EAL 46 The Health of Ealing in the year 1955 EAL 46 The Health of Ealing in the year 1955 BEING THE ANNUAL REPORT OF THE Medical Officer of Health AND i 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 OP THE BOROUGH 24 Section 3.- SANITARY INSPECTION 28 Section 4.- GENERAL 39 Section 5.- STATISTICAL TABLES 42 Section 6.- APPENDIX : REPORT OP THE SCHOOL MEDICAL OFFICER 48 Supplement. 57 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) G.M. Gorrie, Deputy Medical Officer M B ,CH.B., D.P.H G.T.H. Blackie Chief Sanitary Inspector B. Belfield Deputy Chief Sanitary Inspector E. H. Evans Sanitary Inspector C.W. Baxter " " E. W. Budd " " A. E. Pooley " " G. 0. Axon " " A. C. Bamping " " D. J. Anderton " " D.G. Martin (Resigned May) " " Harry M. Birrell Chief Administrative Assistant R. S. Leggatt Senior Clerk R. Angell Clerk D.R.A. Smith ,, Miss D. E. McKenzie Shorthand-Typist Mrs. M. G. By ford " " Mrs. D. Barker Clerk and Typist Miss S. Pox Clerk R.M. Newbury Clerk (Commenced September) R. S. Cox Rodent Operative S.C. Potton " " R. Lazzolo " " L.B. Radford Driver/Disinfector E. Sheldrick " " 5 Mr. Mayor, Aldermen and Councillors, Apart from a wave of measles infection of a mild type which spread through the Borough during the Spring of 1955 no other epidemics were encountered. Small sporadic outbreaks of gastro-enteritis caused by Sonne infection were reported but in the main once again it has been a good year from the public health point of view. Certain special problems arose in connection with the work of the Sanitary Authority, particularly in connection with atmospheric pollution, where the repercussions of the Beaver Report were felt by the public interest shown in contamination of the air. The new Clean Air Bill, which will shortly become law, was introduced and, to keep in 1ine with the need for vigilance throughout the country, there is no doubt that Ealing should take its part in the erection and maintenance of atmospheric pollution gauges in the district. These would give reports of great value to the Department of Industrial and Scientific Research and to other government departments concerned with the prevention of air pollution on a wide scale. This matter is at present under consideration. Certain other matters were again brought before the Council during the year such as the condition of the River Brent, the provision of Mortuary Services in Ealing and the work necessary to implement the Government's slum clearance programme. These have been dealt with in the body of the Report which I trust will prove of interest to the Council. Matters were also raised dealing with the social life of the Borough but the power of Ealing to deal with such items as "Sitters in for old People" etc., are now negligible and any developments on this side of the work will have to be dealt with by the County Council. The loss of the personal services by Ealing as a Borough Council has undoubtedly placed a brake on developments of all kinds in this field. Should Ealing become a County Borough oppor tunities would then immediately arise for experiments and developments of this kind. In the meantime any activities must be geared to the ponderous County Council machine. Certain matters have been dealt with in this report such as Tuberculosis, with which the only concern of the Ealing Council is notifications of the disease. Since, however, the epidemiology of Tuberculosis is still an Ealing problem I have placed before you my views on the 6 present situation in relation to the vaccination of young people with Bacillus Calmette Guerin (BCG). Here the robbing of Ealing's right to control its own problems in its own way seems, in my view, to be a government refusal to allow a capable and intelligent Council the implementation of its own considered opinions. Tuberculosis is a social disease and must be linked with the organisation of the community. Neither the Regional Hospital Boards nor the vast automatism of a huge County Council machine are suitable for handling close family and personal infection. Everyone with experience of controlling this disease would probably agree with me, and yet in order that we may be all impressed into the same mould these facts are ignored. It has indeed been a sad period of readjustment that has overtaken the public health services in the last ten years and no doubt this is linked with the whole question of Local Government reorganisation but we have had long enough to learn of the folly that has been committed. Notes are also included in the Report of other services which are not the responsibility of the local Council but since these are services which affect the general health of the Borough I have no hesitation in including them in my Annual Report in order that the members of the Council may be aware of what is happening in the health services that are out of their control. May I once more take the opportunity in this Report to express my appreciation of the staff, upon the work performed and the excellent standard maintained throughout the year. Our loss of Sanitary Inspectors has been a great handicap to us and it may well take several years to catch up on the leeway that has accumulated. I am, however, happy in the knowledge that the staff will do their utmost to cope with the difficulties of the situation which is not only being felt in Ealing but throughout the country through this lack of suitable staff to undertake these important sanitary duties. Your obedient servant, W. G. BOOTH, Medical Officer of Health. 7 SECTION 1. INFECTIOUS DISEASES CONTROL. NOTIFICATION, Notification is the essential preliminary to control of infectious disease and as more and more has become known about each transmissible infectious disease so has it been made notifiable. The diseases notifiable under the Public Health Act, 1936, are smallpox, cholera, diphtheria, membraneous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fever. The Minister of Health has also made regulations whereby the following diseases are also notifiable; plague, poliomyelitis, tuberculosis, puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute primary pneumonia, acute influenzal pneumonia, measles, whooping cough, acute encephalitis and meningococcal infection. Food Poisoning is notifiable under the provisions of the Food and Drugs Act of 1938. 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. Leaflets describing the essential points of home nursing of persons suffering from infections, and advice as to disinfection are provided when necessary, LABORATORY SERVICE. The laboratory at King Edward Memorial Hospital continues its fine and invaluable work in the diagnosis and prevention of infectious disease. The Public Health Department will arrange for the collection of specimens, e.g. faeces and samples of suspected food or vomited material, and for transmission to the King Edward Memorial Hospital laboratory at the request of a general practitioner. 8 PREVALENCE. 3,335 cases of Infectious Disease were notified in the Borough during the year, Of these 49 were proved not to have suffered from the disease for which they were originally notified reducing the corrected number of cases of Infectious Disease during the year to 3, 286. In 1954 there were 1,284 cases originally notified and these were reduced by correction to 1,154. The difference can be attributed to the incidence of measles. There were 2, 422 cases compared with 132 in the previous year. CERTIFICATION. 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. DISINFECTION, Books which have been handled by infectious persons are stored in a formalin box for three weeks before being returned to a library. DIPHTHERIA. No cases were notified in 1955. The total number of primary immunisations given at the clinics and by General Practitioners was 1,719 and the number of booster doses was 2,311. As the number of live births for the year was 2,295, it can be calculated that the proportion of children in the first year of life who received primary vaccination was 75%. It will be remembered that to obtain a satisfactory state of immunity 70% to 75% of children in the first year of life should be immunised. Our percentage for the year therefore is satisfactory. Although this figure is within satisfactory limits there should be no slacking off in immunisation because it is the experience all over the country that as cases of Diphtheria become fewer and fewer so in the minds of parents there is a tendency to regard the need for immunisation as less and less urgent and so a diminishing number of children each year is presented at the clinic for this purpose. It should not be forgotten that the dramatic fall 9 in the number of Diphtheria cases is due mainly to immunisation against the disease and if the level of immunisation falls sufficiently the disease could regain its former virulence and killing power. DYSENTERY. There were 149 cases notified, 76 less than in the previous year. In 128 cases Shigella Sonnei was isolated, the remaining 21 cases showing no pathogenic organisms. The decrease in the number of cases from the previous year is gratifying but there is no doubt that, as far as this disease is concerned, much greater improvement can be made and the observance of proper personal hygiene and the reporting of even mild cases of diarrhoea are prime factors in the fight to reduce dysentery to a minimum. ENTERIC FEVER. One case of typhoid fever was notified in a girl of 17 years. While on holiday in Italy she had symptoms of diarrhoea, vomiting and a raised temperature. These symptoms subsided and she appeared to recover. A month later, however, she was admitted to hospital as a case of Pneumonia and a routine blood test showed S. Typhi to be present. ENTERIC FEVER CARRIER The person who has been a Paratyphoid B carrier since 1948 was kept under surveillance as usual and routine faeces examinations were carried out at three monthly intervals. During the year she was admitted to Neasden Hospital for a course of treatment recommended for such carriers by the Ministry of Health. Unfortunately however she was unable to stand the strain of disturbed sleep while having three hourly injections and discontinued treatment after three days. ERYSIPELAS. Twelve cases were notified, six less than in the previous year. FOOD POISONING. 36 cases were notified and 11 of these were confirmed by laboratory diagnosis. 10 Ten were diagnosed as S.Typhimurium and one was a staphylococcal infection. This shows a decrease of 32 notifications from the previous year's figure of 78, 15 of which were confirmed by laboratory diagnosis. This decrease to less than half the previous year's number is most creditable to the Borough of Baling but it should be remembered that Food Poisoning is essentially preventible and I feel that the suggestions I made in a previous report for the production of safe food cannot be repeated too often. "Food handlers should realise fully their responsibility and should have a high standard of personal hygiene. Their hands 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, run ning 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. One case of M.T. Malaria was notified in a man of 36 years who had just returned from the Gold Coast. He was 11 admitted to the Hospital for Tropical Diseases for treatment. MEASLES, After the 132 notifications in 1954 the number in 1955 rose to 2,422, which is comparable with the 2,568 notified in 1953. The disease is therefore following its usual behaviour pattern in which epidemics occur biennially with a relatively small number of cases occurring in the intervening years. MENINGOCOCCAL INFECTION. Three notifications were received. An Inspector visited each case and no overcrowding was found. OPHTHALMIA NEONATORUM. Two cases of this disease were notified by private practitioners. Both cleared up after treatment and the eyes in neither case were damaged. PNEUMONIA. 