??? Heston & Isleworth Urban District Council. 1920. ANNUAL REPORTS OF THE Medical Officer of Health AND School Medical Officer FOR THE URBAN DISTRICT OF HESTON AND ISLEWORTH For the Year ending 31st December, 1920. 1920 REPORT on The Health of the HESTON and ISLEWORTH URBAN DISTRICT FOR THE YEAR 1920 by W. A. BERRY, M.D. (Lond). D.P.H., Medical Officer of Health. 50 (M.O.H.) 50 (S.M.O.) Z 7-82. Health Department, Council House, Hounslow. April, 1921. To the Chairman and Members of the Heston and Isleworth Urban District Council. Gentlemen, The Annual Report presented herewith follows the plan required by the Ministry of Health as set forth in their Memorandum of Instructions on the subject for the year 1920. As a result of my report to the Maternity and Child Welfare Committee on the need for greater co-ordination of Health Services, it was decided in the early part of the year to delegate to one Committee the duties previously assigned to the Health Committee, the Medical Inspection Sub-Committee of the Education Committee and the Maternity and Child Welfare Committee. This is a step forward towards the unification of Health Services rendered in this district. Several changes took place in the staff of the Health Department, including the appointment of Dr. Eva Cairns Roberts in place of Dr. Simpson, resigned, the appointment of an additional Health Visitor and a municipal Midwife. Other changes connected with the clerical staff together with marked increases of work in the several sections, necessitated greater efforts on the part of the staff generally, and, I am happy to say, were put forth cheerfully and willingly. I take this opportunity of thanking all for their loyal and efficient service. In conclusion, I beg to express my deep appreciation to the Council for the kind consideration shewn me during the year. I am, Gentlemen, Your obedient servant, W. A. BERRY, Medical Officer of Health. THE HEALTH COMMITTEE of the HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL For the Year ending April, 1921. Members of the Council:— G. A. Griffith, Esq. (Chairman). J. J. Bonnett, Esq. (Vice-Chairman). C. Crush, Esq., j.p. ex-officio (iChairman of the Council). F. W. Langstone, Esq., ex-officio (Vice-Chairman of the Council). A. E. Hales, Esq. R. Langdon, Esq. E. W. Heath, Esq. W. Mann, Esq. J. Weathers, Esq. Selected Members ;— Mrs. E. J. Chedgey. Mrs. M. Mason. „ W. H. Dumsday. P. Murphy, Esq. j.p. Medical Officer of Health: W. A. Berry, m.d., d.p.h. 5 SUMMARY OF VITAL STATISTICS, 1920. Population— At the Census, 1911 43,316 Registrar-General's estimate of nett 43,445 (Birth rate) civil population 41,945 (Deathrate) Birth rate (nett) 24.7 England and Wales 25.4 London 26.6 Death rate (nett) 109.1 England and Wales 12.4 London 12.4 Infantile Mortality Rate 57.72 per 1,000 births England and Wales 80 ,, ,, London 75 „ „ NATURAL AND SOCIAL CONDITIONS. Area. The Urban District of Heston and Isleworth, in the County of Middlesex, has an area of 6,893 acres. It comprises the two parishes of Heston and Isleworth, and is divided for civil purposes into five wards. Heston Parish includes Heston and Hounslow North Wards, and has an area of 3,708 acres. The Parish of Isleworth lies to the east and south of Heston, and is situate on the western bank of the River Thames where that river winds to the north-east towards Kew. The area of this Parish, which embraces Isleworth North and South and Hounslow South Wards, is 3,185 acres. Physical Features. The level of the District rises gradually from the River Thames and reaches at Heston a height of 100 feet above Ordnance Datum. The geological subsoil foundation is valley gravel, which is covered in large areas by loam. This thin loamy covering is of great value for market gardening, to which considerable portions of land within the district are devoted. 6 Social Conditions. It cannot be said that the district has a staple industry, except possibly agriculture in whioh about 1,400 persons are employed. It, however, contains various factories, the principal of which are as follows :— No. of persons employed. Flour Mills 110 Pharmaceutical chemist's factory 650 Colour factory 90 Brewery 300 Rubber factory 550 Soap works 900 Sweet factory 250 whilst on the outskirts of the district there are largo Powder Mills in which a certain number of the inhabitants find employment. Owing to the situation of the District and its being served by the District and London & South Western Railways, as well as by trams and 'buses, a considerable proportion of the inhabitants find occupation in London. Such include (1) Clerks, (2) Professional Men, Merchants, Agents, etc. and (3) Artisans. Public Health is not apparently prejudicially