??? EAL 44 The B Health of Ealing in the year 1953 EAL 44 The Health of Ealing in the year 1953 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. INDEX Page Section 1.—INFECTIOUS DISEASES 7 Section 2.—SANITARY CIRCUMSTANCES OF THE BOROUGH 21 Section 3.—SANITARY INSPECTION 26 Section 4.—GENERAI, 37 Section 5.—STATISTICAL TABLES 41 Section 6.—APPENDIX: REPORT OF THE SCHOOL MEDICAL OFFICER 46 Supplement.—FOR GENERAL INFORMATION 66 4 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 „ „ A. E. Pooley ,, ,, D. H. Smith (resigned 25/3/53) „ „ G. O. Axon „ „ A. C. Bamping „ „ D. J. Anderton (commenced 30/3/53) ,, „ D. G. Martin (commenced 1/6/53) „ „ Harry M. Birrell Chief Administrative Assistant R. S. Leggatt Senior Clerk R. Angeix Clerk D. R. A. Smith ,, J. T. Woolford ,, Miss D. E. McKenzie Shorthand-Typist Mrs. M. G. Byford „ „ Mrs. D. Barker Clerk and Typist R. S. Cox Rodent Operative 5 Mr. Mayor, Aldermen and Councillors, In general the state of health of the inhabitants of the Borough in the year 1953 could be regarded from every aspect as highly satisfactory. No 'smog' effects were felt—although the after effects of the very bad fogs in December, 1952 were carried into early 1953. The old killer, tuberculosis, seems to be well on the retreat, and, although no one can feel that he is likely to be routed for good ,a continuance of the battle on its present course could eliminate tuberculosis from our death lists in about five years' time. The tenderness of care of infant life, and the reduction of maternal mortality to insignificance, are facets of our progress in a healthy way of life that give those of us who have spent a life-time in public health work much solid satisfaction. Our progress in the education of the food handler and school leavers in the prevention of food infections is—like all pioneering— uphill work. We believe, however, that having set our hand to the plough we shall need patience, skill and labour to produce a harvest, and the harvest we aim at—the abolition of the transmission of not only food poisoning, but of all bowel carried disease—is one highly worth securing. Since this certainly includes much poliomyelitis, our ultimate aim is high and we cannot expect quick or spectacular results. The figures you will find in the report show that our drive is not slackening. It has now become, indeed, our firm opinion that no one should be allowed to handle food which will be consumed by the public, without having some sort of short course of instruction in the dangers of carelessness in food preparation. The ignorance of most food handlers on their power to cause illness by means of faulty handling techniques is lamentable. A short course of four talks can revolutionise their approach, and it is difficult to understand how it is that no one is allowed to drive a motor car without being officially tested to make sure that they are not a menace to public safety on the road, whilst anyone, no matter how ignorant they may be of the primary laws of hygiene in relation to food, can be let loose to serve an unsuspecting public without any instructions at all in the elementary rules of hygiene. Personally, I would have been prepared to forgo the whole of the new legislation on Clean Food under the Food and Drugs Amendment Act for a compulsory short course on the hygiene of food handling given through the Local Sanitary Authority to all workers in the food industry. Perhaps we are not yet ready as a country for such positive action but I look forward to the day when the country will be able to say—our food is as safe and clean as it is possible to make it. We are so very far from that at present! The dichotomy of the health services in Ealing by the National Health Service Act of 1946, has taken away from the Borough 6 Council all opportunity for initiative or enterprise in many fields, including maternity and child welfare and care and after care of the aged. It is to be greatly deplored that no step has been taken to rectify this, since much could and should be done by means of local experiment in the various fields that are at present subjugated to the enormous administrative machine controlling the activities of the Local Health Authority. Our artificial division of medicine and preventive medicine into services maintained by Hospital Boards, Executive Councils, Health Authorities, Local Sanitary Authorities and Government Departments, all of whom are financed almost entirely from general taxation, make it difficult to believe that some more simple, more economical, and more effective organisation could not be devised to provide a lively and comprehensive medical service under one reasonably sized unit of population. Personally, after much experience in a wide variety of conditions I should have no hesitation in planning areas of 100,000 to 200,000 population with a few specialised services for really large regions. Ealing would be an excellent area to handle its own health services and it is to be hoped that its good record in the past will enable it to claim an opportunity to return to its proper function in the future. The problem of London government, which of course covers all outer areas such as Ealing, could surely be sorted out by a team of experienced local government officers, and a 'new deal' made. The drift we are now experiencing is inimical to the interests of the good administration upon which must largely rest the welfare of the people. Dr. H. Binysh, Deputy Medical Officer of Health, has been appointed Deputy County Medical Officer of Health to Staffordshire County Council, and this will be a great loss to the department as Dr. Binysh has become extremely valuable in the work of the Sanitary Service of the Borough Council in addition to his work as Senior Assistant Medical Officer in charge of school medical service work. Naturally, we wish to extend our best wishes to Dr. Binysh on his appointment and regret his loss to our department. Changes in staff have been made during the year and to those that have left us I wish to express my appreciation of their services and for those who have joined the staff—welcome. Once more may I express my appreciation of the work of the staff of the Department during the year. Your obedient servant, W. G. BOOTH, Medical Officer of Health. 7 SECTION 1. INFECTIOUS DISEASES The term infectious diseases is given to those diseases which are most readily transmissable from one human being to another and from an animal to a human being. They can be transmitted from one person to another so easily and quickly that in a very short space of time a large number of individuals may become infected so giving rise to an epidemic. In order to help control the spread of these diseases certain of them have been made notifiable that it is to say, the authorities, in this case the Medical Officer of Health of a district, must be informed of their occurrence. In the last one hundred years there has been a great decrease in the incidence of and mortality rate from infectious diseases. This decrease appears to be due to a variety of reasons. In many cases a knowledge of the mode of transmission has been the first step in reduction. The compulsory notification mentioned above has played an important part in the fall in mortality rates of all infectious diseases. In the cases of typhoid and cholera, which were a scourge in this country for many years, the main factors in reduction of mortality have been improvements in water supply and sanitation. These factors are important also in the case of paratyphoid fever, but nowadays, with regard to prevention of this disease, the emphasis is laid on good personal hygiene and clean food. With dysentery also, improved methods of handling and storage of food have led to a reduction in deaths from this cause. The knowledge that typhus was a louse borne infection gave rise to the use of insecticides which successfully controlled this disease. The use of vaccination in smallpox and immunisation in diphtheria have been largely responsible for the rarity of deaths from these diseases at the present time. Chemotherapy and antibiotics have reduced the fatality from measles and whooping cough, mainly by preventing complications. Decline in virulence of the causitive organism has rendered scarlet fever practically innocuous and it is interesting to speculate on the possible decline in virulence of the virus causing influenza. Early Diagnosis. Since these diseases are as a rule most infective in the early stages the importance of early diagnosis in the prevention of spread of disease cannot be over emphasised. It is important therefore that parents should be able to recognise the early signs of the common infectious diseases. 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. 8 Leaflets describing the essential points of home nursing of persons suffering from infections, and advice as to disinfection are provided when necessary. 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 inaminate 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 by use of 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, such as 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. In addition, in cases of food poisoning in which vomiting is a prominent symptom, samples of suspected food or vomited material should be retained wherever possible. These, if examined in the laboratory may not only reveal the identity of the causitive organism but may also help to trace the source of the infection. 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. 9 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. 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. As in the previous year there was no notified case of Diphtheria during the year. Primary immunisation at the Clinics remained about the same, 1,370 children were immunised compared with 1,367 the year before, and 415 children were immunised by General Practitioners against 544 in 1952. The total number of booster doses was exactly the same as in the previous year, 2,513. This number comprises 125 by General Practitioners and 2,388 at the Clinics, compared with 172 and 2,341 respectively in 1952. Since the total number of live births for the year was 2,444 it can be seen that a large proportion of children in the first year of life received primary immunisation. This proportion was approximately 72%. It is considered that to obtain a satisfactory state of immunity 70% to 75% of children in the first year of life should be immunised. There is every reason to be pleased with the present state of immunity of the population of Ealing, but there should be no complacency about this. As the incidence of Diphtheria falls it is all the more important to continue the immunisations, as the natural immunity acquired from exposure to the disease falls off. Dysentery. 132 cases were notified and in 73 the Sonne organism was discovered. All the cases were individual or involved two or three members of a family. There were no major outbreaks. This was a very mild type of enteritis but such a type can rapidly assume epidemic form and cause much concern among parents, as children are mainly affected. To prevent such outbreaks the practice of hand hygiene by all concerned is essential and even mild cases of diarrhoea should be reported. 10 Enteric Fever. There were no cases of Typhoid Fever. Two cases of Paratyphoid Fever were notified. One was a boy of 6 years who returned from school with a high temperature. His condition worsened and he was admitted to Hounslow Hospital where Paratyphoid C was diagnosed. No other member of his family showed any symptoms, and they gave negative laboratory results. The other case was a woman of 32 who discharged herself from a maternity hospital after a normal delivery. Her temperature rose slightly on the 10th day and, although urged to remain in Hospital, she insisted on returning home and was advised to call in her own doctor. As the result of his visit she was admitted to West Middlesex Hospital where she was diagnosed as Paratyphoid and transferred to South Middlesex Hospital. The Authority in whose area the Maternity Hospital was located made exhaustive enquiries and had many laboratory examinations carried out but, as in the first case, there was no evidence of the origin of the infection. Enteric Fever Carrier. As mentioned in last year's report, only one identified Paratyphoid carrier remains in the district. She continues to be kept under surveillance and herself takes all necessary precautions. Erysipelas. 