Middx EAL 27 M AC 439(1) EALING Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer 19 3 6 including Report on the Isolation and Maternity Hospitals, 1936-37. 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. Perry & Routleff Ltd., Printers, Ealing and Uxbridge EAL 27 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health AND School Medical Officer 19 3 6 including Report on the Isolation and Maternity Hospitals, 1936-37. 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. Perry & Routleff Ltd., Printers, Ealing and Uxbridge INDEX. PAGE Ambulance Facilities 16 Births 11 Blind, Deaf, Defective and Epileptic Children 96 Clinics and Treatment Centres 17 Convalescent Treatment 21,91 Deaths 12 Dental Defects and Treatment 29, 88, 97 Diphtheria 70 Disinfection 49, 52 Drainage and Sewerage 46 Ear Defects 84 Employment of Children and Young Persons 98 Factcries and Workshops 52,53 Food, Inspection and Supervision of 61 Health Visiting 25 Hospitals in the District 18 Housing 56 Infant Deaths 13 Infant Life Protection (Children Acts) 30 Infectious Diseases 67,92 Legal Proceedings 50 Maternal Mortality 14 Maternity and Child W elf are 20 Maternity and Nursing Homes 44 Meat and Other Foods 63 Medical Inspection of School Children 78 Medical Treatment of School Children 79 Midwives, Supervision of 32 Midwives Act, 1936. Provision of domiciliary Service 33 Milk 62 Mortuary 51 Nursing in the Home 16 Nutrition 64 Orthopaedic and Postural Defects 90 Pathological Laboratory 15 Population 8 Pre-School Children, Examination of 28 Provision of Meals 94 Public Cleansing 47 Puerperal Fever and Puerperal Pyrexia 71 Sanitary Circumstances of the Borough 46 Scarlet Fever 71 School Hygiene 77 School Medical Service 76 Smoke Abatement 48 Special Clinic 17 Speech, Defective 90 Staff 5 Statistics, Vital and General 8, 9 Tuberculosis 73 Uncleanliness 79 Vision, Defective 80 Water Supply 45 APPENDIX. Report of the Medical Superintendent, Isolation and Maternity Hospitals, 1936-37. 4 PUBLIC HEALTH COMMITTEE. 1935-36. Councillor C. D. Grant (Chairman). Alderman Colonel R. R. Kimmitt, O.B.E., T.I). (Vice-Chairman). Aldermen H. W. Peal, J.P., Mrs. E. S. Taylor, J.P., and W. T. White, J.P. Councillors Mrs. F. M. Baker, J.P., W. J. S. Cox, Mrs. O. A. F. Davis, T. E. Fowler, F. G. Holmes, J. Mansel Lewis, H. A. Merchant, W. Morgans, H. M. Sayers, W. A. Scott and H. Telfer. MATERNITY AND CHILD WELFARE COMMITTEE. 1935-36. Alderman Mrs. E. S. Taylor, J.P. (Chairman). Councillor W. Morgans (Vice-Chairman). Aldermen R. R. Kimmitt, O.B.E., T.D., H. W. Peal, J.P., and W. T. White, J.P. Councillors Mrs. F. M. Baker, J.P., W. J. S. Cox, Mrs. O. A. F. Davis, T. E. Fowler, C. D. Grant, F. G. Holmes, J. Mansel Lewis, H. A. Merchant, W. Morgans, H. M. Sayers, W. A. Scott and H. Telfer. Mesdames Grant, Haddon, Holman, Ludlow, Mayo and Parry. EDUCATION GENERAL PURPOSES SUB-COMMITTEE. 1935-36. (Responsible for the School Medical Service). Councillor T. P. May (Chairman). Alderman J. C. Fuller (Vice-Chairman). Councillor E. H. Atkinson (Chairman, Education Committee), (ex-officio member), Aldermen A. E. Cobbin, Mrs. E. S. Taylor, J.P., and W. T. White, J.P. Councillors E. H. Brooks, J.P., Mrs. O. A. F. Davis, C. W. Jackman, B. Martin, W. Morgans, H. M. Sayers, and G. R. Weeks. The Very Rev. Monsignor H. Barton Brown, M.A. Miss D. L. Beck, M.A., Mr. J. E. Childs, Miss A. Dix Hawkin, and Mrs. A. D. Mayo. 5 STAFF. (At 31st December, 1936). Medical Officer of Health, School Medical Officer and Medical Superintendent of Isolation and Maternity Hospitals— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Medical Officers— John Petrie, M.B., Ch.B., D.P.H. Murdoch MacGregor, M.D., M.B., Ch.B., D.L.O., D.P.H. Dorothy Taylor, M.A., M.B., B.S., M.R.C.S., L.R.C.P., D.P.H. Anne E. Williams-James, L.R.C.P., M.R.C.S., D.P.H., B.Sc., D.C.O.G. Helena B. King, M.B., B.S., M.R.C.S., L.R.C.P. (Part-time). A nte-Natal Consultant—Part-time— John W. Rait Bell, L.R.C.I. & L.M., L.R.C.S.I. & L.M. Surgeon—Orthopaedic Clinic—Part-time— Herbert J. Seddon, F.R.C.S. (Eng.), M.B., B.S., M.R.C.S., L.R.C.P. Ophthalmic Surgeon—Part-time— Leslie Gemmill Scoular, M.B., Ch.B., D.O.M.S. Special Clinic—Part-time— Constance M. Hildred, M.B., Ch.B. Dental Surgeons— C. Colenso, L.D.S. Edward Tribe, L.D.S., R.C.S. Isobel M. M. Cameron, L.D.S. Chief Sanitary Inspector— George W. Stevens*† Sanitary Inspectors— James Stubbs*†, C. P. H. Meadows*†, G. T. H. Blackie*†, Ernest Belfield*†, and Eric H. Evans*†. 6 Supervising Health Visitor— Marguerite Farrow ‡ Health Visitors— Mildred A. Rice‡°§, Freda de la Hoyde‡°§, Ruby N. M. S. Field‡°§, Irene A. Burke‡ °§, Phyllis K. Pepler‡°§, Annie E. Golby‡°§, and Mary M. Compton‡°§. Supervising School Nurse— Hilda Bailey‡ °§. School Nurses— Annie Johnson°§, Mary McGann0, May P. Dorkins0‡, Marjorie Coslett‡°§, Elizabeth Livingstone‡ °§, Olive Moss‡°§, Violet W. Gilbert‡°§, and Lilian C. M. Gilbert‡ °§. Masseuse—Part-time— Florence Hepburn, C.S.M.M.G. Teacher of Class for Stammering Children—Part-time— Honor M. S. Baines. Chief Administrative Clerk— Harry Birrell. Clerks— Public Health Department—William A. J. Turner, and six others. Maternity and Child Welfare—Miss O. Levasseur, and five others. School Medical Service—Miss I. L. Parker, and seven others. *Certificate of Royal Sanitary Institute. †Certificated Inspector of Meat and other Foods. °Trained Nurse. ‡Health Visitor's Certificate. §Certificate of Central Midwives Board. A. Vital Statistics, Social Conditions of the Area, and General Provision of Health Services 8 SUMMARY OF GENERAL STATISTICS. Area (in Acres) 8,667 Population (Census, 1931) 117,707 Population (Estimated), Middle of 1936 145,000 Number of Structurally Separate Dwellings (Census, 1931) 26,717 Number of Houses (1st April, 1936) according to Rate Books 38,489 Number of Families or separate Occupiers (Census, 1931) 31,412 Rateable Value, 1st April, 1936 £1,499,363 Net Produce of a Penny Rate £6,247 Population.—The population of the Borough at the middle of 1936 is estimated by the Registrar General to be 145,000. This estimate of population compares with the figure of 137,550 at the middle of 1935. The Registrar General, therefore, estimates that the population of Ealing has increased by 7,450 in the year- Social Conditions.—The statistics furnished by the Manager of the Local Employment exchange to the Borough Surveyor with regard to unemployed men of 21 years and over reveal a slight increase in the average number of unemployed men during the year. The figures for the last five years are as follows :— Year Average number of men registered as unemployed. 1932 1,961 1933 1,708 1934 1,099 1935 1,002 1936 1,068 9 SUMMARY OF VITAL STATISTICS. Live Births :— Legitimate Males, 1,007 Females, 987 Total, 1,994 2,085 Illegitimate Males, 38 Females, 53 Total, 91 Birth-Rate per 1,000 of Estimated Population 14.4 Still-Births :— Males, 48 Females, 23 Total 71 Rate per 1,000 total Births (Live and Still-Births) 33 Deaths : Males, 671 Females, 763 Total 1,434 Death-Rate per 1,000 of Estimated Population 9.9 Deaths of Infants under one year of age :— Legitimate Males, 53 Females, 38 Total, 91 102 Illegitimate Males, 6 Females, 5 Total, 11 Death-Rate of Infants under one year of age :— All Infants per 1,000 Live Births 49 Legitimate Infants per 1,000 Legitimate Live Births 46 Illegitimate Infants per 1,000 Illegitimate Live Births 121 Deaths from Diseases and Accidents of Pregnancy and Childbirth :— From Sepsis 1 Death Rate per 1,000 Total Births 0.47 From other Causes 1 ,, ,, 0.47 Total 2 ,, ,, 0.93 Total Deaths Death-Rate per 1,000 Population Measles 3 0.02 Whooping Cough 5 0.03 Diphtheria 8 0.06 Scarlet Fever 2 0.01 Influenza 29 0.20 Tuberculosis of Lung 69 0.48 Other Forms of Tuberculosis 19 0.13 Death-Rate per 1,000 Live-Births Diarrhoea (under two years of age) 7 3.4 10 Comparison of Vital Statistics of Ealing with those of England and Wales, Etc., 1936. England and Wales 122 Great Towns (including London) London Ealing Birth-Rate 14.8 14.9 13.6 14.4 Death-Rate 12.1 12.3 12.5 9.9 Infant Death-Rate 59 63 66 49 Measles Death-Rate 0.07 0.0 9 0.14 0.02 Whooping Cough DeathRate 0.05 0.06 0.06 0.03 Diphtheria Death-Rate 0.07 0.08 0.05 0.06 Scarlet Fever Death-Rate 0.01 0.01 0.01 0.01 Influenza Death-Rate 0.14 0.14 0.14 0.20 Diarrhoea (under two years per 1,000 Births) 5.9 8.2 14.4 3.4 Table showing Birth-Rate, Death-Rate and Infant Death-Rate for the Borough of Ealing. Period Birth-Rate Death-Rate Infant Death-Rate 1881—1885 26.8 12.7 104 1886—1890 22.0 11.9 120 1891—1895 19.9 11.5 103 1896—1900 17.3 10.4 113 1901—1905 23.1 11.0 114 1906—1910 23.8 11.5 89 1911—1915 18.6 9.9 76 1916—1920 16.1 11.5 62 1921—1925 15.4 10.7 58 1926—1930 14.5 10.9 49 1931 15.0 10.1 47 1932 14.4 10.8 45 1933 12.7 10.1 50 1934 15.0 9.5 38 1935 13.9 9.9 48 1936 14.4 9.9 49 11 Births.—The total number of births, 2,085, is the highest yearly total recorded in the Borough, and the birth-rate of 14.4 per thousand of population shows an increase on the birth-rate of 13.9 recorded in the previous year. The birth-rate for Ealing is a little lower than the rate for England and Wales which is 14.8. A table showing the birth-rates in recent years is to be found on page 10. Deaths.—The total number of deaths, 1,434, is the highest yearly total recorded in the borough. The death-rate of 9.9 per thousand of population is, however, the same as in the previous year, the increased number of deaths being balanced by the increase in population. The death-rate for the Borough is well below the death-rate of 12.1 for England and Wales. By multiplying the death-rate for Ealing by the " comparability factor " supplied by the Registrar General the death-rate for the Borough can be made comparable with that of other districts. The " factor " for Ealing is 1.01 which makes the " comparable " death-rate, 10.0, very little different from the standard rate of 9.9. The table on page 12 indicates the causes of the 1,434 deaths which have been assigned to the Borough. It will be seen that heart disease and cancer are the predominating causes of death, no less than 592 of the total deaths, or 41 per cent. coming under these headings. In the previous year 37 per cent. of the deaths were due to heart disease and cancer. Pulmonary tuberculosis, with 69 deaths, accounted for the third highest number from an individual cause although the number of deaths due to this disease shows a marked reduction on the total of 94 in the previous year. The deaths from the various infectious diseases are commented upon in a later section of this report, but it will be seen in the following table that in 1936, compared with 1935, there was a reduction from 15 to 8 in the deaths from diphtheria and an increase from 17 to 29 in the deaths from influenza. 12 Causes of Death, 1936. Cause of Death Deaths, 1936 Total Deaths 1935 Male Female Total Typhoid and Paratyphoid Fevers 1 .. _ 1 — Measles 1 2 3 — Scarlet Fever 1 1 2 2 Whooping Cough 1 4 5 3 Diphtheria 5 3 8 15 Influenza 13 16 29 17 Encephalitis Lethargica — 1 1 3 Cerebro-Spinal Fever 2 2 4 1 Tuberculosis of Respiratory System 38 31 69 94 Other Tuberculous Diseases 12 7 19 9 Syphilis — 2 2 2 General Paralysis of the Insane, Tabes Dorsalis 3 1 4 2 Cancer, Malignant Disease 72 130 202 198 Diabetes 6 9 15 22 Cerebral Haemorrhage, etc. 25 41 66 62 Heart Disease 169 221 390 302 Aneurysm 2 5 7 4 Other Circulatory Diseases 30 38 68 53 Bronchitis 25 26 51 32 Pneumonia (all forms) 32 31 63 66 Other Respiratory Diseases 10 6 16 15 Peptic Ulcer 14 5 19 36 Diarrhoea, etc. (Under two years) 5 2 7 12 Appendicitis 4 1 5 13 Cirrhosis of Liver 2 1 3 4 Other Diseases of Liver, etc. 1 4 5 8 Other Digestive Diseases 25 15 40 35 Acute and Chronic Nephritis 17 20 37 45 Puerperal Sepsis — 1 1 5 Other Puerperal Causes — 1 1 6 Congenital Debility, Premature Birth, Malformations, etc. 37 25 62 63 Senility 5 21 26 36 Suicide 12 8 20 12 Other Violence 33 16 49 58 Other Defined Diseases 68 66 134 120 Causes ill-defined or unknown — — — 2 Total 671 763 1,434 1,357 13 Infant Deaths.—The infant death-rate of 49 per thousand births is only one above the death-rate of 48 recorded in the previous year. There were, however, more infant deaths, a total of 102 in the year under review compared with 91 in 1935. The infant death-rate for the Borough, 49, compares very favourably with the rates for England and Wales, for the 122 Great Towns, and for London, which are respectively, 59, 63 and 66. The causes of infant deaths, shown in the table on the following page, indicate prematurity as the cause of 35 of the 102 infant deaths, and pneumonia the cause of fifteen deaths. It will be seen that 48 of the deaths occurred before the infant was one week old, while 58 deaths occurred before the infant was four weeks old. This latter figure gives a neo-natal death-rate of 28 per thousand live births. Causes of Infant Deaths, 1927 to 1936. 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 Diarrhoea and Enteritis 3 5 4 3 5 9 4 11 11 7 Premature Birth 20 14 25 14 19 24 35 20 34 35 Congenital Malformations 9 6 4 9 9 11 13 9 9 10 Congenital Debility 11 6 10 9 11 4 4 3 11 5 Tuberculous Disease — 2 1 2 1 — 1 — — — Syphilis — — — — 1 1 — — — — Meningitis (not Tuberculous) — 1 3 1 4 — — 1 — — Convulsions 2 3 3 6 5 4 3 3 1 — Bronchitis 5 7 2 4 2 — 3 3 — 5 Pneumonia (all forms) 7 4 8 10 11 6 6 8 8 15 Gastritis — 1 1 — — — — 1 — — Common Infectious Diseases 2 — 6 2 1 2 3 1 — — Other Causes 15 12 6 11 15 18 10 17 17 25 Totals 74 61 73 71 84 79 82 77 91 102 14 Deaths at various Ages under One Year of Age, 1936. 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 48 4 1 5 58 11 16 8 9 102 Measles — — — — — — — — — — Meningitis — — — — — — — — — — Convulsions — — — — — — — — — — Bronchitis — — — — — 2 1 1 1 5 Pneumonia — — — — — 4 3 3 5 15 Inflammation of the Stomach — — — — — — — — — — D iarrhoea and Enteritis — — — — — 2 2 2 1 7 Congenital Malformations 5 1 — 1 7 3 — — — 10 Congenital Debility 4 — — — 4 — 1 — — 5 Premature Birth 28 3 1 3 35 — — — — 35 Injury at Birth 5 — — — 5 — — — — 5 Other Diseases Peculiar to Early Infancy 4 — — — 4 __ — — — 4 Inattention at Birth — — — — — — — — — — Other Causes 2 — — 1 3 — 9 2 2 16 Stillbirths.—The number of stillbirths assigned to the Borough was 71, this figure being a little below the total of 74 recorded in the previous year. Maternal Mortality.—The following table shows the maternal death-rates for Ealing and for England and Wales in recent years. In the report for last year it had to be recorded that the maternal death-rate for 1935 was the highest rate recorded in the Borough since 1911. In the year under review, however, it is pleasing to be able to record that the maternal death-rate is the lowest rate recorded since 1917, the total of two maternal deaths which occurred being equivalent to a death-rate of 0.93 per thousand births. The low maternal death-rate for 1936 balances the high rate for 1935, the rate for the two years being 3.16, a very favourable rate compared with previous years and distinctly lower than the rates for England and Wales in each of the last five years. 15 Maternal Mortality per Thousand Births. Period Ealing England and Wales 1911—1915 3.03 4.03 1916—1920 2.70 4.12 1921—1925 4.01 3.90 1926—1930 3.31 4.27 1931 3.85 3.95 1932 3.89 4.06 1933 2.91 4.23 1934 4.32 4.41 1935 5.55 3.93 1936 0.93 3.65 GENERAL PROVISIONS OF HEALTH SERVICES. PATHOLOGICAL LABORATORY. Consequent on the smaller number of cases of diphtheria admitted to the Isolation Hospital the number of examinations carried out in the Pathological Laboratory shows a large reduction compared with the previous year. Specimens Examined in Laboratory. Positive Negative Total 1936 Total 1935 Diphtheria : From the Practitioners in Borough 22 632 654 1,231 From the Isolation Hospital 25 2,521 2,546 6,234 From the School Medical Department 3 144 147 652 Tuberculosis 111 424 535 419 Miscellaneous 13 312 325 270 Total 174 4,033 4,207 8,806 16 ambulance facilities. 1. For infectious disease.—The Chiswick and Ealing Hospitals Committee provide a motor ambulance for the removal of cases of infectious disease to the Isolation Hospital at South Ealing. 2. For accident and illness cases.—The ambulances provided by the Council for dealing with cases of accident and of illness are now stationed at the Fire Station and are manned by members of the Fire Brigade. Two modern ambulances, with a third of an older type kept in reserve, are available. The extent of the calls made upon the service are shown in the following table :— 1931 1932 1933 1934 1935 1936 Cases of Accident 729 711 772 790 756 868 Cases of Illness 1,256 1,322 1,149 1,259 1,261 2,080 Total Cases 1,985 2,033 1,921 2,049 2,017 2,948 Number of Journeys outside the Borough (included above) 268 444 365 596 427 552 Annual Mileage 12,301 13,626 13,265 15,818 16,962 21,070 The runs made by the ambulances and the mileage covered were markedly higher than in the previous year. NURSING IN THE HOME. 1. General diseases.—The Greater Ealing Nursing Association continues to perform most admirable work in providing nurses for attending the sick in their homes. During the year under review a staff of seven full-time and one part-time nurses was employed, and dealt with 1,059 patients, a total of 22,152 visits being made. District nursing in the Northolt area is provided by the Northolt Nursing Association who engage the services of one nurse. 17 2. Infections diseases.—Arrangements continue for the provision of nursing assistance in cases of measles, whooping cough, ophthalmia neonatorum, poliomyelitis, diarrhoea, pneumonia and puerperal sepsis, by the district nurses in return for a contribution to the Association from the Town Council. CLINICS AND TREATMENT CENTRES. Provided by Ealing Town Council. Health Centres (Maternity 13, Mattock Lane, Ealing. and Child Welfare, and Cherington House, Hanwell. School Medical Service) Ravenor Park, Oldfield Lane, Greenford. Greenford Green, Wadham Gardens, Greenford. Peri vale, Horsenden Lane, Greenford. Islips Manor, Eastcote Road, Northolt. Orthopaedic Clinic 13, Mattock Lane, Ealing. Special Clinic (Birth Control) 13, Mattock Lane, Ealing. Provided by Middlesex County Council. Tuberculosis Dispensary Green Man Passage, West Ealing Treatment Centres for Venereal Disease Certain Hospitals in London. Special Clinic.—During the year arrangements were made with the Middlesex County Council by which patients from the County area could be referred to the special clinic for instruction in birth control. The cases dealt with are, of course, only those referred from a Health Centre under the control of the County Council by a Medical Officer who is of opinion that further pregnancies would be detrimental to the health of the mother concerned. The total number of consultations with the medical officer at the special clinic was 220 (including 9 for the Middlesex C.C ). The number of new cases dealt with was 89, including six for the Middlesex County Council. 18 HOSPITALS. 1. Isolation Hospital.—Treatment of cases of infectious disease is carried out at the Clayponds Isolation Hospital, which is under the control of the Chiswick and Ealing Hospitals Committee. During the year the first part of the extensions of this hospital were completed and a detailed account of the new accommodation is given in the Annual Report on the Hospitals, which forms an Appendix to this Report. 2. Maternity Hospital.—Hospital accommodation for maternity patients is provided at the Chiswick and Ealing Maternity Hospital where 22 beds are available for patients from the constituent areas. Considerable progress has been made with the construction of the new Perivale Maternity Hospital situated on the Western Avenue, Greenford. The new hospital will provide accommodation for 43 patients and when it is opened the present Hospital at South Ealing will be discontinued and the buildings will form a part of the Clayponds Isolation Hospital. 3. Smallpox Hospital — Hospital provision for children — Other hospitals.—No change has to be recorded in these hospital arrangements which were described in the report for 1934. B. Maternity and Child Welfare. 20 MATERNITY AND CHILD WELFARE. The provision of a complete and efficient service to ensure the welfare of the expectant and nursing mother and of the young child up to the time of entry into school has always been the earnest desire and aim of the Council since the duty of providing this service was placed upon it by the Maternity and Child Welfare Act, 1918. To enable this work to be carried on in a satisfactory manner it is essential that the buildings available should be suited to the purpose. To ensure this the Council have established six Health Centres, three being built specially for the purpose. The Ravenor Park Centre was opened in 1930 and in recent years has had to cope with the ever increasing population in Greenford. In 1933 the Council decided to provide a new Centre in North Greenford and in 1934 a further decision was made to provide a smaller or subsidiary Centre at Perivale. Various difficulties delayed the building of these two new Centres but on the 24th August they were brought into use for the first time. A description of the new Centres is given on a subsequent page. Alterations were also made durirg the year to two other Centres, additional lavatory accommodation being provided at the Mattock Lane Centre, which was opened as the first Centre in 1919, and certain structural alterations being made at Cherington House, which was opened in 1927, to secure a more efficient arrangement of rooms and floor levels on the first floor which is devoted to maternity and child welfare work. Of greater importance still was the commencement of the building of the new Maternity Hospital at Perivale, where provision will be made for the reception of double the number of cases that can be accommodated in the present hospital at South Ealing which has long proved inadequate to meet the demands for admission. A further extension of the Council's Maternity Service is to be brought about by the Midwives Act, 1936, which requires the provision throughout the country of a salaried service of midwives, either directly by or on behalf of the local authorities at present responsible for the supervision of midwives. The steps taken by the Council to provide this service are detailed on page 34. 21 A new feature of the Council's Maternity and Child Welfare vScheme brought into operation at the end of the year, was the provision of convalescent treatment for nursing mothers and for children under five years of age. New Health Centres.