Special visits or investigations 263 Visits to cases of Ophthalmia Neonatorum 20 Visit to case of Pemphigus Neonatorum 1 Visits to cases of Measles and Whooping Cough 64 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 393 Inspections of Women's Lavatories 69 Visits to children under care of foster-mothers 630 Other visits 7 Total Visits 13,354 Interviews, etc., at Centres 3,505 24 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 end of year 1,057 1,225 1,145 167  Mothers visiting Centre for the first time 562 510 604 101 1,777 Children visiting Centre for the first time : Under 1 year 402 370 376 68 1,216 1 to 5 years 285 275 301 52 913 Total attendances made by mothers 8,166 6,962 6,539 1,467 23,134 Total attendances made by children : Under 1 year 5,911 4,964 4,224 934 16,033 1 to 5 years 3,483 3,397 3,919 1,067 11,866 Average attendance of children each afternoon 62 56 53 38 55 Number of Examinations of children by Medical Officer 2,434 2,674 3,097 656 8,861 Average number of children seen by Medical Officer on each Session 16 18 20 13 17 Children referred to School Clinic for treatmen For Nose and Throat ... ... ... ... 28 For Eyes ... ... ... ... 28 For Teeth ... ... ... ... 366 Orthopaedic Treatment ... ... ... ... 86 Minor Ailments ... ... ... ... 21 Children undergoing Ultra-Violet Ray treatment at mg Edward Hospital 5 Mothers receiving dental treatment 288 Mothers supplied with artificial dentures 99 Children referred to King Edward Hospital for minor operations 47 25 Children referred to King Edward Hospital for other reasons 40 Children referred to other Hospitals 56 Expectant Mothers attending Ante-Natal Clinic : First visits 785 Re-visits 3,548 Number of Consultations by Consultant at Centre 33 Mothers referred to Hospitals 71 Aid was provided for mothers at confinement in the following cases : Consultant aid 13 Medical aid 90 Midwives 49 Accouchement Sets 52 Home Helps 14 Dried Milk supplied at cost price Value £469 11 10 Virol supplied at cost price Value £90 5 5 Cod Liver Oil supplied at cost price Value £171 10 6 Number of cases admitted to the Chiswick and Ealing Maternity Hospital 344 Amount received for treatment at Maternity Hospital £1,631 8 8 Number of orders issued granting a supply of milk, free of charge, for a period of 28 days : For Expectant and Nursing Mothers 984 For Children under five years of age 1,400 Medical Examination of Pre-School Children.—The scheme for the systematic medical examination of children between the ages of one and five years which was instituted in 1931 has now become accepted as part of the full scheme of maternity and child welfare, every effort being made to get all children between the ages mentioned to attend the Centre each year for medical examination. During the year under review 1,944 children were examined, compared with 1,845 during the previous year. The examination and treatment of these young children is carried out on the same lines as in dealing with school children and these examinations serve to bridge the gap before the child comes under the supervision of the School Medical Service. 26 INFANT LIFE PROTECTION (CHILDREN ACTS). The law relating to Infant Life Protection is contained in Part I of the Children Act, 1908, as amended by Part V of the Children and Young Persons Act, 1932, and the Second and Fourth Schedules to this Act. The amendments effected by the Act of 1932 came into force on the 1st January, 1933, and particulars regarding the new requirements with regard to the reception of children for reward were sent to every person in the Borough who had been registered as a fostermother since the 1st April, 1930, when the Council became the authority responsible for the supervision of fosterchildren. Information regarding the Children Acts was also published by advertisement in the local Press and by the display of notices at the Health Centres and on public notice boards. The visiting of children placed in the care of fostermothers is carried out by the Health Visitors, who have been designated Infant Protection Visitors. Information regarding fosterchildren registered in the Borough is given in the following table :— Number of children on the register at the beginning of the year 96 (Number of fostermothers having care of the above children—70). Number of children registered during the year 89 Number of children removed from register during year : Removed by parents from care of fostermother 44 Removed for adoption through a Society 10 Removed to Hospital 2 Removed to a Children's Home or School 11 Child attained nine years of age 1 Child legally adopted by fostermother 2 Child died (No inquest held) 1 Fostermother left district, taking child with her 2 Child removed from care of fostermother at request of Medical Officer of Health 6 79 27 Number of children on register at end of year 106 (Number of fostermothers having care of these children—82). Number of visits made by Infant Protection Visitors 630 It will be seen that during the year six children were removed from the care of fostermothers as a result of requests made by the Medical Officer of Health. In three instances the removal of the child was requested because the person applying for registration was found unsuitable to act as a fostermother, while the removal of the remaining three children was required on account of the fostermothers receiving them being found to have accommodation for one child only. As these requests for the removal of children were complied with proceedings to secure an Order for the removal of a child to a place of safety were not necessary. ORTHOPAEDIC TREATMENT. A scheme, made in co-operation with the Royal National Orthopaedic Hospital, has been in force for some years whereby children under five years of age may be referred to the school medical department for examination by an Orthopaedic Surgeon who attends at the Mattock Lane Centre each month. Treatment by means of massage and special exercises is carried out in the special building provided at the rear of the Mattock Lane Centre, while children requiring hospital treatment are admitted to the Stanmore Branch of the Royal National Orthopaedic Hospital. Details of the children dealt with at the Orthopaedic Clinic are given on page 85. DENTAL TREATMENT OF EXPECTANT AND NURSING MOTHERS. During the year 994 attendances were made by 259 expectant and nursing mothers to receive dental treatment. This is a small increase over the previous year, when 241 mothers attended. Very little opportunity was afforded for conservative work, as in most of the cases referred for treatment advanced decay and sepsis were found. A large number of mothers therefore had complete removal of the teeth. In some of the mouths of the 28 younger mothers it was possible to do fillings, and an opportunity was found to advise the mothers on the treatment of diseased gums and on the care of the teeth during nursing. The work carried out included extractions, fillings and scalings. The number of fillings inserted was 143, and compared with those teeth filled last year was smaller by 54. Extractions totalled 2,073. Full or partial dentures were supplied to 99 mothers as against 114 last year. DENTAL TREATMENT OF PRE-SCHOOL CHILDREN. Attendances of pre-school children at the Centres continue to increase each year. One would like to see more of these children attend, and at a younger age, for nearly all come when they are almost ready to go to school. Their teeth at this time are as a rule very badly decayed and this means extraction. The parents see the folly of neglect when an explanation is given and as a result of this an assurance is usually forthcoming from the parents that the permanent set will be attended to, when necessary, after subsequent inspections in the schools. The work carried out for these children was mostly extractions, but fortunately for the children of the more careful mothers, fillings only were required. In all, 3,039 teeth were removed on account of advanced decay, and 374 teeth were filled. This work was done for 308 children, 638 attendances at the Centres by the children being required. ADMINISTRATION OF MIDWIVES ACTS, 1902 to 1926. The Town Council has been the local supervising authority under the Midwives Acts since the 1st October, 1930. During the year under review 50 midwives notified their intention to practise within the Borough, this number including eleven midwives residing outside the district. In addition, three midwives residing outside the Borough notified that they had acted as a midwife at one case only. Of the 39 midwives residing in the Borough, 17 were engaged in private practice, 13 were engaged in nursing homes, and nine 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. 29 Number of births attended by midwives :— When acting in the capacity of midwife : (a). In Chiswick and Ealing Maternity Hospital 499 (b) In private Nursing Homes 62 (c) At the patient's home 364 When acting in the capacity of maternity nurse (a doctor being in attendance) : (а) In private Nursing Homes 190 (б) At the patient's home 121 Notifications.—The number of notifications received from midwives, in accordance with the Rules of the Central Midwives Board, was as follows :— Notifications of : Sending for medical assistance : On account of a complication of pregnancy 36 On account of a complication during labour 91 On account of a complication during the puerperium 9 On account of the health of the child 23 Still-birth 11 Death—Infant 4 Laying out of a Dead Body 2 Artificial Feeding of Infant 11 Liability of Midwife to be a source of Infection 2 Total 189 Ophthalmia Neonatorum.—Among the 23 notifications of sending for medical assistance on account of the health of the child were included nine on account of inflammation of, or discharge from, the eyes. In three of these cases the medical practitioner called in by the midwife notified the case as ophthalmia neonatorum. Visits to Midwives.—The Assistant Medical Officer who is the Inspector of Midwives visits the midwives resident in the Borough who are engaged in district midwifery. During the year 30 34 routine visits of inspection were made, while one special visit of enquiry was necessary in connection with a case of puerperal pyrexia which occurred in the practice of a midwife. Payment of Fees.—-The Town Council paid to medical practitioners called in by midwives, during the year under review, fees amounting to £117 Is. Od. in respect of 90 claims submitted. The Council has power to recover from the patient, 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 the fees reclaimed was £39 3s. 8d. Post-Certificate Instruction of Midwives.—The arrangements made with the London County Council in previous years for midwives resident in the Borough to attend the courses of lectures and practical demonstrations organised by that authority were continued during 1933, the Town Council being responsible for a proportion of the cost based on the number of midwives who availed themselves of the opportunity to attend. MATERNITY AND NURSING HOMES. The Town Council has been the authority responsible for the administration of the Nursing Homes Registration Act, 1927, since the 1st October, 1930. Seven applications for registration were received during the year, three being in respect of premises not previously used as nursing homes, one in respect of premises formerly conducted as a Christian Science Home and exempted by the Minister of Health from the operation of the Nursing Homes Registration Act, while the remaining three applications were in respect of established nursing homes transferred to new ownership. Six of these applications were approved by the Council, but in the seventh the Council were unable to approve of the use of the premises as a nursing home, or of the arrangements proposed with regard to the nursing of the patients, and, after complying with the requirements of Section 3 (1) of the Nursing Homes Registration Act, made an order that the application be refused. 31 Four applications for the renewal of certificates of exemption and one new application in respect of the Dame Gertrude Young Memorial Convalescent Home, which was opened during the year in connection with the Central London Throat, Nose and Ear Hospital, were granted. The Assistant Medical Officer who acts as Inspector of Midwives and Nursing Homes made 51 visits to nursing homes during the year, while the Chief Sanitary Inspector visited seven homes to give advice regarding various sanitary matters and to take the measurements of the rooms concerned in new applications. In one nursing home it was found that the staffing arrangements were inadequate to deal with the class of case admitted and the Council instructed that the cases in this Home be restricted to chronic cases only. 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 22 (14) 207 (77) Number of applications for registration 7 — Number of Homes registered 6 — Number of Orders made refusing registration 1 Number of Nursing Homes discontinued 2 — Number of Nursing Homes on Register at end of year 26 (14) 239 (68) (The figures shown in brackets indicate the number of Homes and the number of Beds devoted wholly or partly to the reception of maternity cases). The occurrence of several births at an address not registered as a Nursing Home led to the discovery of a person who had been receiving maternity cases into her home without applying for registration under the Nursing Homes Registration Act. The person concerned, who had apparently acted in ignorance, 32 immediately gave an undertaking not to take any cases in the future and, after the matter had been considered by the Council, was warned that should she again receive a case into her house proceedings would be taken against her. 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 complaints were received from the Greenford Ward regarding the insufficient supply of water, particularly on Sundays and Mondays. These complaints were well founded, and representations were made to the Water Company. Since these representations were made the dead ends of mains in different parts of the district have been connected up and a " boosting " station to give greater pressure of water in the higher parts of the district has been established. These works have resulted in a marked improvement in the pressure. A local " boosting " station is yet required in order automatically to raise the pressure in the mains in the highest parts of the district when this increased pressure is required during periods of heavy demand. Rivers and. Streams.—No complaints were received during the year regarding the pollution of any stream running through the district. Drainage and Sewerage.—Excepting in the undeveloped portions of the Mount Park, Greenford and Northolt Wards, the whole of the houses are supplied with water closets and are drained to the sewerage system. During the year a further section of sewer was laid in Church Road, Northolt, and connected to the Bengarth Road pumping station. The drains of 18 houses were connected to this sewer and 18 cesspools were consequently abolished. There are five separate disposal works in the Borough, situated in North Ealing (Perivale), South Ealing, Hanwell, Greenford and Northolt. 33 In view of the progress of the West Middlesex Sewerage Scheme no new plant was installed and no extensions were, made during the year. 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 as a rule one water closet 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 undeveloped areas mentioned, at the end of 1933. of 1933. It shows a further reduction in the number of cesspools, particularly in the Northolt Ward. Wards. Cesspools. Water Closets. PailClosets. Houses within 100 feet of Sewer. No. of Houses., Northolt 44 53 25 6 78 Greenford 13 13 4 6 18 Hanwell North 2 2 — — 2 Mount Park and Drayton 13 16 16 32 72 84 45 12 130 Public Cleansing.—The whole of the Borough is scavenged directly by the Council. House refuse is collected mainly in low loading covered mechanical vehicles, but partly in horse drawn carts, and transported to the two incinerators at South Ealing and Hanwell, which deal adequately with the work they are called upon to perform. There are no earth closets or privies in the Borough. The Council undertake the emptying of certain cesspools on payment of a nominal charge. The sewage is pumped into a tank and afterwards discharged into the nearest sew;er. Refuse Dumps.—The two refuse dumps which have in the past been sources of persistent nuisance have given less trouble during the year. Both are now being conducted on the controlled tipping plan. 34 The St. Marylebone dump has been very well managed, although on one occasion during the year a complaint had to be made on account of the screened material, which was placed on the top of the deposited refuse, being of a putrescent character and giving off an offensive odour. The dump just over the boundary at Yeading is in a much better condition than formerly, and although the controlled tipping is not on the best lines, because too deep and too long a surface is exposed at a time and there is too little covering as the tipping goes on, yet there is much less to complain of because there is no burning. The burning of the rubbish was formerly the main cause of complaint. Smoke Abatement.—It is only occasionally that action is called for in abating nuisances from smoke as there are comparatively few factories in the Borough with steam raising plants. Seventeen observations were made on chimneys during the year, and it was necessary to make representations in five instances 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, 1926. In four cases the nuisance was caused by improper stoking and advice given to the stoker was effectual in causing an abatement; in the other case the stoker was not using the smoke consuming apparatus attached to the boiler. Premises and Occupations subject to Control by the Local Authority.—-There are no common lodging houses in the Borough and there are no Byelaws with respect to houseslet-in-lodgings. There are only two offensive trades carried on in the Borough, namely, fishfrying, which is conducted in 21 separate premises, and that of tallow melting, which is carried on in premises in the Greenford Ward. During the year 11 applications were received for permission to establish the trade of fishfrying. In two instances permission was granted, but in neither was the business commenced prior to the end of the year. All the fishfrying premises except one are equipped with up-to-date frying ranges, most of them with fan extractors, so that nuisance is reduced to a minimum. 35 Schools.—A thorough inspection of all the public elementary and private schools is made at least once a year by the Sanitary Inspectors, and on their reports steps are taken to remedy any defects found. In the control of non-notifiable infectious diseases routine reports of absentees continue to be furnished weekly by the headteachers 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 and to give the mothers advice regarding the prevention of the spread of infection and the avoidance of complications in such conditions as measles and whooping cough. It was not found necessary to close any school in order to check the prevalence of infectious disease. Rag Flock Acts, 1911 and 1928.—Inspections were made of the upholsterers' workshops. In all instances where bedding is made or re-made it was found that wool flock was used. This flock was found to have been purchased from the wholesalers under a guarantee that it conforms to the Government standard of purity. No samples were taken. It is very doubtful if any rag flock is used in the Borough. INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—There are only six cowkeepers on the register as producers of milk. At the end of year there were on the register 123 retail purveyors of milk. Twenty-one 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 nine purveyors of milk were registered with respect to premises used for other purposes to retail milk in sealed receptacles only, seven new purveyors of milk were registered who had purchased premises from others who were on the register, and four with premises in other districts were registered U- retail milk within the Borough. No new dairies were registered during the year. One business was discontinued and the name of the owner was taken off the register as a retail purveyor of milk. 36 Milk (Special Designations) Order, 1923.