AC 439 (1) EALING Middy EAL 28 M Borough of Ealing. ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer 1937 INCLUDING Report on the Isolation and Maternity Hospitals, 1937-38. 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 28 Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer 1937 including Report on the Isolation and Maternity Hospitals, 1937-38. 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 Ambulances 16 Bed Bugs, Eradication of 43 Births 11 Blind, Deaf, Defective and Epileptic Children 90, 101 Clinics and Treatment Centres 18 Convalescent Treatment 22, 86 Deaths 12 Defects found by Medical Inspection 69, 99 Dental Defects and Treatment 27,83, 106 Diphtheria 61 Disinfection 46 Employment of Children and Young Persons 96 Factories and Workshops 47 Health Visiting 23 Hospitals in the District 19 Housing 50 Infant Deaths 13 Infant Life Protection 29 Infectious Diseases 58 Legal Proceedings 44 Malnutrition 69, 100 Maternal Mortal it}- 15 Maternity and Child Welfare 21 Meat and Other Foods 56 Medical Inspection of School Children 69, 98 Medical Treatment of School Children 75, 104 Midwifery Service 29 Midwives, Supervision of 35 Milk 55, 88 Mortuary 45 Nursing Arrangements 17 Nursing Homes, Supervision of 37 Offensive Trades 42, 46 Orthopaedic and Postural Defects 85, 106 Pathological Laboratory 16 Population 8 Pre-School Children, Examination of 25 Provision of Meals 70, 88 Puerperal Fever and Puerperal Pyrexia 62 Sanitary Inspection of the Borough 39 Scarlet Fever 61 School Hygiene 68 School Medical Service 67 Secondary Schools 94 Smoke Abatement 42 Social Conditions 9 Special Clinic 18 Speech, Defective 85 Staff 5 Statistics, Vital and General 8, 9 Tuberculosis 63 Uncleanliness 74 Vision, Defective 76 Water Supply 39 APPENDIX. Report of the Medical Superintendent, Isolation and Maternity Hospitals, 1937-38. 4 PUBLIC HEALTH COMMITTEE. 1936-37. Councillor C. D. Grant (iChairman). Alderman Colonel R. R. Kimmitt, O.B.E., T.D., D.L. (V ice-Chairman). Aldermen H. W. Peal, J.P., Mrs. E. S. Taylor, J.P., and W. T. White, J.P. Councillors Mrs. E. A. Brooks, Mrs. O. A. F. Davis, T. E. Fowler, C. Hudson, J. Hansel Lewis, H. A. Merchant, W. Morgans, C. P. Savage, W. A. Scott, H. Telficr and H. E. Willis. MATERNITY AND CHILD WELFARE COMMITTEE. 1936-37. Alderman Mrs. E. S. Taylor, J.P. (Chairman). Councillor W. Morgans (Vice-Chairman). Aldermen R. R. Kimmitt, O.B.E., T.D., D.L., H. W. Peal, J.P., and W. T. White, J.P. Councillors Mrs. E. A. Brooks, Mrs. O. A. F. Davis, T. E. Fowler, C. D. Grant, C. Hudson, J. Mansel Lewis, H. A. Merchant, W. Morgans, C. P. Savage, W. A. Scott, H. Telfer and H. E. Willis. Mesdames Grant, Haddon, Holman, Jackman, Ludlow, Mayo and Parry. EDUCATION GENERAL PURPOSES SUB-COMMITTEE. 1936-37. (Responsible for School Medical Service). Councillor T. P. May (Chairman). Alderman J. C. Fuller (Vice-Chairman). Councillor E. H. Atkinson (iChairman, Education Committee), (ex-officio member), Aldermen A- E. Cobbin and Mrs. E. S. Taylor, J.P. Councillors E. H. Brooks, J.P., Mrs. O. A. F. Davis, C. W. Jackman, B. Martin, W. Morgans 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, Mrs. A. D. Mayo, Rev. H. J. Beck, and Rev. D. B. Harris, M.A. 5 STAFF. (At 31st December, 1937). Medical Officer of Health, School Medical Officer and Medical Superintendrnt of Isolation and Maternity Hospitals— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Deputy Medical Officer of Health— Llywelyn Roberts, M.D., D.P.H., Medical Officers— John Petrie, M.B., Ch.B., 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. Murdoch MacGregor, M.D., M.B., Ch.B., D.L.O., D.P.H. Donald F. Irvine, M.B., Ch.B., D.P.H. Helena B. King, M.B., B.S., M.R.C.vS., 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. Ophthalm ic 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. Alfred G, Brown, L.D.S. Isobel M. M. Cameron, L.D.S. 6 Chief Sanitary Inspector— George W. Stevens. Sanitary Inspectors— James Stubbs, C. P. H. Meadows, G. T. H. Blackie, Ernest Belfield and Eric H. Evans. Nursing Staff— Supervising School Nurse—Miss Hilda Bailey. There are eight school nurses in addition. Supervising Health Visitor—Miss Marguerite Farrow. There are eight health visitors in addition. M idwives— vSenior Midwife and Teacher of Pupils—Mrs. Ruby K. M. Wingrove. There are eight midwives in addition. Masseuse—Part-time— Miss Florence Hepburn, C.S.M.M.G. Teacher of Class for Stammering Children—Part-time— Honor M. S. Baines. Chief Administrative Clerk— Harry Birrell. Clerical Staff— Public Health Department—William A. J.Turner and eight others. Maternity and Child Welfare—Miss E. Craighill and five others. School Medical Service—Miss I. L. Parker and eight others. A. Vital Statistics, Social Conditions of the Area, and General Provision of Health Services. 8 SUMMARY OF GENERAL STATISTICS. Area (in Acres) 8,739 Population (Census, 1931) 117,707 Population (Estimated Middle of 1937) 156,460 Number of Structurally Separate Dwellings (Census, 1931) 26,717 Number of Families or separate Occupiers (Census, 1931) 31,412 Number of Houses according to Rate Books (1st April, 1937) 41,750 Rateable Value, 1st April, 1937 £1,618,083 Net Produce of a Penny Rate £6,350 Population.—The population of the Borough at the middle of 1937 is estimated by the Registrar General to be 156,460. The estimated population at the middle of 1936 was originally 145,000, this figure being adjusted by the Registrar to 146,300 following the alteration of the Borough boundaries on the 1st April, 1937, when West Twyford was again included in the area. The net increase of population during the twelve months is therefore 10,160, this being the largest annual increase ever recorded. The new Housing Estate of the London County Council on the site of the old Cuckoo Schools at Hanwell is largely responsible for this increase in population as the majority of the new residents moved into it from the County of London during the period embraced in the report. In view of the alteration of the Borough boundaries on the 1st April the statistics supplied by the Registrar General are composite figures combining the records for the first portion of the year, prior to the change of boundaries, with those for the enlarged area for the remaining portion of the year. The Registrar has therefore supplied a modified estimate of population specially designed for use with the composite records of births, deaths and notifiable diseases. This modified estimate of population is 156,070 and this figure has been used in the calculation of the statistics contained in the report. 9 Social Conditions.—Statistics supplied by the local Employment Exchange with regard to unemployed men of 21 years and over show that there has been little change in the last four years. The figures for the last six 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 1937 1,029 When consideration is given to the fact that the population has increased steadily throughout this period, it will be realised that the equality of the figures from 1934 to 1937 is equivalent to a stead}' decrease in unemployment. SUMMARY OF VITAL STATISTICS. Live Births :— Legitimate Males, 1,153 Females, 1,076 Total, 2,229 Illegitimate Males, 43 Females, 48 Total, 91 — 2,320 Birth-Rate per 1,000 of Estimated Population 14.9 Still-Births :— Males, 44 Females, 38 Total 82 Rate per 1,000 total Births (Live and Still-Births) 34 Deaths : Males, 718 Females, 784 Total 1,502 Death-Rate per 1,000 of Estimated Population 9.6 Deaths of Infants under one year of age :— Legitimate Males, 49 Females, 45 Total, 94 Illegitimate Males, 6 Females, 6 Total, 12— 106 Death-Rate of Infants under one year of age :— All Infants per 1,000 Live Births 46 Legitimate Infants per 1,000 Legitimate Live Births 42 Illegitimate Infants per 1,000 Illegitimate Live Births 132 10 Deaths from Diseases and Accidents of Pregnancy and Childbirth :— From Sepsis 1 Death Rate per 1,000 Total Births 0.42 From other Causes 5 ,, ,, 2.08 Total 6 ,, ,, 2.50 Total Deaths Death-Rate per 1,000 Population Measles 1 0.01 Whooping Cough 3 0.02 Diphtheria 2 0.01 Scarlet Fever 1 0.01 Influenza 63 0.40 Tuberculosis of Lung 76 0.49 Other Forms of Tuberculosis 12 0.08 Death-Rate per 1,000 Live-Birtlis Diarrhoea (under two years of age) 11 4.7 Comparison of Vital Statistics of Ealing with those of England and Wales, Etc., 1937. England and Wales 125 Great Towns (including I.ondon) London Ealing Birth-Rate 14.9 14.9 13.3 14.9 Death-Rate 12.4 12.5 12.3 9.6 Infant Death-Rate 58 62 60 46 Measles Death-Rate 0.02 0.03 0.01 0.01 Whooping Cough DeathRate 0.04 0.04 0.06 0.02 Diphtheria Death-Rate 0.07 0.08 0.05 0.01 Scarlet Fever Death-Rate 0.01 0.01 0.01 0.01 Influenza Death-Rate 0.45 0.39 0.38 0.40 Diarrhoea (under two years per 1,000 Births) 5.8 7.9 12.0 4.7 11 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—1935 14.2 10.1 46 1936 14.4 9.9 49 1937 14.9 9.6 46 Births.—The number of berths, 2,320, is the highest recorded in the Borough, being 235 more than the total recorded in 1936. The birth-rate of 14.9 per thousand of population also shows an increase over the rates in the previous two years and on this occasion is equal to the birth-rate for the whole of England and Wales. In 1934 the birth-rate for Ealing was higher than that for the country as a whole, but with this one exception the birth-rate for Ealing has always been below the general birth-rate. A table showing the birth-rates in recent years is to be found on this page. 12 Causes of Death, 1937. Cause of Death Deaths, 1937 i Total Deaths 1936 Male Female Total Typhoid and Paratyphoid Fevers — — 1 Measles — 1 1 3 Scarlet Fever — 1 1 2 Whooping Cough 2 1 3 5 Diphtheria — 2 2 8 Influenza 30 33 63 29 Encephalitis Lethargica — 1 1 1 Cerebro spinal Fever — 1 I 4 Tuberculosis of Respiratory System 46 30 76 69 Other Tuberculous Diseases 5 7 12 19 Syphilis — 1 1 4 General Paralysis of the Insane, Tabes Dorsalis 3 1 4 2 Cancer, Malignant Disease 102 116 218 202 Diabetes 8 20 28 15 Cerebral Haemorrhage, etc. 25 47 72 66 Heart Disease 166 208 374 390 Aneurysm 6 2 8 7 Other Circulatory Diseases 28 34 62 68 Bronchitis 35 28 63 51 Pneumonia (all forms) 40 37 77 63 Other Respiratory Diseases 8 7 15 16 Peptic Ulcer 13 7 20 19 Diarrhoea, etc. (Under two years) 5 6 11 7 Appendicitis 8 2 10 5 Cirrhosis of Liver 2 — 2 3 Other Diseases of Liver, etc. 3 3 6 5 Other Digestive Diseases 15 13 28 40 Acute and Chronic Nephritis 27 16 43 37 Puerperal Sepsis — 1 1 1 Other Puerperal Causes — 5 5 1 Congenital Debility, Premature Birth, Malformations, etc. 33 29 62 62 Senility 4 29 33 26 Suicide 14 6 20 20 Other Violence 30 25 55 49 Other Defined Diseases 60 64 124 134 Causes ill-defined or unknown — — — -— Total 718 783 1,502 1,434 Deaths.—The number of deaths assigned to the Borough is 1,502. Although this total exceeds the number recorded in the previous year by 68, the actual mortality, as evidenced by the death-rate per thousand of population is less. The deathrate for the year under review is 9.6 per thousand of population compared with the rate of 9.9 recorded in 1936. The death-rate for the Borough is well below the death-rate of 12.4 for England and Wales. 13 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 " 9.7 per thousand of population. The causes of the 1,502 deaths are indicated in the table on page 12. It will be seen that heart disease and cancer, with 374 and 218 deaths respectively, are the main causes of death. Tuberculosis, pneumonia, bronchitis and influenza accounted for the next highest numbers of deaths. There is very little difference in the causes of death in the last two years, with the exception of a sharp increase in the mortality from influenza, the deaths having increased from 29 to 63. The influenza death-rate of 0.40 per thousand of population is, however, less than that of 0.45 recorded for England and Wales. The deaths from infectious disease are dealt with in Section F of this report. Infant Deaths.—The infant death-rate of 46 per thousand births is the third lowest recorded in the Borough, the lowest infant death-rate being that of 38 per thousand births recorded in 1934. The actual ntimber of deaths, 106, is higher than in any previous year, this being due, of course, to the greatly increased number of births. The infant death rate for the Borough, 46, compares very favourably indeed with the rates for England and Wales, for the 125 Great Towns and for London, which are respectively 58, 62 and 60. The causes of infant deaths, shown in the following tables, indicate prematurity as the main cause of death, 31 of the 105 infant deaths, and congenital malformations and pneumonia as the next main causes with 15 and 12 deaths respectively. It will be seen that 59 of the deaths occurred before the infant was one week old, while 70 occurred before the infant was four weeks old. This latter figure gives a neo-natal death-rate of 30 per thousand live births. 14 Causes of Infant Deaths, 1928 to 1937. 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 Diarrhoea and Enteritis 5 4 3 5 9 4 11 11 7 10 Premature Birth 14 25 14 19 24 35 20 34 35 31 Congenital Malformations 6 4 9 9 11 13 9 9 10 15 Congenital Debility 6 10 9 11 4 4 3 11 5 2 Tuberculous Disease 2 1 2 1 — 1 — — — 2 Syphilis — — — 1 1 — — — — — Meningitis (not Tuberculous) 1 3 1 4 — — 1 — — Convulsions 3 3 6 5 4 3 3 1 — 1 Bronchitis 7 2 4 2 — 3 3 5 4 Pneumonia (all forms) 4 8 10 11 6 6 8 8 15 12 Gastritis ... 1 1 1 Common Infectious Diseases — 6 2 1 2 3 1 — — — Other Causes 12 6 11 15 18 10 17 17 25 29 Totals 61 73 71 84 79 82 77 91 102 106 Deaths at various Ages under One Year of Age, 1937. 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 mouths and under 12 months Total deaths under 1 year All Causes 59 4 4 3 70 12 12 7 5 106 Measles — — — — — — — — — — Meningitis — — — — — — — — — — Convulsions — — — 1 1 — — — — 1 Bronchitis — — 1 — 1 — 1 1 1 4 Pneumonia 1 — — — 1 2 4 2 3 12 Inflammation of the Stomach — — — — — — — — — — Diarrhoea and Enteritis — — — — — 4 5 1 — 10 Congenital Malformations 9 1 — — 10 3 1 1 — 15 Congenital Debility 1 — 1 — 2 — — — — 2 Premature Birth 28 1 — 1 30 1 — — — 31 Injury at Birth 6 1 — — 7 — — — — 7 Other Diseases Peculiar to Early Infancy 7 — 1 — 8 — — — — 8 Inattention at Birth 4 — — — 4 — — — — 4 Other Causes 3 1 1 1 6 2 1 2 1 12 15 Stillbirths.—The number of stillbirths "which were registered during the year was 82, compared with 71 in the previous year The stillbirth rate is 34 per thousand births. Maternal Mortality.—There were six maternal deaths during the year. The maternal death-rates in recent years for Ealing and for England and Wales are shown in the following table While the death-rate in the Borough has not remained at the low figure recorded in 1936, it is highly satisfactory to find that the death-rate for Ealing is again considerably below that for England and Wales which, it will be seen, again shows a distinct decline. If this improvement can be maintained an adequate reward will be obtained for the work done in recent years to examine the causes of maternal mortality and to make adequate provision for the welfare and safety of the mothers. 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—1935 4.10 4.12 1936 0.93 3.65 1937 2.50 3.23 16 GENERAL PROVISION OF HEALTH SERVICES. PATHOLOGICAL LABORATORY. The following table indicates the number of examinations carried out in the pathological laboratory, which is maintained at the Town Hall. Specimens Examined in Laboratory. Positive Negative Total 1937 Total 1936 Diphtheria : From Medical Practitioners 70 696 766 654 From Isolation Hospital 163 3,164 3,327 2,546 From Health Centres 17 245 262 147 Tuberculosis 73 459 532 535 Miscellaneous 14 445 459 325 Total 337 5,009 5,346 4,207 AMBULANCE FACILITIES. 1. For infections disease.—The Chiswick and Ealing Hospitals Committee provide a motor ambulance for the removal of cases of infectious disease to the Clay ponds Isolation Hospital at South Ealing. 2. For accident and illness cases.—Three ambulances are provided by the Council for dealing with cases of accident and of acute illness. They are housed at the Fire Station and are manned by members of the Fire Brigade. The extent of the calls made upon the service is shown in the following table :— 17 1932 1933 1934 1935 1936 1937 Cases of Accident 711 772 790 756 868 740 Cases of Illness 1,322 1,149 1,259 1,261 2,080 2,663 Total Cases 2,033 1,921 2,049 2,017 2,948 3,403 Number of J ourneys outside the Borough (included above) 444 365 596 427 552 567 Annual Mileage 13,626 13,265 15,818 16,962 21,070 22,868 NURSING IN THE HOME. 1. General diseases.—-The Greater Ealing Nursing Association with a staff of seven district nurses, provide for the nursing of the sick in their own homes. During the year the Association dealt with 1,258 patients, a total of 19,179 visits being made. District nursing in the Northolt area is provided by the Northolt Nursing Association who employ one nurse to serve the Northolt area. 2. Infectious diseases.—The Town Council makes an annual contribution to the two Nursing Associations in respect of nursing services provided in cases of measles, whooping cough, ophthalmia neonatorum, poliomyelitis, diarrhoea, pneumonia and puerperal sepsis. 18 CLINICS AND TREATMENT CENTRES. Provided by Ealing Town Council. Health Centres (Maternity and Child Welfare, and School Medical Service) Orthopaedic Clinic Special Clinic (Birth Control) Mattock Lane, Ealing. Cherington House, Hanwell. Ravenor Park, Oldfield Lane, Greenford. Greenford Green, Wadham Gardens, Greenford. Perivale, Horsenden Lane, Greenford. Islips Manor, Eastcote Road, Northolt. Mattock Lane Centre, Ealing. Mattock Lane Centre, Ealing. Provided by Middlesex County Council. Tuberculosis Dispensary' Treatment Centres for Venereal Disease Green Man Passage, West Ealing. Certain Hospitals in London. Special Clinic.—The medical officer in charge of the Special Clinic attends on two afternoons in each month for the purpose of advising women patients who have been referred from the Health Centres for instruction in birth control. The cases dealt with are those in which the Medical Officer is of opinion that further pregnancies would be detrimental to the health of the mother concerned. The number of new cases dealt with during the year was 107 and the total number of consultations with the medical officer was 307. In addition, 16 cases (involving 23 consultations) were dealt with in accordance with the arrangements made with the Middlesex County Council whereby mothers from the county area may be referred to the clinic. 19 HOSPITALS. 1. Isolation Hospital.—Cases of infectious disease are admitted to the Clayponds Isolation Hospital, South Ealing, which is provided in conjunction with the Brentford and Chiswick Council. Details of the cases admitted to the hospital are given in the Annual Report on the Hospital, which forms an Appendix to this Report. 2. Maternity Hospital.—The new Perivale Maternity Hospital was opened towards the end of the year to replace the old Maternity Hospital at Clayponds Lane. The new hospital has accommodation for 43 patients compared with the accommodation for 22 patients at the old hospital. A description of the new hospital and particulars regarding the patients dealt with during the year will be found in the Report on the Hospital, which forms an Appendix to this Report. 3. Smallpox Hospital — Hospital provision for children — Other hospitals.—No change has to be recorded in these hospital arrangements which have been fully described in previous reports. B. Maternity and Child Welfare. 21 MATERNITY AND CHILD WELFARE. It has always been the aim of the Council to provide a maternity and child welfare service which should be as complete and as efficient as practicable. In recent years there have been many important extensions in this section of public health work. The provision of suitable accommodation is of paramount importance if the work is to be carried on in a proper manner and the fact that there are six health centres in the Borough, three of which have been built specially for the purpose, is evidence of the Council's desire to provide a satisfactory service. On the 1st November the new Perivale Maternity Hospital was opened for the reception of patients, this being undoubtedly the most noteworthy addition to the maternity services in recent years. A full description of the new hospital is contained in the Report on the Hospital, which is included as an Appendix to this report. The hospital is provided in conjunction with the Brentford and Chiswick Council, and has accommodation for almost double the number of patients that could be dealt with at the old Hospital. Despite the increased number of beds the demand for admission has been so great that many cases have had to be refused admission and the extension of the hospital may have to be considered in the near future. Another important addition to the Council's maternity and child welfare scheme was the inauguration of the new midwifery service. On the 1st May eight midwives commenced duty on the staff of the Council for the purpose of providing the domiciliary service under the Midwives Act, 1936. The Act required the provision of an adequate midwifery service not later than the 30th July, 1937, but it was found possible for the new service to come into operation in Ealing three months before this date. Further information regarding the work of the midwives is given on subsequent pages, where it will be seen that the new service has begun in a most successful manner. The extent of the Council's maternity service will be appreciated when it is realised that it will now be possible for about 600 Ealing mothers to be admitted to the Perivale Maternity Hospital and another 700, or more, to be dealt with by the municipal midwives. 