EAL 38 AC 439(1) EALING Borough of Ealing ANNUAL REPORT of the Medical Officer of Health and School Medical Officer 19 47 REGINALD LEADER, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health, Borough School Medical Officer and Medical Superintendent of the Isolation and Maternity Hospitals. Perry & Routleff Ltd., Printers, Ealing and Uxbridge LING CIVIC WEEK, 1947 The Public Health Department (Photographs by Middlesex County Times) Borough of Ealing. ANNUAL REPORT of the Medical Officer of Health and School Medical Officer 19 4 7 REGINALD LEADER. M.R.C.S, L.R.C.P., D.P.H., Medical Officer of Health, Borough School Medical Officer and Medical Superintendent of the Isolation and Maternity Hospitals. To the Mayor, Aldermen and Councillors of the Borough of Ealing. 3 3Oth March, 1948. Mr. Mayor, Ladies and Gentlemen, I have the honour to submit the Annual Report on the health of the Borough for 1947. The period under review has been an energetic one for the department and many matters have come under review. In the Domiciliary Midwifery Service two matters of principle have evolved; firstly, that each midwife, if she so desires, will be allowed. motor transport, and for this purpose the Council has agreed that on application any domiciliary midwife will be entitled to a car allowance and also that a car to be purchased by the department will be held available for emergency journeys; and secondly, that housing accommodation within her district shall be offered to each midwife. To cope with the increased number of births in the district it has been necessary to appoint an extra relief midwife for service throughout the whole Borough, and also a non-medical supervisor who commenced her duties in May of this year. A training scheme in conjunction with the Luton Maternity Hospital for the Part 2 examination of the Central Midwives Board has been inaugurated to assist in providing suitable recruits for the services. With regard to maternity and child welfare generally, it has been found necessary to appoint an additional medical officer whose duties are mainly in connection with the ten additional clinic sessions inaugurated this year, and with other general work in the department. Two weekly Specialist Obstetrical Clinics are now available to all expectant mothers within the Borough, and it is hoped that every expectant mother will be able to attend at least once before her confinement. One of the most important discoveries so far made in medical genetics is the Rhesus blood factor, which probably causes more foetal mortality and more noe-natal and maternal morbidity than does any other single condition. It is with pleasure that I record that arrangements have now been completed to reduce these risks to both mother and child by having ante-natal blood tests performed, as a routine, on all expectant mothers attending the municipal clinics. Psychology is advancing in the field of Social Welfare. In natal work it was formerly regarded as sufficient if a healthy 4 child was born without physical injury to the mother. More and more attention is now being paid to the psychological aspectreassurance of the mother and to the provision of gas and air analgesia. It is noted that as from 1946 every pupil midwife must be trained in the administration of this analgesia and all your present staff of midwives have passed the qualifying examination. Arrangements have been made whereby the supply of dried milk and vitamins available at all the Health Centres has been extended in scope. This is much appreciated by most of the mothers and it is a scheme that may expand considerably in the future. In November, 1947, the Ealing proposals for a special scheme for the training of health visitors received the approval of the Minister of Health. Four student health visitors have been accepted for training in the Authority's clinics and at the National Health Society. Perhaps the most ambitious project during this year has been the proposals for the provision of two temporary health centres, one in South Ealing and the second to serve the West Twyford area. Suitable premises are available and the project has now been placed before the Ministry of Health and the County Council. These will provide Maternity and Child Welfare and School Health services, including dental, in their respective areas. There has been a tendency in recent years to suggest that the control of infections, formerly regarded as the main duty of Medical Officers of Health, is now an established fact and that Social Health Workers can afford to transfer their attention to other fields. This view may be convenient when financial allocations under new legislation are under consideration, but it is in fact untrue, and highly dangerous, as recent outbreaks of Poliomyelitis and Smallpox show. Poliomyelitis, until about 17 years ago was a sporadic disease, but since then it has appeared in epidemic form, and it is hardly necessary to mention that in 1947 there were far more cases of Poliomyelitis in this country than in any previous year. Furthermore, there are no valid grounds for assuming that the outbreak is an isolated phenomenon, unlikely to recur, for measures for the control of this disease are far from perfect and must have caused anxiety in Public Health Departments recently. The epidemic as it appeared in Ealing is described more fully in the report of the Medical Superintendent of the Joint Hospital Committee and it may be noted that the Clavponds Isolation Hospital is one of the three hospitals that collaborated for the purpose of producing the recent film on Poliomyelitis for the 5 Ministry of Health. This was used throughout the country for the instruction and help of the medical profession and other social workers. When copies were available therefore it was exhibited both at the hospital and in the Town Hall on the 2nd September, 1947. The exhibition at the hospital was combined with a clinical demonstration of cases by the Medical Superintendent and a short clinical discussion also took place in the Town Hall after the display. Despite these urgent preoccupations it is pleasing to record that it was possible to recommence the scheme for the operative treatment of tonsil and adenoids for school children and children under the age of 5 at Clayponds Hospital. This waiting list had grown to over 200 children and practically the whole of these have now been dealt with but owing to further demands the scheme is being continued throughout the year. The new dental scheme has now been agreed with the County Council and is in the first instance to double the number of dental officers employed by the Authority. An Orthodontist is to be appointed on a part-time basis to cover the whole area and provision is to be made for special technical work. The new Orthodontic Clinic is to be built in the Cherington Public Health Centre and it is envisaged that adequate dental treatment shall be available for all school children and all those who attend the Maternity and Child Welfare Centres. The Child Guidance Clinic continues to grow. It has been necessary to double the number of sessions held by the Psychiatrist, and a full-time Psychologist and Play Therapist has been appointed and also an additional full-time Psychiatric Social Worker. It is hoped that this will enable the staff to deal with the increased number of children referred to the Centre. The accommodation of 437 places at your seven Day Nurseries has been utilised to its utmost capacity throughout the year and in fact 527 children have been booked for that number of places. Even so there is a large number on the waiting list and if it were possible to double the number of places it appears that at the moment these would soon be filled. It has been possible during the year to increase the capacity of the Stanhope Nursery by some 20 places although much more accommodation is actually required. Medical thought starting from the realisation that disease can be prevented and that sickness is a most damaging factor in our National life has impressed itself at last upon the economists. The latter have demonstrated that sickness costs the Nation some 7 per cent, of its total annual income, and that at 'present the 6 expenditure on prevention of disease is only 4½ per cent, of the total cost of sickness. In this connection a modest experiment has been carried out this Autumn by offering innoculation with a cold vaccine to volunteer members of the Council's staff in an effort to reduce the sickness rate during the winter months from coryza and other minor respiratory infections. Careful records are being kept and the experiment will be reviewed in due course but in the meantime it can be stated that 129 members of the staff availed themselves of this opportunity and some 377 injections have been performed. Ealing has been a Borough since 1901, and as the Local Sanitary Authority deals with environmental hygiene, supervision of food stuffs, the control, prevention and treatment of infectious disease; as the Welfare Authority, administers Maternity and Child Welfare Services, including the Midwifery Service ; and as an excepted district administers, as agents of the Local Education Authority, certain of the School Health Services. The National Health Service Act brings changes in the administration of these services and the personal services pass to the County Council who are now designated the Local Health Authority, and your hospitals administered by the Joint Committee pass to the North West Metropolitan Regional Hospital Board. The effect of these changes which date from the 5th July, 1948, will be that Ealing reverts to its duties of Local Sanitary Authority of the latter part of the last century, and it would appear that there is to be a complete severing of the Health Services from Local Government Units as such. It will be interesting to compare the work done during the last year with that effected during the next few years. I have the honour to be Your obedient servant, REGINALD LEADER, Medical Officer of Health. Town Hall., Ealing, W.5. 31s/ March, 1948. 7 SUMMARY OF STATISTICS. Area (in Acres) 8,739 Population (Census, 1931) 117,707 Population (estimated middle of 1947) 183,940 Rateable Value, 1st April, 1947 £1,902,515 Net Product of a Penny Rate, 1947-8 (estimated) £7,800 Live Births:— Legitimate Males, 1,776 Females, 1,743 Total, 3,519 Illegitimate Males, 72 Females, 75 Total, 147 3,666 Birth-Rate per 1,000 of Estimated Population 19.9 Still-Births:- Males, 41 Females, 40 Total 81 Rate per 1,000 total Births (Live and Still-Births) 21.6 Deaths : Males, 917 Females, 1,015 Total 1,932 Death-Rate per 1,000 of Estimated Population 10.5 Deaths of Infants under one year of age:— Legitimate Males, 70 Females, 54 Total, 124 Illegitimate Males, 5 Females, 5 Total, 10 134 Death-Rate of Infants under one year of age:— All Infants per 1,000 Live Births 37 Legitimate Infants per 1,000 Legitimate Live Births 35 Illegitimate Infants per 1,000 Illegitimate Live Births 68 Deaths from Diseases and Accidents of Pregnancy and Childbirth:— From Sepsis — Death-Rate 1,000 Total Births From other Causes 3 ,, „ „ 0.80 Total 3 „ „ „ 0.80 8 Causes of Death, 1947. Cause of Death. Deaths, 1947 Total Deaths 1946 Male Female Total Typhoid and Paratyphoid Fevers - Cerebro-Spinal Fever 2 4 6 2 Scarlet Fever — 1 1 2 Whooping Cough 1 2 3 2 Diphtheria — Tuberculosis of Respiratory System 24 35 59 78 Other Forms of Tuberculosis 6 5 11 15 Syphilitic Diseases 8 1 9 8 Influenza 4 7 11 17 Measles 1 1 1 Acute Poliomyelitis and Polioencephalitis 3 4 7 Acute Infectious Encephalitis 2 — 2 2 Cancer of B. Cav. and Oesoph. (M.); Uterus (F.) 8 22 30 29 Cancer of Stomach and Duodenum 28 21 49 50 Cancer of Breast — 53 53 34 Cancer of all other Sites 127 77 204 213 Diabetes 4 3 7 14 Intra-Cran, Vase. Lesions 81 124 205 202 Heart Disease 224 302 526 490 Other Diseases of Circulatory System 46 52 98 82 Bronchitis 48 53 101 97 Pneumonia 68 50 118 75 Other Respiratory Diseases 20 7 27 28 Ulcer of Stomach or Duodenum 12 8 20 19 Diarrhoea (under 2 years) 7 4 11 4 Appendicitis 3 2 5 10 Other Digestive Diseases 12 23 35 36 Nephritis 18 14 32 31 Puerperal Post-Abortive Sepsis — — — 1 Other Maternal Causes — 3 3 2 Premature Birth 19 15 34 25 Congenital Malformations, Birth Injury, Infantile Diseases 34 24 58 38 Suicide 11 9 20 11 Road Traffic Accidents 13 3 16 20 Other Violent Causes 30 22 52 44 All other Causes 54 64 118 117 Total 917 1,015 1,932 1,799 9 Table Showing Birth-Rate, Death-Rate and Infant Death-Rate for the Borough of Ealing. Period Birth-Rale Death-Rate Infant Death-Rate 1921—1925 15.4 10.7 58 1926—1930 14.5 10.9 49 1931—1935 14.2 10.1 46 1936—1940 14.7 10.1 45 1941 14.5 10.9 49 1942 17.2 10.3 48 1943 18.8 11.2 40 1944 19.4 10.9 41 1945 17.2 10.1 40 1946 19.7 10.1 27 1947 19.9 10.5 37 Maternal Mortality per Thousand Births. Period Ealing England and Wales 1931—1935 4.10 4.12 1936—1940 2.18 2.95 1941 1.53 2.23 1942 1.79 2.01 1943 2.95 2.29 1944 0.97 1.93 1945 —. 1.79 1946 0.84 1.06 1947 0.80 1.17 HOSPITALS. Isolation Hospital. The Clayponds Isolation Hospital at South Ealing is under the control of the Ealing and Brentford & Chiswick Hospitals Committee. Forty beds were available for the treatment of cases of infectious disease. Information regarding the cases admitted is given in the Annual Report on the Hospital, which forms an Appendix to this Report. 10 Maternity Hospital. The Perivale Maternity Hospital of 43 beds is also under the control of the Ealing and Brentford & Chiswick Hospitals Committee.. Throughout the year this hospital was taxed to the uttermost by the demands for admission, the accommodation being fully booked months in advance throughout the year. The Annual Report on the hospital is included as an Appendix to this Report. AMBULANCE FACILITIES. 1. For Infectious Disease. The Ealing and Brentford & Chiswick Hospitals Committee provide a motor ambulance for the removal of cases of infectious disease to Clayponds Isolation Hospital at South Ealing. 2. For Cases of Accidents and Acute Illness. The establishment of ambulances for accidents and cases of illness is four but unfortunately one of the ambulances has been out of commission for some months owing to inability to replace a part which has become defective. The Middlesex County Council promised replacement early in 1947 but so far nothing has been supplied and we are reduced to two suitably equipped ambulances and an old civil defence ambulance. In spite of this the work performed during the year constituted a record, there being a total of 7,044 calls. In addition to the three ambulances there is also a utility vehicle which is used for the conveyance of sitting cases to hospitals and for the conveyance of school children to health centres or hospitals. The following table shows the extent of the calls made upon the Service during the year. Cases of Accident 866 Cases of Illness 4,379 Cases of Infectious Disease 183 Maternity Cases 1,151 Total cases 6,579 Number of journeys outside the Borough (included above) 1,425 Annual Mileage 52,454 In addition, Gas/Air apparatus was delivered to the homes of 465 maternity cases. 