—Under this Order 90 licences were granted during the year, 15 for the sale of Certified Milk, 23 for Grade A (Tuberculin Tested) Milk, and 52 for Pasteurised Milk. Three samples of Pasteurised Milk were taken for bacteriological examination. In all of them the results came within the standard laid down by the Order. Twenty-five samples of ordinary unclassified milk were examined for general bacterial count. Fourteen of these were found to contain over 200,000 bacteria per cubic centimetre, the maximum being 4,600,000. The attention of the vendors was drawn to the condition of the milk and advice was given to exercise more care in the sterilisation of milk utensils. The advice apparently was of value for further samples gave a more satisfactory result. Twelve samples of ordinary milk were submitted to biological examination at the Lister Institute for the presence of tubercle bacilli, but in no case were these bacilli found. The attention given in recent years to improving the methods of milk distribution has resulted in a high standard of equipment and management. All those premises which are not simply distributing centres have been fitted with steam boilers for the production of steam necessary for the sterilisation of all bottles and utensils. During the past year one dairy was equipped with a bottle washing apparatus with final steam jets and another was provided with a steam sterilising cabinet, these being the two exceptions mentioned in the previous report where proper sterilisation of the bottles was not carried out. The practice of insisting upon proper storage of the milk in general stores has been continued, and all those premises registered for the sale of milk in sealed receptacles only have been provided with insulated containers in which to store the milk. By this means milk delivered at a low temperature keeps well even during the warmest weather. Endeavours to abolish counter pans have met with complete success, there being none now in use in the Borough. 37 Meat and Other Foods.—There were no infringements of the Public Health (Meat) Regulations. No meat is sold from stalls in the Borough. There are four private slaughterhouses, but most of the killing is done in two. During the year 106 cattle, 953 sheep, 763 pigs and 105 calves were slaughtered in these slaughterhouses. All these animals Were stunned by means of a humane implement and all meat was inspected. There is no public slaughterhouse in the Borough. 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. Beef 780 lbs. Pork 821 lbs. Veal 87 lbs. Mutton 33 lbs. Fish 70 lbs. Rabbits 41 lbs. Fruit 400 lbs. Hams 853 lbs. The Slaughter of Animals Act which was passed during the year provides for the slaughtering or stunning with a mechanicallyoperated instrument of all animals killed in a slaughterhouse or knacker's yard, and for the licencing of slaughtermen. The first provision was not, however, applicable to sheep, ewes, wethers, rams and lambs unless adopted by resolution of the Local Authority. A Byelaw for the humane slaughtering of all animals had been in force since 1921 in the Borough, so that it was only natural that the Town Council, at their meeting in September, should resolve to give the necessary notice of their intention to apply Section 1 to the slaughter of sheep, etc., within the Borough. The necessary steps were taken with regard to the licensing of slaughtermen as required by the Act. Fifteen application^ for licences were received. The applicants were of good character and were all granted the necessary authority to slaughter. 38 Food and Drugs Adulteration Act, 1928.—Mr. Richard Robinson, the Chief Officer of the Public Control Department of the Middlesex County Council, has kindly furnished the following information regarding samples of food taken by the staff of his department within the area of the Borough :— List of Samples taken during the year ended 31s/ December, 1933. Article. Taken. Adulterated. Milk 284 7 Milk, sterilized 5 2 Milk, separated ... 1 — Butter 4 — Minced Beef 5 — Meat 2 — Sausages 10 — Hake 22 3 Lemon Soles 14 7 Sweets 1 — Total 348 19 Number of Prosecutions 6 Number of Convictions 4 One prosecution was instituted against a farmer for supplying to an Ealing dairyman three churns of milk containing respectively 10%, 10% and 18% of added water, and fines amounting to £3 together with £10 10s. costs were imposed. Two fishmongers were each fined £1 and costs (25s.) for selling witches for lemon soles, and one fishmonger was fined £1 and costs (21s.) for selling haddock for hake. Summonses against two fishmongers for selling coalfish for hake and megrims for lemon soles were dismissed. Sanitary Inspection of the Borough.—The following tabular statement shows the extent of the work carried out by the Sanitary Inspectors during the year :— 39 General. Number of Premises inspected on Complaint 797 Number of Nuisances observed by Inspectors 136 Number of Premises inspected in connection with Infectious Disease 729 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, etc.) 4,077 Number of Houses inspected under House-to-House Survey 586 Food Inspections 2,943 Total Number of Re-inspections 12,523 Other Inspections 1,273 Total Number of Inspections and Re-inspections 23,064 Number of Intimation Notices given 505 Number of other Letters written 500 Number of Statutory Notices served 120 Proceedings before Magistrates 3 Milk and Dairies Act, Etc. Number of Cowsheds on Register 5 Number of Inspections made of Cowsheds 16 Contraventions of Act or Orders 2 Number of Retail Purveyors of Milk on Register 123 Number of Inspections of Retail Purveyors' Premises 406 Contraventions of Act or Orders 6 Proceedings before Magistrates — Slaughterhouses. Number of Registered or Licensed Slaughterhouses 4 Number of Inspections made 397 Contraventions of Regulations — Proceedings before Magistrates — Factories and Workshops. Registered Workshops 191 Factories 141 Number of Inspections of Factories and Workshops and Workplaces 518 Number of Defects concerning which Notices were sent 66 Proceedings before Magistrates — 40 Offensive Trades. Fried Fish Shops 21 Other Offensive Trades 1 Number of Inspections 239 Contraventions — Disinfection. 'Ropms Disinfected by Spray :— (a) Ordinary Infectious Disease 380 (b) Tuberculosis 148 Rooms stripped and cleansed 55 Articles Disinfected by Steam at Disinfector :— « (a) Ordinary Infectious Disease 1,403 (b) Tuberculosis 554 Articles voluntarily destroyed 208 Particulars of the Sanitary Defects Remedied as a Result of Notices Served and Letters Written. Water Closets repaired or supplied with water or otherwise improved 247 Drains cleared and cleansed 124 Defects in drains repaired 99 Drains reconstructed 64 Dust-bins provided 89 Overcrowding remedied 2 Accumulations of refuse removed 59 Nuisance from fowls and other animals abated 6 Damp-proof courses inserted in walls 307 Ventilation under floors provided 33 Other forms of dampness remedied 224 Yards paved and repaired 144 Floors repaired 72 Roofs, gutters and rain water pipes repaired 344 New soil and ventilating pipes provided 62 Sinks and waste-pipes repaired or renewed 157 Draw taps fixed to main supply 36 Dirty walls and ceilings stripped and cleansed 691 Other defects or nuisances remedied 713 Cisterns cleansed, renewed and covered 21 Houses connected to sewer 20 Water supply re-instated 60 41 Legal proceedings were taken in the following six cases, with the results indicated :— (a) Non-Compliance with Statutory Notices, Section 94, Public Health Act, 1875. The summonses were heard at Ealing Police Court with the following results : (1) Piggeries, Ruislip Road, Hanwell : animals so kept as to be a nuisance or injurious to health. An Order was given for works to be carried out in six weeks. The piggery was eventually abolished. (2) 22, Broughton Road : premises in such a damp and dirty condition as to be a nuisance or injurious to health. An Order was made for notice to be complied within 21 days. An appeal by the owner against this Order to the Divisional Court of the High Court of Justice was dismissed with costs against appellant. (3) 40, Grange Road : obstructed condition of gully. An Order was made for gully to be cleared in 14 days with 8s. 6d. costs against defendant. (b) Section 43, Public Health Act, 1925, Section 9 (1) Housing of the Working Classes Act, 1885, and Section 94, Public Health Act, 1875. Bridge Farm, Northolt : van used for human habitation in such a way as to be a nuisance or injurious to health or to cause a nuisance or give rise to conditions injurious to health. An Order was made prohibiting the use of the van for human habitation in the Borough of Ealing. (c) Section 52, Ealing Corporation Act, 1905. 3, Station Parade, Oldfield Lane, Greenford : dwelling house > not provided with a proper and sufficient water supply. A fine of £5 was inflicted. 42 (d) Section 39, Housing Act, 1930. Whittingham Farm, West End, Northolt : occupation of a dwelling house subject to a Demolition Order. An Order for possession in not less than two, or more than four weeks, was granted. Public Mortuary.—A public mortuary maintained by the Town Council is situated in the Council's Depot in Longfield Avenue and during the year under review 87 bodies were deposited therein. Facilities are provided for medical practitioners to perform post mortem examinations and in 41 cases during the year such an examination was carried out. FACTORIES, WORKSHOPS AND WORKPLACES. 1.—Inspection of Factories, Workshops and Workplaces. Including Inspections made by Sanitary Inspector or Inspectors of Nuisances. Number of Premises (1) Inspections (2) Written Notices (3) Prosecutions (4) Factories 238 11 — (Including Factory Laundries) Workshops ... 280 28 — (Including Workshop Laundries) Workplaces ... — — — (Other than Outworkers' Premises) Total 518 39 — 43 2.—Defects found in Factories, Workshops and Workplaces. Number of Defects Particulars (1) Found (2) Remedied (3) Referred to H.M. Inspector (4) Number of Prosecutions (5) Nuisances under the Public Health Acts— Want of Cleanliness 21 21 Want of Ventilation 2 2 — — Overcrowding — — — — Want of drainage of floors 1 1 — — Other Nuisances 17 17 — — Sanitary accommodation insufficient 5 5 — — unsuitable or defective 16 16 — — not separate for sexes 1 1 — Offences under the Factory and Workshop Acts Illegal occupation of underground bakehouse (s 101) — — — — Other Offences 3 3 — — (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.) — — — — Total 66 66 — — Outwork in Unwholesome Premises, Sec. 108. Nature of Work Instances Notices Served Prosecution Wearing Apparel Making, Etc. — — — Others — — — 44 HOUSING. In December, 1930, the Medical Officer reporting to the Housing Committee on the action contemplated under the Housing Act of 1930, stated that after a survey of the whole Borough he had compiled a 1ist of 81 houses which he proposed, as opportunity offered, to represent as unfit for human habitation. The whole of these with the addition of a further two houses have been dealt with by the Public Health Committee. Undertakings by the owners not to re-let the houses for human habitation have been given in 22 instances, 24 demolition orders have been made, nine houses have been reconditioned, three houses have been voluntarily demolished, and 25 houses have been represented as unfit for human habitation, action regarding these pending at the end of the year. Good progress has been made with the reconditioning of individually unfit houses, 181 having been completed during the year, making a total of 471 out of the 816 estimated in 1930 to be dealt with in five years. 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) 1,816 (b) Number of inspections made for the purpose 1,859 (2) (a) Number of dwelling houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 587 (b) Number of inspections made for the purpose 630 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 43 (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 981 45 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 882 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 — B.—Proceedings under Public Health Acts : (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 86 (2) Number of dwelling houses in which defects were remedied after service of formal notice :— (a) by Owners 74 (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 1 (2) Number of dwelling houses demolished in ance of Demolition Orders 2 46 (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 8 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 — During the year 2,341 houses were built in the Borough by private enterprise. None of these could, strictly speaking, be deemed as houses for the working classes, being intended for purchase by the occupiers. The Town Council completed three houses of the non-parlour type in the South Hanwell Ward. Negotiations have been commenced for the purchase of a site in Cow Lane, Greenford, for the erection of a further 60 houses. These houses will be used primarily for the housing of tenants displaced under Section 19 of the Housing Act, 1930. 47 PREVALENCE OF, AND CONTROL OVER, INFECTIOUS DISEASES. The numbers of cases of the various infectious diseases notified during the past twelve years are indicated in Table V, which shows that during 1933 a further increase occurred in the total number of cases of infectious disease notified. This increase was almost entirely due to the unusual prevalence of scarlet fever. There was also a slight increase over the previous year in the number of cases of diphtheria and of pulmonary tuberculosis, while a marked decrease occurred in the number of cases of pneumonia. Table v. Disease 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Smallpox — — — — — — 1 1 1 — — — Diphtheria 282 56 61 40 72 53 68 90 129 83 54 71 Scarlet Fever 487 142 123 107 156 136 313 231 264 154 407 476 Enteric Fever (including Paratyphoid) 3 5 9 5 4 14 12 1 4 1 3 4 Puerperal Fever 3 9 3 6 1 6 2 2 7 6 4 3 Puerperal Pyrexia — — — — 3 15 16 13 26 18 21 28 Pneumonia : Primary 33 32 47 57 47 66 73 100 78 96 85 56 Influenzal 22 7 27 22 17 38 13 59 12 18 50 32 Acute Poliomyelitis — — 3 — 1 — — 1 — 2 4 3 Cerebro-Spinal Fever — 1 — — — 2 — 1 — — — — Malaria 4 2 — 2 5 6 4 4 2 1 — 1 Dysentery 1 — — — — — 1 — — — — — Erysipelas 22 17 25 17 15 18 28 24 34 20 30 36 Encephalitis Lethargica 3 1 6 4 2 6 3 3 1 1 1 — Tuberculosis :— (a) Pulmonary 69 92 74 90 93 89 99 109 111 141 141 154 (b) Non-Pulmonary 16 26 31 25 21 16 24 27 22 27 27 23 Ophthalmia Neonatorum 10 3 3 6 5 4 8 9 9 9 5 8 Total . 955 393 412 381 442 469 665 675 700 577 832 895 48 Table VI. Diphtheria. Scarlet Fever. January 4 34 February 3 40 March 1 33 April 3 41 May 11 55 June 10 38 July 4 42 August 12 22 September 1 37 October 3 31 November 10 38 December 9 65 Total 71 476 table vii. Cases of Infectious Disease notified during the Year 1932 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 1 6 3 6 29 14 3 5 3 — — 71 67 Scarlet Fever — 12 19 35 32 186 103 28 48 7 4 2 476 383 Enteric Fever (including Paratyphoid) — — — — — — — 1 — 3 — — 4 3 Puerperal Fever — — — — — — — — 3 — — — 3 3 Puerperal Pyrexia — — — — — — — 2 24 2 — — 28 22 Pneumonia : Primary 2 2 — 2 2 3 3 — 10 10 10 12 56 6 Influenzal — — 1 — 1 1 1 2 7 4 10 5 32 3 Acute Poliomyelitis — — — — — 1 1 — 1 — — — 3 1 Cerebro-Spinal Fever — — — — — — — — — — — — — — Malaria — — — — — — — — — 1 — — 1 1 Dysentery — — — — — — — — — — — — — — Erysipelas — — 1 — — 1 1 4 6 7 13 3 36 7 Encephalitis Lethargica — — — — — — — — — — — — — — Tuberculosis : (a) Pulmonary Male — — — — — 2 1 7 39 7 19 2 77 — Female 2 — — — — — 2 11 42 13 6 1 77 — (b) Non-Pulmonary Male — 1 — — — 3 — — 3 1 — — 8 — Female — — — — 1 1 1 2 8 1 1 — 15 — Ophthalmia Neonatorum 8 — — — — — — — — — — — 8 5 Total 13 16 27 40 42 227 127 60 196 59 63 25 895 — 49 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 — — 5 — — — — 1 — 7 Scarlet Fever — — — — 1 4 1 — — 1 — — 7 Enteric Fever (including Paratyphoid) — — — — — — — — — — — — — Puerperal Sepsis — — — — — — — — — 1 — — 1 Pneumonia : Primary 6 1 1 — — 2 — — 5 2 21 22 60 Influenzal — — — — — — — — — 2 6 7 15 Acute Poliomyelitis — — — — — — 2 — — 1 — — 3 Cerebro-Spinal Fever — 1 — — — — — — — — — — 1 Malaria — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — Erysipelas — — — — — — — — 2 — 2 — 4 Encephalitis Lethargica — — — — — — — — — — 1 — 1 Tuberculosis : (a) Pulmonary Male — — — — — — 1 2 11 3 10 1 28 Female — — — — — — — 4 18 5 5 3 35 (b) Non-Pulmonary Male — 1 — — 1 1 — 1 4 — 2 — 10 Female 1 — — — 1 — — — 3 1 — 1 7 Ophthalmia Neonatorum — — — — — — — — — — — — — Totals 7 3 2 — 3 12 4 7 43 16 48 34 179 50 table ix. Cases of Scarlet Fever occurring in each Month, shown according to Wards. Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Total 1933 Total 1932 Drayton 4 9 4 5 7 4 6 2 5 1 2 4 53 55 Castlebar 2 1 2 — 1 — 1 — 4 2 3 2 18 10 Mount Park 1 1 1 1 2 3 2 2 2 1 2 5 23 9 Lammas — 1 2 2 7 6 3 1 7 6 4 11 50 42 Manor — 4 1 4 1 6 1 1 2 — 2 6 28 38 Grange 10 8 6 3 8 1 4 2 4 7 10 10 73 76 Grosvenor 4 5 1 4 4 3 5 1 1 3 4 7 42 31 Hanwell North 4 3 5 9 3 3 1 1 1 — 2 4 36 64 Hanwell South 3 1 6 2 1 4 6 — 1 — 3 5 32 29 Greenford 6 7 4 8 16 5 10 7 4 2 3 10 82 45 Northolt — — 1 3 5 3 3 5 6 9 3 1 39 8 Total 34 40 33 41 55 38 42 22 37 31 38 65 476 407 51 52 Diphtheria.—Although the total number of cases of diphtheria shows an increase compared with the previous year, 71 cases being notified compared with 54, the number is less than in the years 1929, 1930 and 1931. Besides, the occurrence of cases of this disease within the Borough continues to be well below that experienced in the rest of the country. The diphtheria case-rate for Ealing of 0.55 per thousand of population is less than half of the case-rate of 1.18 for England and Wales. Table VI indicates the cases as they occurred in the different months of the year and from this table it will be seen that very few cases indeed occurred in the first four months of the year, while the highest number of cases, 12, occurred in the month of August, although, as a general rule, infectious disease tends to be less prevalent in this month when the schools are closed. During the year there occurred seven deaths which give a death-rate of 0.05 per thousand of population and a mortality rate of 9.86 per cent, of cases notified. The death-rate for Ealing is slightly below that for England and Wales, which is 0.06 per thousand of population. All seven deaths were of females, five occurring after admission to the Chiswick and Ealing Isolation Hospital, one after a patient had been nursed at home for a period of six weeks and one occurring in an institution outside the district. Several of these deaths have demonstrated the calamitous results of delay in administering anti-toxin. They have also pointed out in no uncertain way the dire consequences of delay in diagnosis. Doctors have apparently not all learnt the lesson that it is dangerous to wait for the result of the swab and that it is imperative to treat every suspicious case of diphtheria in the only way which gives the patient every chance of recovery, namely, by the immediate administration of anti-toxin. Every opportunity has been taken to urge medical practitioners to administer antitoxin to suspicious cases. A new method of drawing the attention of local doctors to this important matter has been adopted recently by enclosing a leaflet with every swab outfit issued from the Council's pathological laboratory. This leaflet emphasises the importance of the early treatment of suspicious cases of diphtheria and reminds medical practitioners that a free supply of anti-toxin may be obtained from the Public Health Department for all patients whose home circumstances are poor. 53 " Diagnosis of Diphtheria. When it is suspected, on clinical grounds, that a child may be suffering from diphtheria, it is a wise precaution to treat the case as one of diphtheria without waiting for bacteriological confirmation of the diagnosis. A negative result to a culture made from a single swabbing does not exclude a diagnosis of diphtheria since so many factors may prevent the discovery of the specific organism. The patient's chance of recovery is greatly increased when diphtheria anti-toxin is administered in the earliest stages of the disease, while unnecessary delay may endanger the patient's life. No harm can result if the injection is subsequently proved to have been unnecessary. When the parents are in poor circumstances a free supply of diphtheria anti-toxin may be obtained from the Public Health Department, Town Hall, Ealing." During the year under review 252,000 units were supplied for 29 cases. Scarlet Fever.