18 cases were notified, eight fewer than in 1952. There were no deaths. As stated in a previous report this condition is very amenable to treatment with the sulphonamide group of drugs and no longer presents a Public Health problem. Food Poisoning. Of the 31 cases notified only 10 were confirmed bacteriologically. These 10 comprised 8 Salmonella Typhimurium, 1 Salmonella Enteriditis and 1 Salmonella Thompson. This showed a slight increase on the 26 notifications in the previous year, of which 8 were confirmed bacteriologically. All were isolated cases with the exception of three cases of Salmonella Typhimurium which occurred in one family. In no case was it possible to identify the source of infection. Food Poisoning is essentially preventable and for the production of safe food this well-known slogan should always be borne in mind— "Clean Food, cleanly prepared by clean people in clean kitchens ". Food handlers should realise fully their responsibility and should have a high standard of personal hygiene. Their hands 11 should be in a good condition and clean, their finger nails should be short, clean overalls should be worn and the hair covered with a cap. Minor illnesses should be reported. Cuts should be treated and covered. Colds, running ears or diarrhoeal illnesses should be "stood off " or watched carefully. Firms should provide adequate facilities for their employees for washing their hands. The importance of this, especially after use of the toilet, should be emphasised and notices to this effect displayed in lavatories. Staff should be selected with care and those with a history of enteric or any such illness should not be chosen. With regard to the technique of the kitchen, manual handling of food should be avoided wherever possible. Refrigeration is a keynote and wrappings and covers for food on display are essential. Reconstituted eggs, custard powders and so on should not be kept in a warm place. The kitchen should be constructed so that it is easily cleaned, ventilation and lighting should be adequate and there should also be adequate storage space. The necessity for the above precautions has been fully realised in the Borough and the steps taken by the Chief Sanitary Inspector and his staff to achieve the desired effect are mentioned in a later part of this report. Malaria. Three cases of malaria were notified. These were men aged 25, 29 and 21 respectively. The first had returned from Malaya after spending some years there, the second was also home from the east after eight years in the army and the third had returned from service in Korea. All three cases were confirmed by blood test. Measles. 2,568 notifications were received during the year. While this is a great increase on the 993 cases in the previous year it is not so severe as in 1951 when 3,296 cases occurred. The largest number of cases, 2,001, occurred in the first quarter of the year. There were no deaths. The chief signs of measles in its early stages, and before the appearance of the typical rash, are simply those of a common cold; namely watering of the nose and eyes, and sneezing. This is only one of the many instances of the importance of the isolation of "Coughs and Sneezes before they Spread Diseases." Ophthalmia Neonatorum. No notifications of this condition were received in 1953. 12 Pneumonia. There were 231 notifications received. Of these 74 were influenzal pneumonia. 80 deaths from pneumonia occurred, 5 of which were due to influenzal pneumonia. The total of 231 notifications is a considerable increase on the 1952 figure of 128. The number of deaths was lower, 80 compared with 101 in 1952 when there were 103 less notifications. Puerperal Pyrexia. 61 notifications were received, principally from Perivale Maternity Hospital. Perivale Maternity Hospital 53 Private 7 One notification was withdrawn, leaving 60 There has been an increase in the number of notifications since the definition of the term puerperal pyrexia was amended in 1951. Any febrile condition in which the temperature reaches 100.4°F. on any one occasion within 14 days of childbirth or miscarriage must now be notified. The number of cases notified from Perivale Hospital represents 4.4% of the total births at that hospital, while the number notified by private doctors represents 1.5% of the total home confinements. The difference is probably due partly to the fact that hospital confinement is recommended where there is reason to think that the confinement may not be straightforward and partly to the fact that the hospital routine of recording four hourly thermometer readings contributes to more accurate detection of raised temperatures. Scarlet Fever. This continued to be a very mild form of the disease. 238 notifications were received of which number 233 were confirmed. Smallpox. During the year seven people from abroad who may have been in contact with cases or suspected cases of Smallpox came to Ealing. They were all kept under daily surveillance until the end of the incubation period. Fortunately no case of smallpox developed in the Borough. The popularity of air travel makes ceaseless vigilance essential in this matter. 13 Whooping Cough. The incidence of this disease fluctuates from year to year. There were 491 notifications during 1953 as against the unusually low figure of 77 in 1952 and 550 in 1951. There were 2 deaths in 1953. There are periodic cycles of occurrences, usually in alternate years and this may be because the children who escape infection probably develop a temporary latent immunity. These number twice as many as are attacked. This immunity is, however, short lived, probably of one year's duration and at the end of this time the immunity has waned. The accumulation of susceptibles thus produced leads to an epidemic. The incubation period of whooping cough is usually seven days with rare cases observed up to 21 days. The initial catarrhal stage is very infective. The disease is spread usually by intimate contact rather than more casual contact and is associated with institutions and crowded environments. Within a family the chances are higher of the non-immunes getting whooping cough. It is mainly contracted in infancy and childhood, and the incidence is greater among females. The campaign for immunization against whooping cough, using pertussis/diphtheria vaccine, which was started in the autumn of 1947 has been intensively pursued, yet in spite of this there has been no reduction in the number of cases notified, although the attack appears to be of a milder nature in the children who have been immunized. It is gratifying, however, that the number of deaths during the 6 complete years since the introduction of immunization was only 6 as against 17 for the 6 years preceding the campaign. As a result of a valuable piece of research undertaken by the Deputy Medical Officer of Health, Dr. H. Binysh, into the immunizing efficiency of three types of vaccine and into the degree of local and general reaction caused by each, the type of vaccine used in the Borough was changed during the year. It will be of interest to see if the incidence and mortality are further reduced during the forthcoming years. Acute Anterior Poliomyelitis and Polio-Encephalitis. There were 13 cases of confirmed Poliomyelitis, 6 paralytic and 7 non-paralytic. This is 8 less than in the previous year. One death occurred, a paralytic case of a boy of 13 years. 14 The following table shows the age distribution: Paralytic Non-Paralytic M. F. M. F. Under 1 1—2 1 3—4 1 5—9 3 1 10—14 1 1 15—24 2 25+ 1 2 Total 6 — 6 1 It will be noted that the age distribution has quite definitely changed and that it can no longer be called Infantile Paralysis. An analysis of recent outbreaks revealed the facts that about one third of the cases occurred in children under five years, one third in the 5-15 years of age group and one third in persons above 15 years of age. This difference in the age distribution may be due to a change in the type of virus causing the disease or a change in the resistance acquired in childhood. It has been shown that in countries where hygiene is good the age of onset is postponed and so, therefore, is the immunity states. Investigation into the disease has shown that the virus causing poliomyelitis is very infectious and is spread by the pharyngeal and intestinal excretions of infected persons. Laboratory studies have shown that all infected persons do not show symptoms and indeed, that for every person showing symptoms there may be as many as 10 to 100 infected persons without symptoms. Close contact appears to be an important factor in the spread of disease. Investigations have indicated that infection tends to follow the lines of communication of human beings, affecting particularly those from infected households, and the extent of the spread is to a large extent dependent upon the closeness of contact exposed persons have with the infected persons. These abortive cases present a great public health problem, and emphasise the need for close supervision of all who have been in close contact with a proved case. Tuberculosis. The number of cases notified this year remains practically the same but the number of deaths from this disease fell from 40 in 1952 to 29 in 1953 a fall of no less than 27.5%. Young children of the age of 2, 3 and 4 years are 'Jelly Tested' at the Infant Welfare Clinics. The Chest Clinic follows up the contacts of notified cases of tuberculosis and B.C.G. vaccination is offered in appropriate cases. 15 The Mass X-Ray unit visited the Borough on four occasions for the purpose of examining contacts. At the request of the management they also made a protective factory survey at the Glaxo Laboratories, Greenford. A total of 938 persons at this factory were examined, of whom 7 required further investigation. This does not necessarily indicate tuberculosis. The static Mass X-Ray unit established at Central Middlesex Hospital continues its valuable work. Expectant mothers attending the ante-natal clinics in the Borough have a routine X-ray of chest done here, and other groups who are at special risk or who come into close contact with children are also examined. The following table shows the age and sex of the cases notified and the deaths in 1953. Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 1-5 5 2 5—10 4 1 1 10—15 3 3 2 15—20 12 15 20—25 3 23 1 25—35 19 28 1 2 4 1 35—45 11 15 1 2 3 1 45—55 20 5 4 4 3 3 55—65 19 4 6 65 upwards 7 6 1 1 5 3 Total 103 102 8 12 18 10 — 1 The number of new cases of Pulmonary Tuberculosis notified was 205 compared with 211 in the previous year, while the number of cases of Non-Pulmonary Tuberculosis was 20 compared with 29 in the previous year. There was a total of 29 deaths, (28 Pulmonary, 1 Non-Pulmonary) compared with 37 Pulmonary, 3 Non-Pulmonary in the previous year. Graph to show the trend of notifications of tuberculosis since 1930, and of deaths from tuberculosis. Notifications of tuberculosis (all forms) are shown , and deaths from tuberculosis (all forms) are shown , Both notifications and deaths are shown per 1,000 population. 17 Graph showing the deaths from tuberculosis per 1,000 total population for the years 1945-1953 inclusive as a percentage of the deaths per 1,000 population in 1944. 18 Deaths from Tuberculosis for the Years 1944-1953 inclusive. Year Respiratory Other Forms All Forms (a) 1944 66 5 71 (b) 1945 64 6 70 (c) 1946 78 15 93 (d) 1947 59 11 70 (e) 1948 61 5 66 (f) 1949 70 6 76 ' (g) 1950 48 6 54 (h) 1951 30 4 34 (i) 1952 37 3 40 (j) 1953 Percentage decline in (j) 28 1 29 From (a) 58% 80% 60% From (i) 24% 67% 27.5% Mortality from Tuberculosis in the Borough of Ealing has fallen by 60% in the last ten years and by 27.5% since 1952. This last figure is exceptional but otherwise these figures are comparable with those for England and Wales as a whole. Impressive as the figures are we must not forget that the fall in the number of deaths from tuberculosis has been going on, albeit but gradually at the start, for the last one hundred years. In the decenium 1851-60 the annual deaths numbered 70,000 in a population of only 19 million. It is interesting to contemplate briefly the factors which have contributed to the prevention and treatment of this disease. The improvement in the position by the end of the nineteenth century was due mainly to the progress of sanitary reform. Great improvement in the living conditions of the people followed the Public Health Act of 1875 which confirmed the recommendations of the Sanitary Commission of 1869-71, and aimed at securing the drainage of houses, the sewage of towns, the scavenging of streets, the removal of house refuse, wholesome conditions within houses and the isolation of infectious persons. The progress made since the beginning of this century can be conveniently described by dividing this period into three parts, the first from the beginning of the century until the end of the 1st World War, the second dealing with the inter war years and the third period being the years since the outbreak of World War II. During the first period, the provision of tuberculosis dispensaries and the increase in the number of beds for the exclusive use of patients suffering from tuberculosis, were two invaluable steps forward. It is interesting to note that at first voluntary associations provided all the dispensaries and most of the available beds, but by 1911, Sanitary Authorities had provided 14 dispensaries, and by 1919 the number of beds had almost trebled the 1911 figure. 