—As mentioned on a previous page, two new Health Centres were brought into use during the year. The Greenford Green Centre, situated in Wadliam Gardens, has been built to serve the needs of the rapidly growing area of North Greenford and Wood End. The building has a modern exterior. The external bricks are hand-made sand-faced and the front elevation has Portland stone dressings. The roof is covered with hand-made sand-faced tiles. The plan of the building is U-shaped and is all on one floor, the entrance hall, visitors cloakrooms and clerks' rooms being at the front, the school medical department occupying the west wing and the maternity and child welfare department the east wing. A closed corridor runs along the inside of each wing. The maternity and child welfare department consists of one large waiting room, 30ft. x 16ft., a weighing room, 18ft. x 16ft., with two undressing cubicles, and a medical officer's room, 15ft. x 16ft., staff cloakroom, and a cleaner's storeroom. The school medical department consists of a medical officer's room, 12ft. x 16ft., a waiting room, 18ft. x 16ft., a minor ailment treatment room, 12ft. x 16ft., a dentist's room, 12ft. x 16ft., and a dental recovery room, 9ft. x 16ft., with at the end a staff cloakroom, a bathroom and a storeroom. All the interior walls are oil painted in primrose colour with a brown dado in each of the two waiting rooms. The whole of the floors, with the exception of the lavatories in which the floors and walls are in terrazzo, are laid with polished oak blocks. The cornices are all simple and rounded and every effort has been made to avoid corners and so to facilitate cleanliness. Balanced, metal windows have been installed and through ventilation is provided by the introduction of clerestory-windows over the corridors. 22 The building is heated by means of a low pressure central heating system and hospital pattern radiators, with inset electric fires for supplementary or emergency use, the latter being needed only in very cold weather or if the central heating should fail from any cause. Hot water is supplied to the hand basins from a central boiler. Both boilers are in a stoke-hold below the entrance hall and all pipes are hidden as far as practicable in ducts beneath the floor. All internal doors are of flush oak finish and polished and the fittings are of bronze. All lighting fittings are of modern design, dust proof and hygienic and at the same time technically efficient. The cost of the building was £6,814, and of furnishings £487. From this description it will be recognised that the cost of cleaning the Centre and the subsequent maintenance costs have been reduced to a minimum. In this respect an object lesson will be provided for the mothers attending the Centre. 23 24 25 The Perivale Health Centre, situated in Horsenden Lane, has been built as a subsidiary centre attached to the Ravenor Park Health Centre, to serve the more or less isolated area of Perivale. The building, in modern style, and of multi-coloured bricks, consists of three large rooms, a waiting-room 20ft. x 16ft., a weighing-room 16ft. x 12ft., and a medical officer's room, 14ft. x 12ft., with lavatory accommodation for staff and for mothers and children and with storage room. The building is heated by electric fires and hot water is provided by electric water-heaters. The centre is designed for more restricted use than that of a principal centre such as the Greenford Green Centre just described, and is to be used for medical inspection of school children and the treatment of minor ailments and for infant consultations and antenatal examinations. Children or mothers requiring dental or other special treatment or special examination are referred to the Ravenor Park Health Centre where facilities are provided. The cost of the building was £1,380 and of the furnishing £135. Summary of the Visits made by the Health Visitors. Visits to children under 12 months : (1935) (1936) First visits 2,083 2,071 Return visits 5,185 5,226 Visits to children 1 to 5 years of age 10,501 10,359 Visits to expectant mothers 1,051 1,190 Visits to investigate infant deaths and still-births 99 113 Special visits or investigations 261 195 Visits to cases of Ophthalmia Neonatorum 4 6 Visits to cases of Pemphigus Neonatorum — 1 Visits to cases of Measles and Whooping Cough 242 469 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 401 330 Inspections of Women's Lavatories 83 65 Visits to children under care of foster-mothers 835 840 Other visits 97 272 Total Visits 20,842 21,137 26 Summary of the Work at the Health Centres. Mothers. Expectant mothers attending Ante-Natal Clinics : (1935) (1936) Attending for first time 941 1,112 Total attendances 4,811 5,010 Nursing mothers attending for post-natal examination — 429 Mothers seen by Ante-Natal Consultant 33 58 Mothers referred to School Medical Department for dental treatment 310 398 Mothers referred to Hospitals 40 103 Mothers accepted for admission to the Chiswick and Ealing Maternity Hospital 417 479 Children. Children attending Centres for the first time : (1935) (1936) Under one year of age 1,443 1,611 One to five years of age 1,044 1,243 Total attendances made by children : Under one year of age 18,968 21,064 One to five years of age 14,538 14,260 Number of children examined by Medical Officer : Under one year of age 8,263 8,803 One to five years of age 2,639 2,984 Children referred to School Medical Department: For dental treatment 409 458 For treatment of throat and nose 18 22 For optical treatment 32 17 For orthopaedic treatment 119 148 For treatment of minor ailments 64 135 For diphtheria immunization 51 347 Children referred to King Edward Memorial Hospital : For minor operations 21 17 For ultra-violet ray treatment 2 6 For other reasons 20 39 Children admitted to King Edward Memorial Hospital as indoor cases — 3 Children referred to other Hospitals 39 36 27 Assistance Given. Foods supplied at cost price : (1935) (1936) Dried milk (Value) £552 £679 Virol ( „ ) £103 £121 Cod liver oil ( „ ) £234 £323 Aid provided for mothers at confinement : Midwife provided 78 66 Home help provided 16 15 Accouchement set provided 79 63 Consultant's fee paid 9 5 Medical fees paid (doctor summoned by midwife under Midwives Acts) 138 144 Number of orders issued granting a supply of milk, free of charge, for a period of 28 days : For expectant or nursing mothers 953 856 For children under five years of age 1,571 1,546 Attendances at the Health Centres, 1936. Mattock I.ane Ch'gton House Ravenor Park Perivale Greenf'd Green Islips Manor Number of sessions for mothers 101 100 101 19 17 53 Ante-natal attendances 1,285 1,321 1,630 252 284 238 Post-natal attendances 104 125 117 33 25 25 Average attendance per session 14 14 17 15 18 5 Number of sessions for children 153 149 177 32 36 53 Number of children attending for first time 710 648 900 182 238 176 Total attendances made by children 9,115 8,555 10,881 1,943 2,348 2,482 A verage attendance per session 60 57 62 61 65 47 Number of children seen by doctor 2,807 2,720 3,744 678 945 893 Average number seen per session 18 18 21 19 26 17 28 Medical Examination of Pre-school children.—Medical examination at regular intervals is essential if the health of the young child is to be maintained at the liighest level. In the first year of life the child should be seen by a doctor at frequent intervals. After this it is advisable for medical examinations to occur with some degree of regularity and to secure this regularity efforts are made to obtain the attendance of young children for medical examination immediately after their first, second, third and fourth birthdays with an additional examination at eighteen months of age. When the child attends school, routine examinations take place at about the fifth, eighth and eleventh birthdays. The examinations of pre-school children during the year under review totalled 2,984 and were made up as follows :— At the first birthday 839 At eighteen months 623 At the second birthday 634 At the third birthday 572 At the fourth birthday 316 Total 2,984 Whilst these figures indicate that progress is being maintained much more should be done in the routine medical supervision of the pre-school child and in the early treatment of defects. Treatment of defects.—With child welfare work and school medical work proceeding in the same buildings in each area it is a simple matter to make available for pre-school children all the forms of treatment provided for school children. Information regarding the number of children referred to the school medical department for treatment is to be found on page 26. The largest number, 458, were referred for dental treatment, and the comments of the School Dentist on this part of his work follow. The number submitted for examination by the orthopaedic surgeon was 148 and details regarding their treatment are to be found on page 90. 29 While diphtheria immunization cannot be classed as treatment of a defect, it is satisfactory to note that the number of children referred for immunization was 347, compared with 51 in the previous year. The medical officers and health visitors now endeavour as a routine measure to interest the mothers in the value of immunization at an early age. The number, however, cannot be considered very satisfactory. It requires a sharp or even alarming outbreak of diphtheria followed by intensive propaganda to encourage the parents to appreciate the protective value of immunization. Dental Treatment.—The School Dental Surgeon reports as follows regarding the work carried out for mothers and for children under five years of age :— "Mothers.—There was an increase of 65 in the number of mothers treated during the year. A total of 355 were seen by the two dentists responsible for the treatment. The new Cuckoo Estate was mainly responsible for the increase in number treated, and it may be stated that the mouths of these mothers were usually in a very bad condition, and therefore required removal of nearly all the teeth. An effort was made during the latter half of the year to clear up as many mouths as possible without recourse to extractions of non-carious teeth. This was done wherever sepsis had not advanced too deep, and was the means of saving many sound teeth. The treatment required the thorough scaling of all teeth affected, excision of enlarged gum growths and the filling of the pockets with suitable dressings. This form of treatment usually required four to six visits accompanied by instructions to the patients to carry out certain measures at home. "The total amount of work done was as follows for the 355 mothers treated. Fillings were inserted in 129 teeth, a slightly less number than in the preceding year. The removal of teeth was greater by 521 than in the previous year. Altogether 2,601 permanent teeth were removed. The number of full or partial dentures fitted was 129. This is nineteen greater than in the preceding year. Other operations required in the treatment of mothers were as follows :— 30 Scalings 63 Impressions 126 Bite registrations 112 Tries in 127 Easing dentures 41 Repairs to dentures 6 Gum treatments 294 Total 769 "Altogether 355 mothers paid 1,517 visits to the dentists for this treatment. "Children of Pre-school Age.—The treatment of these children was carried out at all the Centres on one session each week. Any urgent case was seen almost immediately. There was a very small increase in the number treated over the previous year. Altogether 362 were actually treated by the dentists, 28 more than the preceding year. An increase in the number of these children will never be very big at a time, as some mothers naturally have a fear for their children at this age receiving dental treatment, and it is these mothers unfortunately who bring their children to the dentist at school age with advanced decay in one or more teeth. The work carried out was as usual fillings wherever possible in the molar teeth, and extractions under Nitrous Oxide and Oxygen. The number of fillings inserted was 284, and extractions 1,054. These figures show a slight reduction in comparison with last year." INFANT UFE PROTECTION. The supervision of fostermothers in accordance with the Children and Young Persons Acts, 1908 to 1932, is carried out by the Health Visitors who have all been appointed Infant lyife Protection Visitors. Information regarding foster-children registered in the Borough is contained in the following table : Number of children on the register at the beginning of the year 99 (Number of fostermothers having care of the above children, 78). Number of children registered during the year 126 31 Number of children removed from register during year : Removed to care of parent or relative 50 Removed to another fostermother 8 Removed for adoption through a Society 7 Removed to a Children's Home or School 9 Legally adopted by fostermother 2 Died (Inquests held, None) 4 Fostermother left district 7 Attained nine years of age 7 Placed in care of Public Assistance Authority, parent having disappeared 1 Removed from care of fostermother at request of Medical Officer of Health 9 104 Number of children on register at end of year 121 (Number of fostermothers having care of the above children, 92). Number of visits made by Health Visitors 840 During the year a Memorandum was issued to the Health Visitors regarding the supervision of the foster-children in their respective areas, in which it was stated : It is desirable that there should be a very strict standard to which fostermothers should conform and if the home circumstances, the capabilities of the fostermother, a large family, the presence of lodgers, or any other point causes doubt you should not recommend registration. It is not desirable that a woman should be allowed to receive a young baby for whom there will not be adequate room later when the child is older. Application for permission to have more than one child should receive even stricter attention. It is easier to refuse registration at the onset than to secure removal of the child later. Furthermore, no woman should be allowed to continue as a fostermother if her circumstances deteriorate below the standard and steps should be taken to cancel registration. Sometimes this may be achieved by notifying the woman that another child will not be allowed when the present child leaves her care. Some slight relaxation of the requirements may be made in cases where a child is to be received for a short period in an emergency. Where you recommend registration to meet such an emergency please indicate this in your report so that suitable communication may be sent to the applicant permitting registration for the particular child only." It is fortunately becoming a regular practice for persons wishing to become fostermothers to make application for registration previous to their making any arrangements to receive a child. It would be much more satisfactory if all interested in placing foster children made a point of advising prospective fostermothers to apply for approval before steps are taken to receive a 32 child. When a child is found in the care of an unsuitable person it is often difficult to secure its immediate removal, whereas an inspection of the home prior to the child's arrival "would obviate difficulties arising later. Wherever possible assistance and advice is given to persons wishing to act as fostermothers and to persons wishing to place their children in suitable care. From the table of statistics it will be seen that in nine cases the removal of the child had to be requested and in each case this removal was secured without recourse to legal action. SUPERVISION OF MIDWIVES. During the year 54 mid wives notified their intention to practice within the Borough, this number including 13 mid wives residing outside the district. Of the 41 midwives residing within the Borough, 20 were engaged in private practice and 18 were employed in nursing homes, five of these also attending patients in their own homes. All these midwives possessed the certificate of the Central Midwives Board. Number of births attended by midwives : When acting in the capacity of midwife: (a) In private Nursing Homes 73 (b) At the patient's home 569 When acting in the capacity of maternity nurse (a doctor being in attendance) : (a) In private Nursing Homes 187 (b) At the patient's home 151 Notification.—'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 29 On account of a complication during labour 119 On account of a complication during the puerperium 11 On account of the health of the child 29 188 33 Still-birth 12 Death : Of mother — Of child 4 Laying out of a Dead Body 3 Artificial Feeding of Infant 13 Liability of Midwife to be a source of infection 6 Ophthalmia Neonatorum.—The notifications of sending for medical assistance on account of the health of the child included seven cases of inflammation of, or discharge from, the eyes. Two of these cases were notified by the medical attendant as cases of ophthalmia neonatorum. Visits to midwives.—Routine visits to the number of 47 were made by Dr. Dorothy Taylor who acts as Supervisor of Midwives. In addition, six special visits were made with regard to various matters arising in midwives' practices requiring special investigation. Payment of medical fees.—The Town Council paid fees to local medical practitioners, called in by midwives, amounting to £178. 5s. 6d. in respect of 143 claims submitted. The fees were paid in accordance with the scale laid down by the Minister of Health. Where the circumstances permitted, the whole, or part, of the fee was recovered from the husband of the patient. The amount recovered was £69. Is. lOd. Payment of midwives' fees.—In necessitous cases the Council engage midwives for mothers and pay their fees. During the year midwives were engaged in 66 cases. This arrangement will, of course, be terminated when the Council themselves provide a service of midwives under the Midwives Act, 1936. Provision of domiciliary service of midwives, as required by the Midwives Act, 1936.—The steps taken to provide an adequate service of midwives for the Borough, as required by the Midwives Act, 1936, are indicated in the " Report on the Midwives Act, 1936," submitted to the Maternity and Child Welfare Committee on the 29th December, and subsequently approved and adopted by the Town Council. 34 It may be stated here that eight midwives were appointed and commenced their duties on the 1st May, 1937, the appointment of the ninth midwife being deferred. pending experience of the working of the scheme. " REPORT ON THE MIDWIVES ACT, 1936. Objects of the Act. Circular 1569 of the Ministry of Health so succinctly summarises the objects of the Act that it may be quoted :— The principal object of the Act is to secure the organisation throughout the country of a domiciliary service of salaried midwives under the control of the local supervising authorities as an important step in the improvement of the maternity services and in the campaign for reducing maternal mortality. At the same time, the whole status of the midwifery profession will be raised by providing adequate salaries and secure prospects for those midwives who enter the new service, and by compensating those who retire within a specified period and so reducing the present overcrowding in the ranks of the proiession. The Act provides for the establishment by local supervising authorities of a salaried midwives' service ; the payment by those authorities of compensation to midwives who voluntarily retire from practice and to those who are required to retire owing to old age or infirmity ; the payment by the Exchequer of grants towards the cost of the new service and towards the amounts expended in compensation ; the prohibition of maternity nursing by unqualified persons in any area by order of the Minister as soon as he is satisfied that the new service in that area is adequate ; and the periodical attendance at post-certificate courses of all practising midwives. The extent to which the objects will be attained will depend on the readiness with which the midwives who are only attending a small number of cases in the year accept the opportunity of giving up practice, on the support given by the medical practitioners and by the expectant mothers themselves to the whole-time midwives to the exclusion of those independent midwives who only attend a small number of cases and are not intent on taking up midwifery as an earnest profession and lastly on the appreciation of the full import of the new service by local supervising authorities and their recognition of the urgent need for improving the status of the practising midwife. By Section 1, sub-section (1), of the Midwives Act, it is the duty of every local superivising authority to provide, either through voluntary organisations or by itself, an adequate number of whole-time certified midwives who shall be available to. attend on women in their own homes as midwives or maternity nurses during childbirth and during the lying-in period. The lying-in period has now been defined by the Central Midwives Board to mean the time occupied by the labour and a period of not less than 14 days thereafter. The local supervising authority has to submit its proposals to the Minister of Health before the 30th January, 1937, and has to put them into effect before the 30th July following. 