HES 55 1905. ANNUAL REPORT ON THE Health and Sanitary Condition OF THE District of Heston and Isleworth, FOR THE YEAR 1905, BY EDWARD J. STEEGMANN, MB., D.P.H. Medical Officer of Health AND Physician in Charge, Dockwell Hospital. The Health Committee of the Heston and Isleworth Urban District Council, for the year ending April 30th, 1906. Dr. G. A. Gordon, (Chairman). Mr. J. J. Bonnett, ,, C. Crush, ,, R. L. Devonshire, ,, E. W. Goode, ,, W. Mann, ,, P. Mecklenberg, ,, W. G. Palmer, ,, H. C. Sahler, „ C. Robinson (Chairman of Council), ex-officio. To the Chairman and Members of the Heston and Isleworth Urban District Council. Gentlemen, I have the honour to submit to you the following Report on the health and sanitary condition of your district for the year 1905. It is the fifth Annual Report for which I have been responsible as your Medical Officer of Health. The Health Department has been very fully occupied during the year, and at times has worked under great pressure. The area of its duties is constantly increasing, but there has been no corresponding increase in the size of tbe staff that has to carry them out. The growth of population and number of inhabited houses in the district will before long make the appointment of an additional Sanitary Inspector necessary if the work of the Department is to be maintained at the present standard. The duty of testing the drains of all new buildings was taken over in November, 1904, and has now become a part of the ordinary routine work of the Department and a permanent addition to the work of the Inspectors. There can be no doubt that this testing of new drains is of great value, but it must be realised that it has only been possible to carry it out efficiently by sacrificing a certain amount of other work of equal importance, such for instance as regular houseto-house inspection. The most unsatisfactory matter during the year was the large number of cases of Diphtheria in the district. Probably the most satisfactory was the passing of the new bye-laws relating to pig-keeping. Both these matters are dealt with in the Report and need not be further referred to here. In my Reports for 1903 and 1904, I pointed out the necessity for increasing the accommodation for patients at Mogden Hospital. I regret to be obliged to report again that nothing whatever of practical value has been done in the past year towards enlarging the Hospital. I can only point out to the Council that the necessity for enlargement is not less now than it was two years ago, and that the matter is one of urgent importance. 6 The rooms provided for the Health Department in the new Council House are a great improvement on the very limited space it had at its disposal before, and have enabled the note keeping and ordinary office work to be done under far better and more convenient conditions, but the permanent branch-oflice at Isleworth is still waiting for the completion of the alterations to the Public Hall in that town. There has been no change in the staff of the Department. Mr. Smith, the Inspector of Nuisances, and the two Assistant Sanitary Inspectors, Mr. Boberts and Mr. Ashworth, have carried out their duties most ably and efficiently. The amount of work done by them during the year is a record of their energy, and the absence of friction, and small number of the legal proceedings that have been necessary, are proofs of the tact with which it has been exercised. In conclusion I wish to express my thanks to the Chairman and members of the Health Committee. The Chairman's experience and knowledge of public health administration, and the keen interest of the Committee generally in all the matters I have brought before them have been of very great assistance to my colleagues and myself. I am, Gentlemen, Your obedient servant, EDWARD J. STEEGMANN. 7 Summary of Vital Statistics for 1905. Population, estimated to middle of year 33194 Total Births 1030 Birth-rate 310 Deaths (Besidents only) 452 Death-rate 139 Infantile Mortality-rate 1368 Zymotic Death-rate 1.98 Excess of births over deaths (residents only) 532 The above figures have been calculated according to the same method as that used last year, for the purpose of comparison. Comparing them with the summary given in the Report for 1904, the chief points worthy of notice are the following:— An increase of 564 in the population. A decrease of 27 in the total number of births. A decrease of 11 in the number of births amongst residents. A decrease of 1.3 in the birth-rate. A decrease of 98 in the number of deaths amongst residents. A decrease of 2 9 in the death-rate. A small decrease (0 42) in the Zymotic death-rate. Vital Statistics for England and Wales, 1905. Birth Rate. Death Rate. Infant Mortality Rate. England and Wales 27.2 15.2 128 76 great towns 28.2 15.7 140 141 smaller towns 26.9 14.4 132 England and Wales (less the 217 towns) 26.3 14.9 113 s Population. It is impossible to state exactly the number of inhabitants in any given district at any given time without taking a census. In this country a census is only taken once in every ten years, and therefore the population of any place in any one of the other nine years is, of necessity, a matter of more less accurate guess-work. It is difficult to make a correct estimate of the numbers inhabiting districts, and this difficulty increases, and the margin of error becomes greater, the longer the period that has elapsed since the last census. In small towns and localities that are practically at a standstill, neither developing nor decaying, any increase of population is due to the normal excess of births over daaths, and a fairly accurate estimate can ba made. But in districts like this where houses are being built, new roads opened out and estates developed, there is an artificial as well as a natural increase which has a very material effect on the accuracy of any estimate. There are several methods used for estimating populations in periods between censuses, but there is no fixed rule as to which should be employed, and this fact should be taken into account in comparing the vital statistics of one district with another on the figures given by Medical Officers of Health in their annual reports. Actual numbers of births, deaths, and cases of infectious disease, etc., are correct, or should be, because they are mere records of facts; but all rates, such as those of births and deaths (with the exception of the infantile death-rate) are calculated on the number of inhabitants and will vary with the estimate of population. Of the various ways of estimating, two are most frequently used. The first is the method used by the Registrar-General, and may be called the official one. It is made by a mathematical calculation based on the assumption that the same rate of increase that took place between one census and the next will be maintained in the following years. It calculates the increase of population at compound interest, but makes no allowance for fresh capital brought in. The second method is simpler in theory though more difficult in practice, but the result is probably more accurate. It is based on the number of occupied houses at the middle of the year, and the average number of people living in each house. 9 In this Report, and in the four quarterly Reports issued during the year, the statistics given are based on an estimated population calculated according to the method of the Registrar-General. According to this method the population of this district at the middle of the year 1905 was, Heston 11405 Isleworth 21788 Total 33194 This gives a total estimated increase of population since the middle of 1904 of 564. Mr. H. J. Baker, the Clerk to the Council, has made an estimate according to the second method, and calculates that at the middle of the year 1905, the population of the district was 35060 (Heston 11654 and Isleworth 23406). The difference between this number and his estimate for the previous year gives an estimated total increase in the population of 785. Of the two estimates it is practically certain that Mr. Baker's is the more accurate, and in the following pages corrected figures are given based on the larger estimate of population in addition to the official ones, for the purpose of comparison. 10 Deaths. During the year the total number of deaths registered was 675. Of these 223 were persons belonging to other localities, making the real number of deaths of residents 452, of which 239 were males and 213 females. The numbers registered in each of the four quarters of the year are set out in the following tables, the first dealing with all deaths and the second with the deaths of residents only:— Total. Non-Resident. Actual. 1st quarter 199 59 140 2nd ,, 140 58 82 3rd „ 180 54 126 4th „ 156 52 104 675 223 452 Residents only. Males. Females. Total. 1st quarter 67 73 140 2nd ,, 52 30 82 3rd ,, 66 60 126 4th 54 50 104 239 213 452 Death-rate. The death-rate for the year, based on the estimated population and the number of deaths of residents is 13 9 per 1000. This death-rate is nearly 3 per 1000 less than the rate for 1904. It is below the average for the last ten years, and with the exception of 1897, is less than the rate in any one of those years. It must, however, be noted that the death-rate for the whole of England and Wales was lower in 1905 than in 1904. In addition to the deaths of residents registered in the district, 23 deaths of residents occurred outside. In previous years such deaths have not been included, owing to the difficulty of obtaining a record of them, but this year Dr. Young, the County Medical Officer of Health, has obtained the necessary details and seat them to the Medical Officers of Health in each district in Middlesex. 11 If these 23 deaths are added to those registered in the district, the actual number of resident deaths becomes 475 instead of 452 (252 males and 223 females) and the death-rate for the year would be 14.3 instead of 13.9 per 1000. In calculating the death-rate of any district, fcur main factors have to be taken into consideration: (1) the number of inhabitants, (2) the number of deaths registered, (3) the deaths of non-residents registered in the district and (4) the deaths of residents registered in other districts. These various factors have a marked influence on the death-rate for the year, and it is useful to know whether they have been taken into account in making the calculation. To show how the figures can be altered, the death-rate of this district for the year has been worked out in several different ways, and the results set out for comparison. It will be seen that six different death-rates can be calculated, each accurate according to the method used, and the estimate of the population taken as the basis. The two estimates are (a) the mathematical or official one, calculated by logarithms, by which the population is 33194, and (b) the inhabited houses or rate book estimate by which the population is 35060. The results are as follows:— 1. All deaths registered. (a). Mathematical population 20 3 (b). Eate book „ 19 2 2. Eegistered deaths of residents only. (a). Mathematical population 13 6 (b). Eate book „ 12.8 3. Total deaths of Eesidents. (a). Mathematical population 14.3 (b). Eate book „ 13.5 4. Correct Death Eate. Deaths of residents only registered during the year in the district, plus deaths of residents that occurred outside the district in the same time, calculated on the estimated population based on the number of inhabited houses at the middle of the year, and the average number of persons living in each house. According to this method the real death-rate for 1905 is 13.5 per 1000. 12 59 deaths were registered of residents aged 75 and over, of which 29 were males and 30 females. The details of these deaths are as follows:— Males. Females. Total. 75 2 5 7 76 3 2 5 77 2 0 2 78 2 2 4 79 1 3 4 80 4 0 4 81 2 3 5 82 1 3 4 83 2 1 3 84 3 1 4 85 0 2 2 86 2 0 2 87 0 0 0 88 3 2 5 89 0 1 1 90 0 1 1 91 0 1 1 92 0 2 2 93 0 0 0 94 1 0 1 95 0 1 1 96 0 0 0 97 1 0 1 29 30 59 These deaths of old people constitute 13.05 per cent. of all deaths of residents. It is very carious to notice how much alike the proportion of deaths of people aged 75 and over to all deaths has been in the last three years. Deaths at 75 and over. Percentage of all deaths. 1903 61 13.40 1904 72 13.09 1905 59 13.05 13 Deaths in Public Institutions. The following deaths occurred in public institutions during the year:— Residents. Non-Residents. Brentford Union Infirmary 42 216 Mogden Hospital 13 4 Hounslow Hospital 13 0 68 220 Causes of Death. The causes of death and the various ages at which they occurred are given in detail in Table IV., which includes deaths at all ages, and in Table V. dealing only with deaths of infants under 12 months of age. The diseases mentioned in Table IV. are selected by the central authority, and the same Table is given in all annual reports of Medical Officers of Health, but two additional causes of death have been added for this district, as was done last year, namely Broncho-pneumonia and "Senectus." Deaths from the first of these would in other places be included under the heading of diseases of the respiratory organs, and those due to the second under the heading of all other causes. The deaths from infectious and zymotic diseases are referred to elsewhere in this Report. Of the other causes of death detailed in Table IV., the following are perhaps of special interest. Tuberculous Disease. 39 deaths during the year were caused by tuberculosis in some form, compared to 62 in 1904. Of these 39 deaths, 30 were due to Pulmonary Phthisis or Consumption, and of the persons dying from this disease, 70 per cent, were over 25 years of age. All the other 9 deaths from tubercle were in persons under 25 years of age; two-thirds of them were children under 5, and nearly half infants under 12 months. 14 Respiratory Diseases. Excluding Consumption, 82 deaths were caused by diseases of the respiratory organs, of which 31 were due to Bronchitis, 34 to Pneumonia and 16 to Broncho-pneumonia. The deaths from Bronchitis and Broncho-pneumonia all occurred either in young children or elderly people, the majority in the first year or after the age of 65. The deaths due to Pneumonia are fairly evenly distributed through all the age periods. Cancer. All the deaths from this cause were in persons over middleage and nearly half the cases were people aged more than 65. Accidents of Parturition. Of the 3 deaths due to accident or diseases of child-birth, in 1 case the child died and in 2 the mother. 15 Births. The total number of births registered in the district during the year was 1030, a decrease of 27 compared with the number of births in the previous year. 46 of the infants born were the children of women residing only temporarily in the district, and cannot properly be considered as additions to the local population. 