19 Also during this period much was accomplished towards the prevention and treatment of tuberculosis in children by the establishment of the School Medical Service in 1907 and by the opening of voluntary clinics for the welfare of younger children. Another important event was the Local Government Board's Order extending compulsory notification to all forms of tuberculosis. The second period began with the establishment of the Ministry of Health in 1919 and this set up a special medical department concerned solely with tuberculosis which led to tuberculosis schemes becoming more unified and comprehensive. At this time also, the importance of hospital treatment in combination with sanatorium treatment became realised; there were great improvements in radiological apparatus and technique, and medical knowledge generally with regard to treatment of tuberculosis was progressing rapidly. The treatment involving collapse of the lung was becoming popular and giving good results. Good results were also being obtained with non-respiratory tuberculosis by the more extensive use of pasteurised milk and modern methods of orthopaedic treatment. Several events of great importance have occurred since the outbreak of World War II. Two of these occurred in 1943, the introduction of mass miniature radiography leading to earlier detection of the disease in many cases and the scheme of allowances making it possible for people with the disease to give up their work and, freed to a certain extent from financial worries, undertake treatment much earlier than hitherto. The use of new drugs such as streptomycin, P.A.S., and isoniazid have proved of great value and selected groups of the population at special risk have been given B.C.G. vaccination. In the light of these observations let us review the trends in notifications and death from tuberculosis in the last ten years. We have seen that, though the deaths from tuberculosis have fallen markedly, the notifications of the disease have remained at much the same level. What possible explanation can be found for this difference? There can be little doubt that, though all the factors mentioned have played their part in the decrease in the number of deaths, the most potent factors in the decrease are the advances in medical and surgical treatment and, to a lesser extent, earlier diagnosis with consequent prevention of the advanced stage of the disease. The question with regard to notification is not so straightforward. The exactness of the state of notification depends on many factors and can never be completely reliable. Allowing for these variations and despite all the preventive measures mentioned it appears that there has been little or no real change in the number of notifications in the past ten years. As it would be unreasonable to suppose that the steps taken in the last 100 years have had no 20 effect on the incidence of the disease, it seems probable that, without these measures, there would be a still higher incidence with more notifications and that the steady number of notifications observed each year is maintained by some undiagnosed reservoir of infection. It is believed that this reservoir of infection is located in a hard core of the population which does not at any time avail itself of the opportunity of having Chest X-rays at the Mass Radiography Unit. As a result a number of people who have tuberculosis are undiagnosed and remain in the population as a source of infection to others. It would appear therefore that a plan to reduce the notification rate below its present almost stationary level must aim at the early diagnosis of these sources of infection. In order to bring this 'hard core' to the Mass Radiography Unit an intensive and ceaseless propaganda campaign is necessary and we hope that the campaign planned for 1954 will show good results when the Unit visits the Borough in November of next year. Two graphs and a second table show the trends of notifications of tuberculosis in the last ten years, and of deaths from tuberculosis and the percentage decrease in the number of deaths over the same period. 21 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 51,776 houses with an estimated population of 186,100. Fourteen samples were taken from wells at six 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. Drainage and Sewerage. There are 26 permanent houses in the Borough not connected to the Council's sewers. The majority of these are in the outlying areas and there is no immediate prospect of their being drained to the Council's sewerage system until these areas have been further developed. Rivers and Streams. Pollution of River Brent. The pollution of the River Brent is regarded as a matter of prime importance and as a result of investigations carried out last year it was realised that a long term view must be taken and regular sampling and follow-up work undertaken in preventing further contamination. There is little doubt that there has been, as a result of the work so far completed a considerable improvement in the condition of the river. It is not possible at this stage to say how long it will be before we are completely satisfied with the samples that are being taken, but in view of the course of the river through the industrialised areas, it is inevitable that constant and active watch will have to be maintained if we are to prevent the bed of this river becoming fouled by trade wastes and deposited rubbish. Regular reports are being submitted to the Public Health Committee and a close watch is being kept on any change noted in the discharges from any of the numerous sources concerned in this matter. It is, of course, obvious that pollution will enter from other Boroughs through which the River Brent flows, unless co-ordination 22 of effort is made to see that the river is supervised throughout its length. Therefore, a meeting of Medical Officers of Health, the County Engineer and Chief Chemist from Middlesex County Council Sewage Works at Mogden, was arranged at the Ealing Town Hall in order to secure this co-ordination of effort. Much useful information was exchanged and there is little doubt that the meeting will be of value in helping to prevent pollution throughout the length of the river. During the summer months it was noted that children were playing and bathing in the River Brent in its course through the Borough. In view of the investigations which had been carried on over some period, it was felt that this was not a river which could be regarded as entirely safe for such purposes and instructions were given that schools should be notified of the possible dangers involved in allowing children to play in the river, and to take other measures to publicise the position at that time. Atmospheric Pollution. The June Minutes of the Public Health Committee gave some statistics and a map showing the incidence of deaths from pneumonia and bronchitis during the two weeks of the fog. Seventeen deaths were recorded in the first two weeks of January 1953, which could be attributed to this cause, as compared with seven in the corresponding period of the previous year. The increase was. however, less than that for the London area as a whole. For the past three years complaints have been received from the Long Drive area of Greenford regarding damage to growing crops in the gardens adjacent to the factory area. This damage usually occurred in the early summer months and most of the vegetation afterwards largely recovered. This limited our field of enquiry but a considerable number of inspections and investigations were carried out in an effort to ascertain the cause of this damage. Specimens submitted for analysis gave no definite clue as to the cause of the trouble and it was not until the summer of this year (1953), as a result erf reports received from the Clinical Research Association, that the presence of flourine in the atmosphere was suggested as a possible cause of the damage I referred the matter to the Chief Inspector of Alkali works and supplied him with reports of our investigations and the results of the analysis of samples. As a result erf his investigations into the works technique at the factory believed to be involved, a modification of this technique was carried out, and the subsequent analysis of the contents of atmospheric pollution gauges erected in the neighbourhood, have shown that the amount of flourine discharged into the atmosphere has been reduced to negligible proportions. 23 Complaints have also been received during the year regarding the emission of grit and dost from factories in this area and arrangements are now in hand for work to be carried out to the cupolas at the foundry of one of the factories in the neighbourhood and for grit arresters to be built on to the flues. It is hoped that this will result in a substantial reduction of grit and dust discharged into the atmosphere. During the year 121 smoke observations were carried out by the Sanitary Inspectors. Moveable Dwellings. As anticipated in my last year's Annual Report, there has been some improvement in the caravan problem in Northolt. This is due in the main to the continued development and fencing of undeveloped sites in this area. The only remaining large undeveloped sites in the Northolt area are the Lime Trees Estate and certain land fronting Western Avenue owned by the Middlesex County Council. Many complaints have been received during the year from residents in the neighbourhood of the Lime Trees Estate regarding the nuisances caused by the parking of caravans, and these caravans have been forcibly removed from the site on numerous occasions, only to return within a short period. The number of caravans frequenting this area has, however, been reduced appreciably and it is hoped that the rapid building development in Northolt will eventually solve this problem, which has been a source of considerable difficulty for some years past. FOOD HYGIENE It is satisfying to report that the Council's Clean Food Campaign which was inaugurated four years ago is still progressing satisfactorily. As I Lave stated on previous occasions the Council s scheme is based upon the education of the Food Handler in the principles of Food Hygiene, and I am convinced that any scheme for promoting the hygienic preparation and handling of food must provide opportunities for those upon whom the duty of preparing or handling food devolves, to obtain information on the elementary principles of Food Hygiene. Our lecture courses have continued during the year and, although some falling off in the numbers attending has been experienced, they are still receiving the support necessary to justify their continuation. During 1953, 66 lectures were given to Food Handlers of whom 210 received Certificates upon completing the course. Since the scheme commenced four years ago 274 lectures have been given to Food Handlers and 1271 persons have received Certificates of Attendance. 24 The number of Certificates of Food Hygiene awarded during the year to proprietors of food establishments increased by 8 to a total of 57. During 1953, 2134 inspections of food premises were made by the Santary Inspectors and 315 repairs and improvements were carried out. In addition to the lectures to Food Handlers the talks by Sanitary Inspectors to "school leavers" in the Secondary Grammar and Secondary Modern schools in the Borough have been given regularly. 28 talks were given during the year to approximately 1,000 school children. I would like to take this opportunity of expressing my appreciation to the Borough Education Officer and the Head Teachers for their co-operation and assistance which has been so generously given. It is anticipated that the Food & Drugs legislation shortly to be enacted will strengthen the powers of local authorities for improving Food Hygiene standards. This legislation will undoubtedly add to the duties at present performed by the Sanitary Inspectors, but the work carried out in this Borough over the last four years has to some extent anticipated certain aspects of the new legislation and the staffing problem will not present the difficulties which it otherwise might have done. (It is a matter of interest that on the 1st April, 1954, new Regulations came into force requiring notification of certain diseases and requiring precautionary measures to prevent food poisoning. These Regulations give the Medical Officer of Health considerable power in preventing the continuation in employment of persons coming into either the category of suffering from or being the carriers of certain diseases. This power may prove of considerable value in emergency.) A proposal was placed before the Council that the Public Health Department should prepare a film strip in colour for the sum of £65 to accompany the Clean Food lectures which are a regular feature of the winter programme. This film strip was produced during the year and has proved of great value in the work of the department. The cartoons for the strip were designed by Mr. A. Wurmser who also undertakes cartoons and diagrams for the B.B.C. Television service. The strip has been purchased by a number of other Local Authorities for use in their departments. It is intended that a further strip shall be made at a later date to illustrate any new legislation that may be brought into force in the near future. A special broadcast was made on Food Hygiene by the B.B.Cin December 1953 at which a report on the position in various parts of the country was made and a special interview with the Medical 25 Officer of Health was recorded for this programme to give the point of view of the Ealing Borough Council on the matter of Clean Food. 