35 The Town Council may therefore comply with the requirements of the Act either by makiug arrangements with voluntary organisations for the provision of an adequate service of certified midwives or by itself employing such midwives. But as there are at present no voluntary organisations in the Borough employing midwives, the provision of a whole-time domiciliary service of midwives should undoubtedly be undertaken by the Town Council itself. Inasmuch as the cost of the service Will be met out of the general rate fund (with the assistance of Exchequer grants) it would be the best policy for the Council to retain the fullest measure of control over the new service and thus secure the closest possible co-operation between the midwifery service and the general scheme of maternity and child Welfare. Consultations with voluntary organisations and other bodies. The Council is required before submitting to the Minister of Health its proposals for carrying out its duties under the Act, to consult with voluntary organisations which, to the knowledge of the authority, employ or are willing to employ domiciliary midwives in the area, and with local organisations (if any) representing the medical profession and the midwives practising in the area. As no voluntary organisations at present employ midwives in Ealing and as none are known to be willing to employ domiciliary midwives in the area no conference With a voluntary organisation was called for. A Conference took place on the 30th November between representatives of the Maternity and Child Welfare Committee and the Executive Committee of the West Middlesex Division of the British Medical Association who had been nominated at a meeting of the local medical practitioners to put forward the views of the medical profession. As no local organisation was known to represent the midwives practising in the Borough it was deemed advisable to call together all the midwives to explain the terms of the Midwives Act and to consider any views put forward by the midwives themselves. This conference was held on the 19th October and Was attended by the Chairman of the Maternity and Child Welfare Committee and the Medical Officer of Health. The various points put forward at these two conferences have been borne in mind in formulating the suggestions in this report. Number of whole-time salaried midwives required. By Section 1, sub-section (3), of the Act the proposals submitted by the Council have to include particulars of the number of midwives to be engaged. The number required to serve the needs of the Borough is difficult to estimate, particularly as it will not be known until after the scheme is actually in operation how many midwives will continue in independent practice and how many persons will be allowed under Section 6 (1) (c) of the Act to continue to do maternity nursing, that is, to act as a nurse with a doctor attending the confinement and being responsible for the case. The only clue to the number of midwives required is the number of births which occur in private houses in the Borough, allowance being made for those to be dealt with by midwives and nurses outside the scheme. During the year 1935, the total number of births assignable to the Borough Was 1907. Of this number 1,008 births took place in private houses in the district. The estimated number of births during 1936 will be slightly in excess of this figure but it may be assumed that there will be a little over a thousand births taking place in the homes of the patients. A rough estimate of the number which will be dealt with by midwives and nurses in independent practice may be taken as 280. This leaves the number of births to be dealt with by the new service as 720 per annum. 36 It may be suggested that the Maternity Hospital, which is now in course of erection and which will be able to cope With twice the number of births that occur at the present Maternity Hospital, will reduce the number of births that it is suggested will have to be provided for by whole-time midwives. But the additional beds at the new Maternity Hospital may be calculated as providing for some of the cases at present confined in the County Hospitals and in the hospitals in London and for the increased number of child-bearing women who will come into the district as a result of the continued building of houses on the undeveloped land in the Borough. Provision has to be made for the population of the Borough gradually increasing to 200,000 in the course of the next 10 years from its present estimated level of about 150,000. In Circular 1569, already quoted, it is suggested that in populous districts a midwife should usually be capable of attendance on 100 cases in a year, 70 cases as a midwife and 30 as a maternity nurse. Much controversy has taken place regarding this number and it seems advisable, in view of the facts (a) that from the 1st January, 1937, all midwifery cases have to be attended for a period of fourteen days subsequent to the day of birth instead of a period of 10 days, (b) that one of the principal objects of the Act is to improve the conditions of service of the midwives, and (c) that every opportunity should be taken to extend the time devoted to the care of each patient the number of midwives required should be based on the assumption that each Would be responsible for an average of 80 cases during the year. The Council is therefore recommended to engage 9 whole-time midwives to provide for the Borough an adequate service. This number may be regarded as reasonable but it will be quite easy to increase the number if it is found necessary after the scheme has been inaugurated. Until experience of the actual Working of the scheme is obtained it is difficult to say Whether further staff Will be required to carry on the service during the absence of the regular midwives through illness, annual leave, or attendance at post-graduate courses. As assistance in such cases might be a matter of urgency, it is suggested that approval should be given to the engagement by the Medical Officer of Health of temporary assistance to meet any emergencies. It is not anticipated that the number of midwives required Will decrease, but to provide for such a contingency it is advisable to stipulate in the conditions of appointment that the midwives may be required to undertake duties under the Maternity and Child Welfare or School Medical Services of the Council. Midwives at present in practice in the Borough. The number of midwives Who, during the present year, gave notice of intention to practise in the district is 50, of whom 37 reside in the Borough and 13 in adjoining areas. A detailed summary of the domiciliary cases attended by midwives in the Borough is as follows :— No. of Total cases Midwives residing in the Borough. Midwives. in 1935. Number w ith larger practices 8 485 (100, 82, 68, 57, 54, 44, 41 and 39 cases). Number with small practices (10 to 40 cases) 3 53 (23, 18 and 12 cases). Number with under 10 cases per annum 10 12 (6, 6, 0, 0, 0, 0 and 0 cases—three commenced in 1936). Number in nursing homes who also attend a small number of domiciliary cases 6 18 (15,3 and 0 cases—three commenced in 1936). Number entirely employed in nursing homes 10 — Midwives residing outside Borough. (32, 32, 29, 14, 6, 4, 1, 1, 1, 1, 0, 0 and 0 cases) 3 121 50 689 37 As already stated, 1,008 confinements took place in their own homes, so that if 689 were attended by certified midwives, it means that 319 were attended either by nurses or by handy-women, a medical practitioner being in charge of the patient. A large proportion of these 319 must in the future be attended by midwives, only a small number being attended by maternity nurses holding certificates specifically approved by the Minister of Health under Section 6 (1) (e) of the Act. It is a requirement of the Act (Section 2) that notice of proposed appointments to the salaried service should in addition to insertion in the local press, be sent to every midwife who has given notice of her intention to practice in the area. The Minister of Health in Circular 1569 states that it is important that as many as possible of the idependent midwives at present in practice in the area should be absorbed into the new service and that local authorities, when making their first appointments of salaried midwives, will naturally desire to give preference to the most efficient of the independent it idwives practising in the areas. No doubt the Council will accept the advice of the Minister and will particularly consider the claims of those midwives who at present deal with the largest number of cases and who can be deemed efficient. Such an arrangement will provide for the least possible dislocation of the present midwifery practice. Scale of Salaries of Midwives appointed to Service. The Minister of Health in his Circular states that he regards it as of the utmost importance that the midwives employed in the service should be adequately remunerated and expresses confidence that local authorities will in respect of midwives appointed by them adopt scales of salaries which are comparable With those applicable to health visitors employed in the district together with appropriate allowances for travelling expenses. It is recommended, therefore, that the appointed midwives should be placed on salary scale similar to the new B1 scale applicable to Health Visitors and School Nurses of £200, rising by £10 to £300 a year with the proviso that any increases granted should be subject to a special recommendation of the Maternity and Child Welfare Committee which should take into consideration the experience, ability and personality of the midwife, her possession of the certificate of training as a nurse and the number of cases attended in the year. It seems undesirable to discriminate between those who have had general nursing training and those Who have not in regard to the commencing salary in making the first appointments but it should be accepted as a general principle that in all appointments made after the Scheme is in operation a certificate of training in general nursing is required. It is essential that two of the midwives appointed to the staff should hold a teacher's certificate which will enable them to undertake the instruction of pupil midwives in the homes of the mothers in order to co-operate with the training of pupils at the Maternity Hospital. New rules regarding the training of pupil midwives are in course of preparation by the Central Midwives Board and the position of the new Maternity Hospital will be reviewed as a training school under one or other or both of the new categories envisaged by the Board and it is necessary to take steps as recommended by the Board to provide for the appropriate training of the pupils by appointing approved teachers as part of the scheme of Whole-time midwives. In view of the special experience and training of these approved teachers it is recommended that they should receive £25 a year in addition to the scale already mentioned. To encourage midwives in the employment of the Council to improve their status in the profession and thereby be of more value to the Council's Scheme, an additional increment of £10 a year should be granted to any midwife obtaining the teacher's certificate or an increment of £25 a year if she is ultimately employed in training pupils. 38 Appointment of married women. The Minister of Health in his Circular draws special attention to the fact that many authorities have a rule prohibiting the employment of married women and trusts that when first selecting midwives for salaried posts, the local authority will, where necessary, so revise this rule as to enable them to have regard only to their efficiency as midwives, subject, of course, to their ability to undertake whole-time employment. In view of this recommendation by the Minister it is suggested that in respect of the first appointments to the service married women at present in practice in the area be considered, subject to their ability to undertake whole-time employment. Payment of Allowances, provision of equipment, etc. The Council should pay an allowance in respect of the provision and maintenance of a cycle and to meet other travelling expenses incurred in the ordinary course of duty. It is recommended that this allowance should amount to £5 per annum. To facilitate the summoning of the midwife by her patients cr by doctors, the co-operation of all the Whole-time midwives, and the general administration of the service, a telephone should be provided at the midwife's private residence at the expense of the Council. As each midwife will book her own cases directly it is necessary that she should have accommodation at her private residence for the interviewing of patients. An allowance, therefore, should be made in respect of the rent of a room to be set aside for this purpose and it is recommended that this allowance should amount to 5/- per week, or £13 per annum. To provide an efficient service for all parts of the Borough it will be necessary for the midwives to reside in convenient parts of the district and the terms of appointment should provide for the midwives residing in any part of the Borough indicated. The Council should supply all uniform, equipment and dressings required by the midwives and the laundry charges in respect of the uniform should also be met. It is anticipated that suitable arrangements will be made for the laundry work to be carried out at the Maternity Hospital. The midwives appointed Will, according to the Act, have to devote the Whole of their time to the service of the Council and will not be allowed to engage in any other occupation. The nine midwives appointed will be required to maintain an adequate day and night service for seven days a week for the whole of the Borovgh. Every possible step wrill be taken, however, to arrange their work on a reasonable basis. The suggested arrangements for off-duty periods, together with other terms of appointment of a character which are general to appointments made by the Council, are included in the copy of the proposed ' Terms of Appointment of Midwife ' which is attached hereto as Appendix I. The Act provides in Section 2, Sub-section (3), for the admission of midwives employed by the local authority to the superannuation scheme and authorises the addition of any period or periods (not exceeding in the aggregate 10 years) during Which she has practised as a midwife before being employed by the local authority for the purpose of reckoning the amount of the pension on retirement. There is only one midwife practising in the Borough likely to be appointed as a whole-time midwife whose age will necessitate the addition of years of service to bring her within the Council's Superannuation Scheme. 39 Fees payable for the services of the midwives. Section 3 of the Act makes it a duty of the authority to fix a scale of fees payable for the services of the midwives when acting either as midwives or as maternity nurses and to recover such fees from the patient, or from the husband or other person liable to maintain her. The authority may remit part or the whole of the fee. The fees charged should as far as possible be those prevailing in the district. Enquiries among the local midwives have elicited the information that the fees for attendance as a midwife and for attendance as a maternity nurse are the same, but that in some instances a higher fee is charged in respect of attendance on a woman for her first baby. The fees charged by the midwives at present are in respect of attendance for ten days only, Whereas from 1st January, 1937, the period of attendance will be increased to 14 days. The fees vary from £2. 2s. Od. to £2. 5s. Od. in a multipara and from £2. 2s. Od. to £3. 3s. Od. for a primipara, although the occasions on Which the last fee is obtained are small in number. A uniform fee of £2. 10s. Od. for attendance in all cases Would therefore appear to be equitable. There are certainly advantages in having a uniform fee for both the primipara and the multipara. It is suggested that the fees charged should be reduced according to the following scale of family income after deducting rent, rates, insurances and travelling expenses of the worker, but not taking account of maternity benefit : Average weekly income per member of family after excluding rent, rates, etc. Proportion of Fee. Under 10/- No charge. 10/- to 15/- One-third. 15/- to 20/- Two-thirds. Over 20/- Full charge. This scale for recovery of fees is based more or less upon others used in connection with various benefits obtained through the Maternity and Child Welfare Scheme. The other scales, however, should, in view of past experience, be reconsidered. Cases will arise in which the midwife will not render the full period of service and it is recommended that the Medical Officer of Health be authorised to reduce the fee to meet the circumstances of each case. To prevent patients cancelling the services of a midwife without any adequate reason it is recommended that a proportion of the fee, say 5/-, should be payable at the time of booking. The booking fee Would not be refunded except where the cancellation is not the fault of the patient. While the Council will not be able to insist on prepayment of the whole fee due, as is done in connection with patients admitted to the Maternity Hospital, steps will be taker to encourage payment during the expectant period. Booking of Patients. It will be an integral part of the new service to give the patient as free a choice of midwife as is practicable ; the midwife will be booked direct by the patient and not through any intermediate agency. To facilitate the sending for medical aid it is intended to circularise medical men practising in the Borough and to compile a list of those who express their willingness to respond to calls made by the midwives. It is provided in the rules of the Central Midwives Board that the midwife must call in the doctor named by the patient and it is only proposed that the list of doctors shall be used to submit to patients wTho are unable to name a doctor themselves. 40 Financial Provisions. Section 4 deals with the Exchequer grants towards the institution of the new service and provides for increased contributions out of monies provided by Parliament. In effect and simply stated it means that an amount approximating 40 per cent Will be contributed towards any additional expenditure involved in providing for the employment of domiciliary midwives. Compensation to Midwives ceasing or required to cease practice. A midwife, by virtue of Section 5, may, before the expiration of 3 years from the commencement of the Act, surrender her certificate to the local authority, when she becomes entitled to compensation. This compensation is a sum equal to three times the average net annual emoluments derived from her practice as a midwife or maternity nurse during the preceding three years or the period she has practised as a midwife or maternity nurse, whichever period is the shorter. On the other hand an authority may direct within the same period of three years a midwife, who is incapable, by reason of age or infirmity of mind or body, of efficiently performing her duties as a midwife, to surrender her certificate, in which case she becomes entitled to compensation based on five times her ret annual emoluments as provided in the case of voluntary surrender of certificate. One half of the amount paid in compensation by the local authority will be repaid out of Exchequer funds. A person who has voluntarily or compulsorily surrendered her certificate is forbidden to attend as a nurse on a woman in childbirth. It is not known how many midwives Will retire voluntarily from practice and there is, apparently, only one that the Council may have to call upon to cease practice on account of age or infirmity. This midwife can be dealt with at a later date on when the appointments of whole-time midwives are made. Prohibition of Unqualified Persons acting as Maternity Nurses for gain. Section 6 extends the prohibition of unqualified practice in the previous Midwives Acts whilst expressly exempting medical students, pupil midwives and nurses attending cases in a nursing home from the restrictions. It also exempts women who have received approved certificates of training in obstetric nursing. The ultimate result of this Section will be the elimination of the handy-woman whose place will be taken by the certified and, it is to be expected, whole-time midwife. Attendance of Midwives at Courses of Instruction. Section 7 gives power to the Central Midwives Board to frame rules requiring midwives to attend a prescribed course of instruction and makes it compulsory for local authorities to provide or arrange for such courses of instruction for midwives practising in their area. General Administration of the New Service. The supervision of the work of the midwives employed by the Council will be two-fold, (a) in virtue of the Council being the local supervising authority under the Midwives Act and responsible for the supervision of all midwives and (b) by reason of the midwives being officers of the Council 41 It is proposed that Dr. Dorothy Taylor, the Assistant Medical Officer, who at present is the Inspector of Midwives, should continue in this position and that she should include within her duties the supervision of the wholetime midwifery service in the Borough. In view of the added responsibilities of Dr. Taylor and of the very efficient manner in Which she has carried out her duties in the past, I trust the Council will give special consideration to her salary at the appropriate time. There Will undoubtedly be a large amount of new clerical Work to be performed in the Public Health Department, partly in the general administration of the new service and partly in the routine recording of bookings and payments made. The records in connection with the service Will have to be kept in great detail as they will be subject to inspection by the District Auditor. To deal with the Work involved the services of an additional clerk will be required. Recent movements of staff in the department have resulted in the appointment of two juniors to replace older members of the staff and it is recommended that the new appointment should be of an older clerk placed in Grade A With a commencing salary of about £130. As there will be a considerable amount of work to be accomplished in the month previous to the commencement of the new service, which is aimed at on the 1st May. the additional clerk should be appointed so as to commence his duties on the 1st April. Estimated cost of the new Service. The following statement gives the estimated cost of the new service for a full working year and the estimated expenditure during the financial year ending 011 the 31st March, 1938. Estimate for Estimate for the first the financial full ending working year. 31/3/38. £ £ Expenditure— Salaries of Midwives— 2 at £225 450 413 7 at £200 1,400 1,284 Superannuation—Contributions by Council ... 93 85 National Health Insurance—Contributions by Council 14 12 Cycle allowances 45 41 Telephone 54 50 Rent allowances 117 107 Equipment 108 99 Uniform 135 124 Laundry 45 41 Clerical Assistance 130 130 Printing, Advertising and Postages 60 60 Miscellaneous 50 50 2,701 2,496 Income from Patients 900 825 Net Cost of Service £ 1,801 * £ 1,671 * ♦Subject to Exchequer Grant. 42 It will be seen that the estimated cost for a full year is £2,701, from which will be deducted the income from the patients, leaving £1,801 towards which a grant will be received from the Exchequer. The amount of the Exchequer grant will be approximately 40 per cent, of the additional expenditure incurred by the provision of the new service. Which means an approximate net cost of £1,081. In addition to the estimated cost of the new service there is the amount entailed in the granting of compensation to midwives surrendering their certificates either voluntarily or compulsorily. It is difficult to estimate the amount of this compensation until it is known how many midwives will surrender their certificates, but it is expenditure that will not recur after the expiration of 3 years from the commencement of the Act, namely, after 30th July, 1939. Half of the amount of this compensation will be repaid our of Exchequer funds. A general idea of the amount of compensation that might have to be paid to midwives surrendering their certificates may be obtained bv taking the total number of cases attended by midwives in the district in 1935, subtracting from this the number of cases attended by midwives who might be appointed by the Council and calculating an average income from each case as £2. 