—The number of cases of scarlet fever notified during the year under review was 476, an increase of 69 on the total of 407 cases occurring in 1932. The scarlet fever case-rate for the Borough of 3.70 per thousand of population is again above the rate for England and Wales, which is 3.21. Table VI indicates the months of the year in which the cases occurred and shows that the disease continued prevalent throughout the whole twelve months. December, with 65 cases, showed the greatest prevalence, while August, with 22 cases, was the only month in which the average number ot cases was less than one per day. Unfortunately there were seven deaths from the disease. One occurred while the patient was being nursed at home, the second occurred in an institution outside the district, while the remaining five occurred in the Chiswick and Ealing Isolation Hospital. The death-rate from scarlet fever for Ealing of 0.05 per thousand of population is above that for England and Wales, which is 0.02. Although the number of cases notified during the year under review was high the prevalence of cases was less than in 1921 and 1922 when scarlet fever previously reached epidemic proportions. If the disease had been as widespread as in 1921 and 1922, with the increased population one might have had to contend with as many as a thousand cases in a year. The number of cases at the end of the year showed no signs of diminishing, in fact, in the first four months of 1934 the number of notifications increased by almost 50 per cent, compared with the corresponding period of 1933. 54 Throughout the greater part of the year it has been necessary to exercise some measure of selection in regard to the cases admitted to the Isolation Hospital and to arrange, whenever possible, that patients suffering from the disease in a mild form should be nursed at home. For this purpose it has been essential for every case to be visited by the Sanitary Inspector prior to arranging for admission to the hospital so that full information regarding the home circumstances could be available to determine the necessity for removal. Despite this limitation of admissions the accommodation at the Isolation Hospital for cases of scarlet fever was severely taxed throughout the whole year and on several occasions every bed was occupied and urgent cases had to be refused admission. Fortunately the Willesden Isolation Hospital was able to admit ten cases of scarlet fever whose treatment in hospital was urgently necessary. To encourage the home-nursing of cases as far as possible the following letter was issued to all medical practitioners in the Borough of Ealing :— Prevalence of Scarlet Fever. 14th December, 1933. Dear Sir, Owing to the prevalence of scarlet fever in the Borough and the accommodation at the Isolation Hospital being overtaxed it is not possible to remove to hospital all cases of scarlet fever. It is now generally recognised that it is not necessary to treat all cases in hospital and as far as practicable cases should be nursed at home. Whenever the condition of the patient or the home circumstances or both call for the removal of the patient to hospital every effort will be made to effect removal. Sometimes if removal is not immediately practicable it may be in the course of a day or two. To make sure that all cases are treated on their merits an enquiry is made regarding all of them before removal and while the recommendation of the medical practitioner will receive every consideration it must be clearly understood that my decision, as Medical Officer of Health and Medical Superintendent of the Hospital, is the one that must be accepted in all cases. Yours faithfully, THOMAS ORR, Medical Officer." Enteric Fever.—Four cases of enteric fever were notified during the year. Particulars regarding these cases are as follows :— (1) Male, 36 years of age ; a farmer staying at an hotel in Ealing. There was a history of relations in the country also suffering from a similar illness. This led to the discovery of other cases. 55 (2) Male, 38 years of age ; chauffeur at a country house in Sussex where another servant was also said to be ill. (3) Male, 24 years of age. No ascertained source of infection. (4) Female, 37 years of age. No ascertained source of infection. The first case was admitted to the Chiswick and Ealing Isolation Hospital, the second and third cases were admitted, by arrangement, to the Willesden Isolation Hospital, while the fourth case was nursed in the West Middlesex County Hospital. There were no deaths from the disease. Puerperal Fever and Puerperal Pyrexia.—Three cases of puerperal fever were notified during the year, all occurring in the Chiswick and Ealing Maternity Hospital. The case-rate for Ealing of 1.7 per thousand total births compares favourably with the rate of 3.5 per thousand total births for the whole of England and Wales. The number of cases of puerperal pyrexia notified during the year was 28, this showing an increase on the 21 cases notified in the previous year. Nineteen cases occurred in the Chiswick and Ealing Maternity Hospital, one in a private nursing home, one in an institution in London, while the remaining seven cases occurred at home. The case-rate for Ealing of 16.3 per thousand total births is well above the case-rate for England and Wales of 9.6 per thousand total births. These figures suggest that more cases of puerperal pyrexia are experienced in Ealing than in the country generally, but there is one factor that must be taken into consideration in comparing these case-rates. Included in the 19 cases notified from the Chiswick and Ealing Maternity Hospital are seven in which the home address of the patient was in the Borough of Brentford and Chiswick. While the Borough of Ealing has to be credited with all the cases of puerperal pyrexia occurring in the hospital it must be remembered that the births which take place are assigned to the areas in which the homes of the patients are situated. It may be mentioned that on the 1st April, 1934, by reason of the adjustment of the Borough boundaries, the Maternity Hospital was transferred to the area of Brentford and Chiswick, which will, in future, receive all these notifications of puerperal pyrexia. 56 One case notified by a medical practitioner as puerperal pyrexia was diagnosed later as puerperal septicaemia and died. This was the only death occurring from puerperal septicaemia and the death-rate for the Borough from this condition of 0.58 per thousand total births compares very favourably with the rate for England and Wales of 1.71. Primary and Influenzal Pneumonia.—The number of cases of primary pneumonia notified was 56 and the number of cases of influenzal pneumonia 32. The number of deaths registered during the year from these two causes, 60 from primary pneumonia and 15 from influenzal pneumonia, suggests that many cases occur which are not notified. Acute Poliomyelitis.—Three cases of this disease were notified during the year and one of these, a boy 14 years of age, proved fatal. In addition, three deaths from this disease occurred in institutions outside the district, the deaths being assigned to the Borough although the cases were not notified. Cerebro-Spinal Fever.—The death of a child, aged 20 months, was certified as occurring from this disease, the death taking place in an institution outside the Borough. The case was not notified previous to admission to hospital. Encephalitis Lethargica.—No case of this disease was notified during the year, although one death, a woman 62 years of age, was recorded as occurring from this disease in an institution outside the district. Ophthalmia Neonatorum.—Eight cases coming under this heading were notified. A summary of the cases, with the result of treatment, is given in the following table :— Number of Cases Notified No. Treated Vision unimpaired Vision impaired Total Blindness Deaths At Home In Hospital 8 3 5 6 2 — — 57 Malaria and Dysentery.—One case of malaria was notified during the year, this being a man 38 years of age who had spent three years in West Africa and Singapore and who had had a few mild attacks of the disease previously. The diagnosis of a case notified as acute bacillary dysentery was not confirmed and the notification was withdrawn. Tuberculosis.—The number of new cases of tuberculosis notified during the year and the number of deaths which occurred are shown in Table IX. The cases of pulmonary tuberculosis notified for the first time totalled 154, this number showing an increase on the total of 141 cases in each of the two previous years. Twenty-three cases of non-pulmonary tuberculosis were notified, a number which is four less than that recorded in each of the two previous years, and two less than the average for the previous five years. The total number of deaths from the disease was 80 (pulmonary 63, non-pulmonary 17), this figure being one more than in the previous year. Owing to the increase in population, however, the tuberculosis death-rate again shows a slight decrease and the figure of 0.62 per thousand of population is the lowest death-rate from the disease in the last twelve years. Twelve persons were certified as dying from pulmonary tuberculosis although they had not been notified as suffering from the disease, seven of these being attended by local doctors and five dying outside the district. Four deaths from nonpulmonary tuberculosis had not been previously notified, two being attended by local doctors and two dying outside the district. Where a local medical practitioner fails to notify a case previous to death a communication is sent drawing his attention to the requirements of the Public Health (Notification of Infectious Disease) Regulations, 1918. The number of cases remaining on the tuberculosis register at the end of the year was 514 (416 pulmonary and 98 nonpulmonary), this total comparing with 475 (366 pulmonary and 109 non-pulmonary) at the end of 1932. Every effort is made to keep the information in this register up-to-date. Periodically information is obtained from the Tuberculosis Officer regarding 58 cases in attendance at the County Council Dispensary and from the Sanitary Inspectors who visit the homes of patients to ascertain their condition and to verify their continued residence in the Borough. TABLE IX. Tuberculosis. Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 – 2 – – 1 1—5 – – 1 1 — — 2 1 5—10 2 — 3 1 — — 1 — 10—15 1 2 — 1 1 — — — 15—20 7 11 — 2 2 4 1 — 20—25 10 17 — 2 1 10 2 1 25—35 29 25 3 6 10 8 2 2 35—45 7 13 1 1 3 5 — 1 45—55 12 4 — 1 6 3 — — 55—65 7 2 — — 4 2 2 — 65 upwards 2 1 — — 1 3 — 1 Total 77 77 8 15 28 35 10 7 The Tuberculosis Officer has been good enough to supply the following information with respect to patients from the Borough who have been dealt with during 1933 at the Middlesex County Council Dispensary at West Ealing :— Number of persons examined for the first time : (a) Tuberculosis of Lungs 103 (&) Other forms of Tuberculosis 15 Number of persons in Institutions at end of year : (a) Tuberculosis of Lungs 64 (b) Other forms of Tuberculosis 16 Number of persons under observation at end of year 153 Number sent to Sanatoria during year 119 Number sent to Hospital during year 24 59 Whooping Cough and Measles.—Information regarding the prevalence of these two non-notifiable infectious diseases is obtained from the weekly returns of absentees on account of infectious disease which are supplied by the head-teachers of the elementary schools. These returns show that during 1933 as many as 553 children were absent on account of whooping cough in comparison with 187 in the previous year. The absentees due to measles, however, were only 233, this figure being in marked contrast to that of the previous year when 1,829 children were reported to be absent on account of the disease. Seven deaths occurred from whooping cough, giving a deathrate of 0.05 per thousand of population, which is the same as the death-rate for England and Wales. The deaths from whooping cough included three children under one year of age and children of 18 months, 19 months, two years and five years. In six cases out of seven, broncho-pneumonia was stated to be a secondary cause of death. There were no deaths from measles in the Borough although the death-rate from this disease for England and Wales was 0.05 per thousand of population. HEALTH EDUCATION. A very complete summary of the steps taken to impart to the general public a knowledge of matters relating to the health of the individual and of the community was contained in the Annual Report for 1931. During the year under review a new edition of the booklet entitled "The Public Health Service of the Town Council," which sets out in detail the whole of the public health facilities available to residents in the Borough, was published and the issue of many other booklets and leaflets was continued. One additional method of bringing to the notice of the public matters appertaining to public health was adopted by the Council and that was by the display of posters issued by the Central Council for Health Education on a large notice board handed over to the Council by the Empire Marketing Board. 60 LOCAL GOVERNMENT AND OTHER OFFICERS' SUPERANNUATION ACT, 1922. During the year under review 118 medical examinations were made of candidates previous to admission to the Council's staff. The total number of examinations carried out since the Act was adopted in Ealing in 1923 is now 945. Borough of Ealing. EDUCATION COMMITTEE. REPORT OF THE School Medical Officer FOR THE Year ended 31st December, 1933. 62 EDUCATION GENERAL PURPOSES SUB-COMMITTEE, 1932-33. (Responsible for the School Medical Service). Chairman— Councillor H. M. Sayers. V ice- Chairman— Alderman J. C. Fuller. The Rev. C. J. Sharp, M.A. (ex-officio, Chairman of the Education Committee). Councillor G. R. Weeks, (ex-officio, Vice-Chairman of the Education Committee). Alderman W. T. White, J.P. Councillor E. H. Atkinson. Councillor E. H. Brooks. Councillor W. Jennings. Councillor T. P. May. Councillor Mrs. E. S. Taylor, J.P. Miss D. L. Beck, M.A. Mr. J. E. Childs. Mr. E. Heaton. Rev. T. B. Scrutton, M.A. Miss C. G. Wilson, L.L.A. 63 STAFF. School Medical Officer— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Assistant School Medical Officers— John Petrie, M.B., Ch.B., D.P.H. John D. Kershaw, M.B., B.S., D.P.H. Dorothy Taylor, M.B., B.S., M.R.C.S., L.R.C.P. 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, F.R.C.S. (Eng.), M.R.C.S., L.R.C.P. (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). Supervising School Nurse— Hilda Bailey. 64 School Nurses— Annie Johnson. May P. Dorkins. Mary McGann. Marjorie Coslett. Kathleen Howard. 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. 65 CO-ORDINATION. In reports for previous years, particularly in that for 1931, reference was made to the steps taken to obtain the complete co-ordination of the school medical and the maternity and child welfare services and there is therefore no occasion to refer to the matter further except to state that during the year under review 1,944 children between one and five years of age attending the child welfare centres underwent a complete medical examination, records of which were made on the lines of the schedule of school medical inspection, treatment being offered for defects discovered in the same way as with school children. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. At the end of the year there were under the control of the Education Committee 24 schools embracing 41 departments. The new Stanhope Senior School was opened during the year. The building of the Perivale Infants' and Junior School was commenced and plans were being prepared at the end of the year for two new schools, Ravenor Junior and Horsenden Senior. The reconstruction of Christchurch School, a voluntary school, effected a marked improvement which was long overdue. Arising from the transfer of St. John's School to the Local Education Authority it was decided to effect an extensive reconstruction and plans were in course of preparation at the end of the year. Since 1928 the following new schools have been opened:— School. Year opened. Accommodation. Coston Junior 1928 400 Stanhope Infants' 1930 400 Stanhope Junior 1930 400 Horsenden Infants' 1931 400 Horsenden Senior Mixed 1931 400 Coston Senior Girls' 1931 320 Wood End 1931 400 Grange Infants' 1931 400 Bordeston Senior Boys' 1932 360 Stanhope Senior Boys' 1933 400 66 In the following table the increase in the number of children on the School Registers and of children medically inspected in recent years is indicated :— Year. Routine Inspections. Total. Average number on School Registers. Entrants. Intermediates. Leavers. 1926 812 546 456 1,814 6,396 1927 1,316 1,086 1,238 3,640 9,480 1928 1,001 1,557 1,437 3,995 9,744 1929 1,172 1,568 849 3,589 10,442 1930 1,976 1,545 880 4,401 10,822 1931 1,821 2,030 1,084 4,935 11,769 1932 1,604 1,713 1,639 4,956 12,479 1933 1,748 1,857 1,608 5,213 13,253 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 year or attaining twelve before the end of the current year, together with those over that age not previously inspected. 67 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. (&) 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. 68 The following tables give the total number of children in the various schools who were examined at medical inspection. The children included 1,748 entrants, 1,857 intermediates, and 1,608 leavers, making 5,213 as the total number of children inspected in a routine way. Number of Children Inspected. School. Entrants Total Boys Girls Provided. Drayton 58 35 93 Grange 57 58 115 Hobbayne 32 45 77 Lammas 31 37 68 Little Ealing 74 77 151 North Ealing 41 32 73 Northfields 67 57 124 Northolt 26 25 51 Oaklands 64 49 113 St. Ann's 31 32 63 St. John's 8 26 34 St. Mark's 33 49 82 Stanhope 74 97 171 Horsenden 87 88 175 Wood End 12 23 35 Non-Provided. Betham's 83 62 145 St. Joseph's 14 14 28 St. Mary's 27 21 48 St. Saviour's 54 48 102 Total 873 875 1,748 69 Number of Children Inspected. School. Intermediates Total Leavers Total Boys Girls Boys Girls Provided. Central — — — 66 52 118 Coston 56 67 123 117 75 192 Drayton 43 42 85 52 36 88 Grange 69 59 128 21 143 164 Hobbayne 38 55 93 22 17 39 Lammas 41 30 71 — — — Little Ealing 66 42 108 149 20 169 North Ealing 48 66 114 24 20 44 Northfields 63 66 129 — 80 80 Northolt 22 20 42 14 15 29 Oaklands 67 51 118 29 27 56 St. Ann's 32 24 56 84 57 141 St. John's 23 17 40 28 36 64 St. Mark's 32 25 57 10 12 22 Stanhope 81 77 158 28 40 68 Horsenden 103 124 227 73 71 144 Wood End 29 39 68 18 20 38 Bordeston 3 — 3 84 — 84 Non-Provided. Betham's 24 17 41 — — — Christ Church 35 39 74 11 14 25 St. Joseph's 14 14 28 11 12 23 St. Mary's 28 29 57 9 11 20 St. Saviour's 19 18 37 _ _ _ Total 936 921 1857 850 758 1608 70 At the Health Centres 3,060 non-routine inspections were made of children who were submitted by the head-teachers, school enquiry officers or school nurses owing to some defect or suspected defect, and of whom 1,105 attended for re-inspection. On account of a defect being found at a previous routine or non-routine inspection 1,158 children were submitted to a re-examination. There were, therefore, 5,323 special inspections or re-inspections of children. These numbers embrace all the examinations of physically and mentally defective children who are kept under supervision and are re-examined at least once in each year. The total number of children attending public elementary schools who were examined once at least during the year was 8,273. The average number of children on the school register was 13,253. This means that during the year 62.4 per cent, of the children on the registers were medically examined. The average attendance at the schools was 88.6 per cent, of the children on the registers. FINDINGS OF SCHOOL MEDICAL INSPECTION. The number of defects noted on routine medical inspection at the schools and on the occasion of the special inspections or re-inspections are given in Table II. Among the 5,213 children examined in a routine manner there were, excluding uncleanliness and dental disease, 695 defects requiring treatment and 1,480 requiring to be kept under observation without treatment; and among 3,060 children specially examined there were found 2,178 defects requiring treatment and 370 requiring to be kept under observation. Of the children examined at the routine inspections 12.4 per cent, were found to require treatment for defective conditions. (a) Diseases of the Skin.