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 used at present. Chlorine treatment is carried out at each of the swimming pools in use. PUBLIC MORTUARY. The arrangement with the Acton Council for the use of the Acton Mortuary was continued during the year. 213 bodies were taken to this Mortuary and post-mortem examinations were carried out in every case. There is still an urgent need for the provision of mortuary accommodation in the Borough of Ealing and this matter is receiving consideration by the Ealing Borough Council. 26 SECTION 3 SANITARY INSPECTION THE WORK OF THE SANITARY INSPECTORS IN 1953 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 vear ; Public Health Act 1936 Inspections. Premises inspected on complaint 2,551 Other nuisances observed by Inspectors 88 Premises inspected in connection with infectious disease 593 Smoke observations 121 Houses without water supply 32 Inspections of moveable dwellings 747 Other inspections 2,783 Re-inspections 8,937 Intimation Notices served 1,310 Statutory Notices served 236 Letters written 1,940 Proceedings before magistrates 10 Legal Proceedings. Public Health Act 1936, Section 93. Non-compliance with Statutory Notices. In nine cases legal proceedings were taken to enforce compliance with notices requiring the abatement of nuisances. In 7 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 £ 10. 10s. Od. were awarded. In one case the hearing was adjourned and the summons later withdrawn as the work was in hand. One case was taken against the owner of a caravan in respect of noncompliance with an abatement notice and an Order was made for the caravan to be moved within seven days. Public Health Act 1936, Section 75. The owner of one property upon whom a Notice was served to provide a dustbin appealed against this Notice to the Ealing Magistrates Court. The appeal was disallowed by the Magistrates. Dustbins. The ambiguous wording of Section 75 of the Public Health Act, 1936, coupled with the increased cost of dustbins and the fixing of rentals by the Rent Restrictions Acts, has created difficulties in the administration of this Section and representations have been made to the Ministry of Health and Association of Municipal Corporations to secure, if possible, a clarification of this Section of the Public Health Act. 27 The Council's existing policy, namely, that landlords should be required to provide dustbins, unless in any particular case good reason can be shown to the contrary, has upon occasion resulted in difficulties in the Court proceedings. It was therefore recommended that a change of policy should be formulared by the Council and that in those cases where the controlled rent under the Rent Restrictions Act is based upon the 1914 rent, the tenant be required to provide the new dustbin. In other cases the landlord should be required to provide it. This is the present practice of the Council and unless some amendment is made to the Public Health Act or the Council decide to change its policy, it will be adhered to. Food and Drugs Act 1938. Food and Drugs (Milk, Dairies and Artificial Cream j Act, 1950 Milk and Dairies Regulations, 1949, Etc. Complaints received 51 Inspections of Milk Purveyors' Premises 87 Contravention of Regulations — Inspections of Ice Cream Premises 259 Food Inspections 975 Inspections of Food Premises 2,134 Contraventions found 258 Notices served 209 Proceedings before Magistrates 3 Samples of Milk taken 51 Samples of Ice Cream taken 69 Samples of Synthetic Cream taken 33 Samples of other foods taken 9 Legal Proceedings. Food and Drugs Act 1938, Sec. 9. The following three cases were the subject of legal proceedings : 1. Mould in milk bottle—a fine of £5. 5s. Od. was imposed and £1. 2s. Od. costs were awarded. 2. Dirty milk bottle—this case was dismissed by the Magistrates. 3. Rodent droppings in bread—a fine of £5. 0s. Od. was imposed and £1. Is. Od. costs were awarded. List of Food Premises in the Borough of Ealing. Bakehouses 33 Bakers' shops 65 Butchers 121 Cafes and Restaurants 168 Canteens—factory 77 Canteens—school 21 Confectioners 234 28 Dairies and Milk Sellers 66 Fish Fryers 24 Fishmongers 44 Greengrocers 159 Grocers 323 Ice Cream Manufacturers 6 Public Houses 60 Premises registered for the preparation or manufacture of sausages or potted, pressed, pickled or preserved food 94 Premises registered for the sale of Ice Cream 324 Milk Supply. There are 81 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 :— Dealer's Licences Supplementary Licences Total Tuberculin Tested Milk 49 14 63 Pasteurised Milk 53 16 69 Sterilised Milk 56 16 72 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. 51 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 51 51 — 50 1 A subsequent sample was taken from the supplier of the one sample which failed the Methylene Blue Test and this proved satisfactory. In addition, 210 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. 29 Ice Cream. There are 324 premises in the Borough registered for the sale of ice cream. It was found that their ice cream is obtained from six registered manufacturers in the Borough or from 15 manufacturers outside the Borough. Samples from each of these 21 manufacturers were taken once or more during the year, a total of 69 samples of ice cream, ice cream constituents and ice lollies being submitted for bacteriological examination. The results were as follows : Commodity Samples Grade Not Graded 1 2 3 4 Ice Cream— Local Manufacture 11 23 — 4 — — Ice Cream— OtherManufacturers 31 27 2 2 — Ice Cream Constituents 3 3 Ice Lollies 8 — — — 8 69 50 2 6 — 11 11 of these samples were reported to be unsatisfactory— 6 from local manufacturers, and 5 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. 33 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. Almonds 7½ Apricots 4,480 Bacon 2533/4 Bakery Waste 5,856 Barley 10 Beef 4,923½ Biscuits 3,369½ 30 lbs. Brawn 5 Butter 49½ Cake 34 Cheese 711/4 Chocolate 4,328 Cocoa Butter 2,516 Cocoanut 36 Cocoanut Ice 101 Cocoa Powder 2,812 Cod Roes 28 Confectionery 2,352 Corned Beef '282½ Dried Milk 392 Fish 884 Flour 78 Geese 199 Groats 80 Ham 503/4 Kidney 5¼ Lard 248 Liver 176 Luncheon Meat . 123/4 Margarine 13 Mutton and Lamb 661¼ Nuts 653 Oats 76 Offal 195 Pork 877½ Rice 558 Roes 56 Salmon 28 Sausages 466½ Split Peas 122 Steak 2 Suet 15 Sugar 557 Sweetbreads . 85½ Tea 1,913 Tongue Turkey 399 Veal 38½ Foodstuffs not calculated by weight. Ice Cream Bricks, etc. 326 Ice Lollies 158 Chocolate Bars 10 Chocolate Rolls 7 Sponge Cakes 1 Loaves 2 31 lbs. Teacakes 1,704 Cheese portions 183 Rabbits 10 Pig carcases 10 Eggs 4,925 Assorted tins, jars, packets, bottles etc. 29,245 There are two private slaughter-houses in the Borough, but no slaughtering has been carried out in them since 1939. It is anticipated that applications will be received for these slaughterhouses to be re-licensed during 1954. 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) 2,452 (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Act, 1936 10 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 4 (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 1,575 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 1,486 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 — (б) 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 210 (2) Number of dwelling-houses in which defects were remedied after service of formal notice : (а) by Owners 162 (б) 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 1 (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 . — 32 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 1 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit 1 Of the four dwelling houses reported as unfit for human habitation during the year, one is a Council property which will be demolished when the present occupants have been re-housed; the second is an outbuilding which was used for human habitation and which has now reverted to its original use as the occupants have found accommodation in another district; the third is a basement dwelling regarding which a Closing Order was made by the Council and has now been vacated ; and the fourth is a house regarding which Demolition Order procedure was not commenced until 1954. One basement dwelling which was the subject of a Closing Order was rendered fit during the year and the Closing Order determined by the Council. One caravan dwelling which was the subject of a Demolition Order was vacated during the year and the caravan demolished. New Dwellings, 1953-1954. Completion figures for the 12 months period ending March 31st, 1954 were 137 Permanent Houses. 183 Permanent Flats. Factories Acts, 1937 and 1948. Part 1 of the Act. 1. Inspections for the purposes of provisions as to health (including inspections made by the 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 90 105 10 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 462 590 55 - (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - - Total 552 695 65 - 33 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 10 10 — 4 — Overcrowding — — — — — Unreasonable temperature — — — — — Inadequate ventilation 2 2 — 1 — Ineffective drainage of floors 2 2 — — — Sanitary Conveniences : (a) Insufficient 2 1 — — — (6) Unsuitable or defective 36 26 — 1 — (c) Not separate for sexes 2 — — 1 — Other offences against the Act (not including offences relating to out-workers) 18 15 — 4 — Total 72 56 11 — 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 : Slaking, etc. 279 Cleaning and Washing 1 — Furniture and upholstery 8 — Artificial flowers 3 — Paper bags — — Slaking of boxes or other receptacles or parts thereof made wholly or partially of paper 14 — Carding, etc., of buttons, etc. 57 — Feather sorting 4 — Stuffed toys 37 — Cosaques, Christmas crackers, Christmas stockings, etc. . 35 — Lampshades 2 — Brass and Brass articles 1 — Household linen 4 — Total 425 — During 1953, 383 inspections of Outworkers premises were carried out by the Sanitary Inspectors. 34 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 sixty-two instances: Ventilation improved 3 Heating inproved 20 Sanitary accommodation improved 39 Middlesex County Council Act, 1950, Section 11. Under this Section six persons were registered during the year for the sale of food from carts, barrows, other vehicles, etc. There are now 27 persons registered under this Section for the sale of food in this Borough. 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 590 Premises inspected 715 Premises found to be infested with : 1. Rats 503 2. Mice 138 Re-visits to infested premises 2,969 Fees received for treatment £586 7s. Od. In March 1953, the Council adopted a policy whereby all private dwelling houses infested with rats or mice were treated free of charge by the Council's rodent operatives. The question of the control of rodents in private dwellings has since 1949 been somewhat hampered by the charge made by the Council for the destruction of rats and mice in private dwellings. The Council decided in 1949 that a charge of 10s. should be made for this service unless the circumstances of the tenants made it onerous for them to pay it. It was found in 1952 that over 600 private dwellings were infested but only 260 of these had been treated by the Council's own Rodent Operatives. Of these 152 had been charged the 10s. In approximately 350 cases the occupiers had elected to cany out the work of rodent destruction themselves. As it was necessary, however, for the Council's rodent operatives to ensure that the measures taken by the householders were effective the work of the rodent operatives was not therefore appreciably lessened. It was reported to the Public Health Committee in February that practically all neighbouring authorities had decided to make no charge and that the Ministry of Agriculture and Fisheries (Infestation Division) made a grant of approxinately 50% of the 35 net expenditure incurred by the Council in administering the provisions of the Prevention of Damage by Pests Act, 1949. It was therefore decided by the Council that so far as private dwellings were concerned the service should be provided for a trial period of one year without charge. 