0s. Od. This gives the annual emoluments of all the midwives Who might have to be compensated and by multiplying this figure by three it gives the maximum amount of compensation that might have to be paid. Total cases attended by Midwives in 1935 689 Total cases attended by Midwives who might be appointed by the Council 441 Total cases attended by Midwives Who might be compensated 248 Allowing £2. 0s. Od. per case it means total emoluments in year £496 Three times this figure as compensation £1,488 Moiety refunded by Exchequer £744 Maximum net cost of compensation to Council £744 Date of Commencement of the new Service. It is the duty of the local authority to carry its proposals into effect not later than the 30th July. 1937, or such later date as the Minister of Health may allow. Since there are no voluntary organisations to appeal against the scheme it may be brought into operation as soon as the necessary arrangements and appointments can be made, regard being had to the fact that one month's notice must be given of the intention of the Council first to engage midwives in the new Service. Summary of Recommendations. 1. The appointment of nine whole-time certified midwives, two of whom to be teachers approved by the Central Midwives Board. 2. The salaries to be on a similar footing to those paid to Health Visitors and School Nurses (Grade Bl) of £200 to £300 by £10 per annum, increments to be subject to a special recommendation by the Maternity and Child Welfare Committee, with an additional £25 to approved teachers employed in instructing pupil midwives. 43 3. An increment of £10 to be paid to any midwife in the Council's scheme who secures the teacher's certificate, to be increased to £25 if she should be called upon to instruct pupil midwives. 4. While due consideration is given to proficiency and experience, preference to be given to midwives practising in the Borough. 5. The rule relating to the employment of married women not to be applied to the first appointments of midwives under the scheme and years of service, not exceeding ten, to be added Where necessary to bring midwives appointed within the superannuation scheme. 6. The terms of appointment of midwives as set out in Appendix I to be approved. 7. The uniform fee of £2. 10s. Od. to be payable for attendance of midwives on any case, whether as a midwife or as a maternity nurse, and the amount recoverable to be in accordance With the scale contained in the body of the report. 8. The Town Council to provide or make arrangements for the provision of such courses of instruction of midwives practising in the Borough as may be necessary to enable the midwives to comply w'ith the rules thereon made by the Central Midwives Board. 9. An additional Grade A clerk to be appointed to assist in the clerical work involved. 10. Arrangements to be made for the service of Whole-time midwives to come into operation, if practicable, on the 1st May next. 29th December, 1936." APPENDIX I. BOROUGH OF EALING. MIDWIVES ACT, 1936. TERMS OF APPOINTMENT OF MIDWIFE. 1. Applicants must possess the certificate of the Central Midwives Board. (After the 1st J anuarv, 1938. applicants must also be State Registered Xurses). 2. The salary will be in accordance with Grade B1 of the Staff Grading Scheme (£200, rising to £300 by £10 per annum, less five per cent, deduction for superannuation purposes). The appointment will be subject to passing a medical examination by the Council's Medical Officer. The annual increment will be subject to a Special Recommendation of the Maternity and Child Welfare Committee, Who will take into consideration experience, ability, personality, the possession of a certificate of training as a nurse and the number of cases attended. 3. If the person appointed has to act as a teacher of pupil midwives and thus possesses a Certificate as a teacher the commencing salary will be £225 rising to £325 by £10 a year. 4. An increment of £10 per annum will be paid to any Midwife in the Council's service who secures a teacher's certificate which will be increased to £25 if she should be called upon to instruct pupil midwives. 5. The appointment will be terminable by one calendar month's notice on either side. 6. A Midwife appointed Will be required to devote her whole time to the duties and not to engage in private practice or in any other occupation She will be required to pay to the Council all fees or monies of any kind received in the course of her duties. She will be prohibited from receiving presents of any kind. 44 7. She will be required to act under the direction of the Medical Officer of Health and the Inspector of Midwives, who will at all times determine her duties. 8. A Midwife appointed may be required under special circumstances to undertake duties in connection with the Council's Maternity and Child Welfare and School Medical Services. 9. She will be required to reside within an area of the Borough to be determined by the Medical Officer of Health, and to provide at her heme address suitable accommodation for the interviewing of patients, etc. An allowance of £13 per annum will be made in respect of the accommodation provided. 10. A Midwife appointed will be required to provide and use a bicycle in the course of her duties. An allowance of £5 per annum will be made in respect of the provision of the bicycle and other travelling expenses incurred in the ordinary course of duty. The telephone will be provided and the cost met by the Council. 11. Uniform and equipment will be provided by the Council and laundry will be arranged for. 12. Holidays will be allowed to the extent of four Weeks in the year. Alternate week-ends off-duty will, as far as possible, be allowed. The period of week-end off-duty will be from 5 p.m. on Friday, until 10 p.m. on Sunday. Off-duty periods during the week will be dependent on arrangements between the midwives, subject to the approval of the Medical Officer of Health. MATERNITY AND NTJRSING HOMES. The following table gives information regarding nursing homes within the Borough . No. of Homes No. of Beds Number of Nursing Homes on Register at beginning of year - 24 (14) 241 (63) Number of applications for registration 1 Number of Homes registered 1 Number of Nursing Homes on Register at end of year 25 (13) 248 (58) The figures in brackets indicate the number of Homes and the number of beds devoted wholly or partlv to the reception of maternitv cases. Four applications for renewal of certificates of exemption in respect of voluntary hospitals and homes were granted. The nursing homes in the Borough are visited regularly by the Assistant Medical Officer who acts as Supervisor of Midwives, £ total of 47 visits being made during the year. C. Sanitary Circumstances of the Borough. 46 Water.—The North and South Greenford and Northolt Wards are supplied by the Rickmansworth and Uxbridge Valley Water Company ; the rest of the Borough is supplied by the Metropolitan Water Board. Two complaints were received during the year, one regarding the inadequacy of the water supply in the North Greenford Ward, and the other regarding the cloudy condition of the water. Representations were made to the Rickmansworth and Uxbridge Valley Water Company who stated that they would do everything in their power to maintain a full supply in this district, and that the cloudy condition complained of was due to the water being slightly aerated following the charging up of a new section of 18in. main. Rivers and Streams.—There was no occasion for complaint with reference to the condition of the Brent or its tributary stream during the year. Drainage and Sewerage.—With the exception of 52 houses in Northolt Ward, 11 in Greenford North Ward, 1 in Hanwell North Ward, 2 in Mount Park Ward and 5 in Drayton Ward, all houses in the Borough are supplied with water closets and are joined to the sewerage system. During the year 4 houses previously drained to cesspools were connected to the sewer. The sewerage system of the Borough was connected to the West Middlesex sewerage scheme early in the year and the five sewage disposal works at North Ealing, South Ealing, Hanwell, Greenford and Northolt were consequently thrown out of use. Closet Accommodation.—Excepting those parts 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 in the areas mentioned :— 47 Wards Cesspools Water Closets PailClosets Houses within 100 feet of Sewer No. of Houses[/$$$] Northolt 38 29 23 4 52 Greenford 8 8 3 — 11 Hanwell North 1 1 — — 1 Mount Park and Drayton 2 4 3 7 49 42 29 4 71 Public Cleansing.—The whole question of public cleansing in the Borough received the very careful consideration of the Council during the year. The result was that a Manager of Public Cleansing in the Surveyor's Department was appointed to devote his time entirely to this portion of the Council's activities, that the South Ealing Destructor Works "were closed, the Hanwell Destructor Works being continued, that controlled tipping was begun on the site of the old Hanwell Sewage works where ultimately there will be a public recreation ground and that steps were taken to have erected new destructor works on the site of the old Greenford sewage works. Tenders have been obtained for the erection of the works at Greenford and it is expected that at an early date the building will be commenced. It is hoped that in the Annual Report for the current year to give a more detailed description of the changes that have been effected in the Public Cleansing of the Borough as a result of the reorganisation of the work. Refuse Dumps.—A complaint was received during the year alleging the presence of a large number of flies in the vicinity of the St. Marylebone Dump, situated in the Northolt Ward. Investigation within an hour of receiving the complaint proved it to be unjustified. The dump just outside the Borough boundary, in Yeading, to which refuse from Paddington is brought, continues to be conducted in a satisfactory manner. 48 Smoke Abatement.—The Inspectors made 78 observations of chimneys during the year but in only four instances was it necessary to make representations 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 one instance the nuisance was caused by the use of inferior coal and a defect in the smoke consuming apparatus, in two instances the smoke arose from the improper use of refuse incinerators, and in the fourth smoke was caused by the insufficient height of the chimney. Appropriate remedies were applied in all four. 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 houses let in lodgings. Only one offensive trade is carried on in the Borough, namely fishfrying, which is carried on in 27 different premises. During the year 6 applications were received for permission to establish the trade of fishfrying. Permission was granted in two cases. Shops Act, 1934.—During the year four shops were reported by the Shops Inspector as having failed to comply with the provisions of the Shops Act, 1934, relating to ventilation, temperature and sanitary conveniences. Inspections were made by the Sanitary Inspector and in one instance, a railway bookstall, it was found that no heating arrangements had been provided. Upon representations being made to the occupiers a tubular electric heater was installed. In another instance, where there was insufficient W.C. accommodation and an absence of facilities for washing, the shop changed hands shortly after the inspection and no assistants were employed by the new proprietor. In the other two cases the temperature of the shops was taken on a cold day when satisfactory results were obtained. Swimming Baths and Pools.—There are four swimming baths provided by the Council, namely, a women's bath, a first class and a second class bath for men, and a bath reserved exclusively for the use of public elementary school children. 49 These swimming baths are equipped with pressure filters for continuous filtration and the water is treated with chlorine under strict supervision. There are two privately owned swimming pools in the Borough which are run by the Staff Recreation Clubs of two large factories. In both of these pools chemical treatment of the water is carried out. Eradication of Bed Bugs.—Only 6 Council houses were found to be bug infested during the year. In 1935 a review of the Council houses was made with a view to ascertaining the extent of bug infestation. Of the 1,550 houses owned by the Council evidence of bugs was found in 23 houses or 1.5 per cent. of the total. All these houses were successfully disinfested. Evidence of bugs was found in 80 other houses during the year, and all of these were disinfested. The method employed for freeing infested Council houses from bed bugs is by stripping the paper from the walls, loosening or removing all woodwork, the application of blowlamps to the seats of infestation and disinfestation with a proprietary article having a sulphur base. In the case of privately owned houses a notice is served on the owner or occupier to disinfest the house and advice is given as to the methods to be used. In all cases where there is the slightest suspicion of infestation with bugs in the belongings of people about to remove to a Council house disinfestation with Hydrogen Cyanide is carried out, this work being done by a contractor. During the year the furniture and belongings of 26 families were treated by this method. Noise Nuisances.—Section 56 of the Middlesex County Council Act, 1930, provides that a noise nuisance shall be liable to be dealt with in accordance with the provisions relating to nuisances of the Public Health Act, 1875, with the proviso that if the noise is occasioned in the course of any trade, business or occupation it shall be a good defence that the best practicable means of preventing or mitigating it, having regard to the cost, have been adopted. 50 During the year 10 complaints of noise nuisances were received. In 6 instances the complaints were found to be justified. Appropriate action was taken and the noises were reduced to a reasonable amount having regard to the trade or business involved. No action was taken with reference to the other four cases as investigation failed to substantiate the complaint of nuisance. Schools.—A thorough inspection of all the public elementary schools and private schools is made at least once a year by the Sanitary Inspectors, and on their report steps are taken by the Education Committee to remedy any defects found. The owners of private schools now welcome these annual inspections and consider them of great value. In the control of non-notifiable infectious diseases routine reports of absentees continue to be furnished weekly to the public health department by the head teachers of public elementary schools. These give a general idea of the prevalence of infectious 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 during the year to close any school in order to check the prevalence of infectious disease. Rag Flock Acts, 1911 and 1928.—No samples were taken during the year. It is doubtful if any rag flock is used in the Borough. Legal Proceedings.—Legal proceedings were taken in the following six cases with the results indicated:— Non-compliance with Statutory Notices, Section 94, Public Health Act, 1875. 6, 8, 10 and 12, Princes Road. Dampness and general dilapidations. An order was made by the Magistrates for the necessary works to be carried out within six weeks, and a fine of £5 with one guinea costs was inflicted. 177, Boston Road. Dampness and general dilapidations. An order was made by the Magistrates for the necessary works to be completed within three months. 51 23, Western Road. Dampness and general dilapidations. This case was adjourned at the request of the owner's representative, and the necessary work was eventually carried out. 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 94 bodies were deposited therein. It is so fitted that medical practitioners can perform post mortem examinations and in 38 cases during the year such examinations were carried out. The accommodation however is far from adequate and consideration was being given to improvements at the end of the vear. Sanitary Inspection of the Borough.—The following is a summary of the work carried out by the Sanitary Inspectors during the year:— General. Number of Premises inspected on Complaint 1,383 Number of Nuisances observed by Inspectors 176 Number of Premises inspected in connection with Infectious Disease 645 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, etc.) 3,653 Number of Houses inspected under House-to-House Survey 599 Food Inspections 2,747 Total Number of Re-inspections 14,405 Other Inspections 1,625 Total Number of Inspections and Re-inspections 27,063 Number of Intimation Notices given 718 Number of other Letters written 922 Number of Statutory Notices served 200 Proceedings before Magistrates 6 Milk and Dairies Act, Etc. Number of Cowsheds on Register 3 Number of Inspections made of Cowsheds 8 Contraventions of Act or Orders 1 Number of Retail Purveyors of Milk on Register 164 Number of Inspections of Retail Purveyors' Premises 237 Contraventions of Act or Orders 5 Proceedings before Magistrates — 52 Slaughterhouses. Number of Registered or Licensed Slaughterhouses 3 Number of Inspections made 142 Contraventions of Regulations — Proceedings before Magistrates — Factories and Workshops. Registered Workshops 213 Factories 189 Number of Inspections of Factories and Workshops and Workplaces 479 Number of Defects concerning which Notices were sent 83 Proceedings before Magistrates — Offensive Trades. Fried Fish Shops 27 Other Offensive Trades — Number of Inspections 243 Contraventions 5 Disinfection. Rooms Disinfected by Spray:— (a) Ordinary Infectious Disease 12 (b) Tuberculosis109 (c) Other Conditions 139 Rooms treated for Vermin 81 Articles Disinfected by Steam at Disinfector:— (a) Ordinary Infectious Disease 130 (b) Tuberculosis 390 (c) Other Conditions 1,705 Articles voluntarily destroyed 171 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 236 Drains cleared and cleansed 228 Defects in drains repaired 95 Drains reconstructed 53 Dust-bins provided 79 53 Overcrowding remedied 10 Accumulations of refuse removed 97 Nuisance from fowls and other animals abated 9 Damp-proof courses inserted in walls 177 Ventilation under floors provided 26 Other forms of dampness remedied 324 Yards paved and repaired 167 Floors repaired 103 Roofs, gutters and rain water pipes repaired 499 New soil and ventilating pipes provided 51 Sinks and waste-pipes repaired or renewed 210 Draw taps fixed to main supply 16 Dirty walls and ceilings stripped and cleansed 981 Other defects or nuisances remedied 965 Cisterns cleansed, renewed and covered 21 Houses connected to sewer 4 Water supply re-instated 43 Ventilated food cupboards provided 42 FACTORIES, WORKSHOPS AND WORKPLACES. 1.—Inspection of Factories, Workshops and Workplaces Including Inspections made by Sanitary Inspector or Inspectors of Nuisances. Premises Number of Inspections Written Notices Prosecutions Factories (Including Factory Laundries) 238 21 — Workshops (Including Workshop Laundries) 238 16 — Workplaces (Other than Outworkers' Premises) 3 — — Total 479 37 — 54 2.—Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects Number of Prosecutions Found Remedied Referred to H.M. Inspector Nuisances under the Public Health Acts— Want of Cleanliness 23 23 — — Want of Ventilation 2 2 — — Overcrowding — — — — Want of drainage of floors 1 1 — — Other Nuisances 32 32 — — Sanitary accommodation insufficient 5 5 — — unsuitable or defective 8 8 — — not separate for sexes 1 1 — — Offences under the Factory and Workshop Acts Illegal occupation of underground bakehouses (101) — — — — Other Offences 1 1 — — (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 73 73 — — Outwork in Unwholesome Premises, Sec. 108. Nature of Work Instances Notices Served Prosecution Wearing Apparel Making, Etc. — — — Others — — — D. Housing. 56 Housing.—Demolition orders were made under »Section 19 of the Housing Act, 1930, with respect to six houses. Three other houses were represented as unfit for human habitation but with respect to two the owner submitted proposals for their reconditioning which were accepted by the Council, the third being sold and the new owner giving an undertaking not to use the house for human habitation. Altogether, 105 houses have been represented as unfit for human habitation since 1930 when the five years' plan was drawn up, 24 more than were originally estimated. Arising out of these representations there were 63 demolition orders, 23 undertakings from owners not to re-let the houses for human habitation, and 17 houses reconditioned. In respect of the other two houses the owner submitted plans for reconditioning, which were accepted by the Council, but the work had not been carried out by the end of the year. Six other houses were voluntarily demolished prior to definite action being taken by the Council. Housing Act, 1936.—The appointed day for the coming into operation of the overcrowding provisions of the Act was fixed by the Minister of Health to be the 1st April, 1937, for sections 6 (2), 59, 60 and 64, and the 1st October, 1936, for section 62 of the Act. The effect of this latter section is to require that by the 1st April, 1937, every rent book or similar document used in relation to a working class dwelling must contain a prescribed summary of certain provisions of the Act, and a statement of the maximum number of persons who may occupy the dwelling without causing it to be overcrowded. The work which devolved upon the Local Authority under these provisions was considerable as it was estimated that a further 12,000 working class dwellings would have to be measured in order that certificates giving the prescribed numbers could be issued to landlords. Temporary staff, consisting of five measuring assistants and one clerk, were appointed to carry out this work and at the end of the year 7,205 houses had been measured and 2,163 certificates issued. The work was practically completed by the end of March, 1937, when 12,615 houses had been measured, but only 5,710 certificates had been applied for up to the middle of May. In addition to newspaper 57 advertisements, a further method of giving notice of the provisions of the Act was adopted by enclosing a leaflet in the Rate Demand Notices giving the necessary information to landlords but this only produced a few additional applications. Forty-three further cases of overcrowding were discovered during the measuring of the houses, most of these being the result of a change of occupancy since the original enumeration of the district. During the year 22 cases of overcrowding were relieved either by the families being rehoused by the Council or by a change in the family circumstances. Thus by adding these 43 overcrowded houses to those found on the original measurement and deducting the 22 cases of overcrowding relieved we have a total of 335 overcrowded families to be rehoused. 