191 notifications were received, a few less than in the previous year. 79 deaths occurred in the following age groups:- 5-14 years 2 15 - 44 years 2 45 - 64 years 19 65 and over 56 POLIOMYELITIS. There were 58 confirmed cases, 20 paralytic and 38 non-paralytic. One death occurred in a boy of 5 years. The following table shows the age groups in which the cases occurred:- 12  Paralytic Non Paralytic M. F. M. F. Under 1 year 2 — — — 1-2 years 2 1 2 1 3-4 years - 2 2 — 5-9 years 3 3 12 6 10 - 14 years — 1 2 2 15 - 24 years 2 1 2 4 25 and over 1 2 3 2 Totals 10 10 23 15 The increased number of cases, though not approaching epidemic proportion, caused considerable anxiety among parents in the Borough and many and varied enquiries concerning this disease were received and dealt with by the Public Health Department. A large number of Head Teachers also sought advice and it was considered advisable to send to every school a printed list of instructions authorising the general precautions to be taken during the summer months when poliomyelitis is prevalent. There is also a pamphlet distributed at the Town Hall and Public Libraries giving instructions with regard to procedure when a case of poliomyelitis is diagnosed. A - METHODS OF CONTROL. Control of the infected individual, contacts and environment. (i) All cases are notified to the Medical Officer of Health. (ii) All suspected cases are isolated, usually in hospital, for three weeks. (iii) Disinfection of throat discharges, faeces and soiled articles is carried out in hospital. (iv) Quarantine is of unproved value. While quarantine of family contacts is theoretically worthwhile there is no evidence of practical benefit because of the large number of unrecognised infections in the community. (v) Immunisation - A vaccine is at present being prepared by two independent firms and it is hoped that a supply of this, though only limited at first, will be available in the spring of next year. 13 (vi) Investigation - There is a thorough search for sick persons, especially children, to locate unrecognised and unreported cases. (vii) Treatment - There is no specific treatment other than attention to prevention and management of paralysis. B - EPIDEMIC MEASURES. (i) Notice to general practitioners of increased incidence of the disease. (ii) Isolation in bed of all children with fever, pending diagnosis. (iii) Education of the public in personal hygiene in order to prevent spread of the disease through transmission of infectious discharges. (iv) Protection of children so far as practicable against unnecessary close contact with other persons especially with other family groups or outsiders during epidemic prevalence of the disease. Urban schools should not be closed or opening delayed but intensive or competitive athletic programmes should be postponed. (v) Postponement of nose or throat operations where practicable. (vi) Avoidance by children of excessive physical strain. (vii) Postponement of inoculation against diphtheria, whooping cough, etc. (viii) Avoidance of unnecessary travel and visiting. SOME FACTS ABOUT THE VACCINE AND ITS PREPARATION. It was only as recently as 1949 that it was discovered that the poliomyelitis virus would grow and multiply in cells other than the nerve cells of man or monkey. Only cells of the kidneys of man or monkey will allow the virus to multiply to an extent sufficient to permit the making of a vaccine. The vaccine will probably be a "killed" vaccine although search is being carried out for a "living attentuated" vaccine. "Attentuation" means deprivation of power to produce disease without actually killing the virus. The first process in the production of the vaccine is the careful examination of the monkeys to exclude any concurrent disease such as tuberculosis. 14 The kidneys are placed in large bottles, minced and covered with a fluid that will support the growth of the kidney tissue. They are then kept at body temperature for a few days. The virus is now added to the bottles and they are returned to the incubator. At the end of three days, by which time all the kidney cells have been killed and the multiplication of the virus units has ceased, the fluid in the bottle contains enormous numbers of virus particles. Each virus particle has given rise to 10,000 more particles. The number of particles in the dose of vaccine required to protect one child against poliomyelitis is 30 million. The virus fluid is now removed from the bottles and the living virus killed by adding formalin. The final vaccine is a mixture of three vaccines made separately from each of the three types of poliomyelitis known to science. Tests of the vaccine are made at all stages of production by the manufacturers and the final vaccine is tested both by the manufacturer and also by the Department of Biological Standards. As a final safeguard against a dangerous vaccine, a sample of each batch is injected into some fairly healthy monkeys. After four weeks observation the monkeys are killed and the brain and spinal cord of each removed and prepared for examination under the microscope. In this way it is possible to detect infection with poliomyelitis even though it is not sufficiently severe to have caused paralysis. A still further degree of safety is thus assured. PUERPERAL PYREXIA. 43 notifications were received, 44 from Perivale Maternity Hospital and 4 from private practitioners, which is 10 fewer than in the previous year. The value of these figures for statistical purposes is unreliable. It will be remembered that 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 detection of such a temperature in maternity hospitals is rendered possible, but even here by no means certain, by the hospital routine of recording four hourly thermometer readings but many cases which would qualify for notification must be missed in home 15 confinements where it is impossible to record such frequent and reliable temperature readings. SCARLET FEVER, 1955 was a quiet year for scarlet fever, only 118 cases were notified compared with 287 in 1954. The disease was again of a very mild type. SMALLPOX, Five persons who may have been contacts of a case which occurred in a liner returning from the East were kept under uneventful surveillance for the necessary period. TUBERCULOSIS, In recent years I have drawn attention in my Annual Report to the sharp decline in Tuberculosis. During the last five years, as will be seen from the attached table, the pulmonary cases have fallen from 209 to 119, whilst the non pulmonary cases have fallen from 41 to 24. If one looks at the deaths from Tuberculosis the comparison is even more striking. In 1950 there were 48 deaths from pulmonary Tuberculosis and in 1955 there were 17, the figures for non pulmonary Tuberculosis being 5 in 1950 and 3 in 1955. Looking at these figures as part of an epidemiological curve there seems no doubt that we are at the end of a wave of infection which, although the figures may not be reliable before 1837, seems to show that since the London Bills of Mortality were commenced in 1629 there is undoubted evidence of the prevalence of Tuberculosis over a period of about 200 years, The death rate rose steadily to the middle of the 18th century until about 1810 with a death rate of 6,000 per million living. Since then there has been an almost continuous steady decline in Tuberculosis mortality. In 1855 the death rate was 3,600 per million, in 1905 1,600 per million and in 1955 148 per million, It is of particular note that the most conspicuous fall is in the age group 20 24 years, - 100 years ago the death rate in this group was ten times the death rate of today. Among the older groups the death rates were only two to three times what they are at the present phase of the epidemiological curve. Another interesting sidelight on this curve of mortality is the sharp fall in the deaths among children. 16 There are now less than l/10th of the proportion of tuberculosis deaths in the 5-15 year school age group compared with the year 1945. In infancy it is of interest that Whooping Cough now accounts for almost three times as many deaths as Tuberculosis. Notification of Tuberculosis has only been in operation since 1912 and with this notification, the expansion of the work of the Chest Clinics, the tracing of contacts of recent cases, and of recent years the Mass Miniature Radiographical examinations there has been a great increase in the detection of mild cases, formerly a considerable proportion of whom would have overcome their own infection and would probably not have been recognised as cases of tuberculosis at all. With the fall in tuberculosis rates and the likelihood of its disappearance within a few years from our list of major infectious diseases it is important that every possible investigation that can be made regarding the natural trends of the infection should be closely watched.. In this country we have, as a result of tuberculosis testing and X- ray examinations obtained certain data which has shown that the infection which has normally risen from about 10% to 60% between the ages of 5 and 20 years is now in the decline, since the Medical Research Council survey showed that the 15 to 16 year olds who were positive was 40% boys and 55% girls as compared with the Prophit survey of 1948 of a 63% overall figure for the same group. This reduction in infection among children as shown by the Tuberculosis Test gives us the clue to the disappear ance of tuberculosis and could certainly be used as a check in years to come on a possible re-appearance of tuberculosis at the beginning of an epidemiological wave. Testing children by these tuberculosis reactions is a simple matter and is quite easily carried out as part of the normal school inspection. If, however, the use of B.C.G. (which is a live avirulent Tubercle bacillus) is made available to everyone in the country and is used on small children as it is at present in Scandinavian countries then this use of the Tuberculin reaction would of course be valueless since every child given B.C.G. would automatically become positive to Tuberculin test and it would be impossible to assess the amount of infection that is naturally abroad. The recent survey carried out by the Medical Research 17 Council in this country which showed that the use of B.C.G. did lower the incidence of the disease among adolescents by about 50% has posed a dilemma as to the use of B.C.G. for all Authorities concerned in this matter. What is the position in Ealing? We are well aware of the rapid fall in our tuberculosis mortality and the likelihood of its disappearance in a few years. We know that the number of tuberculosis deaths among adolescents, that is the 15 24 year age group, during the last three years was only one (This was a twenty-three year old girl who died in 1955 having been ill over a period of about ten years and having had severe surgical operations on her lungs and coming from a family well known to be subject to tuberculosis). There has been no other case of a death in this 15-24 year age group for three years. Any steps therefore, which are taken in Ealing to reduce infection in this group can be only of very small significance since the total notifications in this group for the same period is only nine. It might be argued that some of these cases might not have occurred had B.C.G. been given but against this must be weighed the fact that many of these cases will undoubtedly recover and in fact had our intensive search been less meticulous it is more than probable that few of these cases would have been discovered and placed under observation. The giving of a live Tubercle bacillus, however aviru lent it may be, must carry some chance of reaction, more severe in some than in other individuals. This must be weighed against the reactions that would be obtained by the use of Tuberculin Testing on a large scale among all adolescents. We of course would lose the opportunity which so far we have preserved of having a controlled group by which to measure the decline of Tuberculosis in our district as compared with that in other areas where B.C.G has been used. This matter is one for careful consideration and should, in my view, be left to the discretion of the Local Sanitary Authority, who are the Authority concerned with the prevention of the spread of infectious disease. Unfortunately, the National Health Service Act places the prevention of disease in this context, namely that of vaccination and immunisation in the hands of the Local Health Authority, which, as far as Ealing is concerned, is the Middlesex County Council. It has now been decided by the Middlesex County Council that B.C.G. vaccination shall be made available in all Boroughs of Middlesex and 18 as Area Medical Officer it would be ray duty to see that the public are made aware that the B.C.G. vaccination can be obtained for children aged 13 and 14 during the last term of 1956, and it will rest with each individual parent to decide whether or not they wish to avail themselves of this method of protection against Tuberculosis. The Borough Council of Ealing, however well aware they may be of the background of Tuberculosis infection in the area, and however they may wish to gain information that would be of vital importance to future generations if anti Tuberculosis campaigns again become necessary, are not able to make decisions