439 (1) EA4M EAL 43 The Stealth of Ealing in the y,ear 1952 EAL 43 The Health of Ealing in the year 1952 being the ANNUAL REPORT OF THE Medical Officer of Health and School Medical Officer WILLIAM G. BOOTH, M.D., B.S., D.P.H., Medical Officer of Health. 2 INDEX Page. Section 1 .—INFECTIOUS DISEASES 7 Section 2.—SANITARY CIRCUMSTANCES OF THE BOROUGH 22 section 3.—SANITARY INSPECTION. 32 Section 4.—GENERAL 42 Section 5.—STATISTICAL TABLES 49 Section 6.—APPENDIX : REPORT OF THE SCHOOL MEDICAL OFFICER 54 Supplement.—FOR GENERAL INFORMATION 73 3 Mr. Mayor, Aldermen and Councillors of the Ealing Borough Council, It is pleasing to be able to record that not a single case of Diphtheria occurred in Ealing during 1952. This is the first time that this has happened, and is a signal tribute to the effectiveness of the linkage of medical science with local government to the benefit of the people. Immunisation of children against Diphtheria has been in the forefront of the Council's public health programme for twenty years or more and the educational work of the Council's Health Visitors can in no way be shown more effectively in its true perspective than in this result. The value of the services of the trained nurse who has been especially trained for her work as a Health Visitor is also shown in the dramatic fall in infant mortality over the last 25 years. It seems but a few years since we were admiring the New Zealand Infant Mortality figures of 25 per 1,000 births when our own were in the 50's, and expressing pious hopes that we might some day approach this amazing rate in this country. Now the rate for the country is 27.6 and Ealing is 22. For this someone should pay tribute to the patient educational force of the Health Visitor, who is undoubtedly mainly responsible. As a Medical Officer of Health of nearly 30 years' service, I should like to give my measure of praise to a service that I have relied upon implicitly and who have never let me down. The country has been well served by its Health Visitors and it is sad to find that they are a dying race. It is to be hoped that their value to the social fabric will be recognised before it is too late. In Ealing we had 16 Health Visitors and School Nurses in 1948 and we have now only 11. To that extent our health services have certainly suffered since the Borough lost its Maternity and Child Welfare powers under the National Health Service Act. The Health Visitors were the shock troops in our immunisation campaign—the fall in immunisation figures is inevitable if they are not available. It is poor policy which provides buildings for services and then is unable to give the services owing to lack of staff. That is the situation we are facing in Ealing. The work undertaken by the Borough as a Local Sanitary Authority as distinct from the work undertaken by the County Council in the Borough shows a lively and progressive spirit. In the pages of this report will be shown the way in which the Public Health Committee has tackled the most troublesome of these. We can now see the wisdom of taking a firm line with the nuisance of the caravan, and there is little doubt that, in spite of the difficulties, we are in sight of a solution. We are sticking obstinately to our long term policy of food hygiene as a Council responsibility, and that over 1,000 people in the food trades have attended our courses and that we have 49 establishments who have gained our certificate of hygiene, gives a measure of our success so far. 4 During the year concern was shown regarding the condition of the River Brent as it flows through Ealing on its way to the River Thames. Undoubtedly it has been contaminated at various points on its course and a County conference convened by Ealing has led to a more lively appreciation of the position and the prospect of a considerable improvement in the position as a result of our efforts. We have made it clear to all concerned that we intend to have a clear stream and not an open sewer in our midst. The laundry service for old people suffering from incontinency has become an established part of our Public Health work and now that we have got through the teething troubles there can be no question of the enormous relief given to the families of people in need of it. This is a small service which could only function where there is the will to make it succeed, and a reasonable size of area to cover. In Ealing's 180,000 population only about 25 persons seem to be regularly in need of the service and yet no section of the community is in worse necessity. It is always a sign of "liveliness" in a department when research is being undertaken and I am glad to inform the Council that the Public Health Department is not neglecting the possibilities of research. Unfortunately, the only officers who can undertake medical investigation are of course your Deputy, Dr. Binysh, and myself. I am pleased to inform you that Dr. Binysh has been carrying out some useful investigations into the results of whooping cough immunisation which have been very valuable to the laboratory services, whilst I (in conjunction with a County Council officer, Dr. Craigmile) have been continuing to investigate and trying to elucidate the prevention of foot deformities in children. Progress is slow, but our knowledge of the ramifications of this problem is widening. A matter of special concern to the health services during 1952 was the fog of December. How it affected Ealing is outlined in the report but its prevention in the future is a matter that needs government action of an energetic kind. That our deaths were about six times as high as they are normally at that time of the year is a matter of great concern and any action that can be taken to prevent this will certainly receive wholehearted support in Ealing. I have, I am afraid, little to say of the system under which the County Council has since 1948 taken over the control of the greater part of the health services of the Borough. The progress of time only emphasises the terrible mistake the Government made when for the sake of "tidy" administration they took the whole of the personal health services out of the hands of the Boroughs and put them into those of the 5 County Councils. Middlesex, of course, like London, is not a County in the same sense as other English counties. It is virtually a country of its own which needs to be broken down into reasonable units, none larger than Ealing for administrative purposes. That a major blunder has been made and should be rectified might well be admitted by the drafters of the National Health Service Act. We have given it a fair trial; now it is time to redraft the Act in order to save the services in Middlesex from the sterility of bureaucracy, for this is inevitable under the present expensive administrative plan. May I take this opportunity, as in former years, of expressing my high appreciation of the efforts of the staff during the year. I have the honour to be, Your obedient servant, W. G. BOOTH, Medical Officer of Health. 6 STAFF OF THE PUBLIC HEALTH DEPARTMENT William G. Booth, Medical Officer of Health m.d., b.s., d.p.h. (also Joint Area Medical Officer of Area 7 (Ealing and Acton), Middlesex County Council) H. Binysh Deputy Medical Officer m.d., b.s., d.p.h., d.t.m. & h. G. T. H. Blackie Chief Sanitary Inspector E. Belfield Deputy Chief Sanitary Inspector E. H. Evans Sanitary Inspector C. W. Baxter „ „ E. W. Budd „ „ E. S. Herbert (resigned 29/12/52) „ „ D. J. Huggins (resigned 15/4/52) „ „ A. E. PoolEy „ „ D.H.Smith „ „ G. O. Axon (appointed 18/4/52) „ „ A. C. Bamping (appointed 18/4/52) „ „ Harry M. Birrell Chief Administrative Assistant R. S. Leggatt Senior Clerk R. AngELL Clerk D. R. A. Smith J. T. Woolford „ (on National Service) Miss D. E. McKenzie Shorthand-Typist Mrs. M. G. Byford „ „ Mrs. D. Barker Clerk and Typist R. S. Cox Rodent Operative 7 SECTION 1. INFECTIOUS DISEASES Notification is the essential preliminary to control of infectious disease. The diseases notifiable under the Public Health Act, 1936, are smallpox, cholera, diphtheria, membraneous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fever. The Minister of Health has also made regulations whereby the following, diseases are also notifiable: plague, poliomyelitis, tuberculosis, puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute primary pneumonia, acute influenzal pneumonia, measles, whooping cough, acute encephalitis and meningococcal infection. Food poisoning is notifiable under the provisions of the Food and Drugs Act of 1938. Exclusion of the Case. School children with infectious disease are usually kept out of school for the following periods: Scarlet Fever Seven days after discharge from hospital or home isolation, unless there is a running nose or ear, sore throat or septic spots, in which case this may need to be extended. Diphtheria Depends on the clinical condition, but usually negative throat swabs are advisable before return to school. Measles 14 days from the appearance of the rash. German Measles 7 days from the appearance of the rash. Whooping Cough 28 days from the appearance of the characteristic whoop. Mumps 14 days from onset or 7 days after ance of all swelling. Chickenpox 14 days after appearance of the rash. Exclusion of Contacts. With the present mild character of most of the infectious diseases, exclusion of contacts from work is only carried out in exceptional cases, where there is a serious risk of spread of infection to others. School children are still excluded if they have been in contact with certain of the infectious fevers but the tendency is to keep this to the minimum to avoid unjustifiable loss of schooling. 8 Home Conditions. When a case of infectious disease is notified the home is visited by the health visitor, or by the sanitary inspector in certain cases, e.g., food poisoning, enteric fever, dysentery, or smallpox. Advice is given as to isolation, disinfection, and home nursing, in order to help prevent spread to others in the household. An attempt is also made to identify the source of infection and remove it where possible. Early Diagnosis. Since these diseases are as a rule most infective in the early stages, it is of prime importance that parents should put children to bed as soon as they appear "off colour" and call in their own family practitioner. It is most unwise to take a child with a rash or a spasmodic cough to a health clinic or doctor's surgery, where there is a risk of infecting others. The family doctor may in doubtful cases call in a consultant from Neasden Isolation Hospital. As part of the health education campaign topical leaflets are distributed through the Town Hall and the Public Libraries when any infectious disease is prevalent. Leaflets describing the essential points of home nursing of persons suffering from infectious conditions and advice as to disinfection are provided when necessary. Routes of Spread. The infectious diseases are caused by living organisms which pass from one person to another. There are two main routes of transmission depending on the main habitat of germs in the body, i.e., the bowels and upper respiratory tract (the nose and throat). The diarrhoeal diseases (enteric fever, dysentery, food poisoning and possibly poliomyelitis) are spread by contamination of food from the bowel, either by inadequate hand washing after the toilet, or by flies or vermin. The respiratory diseases are spread chiefly by droplets sprayed out when blowing the nose. "Coughs and sneezes spread diseases," especially when a handkerchief is not used; and if used, not frequently changed. Insect borne diseases and water borne diseases are now of comparatively minor importance in this country, but constant supervision by the sanitary engineers is essential to prevent any recurrence of the mass outbreaks of previous decades. 9 Disinfection. In recent years far more importance has been attached to the role of the sick person, convalescent, and healthy carrier in the spread of disease—and far less to transmission of disease by inanimate objects. Recent contamination by a sufferer, however, does render these objects infectious for some time and it is therefore of great importance to disinfect all crockery, utensils, handkerchiefs and dejecta by boiling, burning or chemicals as may be appropriate. Library books are disinfected where necessary by the Public Health Department. Terminal disinfection of rooms, bedding and blankets is not usually required after the common childhood diseases. A thorough spring clean with generous use of soap and water is now considered adequate. In certain exceptional cases, smallpox, typhoid and tuberculosis terminal fumigation may still be required and this can be carried out by the staff of the department. Hospitalisation. Persons suffering from certain severe infectious conditions may need hospital care and can be admitted to Neasden Isolation Hospital or to South Middlesex Hospital, Mogden. Laboratory Service. In many cases of diarrhoeal disease exact diagnosis can only be made by the examination of specimens of faeces or blood. The Public Health Department will arrange for the collection of specimens and transmission to the King Edward Memorial Hospital laboratory at the request of a general practitioner. A stock of nose and throat swabs for the diagnosis of diphtheria and pertussis is available at the Town Hall for the use of general practitioners. Food handlers and other persons whose work entails a special responsibility to the public often require bacteriological proof of freedom from infection before returning to work after illness, and this may also be required from children before entry to residential schools or hostels. Certification. International certificates of inoculation and vaccination must be authenticated by the local health officer; and certificates are also regularly given as to the purity and condition of manufacture of certain medicaments manufactured in the Borough and intended for export. 10 When contacts of infectious persons are excluded from work on account of potential risk to others, a certificate is provided to ensure the payment of benefits under the National Insurance Act. Diphtheria. For the first time since notification began there was no notified case of diphtheria during the year in Ealing. A graph is attached showing the dramatic fall in the incidence of attacks and deaths since the immunisation campaign started in 1941. In the 10 years 1932-1941 there were 1,038 cases and 50 deaths in Ealing. This decline does illustrate that preventive techniques when vigorously applied can lead to the almost complete disappearance of a previously common and dangerous illness. Had there been no immunisation campaign it is likely that there would still be about 100 cases of diphtheria annually in our Borough—costing roughly £10,000 pounds in hospital charges as well as the loss of a number of lives—with aU the misery that entails both to the patients and their families. It is regrettable that as the danger of diphtheria becomes more remote there is a tendency for parents to no longer insist on this protection for their children—but it is certain that the disease can and will return if we relax our guard. About half the annual cases of diphtheria are now occurring in a few industrial centres where there is an inadequate immunisation rate. During the year a total of 1,367 children received primary immunis ation at the clinics and 554 were immunised by the General Practitioners—a total of 1921. This is a substantial decline from the figures of 1950—2,446 and 1951—2,270, and one which I view seriously. During the year a steady effort was maintained by the Infant Welfare Clinics and at the school routine medical inspections to bring home the necessity of regular immunisation and booster doses. A more satisfactory position exists with regard to the number of booster doses of which 2,513 were given during the year (2,692 in 1951, 1,155 in 1950), 172 by the General Practitioners and the remainder at the Clinics. The combined alum free diphtheria/pertussis vaccine is now being generally used for primary immunisation with very satisfactory results. This vaccine can be used subcutaneously and minimises the risk of untoward effects. 11 12 Dysentery. 