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) 2,109 (b) Number of inspections made for the purpose 2,115 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 599 (b) Number of inspections made for the purpose 605 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 8 (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 1,263 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 1,131 58 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 141 (2) Number of dwelling houses in which defects were remedied after service of formal notice:— (a) by Owners 114 (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 6 (2) Number of dwelling houses demolished in ance of Demolition Orders 8 (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 1 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 — 59 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — Housing Act, 1935.—Overcrowding. (a) (i) Number of dwellings overcrowded at the end of the year 335 (Number of dwellings overcrowded on survey in 1935—314). (ii) Number of families dwelling therein 335 (iii) Number of persons dwelling therein 1,977½ (b) Number of new cases of overcrowding reported during the year 43 (c) (i) Number of cases of overcrowding relieved during the year 22 (ii) Number of persons concerned in such cases 120 (d) Particulars of any cases in which dwelling houses have again become overcrowded after the Local Authority have taken steps for the abatement of the overcrowding — (e) Any other particulars with respect to overcrowding conditions upon which the Medical Officer of Health may consider it desirable to report — During the year a total of 2,461 new houses were built in the Borough by private enterprise. The Town Council completed 84 houses of the non-parlour type in Greenford South Ward, and there are now 139 houses of varying types in the course of construction. Fifty-nine more houses are under consideration but building has not yet commenced. Byelaws.—During the year the Council made Byelaws under Section 6 of the Housing Act, 1925, as amended by Section 68 of the Housing Act, 1935, for securing the improvement of housing conditions intended or used for occupation by the working classes. 60 The Byelaws enforce, among other things, the provision in any house or part of a house intended or used for occupation by the working classes : (a) Closet accommodation; (b) A supply of water for domestic use ; (c) Accommodation for washing clothes; (d) Accommodation for the storage of food in a reasonably cool position with proper ventilation from the external air wherever practicable and with protection from dust and flies ; (e) Accommodation for the preparation and cooking of food ; adequate for the use of and easily accessible to the persons by whom the house is occupied. These provisions will be very helpful in dealing with the great number of houses in the district of which parts have been let or sublet as separate tenancies. E. Inspection and Supervision of Food. 62 INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—At the end of the year there were only 3 cowkeepers on the register as producers of milk. Two of these were licensed during the year by the Middlesex County Council to produce Accredited Milk. The use of one cowshed was discontinued in October last. At the end of the year there were on the register 164 retail purveyors of milk. Twenty of these registrations were in respect of premises owned by one company and eleven by another and used as places for the sale or distribution of bottled pasteurised milk received from the Central Depots in another district. During the year 14 purveyors of milk were registered, With respect to premises used for other purposes, to retail milk in sealed receptacles only, 2 new purveyors of milk were registered for premises purchased from others who were on the register and one with premises in another district was registered to retail milk within the Borough. Two retail purveyors of milk discontinued their businesses and their names were therefore taken off the register. Milk (Special Designations) Order, 1923 and 1936.— Under these Orders 95 licences Were granted during the year, 18 for the sale of Certified Milk, 26 for the sale of Grade A (Tuberculin Tested) Milk and 51 for Pasteurised Milk. Twelve samples of pasteurised milk were taken for bacteriological examination. In all of them the results came within the standard laid down by the Order. Nineteen samples of ordinary unclassified milk were examined for general bacterial count. Four of these were found to contain over 200,000 bacteria per cubic centimetre, namely 2,375,000, 1,885,000, 1,310,000 and 705,000. The attention of the vendors was called to the condition of the milk, and advice was given in exercising care in the sterilisation of the milk vessels and in the method of storing the milk. The advice given was apparently acted upon, as further samples proved to be satisfactory. Eleven samples of ordinary untreated milk were submitted for bacteriological examination at the Lister Institute for the presence of tubercle bacilli. In no instance was this organism found. 63 The introduction of the Milk (Special Designations) Order, 1936, brought about a change in the designations of graded milks which will now be known as " Tuberculin Tested Milk," " Accredited Milk," and " Pasteurised Milk." Tuberculin Tested Milk is obtained from cows which have been submitted to a tuberculin test at stated periods. It must be produced under approved conditions and must conform to the test laid down by the Order. If the milk is bottled at the place of production the word " Certified " may be added after Tuberculin Tested Milk. This milk may be pasteurised, if a special licence has been obtained, when the word " (Pasteurised) " shall be added after the designation. Accredited Milk is produced from cows which have been submitted to an examination by a veterinary surgeon once in every three months. It shall comply with a standard test and must not be treated by heat or in any other manner likely to affect its nature or qualities. Pasteurised Milk is defined as in the previous Order as milk which has been subjected to a temperature of 145 deg. F. to 150 deg. F. for half an hour and cooled. It must conform to the bacterial standard laid down by the Order. 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 three private slaughterhouses and in the course of the year 48 sheep, 413 pigs and 41 calves were slaughtered in them. All the animals were stunned by means of a humane implement and all the 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:— 64 Beef 9 lbs. Pork 188 lbs. Veal 6 lbs. . Fowl 10 lbs. Rabbits 21 lbs. Fish 59 lbs. Fruit 88 lbs. Meat Pies 20 NUTRITION. In recent years interest in the subject of nutrition has been steadily growing, and it is becoming increasingly obvious that of the factors responsible for health, food plays the most important part. Hitherto attention has been directed to the improvement of environmental conditions and to the prevention of the ravages of infectious disease but research and clinical observations now show more and more clearly that a deficient or faulty diet may produce effects of greater consequence to the individual than either of these two factors. Children may, and frequently do, grow up healthily in spite of bad environment. They may avoid illness although exposed to infection: they may survive, undamaged, an attack of disease, but they cannot survive unscathed prolonged deprivation or deficiency of certain essentials for normal nutrition. Adults deprived of these dietetic essentials suffer from chronic ill health and are readily susceptible to infectious disease. Total deprivation of any of them results in serious illness. These conditions can be prevented and in many cases cured by the inclusion in the diet of adequate quantities of certain " protective foods," foods containing the essential vitamins and mineral salts. Among the most important protective foods are the dairy products, especially milk. Eggs, fat, fish, green vegetables and fresh fruit are also rich in vitamins and minerals. Another essential constituent of the diet is animal protein, which has the function of building new tissues for the growing child and of repairing tissue wastage in the adult. 65 It should be our aim therefore to educate the public regarding the constituents of an adequate diet. Most people usually eat sufficient of the energy giving foods but they require instruction in the necessary amounts of protective foods and animal proteins. Unfortunately these foods are the most costly of all and are the first to be omitted when the family budget is limited. Improvement in economic circumstances, which however is beyond the scope of the Public Health Service, is apparently the only complete solution of the problem. Mothers and young children can be actively assisted by the provision of the most important of all the protective foods, milk. Milk contains all the essentials of a good diet, and its addition in most cases compensates for deficiencies in other components. It is provided free of charge in necessitous cases to expectant and nursing mothers and young children at the Child Welfare Centres and is given to older children under the Milk in Schools Scheme. The examination of children at Child Welfare Centres and on school medical inspection demonstrates that conditions due to sub-optimal nutrition are also to be found among the children of parents who can afford to spend an adequate amount on food. The remedy in such cases is the education of the parents in the simple essentials of a balanced diet, and this information is given in informal talks to parents at the Health Centres and in the course of school medical inspection. A booklet has been issued which explains in simple language what food is required and gives hints on the expenditure to the best advantage of the money available for food. Similar teaching is given to the older girls attending the Domestic Subjects Centres by the teachers who act in close co-operation with the staff of the Public Health Department. In most cases this teaching is likely to be passed on to the mothers. It is found that most parents take an interest in food problems and are anxious to discuss a child's diet in detail and to put into practice suggestions for improvement. Our chief aim should be to make available to the people, in the form of simple rules for daily life, the great mass of information on nutrition which science has now placed at our disposal. If these rules are acted upon a vast improvement in general health must result. F. Prevalence of, and Control over, Infectious and Other Diseases. 67 INFECTIOUS DISEASE. The numbers of cases of the various intectious diseases notified in the past twelve years are indicated below. The total number of cases notified in the year under review is the lowest in the last five years, and this is particularly noteworthy when the continuous increase in the population is considered. Scarlet fever accounted for more than one half of the total cases, a total of over four hundred cases being recorded for the fifth year in succession. Following on two years of abnormal prevalence, the number of cases of diphtheria was the lowest since 1925. Cases of Infectious Disease occurring in the Borough. Disease 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 Smallpox — — — 1 1 1 — — — — — — Diphtheria 40 72 53 68 90 129 83 54 71 195 228 52 Scarlet Fever 107 156 136 313 231 264 154 407 476 493 400 408 Enteric Fever (including Paratyphoid) 5 4 14 12 1 4 1 3 4 3 7 8 Puerperal Fever 6 1 6 2 2 7 6 4 3 3 7 3 Puerperal Pyrexia — 3 15 16 13 26 18 21 28 14 11 9 Pneumonia: Primary 57 47 66 73 100 78 96 85 56 72 59 85 Influenzal 22 17 38 13 59 12 18 50 32 17 11 14 Acute Poliomyelitis — 1 — — 1 — 2 4 3 — 1 2 Cerebro-Spinal Fever — — 2 — 1 — — — — — — — Malaria 2 5 6 4 4 2 1 — 1 1 — 1 Dysentery — — — 1 — — — — — — 1 1 Erysipelas 17 15 18 28 24 34 20 30 36 43 28 28 Encephalitis Lethargica 4 2 6 3 3 1 1 1 — 1 — 1 Tuberculosis:— Pulmonary 90 93 89 99 109 111 141 141 154 139 157 139 Non-Pulmonary 25 21 16 24 27 22 27 27 23 24 23 22 Ophthalmia Neonatorum 6 5 4 8 9 9 9 5 8 5 3 4 Total 381 442 469 665 675 700 577 832 895 1010 936 777 68 Cases of Infectious Disease notified during the Year 1936, showing Age and Ward Distribution. Disease Total Cases Notified Removed to Hospital Deaths Ages of Cases Notified Ward Distribution Drayton Castlebar Mount Park Grange Lammas Manor Grosvenor Han well S. Han well N. Greenford S. Greenford N. Northolt 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 over Smallpox — — — — — — — — — — — — — — — — — — — — — — — — — — Diphtheria 52 49 8 3 1 3 3 6 20 11 1 3 — 1 — 2 2 1 1 10 4 — — 12 9 6 5 Scarlet Fever 408 318 2 2 11 17 14 38 178 76 18 42 6 6 — 13 15 22 23 61 31 62 57 18 42 68 16 Enteric Fever 8 4 1 — — — 1 — — 3 1 1 — 2 — 1 — 1 3 1 1 — — 1 — — — Puerperal Fever 3 2 1 — — — — — — — — 2 1 — — — — — — — — 1 — — — 2 — Puerperal Pyrexia 9 5 — — — — — — — — — 5 4 — — — 1 2 — 1 — 1 — — — 4 — Pneumonia : Primary 85 10 57 4 5 1 1 1 8 6 3 6 14 11 25 7 8 7 9 11 6 6 9 6 5 11 — Influenzal 14 1 6 — — — — — — — 1 4 1 8 — — 1 — l 3 2 2 1 1 3 — — Acute Poliomyelitis 2 1 — — — — — — 2 — — — — — — — — — — — — — — — — 2 — Cerebro-Spinal Fever — — 4 — — — — — — — — — — — — — — — — — — — — — — — — Malaria 1 — — — — — — — — — — 1 — — — — — — — — — — 1 — — — — Dysentery 1 1 — — — — — — — — 1 — — — — — — 1 — — — — — — — — — Erysipelas 28 6 4 — 1 — — — 2 1 1 4 3 14 2 2 3 2 3 2 3 3 — 1 3 3 3 Encephalitis Lethargica 1 — 1 — — — — — — — — — — 1 — — — — — — — — — — — — 1 Tuberculosis : Pulmonary 139 — 69 — — — — — 2 3 16 70 31 14 3 10 7 7 13 18 14 6 6 5 20 25 8 Non-Pulmonary 22 — 19 — —— — 2 1 2 3 2 7 1 4 — — 2 3 — 2 2 2 3 l 2 4 1 Ophthalmia Neonatorum 4 2 — 4 — — — — — — — — — — — — — 1 — — — — — 1 2 — — Total 777 172 13 18 21 21 46 214 103 44 145 61 61 31 35 39 47 53 109 63 73 77 46 86 116 33 69 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 — 1 — — 6 — — — — — — 8 Scarlet Fever 1 1 — — — — — — — — — — 2 Enteric Fever — — — — — — — — — — 1 — 1 Puerperal Sepsis — — — — — — — — 1 — — — 1 Pneumonia : Primary 15 — — — — 1 — — 4 3 14 20 57 Influenzal — — 1 — — — — — — 1 3 1 6 Acute Poliomyelitis — — — — — — — — — — — — — Cerebro-Spinal Fever 3 1 — — — — — — — — — — 4 Malaria — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — Erysipelas — — — — — — — — — — 1 3 4 Encephalitis Lethargica — — — — — — — — — — 1 — 1 Tu berculosis : Pulmonary — 1 — — — — — 6 26 15 17 4 69 Non- Pulmonary — 1 1 1 — 4 2 4 2 1 3 — 19 Ophthalmia Neonatorum — — — — — — — — — — — — — Totals 20 4 3 1 — 11 2 10 33 20 40 28 172 70 Diphtheria.—The number of cases of diphtheria notified during the year was 52, compared with 228 in the previous year, and 195 in 1934. The total of 52 cases may be expressed as a case-rate of 0.35 per thousand of population and only on one previous occasion, in 1904, when the diphtheria case-rate was 0.34, has the disease been less prevalent in the Borough. The distribution of the cases according to age and the numbers occurring in each Ward are indicated on page 68. The occurrence of cases throughout the year was as follows:— Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. 7 1 3 13 11 6 3 5 — 1 1 1 The almost complete absence of the disease in the last four months of the year, when a total of only three cases occurred, is most remarkable. In the previous two years the accommodation in the Isolation Hospital had been insufficient to meet the demands for admission, but in the year under review there was, of course, no difficulty in dealing with the cases. The small number of cases was particularly fortunate as the accommodation in the Isolation Hospital was reduced for a period while the extensions were being proceeded with. During the year eight deaths were recorded, equivalent to a death-rate of 0.06 per thousand of population and a mortalityrate of 15.39 per cent. of cases notified, compared with figures of 0.11 and 6.58 in the previous year. The percentage of cases proving fatal was, unfortunately, comparatively high. The arrangements for the immunization of children against diphtheria were detailed in the report for 1934. During the year under review supplies of prophylactic sufficient for 80 patients were issued at cost price to local medical practitioners for their private patients, and in addition, 490 children were immunized through the school medical department, 200 being of school age and 290 under 5 years. This makes a total of approximately 816 children immunized since the arrangements came into operation in 1935. Anti-toxin for the treatment of patients suffering, or suspected to be suffering from diphtheria, is supplied to local medical practitioners free of cost for patients in poor circumstances and at cost price for other patients. During the year 508,000 units of anti-toxin were issued. 71 Scarlet Fever.—The number of cases of scarlet fever notified during the year was 408, compared with a total of 400 in the previous year. The total of 408 cases is equivalent to a caserate of 2.81 per thousand of population, so that scarlet fever was slightly more prevalent in Ealing than in England and Wales, the case-rate for the country as a whole being 2.53 per thousand of population. The occurrence of cases throughout the year was as follows:— Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. 27 33 51 21 26 27 36 21 46 37 44 39 From these figures it will be seen that the cases occurred throughout the year in a comparatively even manner. The Wards in which the cases occurred are shown on page 68. It will be seen that the highest number of cases, 61, occurred in the Lammas Ward, although Greenford North (58), Hanwell South (57) and Grosvenor (52) provided totals very little below this figure. Two deaths occurred from the disease, both being infants under eighteer months. In both cases broncho-pneumonia was a contributory cause of death. The scarlet fever death-rate for the Borough, 0.01 per thousand of population, is similar to the deathrate for England and Wales. During the year 36 cases were removed to the Acton, Willesden or Hendon Isolation Hospitals on account of the accommodation at the Clayponds Isolation Hospital being inadequate, the inadequancy being mainly due to the disturbance of the bed accommodation occasioned by the extensions. Enteric Fever.—Eight cases coming under this heading were notified, five cases being persons who had recently returned from a holiday in the Bournemouth area where, unfortunately, a widespread outbreak of the disease occurred during the summer months. In the other three cases no source of infection could be discovered. One death occurred among the cases notified. Puerperal Fever and Puerperal Pyrexia.—Three cases of puerperal fever were notified during the year, two occurring in the patients' homes and the other in a London Hospital, the notification of the latter case being transferable to this district. One death was recorded from puerperal fever although the case was not notified prior to death. 72 Nine cases of puerperal pyrexia were notified, four occurring in the patient's own home, three in private nursing homes and two in London hospitals. Three cases received hospital treatment in addition to the two notified from hospitals. None of the cases proved fatal. Pneumonia.—Notifications were received of 85 cases of primary pneumonia and 14 cases of influenzal pneumonia. Many deaths of persons ordinarily resident in Ealing occur from pneumonia in institutions outside the Borough and consequently the number of deaths (57 primary pneumonia and six influenzal pneumonia) bears little relation to the number of notified cases. Malaria and Dysentery.—One case of malaria and one case of dysentery were notified. The former case, a man 33 years of age, had previously spent some years in the West Indies, where presumably he had been infected, but in the case of dysentery, a youth of 16 years, no source of infection could be discovered. The Sonne bacillus was isolated from the latter case. Erysipelas.—Twenty-eight cases were notified during the year, exactly the same number as in the previous year. Encephalitis Lethargica.—One case coming under this heading was notified, this being a woman 53 years of age. One death is shown in the table of deaths, but this was another patient who was not notified during the year under review, but who was reported to have had the disease some years previously. 73 Tuberculosis.—The number of cases of tuberculosis notified during the year and the number of deaths which occurred were as follows :— Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 — — — — — — — — 1—5 — — 2 1 1 — 2 1 5—10 1 1 2 — — — 2 2 10—15 1 2 1 2 — — 2 — 15—20 6 10 1 1 2 4 2 2 20—25 21 12 2 1 5 6 1 — 25—35 22 15 4 — 9 6 1 — 35—45 20 11 — 1 8 7 — 1 45—55 10 1 — 1 6 5 1 1 55—65 2 1 — 3 5 1 1 — 65 upwards 2 1 — — 3 1 — — Total 85 54 12 10 39 30 12 7 The number of new cases of pulmonary tuberculosis was 139 compared with 157 in the previous year. Cases of non-pulmonary tuberculosis, 22 in number, were one less than in 1935. The total deaths from tuberculosis were 88 (pulmonary 69, non-pulmonary 19), being fifteen less than in the preceding year. Nine persons were certified as dying from pulmonary tuberculosis and six from non-pulmonary tuberculosis, although they had not been notified as suffering from the disease. Where the deaths were certified by local medical practitioners their attention was drawn to the necessity of notifying under the Public Health (Notification of Infectious Disease) Regulations, 1918. The number of cases on the Tuberculosis Register at the end of the year was 587 (477 pulmonary and 110 non-pulmonary), compared with 550 at the end of the previous year. The cases on the register are revised periodically and visits are paid by the Sanitary Inspectors to the homes of patients not under the supervision of the Tuberculosis Officer in order to obtain information as to their progress. 74 The following information has been provided by Dr. J. T. Nicol Roe, the Medical Officer in charge of the Tuberculosis Dispensary, West Ealing, maintained by the Middlesex County Council, with regard to residents from the Borough dealt with during the year:— Number of persons examined for the first time: (a) Tuberculosis of Lungs 131 (b) Other forms of Tuberculosis 19 Number of persons in Institutions at end of year: (a) Tuberculosis of Lungs 70 (b) Other forms of Tuberculosis 14 Number of persons under observation at end of year 327 Number sent to Sanatoria during year 94 Number sent to Hospital during year 7 Ophthalmia Neonatorum.