22 The arrangements for the provision of convalescent treatment for nursing mothers and for children under five years of age, commenced in 1936, were continued, and nine mothers with young babies and ten children under five years of age, were sent for varying periods of convalescence. Considerable difficulty was experienced in securing accommodation at suitable homes, especially during the summer months, and the Council has now definitely reserved one bed at the Convalescent Home for Mothers and Babies, May field, and two beds for young children between 1 and 5 years of age at the Hurstleigh Convalescent Home, Tunbridge Wells. When deciding the scale of charges in connection with the midwifery service opportunity was taken to reconsider the whole question of charges for treatment with a view to adopting one scale in place of the many which were in use. The Council has now adopted a scale of charges which applies to all forms of treatment and services with the exception of the provision of milk in necessitous cases and the assessment of fees for treatment in the Maternity Hospital. The new scale is as follows : When average income per member of family after deductions for rent, insurance and fares is below 10/- No charge do. is between 10/-and 15/- One-third do. is between 15/-and 20/-Two-thirds do. is above 20/- Full cost The Council has also decided that, in view of the desirability of having an Obstetric Specialist readily available in all cases of childbirth, the arrangement whereby the patient was required to contribute towards the Consultant's fee should be discontinued. The medical practitioners attending cases in the Borough have been informed that Dr. J. W. Rait Bell may be called in as a consultant at any time and that the Council will accept full responsibility for the payment of his fee. His services were obtained in eight cases during the year. 23 Summary of the Visits made by the Health Visitors. Visits to children under 12 months : (1936) (1937) First visits 2,071 2,402 Return visits 5,226 6,242 Visits to children 1 to 5 years of age 10,359 9,443 Visits to expectant mothers 1,190 2,179 Visits to investigate infant deaths and still-births 113 147 Special visits or investigations 195 268 Visits to cases of Ophthalmia Neonatorum 6 8 Visits to cases of Pemphigus Neonatorum 1 — Visits to cases of Measles and Whooping Cough 469 328 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 330 301 Inspections of Women's Lavatories 65 70 Visits to children under care of foster-mothers 840 784 Other visits 272 140 Total Visits 21,137 22,312 Summary of the Work at the Health Centres. Mothers. Expectant mothers attending Ante-Natal Clinics : (1936) (1937) Attending for the first time 1,112 1,366 Total attendances 5,010 6,320 Nursing mothers attending for post-natal examination 429 585 Mothers seen by Ante-Natal Consultant 58 36 Mothers referred to School Medical Department for dental treatment 398 471 Mothers referred to Hospitals 103 109 Mothers accepted for admission to the Maternity Hospital 479 597 24 Children. Children attending Centres for the first time: (1936) (1937) Under one year of age 1,611 1,996 One to five years of age 1,243 1,384 Total attendances made by children: Under one year of age 21,064 26,711 One to five years of age 14,260 16,797 Number of children examined by Medical Officer: Under one year of age 8,803 10,480 One to five years of age 2,984 3,616 Children referred to School Medical Department: For dental treatment 458 548 For treatment of throat and nose 22 33 For optical treatment 17 56 For orthopaedic treatment 148 142 For treatment of minor ailments 135 150 For diphtheria immunization 347 381 Children referred to King Edward Memorial Hospital: For minor operations 17 33 For ultra-violet ray treatment 5 3 For other reasons 39 28 Children admitted to King Edward Memorial Hospital as indoor cases 3 — Chiidren referred to other Hospitals 36 36 Assistance Given. Food supplied at cost price: (1936) (1937) Dried milk (Value) £679 £902 Virol( „ ) £121 £180 Cod liver oil „ ) £323 £461 Number of orders issued granting a supply of milk, free of charge, for a period of 28 days : For expectant or nursing mothers 856 921 For children under five years of age 1,546 1,955 25 Attendances at the Health Centres, 1937. Mattock Lane Ch'gton House Raven or Park Perivale Greenf'd Green Islips Manor Number of sessions for mothers 101 100 98 59 97 51 Ante-natal attendances 1,451 1,493 1,216 897 1,091 172 Post-natal attendances 98 123 118 93 135 18 Average attendance per session 15 16 14 17 13 4 Number of sessions for children 151 151 161 108 110 52 Number of children attending for first time 722 736 862 425 487 148 Total attendances made by children 10,011 9,392 9,760 6,477 7,565 1,824 Average attendance per session 66 62 61 60 69 35 Number of children seen by doctor 2,836 2,842 3,255 2,003 2,473 687 Average number seen per session 19 19 20 19 22 13 Medical Examination of Pre-school children.—The examinations of pre-school children during the year under review totalled 3,616, compared with 2,984 in the previous year. The number of children examined in each age-group and the number and percentage found to have defects are indicated in the table below. The percentage of children shown in this table to have defects seems high, but it must be explained that many of the defects noted are of a minor character, and the majority require only to be kept under observation. 26 Age-group Number of examinations No. of children with defects Percentage with defects 1 year to 18 months 1,096 310 28 18 months to 2 years 706 246 35 2 years to 3 years 715 303 42 3 years to 4 years 644 338 52 4 years to 5 years 455 263 58 Increasing prominence is now being given to the medical supervision of the pre-school child. In many districts separate sessions are held for these children, definite appointments being sent in the form of invitation cards at about the time of the child's birthday. The mother then attends only with the child in question and the consultation can be held unhampered by the presence of a baby or other young children. This method has not been found either necessary or desirable at any of the Council's Health Centres, partly because it is easier for the mother to bring all her family at one visit and also because it is more satisfactory to see the child as a part of its own family rather than as an isolated unit. The figures given in this table show the high proportion of pre-school children who attend. It is apparent that the percentage of defective children increases with the age-group. This is no doubt due to the fact that many children with no defects cease to attend as the parents consider supervision no longer necessary, and also that there are still parents who bring their children only when "something is wrong." The fact that child consultations are held for supervisory and educative purposes rather than for actual treatment is still not realised by a large majority of parents. The type of defect found varies in each age-group. In the first group (one year to 18 months) the large majority are congenital defects (such as harelip and cleft palate, heart disease, club foot, etc.) together with early signs of rickets, and occasional cases of spastic paralysis and some types of mental deficiency. As growth proceeds, developmental defects become apparent and treatment has to be advised for such conditions as knock knees, bow legs, flat feet and other orthopaedic defects. Dental treatment is available at any age and a large number of older children often attend the centre for the first time on account of dental decay. Speech defects (more common in boys than in girls) become more 27 noticeable as the child approaches school age, although treatment for these is not usually begun until the child attends school. Behaviour problems, such as feeding difficulties, bedwetting and "tantrums" occur throughout the age-groups and appear to be on the increase. The present day habit of life with small families of one or two children is doubtless responsible for this as the children probably receive far too much individual attention and are actually suffering from the effects of over-mothering. The real criterion of this work appears to lie not so much in figures showing numbers of attendances, but in the advantage with which the child starts his school life. A child who has had regular supervision throughout his pre-school life is undoubtedly in a better position than one who has not. In scrutinizing figures obtained from a survey of the entrants at an infant school over a period of two years, it appears at first sight that this is not the case. Of children born in 1931, 31.3 per cent, of those who had attended the Welfare Centre were found still to have defects, whereas of those who had not attended only 30.7 per cent, were defective. But it must be remembered that many of the children attending the Centre have been brought because of some defect, and many of the defects found, particularly orthopaedic defects, require treatment extending over a considerable period of time, so that a child who receives treatment under the Maternity and Child Welfare Service continues without interruption under the School Medical Service. Treatment of Defects.—Facilities for the treatment of defects found in children examined at the child welfare sessions are offered through the school medical department. As far as possible all facilities for treatment available for school children are available for the pre-school child. In addition, expectant and nursing mothers can receive dental treatment from the School Dentist and can be submitted for examination b\ the Ophthalmic Surgeon. Details regarding the number of mothers and children referred or treatment are to be found on page 23. Dental Treatment.—The School Dentist reports as follows regarding the work carried out for mothers and for children under five years of age:— 28 " Mothers.—The number of mothers receiving dental treatment continues to increase. During the year 544 mothers were treated compared with 355 in 1936. This increase is mainly due to those who have moved to the new London County Council Housing Estate at Hanwell, many of whom have been found to require extensive dental treatment. It is gratifying to note, however, that the majority have been quick to respond to the advice given by the medical officers. The treatment given was, as usual, mostly of a radical nature, as the mothers cannot be subjected to prolonged drilling of a tooth in an effort to save it. Many mouths were rendered healthy by scaling and treatment of the gums and where there was a loss of masticatory power full or partial dentures were fitted. Fillings were inserted in 281 teeth, an increase of 152 over the preceding year. Teeth extracted numbered 2,763, a slight increase over the preceding year. Most of the extractions were performed under nitrous oxide and oxygen. Dentures were supplied to 222 mothers, an increase of 93 over the preceding year, and gum treatments were given to 64. The total number of visits made by mothers to receive dental treatment was 2,302. " Children of Pre-school Age.—The number of children under five years of age receiving dental treatment was 458, an increase of 96 over the preceding year. It is a notable fact that the mothers who have received dental treatment for themselves at the centres have shown an interest in their children's teeth and have asked for dental appointments for their children. The number of extractions was 1,484, an increase of 430. All multiple extractions were performed under nitrous oxide and oxygen and only in cases where a single tooth required extraction was a local anaesthetic used. The number of fillings inserted was 146. It is not easy to perform fillings on small children because of the difficulty experienced in opening their mouths and maintaining a dry field of operation. Advice in relation to erupting and non-erupting teeth and other conditions in the mouth was given to 23 mothers. Altogether 875 attendances were made at the centres by children to receive treatment." 29 INFANT LIFE PROTECTION. The supervision of fostermothers is carried out by the Health Visitors who have all been appointed Infant Life 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 (Number of fostermothers having care of the above children, 92). 121 Number of children registered during the year 122 Number of children removed from register during year: Removed to care of parent or relative 68 Removed to another fostermother 16 Removed for adoption through a Society 9 Removed to a Children's Home or School 24 Legally adopted by fostermother 2 Died (Inquest held : None) 1 Fostermother left district 6 Attained nine years of age 4 Removed from care of fostermother at request of Medical Officer of Health 7 — 137 Number of children on register at end of year (Number of fostermothers having care of the above children, 86). 106 Number of visits made by Health Visitors 784 In seven cases it was found necessary to request that a child be removed from a person who had undertaken its care, in six cases because the proposed fostermother or her housing conditions were considered unsuitable and in the seventh case because the fostermother had received a child in excess of the number for which she was approved. In each case the child was removed without any legal action being necessary. MIDWIFERY SERVICE. The Midwifery Service established by the Council in accordance with the provisions of the Midwives Act, 1936, came into operation on the 1st May, 1937. By the end of the year, therefore, the Service had been in operation for a period of eight months. 30 Commencement of Service. The scheme approved by the Council provided for the appointment of nine whole-time midwives. On the 1st May eight midwives took up their duties, the appointment of the ninth midwife being deferred until experience had been gained of the working of the scheme. Seven of the midwives appointed had been practising in the Borough, and the eighth was a midwife from a Birmingham Hospital who was qualified to act as a teacher of pupil midwives. Subsequently the ninth midwife was appointed as it was found necessary to have a relief-midwife to take duty for the other members of the staff during their absence for any reason. When the Service came into operation the cases already booked by the seven midwives with local practices were taken over. The number of these cases was augmented by the patients of two midwives who surrendered their certificates on the 30th April. The Midwifery Service began, therefore, with a fairly full complement of cases and provision had to be made for the complete scheme on the first day of its inauguration. With the exception of their new outdoor uniform, which could not be delivered in time, the midwives were fully equipped to begin their duties on the 1st May. The work carried out by the midwives and the assistance given to the mothers from the 1st May to the 31st December was as follows :— Number of Confinements attended: (a) as midwife 323 (b) as maternity nurse 76 - 399 Number of Visits made by midwives : Confinements attended 399 Nursing visits 6,979 Ante-natal supervision 810 Other visits 678 8,866 Attendances of patients at midwife's house : First visits 340 Return visits 861 1,201 31 Number of accouchement sets issued : Free of charge 82 At cost price 93 175 Number of cases in which Home Help provided 45 Amount of fees collected by midwives £645 Cases attended by independent midwives. Since the Council's Midwifery Service came into operation eight independent midwives resident in the area have given up their practices, five surrendering their certificates and receiving compensation, and three leaving the district, one to take up a municipal appointment elsewhere. In addition, two midwives resident in Southall were appointed to the staff of the Southall Council and will no longer undertake cases in Ealing, and one midwife resident in Wembley has been requested by the Middlesex County Council to surrender her certificate under Section 5 (2) of the Act. At the end of the year there were seven midwives resident in the district and eight in neighbouring areas who were continuing in independent practice in the Borough. In addition, midwives from three nursing homes undertake occasional cases in the patient's own home. The total number of domiciliary cases attended during the whole year by these 18 midwives was 175. The Midwives Act provides for the payment of compensation for the surrender of certificates up to the 30th July, 1939, and some of the remaining independent midwives may decide to surrender their certificates before this date. Prohibition of unqualified persons acting as Maternity Nurses. Following a report by the Medical Officer of Health on the Service, made at the end of October, representations were made by the Council to the Minister of Health requesting that an Order be made applying Section 6 of the Midwives Act, 1936, to the Borough. This Section empowers the Minister of Health to make an Order prohibiting any person other than a state certified midwife or a state registered nurse from attending as a nurse on a woman in childbirth. This prohibition does not extend to (a) any person undergoing training with a view to becoming a duly qualified medical practitioner or a certified midwife, (b) to 32 any person who attends on any patient in any nursing home, or (c) to a woman who, before the first day of January, 1937, has been certified by the authorities of a hospital or other institution, to which the Minister has by order applied this proviso, to have been trained in obstetric nursing and who has given notice in writing to the authority of the area that she has been so certified. There are twelve women known to practise in the area as maternity nurses who are neither state registered nurses nor certified midwives. Five of these have certificates from approved training institutions while the remaining seven will be required to discontinue their work when the Order comes into force. While this may be unfortunate for the women concerned, it must be borne in mind that they have no qualification and that the Midwives Act, 1936, has as one of its main objects the improvement of the standard of midwifery and the elimination of the untrained person. The representations made by the Council resulted in the Minister of Health making an Order applying Section 6 to the Borough from the 1st June, 1938. Attainment of the Objects of the Act. The principal object of the Act was to secure the provision of a domiciliary service of salaried midwives as an important step in the improvement of the maternity services and in the campaign for reducing maternal mortality, and at the same time to raise the whole status of the midwifery profession. The latter object was achieved, in so far as Ealing was concerned, by the appointment of the best qualified and experienced of the local midwives and by placing them in the same grade as the health visitors and school nurses. In addition they receive suitable allowances for travelling and for the provision of accommodation for interviewing patients; they are provided with uniform, equipment and the telephone and they receive adequate off-duty periods and holidays. The improvement of the maternity service at which the Act aims will be brought about (1) by the greater measure of supervision which can be exercised over the midwives, (2) by the adoption of improved methods on the part of staff, (3) by the better conditions under which they will work, and (4) by the greater measure of 33 co-ordination of the whole of the Council's maternity service which can be readily secured now that the midwives have become members of the Council's staff. The first step towards improvement is facilitated by the fact that the midwives come into close contact with the medical staff at the Centres and by their obligation to report all unusual matters immediately to the medical officer in charge of the midwifery service. At the completion of attendance on each patient the case record is submitted to the medical officer who is able to enquire into any unusual feature. The second is attained by the midwives practising as far as possible the technique adopted at the Maternity Hospital. They are required to use gloves and masks when attending confinements and are kept supplied with sterilised maternity sets. These sets comprise two masks, a pair of rubber gloves, towel and powder puff, cord dressing and ligatures. At the same time in the smaller details of equipment the general policy has been to follow the lead given by the hospital. The third point, the improvement of the working conditions of the midwives, has been readily obtained by the arrangement for adequate off-duty times and holidays and by midwives who become exceptionally busy being able to call on colleagues for assistance. The greatest degree of improvement in the maternity service will probably be secured by the fourth and last point, although the actual effect of this may not be readily measured. The inclusion of the midwives as an integral part of the scheme of maternal welfare has rendered possible the co-ordination of the whole of the maternity service. As independent midwives they had become accustomed to a certain measure of co-operation with the Council's maternity scheme,but since taking up their municipal work they have availed themselves of the opportunity of complete co-operation. Home Helps.