28 of them were boys and 18 girls. If these 46 births are deducted from the total, the number of births for the year is 984, 11 less than the number of births amongst residents only in 1904. The fact that in spite of an undoubted increase in the population during the year, the number of children born should be actually less is one deserving of very serious consideration. The following tables show the details of the numbers of births in the different quarters of the year, and it is curious to note the even distribution:— Total births registered 1030 Non-resident births 46 984 Total. Non-resident. Actual. 1st quarter . 275 19 256 2nd „ 252 10 242 3rd ,, 243 11 232 4th ,, 260 6 254 1030 46 984 Residents only. Boys. Girls. Total. 1st quarter . 120 136 256 2nd ,, 121 121 242 3rd ,, 123 109 232 4th „ 118 136 254 482 502 984 Non-resident Births. Boys 28 Girls 18 Total 46 16 Birth-rate. The birth-rate for the year was 310 per 1000, a rate 13 per 1000 lower than 1904, though higher than the average for the last 10 years. This birth-rate is the correct one, based on the population estimated according to the official method and the total number of registered births in the district, but it is somewhat misleading. It is usual in all places to exclude non-resident deaths in calculating the death-rate. It is practically universal to include all non-resident births in calculating the birth-rate, the object of every Medical Officer of Health being to make the one as low and the other as high as possible. Probably in most districts the inclusion of non-resident births makes but little difference to the birth-rate, but in this it has considerable effect, owing to the Infirmary for the Brentford Union being in Isleworth. If the 46 non-resident births were excluded, the birth-rate for the year would be reduced from 310 to 29 6 per 1000. Another and more important factor to consider is the estimate of the population on which the calculation of the rate is made. If the higher (and probably more correct) estimate is taken, the rate becomes still further reduced. On the figures available it is possible to calculate four different birth-rates for the year as follows:— 1. All births registered. (a). Mathematical population 31.0 (b). Eate book ,, 29 3 2. Eesident births only. (a). Mathematical population 29'6 (b). Rate book ,, 28.0 Of these four rates the first (31.0) is the one to be used in comparing this district with the official figures for the country generally, but the last (28.0) is in all probability more accurate. 17 Illegitimate Births. 73 births were registered during the year as illegitimate, 15 less than the number in 1904. This is equal to 7.08 per cent, of all births compared to 8'3 per cent, last year. Of these 73 births, 34 were the children of residents, and 39 of nonresidents. The illegitimate births amongst residents amounted to 345 per cent. The proportion last year was 3'1 per cent. 84.7 per cent, of the non-resident births were illegitimate, a number due to the fact that most of the women who enter the Infirmary for their confinements are unmarried. These relative percentages of illegitimate to all births show very plainly the importance of separating resident from non-resident births. Although in this report such separation is made, it must be remembered that officially all births registered in any district are credited to that district, and are not included in the statistics of the places to which the mothers properly belong. If, therefore, any deductions should be drawn as to the relative morality of Heston and Isleworth and other districts in the Brentford Union, based on the number of illegitimate births in each of them, this point should be borne in mind. Quarterly Rates. The following table shows the birth and death-rate for each of the quarters of the year:— Birth-rate. Death-rate. 1st quarter 33.1 16.8 2nd „ 30.3 9 9 3rd ,, 29.3 15.1 4th ,, 31.3 12.5 These figures are based on the official estimate of the number of inhabitants, and are calculated to equal annual rates, that is what the rate would have been for the whole year if the same number of births and deaths had occurred in the other three quarters as in any particular one. It should be noted that the real rate for the year is by no means the same thing as the average of the four given above. 18 Infantile Mortality. 141 deaths of infants under 12 months of age were registered during the year, equal to an infant mortality rate of 136 8 per 1000 births. This shows a reduction of 38 in the number of deaths and 32 5 in the mortality rate on comparison with the official figures for last year. The official figures, however, include all births and iniant deaths registered in the district, and more accurate statistics are obtained by deducting births and infant deaths of non-residents, and making the calculation on those only properly belonging to the locality. By doing this the real number of infant deaths for the year is 125, compared to 167 in 1904, and the infant mortality rate is 127.0 per 1000 births compared to 167 8. This reduction of 42 in actual numbers of infantile deaths and 40 8 in the infantile mortality rate per 1000 births is undoubtedly satisfactory, but in considering the causes that have brought it about, one important factor must not be overlooked, namely the fewer children born. Amongst residents only there were 20 births less in 1904 than in 1903, and in 1905 11 less than in 1904. These are actual facts, not estimated figures, and the decrease in the number of children born has taken place in spite of the large increase in the population of the district during the past two years. It is obvious that the number of children under 12 months of age in 1905 must be influenced very largely by the number born during 1904. The number of children bom has a greater effect on the general deathrate on all ages than on the infant mortality rate, because the former is calculated on an estimated population and includes deaths at all ages, and the most fatal period of life is the first year. The infant mortality rate is calculated on actual births and infant deaths. Hitherto four tables dealing with vital statistics have been issued officially by the central authority to be filled in and included in the annual reports of all local Medical Officers of Health every year. This year for the first time a fifth table dealing in detail with infant mortality has been issued, and is included in this Report. Up to the present time all deaths of infants under 12 months of age have been grouped together as infantile deaths, and except where special reports have been drawn up no information has been available as to the ages in weeks or months of the infants included. The importance of making some sub-division will be realised by anybody who takes the trouble 19 of considering Table V. for a few moments. When similar tables for a large number of places can be compared the value of the facts contained in them will be great. It will be noted that in the table a separate column is given for each month, and that the first month is further divided into four weeks, making altogether 16 age periods for the infant deaths during the year. The number of deaths from different causes in each of these age periods is also given in the table. A brief analysis of the table for this district may perhaps be useful. In drawing it up all deaths of infants of non-residents have been excluded, so that the total number of infantile deaths considered is 125. Of these 125 deaths, 36, or 28.8 per cent., occurred in the first month (as a matter of fact they were all in the first three weeks). 29 of these 36 deaths, or over 80 per cent., happened in the first week, and these deaths in the first week of life are 23.2 per cent. of the total deaths in the first year of life. 19 deaths took place in the second month of life and 9 in the third, making a total of 64 deaths of children in the first three months of life. In other words, more than half (51.2 per cent.) of the children whose total length of life was less than one year did not survive beyond the first quarter of the possible 12 months. In the fourth, fifth and sixth months 25 deaths occurred, making the total children who died before reaching six months of age 89, or 71'2 per cent. of the 125. 36 infants died between the ages of 6 and 12 months, curiously enough exactly the same number that died within the first month. The following is a summary of the analysis:— Total deaths of infants under 12 months of age 125 Died in first week of life 29 23.2 per cent. „ second ,, 3 24 ,, ,, third ,, 4 32 ,, Died in first month of life 36 28-8 ,, ,, second ,, 19 152 ,, ,, third ,, 9 72 ,, Died before reaching the age of 3 months 64 51.2 ,, Died in fourth, fifth and sixth months 25 20 „ Died before reaching the age of 6 months 89 71.2 ,, Died in seventh to twelfth months 36 28.8 ,, 125 100 20 From the above figures the chances of living for any infant born in the district can be calculated, but not too much weight should be attached to statistics for one year only. It is obvious, however, that its chances are least in the first week, and that if it survives after the first month its prospect is very materially improved. The following table gives the ratio of deaths under 12 months to deaths at all ages from the year 1894:— Year. Percentage. 1894 28.81 1895 22.45 1896 28.95 1897 24.61 1898 31.19 1899 27.32 1900 24.00 1901 28.75 1902 27.86 1903 22.75 1904 30.36 1905 27.65 Causes of Infantile Deaths. The various causes from which the infants died are set out in both Table IV. and Table V. As usual, Diarrhoea was the disease responsible for the greatest number of deaths, but the number was much less than in the previous year. The number dying from this cause was 32, or rather more than a quarter of all the infant deaths, compared with 58, or 34.7 per cent., in 1904. 19 deaths were attributed to "Premature Birth," a cause of death nearly as unsatisfactory as "Marasmus" Debility or "Atrophy." It is perhaps not right to draw any conclusions from it, but it is at least curious that so many infants should have come into the world before the termination of the usual period of gestation, and this number of 19 does not, of course, include any children bom prematurely who managed to survive over the first 12 21 months. Atrophy, Debility and Marasmus caused 15 deaths, and these terms in most cases simply mean improper feeding. Adding these deaths to those due to premature birth gives a total of 34 infant deaths for which it is not unfair to say that the mother was responsible, in most cases no doubt through ignorance. This number is really greater, because some of the deaths placed under "other causes" were due to non-assimilation of food, and probably half at least of the 14 deaths due to "Convulsions" were caused by errors of diet. Five infants died from Whooping-cough, but none from any of the other infectious diseases. The deaths from Whooping-cough and Diarrhoea together give an infantile zymotic death-rate of 3 76 per 1000 births. Five infantile deaths were due to tuberculous diseases, two more than last year. Infantile Mortality-rate. There is far less margin for error in this rate than in the others given in the Eeport, for it is calculated on actual births and deaths registered during the year, and not on any estimated figures. The official infantile mortality-rate is 136.8 per 1000 births. The correct infantile mortality-rate, calculated after deducting the births and deaths of the children of non-residents, is 127.0 per 1000 births. It is 32.5 per 1000 births less than the rate for 1904, and well below the average for the last ten years. It is 40.8 lower than the correct infantile mortality-rate last year. The following table shows the births, deaths under one year, and the infantile mortality-rate for each of the four quarters of the year. Deaths under 1. Births. Rate. First quarter 31 256 121.0 Second ,, 23 242 95.0 Third „ 44 232 185.3 Fourth ,, 27 254 106.0 It should be noted that the above rates are not calculated to annual equivalents, as the quarterly birth and death-rates are, but the rate for each quarter is based on the actual number of births and infant deaths registered in that quarter. 22 Deaths from Zymotic Diseases. The diseases included under the classification of Zymotic are, as in previous years, Small-Pox, Scarlet-fever, Diphtheria, Typhus, Typhoid and simple Fevers, Measles, Whooping-cough, Diarrhoea and Dysentry, and Membraneous Croup. The deaths from these diseases show a decrease of 14, compared to the number dne to similar causes in 1904. The decrease in the total is entirely due to the fewer deaths from Diarrhoea and the absence of any from Measles. The number of deaths from Whooping-cough was 8 compared to 4 last year, and there was a very serious increase of 12 in the number caused by Diphtheria and Croup. The total number of deaths from Zymotic diseases during the year was 66, giving a Zymotic death-rate of 1'98 per 1000 of population. The following table shows the details of the deaths and death-rates for Zymotic diseases in 1905, with the corresponding figures for the previous year:— Disease. 1904 1905 Deaths. Rate. Deaths. Rate. Diphtheria 2 0.06 14 0.42 Measles 6 0.10 Whooping-cough 4 0.12 8 0.24 Diarrhœa 68 2.08 44 1.32 All Zymotic diseases. 80 2.36 66 1.98 23 The Zymotic death-rates in previous years have been as follows:— Year. Rate per 1000 of population. 1895 2.7 1896 2.49 1897 1.39 1898 3.73 1899 2.93 1900 1.79 1901 2.58 1902 1.58 1903 1.43 1904 2.36 1905 1.98 The death-rates per 1000 from certain other common diseases were as follows:— Phthisis and other tuberculous diseases 1.14 Diseases of respiratory organs, excluxing phthisis 2.46 Cancer 0.57 Heart diseases 1.20 Influenza 0.12 24 Statistics for the two separate parishes of Heston and Isleworth. HESTON, 1905. Births. 1st quarter 84 2nd „ 80 3rd ,, 91 4th ,, 82 Total 337 Deaths. Over 1 Under 1 Total 1st quarter 29 7 36 2nd ,, 21 9 30 3rd „ 28 12 40 4 th ,, 27 10 37 Total 105 38 143 Population 11654 Birth-rate 28.9 Death-rate 12.2 Infant-mortality 112.7 ISLEWORTH 1905. Births. 1st quarter 172 2nd ,, 162 3rd ,, 141 4th „ 172 Total 647 Deaths. Over 1 Under 1 Total 1st quarter 80 24 104 2nd ,, 38 14 52 3rd ,, 54 32 86 4th ,, 50 17 67 Total . 222 87 309 Population 23406 Birth-rate 27.5 Death-rate 13.2 Infant-mortality rate 134.4 25 INFECTIOUS DISEASES. The details regarding the amount of infectious disease in the district during the year is one of the least satisfactory matters dealt with in this Keport. There was a large increase in the number of cases notified to the Health Department, the disease chiefly responsible for the increase being Diphtheria, and it cannot be claimed for the Department that its efforts to reduce the number of cases of this particular disease met with much success. The total number of cases of all kinds notified was 233, or 88 more than the number in the previous year. 1905 is the fourth consecutive year during which Measles has not been included in the list of notifiable diseases, and therefore the total number of notified cases in the four years can properly be compared. They are 1902 249 1903 205 1904 145 1905 233 The following table shows the numbers of cases of each disease notified, together with the numbers in the previous year, for comparison:— Disease. 