—Four cases were notified during the year and of these, two were removed to hospital for treatment. The cases were all followed-up by the Health Visitors and in each case the final report indicated that the condition had cleared up and that the child's vision was unimpaired. Measles, Whooping Cough, Etc.—The prevalence of the non-notifiable infectious diseases, such as measles and whooping cough, can be judged by the number of cases occurring among the elementary school children. Each week the head teacher of each school supplies a return of all new cases. The numbers so reported during the year were as follows:— 1935 1936 Measles 142 1,577 Whooping Cough 368 319 Chickenpox 649 493 Mumps 236 686 As Will be seen, measles and mumps were more prevalent, while there was a slight decrease in the cases of whooping cough and chickenpox. G. School Medical Service. 76 SCHOOL MEDICAL SERVICE. In the following table is given information regarding school accommodation and attendance, together with the number of children medically examined and treated, which gives some indication of the increase in the work which the department has been called upon to perform in successive years. Besides the elementary school children enumerated below, the pupils attending the secondary schools in the Borough are also examined and treated in accordance with arrangements made with the Middlesex Education Committee. 1933 1934 1935 1936 Population (Mid - year estimate) 128,800 133,446 137,550 145,000 No. of school departments 41 43 47 47 Accommodation 14,056 14,906 16,749 17,359 Average number on School Rolls during year 13,253 14,077 14,463 15,251 Percentage of School children to population 10.3 10.5 10.5 10.5 Average attendance during year 11,742 12,489 12,932 13,358 Percentage attendance 88.6 88.7 89.4 87.5 No. of children examined at routine inspection 5,213 5,900 5,533 5,996 Percentage of school children examined at routine inspection 39.3 41.9 38.1 39.3 Total number of children who were examined at least once during year 8,273 9,780 9,541 10,364 Percentage of children who were examined at least once during year 62.4 69.5 66.0 67.9 The figures show that there were 463 more children examined at routine medical inspection during the year and that 823 more children than in the previous year were examined at least once. The percentage of children examined at routine inspection and those examined at least once show a slight increase. 77 The percentage attendance is low compared with that in previous years. There was no recognised prevalence of infectious disease to account for the reduction which mainly concerned the infants' schools, and which was generally ascribed to the prevalence of "colds" in the last two months of the year. The "colds" may really have been mild influenza which attacked the adult population in January and February of the present year. Staff.—The increased demand for dental treatment led to the appointment during the year of a third whole-time dentist to replace Mr. John V. Houlton, L.D.S., who, for some years, acted as a part-time officer. The resignation of Miss W. M. Hunt, L.D.S., was received at the time the new appointment was under consideration and two new dental surgeons, Mr. E. Tribe, L.D.S., R.C.S., and Miss I. M. M. Cameron, L.D.S., took up their duties on the 24th August. The opening of the new Health Centres at Greenford Green and Perivale, described under the Maternity and Child Welfare Section of the Annual Report, called for additional nursing and clerical staff, and two school nurses and two clerks were added. The School Medical Nursing staff now comprises one supervising school nurse and eight school nurses. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. No remarks are called for on this occasion under this heading except to say that an enlargement of the Stanhope Infants' School took place, increasing the accommodation from 400 to 500, with in addition a nursery classroom to deal with 40 children and an enlargement of Stanhope Junior Mixed School to 500 from 400 places. Five new school departments are in course of erection. 78 MEDICAL INSPECTION. The medical inspection carried out comprised (1) the routine inspection in the schools of children in the three age-groups recommended by the Board of Education, namely (a) entrants, (b) children at eight years, and (c) children at twelve years; (2) the special inspection of children referred by the head-teachers, school nurses, school enquiry officers, etc.; (3) the annual inspection of physically or mentally defective children; and (4) the inspection of children in connection with the supply of milk at the cost of the Education Committee. FINDINGS OF MEDICAL INSPECTION. A detailed summary of defects found at both routine and special inspections is contained in Table II A on page 101. Among the 5,996 children examined in a routine maimer there were, excluding uncleanliness and dental disease, 767 defects requiring treatment and 1,131 requiring to be kept under observation. The examination of the 4,368 children presented for special inspection revealed 2,848 defects requiring treatment and 345 requiring to be kept under observation. Of the 5,996 children examined at the routine inspections 733, or 12.2 per cent., were found to require treatment for one or more defective conditions. (a) Malnutrition.—The standard of nutrition of the children examined at routine medical inspection is shown in Table II, B., on page 102. The classification is in accordance with the requirements of the Board of Education as set out in the Administrative Memorandum No. 124 issued at the beginning of 1935. The nutrition of the school children in the Borough is extremely good for no less than 97 per cent, of the children examined were classed as "normal" or "excellent," and 175, or 2.9 per cent., were found to be "slightly sub-normal." There were three children, or .1 per cent., recorded in the fourth class, "Nutrition—Bad." 79 (b) Uncleanliness.—The measures taken to deal with uncleanliness and verminous condition were fully described in the report for 1934. The number of children found unclean in the last four years were as follows:— Year. Average number on Rolls. No. of examinations for verminous condition. No. of individual children found unclean. Legal proceedings taken under Attendance Byelaws. 1933 13,253 27,438 625 — 1934 14,077 30,183 760 8 1935 14,463 32,951 755 2 1936 15,251 33,578 830 8 FOLLOWING UP. The arrangements made for following up children found at routine or special inspections to be suffering from defective conditions have been given in detail in previous years. The number of visits made by the school nurses during the year under review was 5,013. ARRANGEMENTS FOR TREATMENT. (a) Minor Ailments and Diseases of the Skin.—Inspection clinics are held at each Health Centre on certain days in the week, and treatment is offered for minor ailments and skin diseases. It will be seen from Table IV, Group I (page 106) that as many as 95.1 per cent, attend the Health Centres for treatment in preference to attending hospitals or private practitioners. 80 The number of cases treated and the total number of attendances made were as follows:— Condition Treated. No. of cases treated. Total attendances made. Skin: Ringworm 12 91 Scabies 25 89 Impetigo 250 2,781 Others 233 1,049 Minor eye defects 191 1,972 Minor ear defects 354 2,408 Miscellaneous: Minor injuries 261 1,222 Sores 662 4,939 Others 27 115 Total 2,015 14,666 (b) Defective Vision.—The report of the Ophthalmic Surgeon, Dr. L. G. Scoular, is herewith submitted. It will be particularly noted that he has discussed the problem of dealing with partially sighted children. His observations, in view of those submitted by Dr. J. D. Kershaw on the same problem in the previous report will have to receive very careful consideration at an early date. "Report on the Eyesight of School Children." "During the year 626 new cases were examined, and there were 927 re-examinations. Comparing this with the numbers seen in 1934 when the last full report was made, there is an increase of 66 new cases and 412 re-examinations. "It is my practice to test every child after drops have been instilled into the eyes, and in the great majority of cases it is possible to prescribe the correct glasses immediately. In some, however, it is necessary to see them in a few days' time to carry 81 out what is known as a subjective test, and after this has been made the glasses are ordered. "One has to explain this, as the figure 927 re-examinations includes these children on whom one has made a subjective test. In order that these cases may be kept separate from the others I have introduced a new method of tabulating them in which there is a separate column for each. "Of the new cases 343 were seen at the Mattock Lane Health Centre and 283 at the Ravenor Park Health Centre, and of the old cases, 462 at the former and 465 at the latter. "The following tables show the relative numbers of the different ocular defects seen at the two centres. "During the year 746 cases had glasses prescribed, and in 143 cases no spectacles were ordered. This last figure is largely made up by hypermetropic children whose eyes become normal as they grow older. "The question as to how often a child's eyes should be examined very largely depends on the type of refractive error found, and one cannot lay down a general rule for all children. Thus, in a case of simple hypermetropia it is not necessary for an examination to be made more than once a year. With hypermetropic astigmatism every 9 to 12 months would be about right. With myopia it is necessary to see the child more frequently, at least every six months, but this depends on the type of case and the rate at which the myopia is increasing. Again, with many squint cases it is necessary to see them frequently, perhaps as often as every 4 to 6 weeks, especially if one is occluding the better eye. Thus it will be seen that there is a great variation in the interval advisable between one examination and another in different children, and only the ophthalmic surgeon is in a position to advise just what this interval should be. For this reason, after examining any child I put down on the card when I want to see the case again ; this is noted by the nurse in charge, and the child is sent for at the proper time "With regard to the treatment of progressive myopes, I have made a list of those cases who, according to the recommendations of the Committee on Partially Sighted Children, would qualify for admission to a special school. The two most important of these recommendations are: 82 (a) Myopia progressing at the rate of more than 1 dioptre a year. (b) Myopia with a visual acuity of 6/24 or worse after correction. "With these as a basis I found 6 cases at Ravenor Park and 3 at Mattock Lane who would qualify for special treatment. This number is probably smaller than one would have expected from previous reports, but in commenting on this fact I would point out (a) that a great many cases of myopia increase at just under 1 dioptre per annum and so escape inclusion ; and (6) that the great majority of myopes, even of fairly high degree, have a better vision than 6/24 when corrected. Of these 9 cases mentioned the majority had a much better vision than 6/24, but their myopia appeared to be increasing by about 1 dioptre per year, and several were advised to stay away from school for several months. After this prolonged rest from eye strain it is probable that their myopia will cease to progress as rapidly, and will no longer be included in the list. "My own personal opinion on the matter is that there is not a sufficient number of highly myopic children in the Borough to justify the provision of a special sight-saving class. As far as one can judge, the great majority of these children get on quite well at the ordinary school, but of course they should have every possible advantage given to them, such as sitting near the blackboard and with good light on their books, etc. The fault I find, however, is not so much with their work at school, as the way they spend their time at home, where every possible minute is taken up with a book, often of poor print and read in a bad light. To prevent this, the nature of the defect has to be fully explained to the parents who must see that the child does a minimum amount of close work." 83 Eye Cases, Mattock Lane, 1936. Condition. New Cases. Re-Inspections. Hypermetropia 72 103 Hypermetropic astigmatism 111 154 Myopia 42 69 Myopic astigmatism 30 76 Mixed astigmatism 13 31 Emmetropia 18 28 Eye diseases 8 4 Welfare cases 9 6 Total squints 40 91 Total 343 462 Eye Cases, Ravenor Park, 1936. Condition. New Cases. Re-Inspections. Hypermetropia 52 74 Hypermetropic astigmatism 89 117 Myopia 30 46 Myopic astigmatism 18 60 Mixed astigmatism 13 18 Emmetropia 12 16 Eye diseases 14 11 Welfare cases 8 6 Total squints 47 117 Total 283 465 84 Total of Cases seen at both Centres. New Cases. Re-Inspections. Mattock Lane 343 462 Ravenor Park 283 465 Total 626 927 Total at both Centres ... ... 1,553 (c) Nose and Throat Defects.—The arrangements for the operative treatment for nose and throat defects at the King Edward Memorial Hospital were described in the report for 1934. During the year under review 72 children were dealt with, 62 being operated on for enlarged tonsils, one for adenoids, and nine for enlarged tonsils and adenoids. (d) Ear Defects.—There is little doubt that by the usual practice at routine medical inspection a large number of ear defects are not detected and that a more detailed examination of the ears is desirable. By the use of the audiometer valuable data can be obtained but its regular application to all school children is laborious and expensive. Moreover, its use is limited to the detection of ear diseases where defect of hearing is present, and cases of ear disease not associated with deafness are liable to go undetected. As an alternative the examination of ears by means of the electric auriscope in all routine medical inspections was considered and was ultimately adopted. Meatus and tympanic membrane are directly examined as a regular practice and where a defect exists or where signs of disease are present, the child is referred to the ear clinic for treatment as well as for investigation of hearing. All the medical officers carrying out the routine medical inspections are now very proficient in the use of the auriscope. 85 Results of Examination. The presence of wax was only noted as a defect where it existed in such quantity as to prevent a sufficient view of the tympanic membrane. Such cases were treated at the Inspection Clinic by syringing. Where this was not successful the case was referred to the Ear Clinic for its removal by other means. After removal of the wax the examination was completed by the auriscope to ensure that no other disease of the ears existed. The results of the examinations were as follows: Total number of medical inspections 5,996 Number with ear defects 135 Percentage with ear defects 2.28 Nature of Defects. No. No. referred to Inspection Clinic. No. referred to Ear Clinic. Wax 116 95 21 Otorrhoea 16 4 12 Earache 2 0 2 Aural Polypus 1 0 1 Total 135 99 36 It is noted in the above table that excessive wax is the predominating defect and although it does not constitute ear disease in the true sense it is a defect which, by reducing auditory acuity, is likely to prevent a child from getting the full benefit from its education. Otorrhoea was found in 16 children and the importance of detecting this cannot be over-estimated for its neglect may lead to more serious disease or irreparable impairment of hearing in later life. The fact that middle ear disease frequently exists without any external evidence of its presence, such as a discharge from the external meatus, makes an auriscopic examination essential to ensure that disease of this nature is absent. 86 The fact that 2.28 per cent. of the children examined suffered from an ear defect which in most cases would have remained undetected without the auriscopic examination has justified this additional feature in the medical inspections, particularly as the time involved in carrying out the inspections has not been materially increased. It is hoped by a continuance of this method to reduce undetected ear disease to a minimum. The Ear Clinic. A special clinic is held once a week at the Mattock Lane and Ravenor Health Centres for the investigation and treatment of ear disease in children of school age and in children attending the Welfare Centres. The clinic is under the supervision of Dr. Murdoch MacGregor, who is specially qualified in this work, and mainly consists of the treatment of chronic otitis media. Children suffering from otorrhoea attend the Health Centres daily for treatment in which the ears are cleansed of discharges and drops are instilled. The cases are examined weekly at the special clinic and in selected cases zinc ionization therapy is carried out. Where this treatment is unsuccessful or where further operative measures are deemed advisable the case is referred to hospital. To ensure that permanent benefit has resulted in those successfully treated no case is finally discharged until repeated examination covering a minimum period cf six months has shown no recurrence of the disease. A case is only considered cured when after this period the ear is dry and there is no impairment of hearing. The cases examined and the results of treatment are shown in the following tables: Number of cases under treatment, 31st December, 1935 24 Number of cases referred from Routine Medical Inspections 36 Number of cases referred from Inspection Clinics 88 Number of cases referred from Child Welfare Centres 6 154 87 Diagnosis. No. Successfully treated and discharged. Successfully treated and under observation. Referred to hospital. Still under treatment. Wax 15 15 — — — Catarrhal deafness 18 13 — — 5 Chronic adhesive process 2 — — 1 1 (Ref. Deaf) School) Acute otitis media 22 18 1 3 — Double acute otitis media 5 5 — — — Chronic otitis media 61 27 17 7 10 Double chronic otitis media 17 10 3 2 2 Otalgia 5 5 — — — Furunculosis 7 7 — — — Acute mastoiditis 1 — — 1 — Aural Polypus 1 — — 1 — 154 100 21 15 18 In the above figures it will be noted that 154 cases were referred to the ear clinic in 1936 and of this number 100 were successfully treated and discharged, 21 cases were successfully treated and were still under observation, whilst of the remaining 33 cases 15 were referred for hospital treatment and 18 were still under treatment at the clinic. It is gratifying to observe the success attained in the treatment of cases of chronic otitis media, particularly since the disease was present in many cases for a number of years. Fiftyseven cases out of a total of 78 were successfully treated, nine cases were referred for hospital treatment and 12 cases continued under treatment at the clinic. Treatment of Chronic Otitis Media by Zinc Ionization Therapy. Number of cases of chronic otitis media referred to Clinic 78 Number of cases treated by Ionization 36 Number of cases successfully treated 20 Number of cases unsuccessfully treated 8 Number of cases still under treatment 8 88 The policy pursued is to select for ionization therapy only those cases which fail to respond to more conservative methods of treatment and in which no contra-indications for this form of therapy are present. The fact that success was attained during the year in 20 cases out of the total of 36 indicates that the application of this method is thoroughly justified and worthy of continuance. Hearing Defect. In each case referred to the clinic bearing was tested before and after treatment. Only in 23 cases out of a total of 154 tested was a persistent hearing defect recorded after treatment. The causes and the steps taken to deal with these 23 cases are recorded below. Diagnosis. No. with hearing defect. No. referred for hospital treatment. Referred to deaf school. No. still under treatment. Chronic otitis media 18 10 — 9 Chronic catarrhal otitis media 2 — — 2 Chronic adhesive process 2 — 1 1 (e) Dental Defects.—The report of Mr. C. Colenso, the Dental Surgeon, gives a survey of the work of dental inspection and treatment during the year. For convenience, the report is inserted in three places in the annual report, the section relating to secondary school children appearing on page 97, that dealing with mothers and pre-school children on page 29, while the section embracing a description of the work among elementary school children follows. 89 "Dental Inspection and Treatment of Elementary School Children during 1936." "During the year, 624 more children than in the previous year were inspected by the dental surgeons at the various schools. The number of children inspected reached a total of 14,534 or 4,845 children inspected by each officer. "The number found to require treatment was 9,465. This is larger than in the preceding year by 526. Those actually treated by the school dental surgeons amounted to 5,967. "The treatment carried out was as usual fillings in permanent teeth, and in certain temporary teeth in very young children, extractions both of permanent and temporary, also "other operations," for example, scalings, dressings to permanent teeth and gum treatments. The number of fillings was 6,421 for permanent teeth. This figure is smaller by sixty than in the previous year. Temporary fillings showed an increase of eighty over the preceding year; 746 of these fillings being applied to the molar teeth of the temporary dentition. "Extractions, both temporary and permanent, totalled 11,053, a little more than last year. Of this number 1,375 were of permanent and 9,678 of temporary teeth. "Other operations " included dressings to teeth, e.g., silver nitrate dressings to anterior and posterior temporary teeth, sedative dressings to cavities in certain permanent and temporary teeth, gum treatments in minor forms of gingivitis. Altogether 853 applications of this character were given. Scaling was done on 118 children's mouths. For the work carried out by the dental surgeons 8,146 attendances were made by the children at all the Centres. "At the special leavers' inspection which takes place three times yearly, in the senior departments of schools, it was found that at the end of the year 76 per cent. children were leaving with their teeth perfectly sound. The coming year will show a higher percentage leaving with completed dental treatment." 90 (f) Orthopaedic Treatment.