—With the appointment of the midwives it was considered desirable to make them responsible, in place of the health visitors, for the supervision of home helps. Instead of expectant mothers having to attend at the health centres to make application for a home help, their circumstances are now considered by the midwife in charge of the case who recommends, if necessary, that a home help be supplied at the cost of the Council. The midwives come into close contact with the home helps when attending patients and can exercise a far greater degree of super- 34 vision than the health visitors were able to do. The opportunity was taken to revise the rules with which the home helps must comply and to compile a new official list of home helps who have proved capable of undertaking the work. At the same time the Council agreed to increase the rate of pay of home helps from £1 Is. Od. per week to £1 5s. Od. per week. During the year home helps were provided by the Council in 45 cases but it is anticipated that there will be much greater demands on this service when the new arrangements are in full operation. Accouchement Sets.—For some years sterilised accouchement sets have been provided for expectant mothers who are in necessitous circumstances. Before the commencement of the new Service, at a conference held with the midwives, information was sought regarding the suitability of the sets provided. Various improvements were suggested and as a result an improved outfit is now available through the midwives. The outfit is contained in a tin box, a little larger than a biscuit tin, and comprises one accouchement sheet 30 ins. x 30 ins., 12 sanitary towels, 12 maternity pads, one sheet waterproof paper, 1 lb. cotton wool and one packet safety pins. Before leaving the manufacturers the outfits are sterilised and are sealed with adhesive tape. The cost of the outfit is 5s. 4d. and during the year 82 were supplied free to necessitous cases and a further 93 were sold at cost price. Training of Pupil Midwives.—As has been previously stated one of the midwives appointed to the staff is qualified to act as a teacher of pupil midwives, this appointment having been made with a view to her undertaking the district training of some of the pupil midwives who receive their other training in the Perivale Maternity Hospital. Under the present conditions of training each pupil is required to devote four weeks to her district training. One pupil was dealt with in June and later in the year, when the midwife had become established in the district, arrangements were made for her to undertake continuously the training of one pupil at a time. The Central Midwives Board has now amended the Rules regarding the training of pupil midwives and has divided the training into two parts. As the Perivale Maternity Hospital has 35 been approved for the first period of training only, and as pupils receiving this training do not require to receive training on the district, the arrangements for pupils to receive district training through the midwifery service will cease at the end of 1938. SUPERVISION OF MIDWIVES. During the year 57 midwives notified their intention to practice within the Borough, this number including 14 midwives residing outside the district. At the end of the year the number of midwives practising in the area was 49, as shown in the following table:— Midwives in service of Council 9 ,, at Perivale Maternity Hospital 11 „ in independent practice: (a) residing in Ealing 7 (b) residing in adjoining areas 8 ,, in private nursing homes 14 All of 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 58 (b) At the patient's home 631 When acting in the capacity of maternity nurse (a doctor being in attendance): (a) In private Nursing Homes 181 (b) At the patient's home 183 Notifications.—The number of notifications received from midwives, in accordance with the Rules of the Central Midwives Board, was as follows :— Notifications of sending for medical assistance On account of a complication of pregnancy 34 On account of a complication during labour 145 On account of a complication during the puerperium 28 On account of the health of the child 49 256 36 Still-birth 12 Death: Of mother 1 Of child 7 Laying out of a Dead Body 8 Artificial Feeding of Infant 19 Liability of Midwife to be a source of infection 16 Ophthalmia Neonatorum.—The notifications of sending for medical assistance on account of the health of the child included twenty-one cases of inflammation of, or discharge from, the eyes. Four of these cases were notified by the medical practitioner as cases of ophthalmia neonatorum. Visits to midwives.—Routine visits to the number of 33 were made by Dr. Dorothy Taylor who acts as Supervisor of Midwives. In addition, nine visits were made to maternity nurses with regard to their work in the district. Payment of medical fees.—The Town Council paid fees to local medical practitioners, called in by midwives, amounting to £224 15s. Od. in respect of 188 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 £52 14s. 5d. As midwives occasionally experienced difficulty in obtaining the services of a doctor in an emergency it was considered desirable to compile a rota of medical practitioners who were willing to answer emergency calls. The medical practitioners were circularized with regard to this rota, and as a result 54 doctors indicated their desire to be included. The rota serves a very useful purpose, but it would be of greater value if steps were taken to ensure that it contained the names only of medical practitioners who have had special experience of obstetrics. 37 SUPERVISION OF NURSING 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 25 (13) 248 (58) Number of applications for registration – – Number of New Homes registered – – Number of Homes discontinued 6 – Number of Nursing Homes on Register at end of year 19 (11) 231 (64) The figures in brackets indicate the number of Homes and the number of beds devoted wholly or partly to the reception of maternity cases. Four applications for renewal of certificates of exemption in respect of voluntary hospitals and homes were granted. In addition a certificate of exemption was granted in respect of the Twyford Abbey Convalescent Home when the readjustment of the Borough boundaries on the 1st April brought that institution into the area again. The nursing homes in the Borough are visited regularly by the Medical Officer who acts as Supervisor of Midwives, a total of 39 visits being made during the year. C. Sanitary Circumstances of the Borough. 39 SANITARY CIRCUMSTANCES OF THE BOROUGH. Water.—The North and South Greenford and Northolt Wards are supplied by the Rickmansworth and Uxbridge Valley Water Company with the exception of five roads in Greenford North Ward which are supplied by the Colne Valley Water Company. The rest of the Borough is supplied by the Metropolitan Water Board. There are eight factories in the Borough using water from deep borings ranging in depth from 300 feet to 600 feet. The water is used for general factory purposes and in four of them it is also used for drinking. Samples from these four supplies were taken and submitted to chemical and bacteriological analysis and the report in each case was that the water was satisfactory for drinking purposes. Samples were also taken from a shallow boring of water which was used in a dairy in connection with the milk cooler and the cold store compressor. The analysis in this instance showed the water to be polluted and its use in the dairy was prohibited. Rivers and Streams.—No complaints were received during the year with reference to the river Brent or its tributary stream. Drainage and Sewerage.—With the exception of 52 houses in Northolt Ward, ten in Greenford North Ward, one in Hanwell North Ward, two in Mount Park Ward and five in Drayton Ward, all houses in the Borough are supplied with water closets and are connected to the sewerage system. During the year one house previously drained to a cesspool was connected to the sewer. Closet Accommodation.—Excepting those parts of the Borough already mentioned the whole of the houses are provided 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:— 40 Wards Cesspools Water Closets PailClosets Houses within 100 feet of Sewer No. of Houses Northolt 38 29 23 4 52 Greenford 7 7 3 — 10 Hanwell North 1 1 — — 1 Mount Park and Drayton 2 4 3 — 7 48 41 29 4 70 Public Cleansing.-—During the year the Public Cleansing Service came under special review. Street Cleansing.—The system was entirely changed over to the Truck Beat System. Scavengers now work singly or in pairs as necessity dictates, each man being equipped with a two-bin truck. The sweepings are collected from the trucks on the beats by specially built covered scavenging lorries. Frequent calls are made on each scavenger during the day. There are now no scavenger gangs and no horses and carts picking up sweepings. Temporary dumps for sweepings are abolished except in a few instances where the last truck loads of the day are set down for early collection next morning. Sweepings are taken to the controlled tips by the lorries immediately after sweeping and are thus expeditiously and efficiently disposed of. A mechanical sweepercollector is also employed. Gully Cleansing.—Two steam gully extractors were put out of use and a modern type of machine obtained. A further machine is being obtained in the near future. Continuous efforts are made to get agreements with estate developers for scavenging and gully cleansing in new streets before their adoption by the Council. A nominal charge is made and the plan is meeting with successful results, so improving the amenities of newly developed estates. Refuse Disposal.— In 1936 ten cells at the Southern Destructor Works were closed down when controlled tipping was commenced on the site of the old Hanwell Sewage Works. There remained I 41 six cells in operation. These six cells after a period of single shift working were closed down in April, 1937, thus ending the disposal of refuse at the Southern Works. Controlled tipping was increased at Hanwell and commenced at the site of the closed Greenford Sewage Works. Hanwell Destructor Works—four cells—-were worked on a single shift throughout the year, disposing of 20 tons of refuse per day, leaving approximately 120 tons per day to be dealt with by controlled tipping. The policy of refuse disposal for the future was carefully considered by the Council. Plans and specifications were prepared, and tenders invited for the provision of separation and incineration works at Greenford. The works are designed to deal with 180 tons per day in the separation plant in one shift, and with the residue of 180 tons in the incineration plant in two 8 hour shifts. The plant will be worked at half capacity at the commencement, the balance of the refuse yield being tipped. The works will be brought up to maximum capacity in stages over a period of years as the sites for tipping become filled up. Included in the contract for building refuse disposal works is provision for an administration block, stores, mess room, shower baths, garage and workshops, thus forming a central public cleansing depot. Refuse Removal.—Eleven horse vehicles of an old type were put out of service in April and an up-to-date type of mechanical vehicle was purchased in their stead. Further mechanical vehicles will in the near future be purchased to replace the remaining horse vehicles. There have now been provided mechanical vehicles for refuse collection at holiday times and for use at other times when unusual demands are made on the scavenging service. This emergency reserve will be augmented when the projected purchases are completed. Refuse Dumps.—No complaints were received during the year of the St. Marylebone Dump situated in the Northolt Ward where a modified system of controlled tipping is in force. The dump at Yeading just outside the Borough boundary to which refuse from Paddington is brought also continues to be conducted in a satisfactory manner. 42 It need hardly be stated that the controlled tip at Hanwell, to which reference has just been made, has been conducted in a very satisfactory manner. Smoke Abatement.—The Sanitary Inspectors made 139 observations of chimneys during the year, but in only two instances was it necessary to make representations regarding the emission of black smoke for a longer period than that allowed by the byelaw. In one instance the nuisance was caused through bad stoking and inferior coal and the complaint was met by the fitting of mechanical stokers to the boilers ; in the other the fault lay in oil-fired boilers and was caused by insufficient attention being given by a temporary stoker. 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 8 applications were received for permission to establish the trade of fishfrying, permission being granted in one case. Shops Act, 1934.—No complaints were received during the year from the Shops Inspector under Section 10 of the Shops Act, 1934, but three shops with insufficient W.C. accommodation were found during inspections for another purpose. An additional W.C. was provided in each of these cases. Swimming Baths and Pools.—Four swimming baths are 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. 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 maintained by the Staff Recreation Clubs of two large factories. Chlorine treatment of the water is carried out in both these pools. 43 Eradication of Bed Bugs.—During the year 12 Council houses and 73 other houses were found to be bug infested. All of these were successfully disinfested. The method employed for freeing infested Council houses from bedbugs is by stripping the paper from the walls, removing or loosening all woodwork, the application of a blow lamp to the seats of infestation and spraying with a contact insecticide. In the case of privately owned houses a notice is served on the owner or occupier to do the necessary stripping of walls, etc., and the rooms are then sprayed with a contact insecticide. Bedding from infested rooms is treated at the Council's steam disinfector. 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 ten families were treated by this method. As regards Council houses, the Housing Department make particular enquiries regarding possible infestation and take steps to make a thorough inspection if infestation is suspected and adopt remedial measures when infestation is confirmed. The tenants are encouraged to report at once any suspected or actual infestation so that remedial measures can be taken early. As regards other houses the tenants are advised to inform the Public Health Department when there are any signs of re-infestation. Nuisance from Noise.—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 good defence that the best practicable means of preventing or mitigating it, having regard to the cost, have been adopted. Only one complaint of noise nuisance was received during the year. This was found to be justified and after appropriate action was taken the noise was reduced to a minimum. Schools.—A thorough inspection of the sanitary arrangements of all the public elementary schools and private schools is made at least once a year by the Sanitary Inspectors, and on their report 44 steps are taken by the Education Committee and by private owners to remedy any defects found. Tlie owners of private schools now welcome these annual inspections and consider them of great value. Reports of absentees from non-notifiable infectious disease 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 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 four cases :— (a) Non-compliance with Statutory Notice, Section 94, Public Health Act, 1875. 91, Eltliorne Avenue. Premises in such a state as to be a nuisance or injurious to health. An Order was made by the Magistrates for the necessary work to be carried out within 14 days. (b) Contravention of the Byelaws with Respect to New Streets and Buildings having regard to Section 23 (b) Public Health Acts, Amendment Act, 1907. 143, Rydal Crescent, 145, Rydal Crescent, 20, Thirlmere Avenue. Failure to submit plans, before converting into more than one dwelling, of a building originally constructed as one dwelling only. In these three cases proceedings were taken against the owner, agent and builder. The owner was fined £2 2s. Od. with £2 costs on each of the three summonses ; the case against the agent was dismissed and the builder was ordered to pay 4s. costs on each summons. 45 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 93 bodies were deposited therein. It is so fitted that medical practitioners can perform post mortem examinations and in 41 cases during the year such examinations were carried out. The accommodation, however, is far from satisfactory, and towards the end of the year the Council decided to build a new mortuary, the plans of which are now in course of preparation. 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 1,444 Number of Nuisances observed by Inspectors 182 Number of Premises inspected in connection with Infectious Disease 595 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Workshops, etc.) 3,224 Number of Houses inspected under House-to-House Survey 708 Food Inspections 2,150 Total Number of Re-inspections 12,144 Other Inspections 1,673 Total Number of Inspections and Re-inspections 22,120 Number of Intimation Notices given 790 Number of other Letters written 1,251 Number of Statutory Notices served 120 Proceedings before Magistrates 4 Milk and Dairies Act, Etc. Number of Cowsheds on Register 2 Number of Inspections made of Cowsheds 6 Contraventions of Act or Orders — Number of Retail Purveyors of Milk on Register 166 Number of Inspections of Retail Purveyors' Premises 162 Contraventions of Act or Orders 4 Proceedings before Magistrates — 46 Slaughterhouses . Number of Registered or Licensed, Slaughterhouses 3 Number of Inspections made 116 Contraventions of 'Regulations 1 Proceedings before Magistrates — Factories and Workshops. Registered Workshops 217 Factories 189 Number of Inspections of Factories and Workshops and Workplaces 500 Number of Defects concerning which Notices were sent 94 Proceedings before Magistrates — Offensive Trades. Fried Fish Shops 27 Other Offensive Trades — Number of Inspections 198 Contraventions 2 Disinfection. Rooms Disinfected by Spray:— (a) Ordinary Infectious Disease 22 (b) Tuberculosis 113 (c) Other Conditions 70 Rooms treated for Vermin 150 Articles Disinfected by Steam at Disinfector:— (a) Ordinary Infectious Disease 135 (6) Tuberculosis 738 (c) Other Conditions 2,367 Articles voluntarily destroyed 215 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 145 Drains cleared and cleansed 255 Defects in drains repaired 102 47 Drains reconstructed 80 Dust-bins provided 60 Overcrowding remedied 104 Accumulations of refuse removed 102 Nuisance from fowls and other animals abated 12 Damp-proof courses inserted in walls 95 Ventilation under floors provided 11 Other forms of dampness remedied 151 Yards paved and repaired 116 Floors repaired 73 Roofs, gutters and rain water pipes repaired 355 New soil and ventilating pipes provided 33 Sinks and waste-pipes repaired or renewed 203 Draw taps fixed to main supply 10 Dirty walls and ceilings stripped and cleansed 650 Other defects or nuisances remedied 730 Cisterns cleansed, renewed and covered 91 Houses connected to sewer 1 Water supply re-instated 33 Ventilated food cupboards provided 36 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) 242 23 — Workshops (Including Workshop Laundries) 219 14 — Workplaces (Other than Outworkers' Premises) 39 — — Total 500 37 — 48 2.