179 cases were notified during the year and in 96 the Sonne organism was discovered. The illness is usually a mild one—but recent investigations have shown that even after clinical recovery the organisms may be found in the patient's stool for many weeks—and such persons are liable to spread infection. The cases were all individual and small family outbreaks. There were 6 familial outbreaks involving 19 persons but no major outbreak in a school or nursery. When a person who suffers from dysentery is engaged in the food handling trades, return to work is not permitted until satisfactory laboratory results are obtained—and an explanation is given as to the importance of personal hygiene. Enteric Fever. There were no cases of Typhoid Fever. Two cases of Paratyphoid were notified. The first was an elderly woman, who was diagnosed as such during routine examinations for another condition while she was in the West Middlesex Hospital. She was symptomless and there was no evidence of the origin of the infection. It is possible she had been a carrier for some years. This patient subsequently died from another complaint. The second case was a child of 13 years who appears to have contracted it while on holiday in Wales, where other cases occurred in the town where she stayed. Enteric Fever Carriers. Only one carrier, a Paratyphoid, remains in the district. (Typhoid carriers mentioned in the previous year's report have removed from the district, which we note with a somewhat selfish satisfaction !) This carrier contracted the disease while on holiday in France in 1949. Since then she has been kept under surveillance and is fully aware of her responsibilities. Erysipelas. 26 cases were notified as against 16 in the previous year. There were no deaths. It has been held to be anomalous that while certain diseases caused by streptococci are notifiable, i.e., erysipelas, and scarlet fever, others such as tonsillitis and cellulitis are not. 13 There is little doubt that the virulence of the streptococcus has declined in recent years but such variations have been described for centuries and the return of the disease to its former severe form is not impossible. Chemotherapy has now greatly lessened the danger, but notification and isolation still remain essential parts of the control of the spread of infectious disease. Only 17 deaths occurred from this cause during the year in England and Wales as compared to 188 in 1941. Food Poisoning. There has been a gratifying reduction during the year of the number of cases of food poisoning and sonne dysentery. The "Clean Food" campaign has been pressed vigorously over the past four years so that many thousands of the key food workers of the Borough are now keenly aware of the risk of food infections and the methods of prevention. During the year 26 notifications were received (8 confirmed bacteriologically) as compared to 86 cases in 1951 (14 confirmed). The causative agent in 6 cases was Salmonella Typhimurium and in the other two B. Enteritidis and B. Aetrycke. The source of infection was not identified in spite of laboratory tests. Malaria. One case, a man of 41 years, who had contracted the disease in India, was diagnosed in Hendon Isolation Hospital. Measles. 993 notifications were received during the year, a great decrease from the 3,296 of the preceding year. The largest number ot cases occurred in the second quarter. At the end of the year there was a slight increase in the number of cases which was a prelude to the nation-wide epidemic of the Spring of 1953. There were no deaths. Measles is caused by a filtrable virus borne by droplet spray entering the nose and throat. The intense coughing, sneezing and watering of the eyes in the early stages resembles a common cold, and the sufferer has many opportunities to spread the condition. Children with these symptoms should be isolated, medical care obtained, and the blotchy rash looked for on the fourth day of illness. 14 Temporary protection can be obtained by use of "immune globulins "or" placental extracts" in special cases, such as a very ailing child exposed to severe risk of the disease, but no successful method of long term active immunisation has yet been discovered. Pneumonia. The number of cases declined in 1952 to 128 (28 influenzal) as compared to 197 (36 influenzal) in 1951. The number of deaths however rose from 93 in 1951 to 101 in 1952, two of which were due to influenzal pneumonia. From these figures it would appear that the mortality in Ealing of primary pneumonia is 99% and that of influenzal pneumonia is 7%. The fallacy lies in the fact that many cases of pneumonia are not notified but all deaths are reported to the Registrar. A similar situation at one time existed with regard to meningococcal infections so that in 1928 more deaths (438) were recorded than there were cases notified (412). Pneumonia is now readily treated in the young and vigorous but still has a high mortality in those at the extremes of life. Acute Anterior Poliomyelitis and Polio-Encephalitis. During the year there were 21 confirmed cases, 17 of which were paralytic and 4 non-paralytic. This represents a substantially more serious state of affairs than in 1951 when there were 10 cases, 3 of which were paralytic. One redeeming feature was the absence of deaths. Close co-operation was maintained during the year with the Medical Research Council Unit which is investigating the spread of poliomyelitis. Reports have recently been received from America of a method of passive immunisation of children using serum from convalescent patients. The method appears to have some value—but would be impractical except during epidemic times since the protection lasts only a few weeks and carries risks of certain complications such as homologous serum jaundice. A more hopeful line of attack is the use of a modified poliomyelitis virus vaccine for active immunisation. This is as yet in the early experimental stage but it does offer the promise of a practical method of prevention should the trials prove successful. 15 The following table shows the age distribution: Paralytic. Non-Paralytic. M. F. M. F. Under 1 1—2 5 1 3—4 1 5—9 1 1 1 10—14 2 1 15—24 1 2 1 25+ 2 1 1 Total 10 7 3 1 Psittacosis. During the year the ban on the import of parrots was relaxed following the finding of the psittacosis virus in several species of sea birds and domestic fowl. Thereafter there were several recorded cases and deaths in England and Wales thought to be due to imported parrots and the ban was reimposed on February 16th, 1953. There was no recorded human case in Ealing—but a parrot in a local pet shop which had been in contact with the disease sickened and died. The carcase was sent for post mortem investigation and meantime another bird in the shop also died. As a precautionary measure the entire stock of parrots in the shop was slaughtered and no human cases followed. Puerperal Pyrexia. There were again no deaths during the year from puerperal pyrexia but the number of cases rose from 38 to 70. Perivale Maternity Hospital 63 Private 6 Nursing Homes 1 This increase is due to the wider definition of this condition introduced in 1951 so that notifications are now received of comparatively minor upsets often quite unrelated to the pregnancy or delivery. There was no major outbreak at the hospital of any infective condition. Close co¬operation exists between the staff of the Perivale Maternity Hospital and the Public Health Department. It would appear likely that the large number of notifications received from Perivale Maternity Hospital as compared to the other local hospitals reflects only a more satisfactory system for notification. 16 Scarlet Fever. This disease is at present exhibiting a very mild form, often no more than a mild sore throat coupled with a characteristic rash—so that in spite of 402 notified cases (399 of which were confirmed), there was no death during the year. The method of active immunisation practised at one time is now in little use because of its limited value and the high incidence of reaction. The causative organism, the haemolytic streptococcus, may still on occasion give rise to severe illness—but control is readily available with the sulphonamides and antibiotics. Smallpox. One person from abroad who was a contact of the disease came to Ealing and was kept under daily surveillance until the end of the incubation period. The decline in the number of primary vaccinations has long been a source of concern. During the year 1,264 children under the age of 15 were vaccinated as compared to 2,416 live births in 1951, i.e., about 50%. The Infant Welfare Centres impress upon mothers the ease, simplicity and safety of primary infant vaccination. Until recently all infants were sent to the General Practitioners for vaccination but vaccination can now be performed at the clinic at the mother's request. Tuberculosis. There has been no marked change during the year with regard to the number of cases and deaths from tuberculosis in Ealing. The schemes which were mentioned in the previous Annual Report are all still in operation for the early detection and prevention of the disease. Young children are "Jelly Tested" at the Infant Welfare Clinics between the age of 2 and 3 years. The adolescent school leavers are Mantoux tested and B.C.G. vaccination performed on those who are Mantoux negative. The Chest Clinic follows up the contacts of notified cases of tuberculosis and B.C.G. vaccination is offered in appropriate cases. The Mass X-ray unit visited the Town Hall and the premises of Messrs. Hoover Ltd. in the summer months. The visit was a complete success and every appointment was booked before the unit actually commenced operations. Publicity was given by posters and through the local press. Bookings were made at the Town Hall, Public Libraries and local chemists. 17 A total of 9,067 persons were examined, of whom 61 required special investigation and further X-rays. It is hoped that such visits may become an annual event. A static Mass X-ray unit has been established at the Central Middlesex Hospital and this has proved of the utmost value for the regular examination of expectant mothers in the Borough attending the ante-natal clinics and other groups who are at special risk or who come into close contact with children. The following table shows the age and sex of the cases notified and the deaths in 1952. New Cases Deaths Age Periods Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F' m ale Male F' m ale Male F'male Male F'male 0—1 1 1 1 1—5 4 1 3 5—10 4 4 3 1 10—15 1 2 1 15—20 6 20 1 2 2 20—25 7 24 2 3 4 3 25—35 29 21 2 3 1 3 1 1 35—45 17 16 3 2 3 1 45—55 21 6 1 2 2 2 55—65 11 4 1 5 1 1 65 upwards 9 2 7 1 Total 110 101 12 17 24 13 2 1 The number of new cases of Pulmonary Tuberculosis notified was 211 compared with 210 in the previous year, while the number of cases of Non-Pulmonary Tuberculosis was 29 compared with 24 in the previous year. There was a total of 40 deaths (37 Pulmonary, 3 Non-Pulmonary) compared with 30 Pulmonary, 4 Non-Pulmonary in the previous year. 18 Whooping Cough. A graph is included showing the number of cases of whooping cough in the Borough since 1940 as compared to the number of cases in England and Wales during the same period. It can be seen that there was a close correlation between the figures until 1952 when there was a very steep decline in the number of notified cases in the Borough to 77, as compared to 550 in the previous year. This is the lowest number of cases recorded in Ealing since notification commenced in 1939. From the figures for England and Wales it would appear that we should have expected about 330 notifications during the year. Part, at least, of the diminution in the number of cases is due to the policy of immunisation of infants against whooping cough. During the year 1,778 children received primary immunisation against whooping cough (1,306 at the Infant Welfare Clinics, 472 from the General Practitioners) and 458 received a booster dose at the age of 5 years. The investigation into the value of whooping cough immunisation, commenced last year, had to be brought to a premature close owing to the shortage of Health Visitor staff, but it did confirm the Medical Research Council's findings that the immunised child usually had a very mild attack while the unimmunised child usually has a severe attack. Whooping Cough is a severe and fatal disease. In 1951 it was responsible for 456 deaths in the United Kingdom. In the period 1940-48 it caused three times as many deaths in the United States as Measles, Mumps, Chickenpox, Rubella, Scarlet Fever, Poliomyelitis and Meningitis put together. A child under the age of 1 year who develops whooping cough has a 1 in 10 chance of dying—so that immunisation of infants at the earliest possible age is desirable. Experiments are now being undertaken at a London Hospital as to the practicability of immunising children immediately after birth. 19 20 Immunisation Figures 1952—Clinics. Age Diphtheria Combined Whooping Cough Reinforcing Whooping Cough Diphtheria Combined Under 1 16 108 1 Age 1 23 815 8 „ 2 9 247 15 „ 3 8 40 3 „ 4 7 24 2 118 50 „ 5 27 12 3 957 150 20 „ 6 7 8 8 284 105 6 „ 7 4 4 89 30 8 „ 8 1 1 92 20 3 „ 9 4 2 1 58 10 7 „ 10 4 263 19 25 „ 11 1 55 3 „ 12 19 2 ,, 13 12 „ 14 5 Total 107 1,260 46 1,952 389 69 CLINICS 1952 1951 1950 Diphtheria 107 270 113 Combined 1,260 1,429 1,501 Whooping Cough 46 70 210 Reinforcing ... 2,341 2,536 1,155 GENERAL PRACTITIONERS—DIPHTHERIA Primary 554 (472 Whooping Cough) 571 612 Reinforcing 172 154 Non-Notifiable Diseases. Weekly returns are received from the head teachers of schools giving the number of children absent with certain non-notifiable diseases. This report is necessarily incomplete since it only relates to children of school age—but it does give an indication of the prevalence of these conditions at different seasons and forms an index of the prevalence of infectious disease from year to year. These figures represent between one-half and one-third of the true number of cases present in the Borough during the year. 1952 1951 Chicken-pox 1,234 1,381 Mumps 787 857 Ringworm 3 8 Scabies 5 5 21 It can be seen that there has been a decline in all the infectious diseases including a satisfactory decrease in the number of cases of Ringworm from 8 to 3. This was a common condition in the early years of the century which has now almost disappeared, possibly due to improved hygienic standards. INFECTIOUS DISEASES IN ENGLAND AND WALES IN 1952. The chief feature of the returns of infectious diseases during 1952 was the absence of an outbreak of influenza in the spring. In the first 13 weeks only 485 deaths were recorded in the great towns from this disease, compared with 7,859 in the first quarter of 1951. The incidence of diphtheria continued to fall during 1952, but the rate of decline was slower. The notifications of diphtheria in 1952 were only 2.9% of the notifications in 1941. The total notifications of acute poliomyelitis were 46% above the total of 1951. The notifications of dysentery were about half the total of 1951, but the incidence remained high. The high level of the enteric fevers was mainly due to the persistent outbreak in South Wales during the third quarter. A comparison of the notifications with those of the four preceding years is given below : 1948 1949 1950 1951 1952 Scarlet Fever 75,460 71,753 66,852 49,431 69,091 Whooping Cough 145,878 102,516 157,714 169,394 116,311 Diphtheria 7,903 4,929 2,858 1,969 1,473 Measles 396,841 384,361 366,116 615,332 400,838 Acute Pneumonia 31,096 34,624 30,714 43,181 31,403 Meningococcal Infections 1,971 1,586 1,745 1,956 1,687 Acute Poliomyelitis 2,175 6,850 8,699 3,093 4,504 Dysentery 5,587 4,819 18,135 29,488 15,665 Typhoid and Paratyphoid Fevers 873 1,138 654 1,438 1,190 Deaths from Influenza in the Great Towns 2,052 8,338 1,019 22 SECTION 2 SANITARY CIRCUMSTANCES OF THE BOROUGH Water There are three sources of supply in the Borough. The Greenford North, Greenford South and Perivale Wards are supplied by the Rickmansworth & Uxbridge Valley Water Company, with the exception of five roads in the Perivale Ward which are served by the Colne Valley Water Company. The remainder of the Borough is supplied by the Metropolitan Water Board. These supplies are not subject to plumbo-solvent action and have been satisfactory both in quantity and quality. Water from public mains is supplied to 51,131 houses with an estimated population of 187,000. Nine samples were taken from wells at eight factories in the Borough using water from deep borings ranging in depth from 300 to 600 feet. The analysis of these samples showed the supplies were wholesome in character. Rivers and Streams. Investigations into the sources of pollution of the River Brent were continued during the year. As this question concerns the Middlesex County Council and a number of Local Authorities in Middlesex, a Conference was called to consider the matter. This Conference was attended by representatives from the Middlesex County Council and from the Boroughs of Brentford & Chiswick, Ealing, Hendon, Southall, Wembley and Willesden. It was agreed that the pollution of the River Brent could be divided into three main sections : 1. Material which was deposited, of a solid or liquid nature, either on the banks or directly into the river. (The former being washed into the river when it is in flood.). 