—The work of the orthopaedic clinic during the year may be summarised as follows: Orthopaedic Clinic. School children. Children under five. Total. Attendances by Surgeon 11 12 23 Number of children seen for first time 139 126 265 Total number of children examined 591 457 1,048 Attendances by Masseuse 91 139 230 Number of cases dealt with 186 65 251 Number of attendances by children 2.214 557 2,771 Children admitted to hospital for operative treatment 9 3 12 Children supplied with special boots or surgical appliances 12 — 12 During the year the average number seen by the Surgeon was 46, the highest number at one session being 68, compared with an average of 45 in the previous year. This is a very large number to be dealt with at each session. Any further increase in the numbers will necessitate arrangements being made for the Surgeon to attend more frequently. (g) Defective Speech.—Two classes are held each week, one at the Mattock Lane and the other at the Ravenor Park Centre. Twelve pupils are dealt with in each class at a time and the children attend twice weekly for lessons which last an hour. The results of treatment are shown in the following table. It must, however, be borne in mind that included in these figures are a number of children whose attendance will continue during 1937. 91 Result of treatment. Stammering. Other speech defect. Cured 1 2 Much improved 6 6 Improved 7 9 Not improved 1 2 (h) Convalescent Treatment.—The arrangements detailed in the report for last year were continued and during the year 33 children were sent to the Russell Cotes School of Recovery, Parkstone, and 9 children to Collington Manor. The usual period of residence is six Weeks, but three children had an extended stay of twelve weeks. In addition, the King Edward Memorial Convalescent Home Fund provided six children with a holiday of two weeks' duration in the summer months at Collington Manor The results of this convalescent treatment has in many cases been remarkable and very few children indeed fail to obtain marked benefit from the short stay under hygienic conditions and with an ample and satisfactory diet. It is now found that the number of places provided is insufficient to meet all the demands for this form of treatment and long waits for vacancies for children are common. Further provision of beds is called for. (i) Diphtheria Immunization.—The arrangements for the immunization of children against diphtheria were detailed in the report for 1935. The number of children attending for treatment is slowly increasing, as the advantages of immunization become known, but as there have been very few cases of the disease in the Borough the stimulus of fear has been lacking. A leaflet explaining the need for diphtheria immunization and the procedure to be adopted is sent, along with the notice of school medical inspection, to the parents of each entrant into 92 the infant schools. When the parent subsequently attends with the child for medical inspection, any questions on the subject are answered by the Medical Officer. During the year the number of school children Schick tested totalled 200, of which number 42 were found to be Schick negative and therefore not to require treatment. Children under five years of age were referred for immunization from the Child Welfare department and 290 of these children received the series of three injections, the usual practice of omitting the preliminary Schick test in young children being adopted. Schick tests were applied subsequently to immunization to determine its effectiveness in 452 cases and ten were found susceptible and were re-immunized. INFECTIOUS DISEASE. The returns sent each week by the head teachers giving particulars of all new cases of non-notifiable infectious disease included 1,577 cases of measles, 319 of whooping cough, 493 of chickenpox and 686 of mumps. Certificates in respect of five schools were supplied during the year under Para. 15 (ii) of the Administrative Memorandum No. 51 issued by the Board of Education. These were given when the prevalence of infectious disease had resulted in the percentage of school attendance falling below 60 per cent., and were as follows : Perivale Infants' School Week ending 27th March : Measles. St. Saviour's School Weeks ending 27th March, 3rd and 8th April : Measles. Betham's School Weeks ending 27th March, 3rd and 8th April : Measles and Mumps. Wood End Infants' School Week ending 8th April : Measles. Drayton Infants' School Weeks ending 15th, 22nd and 29th May : Measles. 93 Children to the number of 273 were excluded under Article 20 (b) of the Education Code for the following conditions : Impetigo 231 Ringworm of head 2 Ringworm of body 8 Scabies 25 Other skin diseases 7 273 No closure took place under Articles 22 or 23 (b) of the Code— Grant Regulations. OPEN-AIR EDUCATION. Reference has been made in previous reports to the steps that are taken to encourage open-air education for the school children. There have been no new developments worthy of record in respect to open-air education during the year. CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND VOLUNTARY BODIES. The co-operation of parents, teachers, school attendance officers and certain voluntary bodies in regard to school medical inspection and especially medical treatment has been alluded to on previous occiasions. The teachers continue to give that wholehearted co-operation and assistance in school medical work which has been noted previously and for which sincere gratitude has been expressed. There is no doubt that a large measure of the success of medical treatment and supervision of the children is due to their lively interest in the school medical service. Among the voluntary bodies which have given much continued help are the Central Aid Society, the National Society for the Prevention of Cruelty to Children and the School Attendance Aid Committee and appreciation of the work carried out by them must be expressed. 94 PHYSICAL TRAINING. In a previous report an account was given of the provision made for physical exercises and organised games in the schools. On the consideration of Circular 1445 on Physical Education issued by the Board of Education the Education Committee decided on the appointment of organisers of physical training. They have since taken steps to co-operate with the Middlesex County Council in appointing a man and a woman as organisers to devote half their time to the public elementary schools in Ealing and the remainder of their time to schools in other parts of the County. PROVISION OF MEALS. The following table indicates the number of children having a daily supply of milk in school. Milk is supplied in bottles containing one-third pint at a cost of one halfpenny. Date. Number on Registers. Number having milk. Percentage having milk. 28/9/1934 14,000 3,200 23.0 31/10/1934 14,066 10,380 73.8 30/11/1934 14,066 9,337 66.4 1/10/1935 14,572 8,175 56.1 1/10/1936 15,477 8,516 55.0 The number of children having milk on the 1st October, 1936, has been sub-divided in the following table to show the number and percentage having milk in the various departments of schools. The following table indicates that two-thirds of the younger children are receiving milk : 95 Number and Percentage of Children having Milk on the 1st October, 1936. No. of school departments in group. No. of children on registers. No. having milk Percentage having milk. 1/10/36 1/10/35 Senior Boys 8 2,225 830 37.3 42.2 Senior Girls 7 1,974 892 45.2 44.0 Mixed. 3 1,165 559 49.7 45.4 Junior Mixed 9 3,319 1,750 52.7 55.8 Junior Mixed and Infants 9 3,185 2,062 64.8 66.4 Infants 11 3,609 2,423 67.1 66.7 Total 47 15,477 8,516 55.0 56.1 The number of children supplied with milk free of charge under Sections 82—85 of the Education Act, 1921, was as follows: Number of children for whom a supply of milk was approved, 1st January, 1936 986 Number of children for whom a supply of milk was approved, 31st December, 1936 1,057 Daily average number of children who received a supply of milk 840 Total number of bottles of milk supplied 178,917 Cost of milk supplied £372 The new arrangements for the medical supervision of all children having milk at the cost of the Education Committee were given in the report for last year. New cases are medically examined before a supply of milk is authorised and all children having milk free are seen by the Medical Officer annually at the time routine medical inspection is conducted at the school. At the present time an enquiry is being carried out to determine the need, if any, for extending the scheme for the feeding of school children, consideration being given to the physical evidences of lack of proper food and the economic circumstances of the family. 96 BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. The return of exceptional children in the area (Table III, page 103) indicates under each heading the school children suffering from blindness, deafness, mental defect, epilepsy, active tuberculosis, crippling, or heart disease. It shows the number of children in each category who are being maintained at Certified Schools, who attend public elementary schools, etc. The figures, compiled from the list of exceptional children on the last day of the year, indicate that 25 children were being maintained at Certified Schools by the Education Committee. NURSERY SCHOOLS. There are nursery classes attached to St. John's and St. Mark's Schools to which children are admitted before their fourth birthday, two classes for 30 children being in the former school and one class for 30 children in the latter. These classes serve their purpose in an admirable way and are exactly in those localities where they are most needed. A nursery class is being established at Stanhope Infants' School, new premises being specially built for the purpose. The children undergo medical examination in the usual manner at the routine inspection at the school to which the classes are attached. To ensure the early examination of all new scholars the infants' schools are visited twice yearly, following the Easter and summer vacations, so that it can be assumed that new admissions to these classes get early medical supervision and treatment. SECONDARY SCHOOLS. Routine medical inspection was conducted as usual on behalf of the Middlesex Education Committee in the four County Schools in the Borough, there being carried out 773 routine and 47 special inspections or a total of 820. Ophthalmic treatment was given during the year to 70 pupils. In 55 of these cases spectacles were prescribed and supplied through the school medical service. The School Dental Surgeon's report on the dental condition of secondary school pupils is as follows: 97 "This is the second year that the children attending the County and Technical vSchools have been inspected and treated by the dental surgeons, 1,538 being inspected in the schools, a little larger number than in the previous year. Those children found to require treatment numbered 897, a smaller number by 81 than in the previous year. The number of children from these schools actually treated amounted to 443, thirty-two more than in 1935. Of this number treated the majority were children who had previously not required any treatment, while a smaller number were routine cases that had developed small probe size cavities in other teeth. There is quite a large number of children in the County Schools whose parents object to treatment or who can dictate to their parents whether they should have treatment or not. Of course some go to private dentists. The objectors come mostly from areas outside Ealing where attendance at the Centres had not been greatly impressed upon them. These cases often come later and ask for treatment on account of toothache or swollen face and then is the opportunity to advise complete treatment and consent is almost invariably given. The work carried out was chiefly conservative in character, 831 teeth being filled. Extractions of the permanent teeth numbered 225. More than half of these extractions were required for regulation purposes. Temporary extractions numbered 83. 'Other operations' consisted of scalings for twenty-seven children and dressings to gums and permanent teeth for 72 children." PAYMENTS BY PARENTS. Payments are required for the various forms of treatment provided by the School Medical Department, with the exception of treatment for minor ailments. These are based upon the family income and are in accordance with scales adopted by the Education Committee. In the report for 1935 a note was made of the arrangements which had been completed with the Hospitals Saving Association by which that Association became responsible for the payment of treatment of school children. The arrangements have worked admirably and have saved the school medical staff an enormous amount of clerical work and it has been found that they have been the means of encouraging many parents to join the Association. 98 HEALTH EDUCATION. Detailed descriptions of the means utilised to spread knowledge on health matters among school children have been given in previous reports and there are no new activities to be reported under this heading. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Children.—The number of children examined in connection with their employment out of school hours was 333 and of this number 30 were found to be unfit for employment. The nature of the employment of those certified as fit was : Boys. Errand boys 94 Milk round 37 Newspaper round 51 Baker's round 32 Order boy 6 Others 80 300 Girls. Shop assistant 1 Cleaning step 1 Domestic help 1 3 303 These children are subject to re-inspection at the time of routine inspection in their school and if it is found that employment is detrimental to their health, sanction to employment out of school hours is withdrawn. This action was found necessary in 16 instances. Routine inspection revealed four children under the permitted age who were working out of school hours, and 40 children who had not obtained the necessary permission. Thirty-eight girls were examined in connection with the issuing of licences under Section 22 of the Children and Young Persons Act, 1933, permitting employment in entertainments. One of the girls was at first found to be unfit for such employment and the licence was not issued until the defect had been remedied. 99 Young Persons.—In the report for 1934 particulars were given of the steps taken to provide the Juvenile Employment Department with information regarding the medical histories of children coming under their care. MISCELLANEOUS. Under this heading have to be grouped the medical examinations made of candidates prior to their appointment on the teaching staff by the Education Committee and of the ever-increasing number of persons added to the Council's technical and clerical staff and manual workers. All of these examinations are carried out by the school medical staff, assisted by school nurses when necessary. During the year 71 teachers and 132 other candidates were medically examined previous to appointment. School Medical Officer and Medical Officer of Health. June 24/h, 1937. 100 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 2,158 Second Age Group 2,212 Third Age Group 1,626 Total 5,996 Number of other Routine Inspections — B.— Other Inspections. Number of Special Inspections 4,368 Number of Re-Inspections 4,098 Total 8,466 C.— Children Found To Require Treatment. Number of individual children found at Routine Medical Inspections to require treatment (excluding Defects of Nutrition, Uncleanliness and Dental Diseases) :— Group. For defective vision (excluding squint). For all other conditions recorded in Table IIa. Total. Entrants 15 194 209 Second Age Group 173 178 336 Third Age Group 92 100 188 Total (Prescribed Groups) 280 472 733 Other Routine Inspections — — — Grand Total 280 472 733 101 TABLE II.— A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1936. DEFECT OR DISEASE Routine Inspections No. of Defects. Special Inspections No. of Defects. Requiring Treatment Requiring to be kept under observation, but net requiring Treatment Requiring Treatment Requiring to be kept under observation, but not requiring Treatment Skin Ringworm, Scalp — — 2 — Body — — 13 — Scabies 2 — 23 — Impetigo 3 — 247 —»- Other Diseases (Non-Tuberculous) 5 4 228 — Eye Blepharitis 4 2 45 — Conjunctivitis 3 — 77 — Keratitis 1 — — — Corneal Opacities — — 1 — Other Conditions 8 2 86 2 Defective Vision (excluding Squint) 280 14 204 5 Squint 39 2 19 — Defective Hearing Ear Otitis Media 2 3 9 1 18 5 84 — Other Ear Diseases 135 1 120 — Nose and Throat Chronic Tonsillitis only 56 366 87 69 Adenoids only 2 3 3 — Chronic Tonsillitis and Adenoids 21 1 28 2 Other Conditions 15 75 93 14 Enlarged Defective Cervical Glands (Non-Tuberculous) — 49 36 14 Speech 10 14 14 9 Heart and Circulation Heart Disease: Organic — 15 — 4 Functional — 26 3 3 Anaemia 1 87 4 24 Lungs Bronchitis 3 20 19 13 Other Non-Tuberculous Diseases 10 29 14 13 Tuberculosis Pulmonary: Definite — — 2 — Suspected — 2 — 16 Non-Pulmonary: Glands — — 3 1 Bones and Joints 1 1 1 1 Skin — — — Other Forms — — — — Nervous System Epilepsy 1 2 3 5 Chorea — 1 6 7 Other Conditions 4 2 4 11 Deformities Rickets Spinal Curvature 1 8 1 2 3 — Other Forms 94 358 59 20 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 40 46 1306 111 TOTAL 767 1131 2848 345 102 B.— CLASSIFICATION OF THE NUTRITION OF CHILDREN INSPECTED DURING THE YEAR IN THE ROUTINE AGE-GROUPS. Age-Groups. Number of Children Inspected. A. (Excellent). B. (Normal). C. (Slightly subnormal) . D. (Bad). No. % No. % No. % No. % Entrants 2,158 99 4.6 1,971 91.3 86 4.0 2 0.1 Second Agegroup 2,212 175 7.9 1,982 89.6 54 2.4 1 0.1 Third Agegroup 1,626 134 8.2 1,457 89.6 35 2.2 — — Other Routine Inspections — — — — — — — — — Total 5,996 408 6.8 5,412 90.2 175 2.9 3 0.1 103 TABLE III. RETURN OF ALL EXCEPTIONAL CHILDREN, IN THE AREA. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 — — — 1 PARTIALLY SIGHTED 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. — 4 9 — — 13 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 11 1 — — 12 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. — — 14 — — 14 104 MENTALLY DEFECTIVE CHILDREN. Feeble-minded Children. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At other Institutions. At no School or Institution. . 2 78 — — 80 EPILEPTIC CHILDREN. Children suffering from Severe Epilepsy. At Certified vSpecial Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 2 — — — 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 — 5 5 II.— Children suffering from Non-Pulmonary Tuberculosis. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — — 1 2 3 105 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 255 — — 256 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 17 ' — — 20 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 1 1 2 CHILDREN SUFFERING FROM MULTIPLE DEFECTS. Combination of defect. At Certified Special Schools At Public Elementary Schools At Other Institutions At no School or Institution Total. Epileptica Feeble-minded — — — 1 1 106 TABLE IV. RETURN OF DEFECTS TREATED DURING THE YEAR. TREATMENT TABLE. Group 1.—Minor Ailments (excluding Uncleanliness, for which see Group 6). Disease or Defect • Number of Defects treated, or under treatment during the year. Under the Authority's Scheme Otherwise Total Skin :— Ringworm—Scalp X-ray treatment — — — Other treatment 2 — 2 Ringworm—Body 10 3 13 Scabies 25 — 25 Impetigo 250 — 250 Other Skin Disease 233 — 233 Minor Bye Defects (External and other, but excluding cases falling in Group II) 191 32 223 Minor Ear Defects 354 3 357 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 950 64 1,014 Total 2,015 102 2,117 107 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 Otherwise Total Errors of Refraction (including Squint) 1108 73 1181 Other Defect or Disease of the Eyes 14 - 14 Total 1122 73 1195 Number of Children for whom Spectacles were :— (a) Prescribed 746 73 819 (6) Obtained 738 73 811 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 72 11 83 — 83 108 Group 4.—Orthopaedic and Postural Defects. Under the Authority's Scheme— Number of children treated Residential treatment with education 9 Residential treatment without education - Non-residential treatment at an orthopaedic clinic 186 Otherwise— Residential treatment with education - Residential treatment without education - Non-residential treatment at an orthopaedic clinic - Total number of children treated 192 Group 5.—Dental Defects. Number of Children who were :— (a) Inspected by the Dentist : Routine Age Groups Aged 5 1,604 Total 14,309 6 1,680 7 1,565 8 1,365 9 1,553 10 1,538 11 1,453 12 1,252 13 1,264 14 918 15 116 16 1 Specials 225 Grand Total 14,534 (b) Found to require treatment 9,465 (c) Actually treated 5,967 Attendances made by children for treatment 8,146 Half-days devoted to :— Inspection 103 Treatment 1107 Total 1,210 Fillings :— Permanent Teeth 6,421 Temporary Teeth 746 Total 7,167 Extractions :— Permanent Teeth 1,375 Temporary Teeth 9,678 Total 11,053 Administrations of General Anaesthetics for Extractions 1,887 Other operations :— Permanent Teeth 1010 Temporary Teeth — Total 1010 109 (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 33,578 (3) Number of individual children found unclean 830 (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 8 MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN) REGULATIONS, 1928. CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1936, TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total Number of Children Notified 2 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 (b) Imbeciles — 1 (c) Others -— — (ii) Children unable to be instructed in a Special School without detriment to the interests of other children : (a) Moral defectives (b) Others — — 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 — 1 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 — 2 CHISWICK AND EALING HOSPITALS COMMITTEE. ISOLATION HOSPITAL. MAERTNITY HOSPITAL. ANNUAL REPORT OF THE MEDICAL SUPERINTENDENT for the year ending 31st MARCH, 1937. THOMAS ORR, M.D., D.Sc., Medical Superintendent. 2 CHISWICK AND EALING HOSPITALS 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. A. J. Burden. Councillor C. D. Grant. 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. Resident Medical Officer, Isolation Hospital— Donald F. Irvine, M.B., Ch.B., D.P.H. Resident Medical Attendant, Maternity Hospital— Anne E. Williams-James, L.R.C.P., M.R.C.S., D.P.H., B.Sc., D.C.O.G. Consulting Surgeon— C. W. Gordon Bryan, F.R.C.S. (Eng.). Consulting Oto-Laryngologist— Arthur Miller, F.R.C.S. (Ed.), D.L.O. 