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 1,149 sewer manholes were dealt with and of these 517 were found to be rat infested. Poison baits were used in the infested manholes. Rag Flock and other Filling Materials Act, 1951. Seven premises have been registered in the Borough since the Act became operative, all of which were inspected during the year. Pet Animals Act, 1951. This Act became operative on the 1st April, 1952. During the year 2 licences were cancelled as the premises had been discontinued and thirteen licences renewed after the premises had been inspected by the Sanitary Inspector. Disinfection. Number of houses where disinfection was carried out 240 Number of houses disinfested of vermin 70 Number of articles disinfected by steam 140 Number of articles voluntary destroyed 203 The arrangement made with the Hammersmith Metropolitan Borough Council in 1952 whereby articles to be disinfected by steam are dealt with at the Scotts Road Depot, W.12, was continued during the year. Summary of Sanitary Defects remedied as a result of Notices Served and Letters written. Animals—nuisances abated 4 Caravans—nuisances abated 138 Cesspools—cleansed — Damp proof courses inserted in walls 17 Dampness—other forms remedied 162 Drains—connected to sewer 4 Drains—cleared and cleansed 504 Drains reconstructed 77 Drains—repaired 178 36 Drains—new soil and ventilating pipes provided 9 Dustbins provided 167 Firegrates—repaired or renewed 98 Floors—sub-floor ventilation provided 13 Floors—repaired or renewed 93 Food cupboards ventilated — Rainwater eaves, gutters, downpipes repaired 228 Refuse—accumulations removed 65 Roofs repaired 302 Sinks repaired or renewed 23 Sink waste pipes repaired or renewed 50 Staircases repaired 12 Walls and ceilings repaired or cleansed 622 Water supply reinstated 32 Water supply—draw taps fixed to main supply 8 Water closets—repaired, reconstructed or improved 175 Windows and doors repaired 267 Yards paved or repaired 10 Other defects remedied or nuisances abated 227 Summary of Work Done and Improvements carried out at Food Premises. Walls and ceilings repaired and cleansed 100 Floors repaired 16 Lighting and ventilation improved 13 Washing facilities provided 4 Hot water provided 21 Sinks provided 13 Storage accommodation improved 27 Water supply provided 2 Water closets cleansed or repaired 7 Refrigeration installed or improved 9 Dustbins supplied 12 Covered display units supplied 2 Other defects remedied 103 37 SECTION 4. GENERAL. MASSAGE AND SPECIAL TREATMENT ESTABLISHMENTS. Two new licences were granted during the year, one of these applicants was already practising but on changing his premises a new licence became necessary. Two establishments were closed, one person moving form the district and the other commenced a visiting practice not requiring registration. At the end of the year 25 establishments remained. One application for a certificate of Exemption from Registration was granted to an applicant who was a member of the Chartered Society of Physiotherapists. Another exempted person ceased to practise in her own home and commenced a visiting practice and then there remained four persons exempted from registration. NURSING HOMES. Eleven nursing homes remained as in the previous year. These were inspected twice during the year by the Deputy Medical Officer of Health. In March authority was given for the extension of 107, Cowper Road, W.7. and also for an increase in the number of beds registered for 34, Eaton Rise, Ealing, W.5. HEALTH EDUCATION. The leaflet display trays in the Town Hall vestibule and in the six main libraries were maintained as before and the demand was approximately the same, 14,500 leaflets being distributed during the year. Also distributed in the same way each month are copies of Better Health, the official journal of the Central Council for Health Education. A leaflet in each copy gives the public information regarding the work of the Department and the various duties of the Sanitary Inspectors. 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 Local Authorities NonTrading Services. 38 During the year the following examinations were carried out : Administrative, Technical and Clerical Staff 41 Sickness Pay Scheme and Superannuation Scheme (Servants) 109 Gunnersbury Park Joint Committee Employees 12 Total 162 Nine persons were rejected who were suffering from the following conditions, or a combination of them : Heart Disease 1 Sinusitis 1 Hernia 2 Asthma 1 Varicose Veins 1 High Blood Pressure 2 Bronchitis 1 HOLIDAYS FOR OLD PEOPLE. The Old People's Welfare Committee sent 268 old people for one week's holiday at Eastbourne or Bexhill, each person paying 1 guinea inclusive. Five hundred and fourteen applications were received and each case was thoroughly investigated before a final selection was made. A grant was made by the Ealing Borough Council to the Ealing Council of Social Services of £750. MEALS ON WHEELS SERVICE. The Ealing area of the British Red Cross Society have for some years organised a " Meals on Wheels " service by which the delivery of a hot meal is made from a mobile van to elderly and invalid persons at a normal charge of Is. per meal. This service is greatly appneciated throughout the Borough and provides some 10,000 meals a year. Less than 7% are supplied under the heading of necessitous cases and without charge. The meals are prepared and cooked at the British Red Cross Society's Ealing headquarters and voluntary helpers accompany the van and serve the meals. These visits are often useful in other ways, since this link through the British Red Cross Society with many of these old and invalid persons enables assistance of other kinds to be given where found to be necessary. It has been the practice of the Ealing Borough Council to make a grant and this amounted to £720 in respect of the year commencing 1st April, 1953. 39 NATIONAL ASSISTANCE ACT, 1948. Section 50—Burial of the Dead. Seven burials were carried out during the year for which the Council accepted financial responsibility. In two cases the full cost was recovered and in the remaining five instances the cost was written off as totally irrecoverable. Section 47. This Section deals with securing the necessary care and attention for persons who (<ii 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. Three such cases were dealt with. In the first an elderly woman was admitted to West Middlesex Hospital for observation while with the help of her relatives attempts were made to clear her house of the accumulations of rubbish. This was portly accomplished when the woman was discharged from hospital, there being little wrong with her beyond being eccentric. The second, also a woman living alone, was taken to West Middlesex Hospital following a complaint regarding the dirty condition of her house. She was a chronic case and subsequently died in hospital. The other case concerned an old lady in poor health unable to look after herself properly who lived with her maid who was also aged and no longer a suitable person to attend to the old lady, who went into a private nursing home voluntarily. The maid refused to leave the house and is still there. PUBLIC HEALTH LAUNDRY SERVICE. The Public Health Laundry Service has now settled into a routine and there seems no reason to anticipate any particular change in the situation. We can now expect that the number of cases on our list will be in the region of 30 each week, all of these being incontinent. There is a steady change of persons using the service by immigration, deaths, removal to hospital, discharge from hospital etc. It is, however, of undoubted value inasmuch as the relatives of persons who are incontinent have had lifted from them a severe burden which makes the nursing problem so much less onerous. There is no doubt that many of these people would have to be in hospital if the laundry service was not available. From this aspect alone considerable economy is effected in the National Health 40 Service and appreciation is continually being expressed both by the relatives and by the hospital authorities for the smooth running of this Ealing service. It was decided during the year not to extend the service to take a similar type of laundry from the Borough of Wembley but to confine the implementation of Section 84 of the Public Health Act to those persons resident in the Borough of Ealing. The repair of the garments dealt with by the above service is quickly and efficiently carried out in a "back room" at the Town Hall. There, for several hours every Wednesday morning a group of ladies give their time and skill voluntarily to render this very valuable service to the aged. Many thanks are due to them and to their Organiser, Miss I. Gerty. 41 SECTION 5. STATISTICAL TABLES. SUMMARY OF STATISTICS. Area (in Acres) 8,783 Population (Census, 1951) 187,306 Population (estimated middle of 1953) 186,100 Rateable Value, 1953-54 £1,961,957 Net Product of a Penny Rate, 1953-54 £8,040 Live Births :— Legitimate Males, 1,220 Females, 1,131 Total 2,351 Illegitimate Males, 50 Females, 63 Total 113 2,464 Birth-Rate per 1,000 of Estimated Population 13.2 Still-Births :— Males, 22 Females, 19 Total 41 Rate per 1,000 total Births (Live and Still-Births 16.4 Deaths : Males, 931 Females, 877 Total 1,808 Death-Rate per 1,000 of Estimated Population 9.7 Deaths of Infants under one year of age :— Legitimate Males, 29 Females, 13 Total 42 Illegitimate Males, 2 Females, — Total 2 —44 Death Rate of Infants under one year of age :— All Infants per 1,000 Live Births 18 Legitimate Infants per 1,000 Legitimate Live Births 18 Illegitimate Infants per 1,000 Illegitimate Live Births 18 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 2 Diphtheria — Scarlet Fever — Influenza 27 Tuberculosis of Lungs 28 Other Forms of Tuberculosis 1 Gastro-Enteritis and Diarrhoea 11 42 Disease 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 Smallpox _ ! Diphtheria 28 13 17 14 29 11 13 16 3 2 — — Scarlet Fever. 180 448 228 340 232 133 204 176 294 203 402 238 Enteric Fever (including Paratyphoid) _ 1 _ _ _ _ 3 8 5 3 2 3 Puerperal Pyrexia 39 41 42 47 35 27 25 27 24 38 70 61 Pneumonia: Primary 105 123 142 no 114 127 189 163 173 162 100 157 Influenzal 17 40 9 14 16 3 6 10 6 38 28 74 Acute Poliomyelitis 2 2 2 3 4 46 10 34 42 10 21 13 Cerebro-Spinal Fever 5 I — 6 6 10 2 14 9 2 — — Malaria 2 — — — — 1 2 — 4 1 1 3 Dysentery 6 5 24 60 10 5 7 23 24 542 179 132 Erysipelas 36 41 30 26 31 38 32 13 24 17 26 18 Polio-Encephalitis — 1 — — — 6 4 3 — — — — Tuberculosis: Pulmonary 223 233 173 194 275 204 206 205 209 210 211 205 Non-Pulmonary 38 5i 30 23 33 25 27 32 4i 24 29 20 Opthalmia Neonatorum 8 4 3 3 3 5 — 5 3 6 — — Totals 689 1004 700 840 788 641 730 706 869 1258 1069 924 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 233 Enteric Fever (including Paratyphoid) 2 Puerperal Pyrexia 60 Pneumonia : Primary 157 Influenzal 74 Acute Poliomyelitis 13 Disease Cerebro-Spinal Fever . — Malaria 3 Dysentery 73 Erysipelas 18 Polio-Encephalitis — Tuberculosis : Pulmonary 205 Non-Pulmonary 20 Ophthalmia Neonatorum — Total 858 43 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 "3 125 236 255 6 — 6 1 1347 1211 — — Numbers corrected : Under i year — — 15 21 — — — 31 34 — — i—2 years 12 12 48 54 1 — — — 258 257 — — 3—4 years 15 14 54 54 1 — 1 — 388 332 — — 5—9 years 68 76 114 118 2 — — 1 633 546 — — 10—14 years 7 16 — 6 1 — 1 — 13 14 — — 15—24 years 7 6 3 1 — — 2 — 18 16 — — 25 and over — — 2 4 1 — 2 — 6 12 — — Age unknown — — — — — — — — — — — — Totals 109 124 236 255 6 — 6 1 1347 1211 — — 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 114 117 69 63 — — — — — — 1 — Numbers corrected: Under 5 years 24 16 12 9 — — — — — — — — 5—14 years 12 22 12 9 — — — — — — — — 15—44 years 29 31 11 12 — — — — — — — — 45—64 years 34 29 4 2 — — — — — — — — 65 and over 15 19 1 I — — — — — — — — Totals 114 117 40 33 — — — — — — — — Paratyphoid Fevers Erysipelas Meningococcal Infection Food Poisoning Other Notifiable Diseases M F M F M F M F Original Corrected Numbers originally notified — 1 5 13 1 2 15 16 M F M F Numbers corrected: Under 5 years 1 1 Malaria (21, 25 and 29 years) 5—14 years 1 — — 2 1 1 1 1 15—44 years — 1 2 2 — — 1 2 3 — 3 — 45—64 years — 1 6 — — 1 2 65 and over 2 3 Puerperal Pyrexia 15-20 years 7 20-35 years 48 35-45 years 5 Totals 1 1 5 1 13 1 2 4 6 60 44 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 io io 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 — — — 2 25 44 75 Influenzal — — — — — — — — — — 3 2 5 Acute Poliomyelitis — — — — — — — — — — — — 1 Meningococcal Infection — — — — — — — — — — — — — Malaria — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — Erysipelas — — — — — — — — — — — — — Encephalitis I,ethargica — — — — — — — — — — — — — Tuberculosis : Pulmonary — — — — — — — — 5 3 12 8 28 Non-Pulmonary — — — — — — — — — — — — 1 OphthalmiaNeonatorum — — — — — — — — — — — — — Measles — — — — — — — — — — — — — Whooping Cough 1 1 — — — — — — — — — — 2 Totals 3 1 — — 1 1 — 5 6 40 54 112 45 DEATHS Causes of Death, 1953. Cause of Death Deaths, 1953 Total Deaths 1952 Male Female Total Tuberculosis, Respiratory 18 10 28 37 Tuberculosis, Other 1 1 3 Syphilitic Disease 4 2 6 11 piphtheria — —. Whooping Cough 2 2 -Meningococcal Infections — — —. 1 Acute Poliomyelitis 1 1 .