influenced by occupations carried on within the district. Poor Law Relief. I am indebted to Mr. F. E. Harmsworth, Clerk to the Brentford Guardians, for information respecting the amounts paid in money and kind as out-relief to poor persons within the parishes of Heston and Isleworth during the year 1920 :— Parish of Heston Parish of Isleworth £ 1477 745 s. 3 12 d. 2 1 £2222 15 3 7 Medical Relief. Particulars as to the extent to which hospital and other forms of gratuitous medical relief are utilised are not available, save in a few instances, as many people apply to hospitals outside the district as for example, the Royal Hospital, Richmond, the West London Hospital, Hammersmith, and other General Hospitals within the Metropolitan area. Poor Law Medical Relief is reported to have been afforded to 185 cases, and some of these received also out-relief and institutional treatment. The Hounslow Hospital is the only voluntary Hospital within the District; it is a modern and well equipped institution doing valuable work, but is scarcely large enough to meet the needs of this district. Its sphere of usefulness will, it is hoped, be extended by the provision of maternity beds. During the year 1920, there were admitted 310 in-patients, whilst 892 received treatment as out-patients. Medical relief is also given by certain voluntary organisations in the district, namely:— The Gunnersbury House Nursing Home. The Hounslow Central Aid Society. The Isleworth District Nursing Association. The Ellis Day Nursery (closed during the year). Curative agencies directly or indirectly under the control of the Council will be referred to under their appropriate headings. They include:— Maternity and Child Welfare Clinics (two centres). School Clinics (inspection and treatment of school children). Hospital provision at Mogden and Dockwell for infectious diseases. VITAL STATISTICS. Population. For the year 1920, the estimate of nett civil population is given under two figures supplied by the Registrar-General. 8 The death-rate population (41,945) excludes all non-civilian males whether serving at home or abroad ; whilst the birth-rate (and marriage-rate) population (43,445) includes all the elements of the population contributing to the birth and marriage rates and may be represented by:— Death-rate population plus this district's proportional share of all non-civilians enlisted from this country. Deaths The number of deaths registered in the district was 913, but 498 of these did not belong to the district, while 43 residents died without the district. Thus the number of deaths properly attributable to the district was 458. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 10-91 per 1,000, which is comparable with the following figures:—12.4 for England and 12 4 for London. The causes of death show substantial reductions in the cases of Influenza, Organic Heart Disease and Bronchitis, but Cancer, Rheumatic Fever and Pneumonia, figure more frequently than in the previous report, whilst deaths from Tuberculosis are the same as in 1919. As it is not possible to calculate the population in each Ward with any reasonable degree of accuracy, I am unable to furnish the death-rate for each separate Ward, but a fairly reliable index to the comparative mortality of the Wards may be found in the Infant death-rates given on page 9. Births. The total number of births registered during the year was 1,169 but 125 of these did not belong to this district, while 30 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 1,074. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 24 7 per 1,000. The birth-rate of England and Wales is 25 4 per 1,000 and for London, 26 5 per 1000. 9 Legitimacy. The following figures give the number of births:— Legitimate. Male. 539 Female. 499 Total. 1038 Illegitimate. Male. 23 Female. 13 Total. 36 Infant Mortality. The figure obtained under this heading is regarded as a valuable index of the sanitary conditions of a district. Furthermore, as it is based on ascertained facts (i.e., the actual numbers of births and infants deaths), it is more reliable than the death-rate which is calculated on an estimated population. The rate for 1920 is 57 per 1,000 births. This is by far the lowest figure on record, and the district is to be congratulated on the appreciable fall that has taken place. The rates for England and Wales and for London during the same period were 80 and 75 respectively. In 1912 the rate for this district was 85, and in 1918 it was 86 ; these were the lowest figures previously recorded. From the undermentioned table, it will be seen that the rate of infant mortality varies in a significant manner from Ward to Ward:— Infant Death-rate During 