2. Polluted surface water sewers and ditches. 3. Storm water overflows from Local Authority sewerage systems. With regard to (1) the County Council representative stated that action was being taken under the provisions of the Rivers (Prevention of Pollution) Act, 1951, but so far only a slight improvement in the situation could be reported. On the question of (2) polluted surface water sewers, samples were being taken regularly by the County Council from suspected outfalls and the results communicated to the Local Authorities concerned. 23 Regarding (3) it was stated that there were thirty storm water overflows in existence along the River Brent and it was expected that some years would elapse before any marked improvement could be expected owing to the heavy capital expenditure involved. In Ealing, by arrangement with the Borough Surveyor, the Sanitary Inspectors have pursued their investigations into the causes of pollution of certain of the surface water sewers in the factory areas of Perivale and the North Circular Road. Numerous samples have been taken from various points in these areas and analysed by courtesy of the Main Drainage Department of the Middlesex County Council. In seven instances pollution was found to be occurring through certain fittings having been wrongly connected to the surface water drainage system. These defects have now been remedied and a further series of tests are being carried out in other parts of these areas. This work must necessarily be a long term policy as it is only by careful testing and sampling that wrong connections can be discovered and this process takes both time and staff. I am hopeful, however, that during 1953 it will be possible to complete our investigations into the sources of pollution of certain of the surface water sewers in the Perivale and North Circular Road areas. Drainage and Sewerage. There are 27 permanent houses in the Borough not connected to the Council's sewers. Of these it is estimated that 3 will be connected during 1953. Atmospheric Pollution. The Sanitary Inspectors during the year made over 100 observations in cases of suspected smoke nuisances. Any chimney (not being the chimney of a house) emitting smoke in such quantity as to be a nuisance, e.g., emitting black smoke for more than 2 minutes in any period of 30 minutes is a statutory nuisance under Sections 101-106 of the Public Health Act, 1936. No abatement notices relating to smoke nuisance required to be served during the year. Between December 5th and 8th, 1952, a high pressure system of relatively cool air was established over the London basin coupled with a prolonged period of almost complete calm. The mass of cold still air immediately above the ground was overlaid by warmer air, with a sharply defined ceiling between the two layers. This "temperature inversion" at a height of 200—500 feet produced a natural water fog and trapped the city's smoke. 24 The first day—Friday, December 5th—was an urban (or smoke) fog, but on subsequent days a water fog formed which spread to rural areas. The fog was dense in Ealing throughout this period although some parts of Central London were worse affected. The effect of four days' emission of smoke from London's chimneys and exhausts of vehicles was to increase the amount of smoke pollution to 14 times the average. At the National Gallery in Trafalgar Square the filters of the air conditioning plant trapped 26 times as much dirt as usual during the day and in one peak period of four hours, 54 times normal. It is usual to find an increase in the number of deaths from bronchitis, pneumonia and heart disease during a severe fog, and indeed this was strikingly shown. In Ealing there were 45 deaths from bronchitis, pneumonia and other respiratory diseases in the two weeks ending December 20th as compared to 210 in the remaining 50 weeks of the year, i.e., 5 times the normal rate and 6 times the number recorded in the corresponding weeks of 1951. Deaths from all causes in the week ending December 15th in Greater London totalled 4,703—this was 3 times the number recorded in the week ending November 15th, i.e., 1865. The number of deaths due to bronchitis and pneumonia increased by 12 times, i.e., from 74 to 872. The increase mainly affected those over the age of 45. It would thus appear likely that the fog was responsible for the loss of some 3,000 lives and as such must be accounted a. major disaster ; one which must not be allowed to recur. The majority of persons who experienced the fog suffered from symptoms such as rawness in the throat, choking, smarting eyes and cough. In London and Middlesex the number of new claims for sickness benefit rose to 28,900 during the fog as compared to 16,300 in the subsequent week. When one considers the effects of the fog on domestic animals, plants, buildings, furnishings, dislocation of transport and increased road accidents the total cost to the community cannot fall far short of £10,000,000. A Governmental Committee has been set up to investigate the causes of the fog and possible methods of prevention. In certain cities such as Manchester smokeless zones have been set up, and long term investigations are being carried out into the use of smokeless fuel and design of heating appliances. 25 26 Moveable Dwellings. For the past three years I have drawn attention in my Annual Reports to the nuisances arising from the presence of gypsy caravans in the Northolt area. These caravans have no sanitary conveniences, water supplies or means of disposing of refuse, and land on which the caravans have been parked is often left in a very insanitary condition. In addition to these Public Health nuisances, considerable trouble is caused by the gypsies' horses straying on to farm land and into gardens with consequent damage to crops. Annoyance is also experienced by residents of houses near to gypsy encampments owing to repeated demands for water. Prior to the war, action was taken from time to time to move caravans from the Northolt area, but the problem at that time was not an acute one, as Northolt was largely a rural district and the adjoining districts in West Middlesex had large undeveloped areas where it was possible for gypsies to encamp without being in close proximity to occupied houses. This position has now changed ; Northolt is rapidly becoming an urban area as also are the neighbouring districts in West Middlesex and the gypsies no longer find it possible to encamp for more than a few days without complaints being received by the Local Authorities concerned with consequent action by the Officers of these Local Authorities to have the caravans removed. It appears that a number of these gypsies have used land in West Middlesex as camping sites for many years as they like to camp near large urban populations in order to make a living by selling clothes pegs, artificial flowers, etc., and dealing in old iron and rags. They are becoming resentful of the fact that the changed character of West Middlesex has necessitated various Local Authorities having to take action against them for creating nuisances. There are no camping sites for gypsy caravans in this area and I understand that all available undeveloped land in Northolt is scheduled for other purposes ; there is, therefore, no alternative to the Council's policy of endeavouring to secure the removal of the caravans from the District in order to present the undoubted nuisances and annoyance to residents which always arise from gypsy caravan encampments near to occupied dwellings. During the past four years large areas of Northolt have been built upon and many undeveloped pieces of land have been fenced as a result of action by this Department with the result that it is becoming increasingly difficult for gypsies to find a site for their caravans in this District and they have now started breaking on to land which has not previously been used by them as caravan encampments. At one time it was sufficient for the Sanitary Inspector to warn the gypsies that unless they had moved within forty-eight hours action would be taken against them and in the 27 majority of cases this threat secured the removal of the caravans outside the area. During recent years, however, the gypsies know that if they move to another area in West Middlesex they will not be allowed to stay so the threat which was once effective is as often as not ignored and direct action has to be taken much more frequently than in the past. We have found that action taken in the Magistrates' Court under the Nuisance provisions of the Public Health Act, 1936, generally results in an Order being made by the Court for the removal of the caravans and at times a small penalty is imposed by the Court but the legal processes often occasion a delay of two to three weeks and allow the gypsies to remain until an Order by the Court has been made and has become effective. During this period many complaints are received from residents regarding the apparent inaction of the Local Authority in dealing with the matter. The other method employed to remove the caravans in the case of land belonging to the Ealing Council is to pull them off sites in the area by means of a lorry or breakdown vehicle specially hired for the purpose. This method necessitates the attendance of the Sanitary Inspector and several policemen in addition to the breakdown vehicle drivers. We have used this method on many occasions this year and from time to time have cleared the whole district of gypsy caravans only to find that within a very short time action taken by neighbouring Authorities forces the caravans to move again and they filter back into the Northolt area. The process of forcibly removing caravans by towing them off land is an expensive one and is only a temporary expedient as the same process has to be repeated several times during the course of the year. Most of the remaining undeveloped land in the Northolt area is owned by the Middlesex County Council and the Ealing Borough Council. In the case of the land owned by the Ealing Borough Council, the greater part is in process of being developed and much of it has been fenced or otherwise protected to prevent access by gypsy caravans but on certain of the sites scheduled for development the gypsies are gaining access to the sites and using them as camping places. Early development of the sites or fencing appears to be the only permanent remedy in these cases. With regard to the land owned by the Middlesex County Council, most of this fronts Western Avenue and as a result of a meeting with Officers of the County Council large tracts of this land have now been fenced off. With the development and fencing of all undeveloped sites in the Northolt area, I anticipate that the problems arising from the presence of gypsy caravans should be solved in the fairly near future. 28 FOOD HYGIENE. We have now had three years' experience in the administration of the Clean Food Campaign in Ealing since it was inaugurated by the holding of a Clean Food Exhibition in the autumn of 1949 and it might be helpful at this stage to assess the progress made during this period and to consider any further steps which might be taken. The scheme envisaged three main lines of action : (1) the education of food handlers in the principles of food hygiene. (2) a systematic inspection of all food premises in the Borough and (3) the award by the Council of Certificates of Food Hygiene to the proprietors of those food establishments which fully comply with the Council's conditions. Details of the progress made under these three headings are given below : 1. Education. It was realised from the commencement of the scheme that the education of the food handler in the principles of food hygiene was an essential feature of any campaign designed to ensure safe food being sold to the public. It was realised also that it might be difficult to attract members of the food trades to attend evening lectures in their own time and if any success was to be achieved in this connection, the lectures would have to be to the point, without too many technicalities and the lecturers would have to be capable of dealing with the subject in a practical and interesting manner. The first lecture was given in December, 1949, and since that time the courses, each consisting of four or five lectures, have been held almost continuously during the autumn and winter months for the past three years. Whilst the syllabus used for the first series has remained practically unchanged, we have introduced film strips and flannelgraphs to illustrate the lectures and the film "Another Case of Food Poisoning" is shown at the final lecture of each series. We have found that the flannelgraph is a very effective aid to the lecturers as also is the limited use of film strips. Although the film "Another Case of Food Poisoning" may exaggerate certain aspects of the problem, we have found it to be an effective aid in bringing out many of the points the lecturers wish to stress; this is especially noticeable in our talks to school children. By the end of 1952, 208 lectures have been given and a total of 1,061 food traders and food handlers had received certificates of attendance upon completing the course. We have a waiting 29 list of persons wishing to attend the course and it is anticipated that there will be sufficient enrolments to continue the lectures well into 1953. In view of the fact that many local authorities which have endeavoured to promote similar educational courses have met with a very poor response, it is satisfactory to record that the numbers completing our lecture course and being awarded certificates of attendance have exceeded our expectations. It is only to be expected, however, that there will be some falling off in the numbers enrolling for future courses, as the more enthusiastic members of the local food trades have already completed the course and considerable persuasion will be required to induce those less enthusiastic to attend. Many of the personnel engaged in the food trades are married women whose household duties will not permit their attendance at evening lectures. By arranging lectures on particular firms' own premises, thus allowing the staff to attend in the firm's time, we have overcome this difficulty in the case of some of the larger food establishments but this is not possible in the case of many of the smaller firms. This is one of the major factors which prevents many local traders from qualifying for a food hygiene certificate. The talk to school "leavers" in the Secondary Modern and Secondary Grammar Schools in the Borough which commenced in 1951 have proved to be an effective means of stimulating interest in the scheme. The children have shown a great interest in the subject and some of the Head Teachers have expressed their appreciation of the manner in which the subject matter is conveyed to the children. There can be very little doubt that many of the children will talk over the subject with their mothers and I think this is to be encouraged. Since these talks commenced in 1951, sixty-one lectures illustrated by flannelgraph and films have been given to over 2,000 school "leavers" at the Secondary Grammar and Secondary Modern Schools in the Borough. I think this Scheme should become a permanent feature of Ealing's Clean Food Campaign. 