—Defects found in Factories, Workshops and Workplaces. Particulars Number of Defects Number of rrosecutions Found Remedied Referred to h.m. Inspector Nuisances undet the Public Health Acts— Want of Cleanliness ... 38 38 — — Want of Ventilation ... 2 2 — — Overcrowding — — — — Want of drainage of floors ... 3 3 — — Other Nuisances 27 27 — — Sanitary aceommo- dation [insufficient 4 4 — unsuitable or defective 20 20 — — Lnot separate for sexes — — — — Offences under the Factory and Workshop Acts Illegal occupation of underground bakehouses (101) — — — — Other Offences — — — — (Excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921 ) Total 94 94 — — D. Housing. 50 Housing.—A Demolition Order was made under Section 11 of the Housing Act, 1936, with respect to one house. Two other houses were represented as unfit for human habitation but in respect of one the owner submitted a proposal for its reconditioning which was accepted by the Council ; the owner of the other gave an undertaking that it should not be used for human habitation. Altogether 108 houses have been represented as unfit for human habitation since 1930 when the five years' plan was drawn up, 27 more than were originally estimated. Arising out of these representations there were 64 demolition orders, 24 undertakings from owners not to re-let the houses for human habitation and 19 houses re-conditioned. In respect of one other house the owner .submitted a plan for reconditioning which was 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.—It was estimated that it would be necessary to measure 12,000 houses in addition to those measured during the survey carried out under the Housing Act, 1935, in order that certificates giving the permitted numbers could be issued to landlords and up to the end of 1936 as man}' as 7,206 houses had been measured. During 1937 a further 5,866 houses were measured making a total of 12, 962, but only 6,585 certificates were applied for and issued. 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) 2,184 (b) Number of inspections made for the purpose 2,187 (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 708 (b) Number of inspections made for the purpose 711 51 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 3 (4) Number of dwelling houses (exclusive of those referred to under the preceding sub-head) found not be be in all respects reasonably fit for human habitation 1,282 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 1,119 3.—Action under Statutory Powers during the Year:- A.—Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936: (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 96 (2) Number of dwelling houses in which defects were remedied after service of formal notice:— (a) by Owners 79 (b) by Local Authority in default of Owners 12 C.—Proceedings under Sections 11 and 13 of the Housing Act, 1936: (1) Number of dwelling houses in respect of which Demolition Orders were made 1 52 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 18 (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 12 of the Housing Act, 1936: (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made — (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit — Housing Act, 1936 (Part IV.).—Overcrowding. (a) (i) Number of dwellings overcrowded at the end of the year (Number of dwellings overcrowded on survey in 1935—314). 316 (ii) Number of families dwelling therein 316 (iii) Number of persons dwelling therein 1,8214 (b) Number of new cases of overcrowding reported during the year 85 (c) (i) Number of cases of overcrowding relieved during the year 104 (ii) Number of persons concerned in such cases 548 (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 — 53 The 85 new cases of overcrowding reported during the year include 60 cases found during the original survey which would become overcrowded in two years by reason of increase in the age of children under 10 years. During the year 2,522 new houses were built in the Borough by private enterprise. The Town Council completed 6 houses of the four-bedroom parlour type, 55 non-parlour houses and 4 one bedroom flats, and there are 113 houses of varying types in course of construction. A further scheme for 284 working class dwellings is contemplated at Northolt. E. Inspection and Supervision of Food. 55 INSPECTION AND SUPERVISION OF FOOD. Milk Supply.—At the end of the year there were only two cowkeepers on the register as producers of milk. One of these was licensed during the year by the Middlesex County Council to produce Accredited Milk. The use of one cowshed was discontinued. At the end of the year there were on the register 166 retail purveyors of milk. Twenty-two of these registrations were in respect of premises owned by one company and twelve 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 5 new purveyors of milk were registered, with respect to premises used for other purposes, to retail milk in sealed receptacles only, and 7 purveyors of milk were registered for premises purchased from others who were on the register. Three retail purveyors of milk discontinued their businesses and their names were therefore taken off the register. Milk (Special Designations) Order, 1936.—-Under this Order 91 licences were granted during the year, 30 for the sale of Tuberculin Tested Milk, one for Accredited Milk and 60 for Pasteurised Milk. Six samples of tuberculin tested milk were submitted for the Methylene Blue Reduction Test. One sample did not satisfy the test and the circumstances were reported to the Medical Officer of Health for the County in which the producer's premises were situated. Five samples of pasteurised milk were taken for bacteriological examination. In all of them the results came within the standard laid down bv the Order. Twenty-two samples of ordinary unclassified milk were examined for bacterial content. Ten of these were found to contain over 200,000 bacteria per cubic centimetre, namely 2,800,000 1,500,000, 1,495,000, 665,000, 640,000, 605,000, 995,000, 770,000, 485,000 and 425,000. The first six results may be disregarded, as the samples were unfortunately delayed before being examined. Subsequent samples proved to be satisfactory. In the others the retailers were advised to give more attention to the sterilization of the milk vessels and further samples gave satisfactory results. 56 Four samples of ordinary untreated milk were submitted for examination at the Lister Institute for the presence of tubercle bacilli. In no sample was this organism discovered. 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 the following table gives the number of animals slaughtered in the course of the year:— Carcases Inspected and Condemned. Cattle excluding Cows Cows Calves Sheep L,ambs Pigs Number killed — — 1 52 270 Number inspected — — 1 52 270 All Diseases except Tuberculosis— Whole carcases condemned — — — — — Carcases of which some part or organ was condemned — — — — 3 Percentage of the number inspected affected with diseases other than tuberculosis — — — — 1.1 Tuberculosis only— Whole carcases condemned — — — — — Carcases of which some part or organ was condemned _ _ — 3 Percentage of the number inspected affected with tuberculosis — — — — 1.1 All the animals were stunned by means of a humane implement. There is no public slaughterhouse in the Borough. In addition to the parts of carcases mentioned in the foregoing table the following were voluntarily surrendered for destruction:— Rabbits 60 lbs. Fish 48 lbs. Fruit 2,909 lbs. F. Prevalence of, and Control over, Infectious and Other Diseases. 58 INFECTIOUS DISEASE. The numbers of cases of the various infectious diseases notified in the past twelve years are indicated below. The total number of cases notified in the year under review shows a small increase over the previous year but is less than that in the three preceding years. It will be seen that there was a decided reduction in the occurrence of scarlet fever, the total of 317 cases being the lowest for six years. Diphtheria cases numbered 123 compared with 52 in the previous year ; nevertheless the prevalence of diphtheria was less in Ealing than in England and Wales. There was little variation in the other diseases with the exception of tuberculosis, the notifications from this disease being the highest on record. Cases of Infectious Disease occurring in the Borough. Disease 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 Smallpox — — 1 1 1 — — — — — — — Diphtheria 72 53 68 90 129 83 54 71 195 228 52 123 Scarlet Fever 156 136 313 231 264 154 407 476 493 400 408 317 Enteric Fever (including Paratyphoid) 4 14 12 1 4 1 3 4 3 7 8 5 Puerperal Fever 1 6 2 2 7 6 4 3 3 7 3 4 Puerperal Pyrexia 3 15 16 13 26 18 21 28 14 11 9 24 Pneumonia: Primary 47 66 73 100 78 96 85 56 72 59 85 60 Influenzal 17 38 13 59 12 18 50 32 17 11 14 37 Acute Poliomyelitis 1 — — 1 — 2 4 3 — 1 2 7 Cerebro-Spinal Fever — 2 — 1 — — — — — — — 1 Malaria 5 6 4 4 2 1 — 1 1 — 1 — Dysentery — 1 — — — — — 1 1 5 Erysipelas 15 18 28 24 34 20 30 36 43 28 28 27 Encephalitis Lethargica 2 6 3 3 1 1 1 — 1 — 1 — Tuberculosis:— Pulmonary 93 89 99 109 111 141 141 154 139 157 139 178 Non-Pulmonary 21 16 24 27 22 27 27 23 24 23 22 37 Ophthalmia Neonatorum 5 4 8 9 9 9 5 8 5 3 4 7 Total 442 469 665 675 700 577 832 895 1010 936 777 832 59 Cases of Infectious Disease notified during the Year 1937, 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 Hanwell S. Hanwell 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 123 121 2 1 2 4 6 8 60 24 6 9 2 1 — 20 2 3 8 19 3 3 4 27 19 13 2 Scarlet Fever 317 258 1 — 6 11 15 28 148 57 14 20 12 6 — 14 15 14 32 38 23 21 24 28 29 69 10 Enteric Fever 5 2 — — — — — — — 1 1 2 1 — — 1 1 — 2 — — — — — — — 1 Puerperal Fever 4 2 1 — — — — — — — — 3 1 — — — — — — — 2 — 1 — 1 — — Puerperal Pyrexia 24 8 — — — — — — — — — 19 5 — — 2 — 3 3 4 4 1 — 2 1 4 — Pneumonia:Primary 60 — 70 5 4 6 2 2 8 1 — 7 8 11 6 5 2 6 7 9 7 4 4 3 5 7 1 Influenzal 37 — 7 1 1 2 — 3 4 — 1 3 5 11 6 1 3 1 6 8 6 — — 3 1 4 4 Acute Poliomyelitis 7 6 1 — — 2 — — 2 2 1 — — — — — 1 — 1 — — — 1 1 2 — 1 Cerebro-Spinal Fever 1 — 1 — — — — — 1 — — — — — — — — — 1 — — — — — — — — Malaria — — — — — — — — — — — — — — — — — — — — — — — — — — — Dysentery 5 4 — — — — — — 4 1 — — — — — 1 — — — — 1 1 — — — 1 1 Erysipelas 27 4 — 1 — — — — — — — — 7 16 3 2 2 5 1 3 — 2 1 2 1 4 4 Encephalitis Lethargica — — 1 — — — — — — — — — — — — — — — — — — — — — — — — Tuberculosis:Pulmonary 178 — 76 — 1 — 1 1 3 — 25 80 37 26 4 12 8 8 13 19 16 10 15 25 17 25 10 Non-Pulmonary 37 — 12 1 — — — — 8 8 3 9 2 4 2 1 2 1 1 4 3 — 1 2 3 16 3 Ophthalmia Neonatorum 7 2 — 7 — — — — — — — — — — — 2 1 1 — 1 — — — — — 2 — Total 832 — 172 16 14 25 24 42 238 94 51 152 80 75 21 61 37 42 75 105 65 32 51 93 79 145 37 60 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 no 10 20 to 35 35 to 45 45 to 65 65 and upwards Totals Diphtheria — — — — — 2 — — — — — — 2 Scarlet Fever — — — — 1 — — — — — — — 1 Enteric Fever — — — — — — — — — — — — — Puerperal Sepsis — — — — — — — — 1 — — — 1 Pneumonia:Primary 12 1 2 — — 2 — — 1 7 20 25 70 Influenzal — — — — — — — — 1 1 2 3 7 Acute Poliomyelitis — — — — — — — 1 — — — — 1 Cerebro-Spinal Fever — — — — — 1 — — — — — — 1 Malaria — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — Erysipelas — — — — — — — — — — — — — Encephalitis Lethargica — — — — — — — — — — 1 1 Tuberculosis:Pulmonary 2 — — — — — — 4 27 17 18 8 76 Non-Pulmonary — 1 — — 1 2 — — 6 1 1 — 12 Ophthalmia Neonatorum — — — — — — — — — — — — — Totals 14 2 2 — 2 7 — 5 36 26 41 37 172 61 Diphtheria.—The number of cases of diphtheria notified during the year was 123 compared with 52 in the previous year. The diphtheria case-rate in 1937 was, however, the second lowest on record and the case-rate of 0.78 per thousand of population compares very favourbly with the rate for England and Wales which is 1.49. The distribution of cases according to age and the numbers occurring in each Ward are indicated on page 59. The occurrence of cases throughout the year was as follows:— Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. 6 6 5 5 2 6 6 7 19 20 20 21 It will be seen that during the first eight months of the year there were very few cases and that the majority of cases occurred from September onwards. During the year two deaths were recorded, equivalent to a death-rate of 0.01 per thousand of population and a mortality rate of 1.63 per cent. of cases notified, compared with the respective figures of 0.06 and 15.39 in the previous year. It is very satisfactory to record such a low mortality rate in 1937, particularly as the mortality in 1936 was abnormally 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 60 patients were issued at cost price to local medical practitioners for their private patients. In addition 709 children were immunized through the school medical department, 317 being of school age and 397 under five years. The total number of children who have been immunized by the school medical staff since the scheme was commenced is now approximately 1,600. Anti-toxin for the use of medical practitioners in cases suffering, or suspected to be suffering from diphtheria, is supplied free of cost for patients in poor circumstances and at cost price for other patients. During the year 320,000 units of anti-toxin were issued. Scarlet Fever.—The number of cases of scarlet fever notified during the year was 317, compared with a total of 408 in the previous year. The number of cases of the disease occurring in the year under review is lower than in the previous five years. The 62 total of 317 cases is equivalent to a case-rate of 2.01 per thousand of population, compared with the case-rate for England and Wales of 2.33 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. 20 25 43 20 19 33 20 7 33 38 29 30 The Wards in which the cases occurred are shown on page 59. It will be seen that North Greenford Ward was most affected with 69 cases during the year. One death occurred from the disease, this being a girl, 4 years of age. The scarlet fever death-rate for the Borough, 0.01 per thousand of population is similar to the death-rate for England and Wales. Enteric Fever.—Five cases coming under this heading were notified. There was no connection between any of the cases and it was not found possible to trace the source of infection. None of the cases proved fatal. Puerperal Fever and Puerperal Pyrexia.—Four cases of puerperal fever and 24 cases of puerperal pyrexia were notified during the year. From the 1st October, 1937, by the operation of the Pubhc Health Act, 1936, the term Puerperal Fever was discontinued and cases previously coming under this heading became notifiable as Puerperal Pyrexia. All four cases of puerperal fever occurred in the patient's own home, two being removed to hospital for treatment. Of the cases of puerperal pyrexia, 13 occurred in the patient's own home, three in nursing homes and eight in hospitals, six of the latter being in hospitals outside the district. Six cases, including two patients who were in nursing homes, were removed to hospital for treatment. None of the notified cases proved fatal although one death from puerperal sepsis is assigned to the district. This was a woman who had been admitted to the West Middlesex County Hospital for her confinement and who subsequently died. 63 Pneumonia.—Notifications were received of 60 cases of primary pneumonia and 37 cases of influenzal pneumonia. There were 70 deaths from primary pneumonia and seven deaths from influenzal pneumonia. Many of the deaths occurred in institutions outside the Borough and the majority of these cases were not notified and are not included in the figures regarding notifications. Malaria and Dysentery.—There were no cases of malaria notified during the year. Five cases of dysentery occurred, this being the highest number of cases in any year. All were children of five to ten years of age. Three occurred at the same time when the children were patients in a children's hospital in London. There were no deaths. Erysipelas.—Twenty-seven cases were notified during the year, this being one less than the number occurring in each of the two previous years. Encephalitis Lethargica.—There were no cases notified during the year from this complaint. One death is shown in the table of deaths but this was a patient who had suffered from the disease some years previously. 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 — 1 1 — — 1—5 2 1 — — — — 1 1 5—10 2 1 3 5 — — 1 1 10—15 — — 3 5 — — — — 15—20 10 15 — 3 2 2 — — 20—25 16 16 — 3 2 5 3 2 25—35 17 31 2 4 12 S — 1 3d—45 26 11 — 2 9 8 — 1 45—55 10 5 2 1 7 2 — 1 55—65 8 3 — 1 7 2 — — 65 upwards 3 1 — 2 6 2 — — Total 94 84 11 26 46 30 5 7 64 The number of new cases of pulmonary tuberculosis was 178 compared with 139 in the previous year. The number of cases of non-pulmonary tuberculosis was 37 compared with 22 in 1936. The total deaths from tuberculosis were 88 (pulmonary 76, nonpulmonary 12), this number being exactly the same as in the preceding year. Sixteen persons were certified as dying from tuberculosis and four 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 their failure to give the proper notification. The number of cases on the tuberculosis register at the end of the year was 688 (551 pulmonary and 137 non-pulmonary) compared with 587 at the end of the previous year. The register is revised periodically and visits are paid by the Sanitary Inspectors to the homes of patients who are not under the supervision of the Tuberculosis Officer, in order to obtain information as to their progress. 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 182 (b) Other forms of Tuberculosis 29 Number of persons in Institutions at end of year:— (a) Tuberculosis of Lungs 104 (b) Other forms of Tuberculosis 19 Number of persons under observation at end of year 383 Number sent to Sanatoria during year 133 Number sent to Hospital during year 24 Ophthalmia Neonatorum.—Seven cases were notified during the year, one being an infant who had been born in a London hospital, the other six having been born at home. The final report on each case was that the condition had cleared up and that the child's vision was unimpaired. 65 Measles, Whooping Cough, Etc.—The prevalence of nonnotifiable 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 last three years were as follows:— 1935 1936 1937 Measles 142 1,577 427 Whooping Cough 368 319 697 Chickenpox 649 493 764 Mumps 236 686 925 It will be seen that whooping cough, chickenpox and mumps were more prevalent in 1937 than in 1936, while there was a large decrease in the cases of measles. G. School Medical Service. 67 SCHOOL MEDICAL SERVICE. In the following table information is given regarding school accommodation and attendance, together with the number of children medically examined and treated. This gives some indication of the increase in the work which the department has been called upon to perform in successive years. In addition to children attending the elementary schools, pupils attending the secondary schools in the Borough were also examined and treated in accordance with arrangements which have been made with the Middlesex Education Committee. 1934 1935 1936 1937 Population (Mid-year estimate) 133,446 137,550 145,000 156,460 No. of school departments 43 47 47 50 Accommodation 14,906 16,749 17,359 19,369 Average number on School Rolls during year 14,077 14,463 15,251 17,062 Percentage of school children to population 10.5 10.5 10.5 10.9 Average attendance during year 12,489 12,932 13,358 14,952 Percentage attendance 88.7 89.4 87.5 87.6 No. of children examined at routine inspection 5,900 5,533 5,996 6,415 Percentage of school children examined at routine inspection 41.9 38.1 39.3 37.6 Total number of children who were examined at least once during year 9,780 9,541 10,364 11,527 Percentage of children who were examined at least once during year 69.5 66.0 67.9 67.5 There were therefore 419 more children examined in the year at routine medical inspection than in the previous year and 1,163 more children were examined at least once. 68 Staff.