1904. 1905. Scarlet Fever 65 85 Diphtheria 37 105 Typhoid Fever 15 8 Puerperal Fever 5 2 Erysipelas 23 33 145 233 The following tables show the details of the notifications during the various quarters and months of the year:— First Quarter. January. February. March. Total. Scarlet Fever 3 7 13 23 Diphtheria 3 5 3 11 Typhoid Fever 0 0 2 2 Erysipelas 2 1 5 8 8 13 23 44 26 Second Quarter. April. May. June. Total. Scarlet Fever 5 7 5 17 Diphtheria 8 2 8 18 Puerperal Fever 0 1 0 1 Erysipelas 3 3 5 11 16 13 18 47 Third Quarter. July. August. September. Total. Scarlet Fever 2 1 3 6 Diphtheria 2 2 14 18 Typhoid Fever 0 0 4 4 Erysipelas 0 1 3 4 4 4 24 32 Fourth Quarter. October. November. December. Total. Scarlet Fever 5 16 19 40 Diphtheria 22 20 15 57 Typhoid Fever 1 0 1 2 Puerperal Fever 0 1 0 1 Erysipelas 5 2 3 10 33 39 38 110 The total number of cases removed to Mogden Hospital was as follows:— Diphtheria 87 Scarlet Fever 77 Typhoid 2 166 Excluding Erysipelas and Puerperal Fever, neither of which diseases are admitted, 83.8 per cent of all the cases notified were removed to Mogden Hospital for treatment. 27 Small-Pox. 1905 is the third consecutive year during which no case of this disease has been notified in the district. The Small-pox Hospital at Dockwell has been maintained throughout the year in an efficient state, ready at any moment to receive patients. One doubtful case from Richmond was admitted for observation, but in all probability the disease was Chicken-pox. The value of Dockwell Hospital was demonstrated during the outbreak of Small-pox in 1901-2, and the necessity of continuing to keep it ready at all times to deal with cases of this disease, will exist till the present unfortunate state of the laws in this country with regard to vaccination is altered. Measles. No figures are available on which to found any estimate as to the number of cases of this disease in the district. The voluntary notifications received from the school teachers were, if anything, below the average. No deaths were registered as having been caused by it, whereas in the previous year there were six. Typhoid Fever. There was a marked decrease in the number of cases of Typhoid notified during the year, compared with 1904. 8 cases occurred, the numbers in the three previous years having been 15, 9 and 10. No deaths were registered as due to it. Scarlet Fever. 85 cases of Scarlet Fever were notified. This number is 20 more than the total in 1904, but 58 less than those notified in 1903, and 27 less than the number in 1902. The actual numbers of cases of Scarlet Fever notified in each of the last five years is as follows:— 1901 104 1902 112 1903 143 1904 65 1905 85 28 The increase, therefore, is not a fact to cause anxiety, as the total number of cases is well below the average for five years. Dealing only with the cases of Scarlet Fever in 1905, certain details are of interest. Reference to Table III. shows that 51 of all the cases (60 per cent.) occurred in the age-period between 5 and 15, and 23 (27 per cent. of the total) in the age-period of 1 to 5. Over 87 per cent. of all the patients were children aged between 1 and 15 years. The average age of all the patients was a little over 8 years, the oldest was 28 years and the youngest six months. 34 of the patients were males and 51 females. 57 of all the cases were children attending the public elementary schools in the district, the numbers from each school being as follows:— Blue School 2 Catholic 2 Grove Road 8 Spring Grove 8 Heston 7 St. John's 2 Hounslow Town 2 St. Mary's 1 Hounslow Heath 7 Worple Road 11 North Street 7 Total 57 53 of the 57 school-children patients suffering from Scarlet Fever were removed to Mogden Hospital for treatment. The total number of cases removed to Mogden was 77, and therefore the school children formed over 68 per cent. of the Scarlet Fever patients from this district treated in the Hospital. Diphtheria. The number of cases of Diphtheria was a cause of very serious anxiety to the Health Department during the year. The total number of notifications was 105, an increase of 68 compared with 1904. The actual numbers of cases of Diphtheria notified in each of the last five years is as follows:— 1901 40 1902 85 1903 29 1904 37 1905 105 29 The age-periods of the patients are set out in Table III., and show that nearly 83 per cent. of them were children between the ages of 1 and 15. The average age of all the cases was a little over 10 years, the oldest being 45 and the youngest 1, but the average age of the great majority of the patients was about 7 years. 55 were males and 50 females. 65 of the total cases were children attending the public elementary schools, the details of these cases being as follows:— Blue School 1 Hounslow Heath 3 Brentford End 1 Hounslow Town 20 Catholic 3 Spring Grove 3 Grove Road 16 St. Mary's 3 Green 1 - Heston 14 Total 65 It should be noted that the above cases were spread over the whole year; at no time did the number of notifications from any one school amount to an epidemic in that particular school. 55 of the school children suffering from Diphtheria were removed to Mogden, forming over 63 per cent. of the total cases of Diphtheria from this district treated in the Hospital. During the year 13 deaths were notified as due to Diphtheria, and one from croup, a disease very closely allied to it. The question of infectious disease and the public elementary schools is dealt with in the Appendix at the end of this Report, but the following brief summary showing the ratio of school cases to all others during the year may be given here:— Scarlet Fever. Total number of cases notified 85 Number attending public elementary schools 57 Proportion of school children—67.0 per cent. Diphtheria. Total number of cases notified 105 Number attending public elementary schools 55 Proportion of school children—61.9 per cent. 30 Cases removed to Mogden Hospital. Scarlet Fever. Total cases removed 77 School children removed 53 Proportion of school children—68.8 per cent. Diphtheria. Total cases removed 87 School children removed 55 Proportion of school children—63.2 per cent. Scarlet Fever and Diphtheria together. Total cases removed to Hospital 164 School children removed 108 Proportion of school children—65.8 per cent. 31 MOGDEN ISOLATION HOSPITAL. The following Report on the number of cases admitted during the year has been prepared by Dr. Power, the Resident Medical Officer:— Return as to Patients for the year ending the 31st day of December, 1905. ] Scarlet Fever. Diphtheria. Enteric Fever. Other diseases. Total. Number in Hospital at Dec. 31st, 1904. From the Borough of Richmond 8 ... ... 1 9 ,, Richmond Union ... ... ... ... ... ,, Heston and Isleworth Urban District 8 6 ... ... 14 ,, Isleworth Union ... ... ... ... ... ,, Hounslow Garrison ... ... ... ... ... ,, Hospital Staff ... ... ... ... ... Totals 16 6 ... 1 23 Admitted during year. From the Borough of Richmond 41 7 2 4 54 ,, Richmond Union ... ... ... 1 1 ,, Heston and Isleworth Urban District 68 82 1 ... 151 „ Isleworth Union 6 7 ... ... 13 „ Hounslow Garrison 1 3 ... ... 4 ,, Hospital Staff 1 ... ... 4 5 Totals 117 99 3 9 228 32 Scarlet Fever. Diphtheria. Enteric Fever. Other diseases. Total. Discharged during the year. From the Borough of Richmond 41 5 1 3 50 ,, Richmond Union ... ... ... 1 1 ,, Heston and Isleworth Urban District 48 63 ... ... 111 ,, Isleworth Union ... 6 ... ... 6 ,, Hounslow Garrison 1 2 ... ... 3 ,, Hospital Staff 1 ... ... 4 5 Totals 91 76 1 8 176 Died during the year. From the Borough of Richmond ... 2 1 1 4 ,, Richmond Union ... ... ... ... ... ,, Heston and Isleworth Urban District 1 12 ... ... 13 ,, Isleworth Union ... ... ... ... ... ,, Hounslow Garrison ... ... ... ... ... „ Hospital Staff ... ... ... ... ... Totals 1 14 1 1 17 Number in Hospital at Dec. 31st, 1905. From the Borough of Richmond 8 ... ... 1 9 ,, Richmond Union ... ... ... ... ... „ Heston and Isleworth Urban District 27 13 1 ... 41 ,, Isleworth Union 6 1 ... ... 7 ,, Hounslow Garrison ... 1 ... ... 1 ,, Hospital Staff ... ... ... ... ... Totals 41 15 1 1 58 33 General Remarks. Total Admissions. The admissions during 1905 amounted to 228, being 74 more than in 1904, and slightly below the average of former years. Diphtheria. 99 cases of this disease were admitted. Not only was the proportion of Diphtheria cases unusually high (99 out of a total of 228) but the total number of cases was in excess of the average (which is 57) and of the previous highest total (85) in 1902. There were 14 deaths, giving a case mortality of 141 per cent., which is slightly above our average mortality in this disease. This was no doubt due to the large number of very severe cases admitted during the late epidemic. Of the total number of cases, 70 were admitted during the last four months of the year. Scarlet Fever. 117 cases were admitted, compared with 97 during the previous year, and an average of 165 for all years. This total promised at one time to be much lower, but there was a sharp epidemic during the last quarter which added 50 cases. One death occured, giving a case mortality of 8 per cent, for the year, the lowest we have ever had. Staff. One member of the staff was warded with Scarlet Fever during the year. In spite of the Diphtheria wards being crowded for several months, it is satisfactory to be able to report that none of the staff contracted the disease, as frequently happens under these conditions. Four members of the staff were warded for various other complaints. 34 Sanitary Work. The routine work done by the Health Department during the year is set out in detail in the three Tables numbered C1, C2 and C3 printed at the end of this Report. These Tables are included in the Reports of all the Medical Officers of Health in the County, and should therefore form a fair guide to estimating the amount of work done in each locality, but till some common definition is adopted of what is to be included under such headings as "Inspection" or "Notice" no fair comparison can really be made. A step towards making these Tables more uniform has been made this year by reducing them from four to three, and so lessening the number of different headings under which the details are divided. It is to be feared that these Tables will not be carefully read by many; they are no doubt dry, and, as they contain nothing exciting or sensational, uninteresting to most people. But they form a record of daily and for the most part unobtrusive work efficiently carried out by the officers of the Council, that is of the highest importance to the health and well-being of the inhabitants of the district. The credit of this work is almost entirely due to the Inspectors, for only a very small portion of it is done by the Medical Officer of Health. Certain facts included in these Tables may be specially pointed out The total number of inspections of houses, premises, etc., was 10539. 101 premises were inspected on account of complaints received, and 200 in connection with infectious diseases. 814 houses were inspected in the course of house-to-house work, and 330 premises were kept under periodical inspection. 3211 cautionary notices were given, of which 704 were verbal. 341 Statutory Orders were issued. Legal proceedings were only taken in four cases, and convictions were obtained in all. Three of the cases were for the recovery of expenses in connection with necessary sanitary work carried out by the Council on private premises, and the fourth was to obtain an order to close a polluted well. 9 dwelling-houses were closed as unfit for habitation. The number of workshops and work-places in the district amounted during the year to 209, and in connection with them 73 contraventions of the Factory Acts wore discovered and remedied. 15 In the second and third of the Tables details will be found relating to the drainage and water supply of the houses, and it is satisfactory to note the very large proportion connected with the sewers, and the very small number not supplied with water from the Company's mains. Drain Testing. The testing of drains is one of the most important of the duties of the Health Department and the bearing of this work on the public health is too obvious to need comment. The reasons for the tests carried out may be roughly divided into three classes:—(1) Complaints received, (2) Infectious diseases and (3) New buildings. (1) 21 complaints of nuisances arising from drains were received, necessitating the testing of the drains of 58 houses. Defeets were found in 48 of these and during the progress of the work of putting them in order 142 re-tests had to be done. (2) It is not always found to be necessary to test the drains of every house in which a case of infectious disease has occurred. During the year 86 cases were the cause of an investigation into the drains of houses. Of these cases 38 were Scarlet-fever. 85 houses were tested in connection with these, and defects were found in 45. In 18 the defect was found in the house in which the illness had commenced, though of course it must not be assumed that the disease was due to the defect. 120 re-tests were carried out whilst the defects were being remedied. 130 houses were examined in consequence of 46 cases of Diphtheria, and detects were found in 71. In 25 of the houses the defect was in the first house. 196 re-tests were made. Two cases of Enteric caused 11 houses to be examined, in 5 of which defects were found. In connection with these three diseases the drains of 226 houses were examined, and defects were found in 121. 348 re-tests, additional to the original test, were made. (3) The testing of the drains of all new houses, prior to the granting of a Habitation Certificate, is carried out in conjunction with the Surveyor's Department. The drains of 504 new buildings were carefully tested and defects were found in 390 (over 77 per cent.) All these 390 houses were re-tested after the defect had been made good. In most of the cases 36 where a defect was discovered it was not of a serious nature, generally being a faulty fitting in the ventilating pipe or something similar, but the large number of defects found proves the value of the system started last year by which the drains of all new buildings are tested before the houses are allowed to be inhabited. The following Table gives a summary of the details referred to above:— Drains Tested. Cause of test. Number. No. houses. No. found defective. No. found intact. No. re-tested. No. of cases in which defects were found at origin of test. Complaint 21 58 48 10 142 - Scarlet Fever 38 85 45 40 120 18 Diphtheria 46 130 71 59 196 25 Enteric 2 11 5 6 32 1 New Buildings - 504 390 114 390 - Total 107 788 559 229 880 44 Factories and Workshops. This year a new set of Tables has been drawn up by the Home Office, showing the work carried out in connection with factories, workshops, laundaries, etc., and here inclnded. It will be seen that the number of these places on the Register at the end of the year has increased from 203 in 1904, to 255. A number of minor contraventions of the Factory Acts were found from time to time on inspection, but in no case was it found necessary to institute legal proceedings to get them remedied. 