11 MATERNITY AND CHILD WELFARE With the number of births showing yet another increase (3,666 live births compared with 3,505 in 1946) it is not surprising that the Maternity and Child Welfare Service had to deal with ever increasing demands for advice and assistance. The distribution of these births according to the place where they occurred provides a striking illustration of the great demand for hospital accommodation. Births in Perivale Maternity Hospital 970 Births in other hospitals 1,110 Births in nursing homes 641 Births at home 945 3,666 Additional sessions, both ante-natal and child welfare, have been necessary to deal with the increased attendances. Even so, the need for additional health centre facilities has become more and more apparent, as there has often been over-crowding in the existing buildings. Proposals to provide temporary health centre facilities in South Ealing and in West Twyford have received special consideration throughout the year and schemes to adapt shop premises for the purpose have been prepared. As with all proposals for new buildings, the approval of the Minister of Health had to be obtained. Before granting his approval the Minister had to seek the views of the County Council on the proposal, in view of the imminent transfer of the welfare services to the County Authority. At the end of the year the matter was still sub judice. Several new facilities having as their objective the welfare of the mother or the child, were provided for the f rst time during the year. Every ante-natal patient can now be referred to an obstetric consultant for examination. Two sessions are held each week, one at the Mattock Lane Health Centre and the other at the Ravenor Park Health Centre. This routine examination takes place at about the 36th week of pregnancy, but patients can be referred for special examination whenever necessary. Another facility provided during the year has been the extension of the scheme of immunisation to include protection against whooping cough. In view of the serious effects of both diphtheria and whooping cough among very young children, the age at which immunisation is offered has been put forward. Notices are now sent out to the parents of all children when they attain the age of six months. Protection against both diphtheria and whooping cough is obtained at the same time, by three injections of combined vaccine at intervals of four weeks. It must 12 be admitted that protection against whooping cough is not so certain as against diphtheria. Nevertheless, a scheme which offers protection for the greatest proportion of the children must surely be worth while. Whooping cough can be one of the most distressing of the complaints of childhood and it is hoped that as increasing numbers are protected against the disease there will be the same satisfactory reduction in the incidence of the disease as was experienced with regard to diphtheria. The actual numbers of children immunised during the year and a review of the results achieved by diphtheria immunisation is included on page 21 & 22. The staffing of the centres has been a matter which has caused some concern, and in view of the shortage of Health Visitors a scheme for training student health visitors has been inaugurated. By the end of the year, four students had been appointed, one to start duty on the 1st January, 1948 and the other three in April. The students are taken for a period of six months during which they attend an approved course of training organised by the National Health Society. During this period the students receive half the pay of a health visitor. The advantage of the scheme to the Council lies in the fact that the students are required to give an undertaking to continue in the service of the Council for a further period of twelve months after they have qualified. They will then, of course, receive the full salary of a health visitor. To provide additional help at the health centres on the afternoons when the welfare sessions are held and to release some of the health visitors for home visiting, a number of trained nurses without the Health Visitors Certificate, have been engaged on a part-time basis. These clinic nurses, as they are called, are able to weigh the children, leaving the trained health visitors free to give advice generally. The increase in the number of staff has warranted the appointment of a superintendent health visitor, this position being recommended for a staff of ten or more health visitors. The new superintendent commenced her duties in December. With a view to decreasing the time expectant mothers have to wait for examination at the ante-natal clinics, a system of timed appointments has been started. While this experiment has not proved a solution in preventing waiting it merits continuance, as it does to some extent reduce periods of waiting. In April, extended facilities for the purchase of dried milk were begun. Later in the year, other food products of special value in infant feeding were also made available at cost price. While there is considered opinion against converting the infant welfare centre into a chemist's shop, the present-day shortages make it obvious that additional supplies of essential foods available in the centres, will help to ensure that the mothers can obtain supplies as required. 13 CARE OF PREMATURE INFANTS. A premature infant is defined as an infant weighing 5½ lbs. or less, at birth. Information regarding the birth weight is now given on the notification cards and from this information the following statistics regarding premature births have been compiled : No. of premature births No. who died during first 24 hours No. who died between 24 hours and one month No. who survived at end of one month At home 18 4 2 12 In hospital or nursing homes 85 5 7 73 Special equipment is available for the care of premature babies born at home. Electric blankets, hot water bottles, and other items are provided, while special cots will be available whenever delivery can be secured (there has been a delay of almost a year in the delivery of these cots). Summary of the Visits made by the Health Visitors. Visits to children under 12 months:— (1946) (1947) t First visits 4,182 3,656 Return visits 3,092 3,711 Visits to children 1 to 5 years of age 4,920 5,099 Visits to expectant mothers 1,676 1,588 Visits to investigate infant deaths and still-births 23 13 Special visits or investigations 253 211 Visits to cases of Ophthalmia Neonatorum — 6 Visits to cases of Measles and Whooping Cough 21 71 Visits to cases of Scarlet Fever on discharge from the Isolation Hospital 83 29 Visits to cases of Poliomyelitis — 9 Inspections of Women's Lavatories 31 22 Visits to children under care of foster-mothers 251 294 Other visits 304 103 Total Visits 14,836 14,812 14 Summary of the Work at the Health Centres. Mothers. (1946) (1947) Expectant Mothers attending Ante-Natal Clinics:— Attending for the first time 2,936 2,318 Total attendances 15,303 14.,789 Nursing mothers attending Post-natal Clinics:— Attending for the first time 135 424 Total attendances 143 468 Children. Children attending Centres for the first time:— Under one year of age 2,721 3,024 One to five years of age 376 437 Total attendances made by children:— Under one year of age 31,426 38,028 One to five years of age 12,483 12,999 Medical Examination of Pre-School Children.-The number of complete medical examinations of children from one to five years of age are indicated in the following table:— Age-Group No. of Examinations 1 year to 18 mouths 1,371 18 months to 2 years 607 2 years to 3 years 652 3 years to 4 years 579 4 years to 5 years 406 3,615 DENTAL TREATMENT. The inspection and treatment of expectant and nursing mothers and children under five years of age, are carried out at each Centre by the three dentists responsible for this work. One half session each week is devoted to the work, although urgent cases are treated immediately. The treatment of mothers involves a large number of extractions, because in a great many cases decay has advanced beyond conservative treatment. The number of mothers seen for the first time totalled 597, a few less than the number in the previous year. The total number of children treated amounted to 325. This figure is greater by 82 than the number treated in 1946. The total attendances made at the Centres for all the work carried out, amounted to 2,397 by mothers, and 678 by children. The actual work performed consists of extractions, fillings, gum treatments and fitting artificial dentures for mothers. The number of permanent teeth removed for extreme decay and sepsis totalled, 1,355. This figure is smaller than the number of teeth 15 extracted during 1946, when 1,604 permanent teeth were removed. The number of temporary teeth removed for children totalled 463. This number is smaller than in the previous year when 521 teeth were removed. Conservative treatment during the year was increased considerably, which is as it should be; but there is still difficulty in getting mothers to bring their children to see the dentist early enough, so that more of the children's teeth can be saved. Altogether 654 permanent teeth, and 310 temporary teeth were made sound by fillings. Other operations consisted of scaling for 94 mothers, and treatment for mouth infections for 281 mothers. Plastic artificial dentures were fitted for 126 mothers, this being 92 fewer than in the preceding year. In addition, there were 1,439 other items of treatment, for both mothers and children. These included dressings of zinc oxide to painful teeth and applications of silver nitrate to temporary teeth in suitable cases. Advice was given to expectant mothers on the care of their own teeth and the teeth of the child. Information was sought by the mothers on the correct diet to give and the manner of cleansing the teeth. Measles and Whooping Cough.— Measles and whooping cough became notifiable under the Measles and Whooping Cough Regulation, 1939. The following number of cases were notified :— Measles 1,189 Whooping Cough 348 There was one death from measles and three deaths from whoooing cough during the year. 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—5 6 3 — 2 1 1 5—10 3 3 4 1 1 — — 10—15 5 8 2 — — 1 — — 15—20 16 19 1 2 — 1 1 1 20—25 14 24 — 3 — 5 1 1 25—35 30 26 2 4 3 8 1 1 35—45 15 8 2 1 4 8 2 2 45—55 8 3 — — 4 5 — — 55—65 8 2 — — 9 4 — — 65 upwards 1 1 — — 5 — — — Total 106 98 12 13 27 32 5 6 16 REPORT ON THE EPIDEMIOLOGY OF POLIOMYELITIS IN EALING DURING 1947. The outbreak of poliomyelitis which occurred in the Borough during the Summer and Autumn of 1947 followed closely the general trend of the disease notified in similar areas on the periphery of the Metropolis and indeed of the total notifications for the country as a whole. Examination of the epidemiology of the disease has been made for comparison with other areas and to illustrate some peculiarities in the local spread of the outbreak. The Borough of Ealing extends to an acreage of 18,739 lying on rising ground to the North of the Thames. Predominantly residential, the Borough has a population of 185,000 and extends from the more industrialised areas of Acton and Willesden to the East to the more rural districts of Middlesex to the West. Situated so near London, on the main road and rail communications to the West, there is considerable free movement of people to and from the metropolis, and considerable North to South traffic by road skirting London to and from the bridges at Chiswick and Kew. General Epidemiological Findings. The outbreak in Ealing may be considered as commencing duiing the last week in July, reaching its maximum incidence during August and early September and then gradually declining to the end of the year. Prior to this period three cases of poliomyelitis had been notified during the Spring of 1947 but in none of these cases was the diagnosis confirmed, and they reflect the growing awareness by the local practitioners of the probable arrival of poliomyelitis. The weekly notifications are as shown in the Chart I. As these individuals were with one exception admitted to hospital for further investigation and treatment it has been possible to determine those cases in which the diagnosis was subsequently confirmed. A total of 70 cases were notified in the Borough, of which 47 were found to be definite cases of poliomyelitis or polioencephalitis. The chart of weekly notifications conforms closely with that of a simple epidemic, there being an explosive outbreak rapidly attaining its maximum and then gradually declining during subsequent months. There is no significant variation in the trend of the weekly notifications to indicate that the outbreak was in anyway modified by important factors during the course of the outbreak although the whole picture may well have been affected by factors operating during the whole period, or initiated at the commencement, 17 Taking the total of 47 confirmed cases this gives an attack rate of 0.25 per 1,000 population. Chart II shows the numbers of confirmed cases in age groups, the attack rate in age groups being : 0-4 years 0.77 per 1,000 5-14 years 1.06 per 1,000 15 upwards 0.06 per 1,000 The sex incidence of the cases was as follows:— Males, 30; Females, 17. Of the total of 47 confirmed cases 6 died, a case mortality rate of 12.8 per cent. Four of these deaths occurred within 24 hours of admission to Hospital. Two autopsies were undertaken at the Clavponds Isolation Hospital. In both cases the findings confirmed the diagnosis and specimens of brain and spinal cord were pieserved for isolation of virus. Incubation Period. Accurate observation of the incubation period of the disease is made difficult by the low attack rate and often the indefinite initial symptoms. In homes where one child in a family has the disease, the parents are naturally over anxious for the health of the other children and mild attacks of sore throat or febrile catarrh tend to be magnified and modified to resemble the first case only to show on clinical examination where necessary confirmed by examination of the cerebrospinal fluid, that there are no grounds for the parents' fears. Two cases deserve notice in this respect. On 4/8/47, Stanley T, age 11 years, became ill with sore throat, pyrexia, headache, backache, with some neck rigidity. He was admitted to the Clavponds Isolation Hospital, 6/8/47, where he rapidly deteriorated with increasing coma, pharyngeal and laryngeal paralysis, and weakness of respiratory muscles, dying in coma, 8/8/47. Diagnosis: acute anterior poliomyelitis. On 8/8/47, his brother, John T age 2.7 12th years, living at the same address became unwell with slight pyrexia, sore throat and stiffness of the neck. He was, therefore, admitted to hospital 9 8 47, where he was definitely drowsy and disinclined to sit up. Examination of the cerebrospinal fluid, 9 8 47, showed Cells 32 lymphocytes per c.m.m. Protein 55 m.grms/100 c.c. He then rapidly improved—all symptoms disappeared in 3 days and subsequent examination of C.S.F., 23 8 47, showed Cells 1 lymphocute per c.m.m. Protein 20 m.grms/1000 c.c. Diagnosis: Abortive Anterior Poliomyelitis. One wonders whether these two children were infected from a common source, the younger child having a greater immunity, or whether Stanley infected John. It is noteworthy that both children had a sore throat at the commencement of the attack. 