1920. per 1,000 births. Average for 1916-20. Heston 70 70.1 Hounslow North 50 73.8 Hounslow South 40 92.4 Isleworth North 80 122.4 Isleworth South 46 67.8 The whole district 57 85.3 10 SANITARY CIRCUMSTANCES. Water Supply. The water supply for the district is from the mains of the Metropolitan Water Board; the quality of water has throughout this year been good, and the service is a constant one. 42 houses in Heston Parish are supplied from the main of the South-West Suburban Water Co. There were, as far as is known, at the end of the year 39 private wells from which the water was used for domestic purposes. Ill three other cases there are wells but an alternative supply from the main exists for domestic purposes. In 104 instances draw-taps were placed on the main to the house, in compliance with notice from the Health Department, in lieu of a supply drawn from an inaccessible and uncovered cistern. Drainage and Sewerage. The sewerage of almost the whole district is arranged on the " separate " system. The sewage is mainly of domestic character, but trade waste from soap works, laundries,dye works, pharmaceutical works and a brewery is also a constituent. The dry weather flow is about 2,000,000 gallons, of which two-thirds reaohes the works by gravitation, the remainder having to be lifted by Shone's Ejectors situated in different parts of the district lying below the level of the works. At the works the crude sewage, after being screened and having grosser materials removed in passage through a detritus tank, is treated in covered septic tanks, the total capacity of which is 1,800,000 gallons. After passing through the septic tanks the sewage is conveyed by covered channels to "contact beds," of which there are 15 occupying close upon 4 acres. Filling of the beds is.effected from below, upwards. Finally the effluent from the contact beds is conveyed by an outlet pipe, 1^ miles long, direct to the Thames. 11 A feature of the works is that frotn the time the crude sewage enters the works till the effluent leaves the contact beds, it is treated under cover thus minimising objectionable smell; and the effluent yielded is very satisfactory. In the western portion of the district, however, there are some houses not yet linked up with the general system. It is to be regretted that at the enquiry by the Ministry of Health during 1919, sanction was not forthcoming for the provision of a sewer along the western portion of Bath Road, which would have enabled houses in the vicinity to be connected with the general system of sewerage. The present methods of drainage employed at these houses are not satisfactory. Closet Accommodation. Accommodation on the water carriage system is almost general throughout the district, 98 per cent, of the houses having water- closets. Scavenging. This is carried out by the Local Authority and is under control of the Surveyor. The refuse is collected weekly and is disposed of by burning in a destructor. During the year there were supplied 453 new ashbins, and 3 ashpits were abolished. Sanitary Inspection of District. Attention is directed to the Table on pages 46—51 where particulars are set forth of the number and nature of premises visited, the defects or nuisances discovered and the action or result of action taken in regard to these. This forms part of the report rendered by the Inspector of Nuisances for the year 1920. Nuisances, Contraventions of Bye-laws, Defective Drainage, etc. The number of premises on which nuisances were outstanding at the end of 1919 was 602. To these, other 1,326 premises, whereat nuisances were recorded in 1920, were added, giving a total of 1,928 premises. Of these 1,363 had the nuisances remedied, leaving 565 premises at which nuisances still existed at the end of the year. 12 During the year, nuisances at 135 houses were reported to the Health Committee, which added to the 64 brought forward from 1919, make a total of 199. Before asking authority to serve statutory notices, the premises are inspected by the Medical Officer of Health and Inspector of Nuisances. Statutory notices were authorised and served in most of these cases, and by the end of the year, the nuisances were remedied in 159 of the houses, leaving 40 cases to be carried forward in 1921. Comparative figures for the years 1918, 1919 and 1920 in connection with nuisances are submitted herewith :— Number of complaints received Premises at which nuisances were located 1918. 152 209 1919. 265 655 1920. 