37 Bakehouses. A list of the bakehouses in the district is given in the Table at the end of this Report. On comparing this Table with the similar one given in the Report for 1904, it will be seen that the total number of bakehouses remains the same, but that one or two then in use are not now occupied. Generally speaking it may be said that the sanitary conditions of the bakehouses is satisfactory. Dairies and Milkshops. A detailed list of the dairies, cowsheds and milksellers in the district is given at the end of this Report, and other facts regarding them will be found in Table C2. In addition to the suppliers of milk included in the list, there are others from neighbouring places who come into this district to sell milk. The Health Department has no control over these persons, and it is possible that the bye-laws in force in the localities in which their cowsheds are situated may differ from those in force in Heston and Isleworth. It is to be hoped that before long not only will similar bye-laws with regard to cowsheds be adopted by all the separate authorities in the County, but also that a uniform system of enforcing and carrying them out will become possible. The contraventions of the bye-laws mentioned in Table C2 were those in connection with which notices were served. There were in addition contraventions that were remedied by other means. The most common faults found were as follows:— Interior of cowshed not properly cleansed 16 Interior roof and walls of cowshed not limewashed 3 Drainage of cowshed not in accordance with Section 7 5 Dairy not thoroughly cleansed 21 Drainage of dairy, milkshop or milkstore not in accordance with bye-laws 18 Yard dirty 10 Proper precautions not taken to prevent exposure of milk to risk of contamination 28 Milk-cans dirty 7 Milk improperly stored 5 38 Daring the year various wholesale dealers have been written to and their attention called to the rusty condition of the interiors of the churns in which the milk is carried, and in some cases to the dirty state of the milk itself. In several of the premises connected with the milk trade improvements have been made during the year, but much more could with great advantage be done. Many places are on the borderline between good and bad; not bad enough to contravene the bye-laws; not nearly good enough to satisfy anyone who realises the dangers of dirty or contaminated milk, and the urgent importance of keeping dairy cows in clean and healthy surroundings. If it could be done, all cows used for the supply of milk for human consumption should be kept day and night in the open air. The ideal cowshed is the one that most nearly resembles this condition. Slaughter Houses. The list of slaughter-houses given at the end of this Report is the same as that given last year. In the Report for 1904, the question of providing a public slaughterhouse was briefly discussed. The value of having a central place under the control of the local authority, in which all animals intended for food could be killed and inspected, is undoubted, but it is to be feared that owing chiefly to the expense involved, some years must elapse before the matter can be seriously taken up in this district. In the meantime, however, a very importan t step has been taken in the adoption by the Council of the principle of not allowing any more private slaughter-houses to be established in the district. Two of the 14 slaughter-houses on the Register are not used for the purpose of killing animals, one having been converted into a store and washing-up shed, and the other utilised for a store and cart shed. The slaughter-houses in use have been frequently inspected, and altogether 16 minor contraventions of the bye-laws have been found and remedied. Most of these were in connection with the cleansing and repairing of walls, paving and pens, and removal of offal. The number of Butcher's shops on the Register in 1904 was 30. During 1905 7 new shops were opened, 5 of which were subsequently closed owing to insufficient trade to support them. The number at the end of the year was 32. 39 Meat Inspection. Bread, milk and meat are practically the only articles of food coming directly under the supervision of the Health department, though unsound food of any sort would be dealt with if found. During the year the following amount of unsound meat was seized and destroyed:— Pigs' kidneys, 72 Sheeps' "plucks," 8 About 1 cwt. of unsound meat and putrid bones found on unoccupied premises. About 28 lbs. of stale meat alleged to be waiting for removal by fat merchant. Special attention was paid during the year to the inspection of pigs and the carcases of these animals intended for food, with particular reference to the possible existence of Tuberculosis. The subject of pig Tuberculosis is one of some considerable practical importance, owing to the different views held by different authorities as to what extent of disease found in a pig when killed justifies the condemnation of the whole carcase. At the present time no uniform system exists. and each individual inspector has to act according to his own particular opinion. It is obvious that this condition of things would make it very difficult to obtain a conviction in any disputed case, and therefore it is very satisfactory to record that in this district no difficulties have arisen, owing chiefly to the willing co-operation of the owners of doubtful carcases. The following is a summary of the inspections made in connection 'with Tubercuiosis in pigs:— Number of carcases slaughtered in this district 360 Number of pigs inspected prior to slaughter 41 Number of inspections of carcases from London markets 78 Number of inspections of carcases from country 20 Total number of pigs and carcases inspected 499 In one case Tuberculosis of the lungs was found, the rest of the carcas6 being apparently perfectly healthy. (The diagnosis of the disease was subsequently proved correct by microscopical examination). The whole carcase was destroyed with the consent of the owner. 40 In two cases Tuberculous glands were found in the neck, the disease being limited absolutely to these glands. In these cases the carcase was not condemmed. In one case the neck glands had been removed prior to the inspection. No sign of disease was found in the rest of the animal. Pig-Keeping. For many years the condition of premises used for keeping large numbers of pigs had been the source of constant complaint from persons living in the neighbourhood of them. In spite of frequent inspections, constant warnings and occasional prosecutions, it was impossible to prevent nuisances arising from places where pigs were kept in any number. There are many such places in the district; when they were first started they were away from inhabited houses, and any nuisance they might cause was not a serious matter. But the growth of population and spread of building areas caused houses to be built much closer to the pig establishments, and greatly increased the number of people affected by the nuisance. Under the bye-laws of the district no pigs might be kept at a distance of less than 60 feet from any dwelling house, but any number might be kept 61 or more feet away. The only remedy for the nuisance suffered by a large and increasing number of inhabitants of the district that would be permanent seemed to be the removal of the cause, and the Council, therefore, drew up and adopted a new bye-law making it illegal to keep more than three pigs over the age of 12 weeks, within a distance of 180 feet of any two or more dwelling houses. This bye-law was sanctioned by the Local Government Board, to become operative in February, 1906. It was most strongly opposed by those interested in the trade, but it is only necessary to read the text of the altered bye-law to see that no real hardship is inflicted by it on anybody. There is plenty of vacant land far removed from any house to which the large pig-breeding and keeping establishments can be removed if they are affected by it. The farmer who keeps a number of pigs can continue to do so if his is the only house within 180 feet of his nearest pig-sty. The cottager who has one pig and breeds one or two litters a year may still do so, provided that he sells the young ones before they reach the age of 12 weeks. He was not allowed previously to build a pig-sty within 60 41 feet of his house, and if he conformed to the old bye-law with respect to this distance, he is not affected by the new. The number of young pigs that his one or two sows may produce is not limited by the bye-law, and it is a matter of common knowledge that most people who breed pigs for profit sell the young ones before they reach the age of three months. The following is the full text of the new bye-laws regulating the keeping of pigs:— 1. The occupier of any premises shall not keep more than three swine, the age of each of which exceeds twelve weeks, within a distance of 180 feet from any two or more dwelling houses not being within the same curtilage as such premises. 2. Every person who shall offend against the foregoing bye-law shall be liable for every such offence to a penalty of Five Pounds, and in the case of a continuing offence to a further penalty of Twenty Shillings for each day after written notice of the offence from the Urban District Council of Heston and Isleworth. Provided nevertheless that the Justices or Court before whom any complaint may be made, or any proceedings may be taken in respect of such offence, may, if they think fit, adjudge the payment as a penalty of any sum less than the full amount of the penalty imposed by this bye-law. 3. These bye-laws shall come into operation at the expiration of six calendar months from the date of their confirmation by the Local Government Board. 42 Annual Report of the Canal Boat Inspector for the year ending December 31st, 1905. Number of visits to Canal 55 Number of Boats inspected 287 Number of Boats conforming the Acts and Regulations 254 Number of Boats contravening the Acts and Regulations 33 Number of men on Boats 407 Number of women on Boats 193 Number of children— Boys over 5 years 64 Boys 5 years and under 42 — 106 Girls over 5 years 60 Girls 5 Years and under 56 — 116 -222 Total number of adult persons allowed by Certificate to occupy the 287 Boats 1028 Total number of adults occupying (inclusive of 222 children equal to 111 adults) 711 Number of Boats with fore-cabins 75 Contraventions. Particulars of Contraventions. Contraventions. Remedied. Outstanding.  Registration, without a certificate 9 7 2 Not properly marked 2 2 — Cabin in a dirty state 3 3 — Insufficient ventilation 10 8 9, Painting not renewed 2 2 — Without a proper water vessel 4 4 — Without a pump 2 2 — Cabin dilapidated 11 6 5 Total ... 43 34 9 43 As recorded in my last report, so again, I am happy to be in a position with a few exceptions, to report the continued satisfactory condition and healthy state of the occupants of the boats inspected by me during the year, there not having been a case of sickness or infectious disease. The steps taken to secure compliance with the Acts and Regulations by means of Complaint Notices and Certificates have proved somewhat more successful than last year, as of the 43 contraventions found, 34 have been remedied, leaving outstanding 9, as against 20 of last year ; of these 20 outstanding contraventions 17 have been remedied, leaving only 3, which from information are also probably remedied. The following remarks as to the contraventions may be of interest:— Non-production of Certificate. There is apparently no fixed place of deposit for the certificate, so that often it cannot be found except by the occupant who put it away. Dirty Cabins. This contravention it will be seen has seldom been met with. Ventilation. This is a matter of opinion with many of the occupants, they consider that the open space in the cabin is all sufficient. With reference to the protection of the ventilators, I have only observed nine boats during the year which were provided with shields. Cabin dilapidated. By Regulation 11, "The master of a canal boat which may have been registered as a dwelling shall cause every cabin that may be used as a dwelling to be kept at all times in a cleanly and habitable condition," but, by Section 1 of the Act of 1877, the owner is also liable if he is at fault. It is very often found that by structural defect the cabin is rendered unfit for habitation in its entirety, or that the boat may have a leak at the bed place causing the bedding to be wet and in a measure therefore that part only is unfit. In conclusion I cannot close my report without again mentioning the urgent need of sanitary accommodation for the women and children on canal boats while stopping in this district. Jas. I. SMITH, Canal Boat Inspector. Report on the administration of the Factory and Workshop Act, 1901, in connection with FACTORIES, WORKSHOPS, LAUNDRIES, WORKPLACES & HOMEWORK. i.—INSPECTION. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (including Factory Laundries) 40 8 Nil. Workshops (including Workshop Laundries) 305 18 Workplaces 60 12 Homeworkers' Premises 16 2 Total 421 40 Nil. 2.—DEFECTS FOUND. Particulars. Number of Defects. Number of Prosecutions Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts:- Want of cleanliness 55 55 Want of ventilation 9 8 Overcrowding 0 0 Want of drainage of floors 5 5 Other nuisances 34 34 Sanitary accommodation— Insufficient 17 17 Unsuitable or defective 5 4 Not separate for sexes 0 0 Offences under the Factory and shop Act:— Illegal occupation of underground bakehouse (s.101) 0 0 Nil. Nil. Breach of special sanitary requirements for bakehouses (ss. 97-100) 0 0 Failure as regards lists of outworkers (s. 107) 0 0 Giving out work to be done in premises which are— Unwholesome (s.108) 0 0 Infected (s.110) 0 0 Allowing wearing apparel to be made in premises infected by scarlet fever or smallpox (s.109) 0 0 Other offences 0 0 Total 125 123 Nil. Nil. 3. OTHER MATTERS. Class. Number. Matters notified to H M. Inspectors of Factories:— Failure to affix Abstract of the Factory and Workshop Act, (s.133) Action taken in matters referred by H.M. Inspectors as remediable under the Public Health Acts, but not under the Factory Act (8. 