18 Visiting home contacts of proved cases, the frequency of mild pharyngitis during the first 10 days was noticed, although this may well be incidental especially at the time of year under review. Of a series of 33 cases at Clayponds Isolation Hospital, 9 complained of sore throat on admission. Course of the Outbreak. The main course of the outbreak in Ealing conforms with that of a simple epidemic although study of the distribution of cases shows some interesting phenomena. During August, two main crops of cases occurred at Greenford and South Ealing, followed in September by an extension in the South Ealing, Hanwell and Drayton Districts. During October and November there were fewer cases notified and these were scattered more uniformly about the Borough. The remarkable immunity of the residents of the Eastern wards of the Borough, especially Castle Bar, Hanger Hill, Mount Park and Grange districts, is shown on the case distribution map and the table giving the attack rates in the various wards of the Borough. The age distribution of cases shows no significant variation throughout the course of the outbreak. Mode of Spread. A detailed field survey was undertaken with a full enquiry into the home circumstances of each case notified. Apart from the case of John and Stanley T no definite evidence of more than one case in a family could be found. Thus close home contact did not appear to have any direct significance in the occurrence of secondary cases, although the case distribution map would indicate that there is spread from case to case, or a common significant factor causing a relatively high incidence in certain highly residential areas. No cases occurred among children attending day nurseries and there was no evidence that attendance at school affected the spread of the disease. Abortive cases constitute a problem and illustrate the necessity for close supervision of contacts of definite cases. Cases were diagnosed as abortive poliomyelitis on investigation in the Clayponds Isolation Hospital, the diagnosis being established on clinical signs supported by examination of the cerebrospinal fluid. Three cases of slight muscle weakness have been seen by the consultant orthopaedic surgeon in the school medical department, probably due to abortive poliomyelitis and these have rapidly improved under supervision and physiotherapy. The diagnosis in these cases can be very difficult as there are usually POLIOMYELITIS—1947. Ward Class of Property Pop. 0-15 July Aug. CASES Nov. Dec. ATTACK RATE PER 1.000 Sept. Oct. July Aug. Sept. Oct. Nov. Dec. Drayton B 2009 — — 3 1 1 — 1.49 .5 .5 — Castlebar A 1987 — — — 1 — — — — .5 — — Hanger Hill A 603 — — 1 — — — — . — 1.65 — — — Mount Park A 855 — — 1 1 — — ' — — 1.17 1.17 — — Grange B 2438 — 2 — — — — — — — — Manor ... B 1482 — 1 2 — — . — — .67 1.34 — — — Lammas C 2585 — 3 2 3 — 1 — 1.16 .77 1.16 — .38 Grosvenor B 1792 1 — 1 — — 1 .56 — .56 — — .56 Hamvell South C 3055 — — — — — — — — .33 — — — Hanwell North C 3748 — 1 — 1 — — — .26 — .26 — — Greenford South C 5527 •— 5 — — 1 — — .90 — — .18 — Greenford Central B 2854 — 2 2 — — — — .70 .70 — — — Perivale B 1485 — 1 1 2 1 — — .67 .67 1.34 .67 — Greenford North B 2214 — 1 — — — — — — — — — — Northolt B 3964 — 1 1 — — — — .25 .25 — — — 20 vague symptoms of a short febrile attack and the slight muscle weakness in a fretful child who has remained in bed for several days is difficult to assess. Lumbar puncture seems scarcely justified to confirm the diagnosis, so vague and fleeting are the clinical symptoms and signs. One wonders how many of these cases are completely missed and how many could be more confidently diagnosed by improved methods of investigation and isolation of the virus. Detailed reports on water supply, milk, food, fruits and canned food have shown nothing to indicate an infecting agent among the common items of food and drink. Early in the outbreak a case occurred following tonsillectomy. On 31/7/47, Claud H—■—, a Dock Labourer's son was admitted to King Edward VII Memorial Hospital for tonsillectomy and he was discharged on 3/8/47, following operation. On 11th August, he complained of difficulty in breathing and' aching legs and was re-admitted to hospital, 14/8/48, where he died 8 hours later, from total respiratory and pharyngeal paralysis. This child was in the last group of children admitted for tonsillectomy at the King Edward Memorial Hospital before operations on the nose and throat were suspended on the advice of the Medical Officer of Health. Preventive Measures. Early in August it was considered advisable to open a separate poliomyelitis block at the Clayponds Isolation Hospital for the reception of cases notified, doubtful cases being first received into the Cubicle Isolation Block until the diagnosis was established, only one case was treated at home. The home circumstances were fully investigated in each case, close contacts being advised to report to their doctor should they be unwell. Two adult contacts employed in factory canteens changed their work temporarily on the advice of the Medical Officer of Health. Children who were home contacts were excluded from school for three weeks. On the occurrence of the disease in a child attending school the classrooms were inspected to ensure satisfactory spacing of desks and adequate ventilation. School canteen staffs and teachers were interviewed regarding recent illness and sickness in their families. With the co-operation of the Head Master or Headmistress, a short notice was usually drafted for the parents of other children in the class, advising them of the occurrence of a case of poliomyelitis in the class and the necessity of reporting the illness to their own doctor. The heads of schools were advised to restrict competitive games to avoid undue fatigue in children and adolescents. School athletic meetings and inter-school cricket and football were suspended until the end of the year, CASE DISTRIBUTION POLIOMYELITIS. EALING, 1947 Chart I. WEEKLY NOTIFICATIONS- POLIOMYELITIS EALING 1947. NOTIFICATIONS RECEIVED. CONFIRMED CASES. 21 Public swimming baths were not closed but measures were taken to ensure adequate chlorination of the baths and avoidance of over-crowding above restricted maximum numbers. Public bathing pools were drained and left dry as it was difficult to control these in the public parks. No steps were taken to restrict the seating or showing of films at cinemas. The local press cooperated well in the campaign and published prepared accounts of the outbreak as it affected local areas from time to time, drawing attention to the general preventive measures. By arrangement with the West Middlesex branch of the British Medical Association, two clinical demonstrations were given at the Clayponds Isolation Hospital and the Town Hall on the 2nd September, followed by the Ministry of Health film on the diagnosis of poliomyelitis. Invitations were sent to practitioners in Ealing, Acton, Brentford and Chiswick and also to the nursing staff of the Health Department. Both meetings were well attended. It was considered advisable to suspend all nose and throat operations and multiple dental extractions from the first week in August in view of the rising number of notifications received and this remained in force until the end of the year. The general practitioners, the public, press and employers co-operated very well in carrying out these preventive measures and it was noticeable that the press accounts of the outbreak as it affected local districts did much to allay public alarm and emphasise simple practical preventive measures. DIPHTHERIA IMMUNIZATION. The introduction of facilities for combined protection against diphtheria and whooping cough make this an appropriate occasion to review what has been achieved in regard to immunization against diphtheria alone. Immunization against diphtheria was first carried out in the Health Centres in 1935. For a few years the number of children protected was small. In 1941 and 1942, as a result of a national advertising campaign, large numbers of children were immunised and since then very active steps have been taken to encourage the mothers to have their children protected. Particular attention is devoted by the health visitors to securing the immunization of the very young children, thus protecting them when they are most vulnerable to infection. The following table shows the number of children immunized each year from 1935 (including those known to have been dealt with by private practitioners), the number of notified cases of diphtheria and the number of deaths. 22  Number of children immunized No. of notified cases of diphtheria Number of deaths 1935 326 228 15 1936 490 52 8 1937 709 123 2 1938 948 142 6 1939 671 92 4 1940 701 33 4 1941 6,433 48 4 1942 7,037 28 5 1943 3,574 13 — 1944 2,232 17 1 1945 3,030 14 1 1946 2,641 29 — 1947 2,772 11 1 The results are so striking, there has been so great a reduction in the number of cases of diphtheria and in the number of deaths, that there can be no doubt whatever as to the value of this work. In the autumn of the year under review, protection against both diphtheria and whooping cough was offered by means of one series of injections, three doses of a combined vaccine being given at monthly intervals. It is hoped that the same satisfactory results will be forthcoming with regard to whooping cough as with diphtheria and the importance of every parent appreciating the value of immunization cannot be over emphasized. The actual work involved in the immunization scheme is performed by the personnel of the School Health Service, who deal with both school children and children under school age, with the exception of those attending the Council's Day Nurseries. The children at the nurseries are immunized on the occasion of the routine visits made by Medical Offirprs The following table shows the work carried out during the Year under review: Children under 5 years immunized against diphtheria 2,497 Children of school age immunized against diphtheria 273 Children given a secondary or reinforcing injection against diphtheria 1,563 Children under 5 years immunized against whooping cough 231 Children of school age immunized against whooping cough 12 It must be pointed out that the numbers immunized against whooping cough give no idea of the lively response of the parents to this new. scheme. The course of injections is spread over twelve weeks and the scheme did not start until the autumn. At the end of the year 1,380 children in addition to those entered in the above table, had commenced a course of injections. 23 NURSERIES. The accommodation at the seven day nurseries has been utilised to the utmost capacity throughout the year. At each nursery there is a long waiting list for admission ; in fact, when vacancies occur it is often only possible to consider those children whose mothers have urgent need to seek employment (e.g. widows, unmarried mothers). To help meet the need for more places in the nurseries an extension of Stanhope Nursery has been arranged. A large room, formerly used as an air raid shelter and pram shed, will now provide places for 20 children. From April, three changes were made in connection with the nurseries. (1) The hours of opening, formerly 6.30 a.m. to 6.30 p.m., were reduced to 7.30 a.m. to 6 p.m. (2) Instead of all seven nurseries opening for a full day on Saturday, only two, Stanhope and Culmington Road, now open on this day. Children from the other five nurseries are permitted to attend one of the nurseries which are open and, where necessary, are collected by car in the morning and are returned in the evening. (3) The charge for admission, formerly one shilling per day, was doubled. Exception is made, however, in cases of necessity and one shilling per day continues as the charge when there is only one parent in employment and also in respect of a second child from the same family. The training of the nursery students has proceeded throughout the year, in preparation for the National Nursery Examination. The two-year course of training is now held at the Acton Technical College by arrangement with the Middlesex County Council. Lectures in further general education as well as in vocational subjects are attended. The practical work at the day nurseries has continued as before and the students are under the close supervision of the superintendent matron. The following is a summary of the attendances during the year: Nursery Official capacity Maximum bookings Total attendances Daily average Highest on any one day Stanhope 70* 84* 16,865 55 78 Culmington Road 85 102 18,004 59 89 Cuckoo 70 84 14,411 54 79 Perivale 58 72 10,698 40 67 Northolt 40 48 9,522 35 45 St. Mark's 44 53 10,821 40 51 Oldfield 50 60 11,726 43 57 * Extension opened February, 1948, increased capacity to 90 and maximum bookings to 108. 24 CHILD LIFE PROTECTION. The work of supervision of foster-mothers, carried out by the health visitors who have all been appointed child protection visitors, is summarized 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, 35). 38 Number of children registered during the year 28 Number of children removed from register during year 28 Number of children on register at end of year (Number of fostermothers having care of the above children, 33). 38 Number of visits made by health visitors 294 ADOPTION OF CHILDREN. Under the Adoption of Children (Regulation) Act, 1939, Section 7(3) private persons participating in the arrangements for an adoption must give notice to the welfare authority in whose district the child is being placed. The duty of supervising these children, until the adoption is completed, is then placed upon the health visitors as part of their duties as Child Protection Visitors. Sixteen persons gave such notice during the year in accordance with the requirements of the Act, the number of children involved being 18. In addition there were 28 other children received for adoption that were visited by the health visitors. These children had either been placed by registered adoption societies or direct by the parent, no third person being involved. Cases such as these are exempted ' from the requirements of Section 7 but do, nevertheless, come in for supervision either at the request of the adoption society, or on account of the local court asking for a report from the health visitor. MIDWIFERY SERVICE. The increase in the total number of births has led to increased demands for the services of the domiciliary midwives and during the year it was necessary for the staff to be increased from 12 to 14. One of the two new appointments was that of a non-medical supervisor, who became responsible for the day-to-day supervision of the work of the midwives under the general supervision of the senior woman assistant medical officer. 25 The cases attended by the midwives were as follows : (a) As midwife 696 (b) As maternity nurse 116 During the year the fee for the attendance of a midwife was increased to £3. 10s. 0d. This is an inclusive fee covering the attendance of the midwife, the attendance of a doctor if his services are required by the midwife, the attendance of a consultant if required by the doctor, the provision of gas and air analgesia and the issue of a sterilised accouchement set. Special equipment for the care of premature babies is also available. The fee, of course, can be reduced in cases of necessity. The Council also decided to accept vouchers issued by the Hospital Saving Association and the Hospital Saturday Fund, the voucher entitling the patient to the services of the midwife without further payment to the Council other than that made by the Association. A fixed amount of £1. 