598 1326 Informal Notices sent— First Second Statutory Notices served 158 18 17 571 232 243 1069 385 231 It is my duty once more to point out that the staff of Sanitary Inspectors is not sufficiently large. The figures set out above show that much greater activity in connection with defective and insanitary property has been manifest during the year under review, but ii has only been possible to give these matters the necessary attention by devoting less time to other, and perhaps equally important, phases of public health work. It must be placed on record that twice during 1920, recommendations urging the appointment of a District Sanitary Inspector to fill the existing vacancy, were sent forward by the Health Committee to the Council, but were defeated. Premises and Occupations controlled by Bye-laws or Regulations. There are about 350 premises in this district which call for periodical inspection such as the following Houses let in Lodgings, Common Lodging Houses, Bakehouses, Slaughter-houses, Cowsheds, Dairies and Milkshops, Offensive Trades, Laundries (non-factory) and Workshops and Work Places. 13 SCHOOLS. Id this district there are 13 public elementary schools of which 3 are modern, the remainder being for the most part old and lacking in good sanitary conditions. During the year detailed inspections were made of the sanitary arrangements provided in each school, and a summary of the defects found is included in the report of the School Medical Service. FOOD. During the War, the inspection of food premises had necessarily to be curtailed, owing to shortage of staff. In the course of the year under report, regular inspection of these places took place. The following is an extract from the records :— No. of Inspections made. Meat 307 Fish 205 Provisions 145 Greengroceries and Fruit 399 Hawkers' Food Stuffs 184 Milk. No material change has been observed during the past year in the conditions under which cow-keeping and milk vending are carried on in the district. 104 inspections were carried out in respect of dairies and milkshops. The Milk (Mothers and Children) Order, 1919, has been administered by the Maternity and Child Welfare Committee, and 381 grants have been made. Milk was granted, either free or at reduced rates, to expectant and nursing mothers, and to children up to the age of five years on a graduated scale according to the family income. Meat. The Memorandum of Instructions issued by the Ministry of Health on the subject of the Annual Report specifies that reference should be made to— 14 1. Meat Inspection. 2. A Public Abattoir. 3. Action taken under Section 117 Public Health Act, 1875. 4. Meat condemned for tuberculosis. 5. Slaughter-houses. 1. Meat Inspection.—The Inspector of Nuisances and the District Sanitary Inspectors hold special certificates for meat inspection. Slaughter-houses and butchers' shops are visited periodically, but during the year no diseased meat was seized and only some 72 lbs. were surrendered. Reference has already been made to the increase of work in connection with insanitary premises, and the consequent relative neglect of other work. There are 8 slaughter-houses and 26 butchers' shops in the district. Each of these received on an average a little over one visit per month ; there is therefore room for improvement. 2. Public Abattoir.—There is no public abattoir in the district, nor are there any arrangements for meat being inspected at the time of slaughter. Killing may take place any time. A public abattoir is indicated together with some form of central clearing house, wherein all meat for consumption in the district would require to be deposited prior to distribution, and thus euable the Inspectors to examine it as to quality and soundness. 3. Action under Section 117, Public Health Act, 1875.—None during 1920. 4. Tubercular Meat.—There was none siezed and none surrendered during the year. 5. The following tabular statement on slaughter-houses is required :— In 1914. In January, 1920. In December, 1920. Registered 6 4 4 Licensed 3 4 4 Total 9 8 8 15 Other Foods. Difficulty has been experienced in controlling and proving precisely when hake-houses receive the periodical cleansing required, and as it is exceptional to find occupiers of such premises exceeding their duty in this respect, an advantage should result wore the required six-monthly cleansing fixed so as to fall say during the first seven days of the months of April and October in each year. The lack of powers to deal effectively with the cleansing and renewal of troughs and other utensils is to be regretted. The methods in vogue for the distribution of bread in this district leave much to be desired. It is not uncommon to see bread vans with open fronts so packed with loaves that there is scarcely room for the driver, and rendering contact with his clothing inevitable, whilst bread so conveyed is exposed to dust from the streets and the horse. Similar criticisms