5)— Nil. Notified by H.M. Inspectors Nil. Reports (of action taken) sent to H.M. Inspectors Nil. Other Nil. Underground Bakehouses (s. 101):— Certificates granted during the year Nil. In use at the end of the year 1 Number of Homework:— Lists. Outworkers. Lists of Outworkers (s. 107):— Lists received 10 6 Addresses of Outworkers —forwarded to other Authorities 2 2 received from other Authorities 5 5 Homework in unwholesome or infected premises:— Wearing Apparel. Other Notices prohibiting homework in unwholesome premises (s. 108) 1 Nil, Cases of infectious disease notified in homeworkers' premises 1 Orders prohibiting homework in infected premises (s. 110) 1 Workshops on the Register (s. 131) at the end of the year:— Factories 24 Workshops, including laundries and bakehouses, including two outworkers workshops 125 Domestic Workshops, including four outworkers workshops 90 Workplaces 16 Total number of workshops on Register 255 Table I. Vital Statistics of Whole District during 1905 and previous years. Year. Estimated Population to middle of year. Births. Total Deaths Registered Total Deaths in public institutions in District Deathsof non resid'ts regist'd in public institutions in District Deaths of residents regist'd in public institutions beyond District Deaths at All Ages (Nett). under 1 year. at all ages. N'mber Rate. N'mber Rate per 1000 births. N'mber Rate. N'mber Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1895 27,895 862 30.9 108 125.0 564 201 ... 83 ... 481 17.2 1896 28,325 790 27.8 119 1506 521 18 3 ... 110 ... 411 14.4 1897 28,765 729 25.3 96 1316 491 170 .. 101 ... 390 13.5 1898 29,185 817 27.7 146 172.5 598 20.4 196 130 ... 468 16.0 1899 29,607 931 81.4 144 154.6 678 22.8 216 151 ... 527 17.7 1900 30,040 813 27.0 127 156.2 682 23.0 262 163 ... 529 17.6 1901 30,959 874 28.5 140 160.1 678 21.8 232 191 ... 487 15.7 1902 31,531 932 29.5 146 1566 734 23.3 300 210 ... 524 16.6 1903 32,075 1055 32.8 104 98.5 634 19.7 262 179 ... 455 14.1 1904 32,630 1057 32.3 179 169.3 750 22.9 290 200 ... 550 16.8 Av. for 95.1904 30,101 882 293 130 148.4 619 20.5 ... 158 ... 462 15.3 1905 33,194 1030 28.8 141 136.8 675 19.2 ... 220 452 13.6 *Rates in Columns 4, 8, and 13 calculated per 1000 of estimated population. Note.—The deaths to be included in Column 7 of this table are the whole of those registered during the year as having actually occurred within the district or division. The deaths to be included in Column 12 are the number in Column 7, corrected by the substraction of the number in Column 10 and the addition of the number in Column 11. By the term "Non-residents" is meant persons brought into the district on account of sickness or infirmity, and dying in public institutions there; and by the term "Residents" is meant persons who have been taken out of the district on account of sickness or infirmity, and have died in public institutions elsewhere. The "Public institutions" to be taken into account for the purposes of these Tables are those into which persons are habitually received on account of sickness or infirmity, such as hospitals, workhouses and lunatic asylums. (These are; Mogden Isolation Hospital, Hounslow Hospital, Dockwell Smallpox Hospital, Union Infirmary, Isleworth, and Wyke House Asylum). Total population at all ages, 30,863. Number of inhabited houses, 5,684. At Census of 1901. Average number of persons per house, 5.4. Area of District in acres (exclusive of area covered by water) 6,859. Table II. Vital Statistics of separate Localities in 1905 and previous years. NAMES OP LOCALITIES. Parish of Heston. 1 Parish of Isleworth. 2 Year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year. Population estimated at middle of each year. Births registered. eaths at all ages. Deaths under 1 year. 1894 1895 NO PREVIOUS RECORD. NO PREVIOUS RECORD 1896 1897 1898 1899 1900 1901 1902 11108 20423 1903 11205 20870 1904 11305 305 152 41 21325 690 398 126 1905 11405 337 143 38 21788 647 309 87 Table III. CASES OF INFECTIOUS DISEASE Notified during the year 1905. Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in each Locality. No. of Cases Removed to Hospital. At all ages At Ages—Years. Hounslow North Ward. Hounslow South Ward. Heston. Isleworth. Union Infirmary. Under 1 1 to 5 5 to 15 15 to 25 25 to 65 65 and upw'ds Smallpox ... ... ... ... ... ... ... ... ... ... ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria 105 25 62 11 7 ... ... ... ... ... ... 87 Memb. Croup ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas 33 ... 3 1 1 22 6 ... ... ... ... ... ... Scarlet Fever 85 1 23 51 8 2 ... ... ... ... ... ... 77 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever 8 ... ... 2 1 5 ... ... ... ... ... ... 2 Relapsing Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Continued Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever 2 ... ... ... ... 2 ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... ... ... ... 233 1 51 116 21 38 6 ... ... ... ... ... 166 Isolation Hospitals: Mogden and Dockwell (Smallpox). Joint Hospitals for Heston-Isleworth and Richmond, Surrey. Table IV. Causes of, and Ages at, Death during 1905. Causes of Death. Deaths in whole District at subjoined Ages. (Residents only.) Deaths in Localities at all ages Total Deaths in Public Institutions in the District. All ages. Under 1. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 62. 65 and upwards. Parish of Heston. Parish of Isleworth Smallpox ... ... ... ... ... ... ... ... ... ... Measles .. ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... Whooping-cough 8 5 3 ... ... ... ... ... ... ... Diphtheria and Membranous Croup 13 ... 7 6 ... ... ... ... ... 14 Croup Fever 1 ... ... 1 ... ... ... ... ... 1 Typhus ... ... ... ... ... ... ... ... ... ... Enteric ... ... ... ... ... ... ... ... ... 1 Other continued ... ... ... ... ... ... ... ... ... ... Influenza 5 ... ... ... ... 3 1 ... ... ... Cholera ... ... ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... ... ... Diarrhoea 43 32 5 ... ... ... 6 ... ... 4 Enteritis 1 ... ... 1 ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... ... 2 Erysipelas 1 1 ... ... ... ... ... ... ... 3 Other septic diseases 12 2 ... 2 ... 4 4 ... ... 13 Phthisis (Pulmonary Tuberculosis) 30 ... ... ... 7 21 2 ... ... 45 Other tubercular diseases 9 4 2 2 1 ... ... ... ... 6 Cancer, malignant disease 19 ... ... ... ... 10 9 ... ... 17 Bronchitis 31 6 3 ... ... 6 16 ... 19 19 Pneumonia 34 4 3 4 5 12 6 ... ... 8 Pleurisy ... ... ... ... ... ... ... ... ... ... Other diseases of Respiratory Organs 1 ... ... ... ... 1 ... ... ... 3 Alcoholism Cirrhosis of Liver 12 ... 1 ... ... 9 2 ... ... 7 Venereal Diseases 1 1 ... ... ... ... ... ... ... 1 Premature Birth 19 19 ... ... ... ... ... ... ... ... Diseases and Accidents of Parturi- 3 1 ... ... 1 1 ... ... ... 1 Heart Diseases 40 4 ... ... 1 21 14 ... ... 18 Accidents 5 ... ... 2 ... 2 1 ... ... 3 Suicides 12 ... ... ... 1 10 1 ... ... 3 Broncho-Pneumonia 16 9 5 ... ... ... 2 ... ... 4 Senectus 23 ... ... ... ... ... 23 ... ... 29 All other causes 113 37 2 3 6 33 32 ... ... 88 All causes 452 125 31 21 23 133 119 ... ... 289 Table V. INFANTILE MORTALITY DURING THE YEAR 1905. Deaths from stated Causes in Weeks and Months under One Year of Age CAUSE OF DEATH. Under 1 Week. 1—2 Weeks. 2—3 Weeks. 3—4 Weeks. Total under 1 Month. 1—2 Months. 2—3 Months. 3—4 Months. 4—5 Months. 5—6 Months. 6—7 Months. 7—8 Months. 8—9 Months. 9—10 Months. 10—11 Months. 11—12 Months. Total Deaths under One Year. All Causes. Certified 28 3 4 35 19 9 7 9 9 11 4 6 7 6 2 124 Uncertified 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Common Infectious Diseases. Small-pox Cnicken-pox Measles Scarlet Fever Diphtheria: Croup Whooping Cough ... ... ... ... ... ... ... 1 ... 1 ... ... 1 ... 1 1 5 Diarrhoeal Diseases. Diarrhoea, all forms ... ... 2 ... 2 3 2 4 4 4 5 2 1 3 1 1 32 Enteritis (not Tuberculous) Gastritis, Gastrointestinal Catarrh Wasting Diseases. Premature Birth 17 ... 1 ... 8 ... 1 ... ... ... ... ... ... ... ... ... 19 Congenital Defects 5 ... ... ... 5 1 ... ... ... ... ... ... ... ... ... ... 6 Injury at Birth 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Want of Breast-milk Atrophy, Debility, Marasmus 3 ... 1 ... 4 7 1 1 1 ... ... ... ... 1 ... 15 Tuberculous Diseases. Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 1 Tuberculous Peritonitis Tabes Mesenterica ... ... ... ... ... 1 1 ... 1 ... ... ... 1 ... ... ... 4 Other Tuberculous Diseases Erysipelas Syphilis ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 Rickets ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... 1 ... 1 ... ... 1 ... ... 3 Convulsions 2 1 ... ... 3 4 1 1 1 1 1 1 1 ... ... ... 14 Bronchitis ... ... ... ... ... 1 ... ... 1 1 ... ... ... 1 2 ... 6 Laryngitis Pneumonia ... ... ... ... ... ... 1 ... ... 1 1 ... ... ... 1 ... 4 Suffocation, overlaying Other Causes 1 2 ... ... 3 2 ... 1 ... ... 3 1 1 2 ... ... 13 29 3 4 36 19 9 7 9 9 11 4 6 7 6 2 125 Population (estimated to middle of 1905) 33,194. Births in the lear :—Legitimate 950; Illegitimate 34. Deaths from all Causes at all Ages—452. *The Children of Residents only are included in this Table. LIST OF DAIRIES, COWSHEDS, AND MILKSELLERS IN THE DISTRICT, Year ending December 31st, 1905. No. Name of Occupier. Address. Dairy. Cowsheds and Position. Number of Cows. Milk Supply. 1 Arnold, J. Steele Road, Isleworth 1 (1) 1 at rear of premises. Dairy, basement 14 Own cows and Taunton Dairy Co. 2 Baker, A. H. New Heston 1 (2) .. Taylor, Cranford 3 Best, Mrs. M. Barrack Road, Hounslow - (3) .. J. W. Weekly, Hounslow Heath. 4 Bignell, H. Heston Road, Lampton 1 1 at rear of premises 3 Own cows 5 Blanchard, F. Kingsley Road, Hounslow (3) ... Denew, Isleworth 6 Bishop, T. Richmond Road, Isleworth 1 ... Arnold, Isleworth 7 Bodger, T. & A. Lower Square, Isleworth 1 (1) 1 at rear of premises 2 Own cows. Peebles, Brentford, & Taylor, Cran- 8 Breed, J. A. Staines Road, Hounslow ... (2) ... J. W. Weekley, Hounslow Heath (ford. 9 Butler, H. B. London Road, Hounslow 1 1 at rear of premises 9 Own cows 10 Coleman, S. Connell, G. London Road, Brentford End. ... (2) ... Callow Park Dairy Co. 11 South Street, Iblewort 1 (2) 1 at rear of premises 1 Own cows and Bodger, Isleworth 12 Cook, A. E. Linkfield Road, Isleworth — (3) ... Arnold, Isleworth 13 Davis, R. H. Barrack Road, Hounslow 1 (2) Taylor, Cranford 14 Debenliam, G. St. John's Road. Isleworth 1 (2) ... Goodenough, Isleworth, and Whiteman & Cox 15 Denew, G. London Road, Isleworth 1 ... Dairy Supply Co. 16 East, W. St. Margaret's Road, Isleworth 1 (2) ... Arnold, Isleworth 17 Eve, W. Han worth Road, Hounslow — (3) Dairy Supply Co. 18 Finch, W. South Street, Isleworth 1(1) 1 at rear of premises 3 Own cows and Dairy Supply Co. 19 Giltrow, F. High Street, Hounslow ... (2) ... Teale, Hounslow 20 Goodenough, E. Wyke Green, Isleworth 1 3 at rear of premises 30 Own cows 21 Gray, C. High Street, Hounslow ... (2) ... Parish, Hounslow 22 Hole, T. 0. Albion Road, Hounslow 1 (3) ... Taylor, Cranford 23 Howard, F. W. Grove Road, Hounslow 1 ... Taylor, Cranford 24 Kite, E. Osborne Road, Hounslow ... Tuckett, Alton, and Gillingham Dairy Co. 25 Lethbridge, F. Whitton Road, Hounslow 1 (1) 1 at Whitton Park 2 Taylor, Cranford 26 Mallage, J. H. London Road, Brentford End. ... (2) ... Own cows and Taylor, Cranford 27 Montgomery, C. Barrack Road, Hounslow ... (3) ... Vicars, Brentford 28 Neville, W. Lances Road, Hounslow 1 (1) 1 at rear of premises 2 Young, Hounslow 29 Newman, A. High Street, Hounslow 1 (1) ... Own cows and Harman, Wokingham 30 Overton, C. London Road, Brentford End. ... (2) ... Taylor, Cranford 31 Palmer, J. A. Haliburton Boad, Isleworth ... (3) ... Eves, Brentford 32 Parish, T. A. Whitton Road, Hounslow 1 (1) 2 at rear of premises 2 Arnold, Isleworth 33 Philp, T. A. Linkfield Road, Isleworth (3) 1 ... Own cows and Taylor, Cranford 34 Peebles, P. Syon House, Isleworth 1 at Syon House, Isleworth 4 Dairy Supply Co. 35 Price, D. High Street, Hounslow 1 (2) ... Own cows 36 Rehm, 0. Bell Road, Hounslow - (3) ... Dairy Supply Co. 37 Roberts, H. Staines Road, Hounslow 1 (1) ... Denew, Isleworth 38 Rouse, S. Staines Road, Hounslow 1 (2) 1 at Benns Common, Hounslow Heath 10 Andrews, Hanworth, Middx. 39 Sahler, H. The Square, Isleworth .. (2) ... Own cows, and Pridiaux, Dorset 40 Slieppard, E. Vine Place, Hounslow ... (3) ... Arnold, Isleworth 41 Simmonds, A. Lower Square, Isleworth 1 (1) ... Rouse, Hounslow 42 Stevens, A. C. High Street, Hounslow ... (2) 1 ... Whiteman & Cox 43 Teale, E. A. Bath Road, Hounslow 3 at rear of premises 30 Taylor, Cranford 44 Turner, J. S. Whitton Road, Hounslow ... (2) ... Own cows 45 Upson, J. G. Cromwell Road, Hounelow - (3) 1 ... Neville, Hounslow 46 Vincent, G. London Road, Isleworih ... Taylor, Cranford 47 48 Weekley, A. J. Han worth Road, Hounslow 1 (1) ... „ „ Weekley, J. W. Hounslow Heath 1 ... „ „ 49 Willcox, J. Ealing ... 1 at Osterley Park 30 Own cows 50 Winn, A. Star Road, Hounslow ...'(3) ... Butler, Hounslow 51 Witt, A. Talbot Road, Isleworth ...(3) Arnold, Isleworth 52 Woollard & Son Staines Road. Hounslow I (I) ... Taylor, Cranford (1) Shop. (2) Selling other goods (Confectionery fcc.) (3) General Dealer. Number of Cowsheds discontinued for Dairy purposes, 4. Number of Cowsheds rendered fit and again registered, 1. „ Shops discontinued the sale of Milk, 8. Previously registered, 2. Placed on Register this year, 6. ,, ,, placed on Register, 9. 12 changes as to occupier have taken place. LIST OF SLAUGHTER HOUSES IN THE DISTRICT During the Year 1905. No. Registered or Licensed. Name of Licensee. Address of Licensee. Situation of Slaughter House. 1 Registered Arnold, William 49, High Street, Hounslow At rear of Premises 2 „ Balch, J. A. 74, South Street, Isleworth „ „ 3 „ Bazeley, Albert U. London Road, Spring Grove „ „ 4 „ Finch, W. P. 197, High Street, Hounslow „ „ 5 „ Finch, F. 113, High Street, Hounslow „ „ 6 „ Hunt, Charles Albany Terrace, Bell Road, Hounslow „ „ 7 Licensed Mash, George Heath Place, Staines Road, Hounslow „ „ 8 Registered Payne, John Aberdeen House, Bell Road, Hounslow .. „ „ 9 „ Roadnight, Thomas 269, High Street, Hounslow „ „ 10 „ Weekly, A. J Woodford Terrace, Hanworth Road, Hounslow „ „ 11 „ Welch, Frederick 86, High Street, Hounslow „ „ 12 „ Woods, Richard J. 173, High Street, Hounslow „ „ 13 „ Yates, Frederick C. 23, Turks Road, St. Margarets London House, Wellington Road North, Hounslow 14 Licensed Young, Jesse Fern Dairy, Hanworth Road, Hounslow At rear of Premises. LIST OF BAKEHOUSES IN THE URBAN DISTRICT OF HESTON AND ISLEWORTH. Year ending December 31st, 1905. No. ADDRESS Position OCCUPIER Level of floor. SANITAION W.C. Sleeping Place. Remarks. Drainage Water Supply 1 New Heston A Paynter & Harle C Con. Co. off main F None near Old, fair. 2 Poplar Cottages, Han worth Road, Hounslow B C. Jefferyes D 6in. E G.I. tank F „ Do. 3 195, High Street, Hounslow B Beckman Bros. C E Pump F „ Old. 4 Post Office, Bath Road, Hounslow A S. J. Carden and S. May C E G.I. tank F „ Not in use, old. 5 26, High Street, Hounslow A T. Cox D 6in. E J J F „ Good condition. 6 4, Heath Place, Staines Road, Hounslow ... A W. Butler C E 9 9 F „ New, fair. 7 High Road, Heston A S. Carter D 6in. E 9 9 F „ Old, fair. 8 High Road, Heston Aa S. Carter D ift. E 9 9 F 2 Do. 9 26, South Street, Isleworth A J. Chapman C E 9 9 F 2 Do. 10 The Bakery, Staines Road, Hounslow A The Misses N. & M. Chapman D 3m. E 9 9 F „ Do. 11 The Bakery, Wellington Road, N., Hounslow A A. Baxter C E „ F 2 New, fair. 12 66, High Street, Hounslow A Sherwin Bros. C E „ F „ Old, fair, not in use. 13 Adeline Place, Staines Road, Hounslow B J. Groves C E 2 F „ New, fair. 14 13, The Square, Isleworth B E. W. Gunner C E „ F „ Old, fair. 15 Wivenhoe House, Hanworth Road, Hounslow A D. Pullen D 3m. E „ F „ Old. 16 112 and 114, High Street, Hounslow Aa W. F. Lovejoy C E 2 F „ Good, patent hot-air ovens. 