—During the year Mr. E. Tribe, L.D.S., resigned, and Mr. Alfred G. Brown, L.D.S., was appointed to take his place. One additional school nurse was appointed, bringing the number of the nursing staff to one supervising and eight school nurses. Dr. Murdoch MacGregor resigned his position as Assistant Medical Officer in October on obtaining another appointment and Dr. John Petrie resigned on the 31st December for a similar reason. They were succeeded by Dr. Humphrey Butcher and by Dr. D. F. Irvine who no longer carries out duties at the Isolation Hospital. THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. It is not necessary to make any comments under this head other than to say that the following new schools were opened during the year to meet the needs of the increased school population:— Cuckoo Junior. Cuckoo Infants. Cuckoo Senior Boys. Coston Senior Girls. Perivale Senior Girls. Stanhope School was enlarged to provide 100 additional places in the Junior Department and 100 places together with accommodation for 40 children in a nursery class in the Infants' Department. MEDICAL INSPECTION. Medical inspection included (1) the routine inspection in the schools of children in the three age-groups recommended by the Board of Education, namely, (a) entrants, (6) 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 69 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 on page 99. Among the 6,415 children examined in a routine manner there were, excluding uncleanliness and dental disease, 810 defects requiring treatment and 1,145 requiring to be kept under observation. The examination of the 5,112 children submitted to special inspection revealed 3,621 defects requiring treatment and 505 requiring to be kept under observation. Of the 6,415 children examined at the routine inspections, 754, or 11.7 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 100. The classification is in accordance with the suggestions of the Board of Education as set out in the Administrative Memorandum No. 124 issued at the beginning of 1935. As noted in the previous year the nutrition of the school children in the Borough is very good, for no less than 97.5 per cent. of the children examined at routine inspections were classed as ''excellent" or "normal," and only 160, or 2.5 per cent., were found to be slightly sub-normal." There was one child classified in the fourth group, "nutrition—bad." During the year an enquiry was carried out regarding the nutrition of the children attending the elementary schools in the Borough. As a result the following report, which is now under consideration, was submitted:— 70 "REPORT ON SURVEY OF SUB-NORMAL NUTRITION IN SCHOOL CHILDREN AND ON THE POSSIBLE NEED FOR A SCHEME FOR PROVIDING MEALS FOR THOSE IN NECESSITOUS CIRCUMSTANCES. In accordance with the resolution of the Education Committee passed on the 2nd February, 1937, I submit herewith a report on sub-normal nutrition in children attending the public elementary schools in Ealing and on the possibility of providing meals for those whose parents are in necessitous circumstances. The first step that had to be taken was to ascertain as far as practicable the total number of school children who were in a condition of sub-normal nutrition. This meant a general survey, which was carried out from June until the end of the year, of the children in the schools. It could be surmised that it would be impracticable with the medical staff at my disposal to examine individually all the children in the schools and therefore means had to be devised by which the sub-normal children could be ascertained without that necessity. The help therefore of the school teachers was invoked. The school teachers are daily in close association with the children and at the same time they are in touch with the parents. They are thus able to formulate in their own minds ideas regarding the nutrition of the children and to glean information as to the financial circumstances of the parents. The head teachers were therefore asked (1) to make a return of the names of all children considered by them to have signs of sub-normal nutrition, and (2) to supply the names of all the children known to be in poor financial circumstances on account of unemployment, large family and so on, in whom no signs of sub-normal nutrition were observed. As a guide to the head teachers a circular letter was issued to them in which it was stated that the physical evidences of sub-normal nutrition to be considered were smallness, thinness, pallor, poor carriage, recurring illnesses such as bronchitis, sore throat, headaches, abdominal pain and frequent colds and educational evidences to be inattention, dullness, irritability, anxious expression, tiredness, mental slowness, and scholastic attainment below probable mental capacity. Thereupon the children whose names appeared on the list were inspected by one of four medical officers in the department who, after consultation with the head teacher, finally placed each child within one of the four groups: {a) Nutrition excellent. (b) Normal. (c) Slightly sub-normal. (d) Definitely sub-normal or bad. The children who were considered by the medical officer to be slightly sub-normal or definitely sub-normal were further investigated. This investigation consisted of : (1) A particular physical examination, (2) A report from the school teacher and (3) An enquiry into the home circumstances by the school nurse. 1. Physical Examination. There is no sure criterion of sub-normal nutrition. The diagnosis is arrived at from a group of signs or symptoms such as poor development, pallor, condition of the skin and lack of muscular tone, which as a whole convey to the mind of the examiner the condition of sub-normality. As a group of signs does not always convey the same impression to different individuals the results obtained might vary according to the medical examiner. Nevertheless, on the whole, because of constant co-operation and consultation between the individual medical examiners, the results may be deemed to 71 give a fairly true picture of the condition of the children in the various schools. In the particular physical examination which followed the first classification steps were taken to ascertain various defects which might possibly be considered to be the result of sub-normal nutrition. Wherever possible the medical officer ascertained from the mother information regarding the child's general health, but unfortunately the mother's help in this respect was not always available. 2. School Teacher's Report. The school teachers supplied information with reference to the child's behaviour, scholastic attainments, previous illnesses and signs of lack of parental care which could only be obtained as a result of long continued contact with and observation of the child. 3. Home Conditions. An enquiry into the home conditions was made by the school nurse and dealt with the size of the family, income, outgoings, employment of the father and mother, housing accommodation, hours of sleep and nature of the diet. The nurse was often able to get from the mother some information regarding the child's previous health and the reason for the child not receiving milk in school, financial straits, lack of interest, etc. General Results. The general results of the enquiry may be stated as follows: (a Discovery of Sub-Normal Children. Number of children on the school registers at the middle of the year (1937) 17,321 School children considered by teachers to be of sub-normal nutrition either on physical or educational grounds or to be in poor financial circumstances 1,097 Of the 1,097 children those considered on examination by medical officers to be of sub-normal nutrition 287 (286 slightly sub-normal and 1 definitely sub-normal or bad). Percentage of school population to be of sub-normal nutrition 1.66 The percentage of sub-normal children is certainly very low. b Factors Contributing to Sub-Normal Nutrition. (1) Size of Family. Average number in family of those considered to be sub-normal (Average size of family in Haling at 1931 Census, 3.6) 6.25 (2) Income of Family (per week). Average income available, after deducting rent, per person (irrespective of age) 6/10 (a) No. of families with over 10/- each person 37 (b) No. of families between 10/- and 7/6 each person 57 (c) No. of families between 7/6 and 6/- each person 33 (d) No. of families below 6/- each person 124 251 This number investigated is less than the number of 287 children found to be sub-normal because information was not available in regard to 36 of them. It is thus evident from these figures that it is the large family and the family in poor financial circumstances that provide by far the largest number of sub-normal children. 72 It may be noted here that in 1933 a Committee on Nutrition appointed by the British Medical Association suggested a figure of 5/10½ as a minimum for providing food for each adult man per week. As at the present ascertained the cost of food would be about 7/1½ per adult man per week. (c) Capabilities of Mother. Information was obtained regarding 190 mothers who were classified as follows : Poor housewives 89 (of whom 26 were suffering from definite illhealth) . Good housewives 101 (d) Employment of Father. Loss of working Capacity, loss due to bad weather or seasonal unemployment were reported in 114 cases. (e) Employment of Mother. Mothers employed away from home during some part of the day 24 (f) Hours of Sleep. The hours of sleep of the children were ascertained and varied from 8 to 14 hours, the average being 11.4 hours. Dependance, however, cannot be placed upon the hours of sleep stated either by the parents or by the children. There are various reasons for inaccuracy into which it is not necessary to enter. There is evidence, however, that the hours of sleep have little effect on the condition of sub-normal nutrition. Conclusions. From what has been stated it is quite apparent that there are three main factors which influence the state of nutrition of the children. The first is the large size of the family, the second the smallness of the family income and the third, which is of necessity closely related to the second, is the uncertain employment of the father. Milk in Schools. A large number of the children ultimately diagnosed as suffering from sub-normal nutrition were already in receipt of milk at the cost of the Education Committee and where the circumstances were considered to be necessitous those that were not already in receipt of milk were granted it forthwith. As many as 68 children were added to the list of those already receiving milk and it may be stated quite definitely that as a result of the survey all sub-normal children whose parents were unable to afford to pay for the milk were given it. Many of them were provided with a third of a pint of milk twice a day at the cost of the Committee. Whereas 19 children had a double supply of milk each day before the survey, 110 had it after. The following figures relating to the provision of milk free of charge to necessitous cases are worth quoting: Number of children receiving milk prior to Nutrition Survey (June 1937) 1,309 Number of these children receiving two onethird pint bottles prior to Survey 19 Number of children receiving milk at end of December 1937 (Survey completed) 1,377 Number of these children receiving two bottles at end of December 1937 110 Cost of milk supplied in the year 1937/1938 £395 Estimated cost of milk for the year 1938/1939 £400 73 The figures show that whilst only 287 children in all the schools were found to be sub-normal, slightly or definitely, as many as 1,377 children were in receipt of milk at the end of the year at the cost of the Committee. Financial necessity of the parents determined the receipt of milk by the children not classified of sub-normal nutrition. The supply of milk in this way goes a long way towards meeting any deficiency in the diet provided at home. The question, however, arises, is the provision of milk sufficient for these children? In my opinion where the financial circumstances are as poor as in the majority of these cases the supply of milk alone is not sufficient and it is necessary to consider whether a scheme for the supply of meals in school is practicable. In the consideration of such a scheme there are certain points that have to be discussed. The first is whether a sufficient number of parents would permit their children to stay in school for their mid-day meal. It is difficult to answer but I am inclined to think that unless there is a large number of children in any school having similar meals at a time the number of parents allowing their children to have meals in school would be small. The second is, if a mid-day meal is provided whether it should be a hot or a cold meal. My own opinion is that if a meal is provided it should be a freshly cooked hot meal. The third point is whether dinners should be provided only for sub-normal children or whether it should be made possible for other children to obtain meals on payment of cost price. Here again it is difficult to forecast what would be the response of the parents to such a proposal. A fourth and last point to call for careful consideration is whether the meals, if provided, should all be prepared in one central kitchen and then distributed to the schools or to a number of feeding centres or whether some arrangement should be made separately in each school. The method of cooking in a central kitchen and of distributing the meals to the various schools or feeding centres is one which is growing in popularity. It is found to be much more economical and, with the development of modern food conveyors, to be practicable in management. If meals have to be supplied to a reasonable number of children in several schools this is the method that seems advisable. Unfortunately, except in the Cuckoo School, the number of children to be dealt with in the schools is relatively small, and in considering the question of providing meals it is necessary to have in mind the number of sub-normal children in each of them. A list of the sub-normal children in the respective schools is as follows: Schools Girls Boys Infants Total Cuckoo 17 22 11 50 St. Ann's 23 6 — 29 Little Ealing — 8 19 27 Grange 13 3 4 20 St. John's Junior Mixed and Infants — — 18 18 Oaklands 6 4 5 15 Stanhope 5 7 2 14 St. Mark's Junior Mixed and Infants — — 14 14 St. Joseph's Junior Mixed and Infants — — 10 10 Horsenden 1 6 2 9 Drayton — 4 4 8 Wood End 6 — 2 8 Selborne — 1 6 7 Northolt Junior Mixed and Infants — — 7 7 Coston 7 — — 7 Northfields 2 2 3 7 Bordeston — 5 — 5 Coston Junior Mixed and Infants — — 5 5 Wood End Junior Mixed and Infants — — 5 5 North Ealing Junior Mixed and Infants — — 3 3 74 Schools Girls Boys Infants Total St. Mary's Junior Mixed and Infants — — 3 3 Hobbayne Junior Mixed and Infants — — 3 3 Ravenor Junior Mixed and Infants — — 3 3 Modern — 3 — 3 Perivale 1 — 2 3 Bethams — — 2 2 Christ Church 1 — — 1 St. Saviour's — — 1 1 Totai 82 71 129 287 It will be seen that the greatest number of sub-normal children are to be found in the Cuckoo School, with St. Ann's, Little Ealing, Grange, St. John's, Qaklands, Stanhope and St. Mark's following in sequence. The small numbers to be dealt with in most of the schools, excepting Cuckoo School, and the wide distribution would render a scheme for the provision of meals not only expensive but difficult. It must be kept in mind that the children enumerated cannot be compelled to have meals and the number participating might not only be small but it might vary greatly in the course of the operation of the scheme. If the scheme is to be embarked upon it might be adopted in one school to begin with, the Cuckoo School, where the largest proportion of the subnormal children are, so as to gain experience of its working, the preparation of the meals being carried out at that school. THOMAS ORR, School Medical Officer. 23rd June, 1938." (b) UncleanuneSS.—The routine 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. 1934 14,077 30,183 760 8 1935 14,463 32,951 755 2 1936 15,251 33,578 830 8 1937 17,062 39,955 882 21 75 FOLLOWING UP. The steps taken to follow up children found at routine or special inspections to be suffering from defective conditions were given in detail in previous years. The number of visits made to the homes of the children by the school nurses during the year was 4,527. ARRANGEMENTS FOR TREATMENT. (a) Minor Ailments and Diseases of the Skin.—The treatment of minor ailments carried out at the Health Centres is shown in Table IV, Group 1 (page 104). It will be seen that as many as 93.6 per cent. of the cases found on medical inspection attend the Health Centres for treatment. 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 17 150 Scabies 112 319 Impetigo 255 2,669 Others 300 920 Minor eye defects 195 2,008 Minor ear defects 314 3,630 Miscellaneous: Minor injuries 249 921 Sores 948 6,169 Others 37 105 Total 2,427 16,891 Included in the number of cases of scabies treated are 15 adults who had to be dealt with at the same time as the children so as to avoid re-infection. 76 (b) Defective Vision.—The report of the Ophthalmic Surgeon, Dr. L. G. Scoular, is as follows:— " Report on the Eyesight of School Children. "During the past year 721 new cases were examined, 332 at Mattock Lane Centre, and 389 at Ravenor Park Centre. This is an increase of 95 as compared with the number of new cases seen in the previous year. "There were 884 re-inspections, of which 433 were at Mattock Lane and 451 at Ravenor Park Centre. Forty children had to be seen a second time before making the final correction, so when these are included it makes a total of 924, which is practically the same as the corresponding number of re-inspections made the year before. "Whereas in 1936 more new cases were seen at Mattock Lane, in 1937 the greater number were examined at Ravenor Park. Correspondingly, there were more re-inspections at Ravenor Park than at Mattock Lane. The explanation of this is no doubt the increasing number of families who have gone to live in the Ravenor Park district, and also the fact that children from this locality who were formerly seen at Mattock Lane are now examined at the new Centre. "In all, 786 pairs of glasses were prescribed, which shows an increase of 40 as compared with the number ordered in 1936. "In the whole year only one child was found whose myopia was sufficiently bad to warrant the diagnosis of progressive myopia, and he was sent to a special school. The year before, 9 such cases were found, but most of them had quite good vision and it was only because their short-sight was developing too fast that they were included in the list. This reduction in the number of progressive myopes bears out the opinion which was expressed in last year's report, namely, that there is not a sufficient number of highly myopic children in the Borough to justify the provision of a special sight saving class." 77 Eye Cases, Mattock Lane Centre, 1937. Condition. New Cases. Re-Inspections. Hypermetropia 75 82 Hypermetropic Astigmatism 91 117 Myopia 42 61 Myopic Astigmatism 28 78 Mixed Astigmatism 9 11 Emmetropia 17 18 Squint 44 48 Eye Diseases 8 11 Welfare Cases 18 7 Total 332 433 Eye Cases, Ravenor Park Centre, 1937. Condition. New Cases. Re-Inspections. Hypermetropia 78 82 Hypermetropic Astigmatism 118 118 Myopia 28 42 Myopic Astigmatism 32 63 Mixed Astigmatism 12 19 Emmetropia 22 28 Squint 67 82 Eye Diseases 16 12 Welfare Cases 16 5 Total 389 451 (c) Nose and Throat Defects.—The arrangements for operative treatment of nose and throat defects at the King Edward Memorial Hospital were described in the report for 1934. During the year under consideration 176 children were treated, 152 being operated on for enlarged tonsils, two for adenoids, and twenty-two for enlarged tonsils and adenoids. 78 (d) Ear Defects.