which lie within the competence of many small areas of populations of 20,000 or 30,000 people. The indignity of such a position seems a small reward for the enterprising and progressive health policies previously given inception in the Borough of Ealing, If there is to be no independence of thought based upon such scientific evidence as is available about these matters then our chances of making real progress will be drastically limited. Most countries in Europe have rushed into B.C.G vaccination in an effort to stamp out Tuberculosis with commendable enthusiasm but those more cautious and re strained in their approach to this problem, such as a number of districts in England similar in character to Ealing can show results from other Tuberculosis work that are comparable in every way with those districts using B.C.G. indiscriminately. In my own view the essential of Tuberculosis control is the detection of the recently infected person as shown by the Tuberculin test. Young children have limited con tacts and by discovering those who are positive to Tuberculosis among young children one is given a much better clue to the finding of the causative case than in any other way. Another factor that must be borne in mind is the loss of this Tuberculin test value which would arise from the use of B.C.G. since progressive Tuberculosis development is greater during the first year or two after conversion from the Tuberculosis negative to the Tuberculosis positive than at any other period. This stage of development can only be found therefore by having a clear cut and reliable method of estimating the development of tuberculosis by conversion to the test. Whilst at the present time it is not proposed in view 19 of the shortage of material, to extend B.C.G. innoculations beyond the thirteen year old group there is a presumption that B.C.G. would be extended to the infant groups when more material becomes available. It is well realised from the Medical Research Council's investigation that 40% of the children are found to be positive reactors and they form a large group in which Tuberculosis cannot be prevented in any case by prophylactic vaccination. It would there fore be necessary if B.C.G. was to be used to its fullest value to offer at a much earlier age, probably before the child had had a chance to acquire Tuberculosis infection naturally, the same vaccination as has been offered under the Ministry of Health scheme. The use of B.C.G, on a mass scale among the whole population, rather than as a weapon in the hands of the Chest Physician to prevent development of infection among selected individuals at high risk, is, in my personal view, an unjustified procedure at this stage in the epidemiological history of Tuberculosis (It is known that in recent years the examination of contacts of known cases has produced 8% of new notifications, These people are of course a greatly increased comparative risk and should be treated as a selected group). Had Ealing remained its own arbitrator in this connection I believe that they would have given long and careful consideration to the desira bility of introducing this grape shot' method of attack in an area such as this, rather than relying upon the efficient judgment of their Chest Physician whose know ledge of this disease in all its manifestations in local conditions is unsurpassed. It is important that the public should be aware of the differences in B.C.G. vaccination and Diphtheria immunisation. In the case of B.C.G. of course there must be preliminary Tuberculin Tests and subsequent tests to be made to ensure that the B.C.G. which is a live germ has been effective. With regard to Diphtheria immunisation, the material which is purely chemical and is in no sense a live organ ism, is given in two injections and no further testing is necessary. We do not know the length of protection which can be afforded by B.C.G. vaccination, nor do we know if the degree of protection is the same in young children as in adolescents. In fact, there are American figures to suggest 20 that the degree of protection is not the same in young children. The American figures also suggest that ten years is the limit of the protection level that is given by B.C.G. after which it may start to wane. What is proposed at present is not that B.C.G. be given to prevent Tuberculosis throughout life but should only be given to the thirteen year olds to reduce the amount of Tuberculosis in adolescents. It might be suggested that half a loaf is better than no bread but this would surely be an argument for encouraging certain districts to remain free of these complicat ing blankets of B.C.G. until some of these controversial factors have been sorted out. No doubt these will take many years to complete satisfactorily, by which time it is to be hoped that Tuberculosis will have continued its present trend and will have practically disappeared. If we are then left with no Tuberculosis but a large machine manufacturing B.C.G. blankets to control a non-existent fire where will be our gain? The great value that has been obtained from Diphtheria immunisation has undoubtedly been built up on the careful work of clinics and the avoidance of reactions among the children. In the widespread use of B.C.G. we shall undoubtedly give rise to a number of local reactions, some persisting over a matter of weeks, or even months, which might easily prejudice many parents against inoculations of all kinds. Those of us who have had many years in Public Health know how carefully one must balance the value of injections against public resentment of reactions of any kind. For this fact alone I would need much convincing that the value of B.C.G. in a community such as Ealing, where adolescent Tuberculosis is becoming almost a rarity, would outweigh the mass resistance which we are likely to get to immunisation as a whole. In Scandinavia it is now thought that mass vaccination of young children is unnecessary because the risk of infection is so low and because of the occasional case of progressive disease due to the vaccination. The abandonment of B.C.G. vaccination has therefore been urged. In my view the rate of Tuberculosis among younger age groups makes tuberculin testing necessary only for the detection of those who are positive as a result of natural infection who may then require periodical X-ray examinations and possibly some medical treatment. It should not 21 be used for the identification of negative reactors prior to vaccination but as Medical Officer of Health of 3aling I can only give my views in this report, and as a Council you will have no opportunity of considering its implementation in your Borough, This may well be one example how with the best of intentions, the legislature of the country can introduce a pseudo scientific dictatorship over an intelligent community. There is little doubt that it is an example of how easily the death knell can be sounded of true local government, TUBERCULOSIS IN EALING IN 1955. The total notifications again showed a decline from 149 in 1954 to 143 in 1955. DEATHS. The following table shown the age and sex of the cases notified and the deaths since 1950. 22 TUBERCULOSIS Age Periods New Cases Pulmonary Non-Pulmonary 1950 1951 1952 1953 1954 1955 1950 1951 1952 1953 1954 1955 M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Under 5 7 3 5 4 5 2 5 2 3 1 1 — 3 1 1 1 — 4 — — 2 — 1 — 5 - 14 6 3 — 4 5 6 7 4 1 2 1 1 2 6 2 1 4 1 1 2 2 2 4 15 - 24 22 36 24 26 13 44 15 38 13 24 16 14 4 2 6 4 2 4 -■ 1 1 2 2 3 25 - 44 37 48 46 37 46 37 30 43 23 26 21 26 6 12 3 3 5 5 2 4 1 4 2 4 45 - 84 30 6 39 17 32 10 39 9 23 11 23 7 3 1 — 3 1 3 4 4 1 3 1 2 Over 65 7 4 8 — 9 2 7 6 3 2 6 3 1 — — — — — 1 1 — 1 2 1 Total 109 100 122 88 110 101 103 102 66 66 68 51 19 22 12 12 12 17 8 12 5 12 10 14 Age Periods Deaths Pulmonary Non-Pulmonary 1950 1951 1952 1953 1954 1955 1950 1951 1952 1953 1954 1955 M. F. M. F. M. F. M. F M F. M F. M. F. M. F M F. M F. M. F. M F. Under 5 — — — — — — — — — — — — — — — — — — — — — — 1 — 5-14 — — — — — — — — — — — — 1 — 1 — — — — — — — — — 15 - 24 2 1 2 2 6 5 — — — — — 1 — 1 — 1 — — — — — — — — 25 - 44 11 7 2 9 4 4 4 4 3 2 3 1 1 — 1 — 1 1 — 1 — — 1 — 45 - 64 15 6 8 1 7 3 9 3 5 3 5 — 1 2 1 — 1 — — — — 1 1 — Over 65 3 3 5 — 7 1 5 3 4 2 6 1 — — — — — — — — — — — — Total 31 17 18 12 24 13 18 10 12 7 14 3 3 3 3 1 2 1 — 1 — 1 3 — 23 The steady yearly falls in both the number of notifications and deaths from tuberculosis so well shown in the two graphs in our last report can be attributed not to one, but to a combination of factors, viz. the natural epidemiological curve, the pasteurisation of milk, improved case finding due to Mass Radiography, the use of antibiotics and the advances made in the technique of chest surgery and the management of tuberculous patients. The Borough of Haling is participating in a clinical trial of B.C,G. vaccination. In our Borough as the following survey shows there were almost 1,000 volunteers and these were divided into three groups. Intake, Total No, of volunteers in trial 998 No. Mantoux positive to OT 1/3000 and 1/100 339 No. vaccinated with B.C.G. 335 No. of unvaccinated controls 330 Follow Up., Average figure for returns of postal forms 84% Average figure of Home visits by Health visitors 92% Average of volunteers returning for X-ray 75% It will be noted that no less than l/3rd of the number of volunteers, and half of the number with a negative result to the Tuberculin test, have been vaccinated with B.C.G. The follow up of our volunteers has so far also been eminently satisfactory. WHOOPING COUGH, The number of cases notified was a little higher than in the previous year. 156 notifications were received. In 1954 there were 116. 24 SECTION 2. SANITARY CIRCUMSTANCES OF THE BOROUGH. WATER. There are three sources of supply in the Borough. The Northolt, Greenford North, Greenford Central and Greenford South Wards, most of Perivale Ward and part of Hanger Hill Ward are supplied by the Rickmansworth and Uxbridge Valley Water Company with the exception of four roads (in part) in the Perivale Ward and one road (in part) in the Hanger Hill 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 piumbo solvent action and have been satisfactory both in quantity and quality. Water from public mains is supplied to 53,117 houses with an estimated population of 184,600. Twelve samples were taken from wells at six factories in the Borough using water from deep borings ranging in depth from 300 to 600 feet. Also five samples were taken from main water supplies, The analysis of all these samples showed that the supplies were wholesome in character. DRAINAGE AND SEWERAGE. There are 23 houses in the Borough not connected to the Council's sewers, one house previously drained to a cesspool having been connected during the year. None of these houses are within a reasonable distance of the Council's sewerage system and there is no immediate prospect of re drainage. RIVERS AND STREAMS. Investigations into the pollution of the River Brent. No. of inspections 325 No. of samples taken by County Engineer's Dept. 27 (a) Satisfactory 14 (b) Unsatisfactory 13 No. of drainage defects found by Sanitary Inspectors (a) In factories 23 (b) In houses 33 No. of drainage defects remedied (a) In factories 21 (b) In houses 32 25 Efforts have been made to continue the work of tracing and remedying sources of pollution in the River Brent but the work has been handicapped during the year by staff shortages and the inability of the Main Drainage Department of the Middlesex County Council to continue the regular analysis of samples submitted by the Sanitary Inspector, Although much good work has been done it has been quite impossible to carry out investigations to our complete satisfaction and it is to be hoped that no serious deterioration in the position will take place while we are waiting the several additions required to bring our staff up to full strength. ATMOSPHERIC POLLUTION. During the year 123 smoke observations were made by the Sanitary Inspectors and in several cases advice was given as to the efficient use of the equipment. In one instance as a result of representation by the Sanitary Inspector smoke consuming apparatus was fitted to the boiler furnace and the nuisance satisfactorily abated. In a second case the firm concerned converted the coal fired boiler to oil fuel and no further complaints were received after this installation was in use. Regarding the Long Drive area of Greenford, grit arrestors were fitted to the cupolas at the British Bath Company's factory in Long Drive early in the year. This was done in a further effort to minimise the alleged