2. Inspection. All the food establishments in the Borough have been thoroughly inspected and a record card completed in respect of each of them. During the past three years 5,793 visits have been made to food premises and 1,123 repairs and improvements have been carried out. These improvements range from the provision of hot water supplies to, in some cases, complete reorganisation of the premises. 30 It is satisfactory to report that co-operation between the Sanitary Inspectors and the food traders generally has been good, and in one case only has it been necessary, so far, to resort to legal proceedings. This case was in the nature of a test case to decide as to whether a kettle on a gas ring was a sufficient supply of hot water within the meaning of the Food and Drugs Act, 1938. On this occasion the Magistrates dismissed the case, but it is possible that the new Food and Drugs legislation which is contemplated may clarify this issue. Much remains to be done in the work of improving food premises, but the difficulty of obtaining building licences for the less essential work may necessitate some delay in securing permanent improvement on some of the premises where the age of the building and the fact that the businesses have outgrown the existing accommodation, necessitates a considerable amount of structural work in order to bring the premises up to modern standards. 3. Food Hygiene Certificates. During 1950 no premises in the Borough had fully complied with the Council's requirements governing the issue of Certificates. In 1951 14 certificates were awarded and this year 35 certificates have been presented making a total of 49 since the scheme commenced. There are a considerable number of food establishments in the Borough which would now qualify for certificates were it not for the difficulty of complying with the condition requiring staff attendance at lectures. At several of these establishments some members of the staff have attended, but there remain others, mostly married women, who cannot be persuaded to attend. It is difficult to see what further measures can be taken to encourage their attendance. 4. Publicity. Various methods have been adopted to publicise the scheme, commencing with the Clean Food Exhibition which attracted an attendance of 8,000 and an account of which was broadcast by the B.B.C. Following the Exhibition a booklet was published by the Council and distributed to all the food traders in the Borough. This booklet has proved to be a very useful means of publicity and we have had many requests for copies from other local authorities. In the Spring of this year the Television Service of the B.B.C. broadcast a Safe Food series in which they were assisted by officers of the Ealing Borough Council. Later in the year a poster campaign was embarked upon. This lasted for six months and whilst it is difficult to assess the results of such a campaign, I think it certainly had the effect of keeping the subject before the public. 31 Talks have been given from time to time to various Women's Organisations in the Borough and also to Food Trade Organisations. The Chief Sanitary Inspector has addressed meetings at Bournemouth, Farnborough and Guildford on the Ealing Clean Food Scheme and we have had many requests from other Local Authorities for information regarding the scheme. I am of the opinion, however, that one of the most useful forms of publicity from a practical viewpoint is that undertaken by the Sanitary Inspectors during their routine inspections of food premises and I think that the success we have so far achieved in our lecture scheme is largely due to the personal approach to those engaged in the food trades and to the establishment of good relations between food traders and the Council's Officers. BATHS AND SWIMMING POOLS. The Council's swimming baths are equipped with pressure filters for continuous filtration and the water is treated with chlorine under strict supervision. Tests for the efficiency of chlorination are taken daily. There are three privately owned swimming pools in the Borough, one of which is not at present in use. One is maintained by the Staff Recreation Club at a large factory and the other is provided in connection with several blocks of flats. Chlorine treatment is carried out at each of them. PUBLIC MORTUARY The arrangement with the Acton Council for the use of the Acton Mortuary was continued during the year. 215 bodies were taken to this Mortuary and post-mortem examinations were carried out in every case. 32 SECTION 3 SANITARY INSPECTION THE WORK OF THE SANITARY INSPECTORS IN 1952 I append a report to the Medical Officer of Health by the Chief Sanitary Inspector giving details of the work of the Sanitary Inspectors during the year ; Public Health Act 1936 Inspections. Premises inspected on complaint 2,433 Other nuisances observed by Inspectors 183 Premises inspected in connection with infectious disease 1,003 Smoke observations 114 Houses without water supply 58 Inspections of movable dwellings 1,108 Other inspections 1,561 Re-inspections 8,266 Intimation Notices served 863 Statury Notices served 289 Letters written 2,277 Proceedings before magistrates 36 Legal Proceedings. Public Health Act 1936, Section 93. Non-compliance with Statutory Notices. In 11 cases legal proceedings were taken to enforce compliance with Notices requiring the abatement of nuisances. In 8 of these cases Orders were made by the Magistrates for the necessary work to be carried out within a stated period and costs amounting to £12 12s. Od. were awarded. In three cases the summonses were adjourned and later withdrawn as the work was largely completed before the hearings. Summonses were issued in a further eight cases but these were withdrawn as the work was completed before the hearings. A further 23 cases were taken against the owners of caravans. In 3 cases Orders were made by the Magistrates for the abatement of nuisances and costs were awarded in 2 cases. In 19 cases fines amounting to £30 1s. 0d. were imposed on the occupants of the caravans for non-compliance with Court Orders. The remaining case was adjourned. Public Health Act, 1936, Section 75. The owners of two properties upon whom Notices were served to provide dustbins appealed against these Notices to the Ealing Magistrates Court. In both cases the appeals were disallowed by the Magistrates. 33 Food and Drugs Act 1938. Food and Drugs (Milk, Dairies and Artificial Cream) Act, 1950. Milk and Dairies Regulations, 1949, Etc. Complaints received 38 Inspections of Milk Purveyors' Premises 103 Contravention of Regulations 3 Inspections of Ice Cream Premises 320 Food Inspections 1,183 Inspections of Food premises 2,258 Contraventions found 194 Notices served 139 Proceedings before Magistrates 5 Samples of Milk taken 59 Samples of Ice Cream taken 96 Samples of Synthetic Cream taken 28 Samples of other foods taken 16 Legal Proceedings. Food and Drugs Act, 1938. Sec. 9. The following four cases relating to the sale of unsound food were the subject of legal proceedings : 1 & 2. Unsound fruit pies—Fines of £10. 10s. 0d. on each of two charges were imposed and £3. 3s. 0d. costs awarded. 3. Bandage in bread—a fine of £5. 5s. 0d. was imposed and £1. 1s. 0d. costs awarded. 4. Petrol jelly in milk—a fine of £5 was imposed and £2. 2s. 0d. costs awarded. Food and Drugs Act, 1938. Sec. 13. A Summons taken against a firm of grocers for not having a sufficient supply of hot water on the premises was dismissed, it being held by the Magistrates that a kettle on a gas ring was a sufficient supply in the circumstances of this particular case. Milk Supply. There are 77 registered distributors of milk in the Borough. During the year licences for the sale of milk under the Milk (Special Designation) Regulations were granted as follows :— 34  Dealers' Licences Supplementary Licences Total Tuberculin Tested Milk 49 10 59 Pasteurised Milk 54 12 66 Sterilised Milk 48 12 60 Under the provisions of the Milk (Special Designations) (Specified Area) Order 1951, all milk sold by retail in the Borough must be "designated milk," i.e., Tuberculin Tested, Pasteurised or Sterilised Milk. Fifty-nine samples of milk were taken and submitted to the Methylene Blue and Phosphatase Tests at the Public Health Laboratory, Ealing. The results were as follows : Designation Samples Phosphatase Methylene Blue Passed Failed Passed Failed Pasteurised 58 56 2 57 1 T.T. Pasteurised 1 1 — 1 — 59 57 2 58 1 Subsequent samples were taken from the suppliers of the 2 samples which failed the Phosphatase Test, and these proved satisfactory. In addition, 249 samples of Pasteurised Milk from processing plants in the Borough were taken by the Officers of the County Council who are the licensing authority under the Milk (Special Designations) Regulations. Of these 2 failed the Methylene Blue Test and 6 failed the Phosphatase Test. Ice Cream. The 319 registered ice cream premises in the Borough were all visited during the year and the source of supply checked. It was found that their ice cream is obtained from one of the 7 registered manufacturers in the Borough or from the 22 manufacturers outside the Borough. Samples from each of these 29 manufacturers were taken once or more during the year, a total of 96 samples of ice cream, ice cream constituents and ice lollies being submitted for bacteriological examination. 35 The results were as follows : Commodity Samples Grade raded 1 2 3 4 Ice Cream— Local Manufacture 42 28 1 11 2 — Ice Cream— OtherManufacturers 44 29 8 4 3 — Ice Cream Constituents 1 — — — — 1 Ice Lollies 9 — — — — 9 96 57 9 15 5 10 Seven of these samples were reported to be unsatisfactory— three from local manufacturers, and four from other manufacturers. Unsatisfactory samples were followed up, either by investigation at the producer's plant in the Borough or by notification to the Authorities concerned where the manufacturer's premises were outside the Borough. Synthetic Cream. Twenty-eight samples of synthetic cream were taken from local manufacturers, all of which received satisfactory bacteriological reports. Inspection of Meat and Other Foods. The following foodstuffs were condemned by the Sanitary Inspectors as unfit for human food in the course of their inspections of the various food premises in the Borough : lbs. Bacon 55 Bakery Waste 11,556 Beef 3,464¾ Biscuits 1,320 Black Pudding 14 Brawn 4 Butter 20 Calves Head 18 ¼ Cheese 157¼ Confectionery 19,386½ Cocoa Butter 692 Figs 40 Fish 1,1724 Flour 942 Ham 111½ Jam 32 36 Lamb 80½ Liver 72 Luncheon Meat 19¼ Margarine 29½ Marmalade 25 Mutton 779¾ Nuts 5,330 Offal 5 Pearl Barley 8 Pork 353 Potato Powder 48 Prawns 8½ Prunes 248 Rabbit 92 Rice 37½ Roes 20 Sago 26½ Sausages 135 Spaghetti 38 Steak 75 Tea 3 Veal 21 In addition, the following other articles of food were also condemned : Eggs (shell) 3,494 Assorted Articles 1,421 Assorted tins, jars and packets 25,769 There are two private slaughter-houses in the Borough, but no slaughtering has been carried out in them since 1939. Housing Statistics. 1. Inspection of dwelling-houses during the year : (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,301 (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Act, 1936 1 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 1,435 2. Remedy of defects during the year without service of formal notices : Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 1,049 37 3. Action under Statutory Powers during the year : A.—Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936 : (1) Number of dwelling-houses in respect of which notices were served requiring repairs — (2) Number of dwelling-houses which were rendered fit after service of formal notices : (а) by Owners — (b) by Local Authority in default of owners — B.—Proceedings under Public Health Act : (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 277 (2) Number of dwelling-houses in which defects were remedied after service of formal notice : (а) by Owners 268 ( b) by Local Authority in default of owner — C.—Proceedings under Sections 11 and 13 of the Housing Act, 1936: (1) Number of dwelling-houses in respect of which Demolition Orders were made — (2) Number of dwelling-houses demolished in pursuance of Demolition Orders -— (3) Number of houses concerning which action has been taken by the Local Authority under Section 19, and with respect to which Owners have given an undertaking that they will not be used for human habitation — D.—Proceedings under Section 12 of the Housing Act, 1936 : (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 2 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit. Housing Progress. The Borough Surveyor informs me that a total of 198 dwellings were completed during the year—as compared to 191 in 1951. Estate Houses Flats 3 bed 2 bed 1 bed 2 bed Elm Trees 24 8 — — Gifford Gardens — — — 2 Ravenor Park 29 2 15 24 Northolt Grange 2 — — 32 Northolt Park 38 22 — — Totals 93 32 15 58 38 Factories Acts, 1937 and 1948. Part 1 of the Act. 1. Inspections for the purposes of provisions as to health (including inspections made by Sanitary Inspectors) : Premises Number on Register Number of Inspections Written Notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4, and 6 are to be enforced by Local Authorities 248 14 1 — (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 413 296 10 — (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) — — — — Total 661 310 11 — 2. Cases in which defects were found : Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspect'r By H.M. Inspect'r Want of cleanliness 8 8 7 — Overcrowding — — — — — Unreasonable temperature — — — — — Inadequate ventilation 2 2 — 1 — Ineffective drainage of floors — — — — — Sanitary Conveniences : (a) Insufficient 10 10 — — — (b) Unsuitable or defective 13 13 — 3 — (c) Not separate for sexes 1 1 — 1 — Other offences against the Act (not including offences relating to out-workers) 16 16 — 7 — Total 50 50 — 19 — 39 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 Sect. 110 (1) (c) No. of instances of work in unwholesome premises Wearing apparel: Making, etc. 151 – Cleaning and Washing 1 – Furniture and upholstery 4 – Artificial flowers 1 – Paper bags 3 – Making of boxes or other receptacles or parts thereof made wholly or partially of paper 6 – Carding, etc., of buttons, etc. 1 – Feather .sorting 2 – Stuffed toys 23 – Cosaques, Christmas crackers, Christmas stockings, etc. 8 – Lampshades 2 – Total 202 – Shops Act, 1950. In co-operation with the Shops Act Inspector, improvements under Section 38 of the Shops Act, 1950, relating to the health and comfort of shop workers were carried out in twenty-five instances : Ventilation improved 2 Heating improved 8 Sanitary accommodation inproved 15 Prevention of Damage by Pests Act, 1949. The following is a summary of the work carried out by the Rodent Operatives acting under the supervision of the Chief Sanitary Inspector: Complaints 556 Premises inspected 818 Premises found to be infested with: .1. Rats 517 2. Mice 189 Re-visits to infested premises 2,106 Fees received for treatment £668 9s. 0d. Premises treated free of charge 108 40 Rodent Control in Sewers. In accordance with the requirements of the Ministry of Agriculture and Fisheries (Infestation Control Division), maintenance treatments of the soil sewers in the Borough were carried out during February and August. A total of 1,246 sewer manholes were dealt with and of these 515 were found to be rat infested. Poison baits were used in the infested manholes. Rag Flock and other Filling Materials Act, 1951. During the year one new application was received for premises to be registered with the Local Authority, making a total of eight registered premises in the Borough since the Act became operative. No samples were taken during the year. Pet Animals Act, 1951. This Act became operative on the 1st April, 1952. During the year fifteen licences were issued to keep Pet Shops in the Borough, after the premises had been inspected by the Sanitary Inspector. Disinfection. Number of