— Measles — Other Infective and Parasitic Diseases 1 3 4 2 Malignant Neoplasm, Stomach 22 23 45 49 ,, ,, Lung, Bronchus 59 12 71 52 „ „ Breast — 42 42 39 „ „ Uterus — 10 10 17 Other Malignant Lymphatic Neoplasms 77 81 158 194 Leukaemia, Aleukaemia 12 4 16 12 Diabetes 5 8 13 13 Vascular Lesions of Nervous System 106 148 254 263 Coronary Disease, Angina 143 99 242 242 Hhypertension with Heart Disease 22 25 47 48 Other Heart Disease 116 150 266 234 Other Circulatory Disease 39 30 69 97 Influenza 10 17 27 7 Pneumonia 46 34 80 101 Bronchitis 94 57 151 110 Other Diseases of Respiratory System 14 6 20 15 Ulcer of Stomach and Duodenum 6 5 11 22 Gastritis, Enteritis and Diarrhoea 2 9 11 6 Nephritis and Nephrosis 9 6 15 9 Hyperplasia of Prostrate 10 — 10 11 Pregnancy, Childbirth, Abortion — 1 1 1 Congenital Malformations 8 7 15 21 Other Defined and Ill-Defined Diseases 57 54 111 152 Motor Vehicle Accidents 13 4 17 16 All other Accidents 26 20 46 52 Suicide 9 3 12 9 Homeicide and Operations of War — — — 2 Totals 931 877 1,808 1,848 46 SECTION 6. SCHOOL HEALTH SERVICE The School Health Service is administered by the Middlesex County Council. Ealing is an excepted district and the general day to day administration of the service is delegated to the Ealing Education Committee, to whom monthly reports are submitted. Treatment of defects found at routine medical examinations is provided either by the Area Health Committee or by the National Health Service according to the wishes of the parents. The steady improvement in the general standard of health of the school child has been maintained and rather more places have been secured at special schools than in previous years. During the year notifications of pulmonary tuberculosis were received concerning three teachers and six pupils teaching at or attending different schools. As a result of these notifications it was considered necessary to carry out epidemiological investigations at eight of the schools concerned. A total of approximately 300 children were patch tested ; 20% of these were found to be positive reactors and they, together with teacher contacts, were X-rayed at Central Middlesex Hospital. The results were in the main satisfactory and a few cases are to be the subject of further reports. No contact has yet been found suffering from active tuberculosis. There was a minor outbreak of headache and sore throat at Perivale Infants' School in June and the symptoms were—violent headache, nausea and sore throat—temperatures rose to 104°. The illness was sudden in onset and of short duration. Swabs were taken and the condition of the throats and duration of the illness did not suggest a streptococcal glandular fever. Some 20 pupils were affected and the outbreak came to an uneventful end. MINOR AILMENT CLINICS. These clinics are held at all centres except Brentside; their purpose is to enable assistant Medical Officers to make fuller examinations of any doubtful cases seen at routine medical examinations, to treat minor conditions and to make freedom from infection examinations. The Minor Ailment Clinics are used as referral centres to the various specialist clinics. Attendances at Minor Ailment Clinics. 1951 1952 1953 5,515 4,972 4,948 ROUTINE MEDICAL INSPECTIONS. Routine medical inspections are held at the schools. Children are examined during their first year at school, during their last year at primary school and prior to leaving school. 47 Numbers Examined. First Age Group 3,295 Second Age Group 2,530 Third Age Group 1,586 Total 7,411 Classification of General Condition. A. Good 2,681 B. Fair 4,673 C. Poor 57 Total 7,411 Defects requiring Treatment found at Routine Medical Inspections. 1950 1951 1952 1953 Skin diseases 617 695 600 540 Defective Vision 358 433 368 290 Squint 24 49 31 43 Defects of hearing 36 51 73 93 Middle Ear disease 33 26 26 18 Nose and Throat 350 389 339 377 Speech 33 47 29 37 Enlarged glands 5 10 6 5 Heart and Circulation 5 13 6 7 Lung Diseases 35 111 107 84 Hernia 1 4 4 7 Postural Defects 17 30 40 18 Flat Foot 86 91 60 42 Epilepsy — 3 1 1 T.B. patch testing for all school entrants was introduced in November. By the end of the year 51 positive reactors were found from the 1383 children examined and were X-rayed at the local Chest Clinic. No positive X-ray reports were made but 6 cases are to be given further examinations within three months of the first X-ray. ASTHMA CLINIC. The Asthma Clinic which started in April 1951 has become very popular with the general practioners as well as the assistant school medical officers. During the year 2,795 attendances were made. Many children who formerly would have been sent to convalescence or open-air school have benefited to such an extent that this has become unnecessary. The clinic is primarily concerned with the provision of remedial breathing exercises. A specially trained physiotherapist taking classes of about ten children at a time gives instruction in correct diaphragmatic breathing which is continued in the child's own home. The doctor in charge makes allergy tests and when 48 necessary a course of desensitisation injections is given. Some cases are referred to a Medical Specialist for an opinion as to whether they are suitable cases for administration of an autogenous vaccine. Allied conditions such as mouth breathing, bronchitis, frequent colds and malformations of the chest are also treated at this clinic. New Cases Seen. 1952—179 1953—210 CHILD GUIDANCE CLINIC. 1. History of Clinic. Child guidance work began in a small way in 1944 with a psychiatrist visiting one session a week and one or two part-time workers using any room which could be found available in an already overcrowded Maternity and Child Welfare Centre. In 1946 a six roomed house at 70 Uxbridge Road was made available and there was an increase of staff but in the ensuing years these premises proved inadequate to house an ever growing service. In September 1953 the clinic was transferred to new premises at 42 Madeley Road. Since 1945 there have been various increases of staff. The present staff is :— One Psychiatrist—6 sessions per week. One Senior Educational Psychologist (full-time). Two Educational Psychologists (part-time). One Psycho-therapist (full-time). Three Psychiatric Social Workers (full-time). Three clerical workers (full-time). There have been a certain number of changes of staff and each change means a long delay and a dislocation of the work more than proportional to the actual loss of man-hours. The special relationship between the Educational Psychologists and the rest of the clinic is such that they can from time to time limit the number of referrals when the waiting list is getting beyond manageable proportions. In 1951 the Psychiatrist was transferred to the North West Metropolitan Regional Hospital Board, who agreed to provide 4 sessions a week permanently and 2 sessions a week temporarily to help wipe out the waiting list which had at that time become particularly long. The waiting list for diagnosis is now somewhat reduced but there is now a waiting list for treatment which is likely to increase until such time as the Regional Hospital Board agrees to provide psychiatric service eleven sessions a week. 49 It is difficult in spite of increased staff to abolish the waiting list. The potential waiting list is almost unlimited and once referring agencies begin to recognise child guidance problems they tend to pick them out with embarrassing frequency. The trend of the demand for the service since 1945 can best be shown in tabular form:- TABLE I. Seen by Psychologists Referred to C.G.C. Seen by Psychiatrist Waiting list at end of year 1945 298 127 84 15 1946 450 146 77 46 1947 320 158 110 52 1948 — 257 115 100 1949 — 164 83 70 1950 318 136 125 50 1951 347 209 126 74 1952 340 178 116 54 1953 380 + 41 (Acton) 200 154 36 TABLE II. Year 1945 1946 1947 1948 1949 1950 1951 1952 1953 Average I.Q. 85 97 104 101 106 110 110 105 102 Average Age 9.1 9.0 9.9 8.8 9.1 8.5 9.0 9.0 8.5 2. The Area the Clinic Serves. This clinic now serves the whole of Middlesex Health Area 7, Ealing, whose total school population is about 25,000, and also Acton, whose school population is about 7,000. We have, however, been seeing Acton cases only since September 1953 when the move to the present premises was completed and the full non-medical staff appointed. 3. The work of the Clinic during the past year. In 1953, 200 new cases were referred to the Centre, the number of cases brought forward from the 1952 waiting list was 54, making a total of 254. The number of new cases dealt with by the Psychiatrist was 154; cases withdrawn before investigation 38; 25 cases were investigated by psychiatric social worker or educational psychologist and advised; one case was passed on to another clinic; number remaining on the waiting list 36. An analysis of work done in the last year is given in the attached tables I to VI. 50 Service is unique in that it is not entirely either a medical and educational or a social service, but combines all three aspects and has evolved its own special method of team-work to fulfil the special task of such a complex service. On the medical side the Child Guidance Service has two major functions:- (i) It is a consultant service for other doctors whether they are doctors of the Local Authority or the general practioners of the neighbourhood. (ii) It is a treatment service for children suffering from emotional instability or psychological disturbance. On the educational side it is also a diagnostic and consultative service for the educational authorities and teachers, in providing intellectual and educational assessments of individual children; and also a treatment service, in that children who are educationally retarded more than in proportion to their intellectual retardation, can be helped to regain their rightful level in the school. On the social side the same two functions are fulfilled. Social workers in other fields want advice and assessment of children and their families and also hope for treatment of social problems, this is the least easy to supply. There are many problems referred to us which are virtually insoluble. The special and complicating factor in Child Guidance work is that every case presented tends to have all three aspects and is rarely confined to one category. Moreover, although the service is called Child Guidance, no child exists in a vacuum and few children have problems without a corresponding problem in their family. Therefore, Child Guidance is a not very accurate name for what is pre-eminently a service to families. In any given case several members of a family may be involved and will have to be considered in diagnosis and in treatment. We have abundant evidence of the association between the disturbance in the child and the disturbance in the home: the more unsatisfactory the home, the more severe the problem in the child. Families attending the Child Guidance Centre are drawn to a large extent from among the psychologically disturbed and the emotionally unstable, with a far higher incidence of the severely neurotic and psychotic, than in the population as a whole. Apart from the consultative and therapeutic work that is done with the patients actually referred to the clinic, an important function is to be a preventive service. It is with this idea that most Child Guidance Services are set up. It is no doubt true that treating individual cases in childhood is in itself a substantial contribution to prevention, in that many will be saved from an adult life of mental illness. Nevertheless, by the time the children have been referred to the Child Guidance Clinic from the schools, 51 they are usually severe cases of mental disturbance and many are already chronic. Consequently, preventive work needs either to start with much younger children or in general dissemination of the principles of mental health among the parents and teachers of the apparently normal child. This type of preventive work is an inevitable accompaniment of the therapeutic work that is done by Child Guidance workers but since the pressure of the work leaves it to be done in an incidental and accidental way rather than systematically, its importance is not, perhaps, sufficiently appreciated. In the eight years since 1946 we have seen on the average 16 children under five each year—approximately 8% of our intake from approximately one third of the child population. It is the exception rather than the rule to be sent a problem, the onset of which is at a later period of the child's life. The average age of referral this year has been eight and a half, consequently, many problems have been incubating for five years or more before we are asked to deal with them. Finally it should be mentioned that Child Guidance is still an experimental and growing service and there is a great need for research. There are still many questions not yet answered but which could be answered by a careful analysis of our records. Every Child Guidance Clinic contains a most valuable store of material— few have time to make use of it. 5. The relationship between the clinic, local general practitioners, local hospitals, local organisations, Area Authorities and the Middlesex County Council. (a) General Practitioners. General Practitioners have free access to the clinic and refer children of any age from birth to school leaving. The number so referred in 1953 was 47. An effort is now being made to inform General Practitioners when one of their patients is referred from another source. (b) Local Hospitals. The clinic is in contact with the Central Middlesex Hospital, West Middlesex Hospital and King Edward Memorial Hospital, whose psychiatric staff have been most co-operative in seeing adult patients and adolescents who have left school. In every year a certain number of children have been referred to hospitals for further medical investigation and treatment and there has been no difficulty in getting children seen and admitted for some physical disease or for mild mental disorder. It is, however, very difficult to get severely disturbed children admitted for observation and treatment. 