12s. 6d. is received in respect of each voucher. Housing accommodation for new staff has been a difficult problem. The essential need that there should be an adequate staff of qualified midwives living in appropriate areas of the borough has, however, now been recognised by the Council, which has provided through the Housing Department, accommodation for four of the midwives. The London County Council have also agreed to rent to the Council accommodation for the midwife serving the Cuckoo Estate. In all these cases the midwife pays rent for the premises in accordance with the recommendations of the Midwives Salaries Committee. The Council have agreed that any midwife providing a car, or auto-cycle, for her official duties, should be paid an appropriate allowance. By the end of the year, however, none of the midwives had availed themselves of this offer. The purchase of a staff car for the Public Health Department, with the midwifery service having first claim on its use, has also been authorised. Difficulty has been experienced, however, in obtaining delivery of a suitable vehicle. The following figures retarding the midwifery service are of interest: Number of nursing visits 13,871 Number of ante-natal visits to patients' homes 719 Examination of patients at ante-natal clinics: First examinations 792 Re-examinations 3,440 Number of patients having gas and air analgesia 391 DOMESTIC HELP SERVICE. Home helps have been provided for maternity cases since the maternity and child welfare scheme was first started in 1919. 28 The provision of domestic help in other cases, such as illness and old age, is a more recent innovation, having its inception in February, 1945, following an authorising memorandum from the Ministry of Health. The two types of cases are now dealt with by the same staff of domestic workers, this proving more practicable than having two separate groups of workers. It is a rule that maternity cases have priority over the other cases and this means that workers have to leave these other cases without warning whenever one of their maternity bookings needs attention. During the year, 125 maternity cases and 369 other cases were assisted. CARE OF ILLEGITIMATE CHILDREN. The Council makes its most active contribution to the work of caring for the illegitimate child by arranging for, and meeting the cost of, hostel accommodation for the mother. During the year, 30 mothers with illegitimate children were admitted to either a pre-natal or post-natal hostel organised by the British Red Cross Society. Many of these mothers, not all of whom were unmarried girls, went to the pre-natal hostel before the baby was born and then to the post-natal hostel after the confinement, remaining there until the problem of the baby's future had been satisfactorily settled. Adoption is the most usual way of securing the welfare of these children. The interviewing in connection with these cases is done by the social worker employed by the Ealing Deanery Moral Welfare Association, who submits recommendations regarding cases which she considers suitable for the hostels. Admission to the hostel is then secured through the Middlesex County Council, who have made arrangements with the British Red Cross Society on behalf of all the welfare authorities in the county. SUPERVISION OF MIDWIVES. The Council have been the Local Supervising Authority under the Midwives Acts since 1930, when the powers were delegated by the County Council. All midwives practising in the borough are required to give notice of their intention to practise and thereafter come under supervision. Number of' midwives practising at end of year:— Midwives in service of Council 14 „ at Perivale Maternity Hospital 12 „ in independent practice 4 ,, in private nursing homes 9 27 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 185 (b) At the patient's home 746 When acting in the capacity of maternity nurse (a doctor being in attendance): (a) In private Nursing Homes 723 (b) At the patient's home 135 SUPERVISION OF NURSING HOMES. The following table gives information regarding nursing homes in the borough:— No. of Homes No, of Beds Number of Nursing Homes on Register at beginning of year 14(6) 218(69) Number of New Homes registered 2 21 Number of Homes discontinued 2 15 Number of Nursing Homes on Register at end of year 14(5) 224(52) The figures in brackets indicate the number of homes and the number of beds whollv or partly devoted to the reception of maternity cases. The medical officer in charge of the supervision of nursing homes made 20 special visits during the year. 28 PREVALENCE OF, AND CONTROL OVER INFECTIOUS AND OTHER DISEASES. Cases of Infectious Disease occurring in the Borough. Disease 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 Smallpox — — — — — — — — — — — Diphtheria 123 142 92 33 48 28 13 17 14 29 11 Scarlet Fever 317 383 303 116 166 180 448 228 340 232 133 Enteric Fever (including Paratyphoid) 5 2 5 4 5 — 1 — — — — Puerperal Pyrexia 24 46 40 30 30 39 41 42 47 35 27 Pneumonia: Primary 60 83 50 66 97 105 123 142 110 114 127 Influenzal 37 18 26 10 27 17 40 9 14 16 3 Acute Poliomyelitis 7 6 1 1 9 2 2 2 3 4 46 Cerebro-Spinal Fever 1 1 — 7 15 5 1 — 6 6 10 Malaria — — — 1 1 2 — — — — 1 Dysentery 5 12 2 — 3 6 5 24 60 10 5 Erysipelas 27 41 37 29 26 36 41 30 26 31 38 Polio-Encephalitis 1 6 Tuberculosis: Pulmonary 178 142 149 156 195 223 233 173 194 275 204 Non-Pulmonary 37 33 38 30 28 38 51 30 23 33 25 Ophthalmia Neonatorum 7 15 16 5 2 8 4 3 3 3 5 Total 828 924 759 488 653 <^89 1004 700 840 788 641 Scarlet Fever.—There were only 133 cases notified during the year, this total being the lowest since 1940. Of these cases 65 were removed to hospital, 48 being accommodated in the Clayponds Hospital and 17 being admitted to isolation hospitals belonging to neighbouring authorities. Diphtheria.—Although 27 cases were notified as diphtheria, all being removed to hospital, only 11 of these cases were subsequently confirmed as suffering from the disease. A review of the results that the diphtheria immunization scheme has had on the incidence of the disease is included on pages 21 & 22 of this Report. 29 SANITARY CIRCUMSTANCES OF THE BOROUGH. Water. (i) The whole of Greenford and Northolt is supplied by the Rickmansworth and Uxbridge Valley Water Company with the exception of five roads south of Whitton Avenue in the Perivale Ward which are supplied by the Colne Valley Water Company. The rest of the Borough is supplied by the Metropolitan Water Board. (ii) No samples were taken during the year from any pipe supply either for bacteriological or chemical analyses. During the year, at the request of the Minister of Health, a survey of the wells with borings into the chalk was carried out. The special report which was prepared is recorded below. (iii) No plumbo-solvent action occurs in any of the water supplies. (iv) There was no action taken in respect of any form of contamination. (v) Water from public mains is supplied to 48,252 houses witli a population of 185,970 (estimated to September, 1947). SPECIAL REPORT OF THE MEDICAL OFFICER OF HEALTH ON WATER OBTAINED FROM BORINGS INTO THE CHALK IN THE BOROUGH OF EALING. At the request of the Minister of Health a survey of the wells with borings into the chalk has been recently carried out. These wells which are twelve in number are all in private ownership and are used in connection with factories. In only four instances are they used for drinking purposes. Samples have been taken of water from eight of these wells which are in use and submitted for both chemical and bacteriological examination and satisfactory results were obtained in each case excepting one, where the supply was found to be polluted, but after a series of samples, taken from various points of this particular supply, the water from the bore was found to be good both chemically and bacteriologically and it was found that pollution was taking place in the pipe which delivers the water into the tanks at the top of the building. Steps were taken to sterilise the pipes and a subsequent sample was reported to be satisfactory. Attached are the particulars of each invividual well, a specimen boring showing the various strata found and the results of chemical and bacteriological examinations of eight of the wells. 30 BOROUGH OF EALING—WELL WATER SUPPLY. No. Depth of Well Protection of Boring Number of gallons per day Use A nalysis 1 4 borings. Nos. 1, 2 and 3, 500 ft., No. 4, 600 ft. No. 1 lined to 120.6" „ 2 118.9" „ 3 120.0" „ 4 120.0" Three borings in boiler house; floor tiled. One in separate pump house with concrete floor. Reservoir holds 100,000 galls, per day. For factory and drinking purposes. Sample taken on 15/10/47 was reported by analyst to be satisfactory for drinking purposes. 2 405 ft. lined to 346 ft. Boring in covered pit in front lawn runs underground to tower and up to reservoir inside building. 20,000 gallons For factory and drinking purposes. Sample taken on 15/10/47 was reported by analyst to be satisfactory for drinking purposes. 3 2 borings, one 450 ft. and one 500 ft. Lined to depth of 158 ft. Each boring in a separate pump house with concrete floor. 15,000 gallons For factory and drinking purposes. Sample taken on 15/10/47 was reported by analyst to be satisfactory for drinking purposes. 4 300 ft. lined to depth of 162 ft. Boring in concrete pit with iron cover. 60,000 gallons For factory and drinking purposes. Sample taken on 15/10/47 was reported by analyst to be satisfactory for drinking purposes. 5 2 borings, one 400 and one 450 ft. lined to depth of 120 ft. Both borings in concrete pits; one with wooden cover the other with a hermetically sealed cover. 120,000 galls. For general factory purposes. Not for drinking. Sample taken on 15/10/47 was reported by analyst to be satisfactory. 6 Boring 275 ft. Boring inside building with iron cover. 5,000 gallons per hour. Every purpose except drinking. Sample taken on 15/10/47 was reported by analyst to be satisfactory. No. Depth of Well Protection of Boring Number of gallons per day Use Analysis 7 400 ft. lined to depth of 150 ft. Boring in building with softening plant ; concrete floor. 3,000 gallons per hour. For general factory purposes. Not for drinking. Sample taken 0n 15/10/47 was reported by analyst to be satisfactory. 8 2 borings, 400 and 550 ft. Lined to depth of 140 ft. One boring in separate pump house with concrete floor. One in concrete pit with iron cover. 24,000 gallons General factory purposes and not for drinking. Sample taken on 15/10/47 was reported by analyst to be satisfactory. 9 370 ft. completely lined. Boring inside building with concrete floor. 12,000 gallons Out of action. Not taken. 10 750 ft. lined to 650 ft. Pumped to 5,000 gall, tank from which supply is drawn. 1,000 gallons Factory purposes only. Pumps defective. Unable to get new part. M.W.B. Water used. Not taken. 11 400 ft. lined to 22 ft. Boring in building with concrete floor. 3,500 gallons. Factory purposes only. Out of action since February 1947. Endeavours to bring into use again. Not taken. 12 500 ft. lined to depth of 300 ft. Boring inside building with electric pump. 1.000 gallons per hour. Not in use. Not taken. 31 32 There appears to be little possibility of pollution in the four wells which are not in use, the reasons for which being as follows: No. 9.—This was discontinued to economise in the use of electricity as the pump was electrically driven. No. 10.—The pump has become defective and it has been found impossible up to the moment to replace the defective part. No. 11.—The supply of water began to fail in February last. No. 12,—This well was bored to obtain a cold supply but was found to be only 11% cooler than the Metropolitan Water Board supply so its use was discontinued. In each of these cases the Company's water is laid on and as soon as it is possible numbers (9), (10) and (11) will be brought into use again and instructions have therefore been given to the owners to notify when this occurs so that samples can be taken immediately. The following gives details of the strata found at a factory in Horsenden Lane, when the 450 ft. boring was sunk in 1929. Ft. Ins. Mold 1 0 Brown Clay 19 0 Blue Clay 75 0 Mottled Clay 34 0 Brown Sand 6 0 Green Sand and Pebbles 5 6 Flints 1 6 Chalk and Flint 305 0 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 3,350 Number of Nuisances observed by Inspectors 61 Number of Premises inspected in connection with Infectious Disease 329 Number of Premises visited by Periodical Inspection (Cowsheds, Dairies, Slaughterhouses, Factories, etc.) 204 Number of Houses inspected under House-to-House Survey Food Inspections 1,205 Total Number of Re-inspections 10,168 Other Inspections 3,372 Total Number of Inspections and Re-inspections 18,689 Number of Intimation Notices given 1,786 Number of other Letters written 2,100 33 Number of Statutory Notices served 282 Proceedings before Magistrates 14 Control of Civil Building. In connection with the Regulations for the Control of Civil Building, Certificates of Essentiality have been issued in respect of 1,551 houses at an estimated cost of £101,159. 7s. Od. This is an increase over the number dealt with in 1946 of 671 houses at a cost of £47,387. 13s. 3d. The Sanitary Inspectors have dealt with all applications for Building Licences which involved work for which Statutory Notices under the Public Health Act had of could have been served. INSPECTION AND SUPERVISION OF FOOD. 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 slaughter houses but no animals were slaughtered in them during the year. There is no public slaughterhouse in the Borough. The following table indicates the amount of various foodstuffs which have been condemned by the Sanitary Inspectors as unfit for food in the course of their inspections at the various food premises in the Borough. lbs. Beef 919 Offal 158¾ Bacon 142 Fish 5,416 Sausage Meat 191 Tinned Meat 2,2961 Fruit and Vegetables 4,497 Confectionery 3,473 Cocoa 4,143½ Cereals 19,693½ Assorted Food 15,263¾ 56,193½ Meat (Tins) 726 Milk (Tins) 4,249 Fish (Tins) 1,355 Assorted Articles 3,995 Eggs 1,129 34 Assorted tins, jars and packets 3,096 Tinned Fruit and Vegetables 6,065 Rabbits 166 RODENT CONTROL. The following is a summary of the work carried out by the Rodent Operative, acting under the direct supervision of the Chief Sanitary Inspector. Complaints 523 Premises inspected 678 Premises found to be infested with : (1) Rats 537 (2) Mice 129 Re-visits to infested premises 851 Number of bodies recovered : (1) Rats 541 (2) Mice 338 Fees received for treatment £277. 16s. lOd. Premises treated free of charge 51 During the year a comprehensive treatment for the destruction of rats in the sewers throughout the Borough was carried out in conjunction with the Borough Engineer and Surveyor's Department. Owing to shortage of manpower it was found to be impossible to carry out the treatment as a whole so the Borough was divided into five self-contained areas corresponding to the connections of the Council's sewers with the West Middlesex Trunk Sewer. The first treatment was commenced on July 1st, 1947, with three squads of men, each consisting of one man loaned by the Divisional Rodent Officer to act as recorder and baiter with two men from the Sewers Section of the Borough Surveyor's Department. 3,189 Manholes were baited of which number 495 or 15.52% were found to be rat infested and were poison baited with biscuit rusk and zinc phosphide. It was necessary to treat 758 manholes during the second treatment and 89, or 2.79% of the whole number originally treated, were found to be still infested and were poison baited with bread mash and arsenious oxide. The whole treatment took three months and four days to complete and the result appears to be entirely satisfactory as the rat infested manholes were reduced from 495 in the first treatment to 89 in the second and from observations of some of the poison baiting in the second treatment it was evident that the rat population in the sewers if not entirely eradicated has been reduced to a minimum. 35 FACTORIES ACT, 1937. Part 1 of the Act. 1.