houses where disinfection was carried out 199 Number of houses disinfested of vermin 70 Number of articles disinfected by steam 130 Number of articles voluntarily destroyed 174 Summary of Sanitary Defects remedied as a result of Notices Served and Letters written. Animals—nuisances abated 2 Caravans—nuisances abated 635 Cesspools—cleansed 1 Damp proof courses inserted in walls 25 Dampness—other forms remedied 281 Drains—connected to sewer 1 Drains—cleared and cleansed 380 Drains reconstructed 41 Drains—repaired 159 Drains—new soil and ventilating pipes provided 10 Dustbins provided 122 Firegrates—repaired or renewed 103 Floors—sub-floor ventilation provided 9 Floors—repaired or renewed 156 Food cupboards ventilated 4 Rainwater eaves, gutters, downpipes repaired 313 Refuse—accumulations removed 51 Roofs repaired 420 Sinks repaired or renewed 17 41 Sink waste pipes repaired or renewed 56 Staircases repaired 26 Walls and ceilings repaired or cleansed 1,118 Water supply reinstated 58 Water supply—draw taps fixed to main supply 5 Water closets—repaired, reconstructed or improved 180 Windows and doors repaired 274 Yards paved or repaired 31 Other defects remedied or nuisances abated 258 Summary of Work Done and Improvements carried out at Food Premises. Walls and ceilings repaired and cleansed 245 Floors repaired 40 Lighting and ventilation improved 30 Washing facilities provided 45 Hot water provided 97 Sinks provided 30 Storage accommodation improved 35 Water supply provided 1 Water closets cleansed or repaired 32 Refrigeration installed or improved 20 Other defects remedied 133 42 SECTION 4. GENERAL. SURVEY OF DEATHS, 1952 The death rate for-the year was 9.9 per 1,000 which shows a satisfactory decline from the 1951 figure of 10.6. The diseases of the heart and circulation continue to comprise the main cause of death; and the figures taken as a whole show little significant change over previous years—a reduction in the amount of "other heart and circulatory disease "being counterbalanced by an increase in the number of " strokes." The number of deaths due to disease of the respiratory system shows a decline of 35 as compared to 1951—but does not equal the excellent figures of 1950. The third most important cause of death is now cancer of various sites. Over the country as a whole cancer of the lung has increased alarmingly in incidence in recent years, i.e. from 622 deaths in 1922 to 13,247 in 1951, and a great number of theories have been put forward as to the possible cause, i.e. road tar, atmospheric pollution, fumes from gas works or cigarette smoke. This increase has not been marked in Ealing and this year's figure of deaths, 52, shows a decline of 17 compared to 1950 and 1951. The total number of deaths from cancer of all sites in Ealing in 1952 was 363—a considerable increase from 89 in 1922. The expectation of life has now risen to 65.8 years at birth for males, and 70.9 years for females, and it is therefore inevitable that there will be an increasing number of deaths from the degenerative diseases and cancer, in the older members of the population. It is pleasant to record that there has been no death this year from Poliomyelitis, Whooping Cough or Diphtheria, and that the number of deaths from diarrhoea and enteritis fell from 12 in 1951 to 6 in 1952. The number of deaths from tuberculosis rose to 40 after the very low figure of 34 in 1951. The number of deaths from nonpulmonary tuberculosis continues to steadily decline, possibly as a result of the policy of allowing only designated milk to be sold in the Borough. There was one maternal death during the year, associated with a miscarriage. It is gratifying to learn that no mother has now died in childbirth in the Borough for several years. 43 The maternal mortality rate for England and Wales has now fallen to .72 per 1,000 total biarths. In 1951 there were no maternal deaths in Ealing and in 1952 the rate was .39 per 1,000 total births. Ealing's infantile mortality rate is now 22 per 1,000 as compared to last year's figure of 25 and the national average of 27.6 per 1,000. 38 of the babies died in the first month of life and 15 between 1 and 12 months. The five main causes of death are Prematurity 13 Respiratory Disease 10 Foetal Abnormality 8 Atelectasis 6 Birth Injury 5 In the 13 cases of prematurity 10 died on the first day of life and none lived more than 5 days. This suggests that the care of the premature baby in the Borough is satisfactory by present standards and that a premature child, who has survived the hazards of birth and is viable has a good chance of survival. 5 other premature babies died but in 2 the main cause of death was birth injury and in 3 cases atelectasis. In the 5 deaths due to birth injury and 6 due to atelectasis, death occurred in the first week of life. The 10 deaths from respiratory disease were all in the first 4 months of life. Other causes of death included erythroblastosis foetalis (2), lack of attention at birth (2) and asphyxia in the cot (2). Up to recent years gastro-enteritis was among the main causes of death of infants, but in 1952 it was responsible for no infant death. This dramatic result has been produced by the improved technique of infant feeding taught by the clinics and a plentiful supply of clean, safe milk—dried, pasteurised and evaporated. If mothers could be brought to realise the importance of isolating the young baby at the first sign of colds or coughs in any other member of the family it would go far to prevent bronchitis and reduce the relatively large proportion of deaths in infants from respiratory disease. HEALTH EDUCATION The leaflet display trays mentioned in last year's Report were maintained throughout the year in the Town Hall and in the six main Libraries. The demand increased in 1952 and a total of 14,100 leaflets were distributed. The interest of the public has also been aroused by the exhibition from time to time of topical posters relating to health subjects and a number of lectures have been given to selected groups. 44 LAUNDRY SERVICE FOR THE INCONTINENT. One of the unforeseen effects of the National Health Service Act was the loss of those services which had been so efficiently provided by many Relieving Officers in various parts of the country. Among these services was one that had grown with the passing of time and appears now to have become the responsibility of the Public Health Service, viz. the care of the aged—neither sick nor well. Many of these "Half-way House" patients are just incontinent, and in order to assist this small but unfortunate group it was decided in August, 1951, to establish a municipal laundry service in association with the Borough of Ealing's laundry which already deals with the baths and education service work. This laundry service was commenced on 1st April, 1952, the delay being due to the difficulty in securing the necessary equipment. Inquiries were made from St. Marylebone and Kensington Borough Councils, where services were already in operation, and full attention has been given to the information and experience they have had in this work. The Public Health Act, 1936, Section 84, dealing with the cleansing of filthy articles gives powers to local sanitary authorities " to cleanse at the authority's expense any article which, upon a certificate of the Medical Officer of Health or the Sanitary Inspector, require to be cleansed in order to prevent injury or danger of injury to the health of any person in the premises." An estimate was made of the number of persons who might come into this category on the assumption, which seemed to be borne out in other districts, that one would have to deal with roughly one to two per 10,000 of the population. In fact, in Ealing with a population of 187,000 our average number of persons in the scheme is approximately 20 each week, and in spite of letters to general practitioners regarding the availability of the scheme, the wide knowledge of its working by the health visitors, district nurses, and home helps, the numbers seem to vary very little. A few are added from time to time by local hospitals from the out-patient departments of the geriatric units in the district, but, in general, one can say that as old people die and come off the list so new ones are added to keep the figure roughly at about 20. The following figures are of interest in this connection : Number of cases dealt with from 1/4/52 to 3/1/53 46 Number of cases died 18 Number of cases removed to hospital 11 Number of cases where other arrangements made 2 Number of cases recommended by: Nurses 30 Doctors 9 Home Help Section 5 Sanitary Inspectors 1 Health Visitors 1 45 When a case is brought to our notice that may need the service, a visit is paid by the sanitary inspector to the household to confirm that the case is one coming within the provisions of Section 84, and to explain the working arrangements. A form giving the articles that may be included in the service is provided, and the relatives or some person able to accept responsibility is instructed in the use of the containers and they are informed at what time the Council van will be calling to pick up soiled linen. It has been found in practice that a twice weekly collection and distribution seems to cover adequately the needs of these persons, and Tuesdays and Fridays have been selected and fit in with the other work of the laundry service of the Council. The Public Health Committee have purchased additional equipment which has been added to the equipment already possessed by the Baths Committee and this is available for other services when it is not being used for the public health service. The staffing of the laundry consists of two persons, a man who receives, checks and disposes of the garments and a woman who assists with the working of the laundry machines and packing. All suitable materials are ironed before return and it has been found from experience that the simplest method of transport is by means of a metal container which can be easily cleaned and disinfected and which is light and easy to carry. These containers pack simply into the Council's van and they are all numbered for identification purposes. The cost of these aluminium containers is £2. 15s. Od. each. (Size 20 in. x 15 in. x 9 in.)—two are required for each case. The establishment of a service of this kind is unquestionably one of great benefit to the community. Many of these patients are in the last stages of some serious illness and it is impossible for relatives to obtain relief from the laundering of clothes and bed-clothes since public laundries will not accept such articles. These patients are often being nursed and cared for by relatives who have their hands completely full and the relief given by means of this laundry service means a great deal to them. There is, of course, an obvious link with the relief of hospital beds by the taking of cases which need hospitalisation only in order to deal with incontinency. The following is a list of the materials that have been handled from the start of the scheme to 3rd January, 1953, and the average number of articles ret urned at each collection by the Health Department's van: Draw Sheets 2,124 Sheets 1,656 Towels 1,258 Pillow Cases 1,065 Handkerchiefs 1,032 46 Nightdresses 857 Vests 444 Pyjama Jackets 352 Blankets 320 Knickers 133 Nightshirts 133 Pyjama Trousers 107 Bedjackets, etc 99 Bed Socks and Stockings 54 Quilts and Bedspreads 53 Napkins 51 Tablecloths (probably been used as Sheets) 42 Pants 40 Combinations 29 Shirts 26 Slips 24 Aprons 22 Dressing Gowns 9 Shawls 8 Body Belts 8 Skirts 7 Nightcaps 5 The number of collections to 3rd January, 1953, is 1,144 and the number of articles per collection averages 8.7. This cost of 19/5d. per collection has, of course, been based upon a few cases and therefore appears to be high for each collection, but the spreading of the number of cases to 30 or perhaps 40, which should not be beyond the capacity of the laundry to handle, would reduce the cost, I am informed by the Borough Treasurer, to less than 10s. per collection. This makes it quite comparable in every way with the cost of ordinary laundry services as dealt with by commercial firms. MEDICAL EXAMINATIONS. Candidates for permanent appointment to the Council's service are required to pass a medical examination on appointment as are manual staff for admission to the Sickness Pay scheme of the National Joint Industrial Council for L,ocal Authorities NonTrading Services. During the year the following examinations were carried out: Administrative, Technical and Clerical Staff 36 Sickness Pay Scheme and Superannuation Scheme (Servants) 142 Gunnersbury Park Joint Committee Employees 13 Total 191 47 Twenty-one persons were rejected who were suffering from the following conditions—or a combination of them: High Blood Pressure 6 Heart disease 4 Hernia 3 Bronchitis 2 Tuberculosis 2 Asthma 2 Cancer, Neurosis, Peptic ulcer, Varicose veins 2 In addition a number of persons who were accepted tor the scheme were referred to hospital or to their own doctor for the correction of some remediable defect. This includes 7 men referred for treatment of hernia and two for dental care. MASSAGE AND SPECIAL TREATMENT ESTABLISHMENTS. Two new licences were granted during the year, one for a fresh establishment and the other for an existing establishment which changed hands. Two establishments were closed and there then remained 26 establishments at the end of the year. Two applicants were refused licences on the grounds that they did not possess the necessary qualifications. Two persons who formerly held certificates of Exemption from Registration by virtue of being members of the Chartered Society of Physiotherapists ceased to practise and one new applicant was granted a certificate. Three persons then held such certificates. NATIONAL ASSISTANCE ACT, 1948 Section 50.—Burial or Cremation of the Dead. Eleven Burials were carried out during the year for which the Council accepted financial responsibility. In three cases the full cost was recovered from the estate of the deceased and in the remaining eight instances it was either only possible to recover part of the cost or the cost was written off as totally irrecoverable. Section 47. This section deals with securing the necessary care and attention for persons who (a) are suffering from grave chronic diseases or being aged, infirm or physically incapacitated are living in insanitary conditions, and (b) are unable to devote to themselves, and are not receiving from other persons, proper care and attention. 48 Three cases were investigated under this Section during the year, in none of which was it found to be necessary to apply for a Court Order for compulsory removal. In two of the cases Officers of the Department, with the assistance of the Area Welfare Officer, succeeded in persuading the old people to enter suitable homes. In the third case the elderly person was assisted by a Home Help and provided with the Meals on Wheels Service and the free Public Health Laundry Service. NURSING HOMES. In the 1951 Report, mention was made of the application of a new owner for the re-opening of a home. Due to unsatisfactory staffing arrangements this application was refused, but was subsequently granted upon adequate staff being engaged. This home was closed voluntarily, however, in September. An application of a new owner in respect of another existing home was also received. This was granted and the new owner is maintaining the high standard which was set by the previous owners. Another nursing home closed voluntarily. At the end of the year there were eleven homes on the Register. 