are merited with regard to the manner in which meat, green vegetables and fruit are exhibited, being exposed to dust or other contamination. Preparation of Sausages, etc. Provision for dealing adequately with premises at which the manufacture of sausages and like commodities is carried on together with the fixing of proper standards for such food stuffs are required. The question of providing such means of control demands early consideration. Sale of Food and Drugs Acts. I am indebted to Dr. C. W. F. Young, County Medical Officer, for the following report prepared by Mr. Robinson, the Chief Officer of the Public Control Department, as to the samples purchased in this area during 1920. List of samples purchased :— Article. No. taken. Adulterated. Milk 329 27 Separated Milk 8 — Cream 3 2 Butter 13 Lard 4 Coffee 4 — 361 29 16 Milk. Of the 27 samples of milk reported against, 19 were informal samples. In 13 of the 19 samples the deficiencies in non-fatty solids, as compared with the presumptive standard, varied from 2 to 4 per cent., only. Of the 8 formal samples reported against, 4 were deficient in non-fatty solids to the extent of 1 per cent., 2 per cent., 2 per cent, and 3 per cent, respectively. Three vendors were cautioned in respect of samples containing slightly larger deficiencies, while one vendor was prosecuted in respect of a sample 10 per cent, deficient in fat, but the summons was dismissed on the warranty defence. Cream. The two samples of cream reported against were purchased from one vendor, one being an informal and the other a formal sample. The offence here was the sale of preserved cream not so labelled, and for this offence the vendor of the samples was cautioned. UNSOUND FOOD, 1920. Tons. cwts. qrs. lbs. Eice I 19 2 12 Fruit 2 18 Vegetables 1 25 Bacon 1 1 11 Meat 2 15½ Babbits ... 14 Fish 8 0 1 Milk (tined) 1 2 23 Butter ... 3 26 Total quantity surrendered, 2 tons, 13 cwts., 2 qrs., 5J- lbs. INFECTIOUS DISEASE. General Remarks. The table on page 42 sets forth by months the number of cases of infectious diseases notified during the year 1920. 17 It will be observed on reference to this table that there were 209 cases of Scarlet Fever notified during 1920. This disease has been more prevalent in the district in common with others in the Greater London area, than was the case in 1919. During the year there were 5 return cases of this disease, all the originating ones having been treated at Mogden Isolation Hospital. S.B. was in hospital 58 days, during which time he had a secondary rash. Two return cases developed 9 and 21 days respectively after his discharge from hospital. I.A. was in hospital 33 days and no complications were noted. A return case occurred 12 days after her discharge from hospital. F.M., discharged from hospital after a stay of 31 days, was responsible for a return case 10 days later. L.L. was in hospital 33 days. Upon discharge some peeling of hands was alleged. A return case followed 9 days after the originating patient's discharge. The table hereunder gives the number of cases of Scarlet Fever and Diphtheria that occurred in the several Institutions in the district during 1920:— Scarlet Fever. Diphtheria. Isleworth Infirmary 3 13 Nazareth House 24 — North Hyde Schools 21 1 Gumley House 1 — " Arniston," The Grove 4 — Boro' Road College — 1 Scarlet Feyer. The following table shows the number of cases which have been notified, and the number and percentage of cases which have been removed to Hospital:— No. of civil cases notified 208 ,, ,, removed to Hospital 170 Percentage of cases removed to Hospital 81.73 18 One case was also reported among the military population and removed to hospital. The incidence rate of Scarlet Fever in the civil population was 4 95 per 1,000. Two deaths took place from this cause during the year. Diphtheria. The following table shows the number of notifications received and the percentage of cases of Diphtheria removed to Hospital:— No. of civil cases notified ... ... ... 90 „ ,, removed to Hospital ... 80 Percentage of cases removed to Hospital 88'88 In addition to these cases, one military case was reported and removed to Hospital. The incidence rate per 1,000 of the civil population was 214. Thirteen cases occurred in public institutions during the year, 11 of the persons affected being non-residents. Four deaths took place from this disease, i.e. a case mortality rate of 4 39 per cent. Diphtheria Antitoxin. During 1920, 21 vials of Antitoxin were supplied to medical practitioners. Typhoid Fever. There were no cases notified during the year. Dysentery. One case was notified and was removed to Hospital, but the diagnosis was not confirmed and eventually it was considered to be Mucous Colitis. Erysipelas. Thirteen cases of this disease were notified, of whom 6 were institution cases, the persons affected being non-residents. No deaths were recorded from this disease. Puerperal Fever. Eight cases of this disease were notified, all were institution cases, the persons affected being non-residents. 