— Inspections for purposes of provisions as to health (including inspections made by Sanitary Inspectors). Premises Number on Register Number of Inspections Written notices Occupiers prosecuted (1) (3) (4) (5) (6) (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 128 98 2 1 (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 464 25 2 – (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) – – – – Total 592 123 4 1 36 2.— Cases in which Defects were found. (If defects were discovered at the premises on two, three or more separate occasions they should be reckoned as two, three or more "cases"). Premises Number of cases in which defects were found. Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector (1) (3) (4) (5) (6) (7) Want of cleanliness (S.l) 8 8 – 7 1 Overcrowding (S.2) – – – – – Unreasonable temperature (S.3) – – – – – Inadequate ventilation (s.4) 2 2 – 2 – Ineffective drainage of floors (s-6) 1 1 – – – Sanitary Conveniences (S.7): (a) insufficient 2 2 – 2 – (b) unsuitable or defective 12 12 – 8 – (c) not separate for sexes 1 1 – 1 – Other offences against the Act (not including offences relating to Outwork) 1 1 – – – Total 27 27 – 20 1 Part VIII of the Act. Outwork (Sections 110 and 111) Nature of Work Section 110 Section 111 No. of out-workers in August list required by Section 110(1) (c) No. of cases of default in sending lists to the Council No. of prosecutions for failure to supply lists No. of instances of work in unwholesome premises Notices served Prosecutions (1) (3) (4) (5) (6) (7) (8) Wearing Apparel Making, etc. 84 – – – – – Cleaning & Washing 2 – – – – – Stuffed toys 1 – – – – – Total 87 – – – – – 37 HEALTH EDUCATION. A written report on the work of the department cannot give much more than a statistical summary of the work done, with a note describing any new work of special interest. It would be difficult to describe, in detail, the many services provided. However, an excellent opportunity to see a graphic description of the whole work of the department was provided by the Civic Exhition, held at the Town Hall for a week in October. This exhibition was planned in such a manner as to show the many ways in which the Council is concerned in the life of the citizen. The Health Services, of course, do affect every inhabitant in the Borough at some time in their lives. The Ante-natal Clinic, Midwifery Service and Maternity Hospital, Child Welfare Centre, School Health Service, Sanitary Inspector's Department, Ambulance Service, Prevention of Infectious Disease and the Isolation Hospital were all represented in the main hall, together with display stands representing the other departments of the municipal service. In addition, a miniature day nursery accommodating children from the nurseries, occupied an ante-room. The attendance of 22,000 visitors at the exhibition fully merited the work entailed in planning and preparing the exhibits. It is, of course, by means such as this exhibition that the public can come to realise the many ways in which local services can be utilised to their personal advantage. A descriptive booklet explaining the work of the Public Health Department also serves a very useful purpose in bringing to the notice of the public the many branches of the health service. SCHOOL HEALTH SERVICE. This is the third report on the School Health Service since the coming into operation of the Education Act, 1944. Apart from slight modifications of procedure the service continued to function on the same lines as in previous years. More attention was paid to the ascertainment of handicapped pupils in the area and the procedure for dealing with verminous children was carried out strictly in accordance with section 54 of the Education Act. Cod liver oil and malt was made available to school children on recommendation and under the supervision of assistant medical officers. Issues were made to children suffering from active rickets malnutrition, chronic chest affections as well as to children convalescing after severe illness. Towards the end of the year the service undertook for the first time the immunisation of pre-school children against whooping 38 cough and the statistics relating to this work will he found on page 22 of this Report. In conjunction with the Ealing and Brentford & Chiswick Hospitals Committee, arrangements were made for a number of children to receive operative treatment for tonsils and adenoids at the Clayponds Isolation Hospital and 202 cases were dealt with in this way. The general work of the service has expanded and for the first time since pre-war days the second age group of school children was medically examined in the schools. The second age group is comprised of children in their last year of attendance at a maintained primary school. STAFF. There were a few changes in the staff during the year caused by resignations but replacements were made in good time to preserve the continuity of the work. Two new appointments were made to the staff of the child guidance centre, a psychologist and play therapist and a psychiatric social worker. In addition to these new appointments the sessions of two other members of the child guidance team were increased. MEDICAL INSPECTION. Periodic medical inspection of pupils in the entrants, second and third age groups was carried out at all maintained schools in the borough. As has been mentioned in the opening remarks of this report it was for the first time since the outbreak of war that the second age group has been subjected to routine medical inspection ; the temporary suspension of this work being due, of course, to the depletion of staff during hostilities. Pupils other than in this group were examined as usual and statistics relating to these inspections will be found in the tables at the end of this report. Under the heading of " special inspections " it will be found that 4,545 were specially examined. This figure relates to children kept under observation and others referred by school nurses, heads of schools and in some cases by school enquiry officers. FINDINGS OF MEDICAL INSPECTION. The statistics relating to periodic medical inspections and other inspections will be found at the end of this report in Table I 39 (A) and (B) on page 53, and the number of individual pupils found at periodic inspection to require treatment are shown under section (C) of the same table. In Table II, page 54, will be found a summary of defects found at periodic and special inspections. Reference has been made in the previous paragraph to the number of children specially examined. It will be observed from perusal of the statistics referred to above that a large number of the children referred for special examination were found to be suffering from infection of the skin. GENERAL CONDITION OF PUPILS INSPECTED. There are only three classifications of general condition of children examined at periodic inspection included in Table II (B), on page 55. This is in accordance with the Ministry of Education requirements, emphasis being placed on physical fitness rather than nutritional standard as in previous years. Under this new classification children are recorded as : A —those better than normal. B —the normal or "fair." C —those below normal or poor. TREATMENT OF DEFECTS. The minor ailment clinics which were held at all the six health Centres in the borough dealt with the majority of children referred for treatment of conditions classified in Table III, Group I, and as will be seen 10,620 attendances were made at the clinics. A large number of the children treated were suffering from a skin infection, or from minor injuries, bruises, sores, etc. DEFECTIVE VISION AND SQUINT. The eye clinics were held as usual at the Mattock Lane and Ravenor Park Health Centres under the direction of the ophthalmic surgeon, Mr. Freeman Heal. 1,366 errors of refraction were dealt with and this number includes cases of squint but does not include other defects or diseases of the eyes. In addition the following cases were referred to hospital : Operative treatment of Squint 2 Operative treatment of Cyst 5 Work carried out in connection with the maternity and child welfare service entailed the examination of 126 pre-school children and 19 expectant and nursing mothers. 40 TREATMENT OF DEFECTS OF NOSE AND THROAT. ' At the commencement of the year there were well over two hundred children on the waiting list for the operative treatment of tonsils and adenoids. As has been mentioned in the opening remarks to this report arrangements were made with the Ealing and Brentford & Chiswick Hospitals Committee for these operations to be performed at the Clayponds Isolation Hospital and 202 cases were dealt with in this way. The number would have been greater had it not have been for the outbreak of poliomyelitis which caused the suspension of operations at the end of the summer vacation. The ear, nose and throat clinics were conducted as usual at two of the main health centres in the borough by the otologist, Mr. Arthur Miller, F.R.C.S., and a summary of his work for the year is set out below : During 1947, 825 attendances were made at the Mattock Lane and Ravenor Park ear clinics. Of these, 718 attendances were made by school children referred from the minor ailment clinics and school inspection, and 107 from the child welfare centres. The treatment advised by the surgeon was carried out at the various health centres and included, ionization and diastolisation, instillation of ear drops and insufflation of iodised boiic acid, politzeration and cauterisation. Thirty cases needing X-Ray for diagnostic purposes were referred by the surgeon to the West Middlesex Hospital or the Central Middlesex Hospital. ORTHOPAEDIC AND POSTURAL DEFECTS. The orthopaedic clinic under the supervision of an orthopaedic surgeon from the Royal National Orthopaedic Hospital was conducted throughout the year at the Mattock Lane Health Centre. There were 8 children admitted to the Stanmore Branch of the hospital referred to above for residential treatment and 138 cases dealt with locally at the clinic. The work at the clinic included treatment by a qualified physiotherapist and also the supplying of children with special boots and surgical appliances. Orthopaedic treatment was not confined to pupils attending maintained schools in the area, the facilities being available to pre-school children. School children made 1,003 attendances for massage and remedial treatment and 519 attendances were recorded in respect of pre-school children. 41 CHILD GUIDANCE TREATMENT. The report of the psychiatrist, Dr. P. Holman, on the years' work at the Centre is as follows:— This year has been one of normal and steady function of the centre. The number of children referred was 158, slightly greater than last year. The principle adopted last year has been maintained. The educational psychologist has seen all cases presenting a problem in the schools. She has seen about 320 cases and referred approximately half of these to us. The proportion referred is thus considerably greater than last year, but on the other hand, owing to the pressure of other work, the educational psychologist has seen fewer cases. In her opinion they have been more urgent cases than those she saw previously, and further, owing to the fact that her first year was so concerned with the problem of backwardness, there have been fewer backward children to occupy her this year, consequently a higher proportion of problems needing the attention of the child guidance centre. Table I. Analysis of Work. During the year 158 cases were referred and 49 were on the waiting list from 1946. Of these 207 cases, 52 were still waiting to be seen at the end of the year. Of the remaining 155 cases, 15 were withdrawn, 29 were discussed by the team and advised by the psychiatric social worker, and 111 were seen by the psychiatrist as in need of the full services of the centre. (An increase of 37 over last year.). Of these 111 children, 46 were discharged after diagnosis and advice, 11 were sent for special medical investigation, 37 were put down for treatment, and 17 formed the objects of special recommendations for change in their environment. (See Table VI). Of these cases given treatment, 12 were carried from 1946 and 26 were taken on in 1947. (An increase of 12 over the year before). Of these 38 cases, 17 were discharged "improved" or "much improved." 2 broke off treatment before we wished to close the case, in both cases through lack of co-operation on the part of the parents; 19 cases were still under treatment at the end of the year. Centre Staff. In the report for 1946 it was suggested that the working time of the staff of the centre ought to be doubled. The increase of work in the early part of this year abundantly justifies this estimate, and in November a second psychiatric social worker to the centre staff and a full time psychologist were appointed, the latter temporarily, at least, to assist the educational psychologist for 42 part of her time. Psychiatrist sessions were at the same time increased from 2 to 4. As these changes came only towards the end of the year, they cannot yet show any marked effect on the volume of work done in the centre. Only 10 cases were awaiting treatment at the end of the year and although it is unsatisfactory not to be able to provide treatment immediately after or within a few weeks of the diagnostic interview, this is an improvement over 1946, and it is hoped that with the increase of staff, this particular waiting list will diminish or disappear. Table II. Symptoms. As usual the number of symptoms exceeds the number of children seen, i.e., many children come to the centre with two or more symptoms, thus for 158 children, there are 239 symptoms. The 4 predominating categories are "fears and anxiety," enuresis, delinquency and backwardness. Backwardness and school difficulties constitute a considerable smaller group of those referred to the centre last year, and it is of particular interest, that children referred to us for school difficulties have been well above the average in intelligence, the average of this group being 118. This is accounted for by the fact that we have had an unusual number of referrals in this group from the grammar schools, and, as in the case of other symptoms, the particular difficulty has not been in itself of such great significance. There have been indications of underlying emotional disturbance in the child and also difficulties in the home, which tends to affect children under the strain of academic work, more perhaps than children where the intellectual standards are lower. The predominance of the category, "fears and anxiety," and the fact that children presenting difficulties in this group are among the youngest coming to the centre, confirms the opinion expressed last year that the system of ascertainment in Ealing is of great value, and that children are referred before their problems have crystallised into specific forms. With regard to delinquency and the group of problems referred to under behaviour disorders, we are still concerned with the comparatively advanced age at which these children reach us. (See Table V). Table III. Home Conditions. In a certain number of children some constitutional disability —either innate or acquired—determines the maladjustment, irrespective of post-natal environment ; examples of this type are children who manifest a change of personality after a head injury, or after meningitis, encephalitis, etc., or who presumably because 43 of genetic factors, suffer from juvenile psychosis. This is a comparatively small group into which only 10 of this year's cases fall. A second much larger group consists of children whose disturbance proceeds primarily from the circumstances to which they are exposed in early childhood. In this group some constitutional predisposition may also exist, i.e., its members succumb to misfortunes which a more robust child would withstand, but the fact remains that, with different treatment they would not have succumbed, and the ill effects can often be undone. This group is the one most likely to yield to child guidance treatment and the majority of our cases fall within it. A further group, however, can be distinguished where circumstances are so adverse that no child could be expected to escape unscathed. 