49 SECTION 5. STATISTICAL TABLES. SUMMARY OF STATISTICS. Area (in Acres) 8,783 Population (Census, 1951) 187,306 Population (estimated middle of 1952) 187,000 Rateable Value, 1952-3 £1,941,604 Net Product of a Penny Rate, 1952-3 £7,900 Live Births Legitimate Males, 1,224 Females, 1,106 Total 2,330 Illegitimate Males, 69 Females, 59 Total 128 2,458 Birth-Rate per 1,000 of Estimated Population 13.1 Still-Births:— Males, 30. Females, 19 Total 49 Rate per 1,000 total Births (Live and Still-Births) 19.5 Deaths: Males, 916. Females, 932 Total 1,848 Death-Rate per 1,000 of Estimated Population 9.9 Deaths of Infants under one year of age:— Legitimate Males, 27 Females, 23 Total 50 Illegitimate Males, 2 Females, 1 Total 3 53 Death Rate of Infants under one year of age:— All Infants per 1,000 Live Births 22 Legitimate Infants per 1,000 Legitimate Live Births 21 Illegitimate Infants per 1,000 Illegitimate Live Births 23 Deaths from Diseases and Accidents of Pregnancy and Childbirth From Sepsis — Death-Rate 1,000 Total Births From other Causes 1 ,, ,, ,, 0.39 Total Deaths Measles – Whooping Cough – Diphtheria – Scarlet Fever – Influenza 7 Tuberculosis of Lungs 37 Other Forms of Tuberculosis 3 Gastro-Enteritis and Diarrhoea 6 50 The number of cases of infectious disease notified in the Borough in the past twelve years is shown in the following table : Cases of Infectious Disease notified in the Borough. Disease 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 Smallpox – – – – – – – – – – – – Diphtheria 48 28 13 17 14 29 11 13 16 3 2 – Scarlet Fever 166 180 448 228 340 232 133 204 176 294 203 402 Enteric Fever (including Paratyphoid) 5 – 1 – – – – 3 8 5 3 2 Puerperal Pyrexia 30 39 41 42 47 35 27 25 27 24 38 70 Pneumonia: Primary 97 105 123 142 110 114 127 189 163 173 162 100 Influenzal 2 7 17 40 9 14 16 3 6 10 6 38 28 Acute Poliomyelitis 9 2 2 2 3 4 46 10 34 42 10 21 Cerebro-Spinal Fever 15 5 1 – 6 6 10 2 14 9 2 – Malaria 1 2 – – – – 1 2 – 4 1 1 Dysentery 3 6 5 24 60 10 5 7 23 24 542 179 Erysipelas 26 36 41 30 26 31 38 32 13 24 17 26 Polio-Encephalitis – – 1 – – – 6 4 3 – – – Tuberculosis: Pulmonary 195 223 233 173 194 275 204 206 205 209 210 211 Non-Pulmonary 28 38 5i 30 23 33 25 27 32 41 24 29 Ophthalmia Neonatorum 2 8 4 3 3 3 5 – 5 3 6 – Totals 653 689 1004 700 840 788 641 730 706 869 1258 1069 The number of cases of infectious disease originally notified sometimes varies due to changes of diagnosis and the following table is therefore given to show the final numbers after correction. Disease Smallpox – Diphtheria – Scarlet Fever 399 Enteric Fever (including Paratyphoid) 2 Puerperal Pyrexia 70 Pneumonia: Primary 100 Influenzal 28 Acute Poliomyelitis 21 Disease Cerebro-Spinal Fever – Malaria 1 Dysentery 96 Erysipelas 26 Polio-Encephalitis – Tuberculosis: Pulmonary 211 Non-Pulmonary 29 Ophthalmia Neonatorum – Total 983 51 Infectious and Other Notifiable Diseases Classified in Age Groups Scarlet Fever Whooping Cough Acute Poliomyelitis Measles Diphtheria Paralytic NonParalytic M F M F M F M F M F M F Numbers originally notified 204 198 35 44 10 6 3 3 508 485 – – Numbers corrected: Under 1 year – – 2 3 – 1 – – 17 9 – – 1–2 years 12 7 10 13 6 – – – 72 77 – – 3–4 years 49 30 9 17 1 – – – 130 129 – – 5–9 years 129 139 13 7 – 1 1 – 277 254 – – 10–14 years 7 17 1 – 2 1 – – 9 9 – – 15–24 years 2 3 – – 1 2 1 – 3 3 – – 25 and over 2 2 – 2 – 2 1 1 – 4 – – Age unknown – – – – – – – – – – – – Totals 201 198 35 42 10 7 3 1 508 485 – – Acute Pneumonia Dysentery Smallpox Acute Encephalitis Enteric or Typhoid Fever Infective PostInfectious M F M F M F M F M F M F Numbers originally notified 69 60 95 84 – – 1 1 – – – – Numbers corrected: Under 5 years 12 8 26 14 – – – – – – – – 5–14 years 7 10 12 16 – – 1 – – – – – 15–44 years 22 12 9 9 – – – 1 – – – – 45–64 years 15 14 4 6 – – – – – – – – 65 and over 12 16 – – – – – – – – Totals 68 60 51 45 – – 1 1 – – – – Paratyphoid Fevers Erysipelas Meningococcal Infection Food Poisoning Other Notifiable Diseases M F M F M F M F Original Corrected Numbers originally notified 2 9 17 1 – 14 10 M F M F Numbers corrected: Under 5 years – – – – – – – – 5–14 years – 1 – 1 – – – 1 15–44 years – – 4 3 – – 2 3 45–64 years – – 5 9 – – 2 – Malaria (41 years) 65 and over – 1 – 4 – – – – 1 – 1 – Puerperal Pyrexia 15–20 yrs. 4 20–35 yrs 58 35–45 yrs 8 Totals – 2 9 17 – – 4 4 70 52 Ages at Death from Notifiable Infectious Diseases. Disease Under One Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and upwards Totals Diphtheria – – – – – – – – – – – – – Scarlet Fever – – – – – – – – – – – – – Enteric Fever – – – – – – – – – – – – – Puerperal Sepsis – – – – – – – – – – – – – Pneumonia: Primary 2 1 1 – – 1 – 2 1 4 14 73 99 Influenzal – – – – – – – – – – 1 1 2 Acute Poliomyelitis – – – – – – – – – – – – – Meningococcal Infection – – – – 1 – – – – – – – 1 Malaria – – – – – – – – – – – – – Dysentery – – – – – – – – – – – – – Erysipelas – – – – – – – – – – – – – Encephalitis L,ethargica – – – – – – – – – – – – – Tuberculosis: Pulmonary – – – – – – – – 6 2 17 12 37 Non-Pulmonary – – – – – – – – – 1 1 1 3 Ophthalmia Neonatoru – – – – – – – – – – – – – Measles – – – – – – – – – – – – – Whooping Cough – – – – – – – – – – – – – Totals 2 1 1 – 1 1 – 2 7 7 33 87 142 53 DEATHS Causes of Death, 1952. Cause of Death Deaths, 1952 Total Deaths 1951 Male Female Total Tuberculosis, Respiratory 24 13 37 30 Tuberculosis, Other 2 1 3 4 Syphilitic Disease 8 3 11 4 Diphtheria – – – – Whooping Cough – – – 1 Meningococcal Infections – 1 1 – Acute Poliomyelitis – – – 1 Measles – – – 1 Other Infective and Parasitic Diseases 2 – 2 8 Malignant Neoplasm, Stomach 27 22 49 56 ,, ,, Lung, Bronchus 48 4 52 69 Breast – 39 39 34 „ Uterus – 17 17 7 Other Malignant Lymphatic Neoplasms 97 97 194 168 Leukaemia, Aleukaemia 8 4 12 5 Diabetes 7 6 13 12 Vascular Lesions of Nervous System 118 145 263 225 Coronary Disease, Angina 159 83 242 258 Hypertension with Heart Disease 17 31 48 72 Other Heart Disease 84 150 234 300 Other Circulatory Disease 43 54 97 66 Influenza 1 6 7 26 Pneumonia 45 56 101 93 Bronchitis 69 41 110 142 Other Diseases of Respiratory System 9 6 15 19 Ulcer of Stomach and Duodenum 13 9 22 17 Gastritis, Enteritis and Diarrhoea 4 2 6 12 Nephritis and Nephrosis 6 3 9 20 Hyperplasia of Prostate 11 – 11 12 Pregnancy, Childbirth, Abortion – 1 1 – Congenital Malformations 10 11 21 15 Other Defined and Ill-Defined Diseases 62 90 152 108 Motor Vehicle Accidents 13 3 16 21 All other Accidents 20 32 52 54 Suicide 8 1 9 8 Homicide and Operations of War 1 1 2 2 Totals 916 932 1,848 1,983 54 SECTION 6. SCHOOL HEALTH SERVICE The School Health Service is now administered by the Middlesex County Council as the Education Authority. Ealing, however, is an "excepted district" for education purposes and the Ealing Education Committee is responsible for arranging examinations of the children. Treatment of any defect discovered is the responsibility of the Area Health Committee of the Middlesex County Council. Under the provision of the Education Act it is the duty of the local education authority to provide for medical inspection at appropriate intervals of pupils in attendance at any school or county college maintained by them. The Act imposes a legal obligation on the parent to allow the child to be examined—but the parent has the right to decide by whom treatment shall be provided, i.e., School Medical Service or General Medical Services. Medical examinations are carried out as a routine during the year of entry into school, during the last year at a primary school, and during the last year at secondary school. 7,237 routine inspections were carried out in 1952 as compared to 6686 in 1951. From time to time the question is raised as to the desirability of such routine medical examination for the very substantial number of children attending private schools in the Borough. There has been found to be a demand for such supervision and not infrequently requests are received from parents for what they consider to be continuation of the clinics' supervision of the health of the child. In theory such extension of the service would appear desirable, but it has not been put into practice, the county health committee not being prepared to agree to Ealing, who have much the largest number of such private schools, being enabled to cover this service. Children who are found to be suffering from some defect are called at regular intervals to assess progress and such reinspections were performed in 2,986 cases in 1952. Children are also sent to the Clinics for examination at the request of the teacher and parent, and such special examination was carried out in 3,669 cases during the year. Thus a total of 13,892 examinations were carried out during the year—an increase of 941 on the previous year's total. These routine examinations are an essential factor in maintaining the health of the school child and discovering the earliest deviation from health. The School Medical Officer no longer 55 expects to find the gross illness and neglect of 50 years ago, but looks for the weakly and ailing child—or the one with some chronic upset who may be helped by special educational treatment, convalescence or nutritional supplements, in addition to the normal medical care. At one time there was a demand for each child to have a routine medical examination every year. Such frequent examinations would bring to light defects not at present discovered, but when one recalls that 60% of the school population are examined each year at present, it suggests that the number of defects discovered would not probably be commensurate with the effort. The general nutritional state of the children continues to improve and last year only 71 children, i.e. 1% were classified as nutritionally poor (97 in 1951). The number of children found at routine medical inspections to be requiring treatment rose from 630 in 1951 to 732 in 1952. However, the following table of defects requiring treatment, found at special as well as routine examinations, shows a satisfactory reduction of many types of illness as compared to last year's figures, i.e., number of skin defects fell from 695 to 600, visual defects from 433 to 368, squint from 49 to 31, speech defects from 47 to 29. Another satisfactory figure was that of heart disease of which only 6 new cases were found during the year. This experience of steady reduction in the number of cases of rheumatic heart disease in children is one shared by many other authorities over the country ; whether it is due to a change in the virulence of the responsible organism, or follows the improved nutritional and housing standards in recent years is impossible to assess. There has been a rise in the number of hearing defects from 51 to 73, but this may be ascribed to the work of the audiometric service which discovers slight degrees of deafness that were previously unnoticed. Tuberculin jelly testing of children has been carried out at schools where there has been some special risk, i.e., infection of one of the pupils or a teacher. In such cases the class is tested "en masse," after obtaining the parents consent, and the positive reactors are sent to the Mass X-ray unit at Central Middlesex Hospital. Fortunately, our investigations have not led to the discovery of any active cases among the contacts of the disease. Dr. Dick's scheme for examination of school leavers with Jelly tests and B.C.G. vaccination is being continued and much valuable information is being obtained. In a number of authorities, schemes of mass jelly testing of the whole school population have been attempted, but the results have not been such as to cause me to recommend commencement of a similar scheme in Ealing at present. 56 The attendance at the Minor Ailment Clinics during the year was 4,972 in 1952 as compared to 5,515 in 1951. The clinics are well attended and perform a useful function in lightening the load on hospital out-patient departments and overworked General Practitioners, by treating the minor infections and accidents of children. The Minor Ailment Clinic now also forms a useful centre for the fuller assessment of problems which cannot be adequately assessed during the hurly burly of a routine medical examination. A large number of behaviour problems and functional conditions such as bed wetting are now coming to these centres for treatment or referral to the Child Guidance Centre and Hospital Out-Patient departments. Defects requiring treatment found at routine special inspections. 1950 1951 1952 Skin diseases 617 695 600 Defective vision 358 433 368 Squint 24 49 31 Defects of hearing 36 51 73 Middle ear disease 33 26 26 Nose and throat 350 389 339 Speech 33 47 29 Enlarged glands 5 10 6 Heart and circulation 5 13 6 Lung diseases 35 111 107 Hernia 1 4 4 Postural defects 17 30 40 Flat foot 86 91 60 Epilepsy – 3 1 ASTHMA EXERCISE CLINIC. In April 1951, a clinic was started at the Ravenor Park Health Centre, to help School children thought to be suffering from Asthma. Since then clinics have commenced at the Laurel House, Greenford Green and Islip Manor Health Centres. In addition to Asthma, children suffering from respiratory infections, frequent colds, allergic rhinitis and malformations of the chest have been treated. The Clinic was primarily concerned with the effect of remedial breathing exercises upon the Asthmatic child and originally these exercises were the only form of therapy given. However, with the opening of new clinics and the increase in the number of patients, additional treatment was suggested. . 57 (a) To those markedly sensitive to Allergy Tests a sation course of injections was given. (b) Those children in whom the infective factor appeared to predominate were sent to a Medical Specialist for an opinion as to whether they were suitable cases for administration of an autogenous vaccine. Originally, the children treated were selected from the School Clinics only, but now the Asthma Clinic treats a few pre-school age children from Child Welfare Clinics and a large number referred by private practitioners and the London Hospitals. The proportion of the various conditions under treatment is : Asthma—50% Bronchitis and frequent colds—42% Malformations of chest—8% The total number of children treated during the last two years had been four hundred and nine. All children are examined by the Clinic Doctor before starting treatment and are seen again at regular intervals, the course of treatment lasting from two to six months. The children are then advised by the Doctor to continue their exercises at home and to maintain the habit of correct diaphragmatic breathing. Less than 3% (i.e. 11) of the children derived no benefit from the exercises. CHILD GUIDANCE CENTRE. Dr. Holman reports : In 1952, 178 new cases were referred to the Child Guidance Centre, 31 less than in 1951 and exactly the same number as in 1950. Rather a large number (56) were withdrawn before investigation and approximately the same number as in the previous year were dealt with by the Psychiatric Social Workers. There was, however, a long waiting list at the beginning of the year, which was reduced only by 19 by the end. Treatment. Of the new cases, 67 were recommended for treatment (23 fewer than in 1951) but 16 children seen in 1951 were awaiting treatment, and 51 children who had been taken on for treatment in 1951 were still attending regularly at the beginning of 1952. 70 were attending regularly but less frequently for "supervision." At the end of the year, 16 cases were on the waiting list for treatment in 1953. 58 Special Educational (Residential) Treatment. There were 21 recommendations for Special Educational Treatment in 1952—11 boys and 10 girls, 11 of primary school age and 10 of secondary. 14 had been placed by the end of the year and none of those placed had waited more than six months. Vacancies were expected early in the new year for three others who will also have been placed within six months of being recommended. This is a great improvement on the situation in previous years. Staff. We are glad to report that an increase in the clerical staff was finally agreed to and to welcome Mrs. Burke, who was appointed on 16th June, 1952. Premises. We learn with relief that new premises have been acquired in Madeley Road for the Clinic, since shortage of space has seriously limited the amount of work that could be done. Many patients have made adverse criticisms of the appearance of our present premises and we can only agree that they do nothing to inspire confidence or encourage attendance. Waiting List and Length of Time on Waiting List. The apparent reduction of the number on the Waiting List represents little, if any, real gain but merely a transfer from our waiting list to that of the Educational Psychologists. Moreover, in the course of 1952 more and more cases tended to be put forward as urgent and to be given priority. Consequently, those who have been waiting a long time waited longer still, though when they finally were seen many were found to be severely ill and to have suffered from the delay. Another consequence of long delay is a tendency to withdraw patients from the lists before they are seen. The following figures illustrate this : Time on Waiting List (months) Number of Patients Number Withdrawn Per Cent. Withdrawn 0—6 25 4 16 6—12 22 13 60 12—15 15 6 40 15 and over 11 9 82 Total 73 32 44 If a name has to remain on a waiting list for fifteen months or more it is almost useless to place it there and if it has to remain for more than six months, there is a 3 in 5 chance that it will be withdrawn. 