—At the routine inspection there were found one case of ringworm of the head, one of ringworm of the body, 4 of impetigo, and 11 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:— 71 Ringworm of Head 7 Ringworm of Body 12 Scabies 27 Impetigo 295 Other Skin Conditions 162 503 (b) Diseases of the Eye.—(1) External.—Five cases of blepharitis, 3 of conjunctivitis, 42 of squint, and four of other abnormal conditions of the eyes were observed at routine medical inspection ; and 47 cases of blepharitis, 68 of conjunctivitis, 26 of squint and 58 of other conditions were found in children referred for special examination. Of these cases, 246 were advised to have treatment and 7 were recommended to be kept under observation. (2) Defective Vision.—-During the routine inspection 250 children were found with defective vision and referred for examination by an Oculist. As a result of special inspection 299 were also referred to an Oculist. (c) Ear Disease and Defective Hearing.—Three cases of defective hearing, 11 of otitis media and 13 other conditions of the ears requiring treatment, and 8 cases of defective hearing and one other condition requiring to be kept under observation, were found at routine medical inspection. Special inspections discovered 2 cases of defective hearing, 70 of otitis media, and 59 of other conditions of the ear requiring treatment and three cases of defective hearing to be kept under observation. (id) Chronic Tonsexitis (Enlarged Tonsils) and Adenoids.— At the routine inspection 160 children were found with chronic tonsillitis, 7 with adenoids, 37 with chronic tonsillitis and adenoids, and six with other conditions of the nose and throat requiring treatment. Children with these conditions who had to be kept under observation numbered 828. In addition, 80 cases of chronic tonsillitis, 4 of adenoids, 28 of chronic tonsillitis and adenoids, and 81 of other conditions requiring treatment, as well as 115 cases of similar diseases of the nose and throat requiring to be kept under observation were found on special inspection. 72 (e) Tuberculosis.—Ten suspected cases of pulmonary tuberculosis requiring to be kept under observation were found at routine medical inspection. One definite case of pulmonary tuberculosis in which the disease was quiescent and therefore had to be kept under observation, and 8 suspected cases were found on special inspection. One case of tuberculosis of the ankle requiring to be kept under observation was found at routine medical inspection and one case of tuberculosis of the glands requiring treatment was found on special examination. (/) Deformities.—The crippled children under supervision at the end of the year numbered 28. One of these was so severely affected that he was unable to attend an ordinary elementary school and was maintained at a Special School. As has been pointed out in previous Annual Reports, 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 the 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 encountered in the course of their duties. Each crippled child newly admitted to school is examined by the orthopaedic surgeon 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 that is required under the Committee's Orthopaedic Scheme. The ascertainment of crippled children under school age through the Child Welfare Centres, and their submission to treatment in the early years of life before being admitted to schools, not only enables early treatment to be effectively carried out, but relieves to a large extent the crippling condition and reduces the amount of treatment required when they enter school. 73 (g) Uncleanliness.—As in previous years, the heads of all the girls attending the public elementary schools were inspected three times in the year after the usual school holidays. Of the 28,695 examinations of children carried out in this way, 625 individual children were found to be in an uncleanly condition and 257, or 0.9 per cent., were excluded. There were 58 children with verminous heads and two with verminous bodies found at the routine medical inspection in the schools and 50 found at special inspection after being referred for examination by the headteachers. The low percentage of exclusions shows that the policy of routine inspections coupled with the exclusion of those with more than a few nits in the head followed by the compelling of the parents to clean the heads of the children and to keep them clean, with the threat of a summons under the School Attendance Byelaws in the background, is the best one. The plan of cleansing the children's heads under Section 87 of the Education Act with the threat of further action is never so effective. The table which follows shows how clean the children have progressively become in the course of the last eleven years. 74 Uncleanliness, 1923—1933. 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 1932 25,252 325 1.3 — 1933 27,438 257 0.9 — INFECTIOUS DISEASE. By means of the returns of non-notifiable infectious disease, supplied at the end of each week by the head-teachers, it was ascertained that during the year the numbers of children absent from school on account of these diseases were as follows :— Measles 233 Whooping Cough 573 Chicken Pox 530 Mumps 582 75 The reduction of the attendance below 60 per cent, was attributed to the prevalence of infectious disease at the following schools and certificates were supplied by the School Medical Officer to that effect under Para. 15 (ii) of the Administrative Memorandum No. 51 of the Board of Education :— Northfields Infants' School, week ending 28th January : (Influenza). Northolt School, week ending 28th January : (Influenza). Children to the number of 277 were excluded during the year under Article 20 (b) of the Education Code for the following conditions apart from uncleanliness :— Conjunctivitis 1 Impetigo 231 Ringworm of Head 7 Ringworm of Body 7 Scabies 27 Other Skin Diseases 4 Total 277 No closure took place under Article 22 or 23 (b) of the Code. TREATMENT OF DEFECTIVE CONDITIONS. [a) Minor Ailments.—The number of cases of minor ailments treated are included in Table IV, Group 1. There were 516 cases of disease of the skin referred for treatment, 431 of which were treated at the Health Centres and 85 otherwise. In this table are shown under the term " Miscellaneous," 561 cases which include such conditions as minor injuries, sores, chilblains, etc., and of these 495 were treated at the Health Centres and 66 otherwise. During the year four cases of ringworm of the head were treated and cured by means of X-rays by Dr. Arthur. It will be seen that of the 299 cases of impetigo, 295 were treated at the Health Centres, and that of 27 cases of scabies, 23 were treated at the Health Centres. 76 As many as 1,190 of the 1,408 children suffering from minor ailments, or 84.5 per cent., were treated at the Health Centres and only 218, or 15.5 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 2,587 Ear Cases 1,055 Eye Cases 2,076 Ringworm 115 Scabies 145 Eczema 139 Minor Injuries 1,184 Others 4,258 Total 11,559 (b) External Eye Disease.—The number of children referred for treatment of external eye diseases was 178, of whom 144 were treated at the Health Centres. (c) Defective Vision.—The report of the School Oculist, Dr. J. D. Kershaw, is here submitted:— " During the year 1933, 887 cases attended the Health Centre for examination by the Oculist, making a total number of 2,586 attendances. Spectacles were prescribed in 747 cases, the remainder either requiring none or needing no change in spectacles previously prescribed. " The numbers show an increase in both new cases and reinspections (12 in the former and 146 in the latter), a fact which is highly gratifying since it means that the ideal of annual reexamination in all cases and six-monthly re-examination in special cases is being more closely approached. In addition, the waiting list has been so reduced that a child referred for testing can be examined within a few days of the defect being reported. " There has been no alteration in the method of examinationAs I mentioned last year, the three attendances made by each patient render prescription more accurate and do not so increase the demands on the staff as to cause any difficulty in coping with 77 the large numbers tested during the year. In fact, it should be possible to deal with an even greater number of children without increasing the number of sessions. Time is frequently wasted by the non-attendance of patients. On some occasions more than half those for whom appointments have been made at a session have failed to keep them and it is very unusual to get a full attendance at a session devoted to retinoscopy. " This serious loss of time is sometimes caused by unavoidable sudden illness of a child or parent and is to this extent impossible to remedy. A commoner cause, however, is the difficulty found by patients in coming to the Mattock Lane Centre from outlying parts of the Borough and it is likely that the holding of sessions at Greenford, to be commenced at Easter, 1934, will obviate this. The wastage would be still further reduced if parents unwilling or unable to bring their children at the time fixed would inform the School Medical Officer of this in time for the vacancy to be given to another child. " The general balance of the figures is much the same as in previous years. Hypermetropia and hypermetropic astigmatism total 388 cases, as against 343 of myopia and myopic astigmatism. The corresponding numbers for 1932 were 360 and 249, the apparent relative increase of myopia and myopic astigmatism being due to the fact that children suffering from these defects in a severe or moderately severe form are tested every six months instead of every year. It is important to remember, also, that slight degrees of myopia produce greater disability than similar degrees of hypermetropia and cause medical aid to be sought earlier, with the result that though almost all the short-sighted children in the Borough are under care, only a comparatively small proportion of the longsighted ones are examined at the Centre. A small degree of hypermetropia is normal in the child but in all probability there is a considerable number of children in our schools who would benefit by the correction of this defect but who are not brought in for treatment by ordinary routine examinations. " The treatment of myopic children is proceeding along the lines I laid down in my last report, with results which, though less satisfying than those of a " sight-saving class," well justify the trouble taken by the teachers. In some schools, indeed the co-operation and interest of the teachers has been obtained to such a degree 78 that the children are being as ably and successfully dealt with as they could be in a special class and are making progress which reflects the highest credit upon those in charge of them. It is unfortunate that circumstances do not permit this in all cases, but exigencies of accommodation and the amount of time demanded of the teachers make it impossible as a general thing. Moreover, the attitude and influence of the parent are incalculable factors which, none the less, are potent to enhance or nullify the pains taken by the teacher. " In view of the seriousness of squinting in small children, it is very gratifying to note that there is an increase in the number of children sent up by the Welfare Centres, both as new cases and for re-inspection. In 1932, eleven new cases were submitted, all with squint, while in 1933 this number increased to twenty-one with squint and two with inflammatory conditions. The remaining fourteen patients from the Welfare Centres were nursing or expectant mothers complaining, in the main, of headache. At the same time, however, no fewer than twenty-five children of school age, suffering from squint, were seen for the first time, showing that there are still young children who are not being treated early enough for this important defect. " Emmetropia, or normal sight, was found in sixty-four children submitted for examination, thirty-four new cases and thirty re-inspections. The latter were mostly long-sighted children who, their symptoms relieved by glasses, had lost their disability. The former were referred for testing on account of conjunctivitis, one case, headache, five cases, visual defect at non-routine inspection, 10 cases, visual defect at school medical inspection, 18 cases. In those suffering from headache, refraction was carried out to exclude any visual defect as a cause, and, if no such disability was found, treatment along other lines wr.s advised. " In those children who appeared to have defective vision at routine or non-routine inspection and were yet found to be emmetropic, the apparent defect can be ascribed to such factors as nervousness or defective illumination of the test type and, a common cause, to the fact that during the testing of the first eye, the second has been covered in such a way that the eyeball has been pressed and its vision temporarily dimmed. For this reason the child 79 should never be asked to cover one eye with the hand while the other is being tested. A card or a folded paper should always be used. " A small number of children counterfeit visual defect because they wish, for purposes of adornment or other reasons, to wear glasses. Such counterfeiting can be detected without much difficulty when a mydriatic is used, a fact which might usefully be brought to the notice of those parents who allow a child's myopia to progress untreated because they believe that his complaints are only due to a desire to wear glasses. It cannot be too strongly stressed that the slightest complaint of blurred or failing vision on the part of a child is an urgent reason for the seeking of medical advice. " The other eye complaints which brought children to the Health Centres were conjunctivitis, blepharitis, and styes. An acute attack of any of these three conditions would receive local treatment, but recurrences or the existence of an inflammation of long standing should always be regarded as a sufficient indication for refraction. Sixteen children with chronic lid affections (stye or blepharitis) were tested by refraction and were all found to have refractive errors. In every case seen again the prescription of glasses was found to be followed by a marked improvement in the inflammation. Of six children with conjunctivitis, five had refractive errors and had their condition improved by the wearing of glasses. " It must be emphasised that recurrent inflammation of the eyes, in the same way as headache, is an early sign of defective vision which is to be regarded as one of nature's warnings which must not be neglected. " On the whole the year has been a highly satisfactory one, in which the routine of eye treatment at present carried out in Ealing has completely justified itself. There is however one criticism and suggestion which might usefully be made. " It is the practice at School Medical Inspection to refer for refraction only those children in whom the visual acuity of one or both eyes is A or less. As was pointed out at the beginning of this report, moderate hypermetropia and slight myopia may and frequently do cause a smaller degree of disability, while yet being severe enough to justify full investigation. While it is impracticable and undesirable to refract fully all children who read S in one or 80 both eyes, they should receive particular consideration and therefore enquiry is made by the Medical Officer inspecting in such a case whether there is any history of headaches, conjunctivitis, blepharitis or styes and whether any member of the family suffers from myopia or astigmatism. The existence of any of these would justify the submission of the child for refraction, since it is better that a child should be tested by refraction and found emmetropic than that it should be left alone and possibly develop a serious defect later. " In the absence of such symptoms or history, the parent should be warned that the child's vision is, apparently, slightly defective, that, although this may be of no significance, there is a possibility of its becoming worse, and that, therefore, the parent should watch carefully for the occurrence of symptoms and should seek treatment if they arise." School Children. New Cases Old Cases. Hypermetropia 98 126 Hypermetropic Astigmatism 65 99 Myopia 102 128 Myopic Astigmatism 45 68 Mixed Astigmatism 23 27 Emmetropia ... 34 30 Total (School children) 367 478 Referred from Welfare Centres. Hypermetropia 16 5 Hypermetropic Astigmatism 9 — Myopia 7 — Myopic Astigmatism 3 — Emmetropia 2 — Total (all cases) 404 483 81 (d) Ear Disease and Hearing.—Of the 153 children with ear defects who received treatment, 120 were treated at the Health Centres. (e) Enlarged Tonsils (Chronic Tonsillitis) and Adenoids.— It is shown in Table IV, Group III, that 84 cases of enlarged tonsils and six cases of enlarged tonsils with adenoids were submitted for operation at the Mattock Lane Health Centre, and that 72 cases were dealt with at hospitals or by private practitioners. Much attention has recently been directed by medical men to the value of the operation of tonsillectomy and particularly to the question of defining what amount of enlargement or pathological condition of the tonsil justifies operation. Since the early days of medical inspection when it was assumed that even a moderate degree of enlargement indicated a pathological condition and justified operation, there has been growing up a decided change of opinion which has been brought about by various circumstances. One circumstance noted in Ealing was that some children recorded when attending a public elementary school as having enlarged tonsils and deemed to require operation were later found on examination in the Secondary School to have normal tonsils even though no operation had been carried out in the meantime. This itself caused much thought, so much so that a definite policy was laid down regarding the giving of advice in cases of enlarged tonsils. In the Annual Report for 1922 it was stated: " The cases in which operation for enlarged tonsils is recommended are those which suffer from {a) repeated attacks of sore throat, (6) repeated colds, (c) chronic enlargement of the tonsils causing more or less obstruction, (d) deafness or earache, (e) otorrhoea or (/) " winter coughs," as they are often called by the parents. In 1922 there was a distinct fall in the number of cases recommended, and consequently submitted, for operation, and this reduced number was maintained for four years but afterwards as a result of changes in personnel, apart from the increase in the school population, the number gradually increased until it was felt that some clear and definite guidance to the medical staff was required. It must not be assumed that the numbers recommended for operation had reached an excessive figure compared with other districts. The number had increased simply in relation to previous numbers 82 in Ealing itself although it remained low in comparison with that of other areas. Before offering this guidance it was considered desirable to study the subject according to the latest evidence available, namely, that of the children themselves in attendance at school who had been found to have on previous examinations some degree of enlargement of the tonsils and who were advised or not, according to the extent of the enlargement, operative treatment. The enquiry was entrusted to Dr. J. D. Kershaw, who received much help from other members of the staff, and whose report is reprinted elsewhere in this report. In consequence of this report, with the conclusions of which there can be wholehearted agreement, a memorandum was issued to the medical staff in which a general plan was formulated in noting degrees of enlarged tonsils and in offering advice to the parents regarding the advisability of operation. The memorandum to the staff is as follows:— " Enlarged Tonsils in School children. "As a consequence of observation of cases of enlarged tonsils in school children and of the results of operations, facts have been elicited which lead to certain general principles being laid down with regard to cases of enlarged tonsils discovered on school medical inspection. " Some conditions appear to be consistently relieved by operation, such as, susceptibility to colds or a winter cough, recurrent sore throats, mouthbreathing, earache, otorrhoea and deafness. Whenever any one of these conditions exists in a marked degree, associated with the presence of enlarged tonsils or adenoids, and has no more obvious cause, it is advisable to recommend operation. " In children who have enlarged tonsils without symptoms, or with symptoms of a less marked degree, a conservative policy should be adopted. Enlarged tonsils should be divided into three groups and should be indicated on the record cards as 1,2 and 3. 