—The Ear Clinic for the investigation and treatment of ear disease held at the Mattock Lane and Ravenor Park Health Centres once a fortnight was in the charge of Dr. Murdoch MacGregor who is specially qualified for this work. Cases were referred from the School Medical and Child Welfare Services. The nature of the examinations and the methods of treatment were similar to those outlined in the report for 1936. The cases examined and the results of treatment were as m the two tables which follow: Number of cases under treatment 31st December, 1936 56 Number of cases referred from Routine Medical Inspections in 1937 80 Number of cases referred from Inspection Clinics in 1937 67 Number of cases referred from Child Welfare Centres in 1937 15 Total 218 In this table it will be noted that 218 cases altogether were referred to the Clinic in 1937, an increase of 64 cases over the previous year. New cases referred for treatment were 162, an increase of 32 over the previous year. Ear Cases Examined in 1937. Diagnosis. No. Successfully treated and discharged. Successfully treated and under observation. Referred to hospital still under treatment. Acute Otitis Media 30 22 5 — 3 Double Acute Otitis Media 2 1 1 — — Chronic Otitis Media 87 15 32 11 29 Double Chronic Otitis Media 29 6 9 3 11 Catarrhal Deafness 23 10 5 1 7 Wax 9 9 — — — Furunculosis 2 2 — — — Congenital Deafness 1 — — — — Acute Mastoiditis 1 — — 1 — Post Auricular Adenitis 1 1 — — 1 Chronic Adhesive Process 1 — — — — Otalgia 1 1 — — — 187 67 52 16 52 79 Of the 218 cases referred for examination 31 failed to attend. Of the 187 attending 67 were successfully treated and discharged, 52 were successfully treated but kept under observation, 16 were referred for hospital treatment and 52 were still under treatment at the clinic at the end of the year. The bulk of the work continued to be the supervision and treatment of otitis media. Cases of otorrhoea were examined and treated once a fortnight until the discharge from the middle ear ceased. This work at the Clinic was supplemented by treatment at the Minor Ailment Clinic each day where the ears were thoroughly cleansed by swabbing and by the instillation of drops by nurses specially instructed in the work. The leaving of this daily treatment or what might be called "ear toilet" to parents has not proved satisfactory. It requires a degree of skill to remove discharge from the middle ear so that the instillation of ear drops may have the desired effect and not merely add to a reservoir of pus in the meatus. The importance of this part of the work cannot be too greatly stressed in the successful treatment of this condition. It is gratifying to note the continued success obtained in the treatment of chronic otitis media. Sixty-two cases out of a total of 116 were successfully treated, 14 were referred for hospital treatment and 40 cases were continuing to receive treatment at the end of the year. In the following table the results of treatment in cases referred to the Clinic in 1936 but which required continued treatment in 1937 are shown:— 80 Results of Treatment in cases referred from 1936. Diagnosis. No. Successfully treated and discharged. Successfully treated and under observation. Referred to hospital Still under treatment. Chronic Otitis Media 28 7 9 8 4 Double Chronic Otitis Media 9 1 2 3 3 Catarrhal Deafness 3 1 — 1 1 Chronic Adhesive Process 1 - — Referred to Deaf School 1 41 9 11 12 9 In this table it will be noted that of 41 cases carried on from 1936, 20 were successfully treated, 12 were referred for hospital treatment and 9 cases continued under treatment. As the greater number of these cases were of the very chronic type of ear disease it is encouraging to record that success is attained in such a large number by insistent treatment. Zinc Ionization. In the treatment of chronic otitis media zinc ionization was continued as a therapeutic aid in selected cases. The cases were as follows:— Cases of chronic otitis media attending clinic 116 Cases treated by zinc ionization 61 Cases successfully treated 24 Cases unsuccessfully treated 12 Cases still under treatment 25 Experience with zinc ionization therapy leads one to conclude that it is a treatment worthy of trial. The practice at the Clinic has been to give the treatment on three occasions at fortnightly intervals. When success has not been obtained after three trials the treatment has not been continued and has been deemed to be unssuccessful. 81 The history of 113 cases of otitis media attending the Clinic was enquired into with a view to ascertaining the cause of the disease. The results were as follows :— No ascertainable cause 63 Common Cold 15 Scarlet Fever 13 Measles 15 Chicken Pox 1 Influenza 1 Whooping Cough 2 After removal of Tonsils and Adenoids 3 Total 113 From the figures it is seen that in 63 cases no ascertainable cause was found which leads one to conclude that the cause in the greater number of these was probably the "common cold.'' During the year 31 children with ear disease were recommended to have the tonsils and adenoids removed as part of the treatment of the ear condition. Of this number 15 either refused to have this done or were awaiting operation at the end of the year. Of the 16 who had the operation, 5 suffered from chronic otitis media, 6 suffered from catarrhal otitis media, and 5 were recovering from acute otitis media. An enquiry into the duration of otitis media prior to attendance of children at the Clinic revealed the following facts in 162 cases :— Duration of 1 week 22 ,, ,, 1 month 24 ,, ,, 3 months 12 ,, „ 6 months 5 ,, „ 1 year 7 ,, „ 2 years 14 ,, „ 3 years 10 ,, „ 4 years 9 ,, „ 5 years 6 ,, ,, more than 5 years 40 Period indefinite 13 82 Most of the above cases, particularly those with a history of the disease of long standing had been treated by their own doctor or at hospital. In many the treatment had either been abandoned or had been intermittent. In some the discharge from the ear was not considered important enough to seek medical advice or had not been noticed by the parents. It is hoped with the continued practice of examining the ears of all children by the auriscope at school medical inspection and at Child Welfare Centres that otitis media will be detected at an early stage of the disease when treatment can be advised. The earlier the disease is detected, supervised and treated the greater is the hope of cure and the more likely the preservation of hearing. Defective Hearing. In each case referred to the Clinic hearing was tested before and after treatment. The audiometer was not used the voice tests being considered satisfactory for all practical purposes. The following table shows the results of treatment in 108 cases which on the initial examination had a defect of hearing:— Diagnosis. No. No. with No. with j defect of permanent hearing but defect of | still under hearing treatment No. cured No. referred to School for Deaf No. referred to Hosp. Catarrhal Deafness 15 0 3 10 — 2 Chronic Otitis Media 70 12 31 14 1 12 Acute Otitis Media 23 4 6 13 - — 108 16 40 37 1 14 Total with some hearing defect on the 31st December, 1937 71 It is seen in this table that 71 cases continued to have defective hearing of greater or less extent after treatment. In 16 of these the hearing defect was considered to be permanent; one case was referred to a School for the Deaf and 14 for hospital treatment. It will probably mean that at least 31 of the total 108 cases will have permanent defective hearing. 83 (e) Dental Defects.—The report of Mr. C. Colenso, the Senior 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 94, that dealing with mothers and pre-school children on page 27, while the section giving a description of the work among elementary school children follows. "Dental Inspection and Treatment of Elementary School Children during the year 1937." "There was an increase in the number of school children inspected and treated during the year. This increase was due chiefly to the large new school on the Cuckoo Estate, and also to new entrants to the schools in the Greenford and Perivale districts. A total of 16,488 children were inspected by the dentists. This is an increase of 1,954 over the preceding year. The number of children who were found to require treatment at the inspections totalled 10,150, an increase of 685 over the previous year. The number of children who were not in need of any treatment at the time of inspection was thus 6,338, or 38 per cent. "The number of children actually treated by the dentists, totalled 6,433, an increase of 466 over the preceding year. Owing to the increased amount of time given to mothers and young children at the Mattock Lane and Greenford Green Centres, appointments could not be given to all the school children requiring treatment, and it was therefore impossible to complete both inspection and treatment of all the children before the end of the year. "The work carried out was mainly of a radical nature, elimination of sepsis being the first consideration. Fillings were inserted in all saveable permanent teeth and also in small cavities in the temporary teeth in young children. The number of fillings inserted in permanent teeth amounted to 4,808. This is a large reduction in comparison with the previous year when 6,421 fillings were inserted. The reduction is mainly accounted for by the fact that more permanent teeth were removed on account of advanced decay and irregularities in dentition found in the children entering the new schools on the Cuckoo Estate. There was an increase 84 in the number of temporary teeth extracted, whereas in the previous year a large amount of time had been spent in filling these temporary teeth. There were more extractions under local anaesthesia in 1937, and this work, although it eased the pressure in the gas sessions, reduced the amount of time available for fillings. The future policy will be to remove decayed temporary teeth, because it has not been found worth while to spend time on conservative treatment for temporary teeth which are seriously decayed. "The total number of fillings inserted in all teeth was 5,202. The total number of permanent teeth extracted was 1,669, an increase of 294 over the preceding year. There was a large increase in the number of temporary teeth extracted, and, as already mentioned, this is the main cause of the decrease in the number of fillings. Altogether 10,877 temporary teeth were removed, as against 9,678 in the previous year, an increase of 1,199. "Orthodontic treatment by means of appliances was included in the dental scheme from the beginning of December, 1937. It was decided that the three most advanced cases of irregularity in each school department should be treated. The cases were sought for at the yearly inspection at each school. The parents were advised to have this treatment if they were at the school inspection, and if not, they were given an appointment to see the dentist at the Centre. The number of appliances fitted was ten. In the future it is expected that there will be further requests from the parents to have this form of treatment. It is gratifying to see the improvement in the mouths and facial appearance of the children who have undergone treatment. "There were three special examinations during the year of children leaving School. It was found that out of 1,350 children who were submitted for inspection 1,086 had sound teeth. This examination provided an excellent opportunity for dealing with children who had previously objected to treatment. An appointment was given as soon as possible after inspection, and the parents were advised that employment would often not be obtained unless the teeth were in a sound condition. It is satisfactory to note that a large number of past objectors availed themselves of the opportunity for treatment which was offered." 85 (/) Orthopaedic Treatment.—The work of the Orthopaedic Clinic during the year may be summarized as follows: Orthopaedic Clinic. School children. Children under five. Total Attendances by Surgeon 12 11 23 Nuniber of children seen for first time 124 152 276 Total number of children examined . 556 484 1,040 Attendances by Masseuse 89 137 226 Number of cases treated 185 93 278 Number of attendances by children 1,555 753 2,308 Children admitted to hospital for operative treatment 27 6 33 Children supplied with special boots or surgical appliances 10 3 13 (g) Defective Speech.—Two classes are held twice in each week one at the Mattock Lane and the other at the Ravenor Park Centre. Twelve children attend the class at a time. Each class lasts an hour. The results of treatment are shown in the following table :— Result of treatment. Stammering Defect. Other speech defect. Cured 1 2 Much improved 6 4 Improved 7 9 Not improved 1 2 86 All cases which are not indicated as cured will continue to attend the class until ultimately cured or until material benefit is obtained. (h) Convalescent Treatment.—The arrangements for convalescent treatment described in the report for 1935 were continued, and during the year 31 children were sent to the Russell Cotes School of Recovery, Parkstone, and 10 children to Collington Manor, Bexhill. The usual period of residence is six weeks with extension to twelve weeks when this is deemed advisable. In addition, the King Edward Memorial Convalescent Home Fund provided eight children with a holiday of two weeks' duration in the summer months at Collington Manor. In the Annual Report for 1936 attention was drawn to the good results obtained in most cases in which convalescent treatment was provided and to the fact that the number of places provided for school children was insufficient. After that report was submitted steps were taken to secure two more places for boys and two for girls and although they were not available before the end of the year they have since then been utilised. (i) Diphtheria Immunization.—The arrangements for the immunization of children against diphtheria were detailed in the report for 1935. During the year the school children Schick tested totalled 312, of which number 46 were found to be Schick negative and therefore not to require treatment. Children under five years of age referred for immunization from the Child Welfare department numbered 397. These children received the two injections without the preliminary Schick test. Schick tests were applied subsequently to immunization in 515 cases to determine its effectiveness when 14 were still found to be susceptible and were therefore re-immunized. INFECTIOUS DISEASE. The returns forwarded each week by the head teachers giving particulars of all new cases of non-notifiable infectious disease coming to their knowledge included 427 cases of measles, 697 of whooping cough, 764 of chickenpox and 925 of mumps. 87 A certificate in respect of one school was given during the year under Para. 15 (ii) of the Administrative Memorandum No. 51 issued by the Board of Education. This had reference to Horsenden Infants' School in which the percentage of school attendance was reduced below 60 per cent, for two weeks on account of the prevalence of measles. Children to the number of 382 were excluded under Article 20 (b) of the Education Code for the following conditions: Impetigo 259 Ringworm of body 9 Scabies 97 Other skin diseases 10 Conjunctivitis 7 382 No closure took place under Articles 22 or 23 (b) of the Code— Grant Regulations. OPEN AIR EDUCATION. In previous reports reference was made to the various ways in which open air education for school children is encouraged. No material changes have taken place in the general scheme but there has been a gradual development of the steps already taken. CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND VOLUNTARY BODIES. In the report for last year, as in those for previous years, reference was made to the co-operation of parents, teachers, school attendance officers and certain voluntary bodies in regard to the school medical service. The deep interest of the teachers and their great help in promoting the treatment of defective conditions and in stimulating the parents to take a sincere interest in the health and progress of their children cannot be too highly valued. The help of all is essential but it is that of the teachers especially that makes the whole scheme of medical inspection and treatment of school children so successful. 88 Acknowledgment of assistance must be made to certain voluntary bodies who have continued to co-operate in various ways such as the Central Aid Society, National Society for the Prevention of Cruelty to Children and the School Attendance Aid Committee. PHYSICAL TRAINING. In a previous report a description was given of the provisions which had been made for physical exercises and organised games in the public elementary schools. As a result of the consideration by the Committee of Circular 1445 on Physical Education, which was issued by the Board of Education in 1936, it was decided to co-operate with the Middlesex Education Committee in appointing as organisers of physical training a man and a woman with special training who would devote part of their time to the school children in Ealing. These organisers were duly appointed to take up their duties on the 1st January, 1938. After a year's experience in organising physical education on approved lines they should be able to present an interesting report which could appropriately be recorded in the next annual report on the School Medical Service. MILK IN SCHOOLS. The following table shows the number of children having a daily supply of milk in school in 1937 and in the two previous years. Milk is supplied in bottles containing one-third pint under the Scheme of the Milk Marketing Board at a cost of one half-penny. Date of Enquiry Number on Registers Number having milk Percentage having milk 1/10/1935 14,572 8,175 56.1 1/10/1936 15,477 8,516 55.0 1/10/1937 17,709 10,987 62.0 89 There was an increase in the percentage of children having milk as ascertained on the 1st October last year compared with the two previous years. This increase was due to the issue previously of leaflets to the parents extolling the virtues of milk as a food. The total number of children having milk in school on the 1st October, 1937, has been sub-divided in the following table to show the number of children and the percentage in the various departments. The table indicates that over three-quarters of the children in the schools for infants were receiving milk. Number and Percentage of Children having Milk on the 1st October, 1937. No. of school departments in group. No. of children on registers. 1 No. having milk. Percentage having milk 1/10/37 .1/10/36 Senior Mixed 1 460 116 25.2 Senior Boys 7 2,132 957 43.8 37.3 Senior Girls 6 2,147 988 46.0 45.2 Mixed 1 356 235 66.0 49.7 Junior Mixed 12 4,758 2,823 59.4 52.7 Junior Mixed and Infants 10 3,637 2,576 70.8 64.8 Infants 12 4,219 3,292 78.0 67.1 49 17,709 10,987 62.0 55.0 The number of children supplied with milk free of charge under Sections 82—85 of the Education Act, 1921, were as follows:— Number of children for whom a supply of milk was approved 1st January, 1937 1,057 Number of children for whom a supply of milk was approved, 31st December, 1937 1,377 Daily average number of children who received a supply milk 1,004 Total number of bottles of milk supplied 191,813 Cost of milk supplied £395 90 BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. Table III gives the number of exceptional children in the area under each heading. It shows the number of these exceptional children in each category who are being maintained at certified schools, those who attend public elementary schools and those who are not attending any school as at the 31st December last year. It will be noted that 31 children were being maintained at certified schools by the Education Committee. As regards mentally defective children the policy has been to notify as ineducable children who on attaining seven years of age have an Intelligence Quotient under 50 per cent. or who after attaining that age and having had a trial in school for one or two years have an Intelligence Quotient between 50 and 60 per cent.; and to keep in parallel or backward classes those with an I.Q. between 60 and 75 per cent. unless they prove "difficult'' or in other words show anti-social tendencies, either at home or at school, when steps are taken to have them admitted to Special Residential Schools for the feeble-minded. There has therefore been no pressing need for the provision of a Special Day School for feeble-minded children. Proposal in Regard to an Open Air School. As to physically defective children an account has been given elsewhere in this report of the treatment of orthopaedic cases who, when surgical treatment is called for, are admitted to the Orthopaedic Hospital where they receive special education, and of the provision made for convalescent treatment of certain children recovering from acute or chronic illness for whom a stay for a short period of six weeks or more is required. But there is a much larger group of children for whom no suitable provision has yet been made but for whom special education of longer duration is required. The children alluded to can best be dealt with in an open air school, the objectives of such a school apart from that of educating the children being:— (1) To improve the physique and nutrition of physically defective or sub-normal children by means of the beneficial action of sunshine, fresh air and well chosen food. 91 (2) To lessen the feeling of restraint which crippled or debilitated children must, perhaps subconsciously, experience and which restricts their outlook upon life. The following are the types of children who might benefit from a stay in an open air school:— (1) Physically Defective Children.—These are children with orthopaedic defects which render them incapable of competing with their more healthy school mates. Most of the children will have received treatment at the orthopaedic hospital for crippling conditions resulting from infantile paralysis, from tuberculous disease of the bones or joints or from congenital defects. (2) Debilitated Children. These are children who are classed as "delicate'' —the "Nutrition C and D" children. The debility may be due to poor home circumstances, insufficient food or inadequate care or to constitutional weakness. A large number of these children will have been under observation for a long time on account of their debility. Some will always be weaklings and more prone than the normal child to fail under the stress of everyday life. With a lengthy period of attendance at an open air school they will become better able to profit from their education and will ultimately attend the ordinary school. There are also children who, at some period of their lives, become delicate, for example, children who have had acute illnesses and operations. Most of these children are sent to Convalescent Homes but some of them would benefit by a short stay at an open air school after their return from the convalescent treatment. Many of the children who undergo tonsillectomy also suffer from chronic nasal catarrh, frequent coughs, bronchitis and enlarged glands of the neck and some of them would benefit from a stay in an open air school for some weeks after the operation. In the same category are the children with middle ear disease, for this complaint is frequently the result of an unhealthy naso-pharynx with possibly adenoids and nasal catarrh. Nervous children, in particular children with a tendency to attacks of chorea, often benefit from the kind of life associated with an open air school. 