17 Inwood Road, Hounslow B A. J. Carden and S. May C E „ F „ Fair. 18 68, South Street, Isleworth B J. Skinner (Mrs.) C E 2 F „ Old, small. 19 46, London Road, Brentford End B A. 0. Gregory C E „ F „ Old, fair. 20 1, Tryon Place, Lampton, Heston Aa Paynter and Harle C E Co. off main F „ Not in use. 21 39, Whitton Road, Hounslow Aa J. T. Richardson ... C E G.I. tank F „ Fair. 22 3, York Place, Staines Road, Hounslow ... A Coates' Bakeries Co., Ltd. D 3m. E „ F „ Old, fair, not in use. 23 Arundel House, St. Margaret's Road,Isleworth A J. B. Cox C E „ F „ Fair. 24 1, Upper Square, Isleworth B II. Sahler C E „ F „ Old, fair. 25 1, Upper Square, Isleworth Aa H. Sahler C E „ F „ Do. 26 if Pembroke Place, London Road, Isleworth A H. K. Scherer D E „ F „ Only underground bakers in district, 27 21, London Road, Brentford End A R. Skilton C E „ F „ Old. (good & well ventilated. 28 5, South Street, Isleworth B Thomas Stracy C E „ F „ Old, unoccupied Dec. quarter. 29 Shropshire House, Staines Road, Hounslow A Coates' Bakeries, Ltd. C E „ F „ Machine mixer, good condition. 3° 7, Woodford Terrace, Hanworth Road, ,, A W. J. Hankin C E „ F „y Old, fair. 31 Hanworth Road, Hounslow A B. Etches C E „ F 2y Fair. 32 180, High Street, Hounslow B W. & E. Wells C E „ F „ Old, good. 33 15, Linkfield Road, Isleworth B H. A. Sapsford C E „ F „ Good, patent hot-air oven. 34 Hanworth Road, Hounslow B Charles Morris C E „ F „ Good condition. 35 159, High Street, Hounslow B F. Giltrow C E „ F „ Good, built 1901. 36 4, Midsummer Place, Staines Road, Hounslow J. A. Breed Fair, built 1904. A.—Attached and communicating with dwelling-house and shop. Aa.—Attached but not communicating with dwelling-house and shop. B.—Detached. C.—Above road level. D.—Below road level. E.—Connected with Council's sewer. F.—Not connected or communicating with Bakehouse or tank serving w.c. Bakehouses not in use—Nos. 4, 12, 20, 22. C1. HESTON AND ISLEWORTH URBAN DISTRICT. Sanitary Work, 1905. Inspections. Notices. Dwelling Houses. Houses let in separate Dwellings or Lodgings. Common Lodging Houses. Canal Boats used as Dwellings. Movable Dwellings, Caravans, Tents, &c. Workshops and Workplaces. Number of Premises inspected on complaint. Number of Premises Inspected in connection with Infectious Diseases. Number of Premises under periodical Inspection. Houses Inspected from House-to-House. Total Number of Houses, Premises, &c., Inspected. autionary Notices Given. atutory Orders Issued. Summonses Served. Convictions Obtained. Houses, Premises, &c., Cleansed, Repaired, &c Closed as Unfit for Habitation. Re-opened after Repairs, Alterations, &c. Demolished. Illegal Underground Dwellings Vacated. Number Registered under Bye-laws. Number of Contraventions. Number Registered under Bye-laws. Number of Contraventions. Number Registered under the Acts. Number of Contraventions of Regulations. Number Observed during the Year. Number of Nuisances therefrom Abated. Number Removed from District. Number in District Contraventions of Factory Acts. 101 200 330 814 10539 3211 341 4 4 318 9 0 0 0 2 6 2 2 0 43 190 21 31 209 73 Excluding Union Cases. Including 704 Verbal Notices. 2 Recovery of expenses incurred under Section 36. 1 Ditto, Section 41. 1 Order to close polluted well. C2. HESTON AND ISLEWORTH URBAN DISTRICT. Sanitary Work, 1905. Laundries. Bakehouses. Slaughterhouses. Cow-sheds. Dairies and Milk-shops. Unsound Food. Adulterated Food. Offensive trades. Water Supply and Water Service. Number in District. Contraventions of Factory Acts. Number in District. Contraventions of Factory Acts. Number on Register. Contraventions of Bye-laws. Number on Register. Contraventions of Bye-laws. Number on Register. Contraventions of Bye-laws, Animals seized. Articles or Parcels seized. Articles or Parcels surrendered. Samples taken. Found adulterated. Number of premises in District. Contraventions of Bye-Laws. Wells. Percentage of Houses supplied from Mains. Cisterns. Draw-Taps removed from Cisterns to Mains. Percentage of Houses supplied on constant system. New, Sunk. Cleansed, Repaired, etc. Closed as Polluted. New, Provided. Cleansed, Repaired, Covered, etc. Overflow Pipes disconnected from Drains. 14 11 32 41 14 6 19 7 51 9 0 0 82 0 0 0 0 0 1 2 99 3 85 0 1 100 72 pigs kidnies. 8 sheeps "plucks." Company's water laid into 3 houses in consequence of closure of wells. C3. HESTON AND ISLEWORTH URBAN DISTRICT. Sanitary Work, 1905. Drainage and Sewerage. Disinfection. Dust. Sundry Nuisances Abated. Water Closets. Percentage of Houses provided with Water Closets. Drains. Cesspools. Percentage of Houses draining into Sewers. Rooms disinfeted Rooms stripped and cleansed. Articles disinfected or destroyed. New bins provided. Periodical frequency of dust removal. Number of complaints of non-removal received (by Health Dept. only). Overcrowding. Smoke. Accumulations of refuse. Foul ditches, ponds, etc., and stagnant water. Foul pigs and other animals. Dampness. Other Nuisances. New, Constructed. Number of Water Closets substituted for Dry Recept acles. Repaired, Supplied with Water or otherwise improved. Examined, Tested, Exposed, etc. Unstopped, Repaired, Trapped, etc. Waste Pipes. Rain Water Pipes, disconnected, repaired, etc. Soil Pipes and Drains ventila ed. Disconnecting Traps or Chambers Inserted. Reconstructed. Rendered Impervious, Emptied, Cleansed, etc. Abolished, and Drain connected to Sewer. 1 - 311 98 789 670 275 45 1 12 1 98 198 - 2970 116 Every 8 days. 52 12 3 593 9 9 515 5 Exclusive of 17 Urinals improved, etc. 559 repaired. Ill unstopped, etc. 218 repaired. 57 dis-connected. Including alterations of 31 vent pipes. Including 4 new laid. Exclusive of 26 rendered efficient. 1 Collection carried out by Surveyor's Department. 112roofs repaired, 110yards. paved & dra ined, 28 gutter ing provided & repaired, 66 ventilation below floor provided.— THE MEDIVAL INSPECTION Extract from a letter written to a member of the Education Committee. The Medical Inspection of the children in the elementary public schools, which during the early part of the year was a somewhat prominent question in this district, seems to have been shelved since April, and to be in danger of being forgotten unless attention is again drawn to it. The opposition to the appointment of a Medical Officer to the Schools and the objections brought forward against it were mainly based on the arguments that the appointment was not necessary, and that the expense would be very great. To my mind this matter is far too important to be dropped, because it does not meet with the approval of the majority, and I trust that you will not think that I am exceeding my duty in again bringing it forward, and pointing out certain facts and figures for your consideration. When the subject was first dissussed, the Education Committee did me the honour to consult me with regard to the general idea and some of the details. This, and the fact that I take a very deep interest in the question, must be my excuse for again referring to it without being invited to do so. At that time, I think it was assumed by many members of« both the Education Committee and the Council that the question of the Medical Inspection of school children was an entirely new idea; that it was more theoretical than practical; and that it would be well to wait and see if any other authority took it up before considering it in this district. The recent publication of the Eeport of the Departmental Committee appointed to inquire into the Medical Inspection of children in public elementary schools, shows that long before the matter had even been thought of in this district many other places had already adopted means to carry it out. This Eeport will doubtless receive the careful attention of the Education Committee, if it has not already done so, and I need not therefore weary you by quoting it in detail. I would only ask you to allow me to refer briefly to some parts of it that seem to me to be of particular interest. iv. In the first place it must be remembered that the terms of reference drawn up by the President of the Board of Education, instructed the Committee to ascertain and report ou what is now being done and with what result in respect of Medical Inspection, and that it was no part of the duty of the members of the Committee to express any opinion, or make any recommendations. The Report in consequence is essentially a statement of fact. Any central action that may be taken on it remains for the Board of Education itself, and I think that it needs no special gift of foresight to believe that in all probabilty it will become at no far distant date the recognised duty of all local education authorities to make provision for the physical as well as the mental well-being of the children uoder their charge. The Report makes it quite clear that education authorities have the power to appoint and pay Medical Officers, (Vol. 1, page 2, par. 6.) and this disposes of one of the points urged agaiust such an appointment here. In speaking of this Report, which really consists of two parts (1) that dealing with the medical inspection of school children, and (2) with the feeding of them, I refer only to the first With the second part I am not now concerned, though I do not in the least undervalue its importance. After reading the Report, I think any open-minded person cannot fail to be impressed by several rather striking general conclusions. One is the success that has attended nearly all the attempts made by various authorities to deal with the physical condition of the children by instituting medical inspection, and this in spite of the fact that the large majority of them were simply experimental, and had only been in operation a comparatively short time when the Report was issued. Another point, and in my opinion the most important in the whole Report, is that diagnosis, not treatment, is the function of the School Medical Officer. It is brought out over and over again in the Report, and is summed up clearly in the following statement : The existence of the defect or ailment is discovered, and the parent is notified of the fact. It is his duty to take steps to get the necessary remedy applied." (Vol. 1, page 3, par. 11). I should like you to take special note of this point, because one of the strongest arguments urged against the appointment of a Medical Officer for our Schools was the belief that it was no good dissovering defects unless the education V. authority was prepared to treat them, and that this would lead to enormous expense. So it probably would, if there was any such intention, but my suggestions contained nothing of the sort, and treatment was never in any way part of the scheme. I have already gone fully into this question, both before the Education Committee and elsewhere, but I should like to take this opportunity to state clearly what I think to be the right view of the matter. Untreated defects or ailments in children may be due to one or more of three causes :— 1. Ignorance of the existence of such ailment or defect. 2. Want of knowledge that these ailments or defects may increase and become a serious handicap to the child in later life if not treated in time. 3. Neglect in obtaining proper medical advice. I intentionally exclude poverty from my list of causes, though I am aware that it is an apparent cause that many would place first. Want of means to pay for medical attendance or advice is no excuse in this country for failing to obtain them for any child in need of them. Even if the parent should hesitate to apply to the Poor Law Guardians, there are out-patient departments at nearly all hospitals where skilled advice can be had for the asking, and in addition there are many charitable societies and parish organisations that exist to help the poor to obtain for themselves and their children any surgical apparatus that may be ordered by a doctor. As a matter of fact no serious surgical case would ever be likely to come under the notice of a School Doctor, for it would have already been obvious to the untrained parent. Hospital experience teaches that the great majority of parents of the poorest class eagerly avail themselves of all the medical help they can get for the treatment of such of their children's diseases as they can detect. Practically the Only thing that systematic inspection of the School children would reveal that had not already been noticed, and that required surgical apparatus would be defects of eyesight necessitating the use of spectacles. My first class is the one to which I attach by far the most importance, and I base this opinion on a not inconsiderable experience of medical work amongst the poor. vi. There are many congenital or acquired defects in children that are not suspected and not found unless specially looked for, and some of them are of a very serious nature. If a child is apparently in good health few parents would consider it necessary to have it examined for abnormalities, yet the defect may be there, and when later on it has made itself apparent, a cure may be far more difficult or perhaps impossible. In most Schools, other than pnblic elementary ones, every boy or girl on entry is carefully examined by the School Doctor as a matter of routine, or a report on the child's physical condition is sent by the family medical attendant. Amongst the poor this is seldom done, for it is nobody's duty unless the education authority undertakes it. The matter is really of national importance, for there can be few if any doctors whose business has been to examine recruits for the Army who have not been struck by the large number of young men who have to be rejected on account of some, physical defect that might have been remedied if it had been discovered in childhood. This aspect of the question is perhaps somewhat out of place here just at present; I only refer to it to point out that the medical inspection of children is a matter of more than mere local interest. Both the Royal Commission on Physical Training and the Committee on Physical Deterioration reported very definitely on its importance from a national point of view. I have no desire to enter too fully into medical details, but it might perhaps be useful to discuss a few general defects that appear to me to call particularly for investigation. Three of these are obvious, namely, eyesight, hearing and teeth. Eyesight. Certain defects, such as squint, cataract, etc., are so easily recognised that the parent cannot fail to notice them. It is the functional defect that has to be searched for, and most of these functional faults are errors of refraction that cannot be noticed or detected except by a skilled observer. A