1 is slight—reaching half way to the posterior pillar of the fauces, 2 is moderate—reaching to the posterior pillar, and 3 is large—concealing part or all of the edge of the posterior pillar. " ' Large ' tonsils (3) should be put down for observation if no symptoms are present and for treatment if any of the above-named symptoms are found. " Tonsils of the other two groups may be ignored if symptomless. The presence of one marked symptom should cause the child to be put down for re-examination after three or six months and the presence of two symptoms / should be regarded as adequate reason for operation. " Tonsils showing evidence of sepsis such as exudate from the crypts, or an inflammatory zone on the anterior pillar of the fauces, should, if associated with no symptoms, be noted in the first place for observation. If they are associated with any symptoms treatment by operation is indicated. When operation is advised ' op ' should be marked after the letter indicating the extent of the enlargement and ' Re ' for observation meaning re-examination. A note indicating the reason for the recommendation of operation is advisable under ' general observations.' " This arbitrary scale is intended as a rough guide only. It should not be allowed to over-ride any urgent indications or contra-indications in individual children. 83 " A further point of importance is that whenever a child is set down for observation in respect of enlarged tonsils, any dental defect should be immediately and completely treated." (/) Defective Speech.—According to the plan mentioned in the last Annual Report, the class for children with defective speech was transferred in January, 1933, to the Ravenor Park Health Centre, Greenford. The accommodation provided in the class is for 12 children only, and at first the places were filled entirely with children suffering from speech defects other than stammering, of whom there were 17 in the district. As children were discharged, their places were filled by others and, when these had all been drafted into the class, further vacancies were filled by stammering children. By the close of 1933 all the children with defects other than stammering had completed their course of treatment and 9 stammerers had begun to attend, the residual vacancies being left for filling in January, 1934. The subjoined table shows the effect of treatment upon the seventeen children who had been discharged during the year. Cured. Much Improved. Improved. Unimproved. Left District. 5 7 4 1 1 Of the four improved, one had made only about one-quarter of the possible number of attendances and it was therefore felt that he was unlikely to benefit by further attendance. The child marked as " unimproved " left the district after only three attendances at the class. Of the nine stammering children remaining in the class at the close of the year, all had begun to show some improvement. The 12 stammering children who ceased to attend the class when it left the Mattock Lane Centre were all advised to continue practice in relaxation and their head-teachers undertook to provide 84 opportunities for this in school. The value of this procedure is shown by the fact that in spite of the cessation of formal special instruction, only one of these children has retrogressed, the remainder having either held their ground or made further progress. It is expected that at some time during 1934 the class will return to Mattock Lane, when provision will be made for a further course of instruction for those who require it. Gratitude is again due to the head-teachers of the schools which these children with speech defects attend, since their interest and co-operation in the treatment is undoubtedly one of the most important factors in ensuring success. (g) Heart Disease and Rheumatism.—During the yeai there were found in the course of routine and special inspections 26 children suffering from organic and 57 from functional affection of the heart and 20 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 depends on their condition, and parents are advised as to treatment. A report of the home conditions in each case is made by the Sanitary Inspector, 19 such reports being made during the year, and defects such as dampness are remedied. Whenever treatment is called for at a hospital school arrangements are made for their admission to the Edgar Lee or the West Wickham Home. (h) Tuberculosis.—Eighteen children were referred to the Tuberculosis Officer for supervision, all being suspected of having tuberculosis of the lungs. One case of glandular tuberculosis was referred to the Tuberculosis Officer for treatment and one of the ankle in which the disease was quiescent was kept under supervision. 85 (i) Orthopaedic Treatment.—During the year the Orthopaedic Surgeon examined, on the occasion of his fortnightly visits, 81 new cases of school children said to be suffering from crippling conditions, lateral curvature, or round shoulders. There were 237 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 by physical exercises over a period of a few months. Eight children received operative treatment at the National Orthopaedic Hospital and 40 were given massage and special exercises. The attendances for massage or special exercises numbered 1,771. Eleven children were supplied with surgical appliances which were ordered by the Surgeon. In addition to the school children, 81 children under five years of age were submitted for a first examination by the Surgeon, 137 re-inspections being subsequently necessary. The attendances of children under five years requiring massage numbered 445. Six children under school age were supplied with special boots or surgical appliances, and one was operated on at Stanmore Hospital. 86 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 16 7 23 Hallux Rigidus — 1 1 Hallux Valgus — 2 2 Hammer Toe 2 — 2 Deformed Hand 1 — 1 Genu Valgum (Knock-knees) 14 25 39 Genu Varum (Bow-legs) 7 1 8 Scoliosis (Lateral Curvature) 12 15 27 Kyphosis (Round Shoulders) 14 17 31 Lordosis (Curvature) 3 4 7 Torticollis (Wry Neck) — 2 2 Paralytic Conditions:— Hemiplegia 1 3 4 Diplegia — 1 1 Paraplegia 1 — 1 Infantile Paralysis 4 4 8 Talipes (Club Foot) 3 1 4 Tuberculous Knee 1* — 1 Tuberculous Hip 1* — 1 Birth Palsy 1 3 4 Spina Bifida 1 — 1 Total 82 86 168 *Quiescent. 87 Orthopaedic Cases—Under Five Years of Age. Boys. Girls. Total. Flat Feet 6 6 12 Genu Valgum 20 17 37 Genu Varum 22 11 33 Torticollis 1 2 3 Congenital Dislocation of Hip — 2 2 Talipes 7 4 11 Congenital Deformity of Foot 1 1 2 Rickets 1 1 2 Hammer Toe 1 1 2 Paraplegia — 1 1 Hemiplegia 1 — 1 Erb's Paralysis — 1 1 Total 60 47 107 (;) Dental Treatment.—The following is the report of the School Dentist, Mr. C. Colenso, L.D.S., on the dental treatment of school children during 1933. " The year under review has shown an increased number of children inspected and treated, due largely, to the increase in school population during the year and also to the re-treatment of twelveyear-old children, who had not required treatment during the previous three years. " Unfortunately the proportion of the parents objecting to treatment of their children remains about the same. In the coming year, it is hoped that there will be a reduction in the number of such objectors, for with greater co-operation which is sought from the teachers in regard to the encouragement of dental treatment, and with additional staff at the Centres, a great effort will be made to clear up some of the very bad mouths which have escaped attention. " Of the 12,855 children inspected (Table IV), 8,471 needed some treatment, 5,058 were actually treated, as against 4,625 in the preceding year, an increase of 433. The number of sound mouths 88 at the end of the year, embracing those found not requiring any treatment and those actually treated, totalled 9,442. This figure gives a percentage of 73 with sound mouths, which should compare very favourably with any similar school population. " The dental work carried out resolves itself into the elimination of oral sepsis by extraction, this being done in a thorough manner on the first inspection of the younger children, from six to nine years of age. For the older children coming under subsequent examination conservative work is the chief form of treatment. " The number of temporary teeth extracted was 8,149, the number being smaller than the preceding year by 709. Extractions of permanent teeth still remain too high, due to casual cases, newcomers to the district, and former objectors who attend the Centres after much damage to the teeth has occurred and when relief of pain forces them to the dentist. Roughly half of these extractions were executed for irregular dentitions. In nearly all cases for regulation, the extraction of one to four premolar teeth is necessary to obtain the correct occlusion of the teeth and jaws. The number of extractions of permanent teeth in both groups was 1,097, which is greater than in the previous year by 138. " The conservative work included fillings in six-year-old molars and other teeth. The ratio of fillings in the former to the latter is nearly 40 to 1. Possibly, irregular or abnormal metabolic changes at the age of six influence this difference in the incidence of dental decay. " The number of permanent fillings inserted was 6,409, a little greater than in 1932. Temporary fillings totalled 648, again a small increase over the preceding year. " The number of entrants found to have sound mouths was 690 or over 50 per cent, of those examined for the first time. The number of children leaving school during the year with sound mouths was 679 out of a total of 919 children examined, or 74 per cent. This percentage could be bettered but for the difficulty in getting the parents to appreciate the need for treatment of every defect found at the yearly inspection in the later years of school life. Many parents do not present their children for treatment because they may have had treatment only the previous year, and do not 89 see any reason for a visit to the dentist again so soon. This fact applies more to those in their last years at school but also to those at younger ages. " For all the work carried out at the various Centres 6,117 attendances were made by the children. When a second visit was made, parents had usually asked for an appointment for further advice or treatment later in the year. When extractions and fillings were required, gas was first given and the extractions completed, then a second visit followed for the fillings. The number of children visiting the Centres for the first time numbered 1,792. A very bad dental condition was found in most of the children attending the new schools, indicating that previous to coming to Ealing the dental supervision and treatment was of an inferior character. These cases throw a larger amount of work on the dentists than the children who had been in Ealing for some years. " Lectures on dental care were given in the schools when time could be found. Special interviews with stubborn objectors were arranged by the dentist at the Centres or at the schools to try to obtain consent for their children to have treatment. Among certain parents there still persists a prejudice against treatment, but it has to be admitted that objections are not so much the result of ignorance as of indifference/' (k) Payments for Treatment.—The following amounts were received during the year for the treatment of children at the Health Centres :— £ s. d. Dental Treatment 237 4 0 Throat Operations 9 5 0 Spectacles 151 1 5 Treatment at National Orthopaedic Hospital 20 14 2 X-ray Treatment for Ringworm of Head 2 6 Surgical Appliances 2 1 6 Massage Treatment 34 8 6 Other Payments from Maternity and Child Welfare Committee, etc. 123 3 2 £578 0 3 90 BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. All blind and all deaf children of school age are sent to Special Residential Schools. Two blind girls and one blind boy were maintained at Certified Schools for the Blind at the end of the year, and two boys and one girl were maintained at Certified Schools for the Partially Blind. Fourteen deaf mutes, eight boys and six girls, were at the end of the year maintained at Certified Schools for the Deaf. One girl suffering from severe epilepsy was maintained at a Certified Special School and one girl was kept at home where she was undergoing treatment by her regular medical attendant. One crippled boy was unable to attend the ordinary public elementary school and was maintained at a Certified Special School. All the other children, 27 in number, undergoing orthopaedic supervision or treatment were able to attend the public elementary schools like normal children. The fact that only one child has to be sent to a Special School is a striking result of the early and effective orthopaedic treatment provided under the Education Committee's Scheme. Two girls suffering from heart disease were maintained at Certified Special Schools and one girl was treated in Hospital. Three feeble-minded girls were maintained at Certified Schools for Mental Defectives. There were 59 feeble-minded children in attendance at public elementary schools. Eleven children were notified during the year to the Local Mental Deficiency Authority; six imbecile girls and four imbecile boys and one boy idiot. In the course of the year six boys and six girls requiring convalescent treatment were maintained for a period of six weeks at the King Edward Memorial Convalescent Home at Bexhill at the cost of the Education Committee. Two boys and two girls were given a summer holiday of two weeks at Bexhill under the King Edward VII Memorial Fund. It was pointed out in the Annual Report for 1932 that the former was only available during the winter months for six boys and six girls, that, even so, markedly beneficial results accrued to the children specially favoured and that there were many other children in the schools in such a condition as to require convalescent treatment for a period of six weeks which ought to be made available throughout the year. 91 In consequence of these remarks in the Annual Report, the Education Committee decided to extend the convalescent treatment of school children and arrangements were made by which two places for boys and two for girls for a stay of six week's duration would be available throughout the whole year at the Russell Cotes School of Recovery, Parkstone, Bournemouth. These arrangements should greatly benefit the health and therefore the education of 28 more children. Should the need become evident the facilities can be readily extended. PHYSICAL TRAINING. In the Annual Report for 1929 an account was given of the provision made in the schools for physical exercises and organised games. There is nothing to add to this unless to say that consequent on the increase in the number of schools, additional playing fields have had to be purchased in the parts of the Borough in which houses are being rapidly built. OPEN-AIR EDUCATION. The advantages of the open-air type of public elementary school built in recent years were very evident during the hot weather experienced last year. Even in the coldest months the ventilation can be easily regulated whilst on the warmest days the rooms can be made completely open on two sides so that the children are taught under the most easily arranged open-air conditions. In the older schools the teachers recognise the advantages of children spending as much time in the open as possible and therefore arrange for classes in the playground whenever the weather permits of this being done. PROVISION OF MEALS. In none of the schools has there at any time been such a number of necessitous children as would render it practicable to make provision for ordinary meals at school. There are undoubtedly children suffering from the lack of sufficient food in small numbers throughout the schools, but their need has been met to a large extent by the provision of milk. The scheme of the 92 National Milk Publicity Council by which school children are supplied with one-third of a pint of milk each morning at the cost of one-penny a day is in operation in the schools and it has been arranged that children whose parents are unable to afford to pay the amount and who are in need of milk shall receive milk at the same time as the other children at the cost of the Education Committee, under Sections 82-85 of the Education Act, 1921. The milk-in-schools scheme is in operation in 37 out of the 41 school departments. At the end of October an effort was made to increase the number of children receiving milk and for this purpose 8,000 copies of a leaflet issued by the National Milk Publicity Council were distributed to children not having milk in school. At the end of October, before the leaflets had been issued, the number of children paying to have milk in school was 2,385, and one month later this number had increased to 2,707. The benefit derived by the children from receiving a regular supply of milk is so great that every effort should be made to encourage the scheme. The number of children supplied with milk under Sections 82-85 of the Education Act, 1921, during the year was as follows :— Number of children for whom a supply of milk was approved, 1st January, 1933 495 Number of children for whom a supply of milk was approved, 31st December, 1933 537 Daily average number of children who received a supply of milk 448 Total number of bottles of milk supplied 93,501 Cost of milk supplied £389. lis. 9d. CO-OPERATION OF OTHERS IN THE SCHOOL MEDICAL SERVICE. Reference has been made in previous reports to the valuable help received from the teachers and school attendance officers in facilitating the work of school medical inspection and in encouraging the treatment of defective children, and to the great assistance rendered in after-care and treatment by certain voluntary bodies, notably, the Central Aid Society, the National Society for the Prevention of Cruelty to Children, the School Attendance Aid Committee and the Middlesex King Edward Memorial Committee. 93 NURSERY SCHOOLS. There are no nursery schools in the Borough. As comparatively few mothers go out to employment and as the housing conditions are much better than in industrial areas, there is little demand for nursery schools. A limited number of children under 5 years of age are admitted to Infants' Schools, but each admission is considered by the School Attendance Committee and it is only in a case of real necessity, for example, where the mother has to go to work, that sanction is given for the admission of the child. SECONDARY SCHOOLS. School medical inspection is carried out at the three Secondary Schools by the School Medical Staff of the Ealing Education Committee. As a large percentage of the pupils attending the Secondary Schools have already been under the medical supervision of this staff, it is not only convenient but appropriate that the supervision should be continued in the same hands. The County Education Committee is at present considering the question of affording dental and ophthalmic treatment to all Secondary School children and the Ealing Education Committee has offered to undertake this treatment as it forms a natural and necessary consequence of medical inspection. HEALTH EDUCATION. As a full description was given in the Annual Report for 1929 of all the activities concerned with health education in the schools, there is no need to discuss them again. The issue by the Board of Education of a greatly extended and improved " Handbook of Suggestions on Health Education " should prove of inestimable value not only as a guide to this particular branch of education of the children of all ages, but as an incentive to the teachers to further, by their interest in the subject, the general health of all those who are under their daily care. 94 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Tne number of children 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 92 None Milk Round 21 Newspaper Round 27 Baker's Round 31 Helping in Shop 6 General Help 1 Order Boy 12 Yard Boy 2 Messenger Boy 7 Messenger and General Work 1 Rounds-boy 1 Weeding 18 General housework 1 220 Two hundred and thirty-one children were examined in connexion with employment, and out of this number eleven were found to be in such a condition of health that their employment was not permitted. At the routine medical inspection of employed children r.t school, nine were found to be suffering in health and their employment was discontinued. Nineteen children were found to be employed without being registered under the Bylaws and two children were found to be under age. In addition there were 16 girls examined for employment of children under the Entertainments Rules, 1920, one being found unfit. 