92 (3) Children with Heart Disease.—A few children are born with serious heart disease and will always need care. There are also many children who have suffered from rheumatism and who have sustained permanent damage to the heart. These children require continuous care in order to maintain their general health and to avoid overstrain. For some of these children an open air school is very advantageous. Estimate of Children for Whom Provision Should be Made. (1) Physically Defective Children.—At the end of the year there were five such children at special residential schools. It is considered that two of these could be taught in an open air school. There were also 24 children with physical defects attending ordinary schools who would benefit from a stay at an open air school. (2) Delicate Children.—There were 87 delicate children under supervision who would benefit by a prolonged stay at an open air school. During the last year there were 49 children who were debilitated to such a degree that they required treatment at a Convalescent Home. Most of these children improved very much because of their stay there, but it was often noticed that much of the good that accrued was undone when they returned to uncongenial homes. Some of these 49 children would have benefitted by a stay of longer duration in an open air school on their return after convalescent treatment. There were 176 tonsil operations performed on children attending Ealing Schools during 1937 and as previously mentioned some of these and some of the children with middle ear disease would have gained in health by a stay in an open air school. During the last year 47 new cases of rheumatism of all degrees of severity were discovered among the elementary school population. Most of these children after recovery were most suitably dealt with in the ordinary school, but some would have had a better chance of complete recovery if they had had a period of supervision in a special school. 93 (c) Children with Heart Disease.—There were at the end of the year 12 children suffering from a severely damaged heart attending elementary schools in Ealing. These children it is recommended should attend an open air school. It may therefore be summarized that the following children would definitely benefit by an open air education:— Physically Defective 26 Delicate Children 87 Cliildren with Heart Disease 12 Other Cliildren 10 135 It is difficult to estimate accurately the number of other children who might find a place at the school but ten is taken as a reasonable figure. The length of stay of each child varies and although the average is six months, a few children may spend most of their school life at an open air school, while others may require accommodation for only two or three months so that the children will be constantly moving with a varying number in regular attendance. To meet all the requirements enumerated it may be estimated that the school should be designed to cater for about 140 children, provision being made for extension of the classrooms should this be called for as the number of children attending public elementary schools in Ealing increases. Suggested Site for School.—It may be taken that a central site for an open air school is not available, but as most of the children would have to be conveyed daily to and from school a central site is not absolutely essential, particularly as the homes of the children are widely separated and the distance to be covered by the conveyance is comparatively long. The site recently acquired at Northolt for school purposes would be as readily accessible as any other. Cost of Transport.—It is impracticable without exact figures as to the number of children to be dealt with and the distance to be travelled to state the cost of transport but it may be said that the yearly cost of conveying children in Willesden to a Special School 94 of this character which accommodates 175 children is £400. It would be advisable to take this figure as an estimate of the cost of transport. Cost of School.—The cost of an open air school is difficult to estimate at the present time without going into detail in regard to its construction but it seems desirable in discussing the question in a preliminary fashion to have in mind a cost of something between £9,000 and £10,000. Cost of Maintenance.—The cost of maintaining a Special Open Air Day School would be about £25 for each child for a year, so that if provision is made for 140 children the cost of maintenance would be £3,500 or a total cost including conveyance of the children of £3,900 per annum. NURSERY SCHOOLS. Nursery classes for children under five years of age are conducted at St. John's, St. Mark's and Stanhope Infant Schools, the last being opened during the year in premises which were specially built for the purpose. Children attending the nursery classes are examined twice yearly in order to ensure that defective conditions receive early treatment. SECONDARY SCHOOLS. Medical inspection was carried out as in former years on behalf of the Middlesex Education Committee in four County Schools in the Borough, 552 routine and 48 special inspections of pupils being made. Ophthalmic treatment was given during the year to 83 pupils attending County Schools and for 82 of these spectacles were prescribed and supplied through the school medical department. Dental inspection of all the pupils attending the County Schools was carried out on behalf of the Middlesex Education Committee and the following is the report of the School Dental Surgeon : 95 "This is the third successive year in which the pupils attending these schools have received dental treatment at the Ealing Health Centres. It was first commenced in 1935, and since that time there has been an increase in the number accepting treatment. By the end of the year under review 392 children had been treated. All the pupils accepting treatment cannot be treated within the year, for only two sessions a week for about 14 weeks, can be spared in which to carry out the work. There are still a number who attend privately for treatment, and these are mostly children from districts away from Ealing. "The work carried out was mostly conservative in character, although there was a large number of extractions of permanent teeth. A number of pupils with bad mouths enter these schools from other districts in the County and extraction is the only treatment that can be given under the circumstances. The number of permanent fillings inserted was 544, and the number of permanent teeth extracted was 182. Other treatments were given to 124 children; these include scaling, treatment of gums, dressings to carious permanent teeth, root canal dressings, and root canal fillings for incisor teeth. Altogether 593 attendances were made at the Ealing and Hanwell Centres, for the treatment given to these pupils." HEALTH EDUCATION. There have been no new developments in the steps taken to spread the knowledge of health matters amongst school children which have been described in previous reports. It is sufficient to say that the steps previously adopted have been continued. 96 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. Children.—The number of children examined in connection with their employment out of school hours was 346 and of this number 16 were found to be unfit for employment The nature of the employment of those certified as fit was: Boys. Errand boys 141 Milk round 42 Newspaper round 45 Baker's round 39 Order boy 11 Others 47 325 Girls. Dancing Instructress 1 Preliminary Horticultural Training 1 Domestic help 3 5 330 These children are submitted to re-examination when routine medical inspection is being carried out 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 to be necessary in 17 instances. At routine inspection four children under the permitted age were found to be working out of school hours, and 80 children were found who had not obtained the necessary permission. Thirty-three 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. Young Persons.—There is intimate co-operation between the Juvenile Employment Department and the School Medical Service in regard to the supervision of juveniles after leaving school. Such information as is available in the records is passed over to the Juvenile Employment Officer and advice on particular boys and girls sought by that officer is most readily given. 97 There can be no doubt that this co-operation proves of the greatest value to the young people concerned not only in relation to their employment but to their general health. MISCELLANEOUS. It is usual to group under this heading the medical examinations which are made of candidates prior to their appointment on the teaching staff of the Education Committee and of other candidates on appointment to various branches of the Council's technical and clerical staff and of manual workers. All these examinations are carried out by the school medical staff assisted by the school nurses. During the year 66 teachers and 364 other candidates were examined. School Medical Officer and Medical Officer of Health. 23rd June, 1938. 98 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 2,729 Second Age Group 2,235 Third Age Group 1,451 Total 6,415 Number of other Routine Inspections — B.—Other Inspections. Number of Special Inspections 5,112 Number of Re-Inspections 5,454 Total 10,566 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 28 223 247 Second Age Group 195 143 316 Third Age Group 140 60 191 Total (Prescribed Groups) 363 426 754 Other Routine Inspections — — — Grand Total 363 426 754 99 TABLE II.—A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTION IN THE YEAR ENDED 31st DECEMBER, 1937. DEFECT OR DISEASE Routine Inspections Special Inspections No. of Defects. 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 — — — — Body — — 17 — Scabies 16 — 81 — Impetigo 5 — 262 — Other Diseases (Non-Tuberculous) 2 — 318 3 Eye Blepharitis 7 1 69 — Conjunctivitis 7 — 75 — Keratitis — — — — Corneal Opacities — — 4 Other Conditions 7 3 71 3 Defective Vision (excluding Squint) 363 1 209 1 Squint 82 — 59 1 Ear Defective Hearing 4 2 16 2 Otitis Media 35 6 143 — Other Ear Diseases 40 15 106 5 Nose and Throat Chronic Tonsillitis only 77 371 138 128 Adenoids only 3 4 4 4 Chronic Tonsillitis and Adenoids 36 8 47 5 Other Conditions 11 108 134 21 Enlarge Defective Cervical Glands (Non-Tuberculous) — 61 26 35 e Speech 3 25 13 6 Heart and Circulation Heart Disease : Organic 2 25 4 8 Functional — 38 3 3 Anaemia — 40 2 21 Lungs Bronchitis 7 46 31 13 Other Non-Tuberculous Diseases Pulmonary : 4 22 15 8 Tuber- culosis Definite — 1 — Suspected — 4 — 22 Non-Pulmonary : Glands — 1 — 3 Bones and Joints — — — — Skin 1 — — — Other Forms 1 2 2 — Nervous System Epilepsy — 4 3 1 Chorea 1 4 6 2 Other Conditions 5 5 6 20 Deformities Rickets — 4 — — Spinal Curvature 12 20 4 7 Other Forms 59 267 66 30 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 20 58 1686 153 TOTAL 810 1145 3621 505 100 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 2,729 86 3.2 2,578 94.5 64 2.3 1 — Second Agegroup 2,235 102 4.5 2,073 92.8 60 2.7 — — Third Agegroup 1,451 118 8.1 1,297 89.4 36 2.5 — — Other Routine Inspections — — — — — — — — — Total 6,415 306 4.8 5,948 92.7 160 2.5 1 — 101 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. — 2 6 — — 8 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 16 — — 16 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. — — 27 — — 27 102 MENTALLY DEFECTIVE CHILDREN. Feeble-minded Children. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. 9 At other Institutions. At no School or Institution. Total. 4 72 — 4 80 EPILEPTIC CHILDREN. Children suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 3 — — — 3 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 — — 3 — 3 II.—Children suffering from Non-Pulmonary Tuberculosis. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — — — — — 103 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 87 — — 87 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 5 19 — — 24 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. — 10 2 12 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. Epileptic and Feeble-minded — — — 1 1 104 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 — — Ringworm—Body 17 — 17 Scabies 97 — 97 Impetigo 255 12 267 Other Skin Disease 300 20 320 Minor Eye Defects (External and other, but excluding cases falling in Group II) 195 41 236 Minor Ear Defects 314 10 324 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc.) 1,234 80 1,314 Total 2,412 163 2,575 105 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) 1209 69 1278 Other Defect or Disease of the Eyes 10 — 10 Total 1219 69 12 88 Number of Children for whom Spectacles were :— 1 (a) Prescribed 797 69 866 (6) Obtained 786 69 855 Group 3.—Treatment of Defects of Nose and Throat. Number of Defects Received Operative Treatment Under the Authority's Scheme in Clinic or Hospital By Private Practitioner or Hospital, apart from the Authority's Scheme Total Received other forms of Treatment Total number Treated 176 10 186 — 186 106 Group 4.—Orthopaedic and Postural Defects. Under the Authority's Scheme— Number of children treated Residential treatment with education 27 Residential treatment without education — Non-residential treatment at an orthopaedic clinic 185 Otherwise— Residential treatment with education — Residential treatment without education 2 Non-residential treatment at an orthopaedic clinic — Total number of children treated 201 Group 5.—Dental Defects. Number of Children who were :— (a) Inspected by the Dentist : Aged Routine Age Groups 5 1,577 Total 16,138 6 1,965 7 1,983 8 1,687 9 1,752 10 1,766 11 1,531 12 1,431 13 1,328 14 1,007 15 104 16 — Specials 350 Grand Total 16,488 (b) Found to require treatment 10,150 (c) Actually treated 6,433 Attendances made by children for treatment 9,016 Half-days devoted to :— Inspection 113 Total 1,329 Treatment 1216 Fillings :— Permanent Teeth 4,808 Total 5,202 Temporary Teeth 394 Extractions :— Permanent Teeth 1,669 Total 12,546 Temporary Teeth 10,877 Administrations of General Anaesthetics for Extractions 2,438 Other operations :— Permanent Teeth 1097 Temporary Teeth — Total 1097 107 Group 6.—Uncleanliness and Verminous Conditions. (1) Average number of visits per School made during the year by the School Nurses 3 (2) Total number of examinations of children in the Schools by School Nurses ... 39,955 (3) Number of individual children found unclean ... 882 (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 21 MENTAL DEFICIENCY (NOTIFICATION OF CHILDREN) REGULATIONS, 1928. CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1937, TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total Number of Children Notified ... 7 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 (6) Imbeciles 4 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 — 1 4. Children who in addition to being mentally defective were blindordeaf ... — — Grand Total 5 2 Chiswick and Ealing Hospitals Committee. CLAYPONDS ISOLATION HOSPITAL. PERIVALE MATERNITY HOSPITAL. ANNUAL REPORT OF THE MEDICAL SUPERINTENDENT FOR THE YEAR ENDING 31st MARCH, 1938. THOMAS ORR, M.D., D.Sc., Medical Superintendent. Terry & Routleff Ltd., Ealing and Uxbridge. 2 CHISWICK AND EALING HOSPITALS COMMITTEE. Alderman G. Jenkin (Chairman). Alderman Col. R. R. Kimmitt, O.B.E., T.D., D.L. (Vice-Chairman). Alderman A. W. Bradford, J.P. Alderman Emily S. Taylor, J.P. Councillor Alice J. Burden. Councillor T. E. Fowler. Councillor Emily Iv. Hill. Councillor W. Morgans. STAFF. Medical Superintendent— Thomas Orr, M.D., D.Sc., Of the Middle Temple, Barrister-at-Law. Medical Attendant, Isolation Hospital— Llywelyn Roberts, M.D., 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.vSc., 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 Obstetricians— John W. Rait Bell, L.R.C.P.I. & L.M., L.R.C.S.I. & Iy.M. Arnold Walker, M.A., M.B., B.Ch., F.R.C.S., M.C.O.G. Considting Ophthalmic Surgeon— Graeme G. Talbot, M.B., Ch.B., F.R.C.S. 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 have the honour to submit the Annual Report on the administration of the Hospitals from the 1st April, 1937, to the 31st March, 1938. ISOLATION HOSPITAL. The total number of cases admitted to the Hospital was 649, 81 more than in the previous year. The highest number under treatment on any day was 101 on the 7th January, 1938, and the lowest number 22 on the 19th August, 1937. The average daily number in Hospital was 69. The following table indicates the number of cases of various diseases treated during the year :— Disease Remaining in Hospital 31st March, 1937 Admitted during year Discharged during year Died during year Remaining in Hospital 31st March, 1938 Scarlet Fever 73 392 426 1 38 Diphtheria 10 203 174 8 31 Measles — 27 16 2 9 Whooping Cough 1 1 2 — Chicken Pox — 4 3 — 1 Puerperal Fever — 5 5 — — Parametritis — 1 1 — — Ophthalmia Neonatorum 4 4 — — Nursing Mother — 1 1 — — Enteric Fever — 5 5 — — Mumps — 1 1 — — Erysipelas — 2 2 — — Chicken pox and pneumonia — 1 1 — — Pneumonia — 1 — 1 — Cervical abscess — 1 1 — — 84 649 642 12 79 4 Scarlet Fever.—Of the 392 cases admitted as scarlet fever 140 were from Brentford and Chiswick and 252 were from Ealing. Of this total 16 were found not to be suffering from the disease and were ultimately diagnosed as follows :— Tonsillitis 6, chicken pox 1, diphtheria 1, gastritis 1, urticaria 1, teething rash 1, common cold 1, bronchitis 1, measles 1, rubella 1, no apparent disease 1. Four cases of scarlet fever were found on admission to be suffering also from a second disease, as follows :—chicken pox 2, measles 1, mumps 1. The incidence of the actual cases of scarlet fever in the various age-groups was as follows :— 1-5 yrs. 5-15 yrs. 15-25 yrs. 25-35 yrs. 35-45 yrs. over 45 yrs. 69 260 23 13 9 2 The complications observed among the cases were as follows Otitis Media and Otorrhoea 36 Mastoiditis 3 Cervical adenitis 44 Rhinitis and rhinorrhoea 55 Post nasal discharge 3 Arthritis and rheumatism 5 Nephritis and albuminuria 11 Bronchitis 3 Tonsillitis 4 Quinsy 2 Pluerisy 3 Pericarditis2 Septic fingers 3 Second attack of Scarlet Fever 11 Empyema 1 Frontal sinusitis 1 Cardiac irregularity 3 Vaginal discharge 2 Septic sores 2 Return cases.—Of the 426 cases discharged during the year eight gave rise to " return " cases of scarlet fever. This gives a low return case rate of 1.87 per cent. 5 Duration of Stay.—The average duration of stay in hospital of all cases of scarlet fever was 34.7 days. Deaths.—One death from scarlet fever occurred during the year. This was a severe case which developed empyema for which operative treatment was called. This death gives a scarlet fever mortality of 0.26 per cent. Diphtheria.—The number of cases admitted as diphtheria was 203, 34 from Brentford and Chiswick, 160 from Ealing, and 9 from Southall. This was 112 more than for the previous year. Of the total number 26 were ultimately diagnosed as follows :— Tonsillitis 13, scarlet fever 2, tonsillitis and nasal carrier of diphtheria 1, meningitis 1, pulmonary tuberculosis 1, retro-pharyngeal abscess 1, Vincent's angina 2, pharyngitis 1, capillary bronchitis 1, peri-tonsillar abscess 2, and no apparent disease 1. Two cases were found to have another disease in addition to diphtheria one having scarlet fever and the other mumps. 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. 36 86 30 13 12 — The following complications were observed :— Secondary Tonsillitis 6 Cardiac irregularity 13 Myocardial degeneration 2 Otitis media and otorrlioea 3 Mastoiditis 1 Early cardiac failure 1 Rhinitis 1 Cervical adenitis 2 Tachycardia 1 Palatal paresis 14 Ocular paresis 2 Pharyngeal paresis 2 Catarrhal jaundice 1 6 Laryngeal Diphtheria.—Four cases were admitted as laryngeal diphtheria. Two were found to be actually suffering from this condition and they recovered without operation. The other two cases were diagnosed as measles and septic meningitis respectively. Deaths.—There were eight deaths among cases sent in as diphtheria but only four were of patients who actually suffered from diphtheria. These four fatal cases of diphtheria were well advanced in the disease on admission. Two of them occurred within three days of admission. The third survived until the fourth day to die of cardiac failure and the fourth, although a severe case, survived for 47 days and then suddenly collapsed and died within 48 hours. The four cases not found to be suffering from diphtheria were ultimately diagnosed respectively as :— Capillary bronchitis, streptococcal tonsillitis with erysipelas of face and broncho-pneumonia, pulmonary tuberculosis and septic meningitis. Return Cases.