59 By neglecting the waiting cases for long enough, the waiting list would presumably extinguish itself. Our aim, however, is not merely to extinguish the waiting list but to make a positive contribution to the mental health of the community. Number attending for Treatment. In the last annual report reference was made to the rate at which old cases accumulate and there has been no abatement in the past year. For instance, there are now more than 70 children placed as maladjusted pupils in residential schools whom we are obliged to see for a statutory examination once a year. Twentyone new ones were admitted to such schools in 1952 and only six were discharged. Consequently, we are bound to get further into arrears each year. The following table shows for each year from 1946 the number of cases attending for treatment or supervision. The number of cases carried over from one year to the next has risen from 23 in 1946 to 152 at the end of 1952. In addition, a large number of children and mothers make occasional attendances. There is no likelihood that there will be any reduction in the difference between the number of cases taken on and the number of cases closed. Number of Cases 1946 1947 1948 1949 1950 1951 1952 Referred 146 158 257 164 178 209 178 *Treatment Old 13 23 31 50 66 102 137 ,, New 25 27 49 51 64 90 67 Total 38 50 80 101 130 192 204 Discharged 15 19 30 35 28 55 84 Carried over 23 31 50 66 102 137 120 * The figures given include both patients attending for "treatment" (i.e. once a week or more) and for "supervision" (less than once a week) but not occasional attendances. In present circumstances either we do not deal with the numbers awaiting our services or do so only at the expense of cases already under our care. Our resources are insufficient and we are continually faced with the problem of laying them out to best advantage. The only solution is more generous staffing, particularly in psychiatric sessions. There has been no increase in psychiatric sessions since 1947 in spite of the steady increase in the volume of work, and in 1952 this has resulted in a falling off in the number of new cases seen by the Psychiatrist. 60 The projected establishment for this Child Guidance Clinic is : 1 full time (or 11 sessions) Psychiatrist. 1 Child Psychotherapist. 3 Psychologists. 3 Psychiatric Social Workers. 3 Clerks. At least six psychiatric sessions are necessary to get abreast of the work arising in the schools in the Ealing area ; if the whole of Area 7 (i.e., Ealing and Acton) is to be covered, eleven sessions will be required. Although 1952 was a smooth running year in which there were no changes in clerical staff, we were still unable to deal with as many cases as were referred to us. The number referred by the Educational Psychologists was kept down to the lowest possible figure to give us an opportunity to catch up with arrears but it was still impossible to make more than a slight reduction in the waiting list. TABLE I. I.—Analysis of Work. Total number of cases referred to the Centre in 1952 178 Total number of cases brought forward from 1951 waiting list 73 251 Total number of new cases dealt with by the Psychitarist: Boys 83 Girls 33 116 Cases withdrawn before investigation 56 Cases investigated by Psychiatric Social Worker and advised by her 25 Cases remaining on waiting list for interview at Centre 54 135 251 II.—Analysis of New Cases seen at Centre. Total number of new cases seen by the Psychiatrist 116 A.—1. Recommended for treatment 69 2. Not put on treatment list ... 17 3. Special recommendations 30 B.—Treatment. 116 1. Psychiatrist 8 2. Play Therapist 34 3. Remedial Teaching 4 4. Play Group 5 51 5. Withdrawn from treatment waiting list 2 On waiting list for treatment in 1953 16 18 69 III.—Analysis of all Treatment Cases. 1. Number of cases carried over for regular treatment from 1951 62 2. Number of cases taken on in 1952 51 113 61 3. Discharged 56 4. Treatment broken off 6 62 5. Number of treatment cases current on December 31st, 1952 51 113 6. Number of old cases remaining under supervision 70 7. Number of cases discharged from supervision 32 8. Number of supervision cases current on December 31st, 1952 38 IV. —Special Recommendations. 70 1. Cases seen in 1952 for placement in schools for maladjusted children 21 2. Other special recommendations 11 32 TABLE II. TABLE OF SYMPTOMS (Including those for which the children were referred and others which were discovered at the diagnostic interview). I.—Primary Behaviour Disorders. Fears and anxiety 39 Solitariness and unsociability 9 Depression and lethargy 7 Difficult to manage at home 42 Difficult to manage at school 21 Temper tantrums 10 Direct aggression 14 Sexual difficulties 4 II.—Psycho-Somatic Disorders. Enuresis 37 Encopresis 3 Sleep disorders 12 Habit spasms 3 Feeding difficulties 2 Hysterical symptoms 5 Speech disorders 2 Asthma 2 Eczema 2 III.—Delinquent Behaviour. Stealing 30 Truancy and absconding 12 IV.—Educational Difficulties. Backwardness 20 Retardation 23 V.—Disorders with Organic Components. Epilepsy 2 62 TABLE III. ANALYSIS OF INTELLIGENCE (178 children referred in 1952) (151 children tested in 1952) 40-49 50-59 60-69 70-79 80-89 90-99 100-109 — — 1 4 22 36 35 110-119 120-129 130-139 140-149 150-159 160-169 170 20 19 10 3 1 — — Untestable Untested Test not completed — Under fives 6 — Awaiting test 14 Withdrawn 4 Not tested 2 1 referred to Hospital Psychiatric Department. 1 tested at Remand Home prior to referral—no I.Q. given. Average I.Q. of 151 children tested 105.3. Pre-school 10 Primary 114 Secondary Modern 34 Grammar 6 Private or Public 11 Technical 1 Special School1 Not known (case withdrawn before investigation) 1 178 TABLE V. SPECIAL RECOMMENDATIONS MADE IN 1952 Number recommended for schools or hostels for maladjusted children or ordinary boarding schools approved under Section 9(i) for the education of maladjusted children 21 Number recommended for schools for E.S.N, children 1 Number recommended for short-term schools 3 Number recommended for change of day school 5 Number recommended for farm training ... — Number recommended for Care of County — Number recommended for schools for physically handicapped ... — Number recommended for hospital in-patient treatment 2 TABLE IV. ANALYSIS OF AGES OF 178 CHILDREN (Number referred in 1952) 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 — 1 2 8 13 18 16 19 21 16 11-12 12-13 13-14 14-15 15-16 16-17 23 14 14 12 1 — Total ... 178 Average age 9 years Boys 118 Girls 60 178 63 SCHOOL DENTAL SERVICE The year 1952 has seen no improvement in the staffing position, and vacancies exist for 3 full time dental officers. Efforts have been made to utilise the present staff to its fullest capacity by instituting evening sessions for the treatment of older school children. A scheme was put into operation on the 1st January, 1952, and has proved a great success. The dental officers and dental attendants, undertake the work voluntarily, but only full time employees of the Middlesex County Council are permitted to take part. The number of evening sessions affords the equivalent addition to the staff of one half time dental officer. It has enabled a proportion of the older school children to obtain full treatment provided they were prepared to attend a clinic during an evening. A large percentage of the children seen and referred for treatment at a number of senior schools availed themselves of the opportunity of having their teeth put in a sound condition. The statistical return shows that 1,762 permanent teeth were saved by inserting 2,048 fillings in the teeth of 659 senior pupils at evening sessions. It is a matter of conjecture how many of these teeth would have had to be extracted, if these children had not the opportunity of this treatment. The shortage of Orthodontic staff has inevitably led to long waiting lists for treatment at the Orthodontic Clinic. The waiting list at Cherington House Clinic, Hanwell, which serves the Ealing area had to be closed during the year and it has not been possible yet to re-open it. This has led to more work of an orthodontic nature being carried out by the dental officers. The orthodontic laboratory of the Royal Dental Hospital of London has continued to supply all the removable appliances required by the orthodontist at Cherington House Clinic. This service which has been in operation some three years is greatly appreciated. The X-ray section of the school dental service is operated by a dental attendant who has been specially trained in this type of work. This is the first full year in which all the radiographs required by the dental officers and orthodontists for diagnostic purposes have been supplied entirely by our own department. A total of 1,245 separate dental skiagrams were taken, the majority of which were for orthodontic purposes. The system of restricted full dental treatment, which was introduced into the Ealing area in 1950 has had to be continued owing to the staffing position which has not improved during the year. The present position is that children in the junior departments of the schools are given routine inspection and the offer of full treatment at approximately annual intervals during the normal 64 daytime sessions. All other children are afforded emergency treatment only, except those in some senior schools who are offered the opportunity of attending during an evening session. This restricted scheme will be discontinued when the staffing position admits. Summary of Statistics for year ended 31st December, 1952. Normal Sessions Evening Sessions Number of New cases 5,470 659 Total attendances 9,279 1,424 Number of Fillings— Permanent Teeth 5,292 2,048 Temporary Teeth 251 — Extractions 7,015 96 EAR, NOSE AND THROAT SERVICE Mr. Arthur Miller, F.R.C.S., D.L.O., Consulting Otologist, conducts special Ear, Nose and Throat Clinics at the Mattock Dane and Ravenor Park Health Centres. Cases are referred to him from the local Doctors, Minor Ailment Clinics, School Nurses and Teachers, on account of Ear, Nose and Throat trouble, including deafness and infection of the Para-nasal sinuses and speech defects. The service of testing children's hearing at school has continued during the year and Pure Tone Audiometric tests for precise evaluation of hearing defects were done to children who have not passed the usual gramophone tests at school. Appropriate treatment to remedy the deafness was administered at the above clinics and subsequent control tests have shown that the hearing had improved in very many children. The tonsils waiting list is now only a small one and 245 operations were performed during the year, as compared to 75 in the previous year. Altogether 181 new cases were seen, and 464 Re-inspections, giving a total of 645 attendances. Medical Treatment was advised in 308 cases and operations advised in 134. AUDIOMETRY SURVEY I very much regret to report that during the year, Mrs. G. V. Chambers, the audiometer operator died after a short illness and was replaced by Mrs. A. D. Wood. In the summer months while Mrs. Wood was being trained in the use of the gramophone and pure tone audiometer, little testing was done—but testing recommenced in the last quarter of the year. 65 The opportunity was taken to review the clerical and administrative arrangements of the service and improved methods were devised for recording results. There was a further temporary delay due to a minor fault in the pure tone audiometer which was out of action for a few weeks. Number of children tested during the year 2,064 Number of children with hearing loss 135 FOOT HEALTH Routine foot inspections have continued during the year in the maintained schools. By the end of the Summer term 1953, two inspections will have been made in all schools established before 1950 as well as a first visit paid to the schools recently opened. Visits are made by Mrs. Murton, a State Registered Nurse, and there is close co-operation with the Head Teachers who appreciate the importance of this care. Children with defects requiring treatment or advice are seen at special foot clinics at which parents are invited to attend. The parents co-operation is essential as so many of the defects arise from wearing ill-fitting or outgrown shoes. The parent is also asked to ensure that the child regularly carries out any exercises suggested and has any suggested modification of the shoes. A table is attached giving the number of routine inspections performed during the year (8,759). A total of 4,560 defects were found, i.e. 52% of children had some defect : 43.3% had a defect of the toes. 6.7% of the arch, and 1.9% had some infection. Defects tend to increase with age, this was strikingly shown with defects of the toes which increased from 23.1% of infants to 60.1% of seniors. Infections, too, were more frequent in the seniors than the younger children, but this was a much smaller problem, i.e. only 3.6% of seniors infected and none of the infants. The defects of the arch do not appear to be related to age, i.e. (8.4%, 6.2%, and 6.4% in the three groups) and tend to diminish slightly with the years. This is a much smaller problem than was once thought. The main problem is that of Hallux Valgus (bent big toe), while the number of mild cases remains high the number of severe cases have decreased with supervision and education. 66 The number of children with ringworm of the toes has greatly decreased but verrucae (plantar warts) are still a problem. Cases tend to be grouped in certain schools but individual cases are scattered throughout all schools. It is difficult to trace source of spread, but early detection and treatment of cases and the cessation of barefoot dancing classes and the use of communal plimsols has helped to prevent spread of infection in some schools. Both these last measures, while expedient, are to be regretted, and the Physical Education Department are concerned about the number of children who do not get full benefit from these activities if they wear outdoor shoes for dancing and physical training. Many parents have willingly provided their children with plimsols or sandals but in a substantial number of cases this has not been done. Badly fitting shoes are still found in about 15% of children and in the senior girls schools it is about 25%. Bad types of shoes are found, particularly, in the secondary modern schools. The popularity of the slip-on "casual" is still great and both it and the high heels are harmful to growing feet. Many parents still express surprise that children grow out of their shoes so quickly but the experience of the Ealing Contributory Shoe Scheme showed that a pair of shoes usually becomes short after about 3-4 months wear. While there is still no shoe on the market which is both cheap and well made, children will continue to wear shoes which are outgrown. A total of 322 children were referred for treatment—314 to the foot clinic, 175 to the chiropodist and 33 to the orthopaedic surgeon. An overall survey of the condition of the children's feet suggests the need for continued vigilance to pick out early signs of trouble and for repeated education of both parents and children in the principles of foot care and good footwear. No. of children Examined 1952-3 Defects found Defects requiring Treatment of Toes of Arches of Infections Foot Clinic Orthopaedic Surgeon Chiro podist Total Infants 1,665 384 140 0 56 4 4 64 Junior 3,564 1,290 223 58 134 12 57 203 Senior 3,530 2,122 226 127 124 17 114 255 Total 8,759 3,796 589 175 314 33 175 522 FOOT HEALTH EDUCATION. The Foot Consultation Clinics have given opportunity for discussion of individual problems with parents, and a chance to direct their attention to the salient points of good foot health. 