52 (c) Local Organisations. Close contact is maintained with Probation Officers, with the Children's Department, School Welfare Officers and others. There is, however, a lack of general social services in this Area. (d) Area Authorities. There is regrettably a diminishing connection with the Public Health Department since the psychiatrist was transferred from the staff of the Area Health Office to that of the Regional Hospital Board. Our relations remain friendly but there is now only a very slender official link. The Centre is more closely connected with the Divisional Education Authority and there have been fortunate relations with both the Education Committee and the Borough Education Officer and his staff. The Borough Education Committee has throughout taken the keenest interest in the work of the Child Guidance Clinic and has always given its support. 6. Special problems connected with the work of the Clinic. Accommodation. Over the last 5 years lack of space interfered quite seriously with the work of the centre but the new premises at Madeley Road provide adequately for all needs. Problems of staffing. The Clinic is exceptionally fortunate at the present time in having a number of workers who are excellently qualified for their work and are capable of working together as a team. The psychiatrist's position at the present time is not altogether an enviable one. In theory her links are with the Regional Hospital Board but these are not very strong and in gaining these she loses contact with the local and central authorities. In-Patient treatment in hospitals and residential schools. Reference has already been made to the shortage of beds in hospitals for severely disturbed children and adolescents. There has been a distinct improvement in the speed of admission to residential schools for maladjusted children. Of 55 cases in 1950 the average delay between recommendation and admission was 4½ months with 50% of children waiting 6 months or longer and 10%, 9 months or longer. In 1952 of the 21 children recommended the delay was not more than 1 month in 10 cases and the remainder averaged 3 months. In 1953, 7 of the 17 children recommended were placed in less than one month and of the remainder only two had to wait for more than 4 months. There are still very few schools where severely disturbed children can get skilled treatment and these extremely difficult and mentally ill children have to be entrusted to persons with very good will but without appropriate training. The high proportion of apparently successful placements is gratifying in the circumstances; the occasional failures, though tragic, are fewer than might be expected. 53 TABLE I. I.—Analysis of Work. Total number of cases referred to the Centre in 1953 200 Total number of cases brought forward from 1952 waiting list 54 - 254 Total number of new cases dealt with by the Psychiatrist : Boys 96 Girls 58 - 154 Cases withdrawn before investigation 38 Cases investigated by Psychiatric Social Worker and advised by her 18 Cases investigated by Educational Psychologist 7 Transferred to Hounslow C.G.C. 1 Cases remaining on waiting list for interview at Centre 36 - 100 - 254 II.—Analysis of New Cases seen at Centre. Total number of new cases seen by the Psychiatrist 154 A.—1. Recommended for treatment 84 2. Not put on treatment list 41 3. Special recommendations 29 154 I?.—Treatment. 1. Psychiatrist 13 2. Play Therapist 35 3. Remedial Teaching (including 7 investigated by Educational Psychologist) 15 63 4. Withdrawn from treatment waiting list 6 5. On waiting list for treatment in 1954 (Less 7 recommended by Educational Psych.) 21 - 27 (90) 83 III. —Analysis of all Treatment Cases. 1. Number of cases carried over for regular treatment from 1952 51 2. Number of cases taken on in 1953 (includes 13 taken on from 1952 treatment waiting list) 76 - 127 3. Discharged 64 4. Treatment broken off 10 74 5. Number of treatment cases current on December 31 st, 1953 53 127 6. Number of old cases remaining under supervision 38 7. Number of cases discharged from supervision 10 8. Number of supervision cases current on December 31st, 1953 28 - 76 IV.—Special Recommendations. 1. Cases seen in 1953 and placed in schools for maladjusted children 18 54 TABLE II. DIVISION OF WORK Psychiatrist. 1. Diagnostic interviews 154 2. Interviews with parents 172 3. Statutory examinations of childrens at Boarding Schools 43 4. Old cases followed up 44 5. Interviews with others 39 6. Treatment 136 7. School visits 9 8. Other visits 2 Psychologists. Tests 91 Treatment interviews 122 Interviews with parents 19 Remedial teaching 271 Psycho-Therapist. Treatment interviews 959 Interviews with parents and others 35 School visits 3 Psychiatric Social Workers. Interviews with parents 765 Interviews with others 65 Group interviews 2 Home visits 138 School visits 9 Other visits 22 Infant Welfare Clinic Sessions 3 TABLE III. 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 41 Solitariness and unsociability 9 Depression and lethargy 9 Difficult to manage at home 54 Difficult to manage at school 26 Temper tantrums 8 Direct aggression 10 Sexual difficulties 7 II.—Psycho-Somatic Disorders. Enuresis 30 Encopresis 6 Sleep disorders 14 Habit spasms 10 Feeding difficulties 4 Hysterical symptoms 6 Speech disorders 3 Asthma 1 Eczema ... 2 III.—Delinquent Behaviour. Stealing 29 Truancy and absconding 20 55 IV.—Educational Difficulties. Backwardness 11 Retardation 27 V.—Disorders with Organic Components. Epilepsy — TABLE IV. ANALYSIS OF INTELLIGENCE (200 children referred in 1953) (182 children tested in 1953) 40^9 50-59 60-69 70-79 80-89 90-99 100-109 1 4 11 27 37 40 110-119 120-129 130-139 140-149 150-159 160-169 170 32 19 10 1 — — — Untestable Untested Tested (not completed) 4 Under fives 5 1 Awaiting test 2 Withdrawn 6 Average I.Q. of 182 children tested 102.4. TABLE V. ANALYSIS OF AGES OF 200 CHILDREN (Number referred in 1953) 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 4 5 8 18 24 17 17 24 25 18 12-13 13-14 14-15 15-16 16-17 17-18 12 19 7 1 — 1 Total 200 Average age 8½ years. Boys 125 Girls 75 200 Pre-School 13 Primary 119 Secondary Modern 29 Grammar 6 Private or Public 17 Technical 2 Special School — Boarding School 11 Approved School 1 Not known 1 (Case withdrawn before Investigation) 1 200 TABLE VI. SPECIAL RECOMMENDATIONS MADE IN 1953 Number recommended for and placed in schools or hostels for mlaadjusted children (including 2 placed but withdrawn later) 18 Number recommended for placement but not yet placed in schools for maladjusted children 3 Number recommended for placement in schools for maladjusted children, but withdrawn 5 26 56 Number recommended for schools for E.S.N, children 1 Number recommended for change of day school 2 Number recommended for Open Air School 2 Number recommended for Speech Therapy 2 Number recommended for Hospital O.P.D. 15 Number recommended for Care of County 1 Number recommended for admission to day school 1 50 In November an experimental arrangement was introduced for a Psychiatric Social Worker to attend at Infant Welfare and School Clinics. Some prejudice exists in the minds of parents with regard to formal referral to a Child Guidance Clinic and it is hoped that by meeting a member of the Child Guidance staff in the familiar atmosphere of the clinic this may be overcome. SCHOOL DENTAL SERVICE The Staffing Position. In my report for 1952 I stated that no improvement in the staffing position had occurred during 1952. This year a marked improvement in recruitment of dental officers has taken place, and as a result of this advance I do not feel I am being over optimistic when I say that the School Dental Service in this area is now out of the doldrums and at last making steady progress. There is of course, as a direct result of the poor staffing position in recent years, a vast amount of leeway to be made up. This backlog of work will gradually be accomplished provided the staff of dental officers can be brought up to the established strength, held at that figure for a number of years and then increased to bring the number of school children allocated to each dental officer to a figure in the region of 2,500. The present figure of 4,600 children per dental officer is far too high ; and even with a full staff the figure would still be approximately 4,000 children per dental officer. This will allow only a portion of the children to obtain complete treatment, and a comprehensive dental service to be efficient should aim at a minimum of an annual inspection and offer of full treatment, if required, for all children within its area. During the year two full-time and two part-time dental officers were appointed to the staff. This brings the present strength to the equivalent of nearly five full-time dental officers. As the majority of these appointments were not made until the second half of the year, the full effect upon the statistical return will not be apparent in the present figures. Towards the end of the year a new part-time orthodontist was appointed, to replace another part-time orthodontist who is at present on extended leave. 57 Discontinuation of the Restricted Scheme. With the greatly improved staffing position it became possible during the latter part of the year to discontinue the restricted scheme which had been in operation in the Ealing part of the area since 1950. The purpose of this scheme was to offer to a certain section of the school population, in this case the 7—11 year old age group, full treatment at approximately yearly intervals. At the time of the introduction of the scheme the number of dental officers on the staff was very low. It was deemed wise therefore to concentrate their efforts on procuring dental fitness for a certain section of children, whilst at the same time offering emergency treatment for the relief of toothache etc., to children of all ages rather than spread the available manpower over a greater number. During the time this scheme was in operation it worked satisfactorily and parents appreciated the necessity of this method of allocating the available dental strength. Evening Sessions. This scheme has now been in operation for two years and continues to be a very excellent method of dealing with the very large number of children in need of treatment. Attendance at these sessions has been good with the consequence that dental officers have been able to work undisturbed by numbers of emergency cases which so often upset the timetable of a busy day time session. Normally only children attending senior schools are sent appointments to attend the clinic in the evening. Every endeavour is made to arrange for the younger children in the senior departments to be given appointments in the earlier part of the evening in order not to disrupt bed times. Three dental officers are taking part in this scheme and between them they have worked 258 sessions during the year. This is an increase over 1952 when 220 sessions were undertaken. As a result of the increased sessions worked the number of attendances for treatment and the total number of fillings performed shows an expected improvement over the previous year. Each child treated required an average of 3.7 fillings in permanent teeth. This is a high figure but it must be borne in mind that in the majority of these cases a lengthy period had intervened since the last routine inspection. The Orthodontic Service. Orthodontia is now accepted as a necessary and integral part of any organised School Dental Service. In this area the large majority of treatment is carried out by specialists in orthodontia as distinct from dental officers. The primary responsibility of the latter being the more fundamental branches of dental surgery, i.e., conservative and surgical treatment. Thus the large amount of orthodontic treatment that has been undertaken has not been at the expense of essential basic treatment. This is often the main 58 criticism of any scheme where specialists in this type of work are not employed. During the major part of the year the assistance of one part time orthodontist has been available. In December however a second part time orthodontist was appointed to do an additional session. The combined total of sessions worked being six per week. The establishment for the area is one full time orthodontist. It is possible that this figure will be realised in 1954, when a second orthondontist who has been on extended leave will rejoin us in April. The very large number of skiagrams needed for the diagnosis of orthondontic cases is catered for by a dental attendant who has received special training in X-ray work. By this method the time of dental officers is saved for more important work. Statistical Observations. From the 1st January, 1953 all parents of children about to be inspected were sent printed invitations to attend the school at the time of their child's dental examination. Previous to this date ; invitations for parents to attend were given verbally via the child and it is therefore probable that in a number of these cases children forgot to inform their mother or father. As a result of these written invitations over 40% of parents attended and were given advice on their children's dental problems. This inevitably reduced the number of children who could be inspected at each session. The following comparison is of interest in this connection : Average number inspected per session 121 1952 Average number of parents per session 3.5 Average number inspected per session 88 1953 Average number of parents per session 36 The mortality rate of permanent teeth is generally recognised as a yardstick by