nuisance in the Long Drive area. Monthly gauge readings taken subsequently to the installation of the arrestors showed considerable fluctuation according to climatic conditions, wind prevalence and the presence or absence of other dust producing processes in the neighbourhood, for example, railway engines, but there was an over-all, if only slight, improvement. It is to be hoped that still further improvement will take place in the future, MOVEABLE DWELLINGS, In the early part of the year numerous prosecutions were taken against the owners of gypsy caravans on the Lime Trees Estate, Northolt. Orders were obtained requiring the removal of the caravans in 20 cases and in a further 10 cases fines amounting to £21 were imposed upon caravan owners for non-compliance with Court Orders. Despite this action by the Department the nuisance from gypsy caravans continued and eventually the Council decided 26 to appoint a permanent watchman on the Lime Trees Estate, whose duty it is to have these caravans removed as soon as they appear on the site. This procedure appears to have been successful, FOOD HYGIENE During 1955, 32 lectures were given to food handlers, of whom 108 received Certificates upon completing the course. Also 13 revision lectures were given to 160 food handlers and 4 lectures to various organisations in the Borough. Since the scheme commenced six years ago, 371 lectures have been given to food handlers and 1,557 persons have received Certificates of Attendance. The number of Certificates of Food Hygiene awarded to food establishments decreased during the year to 54. One new certificate was issued and six withdrawn five owing to the establishments closing and one because the business changed ownership. During 1955, 2,196 inspections of food premises were made by the Sanitary Inspectors and 360 repairs and improve ments were carried out. Twenty talks on Pood Hygiene by the Sanitary Inspec tors to school leavers in the secondary grammar and secon dary modern schools in the Borough were given during the year to approximately 800 school-children. The Food Hygiene Regulations made under the Food and Drugs Act, 1955, came into operation on the 1st January, 1956, and have considerably increased the duties of the Department in respect of Food Hygiene. It is hoped that these Regulations will stimulate interest in the Council's Clean Food Scheme and every effort will be made to encourage the attendance of food handlers and those engaged in food trades to attend our lecture courses. In addition to providing these lecture courses the Sanitary Inspectors will also have the important task of seeing that the Regulations are enforced in food establishments and in inspecting the structural alterations and improvements of premises which in many cases will be required. It cannot, therefore, be stressed too frequently that to carry out the requirements of the Regulations it will be essential to have a full staff. The demand for the film strip on Food Infections made by the Council still continues and a further 15 copies have been sold during the year. 27 In last year's report it was noted that copies of the film strip were sold to Government Departments in New Zealand. South Africa. Burma, Sweden and NewfoundlandIt is gratifying to report also that in the past two years representatives of Health Departments in South Africa, Singapore. Jamaica, Ethiopia and Italy have visited Ealing with the express purpose of studying at first hand educa tional methods used in our classes to food handlers and others in the increasingly important subject of food hygiene. 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 also two privately owned swimming pools in the Borough, PUBLIC MORTUARY The arrangement with the Acton Council for the use of the Acton Mortuary was continued during the year 201 bodies were taken to this Mortuary and post mortem examin ations were carried out in every case but one. While we are grateful to the Acton Council for the use of the Acton Mortuary the need for a mortuary of our own is felt to be desirable. There are, however many aspects of such a project to be studied before a decision is made, for instance, the most suitable site; its proper construction and its staffing are all important. In order to be sure that our own mortuary if and when built would be the most modern of its kind a survey of the mortuary position in Middlesex as a whole was carried out and much valuable information was obtained. The Public Health Committee are constantly endeavouring to find a satisfactory scheme. 28 SECTION 3 SANITARY INSPECTION THE WORK OF THE SANITARY INSPECTORS IN 1955 I append a report to the Medical Officer of Health by the Chief Sanitary Inspector giving details of the work of the Sanitary Inspectors during the year PUBLIC HEALTH ACT, 1936 Inspections Premises inspected on complaint 2,453 Other nuisances observed by Inspectors 73 Premises inspected in connection with infectious disease 574 Smoke observations 123 Houses without water supply 32 Inspections of moveable dwellings 496 Other inspections 2,223 Re inspections 9,298 Intimation Notices served 1,285 Statutory Notices served 322 Letters written 1.750 Proceedings before magistrates 37 Legal Proceedings Public Health Act, 1936 Section 93 Non compliance with Statutory Notices In four cases legal proceedings were taken to enforce compliance with Notices requiring abatement of nuisances. Orders were made in each case by the Magistrates for the necessary work to be carried out in a stated period and costs amounting to £8 8 Od were awarded. In one case proceedings were instituted for non compliance with a Nuisance Order and a fine of £5 was imposed One further case was adjourned sine die as the work was in hand at the time of the hearing and was subsequently completed. Thirty cases were taken against caravan owners in respect of non compliance with Abatement Notices In 20 cases Orders were made by the Magistrates for the caravans to be removed and in 10 cases fines amounting to £21 were imposed upon caravan owners for non compliance with Court Orders. In twelve cases summonses were applied for but withdrawn before the hearings as the necessary work had been completed. 29 Public Health Act, 1936, Section 39 Proceedings were taken in one case for non compliance with a Notice served to execute drainage works A fine of £2 was imposed and £1. 1. 0d. costs awarded. FOOD AND DRUGS ACT, 1938 FOOD AND DRUGS (MILK, DAIRIES AND ARTIFICIAL CREAM) ACT, 1950, MILK AND DAIRIES REGULATIONS, 1949, ETC. Complaints received 77 Inspections of Milk Purveyors Premises 118 Contraventions of Regulations Inspections of Ice Cream Premises 199 Food Inspections 689 Inspections of other Food Premises 1,879 Contraventions found 150 Notices served 148 Unsound food cases reported to the Public Health Committee 6 Proceedings before Magistrates 5 Samples of Milk taken 31 Samples of Ice Cream taken 56 Samples of Synthetic Cream taken 62 Samples of other foods taken 50 LEGAL PROCEEDINGS FOOD AND DRUGS ACT, 1938 In the following four cases proceedings were instituted under Section 9 of the Food and Drugs Act. 1938 Rodent droppings in bread roll - Fined £5 Costs £10.10.0d. Insect in bread Fined £5. Costs £1.1.0d. Cigarette end in bread Fined £5 Costs £5.5.0d. Used bandage in bread Fined £25 Costs £5.5.0d. A further summons was issued against the owner of a bakery in respect of offerees under Section 13 of the Act. The hearing was adjourned and the summons was later with drawn as the necessary work had been completed List of Food Premises in the Borough of Ealing Bakehouses 34 Bakers shops 66 Butchers 122 Cafes and Restaurants 155 Canteens - factory 77 Canteens - school 22 30 Confectioners 238 Dairies and Milk Sellers 68 Pish Fryers 21 Fishmongers 37 Greengrocers 159 Grocers 328 Ice Cream Manufacturers 6 Public Houses 60 Premises registered for the preparation or manufacture of sausages or potted, pressed, pickled or preserved food 100 Premises registered for the sale of Ice Cream 335 Milk Supply. There are 84 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 15 64 Pasteurised Milk 55 17 72 Sterilised Milk 58 17 75 Under the provisions of the Milk (Special Designa tions) (Specified Area) Order, 1951 all milk sold by retail in the Borough must be "designated milk", i.e., Tuberculin Tested, Pasteurised or Sterilised Milk. 30 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 T.T. Pasteurised 2 2 - 1 1 Pasteurised 28 28 - 27 1 Bottle rinse 1 - - - - Subsequent samples were taken from the suppliers of the samples which failed the Methylene Blue Test and these proved satisfactory. 31 In addition, 174 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, Ice Cream, There are 335 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 11 manufacturers outside the Borough. Samples from each of these 17 manufacturers were taken once or more during the year, a total of 56 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 30 18 3 6 2 1 Ice Cream - Other Manufacturers 18 13 - 2 3 - Ice Lollies 2 - - - - 2 Ice Cream Constituents 6 - - - - 6 56 31 3 8 5 9 Three of these samples were reported to be unsatisfactory - all from manufacturers outside the Borough. These samples were followed up. by check samples and investigation at the producer's plant by the Local Authority concerned. Synthetic Cream, 62 samples of synthetic cream were taken from local manufacturers, 61 were found to be satisfactory and one "doubtful". 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: 32 lbs. Bacon 28 Beef 1,991½ Biscuits 49 Cheese 244¾ Chocolates 1 Cocoanut 1 Corned Beef 471¼ Currants 8½ Dried Fruit Salad 12 Dried Milk 40½ Pish 1,104 Flour 56 Ham 93 Hearts 47¾ Kidneys 6O½ Lamb 416½ Liver 237¼ Luncheon Meat 38½ Meat Pie 1¾ Milk Powder 72 Nuts 168 Ox Cheeks 28 Pearl Barley 1 Pork 256¼ Rabbit 3½ Raisins 17 Rice 19¾ Roes 42 Sultanas 90 Sausages 97½ Split Peas 1 Stewing Steak 30 Suet 60 Tapioca 1 Tomatoes 8 Tongue 6¼ Tripe 7½ Veal 117 Winkles 25 Foodstuffs not calculated by weight. Cakes 8 Eggs 1,248 Fish Cakes 21 Ice Cream 122 Lollies 34 Steak Pies 34 Assorted tins, jars, packets, bottles etc. 10,080 Slaughterhouses. There is one licensed slaughterhouse in the Borough but no slaughtering was carried out during the year. MIDDLESEX COUNTY COUNCIL ACT, 1950, SECTION 11 Under this Section, 9 persons were registered during the year for the sale of food from carts, barrows, other vehicles etc. There were 38 persons on the Register at 31st December, 1955. 33 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) 2,141 (2) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Act, 1936 45 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 30 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subhead) found not to be in all respects reasonably fit for human habitation 1,511 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 1,535 3. Action under Statutory Powers during the year; A - Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936: (1) Number of dwelling-houses in respect of which notices were served requiring repairs (2) Number of dwelling-houses which were rendered fit after service of formal notices: (a) by Owners (b) by Local Authority in default of owners B - Proceedings under Public Health Act: (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 249 (2) Number of dwelling-houses in which defects were remedied after service of formal notice. (a) by Owners 203 (b) by Local Authority in default of owner C - Proceedings under Sections 11 and 13 of the Housing Act, 1936: (1) Number of dwelling-houses in respect of which Demolition Orders were made 19 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 3 (3) Number of houses concerning which action has been taken by the Local Authority under Section 19, and with respect to which Owners have given an undertaking that they will not be used for human habitation D - Proceedings under Section 12 of the Housing Act, 1936: (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 3 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit 34 During the year one Clearance Area was declared by the Council. This was in respect of Nos. 1, 2, 3, 4 and 5 Thompsons Cottages, Church Lane, W.5. Subsequently, the Council made a Compulsory Purchase Order which has now been confirmed by the Minister. It is understood that when the houses have been vacated and demolished the site will be re-developed. The following houses became the subject of Demolition Orders: 1, 2 and 3 Ealing Place, W. 5 514 - 532 (evens) Oldfield Lane, Greenford. 