57 of the cases this year fall within this group—a higher proportion than is usually found in child guidance work. This group of cases present home difficulties of so serious a character that a disproportionate amount of time and effort has to be spent on them in order to effect any improvement or alteration. The adverse factors present in this group of cases are tabulated in Table III, but it will be seen that in most cases there is more than one such factor present. If is important to emphasise that, in every one of these cases, however the child may be described in the outside world—delinquent, naughty, refractory, etc., the child is, in fact, a sick child. While the treatment needed is very different from the treatment required for disease of the body, nevertheless, whatever is prescribed has the end in view of restoring mental health if possible, or, at least minimising mental ill-health. Altogether of these 57 cases, only 16 were actually recommended for removal from home, and 9 further children were removed through the work of other agencies (e.g., juvenile court, or by private arrangement). In 3 cases the parents were un-cooperative and nothing further could therefore be done, and in 13 cases removal from home is still under consideration, and we are temporising in the hope that some change in the conditions will occur in the near future. In 7 cases treatment rendered the situation more tolerable, and in 8 cases nothing further could be done. Of these 8 cases the conditions of 5 children were felt to be tolerable, although very unfortunate. Table IV. Intelligence Levels. The average I.Q. this year is significantly above the average for the school population. This is accounted for, partly by the increase in the number of referrals from grammar schools, and partly by the fact already referred to. that the spade work done by the educational psychologist in ascertaining backwardness, and 44 the efforts made to provide more fully for backward children in the schools has diminished the number of dull children who come to the notice of their teachers by reason of disturbance or antisocial behaviour. Table V. Age. The ages of children referred to the centre have been tabulated, and as far as the school population goes there is very little variation in the numbers from age to age. Over the age of 15 there is a much smaller school population, and it is natural that the numbers in this group should be smaller. In the first two years of school life it is also understandable that children in trouble will not have been noticed. What is to be regretted, however, is the very small number of children under school age. Any consideration of the problems we see, makes it obvious that very many, if not the majority of difficulties begin at a very early age., Many of the less serious problems could have been guarded against by help to the parents of babies and toddlers, and some of the most tragic situations could have been avoided altogether, if some machinery had existed for bringing them to light at their inception. Table VI. Special Recommendations. 17 children were recommended by us for removal from home, and as already pointed out, this does not by any means cover the number of children for whom some change is not only desirable, but almost imperative. Of the 17 children, 11 were recommended for boarding school placement, and of these 8 are now placed. At the end of last year there remained 7, for whom no vacancy had been obtained. 5 remained in urgent need of placement, but although removal from home remains in our opinion desirable for the other two, their parents are no longer willing to accept this solution. One of these is a boy nearing the end of his school life for whom other adjustment will therefore soon become possible, but the other is a young child who still gives cause for anxiety and will almost certainly present a more serious problem in the future. Conclusion. It is evident that there is no slackening in the need for the routine services of the centre, and all members of the staff have been working under pressure which shows no signs of diminishing, in addition, the more general side of the work has become better known to schools, to the probation service and to welfare workers in the district, and there has been a great demand for visits to the centre, and for visits from members of our staff to explain the work 45 or to give lectures to parents and teachers and other persons interested in the care and welfare of children. All workers in child guidance are aware that educational work of this kind is among the most fruitful that centres such as ours can undertake. At all times child guidance workers have to assume an unusual degree of responsibility. The object in drawing attention to these points, has been to emphasise the fact, that, the statement of the number of cases seen in the centre, and the arrangements made for their disposal, by no means gives the full picture of the work that the centre undertakes. It is not only in the direct work with children and their families, but in the numerous contact with all those concerned with the welfare of children, that child guidance makes its full contribution. TABLE I. Analysis of Work. Total number of eases referred to the Centre in 1947 158 Total number of cases brought forward from 1946 waiting list 49 207 Total number of new cases dealt with by the psychiatrist : (Boys) 79 (Girls) 32 111 Cases withdrawn before investigation 15 Cases investigated by psychiatric social worker and advised by her 29 Remaining on waiting list for interview at Centre 52 207 Analysis of New Cases seen at Centre. Total number of new cases seen by psychiatrist 111 A. Diagnosis and advice 46 Special recommendations 17 Further hospital investigation 11 B. Treatment— (1) Psychiatrist 5 (2) Play therapist 15 (3) Remedial teaching 5 On waiting list for treatment in 1948 12 111 Analysis of all Treatment Cases. Number of cases carried over from 1946 13 „ „ taken on in 1947 25 38 Discharged, much improved 12 improved 5 Treatment broken off 2 19 Number of cases current on December 31st, 1947 19 38 46 TABLE II. Table of Symptoms. (Including those for which the children were referred and others which were discovered at the diagnostic interview. 1. Nervous Disorders. Fears and anxiety 39 Solitariness and unsocialbility 4 Depression and lethargy 11 54 2. Habit Disorders. Enuresis 32 Sleep disorders 7 Habit spasms 11 Feeding difficulties 3 Epilepsy 3 Hysterical symptoms 3 Speech disorders 1 Asthma 1 Faecal incontinence 2 Migraine 2 Chorea 1 66 3. Behaviour Disorders. Delinquency (including stealing and lying) 25 Difficult to manage at home 11 Difficult to manage at school 11 Aggression 17 Truancy and absconding 10 Sex difficulties 5 Temper tantrums 6 Bizarre symptoms— pre-psychotic 3 88 4. Educational Difficulties. Backward 19 School failure 6 Advice on school placement 4 Advice on school work 2 31 239 TABLE III. Home Conditions—57 Cases. Mother Father Dead 11 . Dead 9 Very dull or defective 3 Delinquent 3 Psychotic or borderline 5 Psychotic or borderline 1 Chronically neurotic 13 Chronically neurotic 4 Stepmother Parents Psychotic 1 Divorced 3 Cruel 2 Separated 2 Child Pronounced marital disharmony 11 Illegitimate 9 Adopted 7 Care and Protection Cases 2 In a Home 1 47 TABLE IV. Analysis of Intelligence of 143 Children. 40-49 50-59 60-69 70-79 80-89 90-99 100-109 1 1 7 7 24 31 24 110-119 120-129 130-139 140-149 150-159 160-169 170-179 21 16 6 2 2 — 1 Average I.Q. 104. TABLE V. Analysis of Ages of Children Referred. 0-1 1-2 2-3 2-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 1 0 0 3 2 6 8 22 20 14 18 11-12 12-13 13-14 14-15 15-16 16-17 17-18 15 9 18 15 5 1 1 Average age 9.9. 6 pre- school, 88 primary, 57 secondary, 7 aged 15 plus. TABLE VI. Special Recommendations—17 Children. Number recommended for schools or hostels for maladjusted children 9 Number recommended for ordinary boarding schools 2 Number recommended for schools for educationally sub-normal children 2 Number recommended for Camp schools 2 Change of Day School 1 Naval training I 17 SPEECH THERAPY. The report of the speech therapist for the year's work is as follows : Speech treatment was given at the following centres :— Mattock Lane Health Centre. Greenford Green Health Centre. Ravenor Park Health Centre. Oldfields School. Cherington House Health Centre. Northolt School Perivale Health Centre. Little Ealing School. The following received treatment :— Stammer 47 Cleft Palate 7 Dyslalia 67 Other defects 3 Attendance.— Good except during bad weather in January, February and during holidays. School Visits.—62 schools visited ; 86 parents interviewed.; approximately 300 children examined. New Patients.—69 new cases admitted for treatment. Discharges.—43 discharged, two of whom have left school, 4 left the district. General.— No treatment was carried out between June and September owing to a change in personnel. Co-operation of school staffs has been very good, and a regular contact with parents has been maintained in most cases. Those working, and therefore unable to attend regularly being kept in touch by weekly notes. 48 DENTAL INSPECTION AND TREATMENT. A complete review of this service was made during the year because of the increasing amount of work placed upon it. It was apparent from this survey that the dental service was quite inadequate to meet current demands and recommendations were therefore made by the Council to the Middlesex County Council for the expansion of the service including an increase in the establishment of dental officers and dental attendants. It was proposed that eventually the establishment should be doubled by the addition of three dental officers and a like number of attendants, the appointment of one additional dental officer and one attendant to be immediate. A further proposal was made for the setting up of an orthodontic clinic at one of the existing health centres with only slight modification of premises and for the employment there of a part-time orthodontist and whole-time dental attendant to provide for the treatment of children suffering from maloclusion. From comparison of statistics over the past ten years it was apparent that the calls on the service had become more numerous not only in respect of treatment required by school children but also in respect of treatment for maternity and child welfare cases. A potential population of 34,320 persons eligible for treatment was being undertaken by three dental surgeons and a similar number of attendants. Consideration was therefore given to the provision of dental clinics at the proposed new health centres in the South Ealing area and in the West Twyford area, and this was visualised when the increase in the establishment was proposed. It is hoped that some of the proposals made will be put into operation during the ensuing year. The inspection and treatment of school children was carried out during the year and all school children in maintained primary and secondary schools were inspected. The detailed report of the Senior dental officer is set out below:— Dental inspection and treatment was carried out during the year by three full time dentists. This year was the first since 1939 that the full number of dentists on a full time basis, were employed. The whole of the work was performed at the five health centres situated in the various areas of the borough. The dental inspections were carried out in the schools, and a certain number of specials were also inspected at the centres. The actual numbers inspected and treated are as follows, and will be compared with the figures given for the previous year. The total number of children inspected was 20,611. The number for 1946 being 19,823, an increase of 788 over the latter year. The number of children found to require treatment totalled 49 8,555. The number of children receiving treatment, and actually completed was 6,105. Those found to require treatment in the previous year totalled 8,905, and the number actually treated for the same year amounted to 5,920; which represents an increase in the number treated, and a decrease in the number found to require treatment for the present year. The number of attendances made at the centres for treatment totalled 11,254. The actual work involves the various forms of treatment required to render the month sound and healthy. It includes : fillings, extractions, gum treatment, orthodontic treatment, scaling, dentures, crown and inlay work, and minor forms of surgery. The number of permanent fillings inserted totalled 4,830. This number is smaller by 194 than that obtained in the previous year. The number of temporary teeth filled totalled 866, an increase above this series of teeth filled in 1946 by 485. The efforts of the dentists is to preserve the temporary teeth until they are naturally lost, as early removal means that the permanent series will possibly be irregular. The number of permanent and temporary extractions amounted to 1,499, and 4,489 respectively. The former is greater by 308, and the latter figure is smaller by 2,036 to the figures given for the previous year. The permanent extraction rate includes a large number removed for orthodontic purposes, and it does not represent the number of teeth that were extracted on account of extreme decay and sepsis. The number of sessions devoted to the work totalled 1,128½, and the number of sessions given by the dentists for inspections at the schools, amounted to 124½. The work performed for other operations involved 4,231 items of treatment. The most important of these operations being the fitting of orthodontic appliances, and the subsequent adjustments (which are many) that are required to complete this treatment, and may take from six months, up to two years to finish. The next important treatment under other operations is treatment for different forms of gum infections. This again takes a large number of visits to cure the condition, and the number of children requiring this treatment is unfortunately increasing. Many temporary teeth were saved by the use of silver nitrate application, thereby increasing the total number of these teeth that could be retained for a longer period in the gums. The figure for this is in the total given for other operations. 