which the efficiency of a service is measured. The ratio of permanent teeth extracted to the number of fillings inserted in permanent teeth in 1952 stood at 1 extraction for every 10.7 fillings. In 1953 this figure has improved to 1 extraction for every 12.6 fillings. These figures discount permanent teeth extracted for othrodontic purposes, as the inclusion of this figure would not show a true reflection of savable teeth compared with unsavable teeth. This is a reasonable figure but one which can be improved upon in future years provided the staffing position remains good. With the increased staff of 1953 a marked increase in the volume of conservative treatment is apparent, to the extent of 2,917 additional fillings in permanent teeth and 1,897 additional fillings in temporary teeth compared with 1952. The ratio of temporary teeth extracted to fillings inserted in temporary teeth has improved this year to approximately 3.4 to 1. When this ratio approaches the figure for permanent teeth viz., 1 to 12.6 and when the figure for permanent teeth lost through caries, has been 59 reduced to an insignificant one, then we can be sure that the School Dental Service has gone a long way to achieving positive dental health for the children. This latter situation is one that all school dental officers look forward to seeing in future years. EAR, NOSE AND THROAT SERVICE Mr. Arthur Miller, Consulting Otologist reports:- The children referred to see me for hearing defects as ascertained by the gramophone and P.T.T. tests were either suffering from chronic catarrh of the middle ear and eustachian tube or have, or have had otorrhoea in the past leaving a scarred tympanic membrane or a dry perforation behind. Head Teachers were informed where it was found advisable that the child should either sit in the front row or should abstain from swimming or both. Head teachers were particularly requested to see that these recommendations follow the children throughout the whole of their school life. In the catarrhal conditions the cause was often found in enlarged adenoids, hypertrophic rhinitis or sinusitis. Children were referred for removal of either tonsils and adenoids or adenoids alone, the general tendency being to spare the tonsils and remove the adenoids where at all possible. The treatment administered was diastolisation and politzeration and eustachian catherisation as well as breathing exercises. In cases where sinusitis was confirmed by X-ray examination Proetz' displacement treatment was practised. With the aid of P.T.T. it was possible to ascertain the results of the treatment which were found to be most gratifying. A number of children were referred for nose and throat conditions without impairment of hearing. In these cases if conservative treatment failed, some were referred for operative treatment. 1952 1953 Number of new cases 181 355 Number of re-inspections 464 353 Total attendances 645 708 Number of operations 245 188 Treatment advised 308 271 Operations advised 134 236 AUDIOMETRY SURVEY Audiometer testing by gramophone and pure tone apparatus is now a routine part of the school medical service. Audiometer testing makes possible the early ascertainment and if necessary treatment of hearing loss. 60 Number of schools visited 13 Number of children examined 5,893 Number of children with hearing loss 162 Number of pure tone tests 128 Number of children referred to E.N.T. specialist 99 FOOT HEALTH Foot health is the subject of careful supervision in Ealing and great importance is attached to early discovery and treatment of defects found. One assistant Medical Officer and a State Registered Nurse, who has specialised in this work since 1949, maintain a constant check on the condition of the children's feet in all the maintained schools. In addition, children under school age are referred to the Foot Clinic from the Welfare Centres. By the end of the year two inspections were made in all the schools established before 1950 and most of the more recently opened schools have had their first inspection. 7,300 children were examined. Some foot defect was found in 42% of the children who had had a previous inspection, compared with 52% with foot defects found at the first inspection. This is an encouraging result and suggests that the three years of work in this department is beginning to bear fruit. Although the majority of these defects are found before they have become severe, it is disturbing to realise that still a large number of school children have feet which are a potential cause of trouble in later life. There is still great need to educate the rising generation in the basic principles of foot health. The number of children with ringworm of the toes and plantar warts, has remained stationary, following a decreased incidence in 1952, when barefoot dancing classes and the use of communal plimsols were discontinued. It was decided to re-introduce barefoot dancing classes in certain schools as an experimental measure and at present a controlled experiment is being made to see if a return to barefoot work causes any increase in the incidence of foot infections. The educational work of the foot health team has continued both to groups of assistant medical officers and health visitors and to many individual children and their parents. A report of the survey made in the schools and of the Ealing Contributory Shoe Scheme was published in the British Medical Journal. As before, the shoe retailers have been most helpful in dealing with requests for special fittings of shoes. There are, however, still shops in the Area who do not insist on fitting their small customers but are prepared to sell shoes over the counter. 61 62 HANDICAPPED CHILDREN. The ascertainment and placement of handicapped pupils continues to form a large part of the school health service, there has been some slight improvement in the availability of places in special schools. There is still however great difficulty in obtaining suitable educational facilities for a child suffering from multiple defects. OPHTHALMIC SERVICE Mr. Freeman-Heal, Consultant Ophthalmologist, reports:- The total number of cases seen was 1,504 (1952—1,522) of which 480 (1952—469) were new cases and 1,024 (1952—1,053) re-inspections. The number of glasses prescribed was 941 (1952— 812). Abnormal Eye Conditions other than errors of refraction were as follows: Congenital Abnormalities. New cases Old cases Squint 89 261 Congenital Nystagmus 3 7 Congenital obstruction Nasal duct 6 1 Progressive or malignant Myopia 2 4 Congenital Cataract 2 2 Congenital defects oculomotor nerves (or muscles) — 2 Coloboma Uveal tract — 1 Dermoid cyst orbital margin — 1 Congenital Ptosis 1 — 63 Abnormalities due to Infection. Blepharitis 6 4 Styes 6 — Corneal Nebulae 1 2 Chronic Conjunctivitis 1 — Keratitis (superficial punctate) 1 — Optic atrophy—bilateral following cerebral abscess - 1 Uveitis — eye blinded from — 1 Abnormalities due to Trauma. Perforation of eye by dart 1 — Excision of eye after injury by catapult — 1 Scarring of cornea from injury 1 — Number of children sent to special schools 1 — Number of children sent for squint operation 3 — ORTHOPAEDIC CLINIC. Mr. G. A. Cholmeley, the Orthopaedic Consultant, reports:- The Orthopaedic Clinics at Mattock Lane and Ravenor Park continue to do valuable and important work in the Borough of Ealing. As the figures for 1953 show, there has been no appreciable reduction in the number of cases examined and, in fact, there has been an increase in the number of attendances for treatment. In-patient treatment when necessary is arranged at the Royal National Orthopaedic Hospital and surgical boots and instruments are supplied through the Workshops of that Hospital. There is thus a firm link between this Hospital and the Orthopaedic Clinics. In order to keep in touch with the General Practitioners, a report is sent on every new case seen at the Clinics. 1952 1953 Number of new cases 152 154 Re-inspections 520 444 Total attendances 672 598 Number referred for physiotherapy 192 135 Number of attendances 1,897 2,156 SPEECH THERAPY. Speech therapy has been carried out in the Borough of Ealing for the last 13 years. Treatment is given at eight clinics and schools where the more serious cases are treated at weekly or fortnightly intervals by one full-time therapist and an assistant attending for two sessions a week. Defects are found in approximately l½-2% of the child population but in 90% of cases the disorder begins between the ages of 3-5 years. It has, therefore, been the policy for some years to commence treatment at an early age. By so doing it has been found that the period of treatment necessary has been reduced. 64 Play Group for Pre-School Children. In January, 1950 a play treatment group was started at Mattock Lane Clinic for children between the ages of 3½ years— 5 years, and in March, 1953 a similar play group was formed at Ravenor Park Clinic. The group meets for eighty minutes twice a week at Mattock Lane and once a week at Ravenor Park and never contains more than eight children at any one time. Experience over the last 3 years has shown the following results:- 50% were able to start school without handicap. 10% needed residential schooling because of multiple defects. 40% started school still handicapped. With the exception of stammerers, speech defective children have great difficulty in grasping the fundamentals of reading as their confusion of sounds leads to a similar confusion of symbols ; number work is often equally impaired. This means they may pass on to the Junior School still unable to read and bearing with them a sense of inadequacy and lack of interest. Thus a good deal of the therapist's present treatment of junior speech defectives is centred on encouraging the child to master his reading problem. Remedial Speech Class. During the year a visit by the department was made to Moor House Residential School for Speech Defectives. Plans have now gone forward for the opening in 1954 of a remedial speech training class in a primary school, with concentrated 5 day a week training (as compared with 15 minutes a week at present). Approval to the opening of this class has now been given and it is proposed to establish this in Stanhope Primary School, Greenford, as soon as a suitable teacher is appointed. The selection of children (since it is a medical problem) will be done by Medical Officers and the Speech Therapist. The age of the children will be between 5-8 years and the class will contain not more than 12 pupils. The general education will be on the lines laid down for children of this age in normal schools. Liaison between teacher, therapist, medical officer and class must be achieved, and case discussions held between teacher and therapist each week. The therapist will visit the class every day, and a Routine Medical Examination will be carried out each term. In the year 1954 it is hoped to report that the Remedial Speech Class is firmly established. 65 M.S.S. Tape Recording Machine. In March, 1953 the M.S.S. Tape Recording Machine was introduced for regular use in the area and is proving an invaluable piece of equipment. The machine is accurate, simple to use and very reliable and is capable of a variety of uses. We are only beginning to discover its possibilities and are sure that as time goes on many more ways of using this valuable instrument will be found. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS 1. Number of children medically examined in order to ascertain whether they were physically fit to undertake employment of a light nature outside school hours 297 2. Number of instances in which the state of health was found to be such that certificates were withheld 1 3. Number of children examined as to fitness to take part in entertainments 14 4. Number of cases in which certificates to take part in entertainments were withheld — MEDICAL EXAMINATION OF TEACHERS Number of Teachers examined as to fitness for appointments 26 INFESTATION WITH VERMIN. The standard of head hygiene remains at high level, of the 51,974 children examined only 252 were found to be infested. In 13 cases cleansing orders were issued but with the increased parental co-operation no compulsory notices were necessary and in no case was legal action taken. 66 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, Westcott Crescent, Fri. mornings. Hanwell, W.7. Cherington House, Cherington Road, Tues. Wed. mornings. Hanwell, W.7. Greenford Green, Wadham Gardens, Fri. mornings. Greenford. Islips Manor, Eastcote Lane, Northolt Mon. Wed. 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. Wed. mornings. Ravenor Park, Oldfield Lane, GreenMon. Thurs. mornings. ford. Child Welfare Clinics. Abbey Parade, North Circular Road, Tues. 2—4 p.m. Ealing. Brentside, Westcott Crescent, Thurs. 2—4 p.m. Hanwell, W.7. Cherington House, Cherington Road, Mon. Tues. & Thurs. Hanwell, W.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 Mon. 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, GreenMon. Tues. Wed. Fri. ford. 2—4p.m. 67 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 mid wives 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 four 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. Perry & Routleff, Ltd. Printers, Ealing and Uxbridge