13, 14, 15, 16 and 17 Bakers Lane, W 5. "St. Aidan", Ealing Green, W.5. Of these, Nos. 1, 2 and 3 Ealing Place, have been vacated and the houses demolished: "St. Aidan", Ealing Green, W. 5, has been vacated but not yet demolished; 514 532 (evens) Oldfield Lane, Greenford, and 13 - 17 (consec.) Bakers Lane, W.5, are still in occupation (with the exception of one house in Oldfield Lane) and the occupants are awaiting re-housing prior to the demolition of the properties. Closing Orders were made by the Council in respect of the following properties; Basement dwelling 25 The Avenue, W 13 -the occupants have been re-housed by the Council and the Closing Order is in operation, 3 Thompsons Cottages, Church Lane, 1.5, - the occupants have been re-housed by the Council but this property is now included in a Clearance Area Basement 130 Church Road, W 7. - this Closing Order is operative. The tenants have not yet been re-housed Basement dwelling 16a Drayton Green Road, W.13, the tenants have been re-housed by the Council and the Closing Order is in operation HOUSING REPAIRS AND RENTS ACT, 1954 During the year .62 applications for Certificates of Disrepair and 41 applications for Certificates of Disrepair to be revoked were granted by the Council. NEW DWELLINGS Completion figures supplied by the Borough Surveyor for the 12 months period ending 31st December, 1955: Houses (1 bedroom) - 6 Houses (2 bedrooms) - 15 Houses (3 bedrooms) - 257 Plats (1 bedroom) - 10 Plats (2 bedrooms) - 134 35 FACTORIES ACTS, 1937 AND 1948 Part I of the Act 1. Inspections for the purposes of provisions as to health (including inspections made by the Sanitary Inspec tors): 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 76 5 - - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 451 333 12 - (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - - Total 527 338 12 - 2. Cases in which defects were found; Particulars Number of cases in which defects were found Number of cases in which prosecu tions were instituted Found Remedied Referred To H.M. Inspector By H.M Inspector Want of cleanliness 3 3 _ _ _ Overcrowding _ _ _ _ _ Unreasonable temperature _ _ _ _ _ Inadequate ventilation _ _ _ _ _ Ineffective drainage of floors _ _ _ _ _ Sanitary Conveniences: (a) Insufficient 5 5 _ _ _ (b) Unsuitable or defective 7 9 _ 3 _ (c) Not separate for sexes _ 1 _ 1 _ Other offences against the Act (not including offences relating to out-worfcers) 3 4 _ _ _ Total 18 *22 _ 4 _ •This figure includes certain defects which were outstanding at the end of 1954. 36 Part VIII of the Act Outwork (Sections 110 and 111) Nature of Work Section 110 Section 111 No. of out- workers in August list required by Sect. 110(1)(c) No. of instances of work in unwholesome premises Wearing apparel: Making, etc. 271 - Cleaning and Washing 1 - Furniture and upholstery 3 - Artificial flowers 10 - Paper bags 2 - Making of boxes or other receptacles or parts thereof made wholly or partially of paper 16 Carding, etc. of buttons, etc. 65 Feather sorting 2 - Stuffed toys 41 - Cosaques, Christmas crackers, Christmas stockings, etc. 57 - Lampshades 12 - Brass and Brass articles 1 - Household linen 1 - Sacks Chocolates and Sweetmeats - - Total 482 - During 1955, 257 inspections of Outworkers premises were carried out by the Sanitary Inspectors. SHOPS ACT. 1950 Improvements under Section 38 of the Shops Act, 1950, relating to the health and comfort of shop workers were carried out in 40 instances: Ventilation improved 16 Heating improved 1 Sanitary accommodation improved 23 PREVENTION OF DAMAGE BY PESTS ACT, 1949 The following is a summary of the work carried out hy the Rodent Operatives acting under the supervision of the Chief Sanitary Inspector: Complaints 958 Premises inspected 1,130 Premises found to be infested with: 1. Rats 798 2. Mice 182 Re-visits to infested premises 3,435 Pees received for treatment at business premises £664.10.0d. 37 Rodent Control in Sewers In accordance with the requirements of the Ministry of Agriculture, Fisheries and Pood (Infestation Control Division), maintenance treatments of the soil sewers in the Borough were carried out during arch and September. A total of 1,206 sewer manholes were dealt with and of these 534 were found to be rat infested. Poison baits were used in the infested manholes. RAG FLOCK AND OTHER FILLING MATERIALS ACT, 1951 Seven premises are registered in the Borough, all of which were inspected during the year. PET ANIMALS ACT, 1951 During the year 2 licences were granted by the Council and 14 licences renewed after the premises had been inspec ted by the Sanitary Inspector. DISINFECTION Number of houses where disinfection was carried out 213 Number of houses disinfested of vermin 48 Number of articles disinfected by steam 107 Number of articles disinfected by formalin spray 427 Number of articles voluntarily destroyed 86 The arrangement made with the Hairmersmith 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 31 Damp proof courses inserted in walls 14 Dampness - other forms remedied 232 Drains - connected to sewer 1 Drains - cleared and cleansed 593 Drains reconstructed 73 Drains - repaired 246 Drains - new soil and ventilating pipes provided 15 Dustbins provided 145 Firegrates - repaired or renewed 86 Floors - sub-floor ventilation provided 19 Floors - repaired or renewed 96 38 Food cupboards ventilated 5 Rainwater eaves gutters, downpipes repaired 235 Refuse - accumulations removed 28 Roofs repaired 302 Sinks repaired or renewed 22 Sink waste pipes repaired or renewed 94 Staircases repaired 13 Walls and ceilings repaired or cleansed 427 Water supply reinstated 32 Water supply draw taps fixed to main supply 6 Water closets - repaired, reconstructed or improved 157 Windows and doors repaired 423 Yards paved or repaired 34 Other defects remedied or nuisances abated 301 SUMMARY OF WORK DONE AND IMPROVEMENTS CARRIED OUT AT FOOD PREMISES Walls and ceilings repaired and cleansed 153 Floors repaired 18 Lighting and ventilation improved 16 Washing facilities provided 9 Hot water provided 18 Sinks provided 13 Storage accommodation improved 20 Water supply provided 3 Water closets cleansed or repaired 23 Refrigeration installed or improved 28 Dustbins supplied 2 Accumulation of refuse cleared 1 Other defects remedied 56 39 SECTION 4. GENERAL MASSAGE AND SPECIAL TREATMENT ESTABLISHMENTS. No new licences were granted during the year and the number of registered establishments remained at 25. Pour persons were again granted exemption from registration by virtue of being members of the Chartered Society of Physiotherapists. NURSING HOMES. No changes took place with regard to Nursing Homes and there are eight registered homes which are inspected annually by the Deputy Medical Officer of Health. HEALTH EDUCATION, Various leaflets published by the Central Council for Health Education are distributed by means of leaflet display trays in the Town Hall Vestibule and in the Public Libraries. The official journal of the Central Council, Better Health, is distributed in the same way. MEALS ON WHEELS SERVICE The following report on the work of the Meals on Wheels Service has been supplied by Mrs, E.V. Bruce, the Divisional Director of the Ealing Area Division of the British Red Cross Society - This Service has been satisfactorily carried on during 1955, and hot meals have been supplied from Monday to Friday inclusive to the aged and infirm people living alone with no-one to care for them and to invalids and the bedridden. The same arrangement is made for the food to be pre pared and cooked at the Ealing Red Cross Headquarters, and there is a choice of meat or fish with two vegetables and milk or steamed pudding. The meals are a great boon and much appreciated by all who receive them. The number of meals delivered during 1955 was 13,710, an increase of 2,100 on the previous year. Although every effort is made to meet all urgent requests there is always a waiting list. Sometimes as many as 63 meals are delivered 40 each day, although the van capacity is only 48. The usual Christmas Dinners of roast turkey with vegetables and Christmas Pudding were given free to those on the list just before Christmas, The new mobile van has been a tremendous help and everyone is now assured of a hot meal." NATIONAL ASSISTANCE ACT, 1948, Section 47. This Section deals with securing the necessary care and attention for persons who (a) are suffering from grave chronic diseases or being aged, infirm or physically incapacitated are living in insanitary conditions, and (b) are unable to devote to themselves, and are not receiving from other persons, proper care and attention. Three such cases were dealt with. The first was a lady of 86 years concerning whom a number of complaints were received from the tenant of the house where she was living. These complaints were quite justified and the situation did not improve in spite of help from the Home Help, the Home Nursing and the Public Health Laundry Service. She was therefore admitted to the West Middlesex Hospital where she has since remained. The second case was an eccentric elderly lady, who collected large quantities of useless clothing, boxes, magazines, etc., and lived in a very dirty condition. Following a mental breakdown she was admitted to Springfield Hospital where she died. The other case was of a lady of 94 years, enfeebled physically and mentally whom it was necessary for her own safety to admit to Hospital. Upon this her son, aged 56, partially blind and mentally defective, voluntarily went into hospital as well. Section 50 - Burial of the Dead. Six burials were carried out during the year for which the Council accepted financial responsibility. In two instances the whole cost was recovered, in two the cost was partially recovered and the remaining two had to be written off as totally irrecoverable. 41 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 Sick ness Pay scheme of the National Joint Industrial Council for Local Authorities Non Trading Services. During the year the following examinations were carried out- Administrative, Technical and Clerical Staff 48 Sickness Pay Scheme (Servants) 73 Gunnersbury Park Joint Committee Employees 4 Total 125 42 SECTION 5 STATISTICAL TABLES SUMMARY OF STATISTICS. Area (in Acres) 8,783 Population (Census, 1951) 187,306 Population (estimated middle of 1955) 184,600 Rateable Value, 1955-56 £3,455,229 Net Product of a Penny Rate, 1955-56 £14,300 Live Births: - Legitimate Males, 1,096 Females, 1,082 Total 2,187 Illegitimate Males, 49 Females, 59 Total 108 Birth-Rate per 1,000 of Estimated Population 12.4 Still-Births: Males, 21 Females, 16 Total 37 Rate per 1,000 total Births (Live and Still-Births) 15,9 Deaths: Males, 953 Females, 923 Total 1,876 Death-Rate per 1,000 of Estimated Population 10. 2 Deaths of Infants under one year of age:- Legitimate Males, 31 Females, 17 Total 48 Illegitimate Males, 3 Females, 1 Total 4 Death-Rate of Infants under one year of age:- All Infants per 1,000 Live Births 22 Legitimate Infants per 1,000 Legitim ate Live Births 22 Illegitimate Infants per 1,000 Illegitimate Live Births 37 Deaths from Diseases and Accidents of Pregnancy and Childbirth; Prom Sepsis - 1 Death Rate per 1,000 Total Births 0.43 Prom other Causes None The number of cases of infectious disease notified in the Borough in the past twelve years is shown in the following table: 43 Cases of Infectious and Other Notifiable Diseases notified in the Borough Disease 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 Smallpox - - - - - - - - - - - - Diphtheria 17 14 29 11 13 16 3 2 - - 1 - Scarlet Fever 228 340 232 133 204 176 294 203 402 238 287 108 Enteric Fever (including Paratyphoid) - - - - 3 8 5 3 2 3 5 7 Puerperal Pyrexia 42 47 35 27 25 27 24 38 70 61 54 44 Pnemonia: Primary 142 110 114 127 189 163 173 162 100 157 152 135 Influenzal 9 14 16 3 6 10 6 38 28 74 52 56 Acute Poliomyelitis 2 3 4 46 10 34 42 10 21 13 5 61 Meningococcal Infection - 6 6 10 2 14 9 2 - - 6 3 Malaria - - - 1 2 - 4 1 1 3 1 1 Dysentery 24 60 10 5 7 23 24 542 179 132 225 149 Erysipelas 30 26 31 38 32 13 24 17 26 18 18 12 Tuberculosis: Pulmonary 173 194 275 204 206 205 209 210 211 205 132 119 Non-Pulmonary 30 23 33 25 27 32 41 24 29 20 17 24 Ophthalmia Neonatorum 3 3 3 5 - 5 3 6 - - 2 2 Measles 127 2,330 791 806 1,379 1,450 1,016 3,296 993 2,558 132 2,422 Whooping Cough 380 236 271 310 383 303 274 550 77 491 116 156 Food Poisoning - - - - - 21 23 86 26 31 78 36 Toals • 1,207 3,046 1,850 1,757 2,492 2,503 2,174 5,190 2,165 4,004 1,284 3,335 44 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 Disease Smallpox - Meningococcal Infection 3 Diphtheria - Malaria 1 Scarlet Fever 108 Dysentery 128 Enteric Fever (including Erysipelas 12 Paratyphoid) 7 Tuberculosis: Puerperal Pyrexia 44 Pulmonary 