50 SCABIES. The treatment of scabies was continued during the year with benzyl benzoate. The number of school children treated has for the past five years gradually decreased as will be seen from comparison of the figures given below :— Number of School Children treated for Scabies. Year No. of Cases 1943 622 1944 473 1945 345 1946 348 1947 343 The school health service also undertakes the treatment of other cases of scabies and these are referred to the health centres by general practitioners and factory medical officers. All who attended the health centres were encouraged to bring their relatives or others living in contact with them if there was any likelihood that they were suffering from the same condition. INFESTATION WITH VERMIN. The number of pupils found to be infested during the year was very low and it is an excellent tribute to the general cleanliness of children in the borough to note that out of 45,274 examinations made it was only found necessary to issue two cleansing orders for the compulsory cleansing of children under the authority's arrangements. The cleanliness surveys were conducted as usual on three occasions during the year and carried out by the school nurses. Statistics relating to this section of the work will be found on page 57, Table V of this Report. INFECTIOUS DISEASE. A summary of the returns submitted by the heads of schools giving particulars of all new cases of infectious disease which came to their knowledge is set out below :— Condition. No. of cases. Measles 806 Whooping Cough 310 Chicken Pox 830 Mumps 262 Ringworm 9 Scabies 62 Sore Throat 268 Other 387 51 POLIOMYELITIS. A total of 67 cases of poliomyelitis were notified in the borough from July to December, the diagnosis being confirmed in 46 cases or 0.25 per 1,000 population at all ages. The first case occurred at the end of July and the outbreak rapidly increased to a maximum during August and September and then gradually declined during the last three months of the year. The disease mainly affected the more heavily populated residential areas of the borough, especially Greenford, Perivale and South Ealing. 24 cases occurred amongst children of school age the attack rate at ages being :— 0-4 years 0.77 per 1,000 5-14 years 1.06 per 1,000 15 upwards 0.06 per 1,000 There was a uniform scatter of cases in school departments in those areas mainly affected and on detailed investigation there was no evidence that attendance at school in any way affected the incidence and in no case was direct contact at school found to be responsible for the spread of the disease. On the occurrence of a case of poliomyelitis in a child of school age, the following measures were adopted:— (1) Child and direct home contacts were excluded from school for a minimum period of three weeks. (2) The child was transferred to Clayponds Isolation Hospital for treatment during the initial period. (3) The child's home was visited and full particulars of home conditions and contacts reported. (4) School was visited, headmaster or headmistress informed, class was inspected and measures taken to ensure adequate spacing of desks and ventilation. Domestic arrangements for school meals inspected and food helpers interviewed. The headmaster usually notified parents of other children in the class where a case of poliomyelitis had occurred. (5) By arrangement with the education department competitive games and sports days were restricted to avoid undue fatigue. (6) Full chlorinisation of all swimming baths in the borough and measures taken to avoid overcrowding in swimming baths, and paddling pools. The large number of cases during August and September necessitated the opening of a poliomyelitis treatment ward at the Clayponds Isolation Hospital. All cases admitted were under supervision of the orthopaedic surgeon from the commencement and where necessary patients were later transferred to the Royal 52 National Orthopaedic Hospital, Stanmore, for further remedial treatment. As was inevitable, some children' notified as having poliomyelitis were subsequently found not to have the disease on investigation in hospital, although this error was not great considering the uncertainty of clinical diagnosis in the initial stages of the disease. On the other hand a few children with slight muscle weakness, probably due to missed poliomyelitis have been referred to the school orthopaedic clinic. Fortunately, in these cases paralysis has been very slight and prognosis good, with adequate supervision and treatment. All cases discharged from hospital are carefully followed up in the school health department under the supervision of the orthopaedic surgeon and attend for physiotherapy and remedial exercises when this is necessary. Employment of Children and Young Persons. The number of children examined in connection with their employment out of school hours was 193 and of these 6 were found unfit for employment. The nature of employment of those considered fit was :— Boys. Errand Boy 52 Milk Round 27 Newspaper Round 75 Bakers Round 11 Others 6 Girls. Shop Assistant 9 Others 7 187 53 STATISTICAL TABLES. The tables required by the Ministry of Education are as follows : TABLE I. MEDICAL INSPECTION OF PUPILS ATTENDING MAINTAINED PRIMARY AND SECONDARY SCHOOLS. A. Periodic Medical Inspections. Number of Inspections in the prescribed Groups : Entrants 2,373 Second Age Group 2,107 Third Age Group 2,250 Total 6,730 Number of other Periodic Inspections – Grand Total 6,730 B. Other Inspections. Number of Special Inspections 4,545 Number of Re-Inspections 1,846 Total 6,391 C. Pupils found to Require Treatment. Number of Individual Pupils found at Periodic Medical Inspection to require Treatment (excluding Dental Diseases and Infestation with Vermin). Group For defective vision (excluding squint) For any of the other conditions recorded in Table IIA Total individual pupils (1) (2) (3) (4) Entrants 2 180 182 Second Age Group 90 119 209 Third Age Group 115 94 209 Total (prescribed groups) 207 393 600 Other Periodic Inspections — — — Grand Total 207 393 600 54 TABLE II. A. RETURN OF DEFECTS FOUND BY MEDICAL INSPECTIONS Defect or Disease Periodic Inspection Special Inspections No. of defects No. of defects Requiring treatment Requiring to be kept under observation but not requiring treatment Requiring treatment Requiring to be kept under observation but not requiring treatment (1) (2) (3) (4) (5) Skin 38 7 1269 82 Eyes— (a) Vision 207 3 152 9 (6) Squint 34 1 27 6 (c) Other 8 5 308 43 Ears— (a) Hearing 8 4 36 2 (6) Otitis Media 3 5 44 2 (c) Other 10 10 201 16 . Nose or Throat 112 344 453 145 Speech 5 8 36 14 Cervical Glands 4 23 16 18 Heart and Circulation 2 61 8 27 Lungs 18 93 73 49 Developmental— (a) Hernia 2 9 4 — (6) Other 6 25 44 16 Orthopaedic— (a) Posture 12 34 6 — (b) Flat foot 34 32 39 7 (c) Other 50 47 95 30 Nervous system— (a) Epilepsy — 9 4 1 (6) Other 15 20 29 32 Psychological— (a) Development — — — — (b) Stability — — — — Other 40 120 767 255 55 B. CLASSIFICATION OF THE GENERAL CONDITION OF PUPILS INSPECTED. Age Groups Number of Pupils Inspected A (Good) B (Fair) C (Poor) No. % of Col. 2 No. % of Col. 2 No. % of Col. 2 (1) (2) (3) (4) (5) (6) (7) (8) Entrants 2,373 454 19.13 1,840 77.54 79 3.33 Second Age Group 2,107 369 17.51 1,691 80.22 47 2.27 Third Age Group 2,250 460 20.44 1,750 77.78 40 1.78 Other Periodic Inspections — — — — — — — Total 6,730 1,283 19.06 5,281 78.47 166 2.47 TABLE III. TREATMENT TABLES. GROUP I.— MINOR AILMENT (excluding Uncleanliness, for which see Table V). Number of Defects treated, or under treatment during the year Skin. Ringworm—Scalp : (i) X-Ray treatment — (ii) Other treatment — Ringworm—Body 25 Scabies 343 Impetigo 110 Other skin diseases 773 Eye Disease 197 (External and other, but excluding errors of refraction, squint and cases admitted to hospital) Ear Defects 295 Miscellaneous 799 (e.g. minor injuries, bruises, sores, chilblains, etc.) Total 2,542 (6) Total number of attendance at minor ailments clinics . 10,620 56 GROUP II.— DEFECTIVE VISION AND SQUINT (excluding Eye Disease treated as Minor Ailments—Group I). No. of defects dealt with Errors of Refraction (including squint) 1,366 Other defect or disease of the eyes (excluding those recorded in Group I) 18 Total 1,384 Number of pupils for whom spectacles were (a) Prescribed 1,312 (6) Obtained 1,315 GROUP III.— TREATMENT OF DEFECTS OF NOSE & THROAT. Total number treated Received operative treatment— (a) for adenoids and chronic tonsillitis 202 (b) for other nose and throat conditions — Received other forms of treatment 51 Total 253 GROUP IV.— ORTHOPAEDIC AND POSTURAL DEFECTS. (a) Number treated as in-patients in hospitals or hospital schools 8 (b) Number treated otherwise, e.g. in clinics or out-patient departments 138 GROUP V.— CHILD GUIDANCE TREATMENT AND SPEECH THERAPY. Number of pupils treated— (a) Under Child Guidance arrangements 1ll (b) Under Speech Therapy arrangements 317 57 TABLE IV—DENTAL INSPECTION AND TREATMENT. (1) Number of pupils inspected by the Authority's Dental Officers:- (a) Periodic age groups 19,410 (b) Specials 1,201 (c) Total (Periodic and Specials) 20,611 (2) Number found to require treatment 8,555 (3) Number actually treated 6,105 (4) Attendances made by pupils for treatment 11,254 (5) Half-days devoted to:— (a) Inspection 124 (b) Treatment 1,128 Total (a) and (b) 1,253 (6) Fillings:— Permanent Teeth 4,830 Temporary Teeth 866 Total 5,696 (7) Extractions:— Permanent Teeth 1,499 Temporary Teeth 4,489 Total 5,988 (8) Administration of General Anaesthetics for extraction 1,693 (9) Other Operations (a) Permanent Teeth 4,231 (b) Temporary Teeth — Total (a) and (b) 5,924 TABLE V. INFESTATION WITH VERMIN. (1) Total number of examinations in the schools by the school nurses or other authorised persons 45,274 (2) Total number of individual pupils found to be infested 887 (3) Number of individual pupils in respect of whom cleansing notices were issued (Section 54 (2), Education Act, 1944) 41 (4) Number of individual pupils in respect of whom cleansing orders were issued (Section 54 (3), Education Act, 1944) 2 Ealing and Brentford & Chiswick Hospitals Committee CLAYPONDS ISOLATION HOSPITAL PERIVALE MATERNITY HOSPITAL ANNUAL REPORT OF THE MEDICAL SUPERINTENDENT FOR THE YEAR ENDING 31st MARCH, 1948 REGINALD LEADER, M.R.C.S., L.R.C.P., D.P.H., Medical Superintendent. 3 Town Hall, Ealing, W.5. 26th April, 1948. Madam Chairman, Ladies and Gentlemen, I have the honour to submit to you the Annual Report on the hospitals for the year 1947-1948. I wish first; to draw your attention to the increased number of admissions into Clayponds Hospital during this period, an increase of over 21% as compared with the previous year and a truly meritorious performance considering the shortages of nursing staff which at times have been acute. The average daily number of patients, while well within the bed capacity of the hospital, has risen from 21.3, to the figure of 30.4, and this was mainly due to the 96 notified cases of poliomyelitis during the epidemic which swept through the two boroughs in 1947. Clayponds had its full share of this and all the various types of the disease were admitted and treated, so that when the Ministry produced their film on Poliomyelitis for the benefit of health authorities throughout the country it was natural that this hospital should be selected as one of the three that collaborated to supply cases. It is gratifying to note that it was found possible this year to commence the scheme for the operative treatment of tonsils and adenoids and so reduce the long waiting lists of cases that had accumulated in the previous years. In all, 368 cases were admitted and had the operation. It is to be noted that of the 39 patients admitted as suffering from diphtheria, only two were in fact cases of diphtheria, with of course no deaths; a testimony to the control of this disease by the Public Health Departments in the respective areas. In my experience, Gastroenteritis and Whooping Cough are now without doubt, the two most serious of infantile diseases, and the most fatal in infants under the age of one year, and all avenues of prevention and treatment merit exploration. It will be remembered that the Ministry of Health last year in conjunction with the Central Midwives Board advised that patients could be discharged from maternity units on the tenth day instead of the fourteenth, and although the average stay in Perivale during the last year has been slightly over 12 days, it was found possible to admit the record number of 1,301 patients. 4 This is a tremendous achievement for both medical and nursing staff, and in effect means that the hospital is practically doing the work of a 60 bedded hospital. Under such conditions some variation of the recommendations of the Midwives Salaries Committee might be considered justifiable, especially with regard to senior staff who in such circumstances may have additional responsibility. The record of emergency cases is good, and it is pleasing to note that additional equipment has been added this year to deal wich premature babies. In conclusion, I take the opportunity of thanking the members of the Committee for their generous support on all occasions. I also wish to mention Dr. George Taylor who acted as my deputy at Clayponds, and Dr. Dorothy Taylor, my deputy at Perivale; and throughout my period of office I have had the unfailing help and guidance of your Clerk, Mr. Harry Birrell. I am, Ladies and Gentlemen, Your obedient Servant, REGINALD LEADER, Medical Superintendent. 5 CLAYPONDS ISOLATION HOSPITAL The total number of patients admitted to Hospital in the year 1947-48 was 463. The highest number of patients in hospital on any day was 47, on March 24th, 1948, and the lowest was 11 + 5 T.A. on Mav 5th, 1947. The average daily number was 30.4. The following table indicates the number of cases of each disease admitted during the year. Disease Remaining in Hospital, 31st March, 1947 Admitted during the year Discharged during the year Died during the year Remaining in Hospital, 31st March, 1948 Scarlet Fever 5 118 — 1 — Diphtheria — 2 1 — 1 Meningitis 2 2 4 — — Measles 10 41 — — — Chickenpox — 14 — — — Mumps 1 9 — — — Puerperal complications 1 4 5 — — Gastroenteritis 1 35 — 5 — Dysentery — 6 — 1 — Erysipelas — 17 17 — — Poliomyelitis — 61 — 5 1 Whooping Cough 2 34 — 3 — Tonsilitis — 45 — — — Pneumoccocal infections — 10 — — — No abnormality detected — 8 8 — — Pyraxea of unknown origin — 8 8 — — Bronchitis — 7 7 — — Laryngitis — 6 6 — — Otitis Media — 3 3 — — Sinusitis — 2 1 — 1 Pyelonephritis — 2 2 — — Urticaria — 2 2 — — Pharyngitis — 5 5 — — Abortion — 2 2 — — Rubella — 1 1 — — Furunculosis — 1 1 — — Syphilis — 1 1 — — Post Tonsillectomy exudate — 1 1 — — Paroxysmal tachycardia — 1 1 — — Scabies — 1 1 — — Tinea vesicolor — 1 1 — — Tuberculous meningitis — 1 — 1 — Rheumatism — 1 1 — — Cerebral haemorrhage — 1 — 1 — Cervical adenitis — 1 1 — — Neuritis — 1 1 — — Ringworm — 1 1 — — Submaxillery cellulitis — 1 1 — — Infective dermatitis — 1 1 — — Drug eruption — 1 1 — — Vincents' angina 1 1 2 — — Nursing Mothers 1 — 1 — — Pelvic sepsis — 1 — — 1 Migraine — 2 2 — — 6 Diphtheria. There were 39 notifications of which only 2 gave bacteriological proof of diphtheria. Neither of these cases was severe; one patient had been actively immunised. These figures include 4 cases notified as laryngeal diphtheria which proved to be non-diphtheritic laryngitis. In addition, 3 suspected carriers were investigated and found to be free from infection. One case was diagnosed as cerebral haemorrhage and died shortly after admission. Another succumbed from acute bronchopneumonia. The following cases were admitted as suffering from diphtheria and the diagnosis altered as shown. Tonsillitis 25 Laryngitis 4 Scarlet fever 2 Mumps 1 Vincents' angina 1 Post tonsillectomy exudate 1 Cerebral haemorrhage 1 Bronchopneumonia 1 Chickenpox 1 Scarlet Fever.