—There was one return case. A child was discharged with no evidence of the diphtheria bacillus in his throat, but in three weeks' time a sister was admitted with diphtheria. Duration of Stay.—The average duration of stay in Hospital for cases of diphtheria was 48.8 days. Other Diseases.—Cases of measles to the number of 24, mostly complicated, were admitted for treatment. Two of these cases died, one from pneumonia and the other from acute appendicitis and peritonitis. One case was admitted with pneumonia with a purpuric rash and died, there being no evidence of measles. Cubicle Block.—The cubicle block which was opened in the previous year proved of great value from the administrative point of view. The value is indicated by the different kinds of cases dealt with in them during the year. These were as follows :— Ophthalmia 3, puerperal sepsis 7, scarlet fever with diphtheria 11, scarlet fever (suspected) 6, scarlet fever with measles 6, scarlet fever with chickenpox 5, scarlet fever 7 with mumps 3, scarlet fever with dysentery 1, scarlet fever with mastoiditis 1, diphtheria (suspected) 16, diphtheria carriers (5 for operation) 11, diphtheria with mumps 1, diphtheria with measles 1, whooping cough 1, whooping cough with measles 1, measles 10, enteric fever 3, (2 paratyphoid B, 1 typhoid), enteric fever (suspected) 2, erysipelas 2, chickenpox 4, peritonsillar abscess 1, mumps 2, others 4. Dysentery.—One patient, a girl aged 8 years, admitted as a scarlet fever, developed symptoms of dysentery 14 days after admission with vomiting and blood stained stools accompanied by slight abdominal pain. The bacillus dvsenteriae (Sonne) was isolated in this case. She ultimately recovered. Twelve other cases in the same ward had loose stools at about the same time. There was, however, no vomiting and no blood or mucus in the stools. Examination of the stools was negative so far as the specific organism was concerned. Steps were, of course, taken to isolate the actual case of dysentery and those suspected and fortunately no further cases occurred. Illness of Staff.—The following cases of illness of the staff occurred during the year :— Probationers Arthritis 1, tonsillitis 1. Private Nurses Tonsillitis 2. Kitchen Maids Tonsillitis 1. Lodge-keeper Influenza. Dr. Miller, the Consulting Oto-Laryngologist, made 17 visits during the year and performed seven mastoid operations and 13 operations for the removal of tonsils and adenoids. Seven of the latter operations were on patients from Southall Isolation Hospital and were carried out at the special request of the Medical Superintendent of that hospital from which they were admitted for this purpose. Mr. Gordon Bryan, the Consulting Surgeon, made four visits to the hospital during the year. 8 MATERNITY HOSPITAL. The new Maternity Hospital was opened for the admission of cases on the 1st November, 1937, and it is therefore desirable that the report should be divided into two sections, the first dealing with the period April 1st to October 31st, 1937, concerned with the admissions to the Old Maternity Hospital and the second dealing with the period from the 1st November, 1937, to the 31st March, 1938, dealing with the admissions to the new Maternity Hospital. OLD MATERNITY HOSPITAL. April 1st to October 31st, 1937. Mothers.—The 297 cases admitted to the Hospital from the 1st April to the 31st October, 1937, from the two districts were as follows :— Month Ealing Brentford and Chiswick Total April 31 9 40 May 36 8 44 June 29 16 45 July 33 8 41 August 37 3 40 September 28 12 40 October 41 6 47 235 62 297 On the 14th, 15th and 16th May, there were as many as 33 patients in Hospital. The average period which each patient spent in hospital was 16.46 days. Emergency Cases.—One emergency case was admitted.. This patient had a normal delivery. Ante-Natal Cases.—Twenty-six ante-natal cases were admitted for treatment. The conditions from which they were suffering were as follows :— 9 Toxaemia ... ... ... ... ... ... 13 Urinary infection (one with mitral stenosis) 3 Hypertension and toxaemia 1 Placenta praevia 2 Suspected disproportion 2 Tired (needing rest from home cares) 3 Pressure oedema 1 Premature rupture of membranes 1 Of these cases, seven recovered sufficiently to be discharged to await at home the onset of labour, one was transferred to the West Middlesex Hospital for immediate induction of labour, and one was transferred to King Edward Memorial Hospital on account of severe pyelitis. Surgical induction was done in the following eight cases :— Toxaemia (one with hypertension) 5 Severe concealed accidental haemorrhage 1 Suspected disproportion 1 Hydramnios 1 Abnormalities and complications during Labour :— Perineal tears 61 Forceps delivery, (following manual rotation of persistent occipito-posterior 2, for primary uterine inertia 1, for foetal distress 1, for prolapse of cord 1, mild disproportion 2). In the last two cases forceps were applied by Dr. Bell following trial labour for suspected disproportion7 Breech with extended legs (assisted delivery) 2 Breech with extended legs (unassisted delivery) 2 Complete breech (assisted delivery) 2 Complete breech (unassisted delivery) 4 Twin pregnancies, (two vertices 1, vertex and breech 3) 4 Placenta praevia (lateral) one treated by rupture of membranes and one by podalic version and bringing down a leg 2 10 Placenta praevia (marginal) unassisted delivery 1 Post-partum haemorrhage 1 Complications in the puerperium not associated with pyrexia : Foot drop due to pressure on lumbo-sacral nerve due to forceps delivery 1 Thrombosed varicose veins 4 Laryngitis and bronchitis 2 Tenosynovitis of extensor tendons of wrist 1 Puerperal Pyrexia.—Nine cases of puerperal pyrexia occurred. These cases were suffering from :— Mild uterine sepsis (two following forceps delivery) 5 Infected perineum (following forceps delivery) 1 Urinary infection 1 Coryza 1 Pulmonary embolism complicating lateral placenta praevia 1 Fourteen cases of mild (non-notifiable) pyrexia in the puerperium were due to :— Retained products 7 Mild parametritis 1 Mild urinary infection 2 Acute mastitis 2 vSeptic abrasion of post vaginal wall 1 Anaemia and debility following toxaemia of pregnancy 1 Children. Number of Infants born :— Males 161 Females 138 Total 299 11 Number of cases of twins (8 babies) 4 Number of cases of premature infants (born alive): 34-36 weeks development 4 36-38 weeks development 3 Stillbirths : Total 9. Macerated (full term) 1 Fresh (full term). Concealed accidental haemorrhage 1 Toxaemia of pregnancy 1 Forceps delivery 1 Premature. Lateral placenta praevia 1 Locked twins (28 weeks maturity) 2 Hypertension and toxaemia 1 Podalic version for lateral placenta praevia 1 Infant Deaths.—Total 4. Intra peritoneal haemorrhage from bi-lateral haemorrhagic cysts of suprarenal glands (confirmed by autopsy) 1 Icterus gravis (autopsy refused) 1 Intracranial haemorrhage (1 confirmed by autopsy) 2 Abnormalities in Surviving Infants: Haemorrhage of new-born 4 Harelip and cleft palate 2 Cephal-haematoma 1 Ophthalmia neonatorum 1 Convulsions 1 Septic fingers 1 Infants Weaned: Total 2. Weaned due to debility and anaemia of mother 1 Weaned due to transference of mother to Queen Charlotte's Isolation Block on account of pyrexia 12 Patients transferred to other Hospitals: To Chiswick and Ealing Isolation Hospital. With uterine sepsis 2 Retained products 2 Mild parametritis 1 To Queen Charlotte's Isolation Block. Mild uterine sepsis 1 To West Middlesex County Hospital. For immediate induction of labour 1 To King Edward Memorial Hospital Patient with severe Pyelitis 1 Maternal Death.—There was one death. This was a case of lateral placenta praevia with a large post-mature child. The patient had a pulmonary embolism before the unassisted delivery of a stillborn child. She died twenty-four hours later. Consulting Obstetrician.—Dr. J. W. Rait Bell, the Consulting Obstetrician, was called to the Hospital on eight occasions during the period under review. Training of Pupils.—Up to the 31st October, 1937, 14 Pupils completed their course of training and entered for the examination of the Central Midwives Board. All of these pupils were successful. PERIVALE MATERNITY HOSPITAL. Mothers.—The 300 cases admitted to the Hospital during the period 1st November, 1937, to 31st March, 1938, from the two districts were as follows:— Month Ealing Brentford and Chiswick Total November 43 10 53 December 41 9 50 J anuary 59 11 70 February 51 8 59 March 58 10 68 252 48 300 13 The greatest number of patients in the hospital on any one day was 46. This was on the 29th January, 1938. The average period of stay in the hospital-was 15.403 days. Emergency Cases.—Total 3. 1. The patient was admitted because of intra-uterine death of the foetus and had a normal delivery, after medical induction, of a macerated foetus of 34 weeks development with a puerperium that was uneventful. 2. A primipara was admitted because the infant was a breech with extended legs. The patient required assistance to bring down the legs and both mother and baby did well. 3. A patient was admitted in advanced labour, having made no arrangements for her confinement. The patient had a normal delivery and both mother and child did well. Two patients were delivered at their own homes and were admitted to hospital for the puerperium. One patient was delivered of a premature still born child and the other patient was delivered of a macerated foetus after death in utero had been diagnosed. Ante-Natal Cases.—Thirty-eight ante-natal cases were admitted for treatment. The conditions from which they were suffering were as follows:— Toxaemia 18 Suspected disproportion 7 Mild accidental haemorrhage 2 Placenta praevia 1 Hypertension and toxaemia 1 Tired (needing rest from home cares) 3 Premature rupture of membranes 2 Thrombosed varicose veins 1 Pleurisy 1 Inguinal adenitis 1 Urinary infection 1 Of these cases, twelve recovered sufficiently to be discharged to await the onset of labour at home. 14 Surgical induction was clone in the following eight cases:— Toxaemia of pregnancy, including one case of persistent hypertension 4 Suspected disproportion 1 Post maturity 1 Anencephalic monster and hydramnios, confirmed by Xrays 1 Mental derangement in patient with congenital syphilis 1 Abnormalities and Complications during Labour: Perineal tears 71 Forceps delivery 9 (following manual rotation for persistent Occipito-posterior position 3, for delay in second stage 4, for foetal distress 2). Two of the three cases required only gas and air analgesia. Podalic version and perforation of after-coming head of dead post mature child by Dr. Bell 1 Extraction of breech after podalic version for prolapse of cord 1 Breech with extended legs (assisted delivery) 7 Breech with extended legs (unassisted delivery) 5 Twin pregnancies, (two vertices 1, one vertex and one breech 1) 2 Placenta praevia (lateral) 2 Of these one was a normal delivery and the other required extraction of breech after podalic version due to prolapse of cord by Dr. Bell. Accidental ante-partum haemorrhage 1 Severe concealed accidental haemorrhage ... 1 Mild Haemorrhage 1 Eclampsia during delivery 2 Complications in the puerperium not associated with pyrexia:— Mental derangement 1 15 Thrombosed varicose veins 4 Haematoma of vagina and perineum following toxaemia of pregnancy 1 Bronchitis 1 Abnormalities and Complications during the puerperium:— Ten cases of Puerperal pyrexia occurred in patients as follows:— Breast abscess (one of these patients also had a thrombosed femoral vein) 2 Acute mastitis 4 Pyelitis 1 Infected perineum following forceps delivery 1 Measles 2 Mild pyrexia not notifiable in the puerperium:— Retained products 16 Mild uterine and perineal infection following forceps delivery 1 Acute mastitis 2 Septic spot on breast 1 Coryza 2 Thrombosed varicose veins and slight pulmonary embolism 1 Secondary post partum haemorrhage 1 Children. Number of Infants born:— Males 156 Females 141 297 Number of cases of twins (4 babies) 2 Number of cases of premature infants (born alive):— 28-30 weeks development 2 30-32 weeks development 1 34-36 weeks development 2 36-38 weeks development 2 16 Stillbirths.—Macerated 7. of these five were diagnosed as death of the foetus in utero in the ante-natal clinics. One was admitted as an emergency case because of death of the foetus and one died while the mother was under treatment for toxaemia of pregnancy in the hospital. Fresh (Full term) 6. Bipolar version for placenta praevia followed by prolapse of cord 1 Post maturity requiring perforation of after coming head of stillborn infant 1 No definite cause (very stout patient) 1 Anencephaly 1 Maternal eclampsia (34 weeks) 1 Surgical induction for severe hypertension and toxaemia (32 weeks) 1 Neo-Natal Deaths. Total 7 Prematurity 3 Atelectasis and prematurity 1 Cerebral haemorrhage (one confirmed by autopsy) 2 Mongol with atresia of oesophagus (autopsy performed) 1 Mai formations in infants born alive:— Mongol, one of which died 2 Ectopia testis 1 Cephalhaematoma 2 Spina Bifida (one twin) 1 Pyloric stenosis 1 Illness of Infants :— Cerebral irritation 1 Melaena neonatorum 1 Measles 1 Injury to leg during breech delivery 1 Septic spots 3 (1 infant detained in hospital 28 days), 17 Infants Weaned. Total 9. Owing to condition of mother's breasts 5 Owing to general health of mother 4 Patients transferred to other Hospitals:— To Chiswick and Ealing Isolation Hospital. Mother and infant with measles 1 To Hendon Isolation Hospital. Mother with measles and infant who subsequently developed measles 1 To King Edward Memorial Hospital. Infant with pyloric stenosis transferred for operative treatment. Mother went with child. Maternal Death. There was one death. This patient was admitted as an urgent case with severe concealed ante-partum haemorrhage. Artificial rupture of membranes failed to start uterine contractions. Traction of the child's head also failed to incite contractions. The patient died undelivered within six hours of admission. The Consulting Obstetrician was present throughout. Consulting Obstetrician.—Dr. J. W. Rait Bell, the Consulting Obstetrician, was called to the Hospital on seventeen occasions during the period under review. Training of Pupils.—Up to the 31st March, 1938, 6 pupils completed their course of training and entered for the examination of the Central Midwives Board. Four of these pupils were successful. 18 PARTICULARS OF THE NEW HOSPITAL. For some years the Maternity Hospital at Clayponds Lane has been quite incapable of meeting the needs of the two Boroughs, and the entirely new Hospital which has been opened at Perivale has been the result of the determination of the two Councils to meet the ever increasing demand for accommodation for maternity cases. The old maternity hospital has been added to the Isolation Hospital to extend its accommodation. The new Hospital consists of a two-storey Ward Block of 40 beds with a separate Labour Block connected with the main Block by means of a corridor, an Isolation Block of three beds, an Administrative Block, a Laundry and Engineering Block, a Mortuary and a Lodge. Whilst the main entrance to the grounds of the Hospital is from Western Avenue, on the north, the main entrance and the front of the buildings face the opposite side and thus all the wards and most of the rooms in the Administrative Block have a south aspect. The design generally is in the modern functional style and the external walls are faced with "Keymer" hand-made sand-faced bricks. Ward Block. This is a two-storied building with each floor similar in plan Each floor is composed of two units each consisting of a 6-bedded ward at the end of the corridor with four single-bed wards arranged alongside it with a central nursery for babies serving two units. Observation windows in the doors in the corridor enable the nursing staff to keep the patients under continuous observation. All the wards are on the south side of the building and those on the ground floor have casement doors so that the beds can be wheeled out into the open on to a paved area if the weather permits. On the north side of the corridor are the various sluice rooms, bathrooms, duty rooms and sterilising rooms. A closed corridor runs from the centre of the north side to the Labour Block. 19 Labour Block. This has two labour wards, an operating theatre, an examination room (which is fitted so that it can be used as an emergency labour ward), a sterilising room, a linen room and a receiving room with bathroom on the north side of the corridor and a duty room and sluice room facing south on the other side. Some of the main features of these blocks are the following:— The floors of the wards in the Ward and Isolation Blocks are in natural waxed strip oak throughout, the floors of the corridors are cork-tiled and the sluice and sterilising rooms are finished in terrazzo. Throughout the Labour Block all floors and dados are finished in light green terrazzo. All doors are solid flush oak, veneered, with chromium plated easy-clean fittings. All windows are of heavy section metal, those in the six-bedded wards and in the single-bedded wards on the first floor being of the sliding-folding type. In the Ward and Labour Blocks a silent signal (light) system has been installed by means of which patients can call a nurse without the noise of bells. The lift between the two floors facilitates the movement of patients and stores. A modern Scialytic shadowless light is installed in the Operating Theatre and a "Keepalite" emergency lighting system, which automatically provides sufficient light should the main electricity current fail is fitted in the operating theatre and labour wards. The lighting fittings throughout the blocks are of a special modern type. There is an electric light over each bed and there are dimmed night lights in the large wards and in the corridors. Modern tubular metal furniture has been provided for the Labour Block and plain waxed oak furniture in the Ward Block. All bedsteads are of tubular steel finished in "Olasto" aluminium. Bassinet cots are provided for the babies and these can be readily wheeled to and from the nurseries and the wards. 20 Administrative Block. The Administrative Block consists of three floors, the second and third providing the bedroom accommodation for the staff, a lecture room, a sewing room, a staff ironing room and the linen stores. Each of the thirty-six bedrooms is equipped with a washhand basin and with a hot water radiator and the furnishing is such as to make the room comfortable for use as a bedroom and as a private sitting-room. Ample lavatory accommodation has been provided for nurses and maids and there is an ironing room in which nurses can wash and iron any special articles of apparel they wish to do themselves. Shampoo fittings are provided in the lavatories on each floor. On the ground floor are the suites of rooms for the Resident Medical Officer and the Matron, sitting rooms for sisters, nurses and maids, a large staff dining room which can also be used as a recreation room and a large and well equipped kitchen, with storerooms and refrigerator. On either side of the entrance is an office, one for the Medical Officer and the other for the Matron. A small telephone room is available for the use of the staff. The doors throughout are flush oak, veneered, the flooring of the rooms is of oak in strips, the corridors are laid with cork, the bathrooms with terrazzo and the kitchens with quarry tiles. All the decorations have been carried out in quiet and unobtrusive, yet pleasant, colouring with the furniture and woodwork in natural waxed oak. The central heating, the domestic hot water and the laundry are supplied by two of the latest "Economic" type boilers, complete with steam turbine pumps in duplicate, and calorifiers. A water softening plant has also been provided. The hospital has been so constructed that another twenty-four beds for patients and twenty bedrooms for staff can be added at a comparatively low cost, the present kitchen and engineering services being sufficient for the enlarged hospital. 21 In presenting this report I again take the opportunity of expressing my appreciation of the great and unfailing assistance given to me not only by the medical staff and the matrons of the two hospitals but by the Secretary, Mr. Birrell, and the Treasurer, Mr. Owen. I am, Ladies and Gentlemen, Your obedient Servant, THOMAS ORR, Medical Superintendent. PERI VALE MATERNITY HOSPITAL. WARD BLOCK PERIVALE MATERNITY HOSPITAL. AD A11X Ib'l'R ATI vii_ n 1,0 CK PERIVALE MATERNITY HOSPITAL GROUND FLOOR PLAN ADMINISTRATIVE BLOCK PERIVALE MATERNITY HOSPITAL. GROUND FLOOR PLAN WARD BLOCK