119 Pneumonia- Non-Pulmonary 24 Primary 135 Ophthalmia Neonatorum 2 Influen al 56 Measles 2,422 Acute Poliomyelitis 58 Whooping Cough 156 Food Poisoning 11 Total 3,286 45 Infectious and Other Notifiable Diseases Classified in Age Groups Scarlet Fever Whooping Cough Acute Poliomyelitis Measles Diphtheria Paralytic Non-Paralytic M P M F M P M P M F M F Numbers originally Notified 54 64 92 64 12 9 24 16 1,290 1,132 - - Numbers corrected: Under 1 year - - 5 4 2 - - - 30 32 - - 1-2 years 2 3 23 19 2 1 2 1 276 212 - - 3-4 years 14 10 24 16 - 2 2 - 322 299 - - 5-9 years 31 41 37 18 3 3 12 6 639 568 - - 10 - 14 years 4 7 2 4 1 2 2 13 13 - - 15 - 24 years 2 1 - - 2 1 2 4 8 3 - - 25 and over 1 2 1 2 1 2 3 2 2 5 - - Age unknown - - - - - - - - - - - - Totals 54 64 92 64 10 10 23 15 1,290 1,132 - - Acute Pneumonia Dysentery Smallpox Acute Encephalitis Enteric or Typhoid Fever Infective Post-Infectious M F M F M F M F M F M F Numbers originally Notified 100 91 73 76 - - - - - - - 1 Numbers corrected: Under 5 years 18 12 11 12 - - - - - - - - 5-14 years 16 13 22 18 - - - - - - - - 15 - 44 years 28 23 18 30 - - - - - - - 1 45 - 64 years 22 22 8 5 - - - - - - - - 65 and over 16 21 2 2 - - - - - - - - Totals 100 91 61 67 - - - - - - - 1 46  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 6 6 2 1 20 16 M F M F Numbers corrected: Malaria Under 5 years 1 1 - _ 1 _ 3 _ l - 1 - 5-14 years 15 - 44 years - 3 1 2 4 1 1 1 2 1 3 Ophth, Neonatorum 45 - 64 years - - 3 1 - - 1 - 2 | - | 2 | - 65 and over - - 1 1 - - - - Puerperal Pyrexia Totals 1 5 6 6 2 1 7 4 15 - 20 years 3 20 - 35 years 38 Tuberculosis 35 - 45 years 3 Respiratory Meninges C.N.S. Other M F M F M F Numbers originally notified: Total (all ages) 68 51 1 - 9 14 Final numbers after correction Under 5 years 1 - - - 1 - 5 - 14 years 1 1 1 - 1 4 15 - 24 years 16 14 - - 2 3 25 - 44 years 21 26 - - 2 4 45 - 64 years 23 7 - - 1 2 65 and over 6 3 - - 2 1 Age unknown - - - - - - Total (all ages) 68 51 1 - 9 14 47 DEATHS Causes of Deaths, 1955 Cause of Death Deaths, 1955 Total Deaths 1954 Male Female Total Tuberculosis, Respiratory 14 3 17 19 Tuberculosis, Other 3 - 3 1 Syphilitic Disease 3 - 3 5 Diphtheria - - - - Whooping Cough - - - - Meningococcal Infections - - - - Acute Poliomyelitis 1 - 1 2 Measles - - - - Other Infective and Parasitic Diseases - 1 1 2 Malignant Neoplasm, Stonach 26 30 56 46 " Lung, Bronchus 67 19 86 85 " " Breast 43 43 44 " " Uterus - 12 12 9 Other Malignant Lymphatic Neoplasms 88 84 172 201 Leukaemia, Aleukaemia 7 6 13 14 Diabetes 5 13 18 13 Vascular Lesions of Nervous System 103 154 257 225 Coronary Disease. Angina 178 99 277 300 Hypertension with Heart Disease 24 28 52 35 Other Heart Disease 105 144 249 238 Other Circulatory Disease 38 45 83 69 Influenza 2 4 6 1 Pneumonia 38 41 79 54 Bronchitis 73 42 115 106 Other Diseases of Respiratory System 11 8 19 14 Ulcer of Stomach and Duodenum 20 8 28 18 Gastritis Enteritis and Diarrhoea 5 4 9 5 Nephritis and Nephrosis 7 7 14 11 Hyperplasia of Prostate 10 - 10 10 Pregnancy Childbirth,Abortion - 1 1 - Congenital Malformations 8 11 19 12 Other Defined and Ill-Defined Diseases 68 90 158 118 Motor Vehicle Accidents 15 6 21 24 All other Accidents 17 13 30 38 Suicide 15 7 22 30 Homicides and Operations of War 2 - 2 2 Totals 953 93 1,876 1,751 48 SECTION 6. SCHOOL HEALTH SERVICE. The health of the school child can probably best be shown in the classification of the general condition of children at the routine medical inspections. In 1955 there was a further decline in the number classified as in poor condition. In 1953 57 children were placed in this category, 44 children in 1954 and only 16 in the year under review. One case of Pulmonary Tuberculosis in a school child necessitated investigation. All class contacts were mass X-rayed and no other case was discovered. These precautions are taken to ensure that there is no source of infection in school. Ten children contracted Paralytic Poliomyelitis in 1955. There were no deaths among school children from this disease. It has been possible in 1955 to place nearly all children requiring special education. The young educationally sub normal pupil presents a difficulty in this respect. The mental age of the child is the deciding factor of admission and according to the degree of backwardness the child may reach a chronological age of anything up to ten years before he reaches a mental age of five years. MINOR AILMENT CLINICS These clinics continue to deal with large numbers of children with minor disorders and provide a means for a more detailed study of any defects noticed at routine inspections. Attendances at Minor Ailment Clinics 1953 1954 1955 4,948 6,746 6,087 ROUTINE MEDICAL INSPECTIONS Three routine inspections are carried out during the child's school life, during their first year at school, during their last year at primary school and prior to leaving school. Numbers Examined First age group 2,552 Second age group 2,665 Third age group 1,604 Total 6,821 49 Classification of General Condition 'A' Good 2,708 'B' Pair 4,097 V Poor 16 Total 6,821 Defects requiring Treatment found at Routine Medical Inspection 1952 1953 1954 1955 Skin Diseases 600 540 581 559 Defective Vision 368 290 366 444 Squint 31 43 43 37 Defects of Hearing 73 93 116 68 Middle Ear Diseases 26 18 27 32 Nose and Throat Diseases 339 377 382 242 Speech Defects 29 37 44 34 Enlarged Glands 6 5 7 6 Heart - Circulation conditions 6 7 20 14 Lung Diseases 107 84 93 79 Hernia 4 7 9 2 Postural Defects 40 18 38 24 Flat Foot 60 42 110 97 Epilepsy 1 1 2 3 ASTHMA CLINIC The Asthma Clinic has continued to treat both the asthmatic children and those with recurrent bronchitis with success. V'e have undertaken work from many of the Hospitals in Central London, thus curtailing long bus and underground journeys. This is of great benefit to these delicate child ren since the fatigue of travelling often lessens the value of the treatment given. We have continued to keep the educational needs of the children in view. As far as possible those with approaching examinations have been treated after school. Total attendances 1,940. SCHOOL DENTAL SERVICE The general lack of dental surgeons arid the uncertainty as to the future of the school dental service as a result of the proposed introduction of dental auxiliary workers, are the factors that have influenced the School Service greatly during 1955. In Ealing we have had two. resignations of full-time dental officers, one to be married and one to go into private practice. Neither of these has been replaced by a full-time officer. The average age of our full-time dental officers is 47. We have had a number of applications from newly qualified dental surgeons 50 who require a post either full or part-time for a short period (even as little as a month) but such coming and going does not make for an efficient, personal service. Prom the above facts it will be appreciated that the problem is the attraction of younger members of the profession into the service on full-time permanent engagements. By some redisposition of the allocation of schools to particular clinics we have succeeded in catching up much of the arrears of inspection and treatment. A considerable number of parents seek private treatment for their children and this does enable us to provide, with rather less delay, treatment for those who wish to attend the clincis. The school inspections serve the very important purpose of drawing all parents attention to the need for treatment, though subsequently they may prefer to make their own arrangements. School inspections are arranged so that there shall be a minimum delay between inspection and treatment. The ratio of permanent teeth extracted to permanent fillings has improved significantly. In 1954 the figures of 1 extraction to 12 6 fillings, and in 1955. 1 extraction to 14 3 fillings. This is the best figure we have recorded. Though a slightly smaller number of temporary fillings were carried out in 1955* the ratio of temporary extractions to temporary fillings has again improved and is now 1,4 to 1. Due to staff changes fewer evenings were worked during 1955 but as far as output is concerned the scheme continues to be a success. The orthodontic service continues to be a well used and popular service, but the end of the year found us with a rather larger waiting list than hitherto as our two part-time orthodontists had unavoidably reduced their number of weekly attendances. This will be only a temporary setback and we will return to normal working early in 1956. 1955 has been a year of change and uncertainty for the school dental service and it is impossible to forecast the future. It will be a great pity if lack of recruits to the ranks of school dental surgeons should cause any loss of ground we have regained in the last 3 years. 51 Attendances Treatment completed Fillings Permanent Teeth Fillings Temporary Teeth Extractions Permanent Teeth Extractions Temporary Teeth Anaes thetics Orthodontic treatment New Cases[/$$$] Gas Local 17202 6017 10730 3793 844 5206 2409 4303 360 EAR, NOSE AND THROAT SERVICE Mr. Arthur Miller, Consulting Otologist, reports:- Children suffering from mouth breathing, sore throats, nasal, Eustachian and middle ear catarrh, which is often associated with deafness, also children who have not passed the gramophone and pure tone audiometry test, are referred to see me by the Medical Officers. i The cause of the trouble was often found to be due to enlarged adenoids and turbinates, sinusitis and infected tonsils. It has been very helpful to get an X ray confirmation of the sinus infection from King Edward memorial Hospital and great use has been made of the facilities provided. The treatment administered was diastolisation, politz eration and Eustachian catherisation as well as breathing exercises. In cases where sinusitis was confirmed, Proetz displacement treatment was practised. 1954 1955 Number of new cases 198 193 Number of Re-inspections 369 301 Total attendances 667 494 Number treatment advised 364 227 Number operation advised 160 106 Audiometry Report Number of schools visited 16 Number of children examined 6 700 Number of children with hearing loss 103 Number of pure tone tests 123 Number referred to E.N,T. Specialist 71 FOOT HEALTH A specially trained nurse has again inspected 8,972 children's feet in 30 schools this year, of whom 205, together with children under five referred from the Welfare 52 Centres, were seen by the Assistant Medical Officer in charge of Foot Health. The need for a well shaped, well fitting shoe which is checked for size every three to four months at a shoe shop, is stressed, and the wearing of "Casuals" i£ discoui'iged. A Verruca Survey was carried out during the year, and children so infected were asked to complete a questionnaire. Of a total 8,972 children seen, 144 had verrucae, an overall incidence of 1.6%, as compared with 0,9% in 1954. Analysis of the results showed that there was a steady increase of verrucae with age, cases rarely occurring in the infant schools, and that girls are more affected than boys. This is in accordance with the few other surveys that have been published. To determine the mode of spread of the virus infection has proved more difficult; 67% of the children attended the local swimming bath, and the data concerning the frequency of washing feet, the changing of socks, and sharing of shoes etc. was inconclusive. A further survey is being prepared which it is hoped will throw more light on the subject. In the meantime an attempt has been made to reduce this high incidence of verrucae by instituting a regular foot inspection every term in all the junior and senior grade schools. This is usually carried out at the time of the head inspection and is done by the Health Visitors and School Nurses. A surprising number of verruca have been found, most of them completely unsuspected by the children concerned. Of 18,079 children inspected in one term 334 were found to have verrucae. Treatment has been given at the Minor Ailment Clinics and by the Chiropodist. The method used is successful though time consuming, and because of this an approach was made to the Regional Hospital Board for a weekly treatment session at a local hospital. This was refused, however, on the grounds that hospital outpatient Departments are already overcrowded. 53 Males Fetiales Under 11 Over 11 Males under 11 Fenales jnder 11 Wales over 11 Fetales over 11 Schools Visited 30 Total children examined 8972 4009 4963 4664 4308 2321 2333 1678 2630 Incidence of Verruca 144 46 98 28 116 12 16 34 82 Percentage 1.6 1. 1 2. .5 2.7 .5 .7 2. 3. 1 Incidence of Tinea 61 44 17 8 53 6 2 38 15 Percentage .6 1. .3 . 