95 SPECIAL ENQUIRY. The following report, to which allusion has already been made, is a valuable contribution to the subject of enlarged tonsils (chronic tonsillitis) and the value of operation. The conclusions are short and definite and therefore all the more worthy of note. " The Value of Tonsillectomy in School-children. By John D. Kershaw, M.B., B.S., D.P.H. "This paper is only one of many which have been published or delivered during the past two or three years on a subject which was honoured with a formal discussion at the Centenary meeting of the British Medical Association in London in 1932. On all sides we hear of a general calling into question of the operation of tonsillectomy and its results, even by many who were not long ago prominent upholders of the operation and its validity. It might not be amiss, therefore, if I briefly sketched, by way of introduction, the history of the operation of tonsillectomy before the present phase or reaction set in. "T. B. Layton, in March, 1933, published a paper in the Lancet in which he dealt with something of the historical aspect of the matter. He went back as far as the days of Morell Mackenzie who, in 1880, described the enlarged tonsil as being 'often the size of a chestnut but sometimes attaining the dimensions of a bantam's egg and, in rare instances, nearly the size of a hen's egg.' The important indication for operation was respiratory obstruction and one can appreciate the reasons why Ambroise Pare, in 1509, went so far as to advocate tracheotomy in severe cases of tonsillar enlargement. These enormous tonsils, however, would seem to us of the present day to have a place only in history, which place is still important, since there is no doubt that such great enlargements had much to do with the development of the attitude which, until recently, was invariably taken up by the surgeon toward the tonsil—that it was an organ essentially vicious, whose only proper place was in an anatomical museum. "The removal of the tonsils, though practised long before the beginning of the Christian era and traceable back into ancient Greek civilisation, was, until a very few years ago, an operation fraught 96 with serious difficulties and dangers and, therefore, eschewed by the great majority of surgeons. The introduction of the sharp guillotine just over a hundred years ago facilitated the partial removal of the organs, but their complete removal, tonsillectomy, as we know it, dates as a common operation only from 1908 when Waugh elaborated the technique of removal by blunt dissection. For three years this operation reigned unchallenged in the field till in 1911 Whillis and Sluder, simultaneously on the two sides of the Atlantic, introduced their methods of enucleation by means of the blunt guillotine. "The surgical world now possessed two methods, both safe and both comparatively easy, of removing the tonsils and it naturally made full use of the new techniques presented to it. On the whole I incline to blame the blunt guillotine for much of the slaughter of tonsils which has taken place during the last twenty years. While dissection still demanded a prolonged operation for which efficient hospital accommodation was desirable, the other technique was free from these disadvantages. It was swift and, in most cases, sure. It required only a short anaesthesia. Moreover, the technique was such that it could be acquired in a short time by any reasonably competent House Surgeon. Every practitioner learned to carry it out before he entered general medical practice, and it remained with him as the only operation which he could satisfactorily perform in a best bedroom or parlour. One cannot be surprised that, faced on the one hand with the knowledge that his peers and superiors were blaming the tonsil for every illness which baffled their medical skill and on the other with the consciousness that in this operation, at least, he could well emulate the specialist, he was swift, if not always sure, in carrying out tonsillectomy, until, as Alison Glover has recently pointed out, seventy per cent. of the entrants to one of our great Public Schools had had their tonsils removed before the age of thirteen. "A reaction was inevitable. Modern developments in pathology and physiology had brought forward new and surer ground for the old theory that the tonsils possess a protective function. Lay statesmen, seeking to reduce public health expenses, challenged the value of tonsillectomy, not on scientific grounds, but merely because many operations were carried out under the Public Health Service and because there exists a basic principle for 97 minds of a certain type that anything which exists in large quantity is extravagant, unnecessary, and wasteful. Even fashion, after her kind, had changed. "I propose to question the value of tonsillectomy upon another ground and, to do so, I must put forward two fundamental propositions with which, I hope, there is agreement. The first is that an operation is unnecessary and unjustified if it is performed without adequate indication. The second defines an adequate indication as the presence of a harmful condition which we have good reason to expect will be alleviated by the performance of the operation. With these as a basis I propose to survey the indications which are at present regarded as adequate for tonsillectomy and to illustrate them by my own observations on some fifteen hundred children. "Layton regards tonsillectomy in a child under the age of eight as an operation hardly ever necessary or justifiable. At the other extreme come those who consider the operation to be one of the greatest boons ever conferred upon suffering humanity and one which should be extended to all in whom it can possibly appear desirable. In the hope of finding a satisfactory mean I have taken a list of indications from the generally accepted textbook of Irwin Moore, placing his less common indications first. "Retro-ocular neuritis (three cases quoted), colitis and chronic appendicitis, gastro-intestinal dyspepsia, impaired nutrition, possibly associated with anaemia, and chronic ill-health form the first group. All these indications depend for their validity upon the effect of the tonsil as a septic focus. Admittedly the tonsil can and often does act as such a focus, but it is only one of many. The teeth, the colon, the nasal accessory sinuses may all be equally guilty and it is both unfair and unscientific to remove the tonsil merely because it is the most accessible of these possible culprits, or to treat a case in which a septic focus is suspected by the removal, seriatim, of all possible foci until symptoms cease or the supply of foci becomes exhausted. Unless definite indications point to the guilt of the tonsil it has as much right as the appendix or the colon to remain in situ. "Next are cited remote neuropathic reflexes of tonsillar origin, such as spasmodic cough, vomiting, gastric pain, bronchial asthma and intermittent otalgia. Again we have to eliminate other possible causes before we condemn the tonsils. It is humiliating 98 to remove tonsils for asthma, only to find the condition unalleviated and responding later to vaccine treatment. It is equally humiliating to remove them for otalgia and to find, after that has failed, that a dentist can remove the source of trouble in a few moments. Again there is need for this process of elimination of other causes of the disability before the tonsils are removed. "Mental apathy, or Aprosexia, was a term given by Guye of Amsterdam to a condition which he found alleviated by tonsillectomy. Gawne, in Lancashire, last year investigated the intelligence quotients of a hundred children with adenoids and a hundred normal ones, and found them to be lower in the former group. The condition of these children after operation has not yet been investigated. On the other hand some observers deny the existence of aprosexia as a clinical entity, and Glover, in 1932, accepted the view that such defect as exists is due rather to the nasal sinuses than to the tonsils and adenoids. "Increased susceptibility to infectious diseases, which some observers claim to have found associated with enlarged tonsils, is not constantly so found by authorities on those diseases. "Obstructive hypertrophy, reflex laryngeal spasm with respiratory obstruction and new growths of the tonsil are indications with which no one will quarrel. "Cervical adenitis, however, though quoted by Moore, cannot possibly be regarded as an indication sufficient in itself. If the tonsils be regarded as a first line of defence against disease, the glands are the second line. When, therefore, other possible sites of sepsis are eliminated, cervical adenitis suggests either that the tonsils are the sites of chronic sepsis or that they are failing to cope adequately with invading organisms. In the former case operation is indicated, but in the latter it will leave the patient worse off than before, since the glands in question will continue to drain the pharyngeal wall long after the tonsils are removed and will continue to enlarge in any slight acute infection of that region. So a difficult and important question has to be answered before we act. Probably it is wisest to take adenitis into consideration only when there are other signs or symptoms which support the idea that the tonsil is a septic focus. 99 "Now let us pass to the commoner reasons for tonsillectomy; those for which the vast majority of the enormous number of operations carried out at the present day are performed. First among them we can place respiratory affections. I do not propose to draw any fine distinction between those of the upper respiratory tract—colds in the head—and those in the lower respiratory tract, since in children the difference is one of degree rather than of kind. Second should come the recurrent sore throat, with which I couple frank tonsillitis. Third place (this is not intended as a ranking in order of gravity) is taken by mouth-breathing and fourth by affections of the ear, including deafness, otalgia, and otorrhoea, while last, but by no means least, I place enlargement of the tonsil without noteworthy symptoms. "In endeavouring to evaluate the indications and end-results of the operation I took these indications and tried to find how far they satisfied my second postulate, i.e., if they were constantly relieved by the performance of the operation. I examined all those children in Ealing who had been subjected to the operation during the last three years and have here the results of investigation of 416 of them. " Owing to changes in personnel and variations in individual standards, the only possible source of a history in these cases was the parent. An initial series of some fifty cases, not included in these results, was therefore investigated, in order to see if the parents were, as a rule, able to give a satisfactory history and in order, also, to develop a technique of questioning which would not, in any way, influence the replies and, therefore, the results. At the close of this preliminary work I was convinced that satisfactory histories could be obtained and I was able to standardise the questions which were to elicit them. Moreover, during the investigation proper, any history which was at all vague or which required leading questions for its elicitation, was summarily rejected. " Three hundred and fifty-three children had suffered from frequent cold or coughs, before operation. Two hundred and ninety-five, or eighty-four per cent. of these had improved after operation. The remaining sixteen per cent. were unimproved. "Two hundred and nineteen had suffered from recurrent sore throats. Of these, two hundred and nine were better (ninety-five point five per cent.). 100 "Two hundred and fifty had been mouth breathers before the operation. One hundred and eighty-eight, or seventy-five per cent., had improved. "Seventy-three had had one or more of the three ear affections which I mentioned. Of these, fifty-nine, or rather more than eighty per cent., had had no recurrence since the operation. "These figures correspond closely with those of other observers, such as Courtenay Yorke of Liverpool, Keen of Leicester, Wilkins of Birmingham, and Tighe of Swansea. The main distinction between this and the other investigations is that it has classified symptoms rather than taken the cases as a whole. If the symptoms be taken altogether, the percentage of improvement is eighty-four, which correlates well with the eighty-seven per cent. in Birmingham who 'unquestionably justified the treatment.' In the worst series of results, those in the mouth-breathers, the percentage of successes is seventy-five. An indication so constantly relieved as that may be taken as genuine. "Before leaving these figures, however, there remains one very significant point. While the work was in progress, I received the impression that children operated on in our own school clinic benefited more than those dealt with privately. I have, therefore, separated the two groups, with the following results:— "1. Suspectibility to colds. Of 206 children treated at the clinic, 89% were improved. Of 147 treated in hospital or privately, 76% were improved. 2. Frequent sore throats. Of 148 treated at the clinic, 97% were improved, the remaining cases only yielding 85.5% of successes. "3. Mouth breathing. Here the disparity was more marked, the clinic curing 90% of its cases and the hospitals only 53% of theirs. "4. Ear affections. The numbers here are smaller, but the clinic cured 97% of 36 and the hospitals only 64% of 37. "It is extremely important to find the reasons for this discrepancy, partly in order that the School Clinics may successfully defend themselves against the criticisms which are constantly being levelled against them by the opponents of State Medical Services 101 and partly in order that the hospitals may be given the opportunity to profit by the experience of the clinics and thus improve their own results. "The first possible reason for the difference is that the cases dealt with by the hospitals may be an accidentally unfavourable selection. As regards the degree of tonsillar or ancillary disease, this possibility is negligible. It seemed possible, however, that the hospitals might be drawing their patients from a lower social stratum than the clinic, with a less favourable home environment, which hampered recovery. "About one -half of the children under consideration were, therefore, investigated from this point of view. The two facts which emerged were first, that the hospital patients averaged rather more favourable home circumstances than the rest and second, that within the groups, home circumstances did not differ significantly between the improved and the unimproved. "Operative technique is not to blame. The tonsils had been as efficiently removed by outside and hospital practitioners as by our own surgeon with a very few exceptions, in which, incidentally, the results were not notably unsatisfactory. "It follows, therefore, that after-treatment is the deciding factor. The hospital patient, though kept in the ward over-night, is only seen later in order that gross operative failures may be discovered. The clinic patient, though sent home by ambulance the same afternoon, is visited on the second and fourth days, and subsequently if necessary, by the school nurse who advises the mother about nasal and oral hygiene for the child and gives her a leaflet setting out a scheme of breathing exercises, not leaving the house till she is satisfied that both mother and child understand the need for and the practice of the exercises. "It would appear that here lies the key to success. Further corroboration is seen in the fact that half the clinic's failures in children susceptible to respiratory affections and one-third of those in mouth breathers occurred in children whose parents confessed that they had not carried out the exercises. "I would suggest, therefore, that particular attention should be paid to this point by School Medical Officers whose local authorities carry out tonsillectomy. Moreover, parents who wish to have 102 their children operated upon privately or in Hospital should be warned of the need for after-care and asked to notify the School Medical Officer of the date of operation. He could then arrange for the school nurse to visit the child and give the necessary instruction. This would not involve any great increase in the work of the department and it would probably make all the difference between success and failure in between ten and thirty per cent. of children. "The next indication for operation which requires consideration is Rheumatism. A history of rheumatic pains or other symptoms was asked for among the questions put to the parents, thirty children being found to have had rheumatic symptoms before operation. Of these, twenty had improved since tonsillectomy and ten had not. Among the last 266 children investigated, however, 51 had a history of rheumatism and thirty-five of these had shown no symptoms till after the operation. "The records of all children in the borough noted as rheumatic at School Medical Inspection were next investigated. Of these there were 96, 43 having had their tonsils removed. Out of the 43, 21 had had no symptoms till after operation, 14 had been improved by operation, and 8 had not. As regards the children with tonsils in situ, 30 of the 53 had apparently normal tonsils, 19 slightly enlarged ones and 4 grossly enlarged or septic tonsils. "These figures are inconclusive, and it would be unwise to be dogmatic about them. They give no warrant for the course practised by some people, removal of the tonsils in all cases of rheumatism, however slight, but they throw little light upon the vexed question of the relation of the tonsils to rheumatism generally They may be regarded as giving ground for the suggestion that the protective function of the tonsils extends to rheumatic conditions and that premature removal may actually increase the child's susceptibility. On the other hand, the greatest age of incidence of rheumatic conditions is not earlier than eight and, as some of these children had lost their tonsils before that age the protective function had not really been tested. "The last indication and, taking the medical practitioners in this country as a whole, the commonest accepted indication, is enlargement of the tonsils, whether associated with symptoms or not. Some practitioners hold it as an article of faith that an 103 larged tonsil is, ipso facto, a harmful one. Others, more rational, regard size as an indication of sepsis and believe that the potential and actual dangers of sepsis outweigh the advantages of the protective function. "For wholesale removal on principle there is no justification. But prophylactic removal has a certain amount of theory behind it and demands serious consideration. We know that the normal tonsil tends to atrophy when its possessor reaches the age of puberty. Does the enlarged tonsil behave in the same way, or does it remain large ? And how often does the large, symptomless tonsil subsequently give rise to symptoms? "For some years a conservative policy has been adopted towards tonsils in Ealing, though its application has been modified in detail by changes in personnel. The general principle has been to advise operation only in those cases where enlargement of the tonsils is associated with symptoms such as those mentioned previously. Enlarged tonsils not associated with symptoms have been kept under periodical observation and the children falling into this category are at present about 1,800 in number. Of these, 1,092 were examined ; 268 under 8 years old, 389 between 8 and 11, and 435 over 11 years. They were classed under a scheme modified from that propounded by Paton in 1928, his groups being reduced to four. These are : very small—tonsils invisible or only just visible, small—reaching half way to the posterior pillar of the fauces, moderate—reaching to the posterior pillar and large— concealing part or the whole of the posterior pillar. "In evaluating the results, the cardinal symptoms considered in the investigation of operative results were used. 