—Scarlet Fever admissions numbered 118, (57 from Ealing and 61 from Brentford & Chiswick). The age distribution of the cases was as follows: Under 1 1-2 3-5 6-10 11-15 16-24 25 and over 1 13 44 41 11 6 2 The following complications were encountered either on admission or during the course of treatment: Otitis Media 7 Rhinitis 5 Cervical adenitis 4 Chickenpox 3 Secondary tonsillitis 3 Measles 3 Whooping Cough 2 Serum reaction 2 Bronchopneumonia 3 Furunculosis 1 Bronchitis 1 Herpes labialis 1 Pemphigus 1 Myocarditis (mild) 2 The patient under 1 year developed acute broncho-pneumonia which proceeded to empyema and the infant died. The case of pemphigus was a recurrence of a persistent staphylococcal infection that proved very resistant to treatment. The cases of chicken-pox were admitted in that state. One case was admitted while incubating measles and cross-infected 2 others. Two sisters were admitted suffering from scarlet fever and severe whooping cough. The following cases were notified as Scarlet Fever but diagnosis had to be amended as shown: Tonsillitis 7 Tinea vesicolor 1 7 Measles 3 Urticaria 1 Rubella 1 Poliomyelitis 1 Conversely, a case notified as diphtheria proved to be scarlet fever, as did one notified as poliomyelitis. Meningitis.—There were two proved cases of cerebro-spinal meningitis both of which had full recovery. Other cases that were notified as meningitis were found to be : Lobar pneumonia 2 Tonsillitis 1 Poliomyelitis 1 Measles.—41 cases of measles were treated, 13 from Brentford & Chiswick, 27 from Ealing, and 1 from Isleworth. All cases recovered. One case notified as scarlet fever was later diagnosed as measles. Other cases notified as measles had to be amended as follows : Scarlet fever 2 Drug eruption 1 Gastro enteritis 1 Three cases were admitted with the double infection of measles and whooping cough. Complications: Bronchopneumonia 8 Whooping Cough 3 Tuberculous abscess 1 Otitis media 5 Hilar adenitis 2 Whooping Cough.—There were 34 cases, 12 from Brentford & Chiswick and 22 from Ealing. One case died within 3½ hours of admission. Another died from cerebral thrombosis after 34 days in hospital. A third death was due to whooping cough and gastroenteritis. All of those patients were under 1 year. The age distribution was as follows : Under 1 year 1-2 2-5 Over 5 14 5 7 8 Complications: Bronchopneumonia 7 Cellulitis 1 Gastroenteritis 3 Axillary Abscess 1 8 Furunculosis 1 Osteomyelitis 1 Eczema 1 Convulsions 2 Two cases of concurrent scarlet fever, and 3 of measles have already been included under those headings. Cases notified as whooping cough and otherwise "diagnosed were : Pneumonia 3 Bronchitis 4 Tonsillitis 1 Intestinal Diseases. (a) Gastroenteritis is still the most serious of infantile diseases. Of 35 cases, 23 were infants under a year and 4 of them died ; there were no other deaths. Age incidence: 0-1 1-2 2 and over 23 5 7 = 35. One died within 40 minutes of admission; a Coroner's Postmortem examination confirmed diagnosis. Another succumbed to the double infection of gastro-enteritis and whooping cough. Another was recovering from a severe attack when he developed broncho-pneumonia which precipitated his death. One infant, of 3 months, with a severe infection had 2 severe relapses and death seemed imminent. He was transferred to the M.R.C. Unit in Princess Louise Hospital for a course of streptomycin. He made a complete recovery. (b) 6 cases of Sonne dysentery were treated, 3 from Chiswick and 3 from Ealing. One infant of 9 months developed bronchopneumonia and died. Post-mortem examination confirmed diagnosis and showed typical extensive dysenteric ulceration. Cases notified as typhoid fever were found to be respectively: coliform pyelonephritis, pelvic sepsis and pneumococcal septicaemia with cerebral abscess formation. Erysipelas.—There were 17 cases, all of which recovered uneventfully. Chickenpox.—14 cases were treated in hospital, usually because nursing facilities were not available at home, or because of concomitant maladies. 9 Other conditions present were: Gastroenteritis 1 Impetigo 1 Pneumonia 2 Erysipelas 1 Abscess of leg 2 Otitis media 1 Leukaemia 1 Cellulitis 1 Two of the cases had been notified as poliomyelitis and smallpox respectively. One case notified as chickenpox was diagnosed as secondary syphilis. Mumps.—91 cases of mumps were admitted. One developed sub-maxillary adenitis. Two adults were admitted because of complicating orchitis. Two cases had chickenpox in addition. Puerperal Complications.—There were 3 cases of puerperal pyrexia and one post-partum haemorrhage. All were mild and recovered uneventfully. Poliomyelitis.—There was an unprecedented epidemic of infantile paralysis, most of the cases occurring during the Summer. Of 61 cases, 27 occurred in the Chiswick and 34 m the Ealing areas. The accompanying diagram gives an analysis of the cases. Type of Disease Age in Years. Over 30 Total 0-1 1-2 2-3 3-5 5-10 10-15 15-20 20-30 Abortive — — 2 2 6 4 — — — 14 Meningeal — — — 2 1 1 — — — 4 Spinal 4 5 — 4 7 3 2 4 3 32 Encephalitis — — 2 — 3 2 1 2 1 11 4 5 4 8 17 10 3 6 4 61 There were 5 fatal cases, all children. 25 cases were transferred to the National Orthopaedic Hospital (or its convalescent home) at Stanmore for physiotherapeutic and orthopaedic treatment. One adult is still awaiting transfer to Stanmore Hospital. One adult was transferred to Royal Naval Hospital, Haslar for further treatment. One case notified as scarlet fever proved to be polioencephalitis. Other cases notified as poliomyelitis were later diagnosed as: Pyrexia of unknown origin 6 Pharyngitis 4 Laryngitis 1 Bronchitis 2 Tuberculous meningitis (fatal) 1 Sinusitis 1 Tonsillitis 6 Cervical adenitis 1 Scarlet Fever 1 Gastro-enteritis 1 Rheumatism 1 No abnormality detected 5 10 Migraine 2 Urticaria 1 Neuritis 1 Chickenpox 1 » Operations for Removal of Tonsils and Adenoids.— 368 cases. The operation sessions were increased from two to three each week as from 28/4/47, in view of the waiting list of cases. All operations were suspended during the period 24/7/47 to 11/1/48, owing to the poliomyelitis outbreak. Staff Illnesses.—6 members of the staff have been ill during the year suffering from: Appendicitis 2 Appendicectomy performed in each case at King Edward Memorial Hospital. Tonsillitis 1 Cervical Adenitis 1 Sonne Dysentery 1 Cardia Debility Basal Bronchiolitis, Tachycardia 1 Consultant Staff.--The following Consultants were called in during the year. Mr. Miller 1 visit Dr. Maurice Shaw 5 visits Mr. Freeman Heal 1 visit Mr. Murray 2 visits Mr. Cholmeley 23 visits recorded 11 * PERIVALE MATERNITY HOSPITAL Annual Report for Year 1st April, 1947 to 31st March, 1948. During the year 1st April, 1947 to 31st March, 1948, 1,301 patients were admitted to the hospital. These included 14 emergency cases. Month Ealing Brentford & Chiswick Other Districts Total April 80 27 — 107 May 82 27 — 109 June 80 28 — 108 July 79 29 — 108 August 75 26 — 101 September 99 24 — 123 October 86 21 — 107 November 92 25 — 117 December 89 23 — 112 January 89 16 — 105 February 79 28 — 107 March 71 26 — 97 1,001 300 — 1,301 The greatest number of patients in hospital on any day was 58 on 11th June, 1947. The average period of stay was 12.385 days. Emergency Cases. The 14 emergency cases admitted were as follows : 1. A primipara aged 26 years, a midwife's case. Admitted from the ante-natal clinic as a toxaemia of pregnancy. She had oedema and hypertension which responded to treatment. She was discharged. She was later re-admitted in labour and delivered herself normally. Both mother and child were well on discharge. 2. Gravida 2 (previous stillbirth) aged 27 years, a Midwife's case. Admitted from the ante-natal clinic with severe anaemia. This was treated by iron, liver and blood transfusion. She was then transferred to a Convalescent Home to await delivery. She was admitted in labour and had a normal delivery and puerperium. Both mother and child were discharged well. 3. Gravida 3 aged 28 years, a midwife's case. Admitted from the district as an emergency. A transverse lie was found with prolapse of the hand. The foetal heart failed shortly after admission. An internal version was performed and a leg pulled down. She was delivered of a full time infant which was stillborn. 12 She was discharged in a satisfactory condition to the midwife after 3 days in hospital. 4. Primipara, aged 22 years, sent in by her doctor. She was admitted in labour and delivered of a 4 lb. premature infant. The duration of pregnancy was thought to be 32 weeks. The infant survived for eleven days and then died suddenly. No cause was found for the premature labour. The mother was discharged well. 5. Primipara, aged 25 years. Sent in by her own doctor. She had a primary uterine inertia and had been in labour for 2 days before admission. Forceps were applied on full dilatation of the cervix and she was delivered of a living full term child. The placenta was expelled normally but the patient lost 45 ozs. of blood and became very shocked. She was given 2 pints of plasma and one pint of blood. Her condition improved rapidly and she was sent home to the care of her own doctor on the seventh day, both she and the baby being in a satisfactory condition. 6. Gravida 3, aged 41 years, sent in by her Doctor. She was admitted as an ante-partum haemorrhage. On admission the placenta was felt lateral to the os. The membranes were ruptured and a foot was brought down. The foetal heart failed and she was delivered of a stillbirth weighing 4 lbs. 8 ozs. The placenta was expelled normally and the total loss was about 30 ozs. She was treated for toxaemia and was discharged in a satisfactory condition. 7. Gravida 6, aged 37 years, sent in by own doctor. On admission it was found that she had given birth to a live child 3 hours previously weighing 3½ lbs. and about six weeks premature. The condition of mother and child was good. No cause was found for the premature labour. The mother was discharged on the 10th day and attended subsequently for breast feeding. The child was discharged on the 57th day when it weighed 5 lbs. 8. Primipara, aged 32 years, sent in by her own doctor. She gave a history of being in labour for two days. She delivered herself normally but developed a pyrexia of unknown origin and was transferred to Clayponds Hospital on her 3rd day. The baby was shocked at birth and was transferred to Clayponds as soon as it was fit. 9. Primipara, aged 31 years, a midwife's case. Admitted from the ante-natal clinic with hypertension and oedema. She improved under treatment. Surgical induction was carried out and labour commenced with irregular pains. After 48 hours of irregular contractions the foetal heart became irregular. Forceps were applied and the child delivered, but it failed to respond to resuscitation. During the puerperium the mother developed pyelitis 13 which cleared with treatment. She was discharged on her 12th day with slight residual hypertension. 10. Primipara, aged 22 years. Sent in by her own Doctor. She had been delivered at home by forceps and was suffering from an extensive 2nd degree tear. This was repaired. The puerperium was normal and baby and mother were discharged well. 11. Gravida, 3 aged 32 years, a midwife's case. Admitted from the ante-natal clinic with hypertension. She had a surgical induction after 3 weeks medical treatment in hospital. The confinement was normal and both mother and child were discharged fit. 12'. Primipara, aged 22 years, a midwife's case sent in by Doctor. She had had a forceps delivery on the district with an extensive perineal tear. This was sutured and healed well. She ran a temperature (which was controlled by penicillin) during the first few days in hospital. She was discharged with the baby on her 10th day, both being fit and well. 13. Gravida 3, aged 26 years. She was admitted with lower abdominal pains. This subsided with rest and she was discharged with the diagnosis of threatened premature labour after 9 days. 14. Gravida 3, aged 32 years, a midwife's case. She was admitted from the clinic with a high blood pressure. This did not respond to medical treatment and surgical induction was performed. She had a normal delivery of a full term child. She was discharged after 36 days in hospital to rest at home.. The child was satisfactory on discharge. Booked Cases. Ante-natal Cases admitted for Treatment. 159 patients were admitted during the pregnancy for treatment. The conditions for which they were admitted are as follows : Toxaemia 74 Hypertension 18 Oedema 4 Nephritis 1 Pyelitis 8 Haematuria 1 Cardiac 7 Anaemia 1 Phlebitis 1 Parkinsonism 1 Epilepsy 1 Enteritis 1 14 Influenza 1 Thrush 1 Fibroids 1 Trial Labour 10 Postmaturity 13 Hydramnios 2 Threatened miscarriage 1 Ante-partum haemorrhage 13 Abnormal Presentations. Persistent occipito-posterior 9 Twin pregnancy: (а) Vertices 9 (b) Vertex and breech 7 (c) Breeches 1 Breech: (а) Flexed Breech (1) Primipara 5 (2) Multipara 9 (b) Extended breech (1) Primipara 10 (2) Multipara 4 (c) Breech Extraction 2 Prolapsed cord 3 Transverse lie 3 Face 1 Vertex and prolapsed hand 1 Obstetrical Manipulations and Operations. Episiotomy 91 External version 12 Internal version 1 Rupture of membranes 33 Forceps Delivery. (а) Foetal distress 14 (b) Maternal distress 34 (c) Deep transverse arrest 11 Caesarian Section. (а) Classical: (1) Persistent transverse lie 1 (2) Breech in contracted Pelvis 1 (b) Lower Segment: (1) Primipara breech in contracted Pelvis 1 (2) Disproportion 1 Removal of dermoid cyst 1 Currettage 1 Biopsy of fibroid 1 Haemorrhages. Post Partum. (а) Moderate 106 (b) Severe 34 (c) Secondary 4 (d) Manual removal of placenta 13 Ante-Partum. (a) Accidental 11 (b) Placenta Praevia (lateral) 2 15 Notifiable Pyrexia 13 Uterine infection 3 Pyelitis 3 Basal congestion 1 Flushed breasts 3 Unknown aetiology 3 Non-notifiable Pyrexia during puerperium 62 Pyelitis 29 Flushed breasts 10 Uterine infection 17 Phthisis 2 Influenza 2 Streptococcal sore throat 1 Catarrhal jaundice 1 Other abnormalities. Obstetric shock 15 Eclampsia 3 Cardiac failure 1 Bartholins cyst 1 Patients transferred to other Hospitals. To Clayponds Isolation Hospital 3 (a) Haemolytic Streptococcal infection 1 (b) Unknown pyrexia 1 (c) Infective enteritis 1 To the Westminster Hospital 2 (а) Tumour of small intestine 1 (b) Essential hypertension 1 To King Edward Memorial Hospital with acute appendicitis 1 Maternal Deaths 1 This patient was admitted ante-natally with a pre-eclamptic toxaemia. She delivered herself spontaneously of a living child. She had a post-partum haemorrhage. The placenta was retained and was removed manually. She was very shocked. Bleeding persisted despite transfusion, etc., and became generalised from other mucous surfaces. Post mortem report—Death from obstetric shock and haemorrhage. INFANTS. Number of infants born 1,312 Males (alive) 654 Females (alive) 637 Stillborn 21 Neo-natal deaths 11 Still births. Fresh. (a) Full term 7 (b) Premature 3 (c) Deformities incompatible with life 4 Macerated 7 16 Premature Infants. Gestation Born alive Died 28-30 weeks 7 3 30-34 weeks 12 1 34-36 weeks 6 2 36-38 weeks 26 — Infants Weaned. Due to inadequate lactation of mother 3 Pulmonary tuberculosis in mother 3 Disease of breast in mother 5 Cardiac disease of the mother 2 Infants transferred to other Hospitals. To West Middlesex Hospital with Hypospadias ? imperforate urethra 1 To Great Ormond Street Hospital with laryngeal stridor 1 with erythroblastosis 1 To West London Hospital for investigation 1 To Queen Elizabeth Hospital with abscess of the back 1 To West London Hospital with Obstructive Jaundice 1 Consultants called in. Dr. J. W. Rait Bell on 15 occasions. Mr. Arnold Walker on 7 occasions. Mr. E. R. Rees on 5 occasions. Dr. Potter on 4 occasions. Dr. Newton on 1 occasion. Training of Pupils. During the year ended 31st March, 1948, 43 pupils completed their course of training and entered for the Part I examination of the Central Midwives Board. 36 pupils were successful.