1 1.2 .3 .01 2.2 .5 HANDICAPPED CHILDREN The following table sets out in their various categories the number of handicapped pupils as at 31st December, 1955. In Special Schools Day In Special Schools Residential In Maintained Primary an^ Secondary Schools Total Blind _ 3 - 3 Partially Sighted 5 2 1 8 Deaf 5 9 - 14 Partially Deaf 10 10 - 20 Educationally Sub-Normal 20 19 39 Epileptic - 1 - 1 Maladjusted - 30 23 53 Physically Handicapped 15 9 5 29 Speech Defects .. - 1 3 4 Delicate 3 19 96 118 Multiple Defects - - 1 1 Totals 58 103 129 290 OPHTHALMIC SERVICE Mr. Freeman, Heal, Consultant Ophthalmologist, reports:- The total number of cases seen was 1,606 (1954 - 1,545) of which 537 (1954- 464) were new cases, and 1,069 (1954 1,081) were re-inspections. The total attendances were 1,606 (1954 - 1,545). The number of pairs of glasses prescribed was 1,015 (1954 - 916). 54 Abnormal Eye Conditions other than Errors of Refraction were as follows:- Congenital Abnormalities New Cases Old Cases Squint 77 229 59 of these Squint cases were under 5 years of age. Congenital Nystagmus 3 8 Congenital obstruction nasal duct 1 1 Progressive or Malignant Myopia 1 3 Ptosis 2 Dermoid cyst in region of orbit - 1 Melanoma of choroid - 1 Congenital scarring of cornea 1 Congenital detachment of retina 1 Congenitally defective vision without obvious cause - 1 Abnormalities due to Infection Blepharitis 1 6 Conjunctivitis 4 Styes 3 Corneal Nebulae - 4 Meibomian Cyst 1 Uveitis - Eye blinded from - 1 Phthisis Bulbi - 1 Choroiditis - ? Toxoplasmosis - 1 Abnormalities due to Trauma Corneal scarring - 1 Birth trauma - defective mobility of globe - 1 Abnormalities of unknown Etiology Optic atrophy 1 Number of children sent for squint training 4 ORTHOPAEDIC CLINIC Mr. J, A. Cholmeley, the Orthopaedic Consultant, reports:- There is nothing of special note to report on the work of the Orthopaedic Clinics during the past year. There has been some fall in the number of school and pre-school children referred during 1955. Shoe and foot inspections carried out in the schools by one of the school nursing staff are valuable as is the advice given to parents with regard to shoe fitting. The Chiropodist is also a valuable member of the orthopaedic team and the work of these two reduces the number of cases of school children which need referring to the Orthopaedic Clinics. Fortunately, in the summer of 1954, there were very few cases of poliomyelitis in the Borough but there have been more during the past summer and some of these are now being referred to the Orthopaedic Clinics for treatment. The treatment of these poliomyelitis cases is both time consuming and prolonged and will certainly be reflected 55 in the number of physiotherapy treatments given in the forthcoming year. 1954 1955 Number of new cases 164 125 Number of re-inspections 422 383 Total attendances 586 508 Number of children referred for physiotherapy 163 167 Number of attendances 2,970 2,930 SPEECH THERAPY During 1955 the number of children with speech disorders requiring treatment was 266, representing 1.1% of the school population. The types of defect encountered are: - (1) Dyslalia - Mixing or missing out of consonants. (2) Aphasia Absence of speech. (3) Dysarthria Defects due to disorders of the articulatory muscles or soft palate, (4) Stammering. Treatment varies according to the type of defect, but may involve exercises, play therapy, the teaching of imita tion, correction of any causative defect, and advice to parents on management of children with defects. The activities of the Speech Therapists include (1) Seventeen clinic sessions where each child receives the benefit of individual attention. (2) Three playgroups in which up to eight 3 5 year olds receive play therapy, (3) School visits which have proved invaluable for group tuition, consultation with Head Teachers and screening of children with a view to speech therapy. (4) The speech class which enables help to be given to children with the most severe defects is limited to ten in number in charge of a specially quali fied teacher, and is visited thrice weekly by the Senior Speech Therapist. Progress of these child ren, both in education and speech, has continued to justify this as a most valuable part of the Borough's Speech Therapy Organisation. All children having speech therapy are medically examined at least twice yearly and close liaison between 56 Speech Therapists and the Assistant Medical Officer in charge has been maintained. Regular conferences are held to decide the programme of treatment of each child and to initiate further investigations or specialist advice. 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 358 (2) Number of instances in which the state of health was found to be such that certificates were with held 1 (3) Number of children examined as to fitness to take part in entertainments 19 (4) Number of cases in which certificates to take part in entertainments were withheld EDUCATION ACTa 1944 Sections 57(3), 57(4) and 57(5) Cases dealt with under Section 57, Education Act, 1944 Sub-Section 3 10 Sub-Section 4 Sub-Sect ion 5 7 Cases de-notified under Section 8, Education (Miscellaneous Provisions) Act, 1948 MEDICAL EXAMINATION OF TEACHERS Number of Teachers examined as to fitness for appointments 28 INFESTATION WITH VERMIN There has been a further welcome decline in the number of children infested with vermin and it is hoped that with continued parental co-operation this decline will continue. The total number of examinations made was 55,244 and 146 children were found to be infested. 57 SUPPLEMENT Items of interest concerning the Health Service adminis° tered by the Middlesex County Council as Local Health Authority HOME NURSING SERVICE Home Nursing is a difficult subject to review in a series of statistical tables. Nursing is a professional service of a purely personal character which cannot readily be reduced to a formula of figures. Nevertheless, it is essential to have available all the information that can be obtained. The only way to administer a steadily expanding service, such as Home Nursing, is to study all the relevant, and even the seemingly irrelevant, available facts. The first consideration in preparing such statistics is to decide whether "cases" or "visits'5 shall be the standard by which to make comparisons. The difficulty with regard to 'cases" is that there are such wide differences between individual cases. One case", perhaps of diabetes or of disseminated sclerosis, may need a daily visit for several years. Another case" may need one visit only despite the fact that he is suffering from one of the conditions just mentioned. In 1955, one patient had as many as 587 visits during that year alone and this emphas izes the difficulty of making realistic comparisons on the basis of numbers of cases suffering from particular conditions. Statistics based upon visits" would seem to offer a more reliable basis for making comparisons. A "visit", however, may be for the purpose of simply giving an injec tion, taking a bare ten minutes, or the "visit" may be made to give general nursing care to a very ill person, taking best part of an hour and even requiring the presence of two nurses. All these factors need to be borne in mind, therefore, when considering the statistics now presented regarding Home Nursing within the Ealing portion of Area 7 during the three years, 1953, 1954 and 1955. Perhaps their greatest value lies in the general impression they give of the trend in the nursing services provided for a population of about 185,000. Table A gives a general summary of the work during the three years. This Table shows that the number of new 58 cases referred for home nursing fell from 4,747 to 3,763 and then to 3,595. Despite this fall in cases, the total visits in each of the three years has remained almost identical, 87,076, 87.159 and 87,613. A reason for this decline in the number of new cases is easy to find. There has been a very great reduction in the number of cases to which a nurse is called to give injections of penicillin. This is clearly shown by the following figures.- 1953 1954 1955 Penicillin Cases 2,529 1,724 1.528 All other Cases 2,218 2,041 2,067 Whether the reduction in the number of cases for which penicillin is prescribed is due to there having been a lessened incidence of the conditions concerned, or whether it is due to medical practitioners adopting new forms of treatment which do not require the attendance of a nurse, is not known. The statistics can only show the work which is performed. It is known, however, that it is now possible to give penicillin orally. Whether there will be a wide spread use of penicillin given orally cannot be foreseen. A complete change over from injections to oral administra tion of penicillin might reduce by 50% the cases referred to the nurses, but there would not be a corresponding reduction in their work. In Table C are given details of the total visits made to give the various forms of treat ment. It shows that the total visits to give penicillin injections amounted to only 9,950 or 11 4 per cent, of all visits. In addition these visits are among those taking up the least amount of time per visit. Table Bgives the sex, age grouping and form of treatment given to the 3,595 new cases in 1955. Table C gives for each of the three years 1953 to 1955 the numbers of new cases of the various conditions treated and the various forms of treatment provided. In addition, Table C gives details of the cases remaining on the register at the end of 1955 which provides a general picture of the numbers of the various conditions under treatment at any particular time, and finally shows the total visits made during that year. Table C reveals great reductions in the numbers of cases coming under certain headings, examples being as fol lows: - 59 Bronchitis Diseases of Ear Pneumonia Tuberculosis 1953 730 290 263 175 1954 412 130 180 126 1955 429 109 132 90 The first three of these conditions are among those for which injections of penicillin figure as the main form of treatment. Tuberculosis, however, does not come within the same category and, as this is a notifiable disease, some further research has been made to ascertain the cause of the reduction. Notifications of tuberculosis have shown a reduction, but not to the same extent as the number of cases referred for Home Nursing. Notifications in 1953 were 225, in 1954 they were 149 and in 1955 they were 142. The reduction in the number of cases requiring home treatment can be accounted for partly by the reduc tion in notified cases, partly hy the recent introduction of specific drugs, P.A. S, and Izoniazid which can be taken by mouth and which are to some extend replacing strepto mycin which needs to be given by injection, and partly to the fact that patients are now able to be admitted to hospital almost at once and require no pre-hospital treat ment. The major portion of the nurses' time is spent among old people. This is shown, conclusively, by the following figures: - In Table C is shown the nature of the 754 cases remain ing on the books at 31st December, 1955. Of this total, as many as 507, or 67 2% were 65 years of age or over. Most of the visits to give general nursing care are made to these elderly patients and these visits necessarily take longer than visits for injections, a factor which emphasizes the contention that the care of the aged at home has become the home nurses' main function. The Home Nursing Service may, in fact, be regarded as serving two main functions. The first is to relieve the demand for the accommodation of old people in hospital by nursing many such cases in their own homes. The second is 1953 1954 1955 Number of new cases 65 years and over % of total new cases 1,588 1,375 1,396 33 4 36.6 38.8 Total visits to cases 65 years and over % of total visits 48,553 51.486 53,361 55, 8 59.1 61 0 60 by the home nurses complementing the local medical practitioner service by carrying out nursing services at home under the direction of the family doctor. Other lesser functions which the nurses perform are (1) providing home treatment for cases of tuberculosis and (2) dealing with cases referred by hospitals some in preparation for X ray investigations and others for the purpose of continuing post operative or other specific care. The provision of hospital accommodation is certainly far more expensive to the State than the provision of facilities to provide nursing care at home, A recent re port on hospital accorrmodation showed the cost per patient to range between £16 and £19 per week. The latest costing return regarding the Home Nursing Service in Area 7, shows the average cost per visit to be 4s. Od. A daily visit by a nurse would, on this basis, cost £1. 