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. Mr. Chairman, Ladies and Gentlemen, I liave the honour to submit the Anuual Report on the administration of the Hospitals from the 1st April, 1936, to the 31st March, 1937. ISOLATION HOSPITAL. The total number of cases admitted to the Hospital was 568, being 31 less than in the previous year. The highest daily number under treatment was 84 on the 31st March, and the lowest 36 on the 21st November. The average daily number was 57. The hospital accommodation again proved inadequate before the two new wards were ready for occupation, and 54 cases of scarlet fever, five of diphtheria and one of enteric fever had to be sent to neighbouring Isolation Hospitals. The following table indicates the number of cases of the va rious diseases treated during the year :— Disease Remaining in Hospital 31st March, 1936 Admitted during year Discharged during year Died during year. Remaining in Hospital 31st March, 1937 Scarlet Fever 58 449 430 4 73 Diphtheria 6 91 84 3 10 Measles 8 15 22 1 — Whooping Cough — 2 — 1 1 Erysipelas — 2 2 — — Puerperal Sepsis — 1 1 — — Dysentery — 1 1 — — Enteric Fever — 1 1 — — Pneumonia — 1 1 — — Chickenpox — 4 4 — — Ophthalmia Neonatorum 1 1 — — Pemphigus 1 1 — — Totals 73 568 548 9 84 4 Scarlet Fever.—Of the 449 cases admitted as scarlet fever 276 were from Ealing, 164 from Brentford and Chiswick and 8 were from Southall. Ten of the total were found not to be suffering from the disease and were ultimately diagnosed as follows :— Common cold 1, septic rash 1, streptococcal septicaemia 1, measles 1, tonsillitis 3, influenzal pneumonia 1, serum rash 1 and urticaria 1. % Four cases of scarlet fever were found on admission to be suffering also from a second disease, as follows :— Chickenpox 2, whooping cough 1, measles 1. The incidence of the actual cases of scariet 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. 103 270 30 20 10 6 The complications observed among the cases were as follows :— Rhinorrhoea 90 Secondary tonsillitis 8 Peritonsillar abscess 5 Cervical adenitis 63 Cervical gland abscess 2 Otitis media and otorrhoea 38 Meatal furunculosis 1 Basal meningitis 1 Nephritis 21 Arthritis 4 Relapse (with rash) 22 Bronchitis 4 Broncho-pneumonia 3 Pleural effusion 2 Empyema 2 Septicsores 10 J aundice 2 Frontal sinusitis 1 Cardiac irregularity 2 Septic rash—face and scalp 1 Vaginal discharge 1 Serum abscess 1 5 Dr. A. Miller, the Consulting Oto-Larvngologist, made nine visits to the Hospital during the year and performed four mastoid operations and four operations for the removal of tonsils and adenoids. Mr. Gordon Bryan, the Consulting Surgeon, made four visits to the Hospital. Return cases.—Of the 430 cases discharged during the year five gave rise to "return" cases of scarlet fever. This gives a low return case rate of 1.2 per cent. Duration of Stay.—The average duration of stay in Hospital of all cases of scarlet fever was 37 days. Deaths.—There were four deaths of patients admitted with a diagnosis of scarlet fever. Particulars of these are as follows :— (1) Septic scarlet fever; died of broncho-pneumonia and empyema. (2) Simple scarlet fever; had broncho-pneumonia just before contracting scarlet fever and this relapsed. Developed empyema and basal meningitis. (3) Simple scarlet fever. Died of broncho-pneumonia and angioneurotic oedema. (4) Scarlet fever not confirmed. Died of influenzal pneumonia. The 3 deaths of actual cases of scarlet fever give a scarlet fever mortality rate of 0.7 per cent. Diphtheria.—The number of cases admitted as diphtheria from the two districts was 64 from Ealing and 27 from Brentford and Chiswick, making a total of 91, 121 less than in the previous year. In this number are included two cases of bacteriological diphtheria in whom there were no clinical symptoms of the disease. Of the total number, 33 were ultimately diagnosed as not suffering from diphtheria. The final diagnoses in these cases were as follows :— Tonsillitis 16, measles 3, scarlet fever 2, quinsy 2, bronchitis 1, Vincent's angina 2, tonsillitis and laryngitis 1, tonsillitis and bronchitis 1, catarrhal rhinitis 1, no apparent disease 1, broncho-pneumonia 1, common cold 1, chronic otitis media 1. 6 The incidence of the actual cases of diphtheria in the various age-groups was as follows :— 1-5 yrs. 5-10 yrs. 10-15 yrs. 15-25 yrs. 25-45 yrs. Over 45 yrs. 12 18 20 4 3 1 The following complications were observed :— Tonsillitis 4 Rhinitis 1 Myocardial degeneration 2 Cardiac irregularity 3 Palatal paresis 2 Pharyngeal paralysis 1 Ocular paresis 1 Cardiac failure 3 Laryngeal Diphtheria.—Four cases were admitted with a diagnosis of laryngeal diphtheria, but only one was found to be actually suffering from this disease. This case recovered without operation. The other three cases were ultimately diagnosed as measles, bronchitis, and broncho-pneumonia respectively. Deaths.—There were three deaths from diphtheria, two cliildren and one adult. All were admitted late in the disease, one having been treated by the doctor for tonsillitis for nine days before being seat into hospital. In the other two cases a doctor had not been sent for until the disease was well advanced. This gives a mortality rate of 5.2 per cent. Duration of Stay.—The average duration of stay in hospital for cases of diphtheria was 46.5 days. There were no "return" cases. During the period beginning the 19th September and ending the 24tli December, although there were several suspected cases, no cases of actual diphtheria were admitted to the hospital. Measles.—During the year twenty-three cases of measles were treated and discharged. There was one death, a child of 4 years who was suffering from lobar pneumonia on admission. 7 The complications observed among the cases were as follows :— Broncho-pneumonia 2 Lobar pneumonia 1 Follicular tonsillitis 1 Otorrhoea 2 Rhinitis 1 Illness of Staff.—The following members of the staff were ill during the year:— Sister Cervical adenitis. Tonsils and adenoids removed. Probationers Tonsillitis 1, catarrhal jaundice 1, appendicitis 1, scarlet fever 2. Private Nurses Influenza 1, scarlet fever 1. Maids Tonsillitis 2, phlebitis 1. There were no cases of diphtheria among the staff. The two probationers who contracted scarlet fever had been found to have positive Dick reactions but had not been in hospital long enough to be immunised. Cubicle Block.—The new cubicle block, comprising 12 beds, was used for three months at the end of the year, and, as had been anticipated, was found extremely useful in the control of crossinfection and in the nursing of cases which were unsuitable for admission to a general ward. For a period of six weeks the number of cases of diphtheria in the hospital was so small that it was found possible to nurse them in the cubicle block along with other diseases and thus save the expense of opening a large ward. During the short period that the ward was in use, up to the 31st March, the following diseases were treated without the occurrence of crossinfection :— I Diphtheria 10, scarlet fever and measles 4, scarlet fever and chickenpox 2, lobar pneumonia 1, broncho-pneumonia (admitted as laryngeal diphtheria) 1, scarlet fever, whooping cough and measles 1, whooping cough and bronchopneumonia 2, enteric fever 1, dysentery 1, erysipelas 1, acute osteomyelitis (admitted as erysipelas) 1, puerperal pyrexia 1. 8 New Staff.—When the two new wards were opened at the end of the year they necessitated an increase in staff and the opportunity was taken for a certain amount of re-organisation in preparation for the completion of the extension scheme when the new Maternity Hospital is opened towards the end of 1937 and the old Maternity Hospital is added to the Isolation Hospital. The following new members of the staff were appointed and took up duty :— Resident Medical Officer. House Steward. Engineer. Kitchen Superintendent. Cost of Maintenance, Etc. £ s. d. Salaries 4,132 0 3 Repairs to Buildings, etc. 366 5 10 Furniture, fittings and utensils 1,428 15 7 Maintenance of ambulance 272 2 5 Medical and surgical requisites 665 12 2 Provisions 1,866 9 10 Fuel, light and cleaning 1,349 10 3 Rates, taxes and insurance 764 10 5 Miscellaneous 299 13 1 Superannuation—employer's contribution 140 14 9 Loan charges 1,281 17 2 £12,567 11 9 Administrative Charges—proportion 419 12 2 12,987 3 11 Less Income 165 9 0 Net Cost £12,821 14 11 The patients spent 20,666 days in hospital, so that the average cost of each patient per day was 12/5. Taking the patient-days 20,666 and the staff-days 13,177, or a total of 33,843, the average cost of food works out at 1/1 £ per person per day. Daily workers get limited meals each day and are counted half a full day's food per day. ADMINISTRATIVE BLOCK CLAYPONDS ISOLATION HOSPITAL CUBICLE BLOCK. CLAYPONDS ISOLATION HOSPITAL WARD BLOCK 9 The cost of each patient-dav is higher than in previous years but this is accounted for by the fact that included in the costs for the year are the loan charges on the new buildings which could not be used for patients to any great extent before the end of the year and the inclusion of large items of furniture supplied to the old parts of the administrative block which were renovated. Extension of Hospital. This seems an opportune place to make a report on the opening of the new section of the Isolation Hospital the building of which was first mooted in 1930 and which was actually begun in 1935. The opening ceremony was performed by the Mayor of Ealing and the Mayor of Brentford and Chiswick, the former performing the function v\ith regard to the Administrative Block and the latter the Ward Block. The present extensions consist of a greatly enlarged Administrative Block, a Cubicle Block for cases of different diseases, and a Ward Block for cases of diphtheria. The design generally of the extensions is of a Georgian character : the external walls are faced with "Keymer" handmade sand-faced bricks and the roofs are covered with Maidenhead hand-made tiles. Administrative Block.—The extension of the Administrative Block has been brought about by building round the small original block and has been done in such a way that very little of the old structure remains to be seen. New dining and sitting rooms, new bedrooms and new kitchens have been provided and an improvement of the old bedrooms and other rooms has been made. The new nurses' common room is 50ft. x 29ft., and is divided by a folding partition into a dining room and a sitting room. By the folding of the partition the room can be used as a staff recreation room. The large new kitchen has been equipped entirely with modern apparatus and with large storerooms and a refrigerator. There are also sitting rooms in this Block for vSisters and for the Deputy Matron, a maids' dining room and a telephone room for the use of the staff. Suitable lavatory accommodation has been provided for maids and nurses and there is an ironing room in which 10 nurses can wash and iron any special articles of apparel they wish to do themselves. All the new bedrooms have been equipped with washhand basins and with hot water radiators and the furnishing is such as to make the room comfortable for use as a bedroom and as a private sitting room. The doors are solid flush laminated with oak facing. The flooring on the ground floor and in the bedrooms is of oak and cork flooring is laid on the bedroom corridors for quietness. The main staircase is constructed of reinforced concrete faced with terrazzo, with wrought iron balustrading and bronze handrail. The lighting fittings throughout are of a type specially suitable for hospital use. All the decorations have been carried out in quiet and unobtrusive yet pleasant colouring with the furniture and woodwork in natural waxed oak. Cubicle Block.—This consists of twelve single-bed rooms or cubicles for patients, six on each side of the duty room, arranged along a corridor with observation windows in the duty room and along the corridor which enable the nursing staff to keep the patients under continuous observation. The sluice room is in the centre of the building and bathrooms and lavatories are at either end. Casement doors lead from each cubicle on the south side to a paved area so that the beds can be wheeled out if weather conditions permit. The windows are of metal, sliding and folding, opening to 100 per cent. The flooring throughout the Block is in natural waxed oak with the exception of the sanitary section which is in terrazzo. The wooden furniture is also in waxed natural oak and all doors are solid-flush-laminated oak faced. Each cubicle has a small table, a bedside locker and a chair upholstered in rexine with a Dunlopillo cushion seat. The lighting fittings throughout are, as in the Administrative Block, of a special modern type. There is a lighting fitting over each bed and there are dimmed night-lights in the corridors. 11 Ward Block.—This is a Block of two main wards, each 60ft. x 24ft. with a duty room in the centre. There are two small wards 16ft. x 12ft., one at each end of the Block. There are two casement doors on the south side of each main ward which open on to a paved area. Each ward is equipped with sluice rooms, bathrooms, lavatories and store rooms. The general construction and equipment are on similar lines to the Cubicle Block. The cost of the extensions was £90,497. Mr. Evan E. Morgan, the chief Architectural Assistant to the Borough Engineer and Surveyor of the Borough of Ealing was responsible for planning the extensions in accordance with the directions of the Committee and the Medical Superintendent. The Ealing Borough Electrical Engineer, Mr. Ronald Birt, B.Sc., A.M.I.E.E., was responsible for drawing up the specification of the electrical installation and for the execution of this work. This completes the first stage of the extensions ; the second stage will be entered upon when the new Maternity Hospital is opened at the end of this year, when the old Maternity Hospital will be added to the Isolation Hospital and when the central engineering services for the enlarged Isolation Hospital will be extended and the Administrative Block of the old Maternity Hospital will be improved. MATERNITY HOSPITAL. The number of patients admitted to the Maternity Hospital during the year ending 31st March, 1937, was 543, 27 more than in the previous year. The cases admitted to the Hospital in each year since it was opened were as follows :— 1921-22 109 1029-30 534 1922-23 235 1930-31 561 1923-24 284 1931-32 546 1924-25 369 1932-33 524 1925-26 388 1933-34 509 1926-27 358 1934-35 508 1927-28 407 1935-36 516 1928-29 450 1936-37 543 12 The 543 cases admitted to the Hospital during the period under review came from the two districts as follows :— Month Ealing Brentford and Chiswick Total April 38 13 51 May 35 10 45 June 37 12 49 July 25 14 39 August 42 12 54 September 33 6 39 October 23 12 35 November 34 13 47 December 29 14 43 January 26 17 43 February 33 8 41 March 43 14 57 398 145 543 The greatest number of patients in the hospital on any one day was 34. The average period which each patient spent in the hospital was 15.28 days. Emergency Cases.—Seven emergency cases were admitted during the year. These cases, which were all seen previously to admission by Dr. J. W. Bell, were as follows :— (1) Placenta praevia on which Caesarian Section was performed. (2) Suspected disproportion, which resulted in unassisted delivery. (3) Slight disproportion. Forceps used. (4) Primary uterine inertia. Forceps used. (5) Suspected disproportion. Forceps used. (6) Admitted for observation for two days. Not in labour. (7) Primary uterine inertia. Forceps used followed by manual removal of adherent placenta. 13 Ante-Natal Cases.—Fifty-three ante-natal cases were admitted for treatment. The conditions from which they were suffering were as follows:— Toxaemia (including two with mild ante-partum haemorrhage and two with twin pregnancies) 25 Urinary infection 5 Heart lesion (mitral stenosis) 1 Hydramnios 1 Death of foetus 1 Vaginal discharge 1 Mild accidental haemorrhage 5 Brorchitis 1 Pressure oedema 1 Severe varicose veins 1 Tired (needing rest from home cares) 5 Neurotic vomiting 1 Placenta Praevia 2 Suspected disproportion 3 Of these cases, twenty-five recovered sufficiently to be discharged to await at home the onset of labour. Surgical induction was done in the following six cases :— Toxaemia 3 Lateral placenta praevia 1 Postmaturity 1 Bad obstetric history 1 Abnormalities and Complications during Labour. Perineal tears 114 Episiotomy 1 Forceps delivery, (following manual rotation of persistent occipito-posterior 3, for delivery face to pubes 4, for primary uterine inertia 8, for foetal distress 1, for delivery following secondary uterine inertia 1) 17 Low forceps, under nitrous oxide and air analgesia 8 Breech with extended legs 6 14 Breech complete 5 Face (anencephah) 1 Persistent face to pubes (unassisted delivery) 2 Impacted shoulders (full-term macerated foetus) 1 Twin pregnancies, (two vertices 4, two breeches 1, vertex and breech ?) 7 (one set born before admissior) Placenta praevia (lateral) (two unassisted and one spontaneous delivery after artificial rupture of membranes) 3 Placenta praevia (central)— Caesarian section 1 Severe concealed accidental haemorrhage 1 Post-partum haemorrhage, (moderate 6, severe 1) 7 Secondary post-partum haemorrhage 1 Retained placenta requiring manual removal 1 Placenta nipped in cervix and requiring removal 1 Thirteen cases of puerperal pyrexia occurred. These cases were suffering from:— Mild uterine sepsis (one due to retained products) 3 Localised pelvic peritonitis following Caesarian section for central placenta praevia 1 Urinary infection 3 Acute mastitis 1 Influenza 3 Thrombosis of superficial veins of leg 1 Lobar pneumonia and empyema (admitted with influenza) 1 Children. Number of Infants born. Males 288 Females 262 Total 550 15 Number of cases of twins (14 babies) 7 Number of cases of premature infants (born alive) 13 34-36 weeks development 7 30 „ „ 2 (twins born before admission) 28 „ „ 4 (including one set of twins, the mother of whom had severe toxaemia). Stillbirths. Total 14. Macerated (full term 3, 30 weeks 1) 4 Anencephaly 1 Full term (fresh) Forceps 2 Extended breech 1 Mother with severe concealed accidental haemorrhage 1 Mother with severe urinary infection 1 Following N20 and air analgesia 1 Normal unassisted deliveries 2 — 8 Premature (fresh)— Mother with severe toxaemia 1 Infant Deaths. Total 15. Atelectasis (both 36 weeks, one following Caesarian section for central placenta praevia) 2 Intracranial haemorrhage (2 confirmed by autopsy) 3 Prematurity (including 2 sets of twins 28-30 weeks) 7 Haemorrhage of the newborn (confirmed by autopsy) 1 Broncho-pneumonia 1 Asphyxia neonatorum 1 16 Abnormalities in Surviving Infants.- . Pyloric stenosis (transferred to West Middlesex County Hospital for operative treatment) 1 Pyloric spasm 2 Harelip (unilateral) 1 Mild talipes-calcaneo valgus 2 Open spina bifida 1 Left inguinal hernia 1 Severe jaundice (one with spasmophilia) 2 Cephal-haemotoma 4 Accessory auricles 2 Mongol 1 Broncho-pneumonia 1 Fracture of clavicle during delivery of extended breech 1 Skin condition (Abscesses following forceps delivery 1, slough of small piece of scalp following application of forceps 1, septic spots 1, trauma of buttocks 1) 4 Infants weaned. Total 6. Weaned on account of mother's breast conditions 4 Secondary P.P.H. in mother 1 Premature infant unable to suck (kept in hospital 4 weeks after discharge of mother) 1 Patients transferred to other hospitals. To West Middlesex County Hospital. Infant with pyloric stenosis, for operative treatment 1 To King Edward Memorial Hospital. Mother with pneumococcal empyema, for operative treatment 1 To Isolation Hospital. Mild uterine sepsis following premature rupture of membranes 1 17 Consulting Obstetrician. Dr. J. W. Rait Bell, the Consulting Obstetrician, was called to the hospital on eight occasions during the year. Training of Pupils. During the year 18 pupils completed their course of training and entered for the examination of the Central Midwives Board. All of these pupils were successful. Cost of Maintenance, Etc. £ s. d. Salaries— Medical 171 8 0 Nurses 577 5 9 Other staff 1,042 16 4 Repairs to buildings, etc. 141 9 9 Furniture, fittings and utensils 240 8 11 Medical and surgical requisites 215 17 1 Provisions 1,031 5 4 Fuel, light and cleaning 795 18 4 Rates, taxes and insurance 275 8 4 Miscellaneous 93 0 1 Superannuation—employer's contribution 111 8 4 Loan charges 1,024 9 0 Administrative charges—proportion 5,720 15 3 . 179 11 11 Less Income from patients 5,900 7 2 2,558 19 6 £3,341 7 8 18 The patients spent 8,295 days in hospital, which makes the gross cost of each patient per day 14/2¾ or £4 19s. 7d. per week, and the net cost, after deducting the amounts paid by the patients, 8/0¾ per day, or £2 16s. 5d. per week. With the patient days 8,295 and the staff days 8,483, or a total of 16,778, the average cost of food for patients and staff is l/2¾ per person per day. The cost of food per patient per day is less than in the previous year by a halfpenny, or 3½d. per week. The building of the new Maternity Hospital at Perivale was begun in August after delays consequent on the claim put forward by the Ealing Town Council that they were themselves maintaining a Maternity Hospital and at the same time contributing to the maintenance of maternity bed accommodation for the whole county, in other words it was contended that they were paying twice for the same service. In view of the favourable turn of the negotiations in the early part of the year the Ealing Town Council consented to the work being begun and later the proposals put forward at a conference of representatives of both councils were finally ratified by the County Council. These proposals mean, in effect, that the Middlesex County Council will make a payment to the Ealing and the Brentford and Chiswick Town Councils through the Hospitals Committee for each case admitted to the joint Maternity Hospital from the two areas, the payment to be determined by the average cost of maternity cases in the County Maternity Hospitals. The new Perivale Maternity Hospital is likely to be ready for use in October, 1937, and with the transfer of cases to the new Maternity Hospital the old Maternity Hospital will be added to the Isolation Hospital. In the annual report for 1935-36, 1 referred to the work of the previous four years having been of a strenuous and difficult character and the same must be said of the year 1936-1937. In all this strenuous period, as has been said on a previous occasion, there is one whose work had been of the greatest value to the Committee and to myself and that is Mr. H. Birrell, the Clerk to the Committee. His work has really been of outstanding merit. 19 The Medical Staff and Matrons of the two Hospitals are deserving of appreciation and gratitude for their consistent efficient service to the Committee. Lastly, I cannot refrain from taking this opportunity of expressing to the members of the Committee my sincere thanks for their great encouragement and their frequently expressed appreciation of my work. I am, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Superintendent. Town Hall., Ealing, W.5. June 23rd, 1937. :