'Large' tonsils were set down for further observation and, if associated with any one of the symptoms, for operation. In the other groups, one symptom called for observation and two for operation. In addition, even a small tonsil with the slightest sign indicative of sepsis was treated as if it belonged to the ' Large ' group. "In all age-groups the majority of the tonsils fell into the 'small' and 'moderate' classes. It was noteworthy, however, that the 'very small' group comprised 10% of the youngest children, 14.4% of the middle group, and 21.1% of the oldest group. The 'large' class showed a corresponding fall—5.6%, 4.9%, and 2.9%. 104 "These figures suggest that the large tonsil tends to atrophyjust like the normal one. "As many as 5.4% of all the children had had their tonsils removed by outside practitioners, but in only about half of these was any history of symptoms to be obtained. As a rule the family doctor had been called in to deal with some other complaint, and, seeing large tonsils, had advised their removal. "Children showing symptoms and, therefore, set down for further observation, comprised 17.5%, 14.6%, and 10.3% of the respective age-groups, entrants, age-8 group, and leavers, the operation cases being 5.9%, 3.8%, and 2.0%. Assuming that one-half of the tonsils removed by outside practitioners actually showed symptoms before operation, this gives us a total in the age-groups of 27.6%, 21.3%, and 12.4% with symptoms, of whom only 10.1%, 6.7% and 4.1% had the symptoms so far developed as to require or justify operation. In other words, had common practice been followed with these 1,092 children, over 1,000 of them would have had their tonsils removed without need and without the likelihood of benefit. "There is neither reason nor excuse, at the present day, for wholesale removal of large tonsils. In the School Medical Service we have an organisation admirably adapted for keeping under observation those children who need it and for ensuring that, if operation becomes necessary after a time, it can be carried out. I would suggest, as a practical policy, that the classification of enlarged tonsils into these four groups should be followed as a routine and that this suggested arbitrary scale for operation or observation should be used, with, of course, the observance of discretion in individual cases. 105 "Thirdly, the unique position of the School Medical Officer is of great value and ought to be utilised, for by virtue of it he is able to hold his hand while he considers a case soberly and to keep it under observation before he decides to act. "In conclusion, I should like to thank Dr. Orr, the School Medical Officer, for pennission to carry out this investigation, and for his assistance in it. My thanks are also due to my colleagues for enabling me to give time to the work and last, but by no means least, to the School Nurses and to the clerical staff for carrying out the considerable amount of extra work which the investigation entailed.'' REFERENCES. 1. Layton, T. B. Lancet, 1933, i, 509. 3. Glover, J. A. Post-Graduate Medical Journal, 1934., Vol x, No. 99, 12. 3. Gawne, S. C. The Medical Officer, 1933. Vol. xlix, 65. 4. Glover, J. A., and Wilson, J. British Medical Journal, 1932, ii, 512. 5. Keen, J. A. Lancet, 1933, i, 979. 6. Wilkins, E. H. The Medical Officer. Vol. xlix, 175. 106 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 621 Impetigo 562 Scabies 78 Ringworm 47 Eczema 26 Minor Injuries 251 Teachers on Appointment 49 Miscellaneous 3,904 Total 5,538 THOMAS ORR, School Medical Officer. June 28th, 1934. 107 STATISTICAL TABLES. The Tables required, by the Board of Education are as follows:— TABLE I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups:— Entrants 1,748 Second Age Group 1,857 Third Age Group 1,608 Total 5,213 Number of other Routine Inspections — B.—Other Inspections. Number of Special Inspections 3,060 Number of Re-Inspections 2,263 Total 5,323 108 TABLE II. A.—RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1933. DEFECT OR DISEASE Routine Inspections No. of Defects Special Inspections 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 – 37 1 1 Skin Ringworm, Scalp 1 — 7 — ,, Body 1 — 12 — Scabies — — 27 — Impetigo 4 — 295 — Other Diseases (Non-Tuberculous) 10 1 159 3 Eye Blepharitis 5 — 47 —- Conjunctivitis 3 — 68 — Keratitis — — 1 — Corneal Opacities — — — — Defective Vision (excluding Squint) 250 13 299 5 Squint 41 1 26 — Other Conditions 4 — 51 6 Ear Defective Hearing 3 8 2 3 Otitis Media 11 — 70 — Other Ear Diseases 13 1 59 – Nose and Throat Chronic Tonsillitis only 160 745 80 68 Adenoids only 7 8 4 2 Chronic Tonsillitis and Adenoids 37 1 28 3 Other Conditions 6 74 81 42 Enlarged Cervical Glands (Non-Tuberculous) — 72 5 20 Defective Speech 14 — 22 — Heart and Circulation Heart Disease: Organic — 21 — 5 Functional — 47 — 10 Anaemia — 23 1 22 Lungs Bronchitis 2 79 8 15 Other Non-Tuberculous Diseases 4 25 — 7 Tuber. culosis Pulmonary: Definite — — — 1 Suspected — 10 — 8 Non-Pulmonary: Glands — — 1 — Bones and Joints — 1 — — Skin — — — – Other Forms — — — – Nervous System Epilepsy — 9 — 1 Chorea 1 1 1 4 Other Conditions — 3 — 7 Deformities Rickets — 3 — —— Spinal Curvature 5 3 4 — Other Forms 94 254 44 23 Rheumatism (apart from those affected with Organic Heart Disease) 1 7 1 11 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases 18 33 774 103 109 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) Prescribed Groups :— Entrants 1,748 203 11.6 Second Age Group 1,857 254 13.6 Third Age Group 1,608 189 11.7 Total (Prescribed Groups) 5,213 646 12.4 Other Routine Inspections — — — 110 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Feeble-minded and Epileptic 3 BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 — — — 3 PARTIALLY BLIND CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 3 30 — — 33 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 14 — — — 14 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — – – — — — 1ll MENTALLY DEFECTIVE CHILDREN. Feeble-minded Children. At Certified Schools for MentallyDefective Children. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 59 — — 62 EPILEPTIC CHILDREN. Children suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 — — 1 2 PHYSICALLY DEFECTIVE CHILDREN. A. Tuberculous Children. I.—Children suffering from Pulmonary Tuberculosis. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 2 — — 3 II.—Children suffering from Non-Pulmonary Tuberculosis. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 5 1 — 6 112 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 4 239 — — 243 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 27 — — 28 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 2 3 1 — 6 113 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR. TREATMENT TABLE. Group 1.—Minor Ailments (excluding Uncleanliness, for which see Group VI). Disease or Defect Number of Defects treated, or under treatment during the year. Under the Authority's Scheme Otherwise Total (1) (2) (3) (4) Skin :— Ringworm—Scalp (Show separately in brackets the number which were treated with X-Rays) 5 (4) 3 8 (4) Ringworm—Body 11 2 13 Scabies 23 4 27 Impetigo 295 4 299 Other Skin Disease 97 72 169 Minor Eye Defects (External and other, but excluding cases falling in Group II) 144 34 178 Minor Ear Defects 120 33 153 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 495 66 561 Total 1,190 218 1,408 114 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 By Private Practitioner or at Hospital, apart from the Authority's Scheme Otherwise Total (i) (2) (3) (4) (5) Errors of Refraction (including Squint) 887 44 931 Other Defect or Disease of the Eyes (excluding those recorded in Group 1) – — – — Total 887 44 – 931 Total number of children for whom Spectacles were prescribed:— (a) Under the Authority's Scheme 747 (6) Otherwise 44 Total number of children who obtained or received Spectacles:— (a) Under the Authority's Scheme 737 (b) Otherwise 44 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) 90 72 162 – 162 115 Group 4.—Orthopaedic and Postural Defects. Under the Authority's Scheme— Number of children treated Residential treatment with education 8 Residential treatment without education — Non-residential treatment at an orthopaedic clinic 126 Otherwise— Residential treatment with education — Residential treatment without education 1 Non-residential treatment at an orthopaedic clinic — Total 135 Group 5.—Dental Delects. (1) Number of Children who were :— (a) Inspected by the Dentist: Aged Routine Age Groups 5 1,131 Total 12,748 6 1,357 7 1,406 8 1,360 9 1,335 10 1,433 11 1,287 12 1,247 13 1,391 14 697 15 95 16 9 Specials 107 Grand Total 12,855 (6) Found to require treatment 8,471 (c) Actually treated 5,058 (2) Half-days devoted to:— Inspection 96 Total 1,032 Treatment 936 (3) Attendances made by children for treatment 6,117 (4) Fillings:— Permanent Teeth 6,409 Total 7,057 Temporary Teeth 648 (5) Extractions:— Permanent Teeth 1,097 Total 9,246 Temporary Teeth 8,149 (6) Administrations of General Anaesthetics for Extractions 1,252 (7) Other operations:— Permanent Teeth — Total — Temporary Teeth – 116 Group 6.—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 ... 28,695 (3) Number of individual children found unclean 625 (4) Number of children cleansed under arrangements made by the Local Education Authority – (5) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 — (b) Under School Attendance Bvelaws — MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN) REGULATIONS, 1928. STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1933, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total Number of Children Notified 11 ANALYSIS OF THE ABOVE TOTAL. Diagnosis. Boys. Girls. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a Special School : (a) Idiots 1 — (b) Imbeciles 4 6 (c) Others — — (ii) Children unable to be instructed in a Special School without detriment to the interests of other children : (a) Moral defectives — — (6) Others — — 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 — – 3. Feeble-minded children notified under Article 3, i.e., " special circumstances '' cases — — 4. Children who in addition to being mentally defective were blind or deaf — — Grand Total 5 6 Chiswick and Ealing Hospital Committee. ISOLATION HOSPITAL. MATERNITY HOSPITAL. ANNUAL REPORT of the MEDICAL SUPERINTENDENT for the year ending 31st MARCH, 1934. THOMAS ORR, M.D., D.Sc., Medical Superintendent. 2 CHISWICK AND EALING HOSPITALS COMMITTEE. COMMITTEE. Alderman G. Jenkin [Chairman). Alderman W. T. White, J.P. ( Vice-chairman). Alderman A. W. Bradford. Alderman Col. R. R. Kimmitt, O.B.E., T.D. Alderman Mrs. E. S. Taylor, J.P. Councillor Mrs. F. M. Baker, J.P. Councillor C. E. Edwards. Councillor Mrs. E. L. Hill. 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— Helen R. B. Buck, M.B., B.S., M.R.C.S., L.R.C.P. 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 M. P. B. Gardner. Clerk to Committee—Harry Birrell. Treasurer—E. C. T. Owen. 3 CHISWICK AND EALING HOSPITALS COMMITTEE. Mil. Chairman, Ladies and Gentlemen, I have the honour to submit to you the Annual Report on the administration of the Hospitals. ISOLATION HOSPITAL. The outbreak of scarlet fever which started in the previous year continued during the year 1933-34, and again demonstrated the inadequacy of the present hospital accommodation. The annex had to be used for several lengthy periods and, in spite of the fact that whenever possible cases were nursed at home, a number of cases had again to be sent to Willesden Isolation Hospital. The total number of cases admitted to the Hospital was 872, being 57 more than the previous year. The highest daily number under treatment was 127 on June 5th and 6th, and the lowest 61 on September 1st. The average daily number was 97. The following table indicates the number of cases of the various diseases treated during the year :— Disease. Remaining in Hospital March 31st, 1933. Admitted during year. Discharged during year. Died during year. Remaining in Hospital March 31st, 1934. Scarlet Fever 74 680 675 5 74 Diphtheria 20 187 178 10 19 Ophthalmia Neonatorum 2 2 — — Enteric Fever 1 — 1 — — Puerperal Fever — 2 2 — — Erysipelas — 1 1 — — Totals 95 872 859 15 93 Scarlet Fever.—Of the 680 cases admitted as scarlet fever, 399 were from the Borough of Ealing and 281 from the Borough of Brentford and Chiswick. Thirty of the total were not suffering from the disease and were ultimately diagnosed as follows:— 4 Tonsillitis 5, septic rash 1, tonsillitis and bronchitis 1, tonsillitis and quinsy 1, measles 1, influenza 7, drug rash 2, headache 1, pyaemic abscess 1, facial erysipelas 1, rheumatic fever 1, no apparent disease 8. One case of scarlet fever was found on admission to be suffering also from pneumonia, one also from chicken-pox, two from whooping cough and one from shingles. 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. Over 45 yrs 130 404 61 36 14 5 The complications observed in the course of the disease were as follows:— Rhinorrhoea 174 Cervical adenitis 86 Cervical gland abscess 7 Otorrhoea 74 Otitis media 4 Nephritis and albuminuria 29 Arthritis 12 Relapse 12 Cardiac affections 4 Ethmoid abscess 2 Abscess over ear 1 Abscess' of jaw 2 Pyaemic abscess 1 Furunculosis 1 Septic sores 1 Vaginal discharge 10 Meningitis 1 Pneumonia 1 Bronchitis 2 Secondary tonsillitis 1 Quinsy 2 Septic fingers 3 5 During the year the Consulting Oto-Laryngologist, Dr. Dan McKenzie, made 47 visits to the hospital. He performed mastoid operations on 24 patients, twelve of these being double mastoids. Dr. McKenzie also performed minor operations on the following patients:— Ethmoid abscess opened 2 Tonsils and adenoids removed 3 Adenoids removed 2 Antrum irrigation 1 Paracentesis 2 The Consulting Surgeon, Mr. Gordon Bryan, made three visits to the Hospital, twice to open pyaemic abscesses and once to drain an abscess in the buttock. The following minor operations were also performed on scarlet fever patients:— Cervical gland abscesses incised 7 Abscess of jaw incised 2 Cross Infection.—In the North Block five cases of chickenpox occurred, the source of infection apparently being a boy who developed herpes zoster shortly after admission. In the South Block 16 cases of chicken-pox occurred following an attack in a boy who had already been five weeks in hospital. In this case the primary source was not discovered. Both outbreaks of chickenpox were extremely difficult to control owing to the lack of accommodation for the isolation of susceptible contacts. At the same time it was found impossible to place the affected wards in quarantine since the beds were required for the admission of new cases of scarlet fever whose treatment in hospital was urgently required. Return Cases.—Of the 675 cases discharged during the year, 24 gave rise to return cases of scarlet fever, 13 being patients from Ealing and 11 from Brentford and Chiswick. This gives a return case-rate of 3.69 per cent. Deaths.—Five patients admitted with a diagnosis of scarlet fever died, giving a case mortality of 0.73 per cent. 6 They were as follows: No. Age Sex Days in Hospital Complications Remarks l. 4 F. 9 R. and L,. otitis media Septic scarlet fever 2. 5 M. 38 R. and L. otitis media Septic sinus thrombosis Cerebellar abscess R. and L. mastoid operation Ext. j ugular vein ligatured Cerebellar abscess drained 3. 5 F. 42 R. and L. otitis media Meningitis R. and L. mastoids explored after onset of meningitis, but nothing abnormal found 4. 9 F. 25 Cervical adenitis Nephritis Pneumonia and empyema 5. 7 M. 10 L,obar pneumonia Duration of Stay.—The average duration of stay in hospital of all cases of scarlet fever was 40.2 days. The average duration of stay of those patients who had mastoid operations was 83 days. Diphtheria.—The number of cases admitted as diphtheria from the two districts was 99 from Ealing and 88 from Brentford and Chiswick, making a total of 187, 76 more than in the previous year. Of this number 27 were ultimately diagnosed as not suffering from diphtheria. The final diagnoses in these cases were as follows:— Laryngitis 1, tonsillitis 17, scarlet fever 2, quinsy 1, stomatitis 1, nasal catarrh 1, cellulitis of neck 1, laryngeal obstruction 1, no apparent disease 2. Five cases of diphtheria were found on admission to be suffering also from scarlet fever. 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. Over 45 yrs 34 76 30 7 13 — 7 The following complications were observed among the cases:— Palatal paresis 11 Pharyngeal paresis 1 Ocular paresis 4 Facial paresis 1 Neck paresis 1 Rectus paresis 1 Vagus paresis 1 Cardiac involvement 8 Myocardial degeneration 2 Cervical adenitis 5 Cervical gland abscess 1 Rhinorrhoea 1 Otorrhoea 4 Secondary tonsillitis 2 Nephritis 2 Vaginal discharge 1 There were nine cases of laryngeal diphtheria. Two required tracheotomy, and of these one died and one recovered. 8 Deaths.—There were ten deaths from diphtheria, giving a case mortality of 6.49 per cent. They are recorded as follows:— No. Day of Disease when Admitted Days in Hospital before Death Remarks 1. 6 27 Severe faucial diphtheria. 2. 4 8 Severe faucial diphtheria. 3. 4 2 Haemorrhagic diphtheria. 4. 4 7 Severe faucial diphtheria. 5. 7 1 Severe laryngeal diphtheria. Tracheotomy performed. 6. 5 4 Severe faucial diphtheria. 7. 3 1 Severe laryngeal and faucial diphtheria. 8. 3 2 Severe faucial diphtheria. 9. 4 9 Severe faucial diphtheria. 10. 3 8 Severe faucial diphtheria. In the above table it is seen that the cases had been ill for three to seven days before the specific treatment by anti-toxin was given. The delay in treatment was in some cases due to the doctor not having been sent for early enough, but unfortunately in others it was due to the doctor having waited for the result of the swab before considering the case as one of diphtheria. These deaths emphasize the need for treating all suspected cases as diphtheria by giving anti-toxin at the earliest possible opportunity. 9 Cross Infection.—Two cases of diphtheria were cross infected with scarlet fever, one with measles and four with chicken-pox while in the ward. There were two return cases. The average duration of stay in hospital for diphtheria cases was 44.7 days. Puerperal Fever.—Two cases were admitted with this diagnosis and were found to be suffering from uterine sepsis, one complicated by breast abscess. Both recovered. Ophthalmia Neonatorum.—Two infants were admitted for treatment. In one case the eyes were clear on discharge, but in the other the right eye was opaque. This patient was sent to Moorfields Eye Hospital for further treatment. Facial Erysipelas.—This patient had been nursing a child at home with scarlet fever. Cases Admitted from Other Hospitals.