8s. Od. per week. Added to this might be the cost of providing a home help, also through the County Health Service, for, say, 15 hours during the week. The Home Help Service costs 3s. 6d, per hour, so this would add £2. 12s. 6d. per week to the cost of the nurse, a total of £4, 0s. 6d. Medicines or dressings, whether prescribed for use at home or in hospital, pre sumably cost much the same - the chemists' charge on the one hand will be balanced by the hospital dispensary costs on the other. These figures regarding the cost of the respective services are not included with a view to criticising one service as against the other. They are intended to show that the Home Nursing Service is performing a most valuable service for the community at a relatively small cost. When the compilation of special statistics regarding Home Nursing was commenced some years ago, the intention was that they should be of a purely experimental nature. Each year some different aspect of the work has been investigated. This year special attention has been directed to answering the question "Who makes use of the Home Nursing Service?" Table A shows that 83.1% of the total cases were referred by medical practitioners, 14.6% by hospitals and 2.3% came from other sources. Further research has been made to show whether the medical practitioners make a uniform demand on the service, or whether there is any noteworthy feature to be derived fil from a knowledge of the numbers and types of cases referred by individual doctors. The numbers of new cases referred during 1955 by the medical practitioners resident in the Borough of Ealing are shown in Table D. Five doctors each referred over 100 cases, the greatest number by any one doctor being 301. Five doctors referred no cases at all, although this may have been due to their having a private residence in Ealing but practising mainly from a surgery outside the district. Table D also shows the treatments required by the cases referred by the seventeen doctors who referred over 50 cases in the year. It is difficult to compare the numbers of cases referred by individual doctors as the potential use that each may make of the Home Nursing Service is probably determined by the size of his practice - particularly his National Health Service panel - information which is not available. One fact, however, which is clearly revealed is that the position which many of the doctors hold in the list depends entirely on the number of cases referred for penicillin injections. Conclusions^ The conclusions arrived at may be briefly summarized as follows. In the three years 1953 to 1955 there has been a reduction in the total cases referred for home nursing due to fewer cases requiring injections of penicillin. The total visits made by the nurses has, however, remained unchanged owing to there being a higher percentage of cases in the age group 65 years and over, which tend to require attention over long periods. The cost of providing a Home Nurse and a Home Help for a typical patient is estimated at £4 per week, compared with a cost of £16 to £19 per week for accommodation in hospital. There are great disparities in the use made of the service by individual medical practitioners, dependent mainly on the propensity of certain doctors to prescribe penicillin by injection. 62 A HOME NURSING STATISTICS •> SUMMARY 1953 Number % 1954 Number % 1955 Number % TOTAL VISITS 87,076 87,159 87,613 NEW CASES March Quarter 1,745 36. 8 1,230 32.7 1,209 33.6 June Quarter 1,059 22.3 828 22.0 794 22.1 September Quarter 814 17. 1 744 19.7 694 19.3 December Quarter 1, 129 23.8 961 25.6 898 25.0 Total 4,747 100.0 3,763 100.0 3,595 100.0 Cases brought forward from previous year 522 649 686 Total cases dealt with 5, 269 4, 412 4,281 Cases having 25 or more visits in the year 653 830 833 AGE GROUPING (New Cases) 0 - 4 340 7.2 161 4.3 131 3.7 5-15 564 11.9 295 7.8 248 6.9 16 - 64 2,255 47.5 1,932 51.3 1,820 50.6 65+ 1, 588 33.4 1,375 36.6 1,396 38.8 Total 4,747 100.0 3,763 100.0 3,595 100.0 NATURE OP TREATMENT REQUIRED (New Cases) General Care 519 10.9 514 13.7 463 12.9 Dressings 227 4.6 224 6.0 249 6.9 Blanket Baths 69 1.4 73 1.9 73 2.0 Enemas 387 8.2 403 10.7 441 12.3 Penicillin Injections 2,529 53.3 1,724 45.8 1,528 42.5 Other Injections 724 15.2 694 18.4 670 18.6 Other Treatments 292 6.2 131 3.5 171 4.8 Total 4,747 100.0 3,763 100.0 3,595 100.0 CASES REFERRED BY Medical Practitioners Not available Not available 2,986 83. 1 Hospitals 525 14.6 Other Sources 84 2.3 Total 3. 595 100.0 63 B NEW CASES Condition Total Cases 1955 Sex Age Grouping Treatment Given A General Nursm g P Injections - Streptomycin B Dressing C Blanket Bath G Injections - Diuretics M F 0/4 5/15 16/64 65 + D Enema H Injections - Insulin E Injections - I Other Injections Penicillin J Other Treatments A B C D E F G H I J Tuberculosis 90 52 38 . . 83 7 1 3 . _ 4 80 . _ _ 2 Infectious Diseases 49 28 21 2 8 24 15 1 2 - - 25 - - - 19 2 Threadworms 7 3 4 1 4 2 - - - - 7 - - - - - - New Growths 101 42 59 - - 51 50 57 13 2 6 2 1 1 - 16 3 Diabetes 50 8 42 - - 21 29 - - - - - - - 50 - - Diseases of Blood 69 17 52 - - 23 46 3 - - - - - . - 66 - Vascular lesions affecting Central Nervous System 86 25 61 m _ 13 73 76 _ 9 _ 1 _ . _ _ . Other Mental and Nervous Diseases 45 11 34 m 30 15 15 3 _ _ _ _ _ 27 Diseases of Ear 109 59 50 21 46 39 3 - 1 - - 107 - - - - 1 Diseases of Circulatory System 406 160 246 - 1 132 273 64 8 5 - 13 2 303 - 9 2 Diseases of Veins 21 8 13 - - 7 14 - 18 - - 2 - - - 1 - Upper Respiratory Infections 253 108 145 12 45 192 4 - - - - 251 2 - - - - Influenza 51 23 28 5 9 34 3 3 - - - 48 - - - - - Pneumonia - all forms 132 61 71 4 12 72 44 16 - - - 115 - - - 1 - Bronchitis 429 199 230 24 20 198 187 39 - 1 - 386 1 2 - - - Pleurisy 46 21 25 - - 34 12 3 - - - 41 - - - - 2 Other Diseases of Respiratory System 80 44 36 4 5 51 20 2 . . _ 67 4 1 _ 5 1 Diseases of Digestive System 58 21 37 5 7 28 18 10 - - 6 35 6 - - 1 - Constipation 276 103 173 13 21 120 122 1 - - 275 - - - - - - Diseases of Genito-urinary System 71 16 55 2 5 49 15 5 1 - - 34 3 - - 4 24 64 Prolapse of Uterus 78 78 _ _ 33 45 _ _ _ 2 _ _ _ _ 76[/$$$] Infections of Skin and Subcutaneous Tissue 340 134 206 6 29 237 68 4 46 277 2 1 7 3 Other Diseases of Skin 4 1 3 - - 1 3 - 3 - _ _ - . 1 - Diseases of Muscles, Bones and Joints 85 19 66 35 50 24 2 18 6 1 30 4 Senility 133 44 89 - - - 133 103 1 25 - - - - - 3 1 Injury 57 20 37 1 8 18 30 15 25 7 - 6 1 - - 1 2 Preparation for X-ray 124 56 68 1 1 85 37 - - - 124 - - - - •T - Post-operative Care 174 79 95 6 2 99 67 11 119 1 14 5 - - - 5 19 Others 119 39 80 24 25 57 13 7 2 2 8 67 2 1 - 4 26 Diseases associated with pregnancy 52 - 52 - - 52 - 3 5 - 1 34 1 - - 5 3 Totals 3595 1401 2194 131 248 1820 1396 463 249 73 441 1528 105 309 51 205 171 65 c Conditions Treated New Cases Cases on Register 31st Dec. 1955 Cases Visited in 1955 1953 1954 1955 Total Cases Total Visits Tuberculosis 175 126 90 33 115 4447 Infectious Diseases 61 42 49 3 52 424 Threadworms 36 11 7 - 8 15 New Growths 132 135 101 12 115 3220 Diabetes 87 59 50 37 93 12280 Diseases of Blood 63 50 69 67 126 3249 Vascular lesions affecting Central Nervous System 111 130 86 37 126 5583 Other Mental and Nervous Diseases 44 32 45 17 53 2202 Diseases of Ear 290 130 109 - 111 507 Diseases of Circulatory System 372 408 406 228 615 21198 Diseases of Veins 61 68 21 11 27 861 Upper Respiratory Infections 326 277 253 7 261 1403 Influenza 74 33 51 4 51 301 Pneumonia - all forms 263 180 132 1 141 1275 Bronchitis 730 412 429 23 447 4350 Pleurisy 60 42 46 - 47 328 Other Diseases of Respiratory System 50 75 80 6 86 1045 Diseases of Digestive System 74 48 58 4 65 659 Constipation 228 233 276 6 283 1142 Diseases of Genito-urinary System 144 77 71 4 76 925 Prolapse of Uterus 109 42 78 82 117 434 Infections of Skin and Subcutaneous Tissue 460 402 340 18 361 4134 Other Diseases of Skin 20 9 4 2 9 201 Diseases of Muscles, Bones and joints 85 96 85 48 129 4332 Senility 152 159 133 60 200 5552 Injury 81 64 57 11 71 1689 Preparation for X-ray 110 122 123 - 123 145 Post-Operative Care 102 125 175 25 191 3892 Others 201 112 119 6 128 1404 Diseases associated with pregnancy 46 64 52 2 54 416 Totals 4747 3763 3595 754 4281 87613 Treatment Required A General Nursing 519 514 463 143 608 21110 B Dressing 227 224 249 47 292 8232 C Blanket Bath 69 73 73 65 138 3746 0 Enema 387 403 441 8 447 1422 E Injections - Penicillin 2529 1724 1528 32 1568 9950 F Injections - Streptomycin 167 120 105 32 133 4145 G Injections - Diuretics 263 323 309 206 460 17952 H Injections - Insulin 80 58 51 37 115 12280 I Other Injections 194 187 205 92 298 6882 J Other Treatments 292 131 171 92 222 1894 Totals 4747 3763 3595 754 4281 87613 66 D Use made of Service by individual Medical Practitioners resident in Ealing No. of Cases referred in 1955 No, of Doctors Over 100 5 76 - 100 3 51-75 9 26 - 50 13 11 - 25 30 1-10 - 23 0 5 88 Details of Cases referred by Doctors giving more than 50 Cases in Year Doctor Total Cases in 1955 Treatment Given A General Nursing P InjectionsStreptomycin B Dressing C Blanket Bath G Injections -• Diuretics D Enema H Injections -• insulin E Injections Penicillin 1 Other Injections J Other Treatments A B c D E P G H I J 1 301 12 5 - 8 250 4 8 1 9 4 2 132 10 5 - 23 59 5 10 - 5 15 3 128 4 4 1 5 105 1 3 1 4 - 4 126 10 2 2 5 83 3 16 - - 5 5 108 13 3 2 5 70 - 3 1 11 - 6 96 14 8 - 10 28 - 3 1 27 5 7 92 4 2 1 1 73 5 3 - 1 2 8 83 1 - - 1 76 1 2 - 2 - 9 72 9 3 1 6 44 1 4 - 2 2 10 72 13 2 1 11 32 3 5 - - 5 11 71 10 2 3 7 36 - 9 - 3 1 12 70 12 2 3 5 28 1 17 - 2 - 13 59 5 1 2 11 29 2 7 1 1 - 14 57 5 3 1 4 30 - 3 1 7 3 15 56 2 - - 2 52 - - - - - 16 54 5 6 - 9 29 1 2 - 1 1 17 51 7 1 1 13 11 1 5 3 9 - 67 HOME HELP SERVICE A summary of cases which received help during the year 1955 is given below:- Type of Case Under 60 years of age Over 60 years of age Total Confinement 144 . 144 Ante-Natal 18 - 18 Post-Natal 37 - 37 Tuberculosis 70 8 78 Senility - 34 34 Acute Sick 179 56 235 Chronic sick 49 724 773 Accidents 6 4 10 Others 11 1 12 Totals 514 827 1,341 Included in the above figures are 761 new cases which were received during the year. An additional 212 cases applied for help and were visited but cancelled. FOB 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. Baling and Acton forming Area No. 7- In Haling the local adminis tration 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 Abbey Parade, North Circular Road, Ealing. Brentside, Westcott Crescent, Hanwell, W.7. Cherington House, Cherington Road, Hanwell, W.7. Greenford Green, Wadham Gardens, Greenford. Islips Manor, Eastcote Lane, Northolt. Laurel House, Windmill Road, Ealing. Mattock Lane, 13 Mattock Lane, Ealing, W. 5. Times mornings, Tues. Fri. mornings. Tues. Wed. mornings. Tues. Fri. mornings. Mon. Wed. mornings. Thurs. mornings. Wed. Thurs. Fri. mornings. 68 Perivale, Horsenden Lane, Greenford Wed. mornings Ravenor Park, Oldfield Lane, Mon Thurs- mornings Greenford, Child Welfare Clinics Abbey Parade, North Circular Road, Tues Fri 2 - 4 p m. Ealing, Brentside, Westcott Crescent, Thurs 2 4pm. Hanwell, W. 7. Cherington House, Cherington Road, Mon Tues Thurs. Hanwell, W. 7. 2-4 p.m. Greenford Green, Wadham Gardens, Tues. Wed. Fri. Greenford. 2 - 4 p m, Islips Manor, Eastcote Lane, Mon. Thurs 2-4 p.m Northolt, Northolt Grange Community Centre, Tues 2 - 4 p m Northolt 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, Mon. Tues. Wed. Fri. Greenford. 2 - 4 p.m. DOMICILIARY MIDWIFERY SERVICE An expectant mother can obtain the services of a "general practitioner obstetrician" for her confinement in her own home. As an alternative she can obtain the services of a County Council midwife who will attend her in the home either as a midwife, delivering the child herself, or as a maternity nurse when the mother is arranging for her doctor to attend the confinement. If the services of one of these midwives is needed, application should be made through the Maternity and Child Welfare Clinic. HOME NURSING SERVICE Free Nursing Service in the home to cover all types of sickness is now available for every one 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 69 ness, aged people in need of help, cases of tuberculosis and sickness in the home where there are very young child ren. Applicants needing Domestic Help should apply to the Area Health Office. Town Hall, Haling. A charge is made for this service, although this is reduced in cases of hardship. DAY NURSERIES There are two 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.