child may be long-sighted or short-sighted, and still be able to see apparently as well as any other normal child of similar age, but he is only able to do this by an unconscious exertion of muscular power in accommodating the eye. In other words, it is only by extra exertion that this child is able to focus vii. objects. He does not know that he is working harder than other children to see, but the effect of the strain is revealed by headaches and weariness, and eventually by the defect in the eyesight becoming too great for the natural powers of accommodation to overcome. Proper lens would not only remove the strain, but in most cases would cure the condition. It does not follow that because a person has to wear spectacles for some years in childhood that he will have to wear them all his life. But the error of refraction does not cure itself, and tends to become worse if left untreated. I have little doubt that nearly all parents would themselves take steps to rectify these errors did they but know of them. It is surely the duty of the Education Authority, which stands in loco parentis to the child, to discover and point them out. In the great majority of these cases the glasses required would be of a simple kind, and the cost of a pair of spectacles probably not more than a few shillings, perhaps from 2/6 to 3/6 a pair. The question of the provision of spectacles is considered in the Report, and various instances are quoted where arrangements are made to assist the parent too poor to buy them unaided. (Vol. I., page 28, par. 105). The plans adopted at Bolton and Salford seem to be the most practicable, as by them the parent eventually pays the whole cost, and probably therefore takes care that they are properly used. Defective Hearing and Teeth. Defective hearing is not so common as faulty eyesight, and the proportion of cases in which treatment shows immediately beneficial results is far smaller. Nevertheless there are a few cases in which the deafness can be remedied by simple means, such for instance as those due to adenoid growths, but I am not enthusiastic enough to expect any very great general benefit to result from medical inspection of children with defective hearing. Nor do I anticipate that much improvement would result from inspection of the teeth of the children, becausc I am not prepared to urge the appointment of a School Dentist. But it is an undoubted fact that defective teeth are a frequent cause of ill-heath, and that many young adults, in all other respects perfectly fit, are annually refused entry into the Army on account of bad teeth. The greatest benefit that would result from periodical inspection of teeth would be noticed after the children had been taught how to take proper care of them and to keep them clean. viii. There are three other medical points of a general character not specially mentioned in the Report, to which I should like to allude ; three defects that may exist in any child without the parent being aware of the fact. These are Heart Disease, Hernia and Lung Disease. Heart Disease. This may be either congenital or acquired, that is the child may have been born with some organic defect in the valves of the heart, or such defect may have developed after some strain or illness such as Rheumatic Fever. In either case the fact that the child has a weak heart may not be known till it faints or becomes ill on any sudden or unusual exertion, and till then nobody knows that extra exertion is bad for the child, and in some cases might even be fatal. A very brief examination with a stethoscope would at once defect the abnormality. Hernia. Many boys, and some girls, are ruptured, or have a condition predisposing to hernia. Probably in most cases this is known to the parent and the School Teacher may have been told, but it is surprising how many children there are in whom this serious defect is only found on being specially looked for. These two conditions, Heart Disease and Hernia, are specially important in view of the fact that physical exercises, drill and gymnastics in some form or other are now compulsory in all our Schools in this district. It seems to me that the Education Committee is running a grave risk in insisting that every child must take violent exercise without first being satisfied that they are not subjecting the child to any danger by so doing. Lung Disease. This condition is one of less direct moment than the other two. It is, I think, one that affects the general community of the Schools more than the individual child. The only disease of the lungs that need be considered now is consumption. I have no means of estimating the proportion of children in our Schools affected with pulmonary tuberculosis, but I imagine that it is small. But however small the total number of children may be, it must be remembered that consumption is an infectious disease, and even one child suffering from it is a possible source of danger to others, and should be excluded. An advanced case of consumption is obvious to all, but it requires skilled examination to detect one in an early stage. IX. Turning now from the general aspect of the question of medical inspection, it may be well to consider it more particularly with reference to our own district, and its importance in connection with certain specific diseases. The history of the proposed appointment of a School Doctor by the Education Committee, the various stages the matter has passed through, and its present position is fully stated in Appendix I. of the Second Annual Report of the Education Committee, published in April, 1905. The proposed duties of the Medical Officer there set out, are practically those that I suggested to the Committee, but they were drawn up on the assumption that the doctor appointed would give up his whole time to the work. I am still of the opinion that a whole-time doctor for the Schools in this district would find plenty of work to keep him very fully occupied, but I think that the time is not yet ripe to ask for this, and that the ratepayer will have gradually to be shown the good that would result, and be educated to understand the importance of medical inspection, before he will cease to oppose such an appointment. A part-time doctor would probably not be objected to, and might even be approved of by some of the more enlightened inhabitants. Half a loaf being better than no bread, I think those members of the Committee who supported the original idea, might modify their views and be content for the present with a more limited one. This would of course necessitate a modification of the scheme of duties to be carried out. A definite schema cannot be properly made till the amount of time that the Medical Officer would be expected to devote to it has been settled, but there are certain main points to be insisted on, leaving the details to be arranged later on. I suggest the following, simply as the basis for discussion:— The duties of a Medical School Inspector may be divided into three chief groups:— 1. The general inspection of the children and teachers in the schools. 2. The special inspection of the abnormal and unhealthy. 3. Detective and preventive measures in connection with infectious diseases. (1). The ideal thing under the first of these headings would be a careful and systematic anthropometrical survey of every child every year, including records of weight, height, chest measurement and details of the physical development X. of each individual child during its School life. I am Utopian enough to believe that some time in the future this will be done in every Elementary School in the country, and that the Government grant will be based just as much on the physical progress of the child as it now is on the mental. It is of course impossible now, and absolutely out of the question here, but the importance of such a survey has been recognised by the highest authorities both as a " means for ascertaining the facts of National physique and the means that may be adopted for its improvement, and for retarding such deterioration as may be in progress." For the present all that could be aimed at in this direction in this district would be a very general inspection, intended in the first instance for the weeding-out of the unfit, and the selection of certain children for subsequent more detailed examination. Later on it might be possible for each child to be examined at least once with some care, and possibly the best time for this would be when it passed from the infant department into the Schools. A skilled medical examiner can satisfy himself in a very few minutes that a child has no special defect, and the details of height and chest measurement, and even a rough but fairly accurate test of the sight can be made and entered in the record by a non-medical assistant, such as a junior teacher, acting under instruction. (2). The special examination of the abnormal and unhealthy would deal with two classes of cases, apart from those coming under the third heading. One of these includes those children suffering from defects of eyesight, weak heart, etc., which I have already considered. The other, children affected with Ringworm, Itch and verminous heads, and those in a condition of general uncleanliness. Ringworm and parasites in the hair or skin are difficult conditions to deal with, because the cure demands energetic treatment, and the mere fact that the parent has sent the child to school suffering from a condition not requiring skilled observation to detect proves in most cases that the parent is negligent. The method to be adopted in this district with regard to such cases would require careful consideration. The necsssity of doing something is so obvious that I need not insist on it here. The question is referred to at some length in the Report (Vol. 1, pages 24 and 25, pars. 94, 95 and 96). xi. (3). Infectious Diseases. Before entering into this question I would point out that the statement on page 98 of the first volume of the Report, to the effect that nothing is being done in this district with regard to medical matters connected with the children in the Schools is not quite correct. A system of voluntary notification between the head teacher of each School and the Health Department is in force, and has been for some years. If a child is absent from School on account of what the teacher has reason to think is some infectious disease, or is sent home because the teacher thinks it is suffering from some such disease, the teacher sends a notification to the Health Department on a form supplied by the Department, giving the name and address of the child. When a case of infectious disease is notified officially to the Department, a printed notice is sent to the head teacher, informing him that a certain child attending his School is sufferring from an infectious disease, and that it and all other children in the same house or family must be excluded for a stated period. This is all that can be done under the powers possessed by the Medical Officer of Health at present, and the notifications received from the teachers are not nearly so numerous as I should like them to be. It is not part of the duty of the teachers to send these notifications, and I am afraid that except in times of epidemics they very often forget to do so. I in no way blame the teachers. They do all they have time for, cousidering that they have no definite instructions in connection with medical inspection, and I have always received from them the most willing help and co-operation whenever I have had occasion to visit any of the schools. There are four specific infectious diseases to which children are peculiarly liable—namely, Scarlet Fever, Diphtheria, Measles and Chicken-pox, and the work of the Medical Officer to the Schools in connection with them would form the most important part of his duties, and the part from which the first good results would be seen. Only two of these, Scarlet Fever and Diphtheria, are notified officially under the Act to me in this district, but of the infectious diseases that the Health Department has to investigate they are of primary importance. The great majority of the cases of these two diseases notified are children attending the public elementary schools, and they form a large percentage of the patients admitted to Mogden Hospital. The other two are not notifiable in this district, and therefore cases of them do not come to my notice officially. It may be well to consider each of these four diseases by itself. xii. Chicken-pox. I do not think that the question of Chicken-pox in the Schools is a very serious one. It is a highly infectious disease, but is seldom fatal, and I think it is safe to assume that few cases go unrecognised. In times of Small-pox scares, when the danger of mistakes would be greatest, the parent seldom fails to call in a doctor at the earliest moment, and the responsibility of dealing with it rests more on the Health Department than on the Education Committee. Measles. Measles is a very different matter. It is the most common infectious disease of childhood, and I think I am correct in saying that it is the cause of absence from the school of most of the children who are really kept at home on account of illness. For some time Measles was included amongst the diseases to be notified under the Act in this district, but this has not been so during the last four years, for reasons that I need not enter into now, but with which I entirely agree. Since, however, medical certificates of Measles are not sent to me, the Health Department has no official means of knowing of the existence of cases, and can neither take steps to prevent the infection spreading, or give advice to the parent as to the treatment of the child. Proper treatment is of great moment, for Measles is a serious complaint. Too often it is looked upon as an inevitable incident in childhood, and one requiring no more care than the cutting of a tooth. The proportion of cases seen by a doctor is small compared to the total number of cases that arise. It is important from an administrative point of view that cases of Measles should be recognised early and excluded from the Schools, particularly in the infant classes, and it is especially important from the child's point of view that if he is not attended by a doctor his parent should be warned of the necessity of careful treatment. Co-operation between the School Doctor, the teachers and the Health Department would do much towards carrying out both these points. I am afraid that even a perfect system of medical inspection would not materially lessen the number of real cases of Measles amongst the School children, but advising the parent to call in a doctor, and informing him that it is a dangerous disease, might possibly reduce the case mortality. Scarlet Fever. I am not very sanguine either that, except in times of epidemics, medical inspection would do much towards reducing the number of cases of Scarlet Fever arising amongst the School chiidren. Indirect benefit xiii. would result