67 Informal talks have been given on this subject to several of the Parent-Teachers Association Groups and Townswomen's Guilds in the area. Dr. Craigmile lectured to the Women Public Health Officers Association Refresher Course for Health Visitors at Southland Training College, Wimbledon, on the work being done at the foot inspections and clinics in Baling. In addition a wider public has been reached through the B.B.C. During the summer of 1952, I was asked to organise and appear in a Television Series of six 10 minute items "Your Children's Feet" shown on Women's Hour. This series aroused so much interest that an additional session was arranged to answer some of the many questions which had been sent to the Television Studios. Chiropody Clinic. The chiropodist continued to attend at the Ravenor Park and Mattock Lane Clinics. No. of New cases: 1952 1951 Ante-natal Mothers 13 4 0-5 years 12 10 5-15 years 282 187 Total 307 201 Verrucae 198 140 HANDICAPPED CHILDREN. The Education Act, 1944, provides that children shall be educated in conformity with their age, ability and aptitude. An important function of the school health service is to ascertain which children are so handicapped by reason of mental or physical defect as to require special educational treatment. At the end of 1952 the following numbers of children in Ealing had been so ascertained : Blind 1 Partially sighted 8 Deaf 17 Partially Deaf 16 Delicate 210 Diabetic 6 Educationally sub-normal 99 Epileptic 7 Maladjusted 71 Physically handicapped 31 Speech defects 4 Multiple defects 3 68 Of these 135 had been placed in special residential schools, 49 in special day schools, 6 in independent schools, 9 received home tuition and 274 were in maintained primary and secondary schools. The delicate children form the largest group. Many are treated in the ordinary schools by the provision of extra nutrients and special supervision—others need to go away for periods of convalescence or have spells at open air schools. During the year the report of the Chief Medical Officer of the Ministry of Education strongly criticised the running of a number of the Open Air Schools and suggested that with improved hygienic standards in the new schools, special open air schools would not be required in the future. The beneficial effects on the children of treatment at the Open Air Schools maintained by the Middlesex County Council has been striking—and these schools will continue to serve a useful function so long as overctowding of school premises remains, and it is necessary to use old and out-dated buildings. The parents of children who have attended the Open Air Schools have unanimously praised the facilities, premises and effect on the children. There has been a reduction in the waiting list for special schools for educationally subnormal children, following the provision of several new schools in Middlesex, but the waiting list for ineducable children who require institutional care is as long as ever. Two opportunity classes in the Brentside School have continued to successfully treat the milder cases. A proposal to extend these facilities has unfortunately proved impractical owing to lack of suitable premises. The first residential school for the treatment of children with severe speech defects has been opened in recent years and has done very useful pioneer work in this field. One child from Ealing has been placed in the school. OPHTHALMIC SERVICE Children with defects of vision are referred from the school doctors and minor ailments clinic to the care of the Consultant Ophthalmologist, Mr. Freeman Heal, and seen at the Mattock Lane and Ravenor Park Clinics. The total number of cases seen was 1522 (1951—1214) of which 469 (1951—468) were new cases and 1053 (1951—746) re-inspections. The number of glasses prescribed was 812 (1951—799). Abnormal eye conditions other than errors of refraction were as follows: 69 Congenital Abnormalities. New cases ases Squint 50 231 Congenital Nystagmus 4 6 Progressive or Malignant Myopia 1 4 Congenital Cataract 1 — Congenital defects Oculo motor nerves 1 2 Coloboma Uveal tract — 1 Retinitis Pigmentosa — 1 Buphthalmos 1 — abnormalities due to Infection. Blepharitis 3 1 Styes 1 — Meibomian Cysts 1 — Corneal Nebulae 1 — Follicular Conjunctivitis 1 — Optic Atrophy following Cerebral Abscess — 1 Blind eye from Uveitis 1 — Abnormalities due to Trauma. Loss of Eye from accident — 1 Abnormalities of Unknown Etiology. Coats Disease 1 Number of children sent to special schools 1 — Number of children sent for squint operation 2 — ORTHOPAEDIC CLINIC. During the year 1952 there has been no appreciable lessening of attendances at the Ealing Orthopaedic Clinic. The number of new cases of school age examined is the same as in 1951—i.e. 152, although the number of re-attendances during the year was 53 less (520 and 573). During 1952 there was a small drop in the number of attendances for physiotherapy and this may have been due to the absence of one of the Physiotherapists (Mrs. Parish) on account of illness, as both parents and children always take a little while to get used to a change of physiotherapist or surgeon. Quite a considerable number under school age are referred from the Welfare Clinics—97 in 1952 as compared with 89 in 1951 and in the past year 1,314 attendances were made for physiotherapy compared with 1,350 in 1951. Here again the temporary change in physiotherapist during Mrs. Parish's illness will have had its effect. The Council's Orthopaedic Clinic fills a very real need, partly as a Consultative Clinic and partly as an Orthopaedic Treatment Centre. Treatment is now given in various Health Clinics, particularly in the more recently developed and outlying parts of the Borough so reducing the loss of school hours to the minimum and the number of hours which parents would have to spend in journeying to and from hospital out-patient departments. This latter is particularly important in the case of small children and babies and is much appreciated by the mothers of small babies on account of travelling and feeding difficulties. 70 SPEECH THERAPY. Speech Therapy treatment has been given in the Borough for the last twelve years. The school population of the borough has increased from 19,715 in 1946, to 23,370 in 1953. The number of speech defectives is between 1½% to 2% of the school population. Thus, at present some 450 children have to be considered. Treatment occupying 12 sessions each week at is present given at nine Clinics and schools where the more serious cases (200—220) are treated at weekly or fortnightly intervals. Treatment is given by a full-time therapist and an assistant attending two sessions per week. Treatment was given at the following clinics : Mattock Lane Greenford Green Perivale Cherington House Ravenor Park Islips Manor Laurel House Oldfield School Northolt School In September visits to Northolt School ceased as the numbers did not warrant regular visits. The time saved was employed at Ravenor Park Clinic which had the longest waiting list. The children treated during the year fell into the following classes: Stammer 31 Cleft Palate 6 Aphasia 6 Idioglossia 33 Dyslalia 97 Dysarthria 8 Total 181 Discharged 60 New 104 It was possible to undertake treatment for 44 more patients than the number that were discharged, as a number of the new cases were treated in groups. 90% of children's speech disorders begin between the ages of three and five years and between 1946/1949 it was aimed to clear as many of the older children from the clinics as possible, thus enabling disorders to be dealt with at their inception. By this method the periods of treatment necessary were reduced. 71 Schools. Fewer schools were visited this year as visiting sessions became utilised for treatment but regular contact has been maintained by telephone with Heads of Schools who are attempting to help their own speech-defective children by carrying out exercises given by the Speech Therapist. The Speech Therapist has made several visits to schools on request—one session a week being reserved for this purpose since September. Play Group for Pre-School Children. During 1949 the Speech Therapist was able to give much more time to consultation with the mothers of under-fives and in January, 1950 a play treatment group was started at Mattock Lane Clinic for children between the ages of three years six months and five years. The group meets for eighty minutes twice a week and never contains more than eight children at any one time. Since it began in 1950 twenty children have passed through the group and a summary of these cases is given below : 4 came with no speech (Aphasia). (1 was discharged as satisfactory, 3 are at school and receiving individual treatment). 2 had a language of their own (Idioglossia) (both are now at school and receiving individual treatment). 9 mixed, or missed out, all consonants (Dyslalia). (7 were discharged as satisfactory, 2 are at school receiving individual treatment). 1 had paralysis of the tongue and soft palate (Dysarthria), (is now at school and receiving individual treatment). 2 stammered. (1 is discharged as satisfactory, 1 still needs treatment). 2 were eventually proved of very low intelligence, and sent to Residential Schools. Thus, out of twenty, nine children were discharged, two were found to need residential schooling, and nine started school still handicapped. These children were drawn almost entirely from the Mattock Lane area on the recommendation of the Medical Officers, Health Visitors and Child Guidance Centre. In the near future it is hoped to extend this form of pre-school treatment to the Greenford area. In 1952 50% of the group started Primary school completely free of speech handicap. 25%started with dyslalia but could make themselves understood. One child was kept in Play Group for one term after he was 5 and then started school with adequate though limited speech. One started with little speech but continued to have weekly treatment and was speaking normally by his 6th year. Staff. We were sorry to lose the services of Miss Sorby in July but Mrs. Webb, her successor, has quickly picked up the threads and made satisfactory progress with the children in the Laurel House area. 72 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. The Bye-laws governing the employment of children in Middlesex are as follows : No child is permitted to be employed under the age of 13 years. Total weekly hours of employment must not exceed 16 during school holidays. There must be no employment before 7 a.m. or after 7 p.m. A child may be employed before school from 7 to 8 a.m. for the delivery of milk or newspapers, but shall not be employed for more than 1 hour (after school) between 5 and 7 p.m. On Saturday 4 hours work is permitted and on Sunday 2 hours between 7 and 10 a.m. for delivery of milk and newspapers. There are a number of undesirable employments which are prohibited for children, e.g. sale of liquors, work in slaughterhouses, window cleaning, etc. 225 pupils were medically examined to determine if they were fit for employment. In 2 cases permission was not granted. 8 children were examined and found to be fit to take part in entertainments. EXAMINATION OF TEACHERS. 21 teachers were medically examined on appointment to determine physical fitness for their duties. INFESTATION WITH VERMIN. Once again there has been a further improvement during the year in the standard of head hygiene. In the course of 53,959 examinations only 225 pupils were found to be infested, i.e. .42%. This is a marked improvement over last year's figure of 338 and the 1950 total of 493. We may compare this figure of .42% with Birmingham 8.6% in 1951. London County Council 3.2% in 1950. Bournemouth .7% in 1950 Acton 1.4% in 1951. England & Wales 6% in 1951. In five cases a compulsory cleansing order was served. This is only done when the child has been repeatedly found to be verminous and all efforts to help and educate the parents have failed. The school nurses are always willing to advise any parent as to the best methods of treatment and prevention of infestation, and stocks of insecticidal lotions are kept at the clinics. 73 SUPPLEMENT—FOR GENERAL INFORMATION. Health Services provided by the Local Health Authority. In Middlesex the Local Health Authority under the National Health Service Act is the Middlesex County Council. They have formed ten areas in the County, Ealing and Acton forming Area No. 7. In Ealing the local administration is carried out at the Town Hall, Ealing. Maternity and Child Welfare Clinics. The following are the addresses of the Maternity and Child Welfare Clinics in Ealing : Ante-Natal Clinics. (Interviews by Appointment). Address Times Abbey Parade, North Circular Road, Tues. mornings. Ealing. Brentside, Community Centre, West- Fri. mornings. cott Crescent, Hanwell, W.7. Cherington House, Cherington Road, Tues. Wed. mornings. Hanwell, W.7. Greenford Green, Wadham Gardens, Tues. Fri. mornings. Greenford. Islips Manor, Eastcote Lane, Northolt Mon. Thurs. mornings. Laurel House, Windmill Road, Ealing Thurs. mornings. Mattock Lane, 13, Mattock Lane, Wed. Thurs. and Ealing, W.5. Fri. mornings. Perivale, Horsenden Lane, Greenford. Thurs. mornings. Ravenor Park, Oldfield Lane, Green- Mon. Wed. Fri. mornings. ford Child Welfare Clinics. Abbey Parade, North Circular Road, Tues. 2—4 p.m. Ealing Brentside, Community Centre, West- Thurs. 2—4 p.m. cott Crescent, Hanwell, W.7. Cherington House, Cherington Road, Mon. Tues. & Thurs. Hanwell, WT.7. 2—4 p.m. Greenford Green, Wadham Gardens, Tues. Fri. 2—4 p.m. Greenford Islips Manor, Eastcote Lane, Northolt Mon. Thurs. 2—4 p.m. Kingshill Community Centre, Northolt Tues. 2—4 p.m. Laurel House, Windmill Road, Ealing Tues. Thurs. 2—4 p.m. Mattock Lane, 13, Mattock Lane, Mon. Wed. Thurs. Fri. Ealing 2—4 p.m. Perivale, Horsenden Lane, Greenford Mon. Thurs. 2—4 p.m. Ravenor Park, Oldfield Lane, Green- Mon. Tiies. Wed. Fri. ford 2—4 p.m. 74 Domiciliary Midwifery Service. An expectant mother can obtain the services of a "general practitioner obstetrician" for her confinement in her own home. As an alternative she can obtain the services of a County Council midwife who will attend her in the home either as a midwife, delivering the child herself, or as a maternity nurse when the mother is arranging for her doctor to attend the confinement. If the services of one of these midwives is needed, application should be made through the Maternity and Child Welfare Clinic. Home Nursing Service. Free Nursing Service in the home to cover all types of sickness is now available for everyone for as long as it is necessary. There are a number of nurses in the Area whose services are made available at the request of the medical practitioner and they work under his instruction. Further details regarding this service can be obtained from the Area Medical Officer, Town Hall, Ealing. Home Help Service. In addition to the arrangements made to provide domestic help during confinement at home, domestic help is also provided in other cases of emergency such as sickness, aged people in need of help, cases of tuberculosis and sickness in the home where there are very young children. Applicants needing Domestic Help should apply to the Area Health Office, Town Hall, Ealing. A charge is made for this service, although this is reduced in cases of hardship. Day Nurseries. There are seven Day Nurseries in the Ealing portion of the area for the care of children under five years of age. Admission is restricted as a general rule to children whose mothers need to go out to work, although in exceptional circumstances, e.g. during the mother's illness or other emergency, other children may be accepted. The nurseries are open from 7.30 a.m. to 6 p.m. Applications for admission should be made to the Area Medical Officer, Town Hall, Ealing. A charge is made for this service on a sliding scale based on the parents income. There is a normal minimum charge of 2/- per day which may be cancelled in cases of exceptional hardship. Perry & Routleff Ltd. Printers and Stationers Ealing and Uxbridge