—Twenty-one cases were admitted from neighbouring general hospitals suffering from the following conditions :— West Middlesex County Hospital. Scarlet fever and abscess of neck 1 King Edward Memorial Hospital, Ealing. Scarlet fever and left otitis media 1 Scarlet fever and pernicious anaemia 1 Scarlet fever, following removal of tonsils and adenoids 1 Scarlet fever, awaiting removal of tonsils and adenoids 1 Scarlet fever—malnutrition (found |not to be scarlet fever but influenza) 1 Scarlet fever and pneumonia l Scarlet fever and left myringotomy l Scarlet fever—congenital heart disease 1 Scarlet fever, awaiting operation for currettage 1 10 Chiswick Hospital. Scarlet fever, lacerated wound right leg (scarlet fever not confirmed—tonsillitis) 1 Scarlet fever—vaginitis, no apparent disease 1 Scarlet fever and axillary abscess 1 Scarlet fever following removal of tonsils and adenoids 1 Scarlet fever and septic wound of knee 1 Brentford Cottage Hospital. Acute rheumatism following scarlet fever 1 Dame Margaret Young Memorial Convalescent Home (Patients from Gray's Inn Road Hospital). Scarlet fever and mastoid (one incubating measles) 3 Scarlet fever and left myringotomy 1 Diphtheria and mastoid 2 Illness of Staff. Influenza Matron, two probationers and one private nurse. Influenza and quinsy One staff nurse. Quinsy One maid. Scarlet fever Two private nurses and one maid. Gastritis One private nurse and one maid. Scalded hand One probationer. Tonsillitis One sister and five probationers. Haematemesis One staff nurse. (Removed to King Edward Memorial Hospital). Bronchitis Porter. Nasal catarrh Gatekeeper. Sprained ankle One probationer. Jaundice One probationer. 11 Cost of Maintenance, Etc. £ s. d. Salaries 3,473 12 11 Repairs to buildings 459 6 5 Furniture, fittings and utensils 596 15 11 Maintenance of ambulance 232 7 9 Medical and surgical requisites 895 10 11 Provisions 2,313 17 6 Fuel, light and cleaning 1,149 10 2 Rates, taxes and insurance 743 9 1 Miscellaneous 157 5 10 Superannuation—employer's contribution 69 19 6 Loan Charges 1,651 10 11 Closing of path 42 6 10 Making of path 167 13 6 11,953 7 3 Administrative Charges—proportion 379 16 2 £12,333 3 5 The patients spent 35,643 days in hospital, so that the average cost of each patient per day was 6/11½. Taking the patient-days 35,643, and the staff-days 13,031, or a total of 48,674, the average cost of food works out at ll½d. per person per day. MATERNITY HOSPITAL. The number of patients admitted to the Maternity Hospital during the period 1st April, 1933, to the 31st March, 1934, was 509, a total which is slightly below that of the previous twelve months. The cases admitted to the hospital in successive years since its opening have been as follows:— 1921-22 109 1928-29 450 1922-23 235 1929-30 534 1923-24 284 1930-31 561 1924-25 369 1931-32 546 1925-26 388 1932-33 524 1926-27 358 1933-34 509 1927-28 407 12 It will be seen that in each of the last three years there has been a decrease in the number of cases admitted. This reduction in the number of admissions has not been due to lessened demand for admission, but to steps that have had to be taken to reduce the overcrowding ot the wards by curtailing the bookings. For a part of the year under review the number of applications accepted for admission to the 22 beds in the hospital was limited to 40 for each calendar month, but so many pressing applications were received that it was deemed advisable to revert to the former number of 44 cases per month and to carry on the hospital at times of pressure as well as possible. The overwhelming demand for admission to the hospital can be gathered when it is realised that the accommodation is usually fully booked at least four months in advance. This means that if a woman applies for admission during the last four months of her pregnancy, no matter how desirable her admission to hospital may be, her application can only be considered in very exceptional circumstances. The necessity for the extension of the Maternity Hospital to meet this demand for admission has been emphasized in each Annual Report from 1930 onwards. Following the adoption of the Special Report in 1930, the Hospitals Committee decided to take steps to extend the Maternity Hospital, but the national financial crisis in 1931 caused the proposals to be held in abeyance. Recently the demand for admission to the Maternity Hospital increased to such an extent that, coupled with the urgent necessity for the extension of the Isolation Hospital, further postponement of the extensions became impossible. When consideration of the extensions was revived it became apparent that the interests of the community would be best served by a comprehensive scheme of extension which would provide for some years to come. A report was therefore submitted recommending that the present Maternity Hospital, which prior to the formation of the Hospitals Committee was the Chiswick Isolation Hospital, should be amalgamated with the Isolation Hospital, which it adjoins, and extended to make 140 beds available for infectious cases, and that an entirely new Maternity Hospital of 42 beds should be provided. This recommendation was approved by the Committee. (A copy of the report is appended). 13 The proposal to erect the new Maternity Hospital on a site adjoining the Western Avenue at Peri vale was subsequently approved by the Councils of the constituent authorities and plans are now in the course of preparation. The 509 cases admitted to hospital during the period under review came from the two districts as follows:— Month Ealing Brentford and Chiswick Total April 22 14 36 May 23 15 38 J une 30 13 43 July 26 10 36 August 29 10 39 September 35 14 49 October 35 14 49 November 33 10 43 December 31 9 40 J anuary .. 33 15 48 February ... 25 13 38 March 35 15 50 357 152 509 Emergency Cases.—Seven emergency cases were admitted during the year. Three were cases of toxaemia, two of which had normal labours resulting in live infants, the third resulting in a premature still-born infant following surgical induction for pre-eclampsia. Two were cases of extended breech presentation with some degree of pelvic contraction, which had very difficult assisted labours, the infants failing to breathe after birth in both of them. One case of placenta praevia (marginal) was treated for alarming haemorrhage, the infant being still-born. One case of acute pyelitis recovered sufficiently to have the confinement at home. All these mothers made uninterrupted recoveries. 14 Ante-Natal Cases.—Eighty-one cases were admitted for treatment. These were suffering from:— Toxaemia 31 Pyelitis 3 Bacilluria 1 Hyperemesis gravidarum 2 Threatened disproportion 18 Postmaturity 9 Extended breech 6 Antepartum death of foetus 1 Antepartum (accidental) haemorrhage 3 Cardiac cases 2 Sciatica 1 Influenza 1 Debility 3 Of these cases, 45 remained in the hospital until the confinement took place, while the remaining 36 were discharged with their condition improved, to return to the hospital later for the confinement. Other ante-natal abnormalities encountered, but not admitted before labour, were:— Toxaemia 5 Cardiac 3 Pyelitis 4 Hydramnios 1 Congenital dislocation of hip 1 Intrauterine death of foetus 2 Abnormalities and Complications during Labour. Caesarean section (for eclampsia and previous Caesarean section) 1 Forceps delivery— For Eclampsia 3, uterine inertia 2, foetal distress 2, maternal distress 2, incomplete rotation occipito-posterior 4, other reasons 6 19 15 Breech presentation— Extended, assisted delivery 12 Complete, normal delivery (4 twins, 1 triplet) 11 Complete, delayed delivery of head due to hydrocephalus 1 24 Persistent occipito-posterior presentation— Forceps delivery 2 Spontaneous delivery 6 8 Shoulder presentation 1 Episiotomy 18 Perineal rupture (requiring more than one stitch) 81 Twins 7 Triplets 1 Eclampsia— Forceps delivery 3 Caesarean section 1 Died undelivered 1 5 Antepartum haemorrhage— Marginal placenta praevia 1 Toxaemic (?) 1 2 Uterine inertia 4 Hydramnios 2 Contraction ring 1 Retained placenta 3 Post-partum haemorrhage of moderate severity 9 Birth before arrival 3 Abnormalitis and Complications during Puerperium. Pyelitis, cystitis or bacilluria— First developed in pregnancy 7 First developed in puerperium 7 14 16 Mastitis (without abscess formation) 4 Eclampsia 1 Phlebitis 8 Localized uterine sepsis 6 Secondary uterine haemorrhage 2 Vaginal haematoma 1 Mental derangement 2 In addition to the above, 17 cases of puerperal pyrexia occurred, all of which eventually made good recoveries. These cases were suffering from:— Localized uterine sepsis (forceps delivery in one case) 8 Pyelitis (one causing secondary uterine infection) 4 Mastitis (without abscess formation) 3 Mastoiditis 1 Pneumonia following influenza, with pyelitis and phlebitis (forceps delivery) 1 Maternal Death. There was one maternal death. The patient was admitted from an Ante-natal clinic on the first appearance of albuminuria. Within four hours of admission she developed eclampsia and in spite of all treatment died five hours later, undelivered and without regaining consciousness. Patients Discharged to other Hospitals. To Chiswick and Ealing Isolation Hospital. Localized uterine infection 2 To Queen Charlotte's Isolation Hospital. Haemolytic streptococcal uterine infection 2 Pyelitis with secondary B. Coliuterine infection 1 To West Middlesex County Hospital. Mastoiditis 1 3 Mental derangement 2 — 3 17 Children. Number of Infants born. Males 252 Females 259 Total 511 Number of cases of twins 7 Number of cases of triplets 1 Number of cases of premature infants (born alive), 57 38 weeks development (2 twins) 27 37 „ „ 5 36 „ „ (4 twins) 11 35 „ „ 1 33-34 weeks development 3 31-32 „ „ (3 triplets) 8 29-30 „ „ (2 twins) 2 Of these infants 8 died, 1 of 34 weeks development, 5 of 32 weeks (including triplets) and 2 of 30 weeks (twins). Stillbirths Total 17. Macerated: Prematurity 5 Anencephalic foetus 1 Prolonged labour. Death during first stage 3 Fresh: Prematurity 2 Asphyxia— Difficult breech delivery—emergency cases 2 Intracranial injury following normal labour 2 Cord several times round neck, delay with shoulders 1 Cause uncertain, possible intracranial injury 1 6 18 Infant Deaths. Total, 11. Prematurity 8 Congenital heart (antepartum haemorrhage in mother). 1 Intracranial injury and atalectasis (following prolonged but normal labour). 1 Atalectasis 1 Abnormalities in Infants born alive and discharged. Congenital heart 2 Convulsions 1 Multiple deformities, Klippel-Feil disease 1 Melaena neonatorum 1 Icterus neonatorum (severe) 2 Tracheal obstruction 1 Talipes 5 Tongue-tie 2 Cephal-haematoma 5 Ophthalmia Neonatorum. No cases occurred. Infants transferred to other Hospitals. To Vincent Square Infants' Hospital. Multiple deformities, Klippel-Feil disease 1 Dr. J. W. Rait Bell, the consulting obstetrician, was called in on 14 occasions during the year. 19 Cost of Maintenance, Etc. £ s. d. Salaries— Medical 216 1 6 Nurses 506 13 11 Other staff 987 15 3 Repairs to buildings 384 19 7 Furniture, fittings and utensils 327 6 4 Medical and surgical requisites 218 16 2 Provisions 956 2 3 Fuel, light and cleaning 724 18 4 Rates, taxes and insurance 366 2 2 Miscellaneous 72 6 0 Superannuation—employer's contribution 56 12 8 Loan Charges 738 4 11 5,555 19 1 Admi nistrative Charges 179 6 11 5,735 6 0 Less Income from patients 2,282 1 6 £3,453 4 6 The patients spent 7,763 days in hospital, which makes the gross cost of each patient per day 14s. 9d. or £5 3s. 6½d. per week, and the net cost, after deducting the amounts paid by the patients, 8s. 10¾d. per day or £3 2s. 3½d. per week. With the patient days 7,763 and the staff days 8,328, or a total of 16,091, the average cost of food for patients and staff is Is. 2£d. per person per day. I am, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Superintendent. Town Hall, Ealing, W.5. 21th June, 1934. 20 CHISWICK AND EALING HOSPITALS COMMITTEE. REPORT ON THE PROPOSED EXTENSIONS OF THE ISOLATION AND MATERNITY HOSPITALS. You will recollect that on presenting my Annual Report for 1929-30 I pointed out the necessity for additional beds at both the Isolation and Maternity Hospitals. As regards the Isolation Hospital I stated:— “During the winter months so many cases of diphtheria had to be dealt with that the Diphtheria Block and the Temporary Block were overcrowded. Although these two blocks may be reckoned to have accommodation for 22 patients, on 133 days of the year the patients exceeded that number. At one time there were as many as 36 patients. With overcrowded conditions such as have been experienced not only is nursing more difficult but constant anxiety is experienced in treating other diseases, such as enteric fever or cerebro-spinal fever, and in dealing with cross-infected cases. Since the Hospitals Committee was formed in 1921 the population served has increased from 108,750 to 163,040, and in the meantime only 16 beds have been added by the inclusion of the Brentford Hospital and these can only be utilised for treating convalescent cases of scarlet fever during an epidemic of that disease. It is thus evident that the Committee will have to consider at an early date the necessity of extending the hospital to meet the needs of the increased population and particularly the needs in the way of treating cases of diphtheria and diseases other than scarlet fever. A block consisting of two groups of cubicle wards for treating different kinds of disease at the same time is what is most required." As regards the Maternity Hospital I remarked as follows:— "So popular has the hospital become that at times we have had to book cases beyond the capacity of the hospital and even with that we have had to discontinue booking on three occasions during the year. On the 29th April, 1929, booking was stopped for the month of June, on the 21st January, 1930, booking was stopped for both the months of March and April, and on the 19th March, 1930, booking had to be stopped for the month of May. The hospital accommodation is recognised to be 22 beds, but on 153 days of the year the number of patients exceeded this number. The maximum number of patients in hospital on any day was 33 and the lowest number 9, the average over the whole year being 21. All the patients admitted were those coming within the scheme, that is, the family income and home circumstances entitled them to treatment in the hospital. It is thus evident that the Committee will have at an early date to consider the need for extending the bed accommodation to meet the increasing demands of the population served." It need hardly be stated that since that report was presented the need for extension has been more marked each year and this need has been particularly striking during last year, when on the occasion of an unusual prevalence of scarlet fever and diphtheria, the Isolation Hospital was quite unable to meet the demands of the districts served and urgent cases had to be sent to an adjoining hospital, while others had to be nursed at home. The pressing need for extension has been evident at the Maternity Hospital, for which the booking of beds has usually had to be discontinued four months in advance and many mothers have had to be refused admission. APPENDIX. 21 Whereas in 1929 the population being served by the hospitals was stated to be 163,000, the population now served is 188,000. On the submission in 1930 of my report, which was approved and adopted, the Committee recognised the need for extensions of the hospitals. On account of the national financial crisis in 1931 the consideration of extensions was postponed. The proposals, however, came up for consideration on the 28th J une of this year, when the general scheme put forward by me, accompanied by sketch plans, was approved of and the following resolution was passed:— Extensions of Hospitals. The Committee viewed both hospitals and considered the suggestions of the Medical Superintendent for new wards and administrative quarters, sketch plans of which he submitted to them. Resolved: That the general scheme of extensions as outlined by the Medical Superintendent be approved and that he be requested to proceed with the preparation of complete plans and particulars of the general details for consideration at a later meeting. On that occasion the proposals were as follows:— Isolation Hospital. 1. A new block of 22 beds for cases of diphtheria. 2. A new block of 12 cubicle beds. 3. Extensions to the present Administrative Block, laundry, etc. 4. A new block for the accommodation of nurses. Maternity Hospital. 1. A new Labour Block. 2. A new ward block of 22 beds. 3. Additions to the Administrative Block. Since going into the details of these extensions with the Borough Surveyors concerned, Mr. W. R. Hicks (Isolation Hospital) and Mr. L. A. Cooper (Maternity Hospital), and into their probable cost I have become impressed by the fact that they require re-consideration. On a previous occasion when discussing the future of the Isolation Hospital you accepted my suggestion that the present Maternity Hospital, which before 1921 was an Isolation Hospital, may ultimately be added to the Isolation Hospital and the whole become one Isolation Hospital. I have now come to the conclusion that now is the time to accomplish this amalgamation, because in the first place a large extension of the administrative accommodation at the Isolation Hospital would be avoided and in the second place a large amount spent in altering the Maternity Hospital now would be ultimately wasted if at a later date the Maternity Hospital were added to the Isolation Hospital. If the Maternity Hospital is added on the present occasion to the Isolation Hospital it would mean the addition of 18 more beds. These added to the number of diphtheria and cubicle beds proposed would mean an increase in the number of beds at the Isolation Hospital of 52. I have been able to get a rough estimate of the cost of the extensions of the two hospitals as placed before you at the meeting in June last and this is as follows:— 22 Isolation Hospital. New Diphtheria Block—22 beds £7,360 New Cubicle Block—12 beds £4,560 Additions to old Administrative Block, laundry, etc. £7,000 New Nurses' Home £7,000 £25,920 Maternity Hospital. New Labour Block £6,380 New Ward Block £14,985 Extensions of and alterations to Administrative Block, including extension of heating chamber, new kitchen equipment, etc. £11,350 £32,715 If the Maternity Hospital were added to the Isolation Hospital the expenditure of £7,000 on a new Nurses' Home could be saved in the extension of the Isolation Hospital. This, added to the cost of alterations to the Maternity Hospital, would mean a total of £39,715, which sum would be sufficient for the building of an entirely new Maternity Hospital of 44 beds built on the most up-to-date lines. As a site for this new Maternity Hospital I have in mind one which is excellent for the purpose, which is practically in the centre of the Borough of Ealing and which is the property of the Ealing Town Council, namely, the site of what was formerly the Smallpox Hospital, between the Ruislip Road and the Western Avenue. This is at present let as a private recreation ground. The site extends to 26 acres but only four acres, near the Western Avenue, would be required. It might, on first consideration, be felt that placing the Maternity Hospital there would put the patients from Brentford and Chiswick at a disadvantage. When one considers that most of the patients travel by ambulance to the hospital there can be little objection on this ground, especially as there is no difficulty in all the patients being conveyed to the Maternity Hospital by ambulance. Besides, at the present time the furthest distance patients usually travel from Brentford and Chiswick to the existing Maternity Hospital is about two miles, whereas many of the patients in the Borough of Ealing travel six or even seven miles. The new site for the Maternity Hospital would tend to equalise the distance travelled from both districts. I am firmly convinced that to go on with the alterations first suggested would result in expenditure which would be wasted when the Isolation Hospital is later extended to include the Maternity Hospital and that we would get a Maternity Hospital which would never be ideal for its purpose. I recommend, therefore, that the present Isolation Hospital and the present Maternity Hospital be amalgamated to form one Isolation Hospital and that steps be taken to build an entirely new Maternity Hospital on the site suggested. This would be a wise and far-seeing policy which I am confident would ultimately redound to the credit of both constituent Councils. 23 Summary of Recommendations. 1. The amalgamation of the Isolation and Maternity Hospitals to form an enlarged Isolation Hospital. 2. The erection of a Diphtheria Block of 22 beds at an estimated cost of £7,360. 3. The erection of a Cubicle Block of 12 beds at an estimated cost of £4,560. 4. Extensions to the Administrative Block of Isolation Hospital, laundry, etc., at an estimated cost of £7,000. 5. The erection of a new Maternity Hospital on a site in Ealing at an estimated cost of £35,000. THOMAS ORR, Medical Superintendent. 25th October, 1933.