from instruction given to the teachers in special watching of doubtful cases, and selection by them of suspicious children for special examination by the School doctor. Diphtheria. Diphtheria is certainly the most serious of the four diseases I am considering, but at the same time it is the only one that can be attacked in a clear and scientific manner, with a well founded hope of success. I have no doubt whatever that the appointment of a Medical Officer to the Schools would be more than justified if his sole work was in connection with this disease. I need not enlarge on the danger and heavy mortality it causes; that is known to everybody. But I would remind you that during the past few months the number of cases in this district has been considerably above the average, and most of the patients have been children attending the public Elementary Schools. Practically every School has had cases, some many, others only one or two. The number of cases has not reached what might be called an epidemic, and though they have been a source of considerable anxiety to me, at no time has the total arising in any one particular School been sufficient to justify the special and drastic measures that, as Medical Officer of Health, are the only ones I have power to employ. As you know, practically all that a Medical Officer of Health can do under his present powers to deal with an outbreak of infectious disease in a School, is to close that School, and thereby deprive all the children attending it of teaching for an indefinite time. Closing a School is for this and other reasons, in my opinion, quite unjustifiable, except under very exceptional circumstances. It is a confession of weakness and lack of energy, for it only tends to hide the symptons without attacking and removing the cause. Careful investigation during the past few months has failed to reveal any common source of infection in any of the Schools in which cases of Diphtheria have arisen. Very seldom has more than one secondary case been traced to a primary one. As a matter of course and ordinary routine practice, whenever a case of Diphtheria has been notified, any other children in the same house or family have been excluded from School till after the normal period of incubation has passed, but nevertheless other cases have occurred in that Schcol at odd intervals. The usual inquiries that are always made by the Sanitary Inspectors in all cases of infectious disease notified, have, only in a very few instances, shown any xiv. possible source of infection outside the schools, and the teachers I know have been particularly active in noticing any case of sore throat or other suspicious symptom, and excluding the child. Now, in considering the question of Diphtheria in Schools, and the proper means to be adopted in dealing with it, certain well-known facts must be kept in mind. These facts may be summarised as follows:— 1. Diphtheria is caused by a specific bacillus, easily recognised, and always present in the throats of persons suffering from the disease. 2. This bacillus may be present in the throats of persons showing no clinical symptoms of the disease, and apparently perfectly well, they themselves being either protected by a previous mild attack, or from some cause being immune to the disease. 3. These persons, though themselves unaffected, are as infectious to others as a patient actually suffering from Diphtheria. They are really more dangerous as possible sources of infection, because whilst they may convey the disease to anyone coming in contact with them, they are not known as potential centres of danger, and no precautions are taken with regard to them. These facts are not theoretical; they are based on scientific knowledge, and there is no doubt about them. What is uncertain is how long the bacillus may remain active in healthy persons, but this does not affect the measures that should be taken for discovering it. Fortunately the search for the diphtheria bacillus is not a difficult matter, but it can only be carried out by a skilled investigator using bacteriological methods. It may be useful to explain as simply as possible what these methods are, and the procedure they entail. A "swab" is first taken from the throat of the suspected person. This means that a small plug of sterilised cotton-wool is rubbed over that part of the back of the throat in which the bacillus is usually found. Tubes containing some culture medium favourable to the growth of the bacillus are then inoculated from the swabs, and placed in the incubator. Next day microorganisms will be found to be growing on the surface of the culture-medium, and XV. microscopic examination of these colonies will reveal the presence of the true diphtheria bacillus if it was in the throat of the person from whom the swab was taken. There is nothing very new, and nothing at all original in this. The question of the control of Diphtheria as a school disease is mentioned frequently in the Report, and I need only refer you to the remarks of Dr. Kerr (Vol. II., page 238) where he states that any outbreak in a London School can be stamped out in two or three days. This may, or may not be so in London, but I do not anticipate that so good a result could be reasonably expected under any circumstances in this district. The benefit that I should look for would be the prevention of epidemics, and I believe that a scientific and properly organised system of dealing with every isolated case of Diphtheria in our Schools would not only have the effect of greatly reducing the number arising in them, but would also materially lessen the total number of cases in the district of patients other than school children. Diphtheria amongst the School children in this district is a matter that very closely affects the public, and is directly the cause of considerable expense. During the year 1905, nearly 62 per cent. of the total cases of Diphtheria notified were children attending the Public Elementary Schools, and these children formed over 63 per cent. of the cases of this disease from this district, treated at the public cost in Mogden Hospital during the same period Any definite system to be arranged in this district in connection with Diphtheria, would of course have to be carefully considered in its details after the appointment of, and in consultation with the School Doctor who would have to carry it out, but the general idea would be as follows:— On the notification of a case of Diphtheria in a child attending any one particular School, the School Doctor would be at once informed by the Health Department, and would keep that School under special observation, and warn the teachers to exercise extra care in noticing the appearance of the children. He would make a general inspection of all the children, and a special inspection of those likely to have come in contact with the affected child, Possibly one or two might be found to have obvious signs, such as sore throat. Probably it would not be necessary to examine the xvi. throats of all the children in the School bacteriologically, but this would have to be done of all the children who had been in the same class or the same room as the patient. This would not be so big a matter as it appears. With the help of the teacher of the class from 25 to 30 swabs can be taken in an hour without difficulty. Each swab would be labelled with the name or number of the child from whom it was taken, and cultures would be made from it which would be labelled in the same way. In 24 hours or so the result of the examination would be complete, and almost all the infected children would be known, and would be excluded from the Schools under observation. The chief practical difficulty is what to do with these excluded children. One or two would perhaps develop the disease in the ordinary way, and would be removed to Hospital on the first signs of it. The greater number would remain perfectly well, but still dangerous to others, and repeated examinations would have to be made of their throats till they were found to be free from the bacillus. Unfortunately no means are at present known of destroying the bacillus in situ, but by daily application of some antiseptic the danger of the bacillus escaping and infecting others is greatly reduced, if not entirely prevented. Possibly some arrangement might be made for the suspicious children to attend daily at some convenient place for this treatment instead of going to School, but in all probability the total number of such children would be very small. All the bacteriological work in connection with Diphtheria could be carried out in a Laboratory that has been provided in the new Council House. The expense would be small compared to the importance of the work, and it would be easy to divide the share of the cost of the Laboratory to be paid for by the Education Committee. It would at most amount to a few pounds a year after the preliminary purchase of apparatus. So much for the three chief divisions of the duties of the Medical Officer. I will only refer to one other that he might well undertake, and that is the medical examination of all candidates for appointments as teachers under the Committee. xvii. I understand that the whole question of the medical inspection of School children in our district has been referred to a Sub-Committee, and that in the meantime no further action is to be taken, but I assume that the matter will have to be considered at some future time, and the arguments for and against the appointment of a School Doctor discussed. I should like to suggest one or two points with regard to the financial aspect of the question. The matter of cost is frequently referred to in the Report I have already quoted, but I am unable to agree with the conclusions drawn so far as they would apply to this district. The Report states that in no place has the cost of medical inspection exceeded one-tenth of a penny in the pound. No figures, however, are given as to the number of children and the value of a penny rate in any one district, or the basis on which the calculation of expense was made. There are nearly 6000 School children and about 200 teachers in this district, and I do not think that their medical inspection could be carried out at the present time at a less cost than the amount that would represent a rate of from a third of a penny to a halfpenny in the pound. The rate required would, however, tend to become less each year, for the cost of inspection would only increase slowly, if at all, whereas the value of a halfpenny rate becomes more every year. I am informed that the present cost of education in this district amounts to a rate of 1/4 in the pound. Even the addition of a halfpenny would only amount to an increase of a little more than 3 per cent. on this rate, supposing that the whole cost of the extra expenditure was borne by the ratepayer. But there is another aspect to the question of expense that I think may be quite fairly taken into account, and that is that medical inspection may be expected to a certain extent to re-pay some of the outlay. Taking the figures given in your last Annual Report, I find that the sum received from the Board of Education, that is the Annual Grant based on attendance only, amounted to about £9,200. During the same year the number of children on the books was 5664, and the average attendance was 4796. This, I conclude, means that adding together the various days on which children were absent from School, the total number of children during the year who might have attended, but for some cause or other did not, amounted to 868. xviii. The total grant earned, therefore, daring the year was earned by 4796 children, not 5664, and it amounted to £1 18s. 4d. per child. To avoid overstating the case I will assume the annual earning of each child who attended to have been £1 17s. 6d. Now, if the children who were absent had each earned the same sum by attending, the total grant would have been increased by at least £1600 in the year. This would have meant an attendance of 100 per cent. which it would be absurd to expect or hope for, but the point is, would a system of medical inspection have any effect in reducing the number of children absent from School? I venture to think that it would, though actual experience only can prove the correctness or otherwise of this opinion. I have no means of examining the various causes responsible for the absence of the 868 children who did not attend, but I can safely conclude that illness was the chief one given by the parents. The health of the child was either the cause or the excuse for its non-attendance, and I am afraid that in many instances the child was really quite well enough to go to School. I think that probably at least 10 per cent. of the children who were nominally excused attendance were in fact quite well, and should have been at School. This seems an unfair statement, but I believe it is not exaggerated. I have more than once found on personal inquiry that many children whose parents had sent word to the school that they were ill and could not attend, were quite well and kept at home to assist in domestic work or for some other reason. I am aware that at the present time the parent is supposed to send in a medical certificate in case of absence from illness, and that the Education Committee has paid over £20 in one year for such certificates. But this system works a good deal better in theory than in practice. Usually, when the child has only been absent for a day or two, no certificate is demanded. In many other cases the attendance officer leaves the certificate with the parent, and she takes it to a doctor after the child has recovered and asks him to sign it. If the doctor does so, not having seen the child during the supposed illness, he can only do it on the statement of the parent, and the certificate can have but little value. This is especially true in regard to Measles, probably the commonest reason given for absence. I think that if the parents knew that the official Medical Officer of the education authority might come and satisfy himself that the child was really xix. unfit to attend, the number of cases of malingering would diminish, and the attendance increase in consequence. If only 5 per cent. of the 868 absent children had attended, it would have meant a sum of over £80 added to the grant, and in addition the Gommtttee, by having their own doctor, would have saved most if not all of the £20 spent on medical certificates. On the other hand it is only fair to point out that probably a certain number of children now attending School would be excluded as being unfit on medical examination, and this would tend to reduce the number of attendances. This reduction would, however, be possibly more than balanced by the number of children whose period of exclusion on account of real disease such as ringworm, verminous heads, itch, etc., would be lessened if proper treatment at home was insisted upon. Yours faithfully, EDWARD J. STEEGMANN. January, 1906.