19 Ophthalmia Neonatorum. Eight children were notified as suffering from this disease, 3 of the cases were treated at the Infirmary, 2 being from outside the district. Accepting six cases as belonging to this district is equivalent to a case rate of 55 per 1,000 births. Encephalitis Lethargica. There were 2 cases notified of this disease, both of which proved fatal. Cerebro-Spinal Fever. One case of this disease was notified and proved fatal. Acute Poliomyelitis. There were no cases notified. Pneumonia. 25 cases were notified, 15 being non-residents in the Infirmary. Malaria. Three cases were notified, all being recurrences. Pulmonary Tuberculosis. The number of new cases notified during the year was 49. 22 cases (or 45%) were notified from Institutions :— Sanatoria 8, Infirmary 4, General Hospitals 10. The large proportion of cases which come under observation for the first time as a result of notification from an Institution would appear to show that the notification of cases by private practitioners is not as complete as it should be. Other Forms of Tuberculosis. The number of new cases notified during the year was 6. tive of them were notified as receiving institutional treatment. 20 Non-notifiable Diseases. Information respecting non-notifiable infectious diseases is usually gained through notifications by the School Attendance Officers. The undermentioned table sets forth the numbers of such cases for the year :— Measles 565 Bubella 4 Chicken pox 64 Mumps 30 Whooping Cough 203 Upon receipt of information of the existence of a case, inquiry is made by a Health Visitor to obtain all necessary facts. Influenza. The mortality from Influenza was 0 021 per 1,000. Small-Pox. No vaccinations were performed by the Medical Officer of Health under the Public Health (Small-Pox Prevention) Regulations, 1917, during the year under review. Cleansing of Verminous Persons. Particulars are asked for as to the facilities available in the district for the cleansing and disinfection of verminous persons and their belongings. Neither the Education Authority nor the Sanitary Authority possesses a cleansing station. This matter has been brought to the notice of the Education Committee on many occasions. Where application is made, the Health Department undertakes the spraying of rooms for the removal of bed bugs, and bedding and clothing generally can be disinfected by steam at Mogden Isolation Hospital. MATERNITY AND CHILD WELFARE. The Inspection of Midwives is under the supervision of tbe County Council. It is, however, generally recognised that the '21 authority administering a Maternity and Child Welfare Scheme should also exercise control over the Midwives practising in its area; thus only can the old-fashioned registered midwife receive adequate supervision. During the year it was necessary to report to the Supervising Authority five Midwives for breaches of the rules of the Central Midwives Board as follows:—Failure to report inflamed and unhealed navels, inflammation of eyes and offensive lochia. These troubles were discovered by Health Visitors subsequent to the Midwife leaving the case, and in several instances stout denial was made by the midwife that the condition existed during the time she was in attendance. In this district it is the piactice of the Health Visitors not to visit the newly-born till 14 days after the birth, in order not to interfere with the Midwife. Were the Local Authority the supervising one under the Midwives Acts, visits might be made earlier and such conditions would be bound to receive attention, for Midwives, to avoid reprimand, would find it wiser to comply with the rules. An innovation was made in the latter part of the year by the appointment of a Municipal Midwife on a salary basis, the Council receiving the fees. Nurse Barcroft, the Midwife appointed, took up her duties in December. By attending at the Infant Welfare Centres she has quickly got to know many of the mothers, who express their appreciation of her services. To comply with the Midwives Acts, she is under the supervision of the Middlesex County Council's Inspector of Midwives. Work at Clinics. The two clinics at the Council House and Isleworth Public Hall respectively have remained open throughout the year, and, judging by the attendances at each, have shewn no signs of their popularity waning. The attendances totalled 3,599 for the year as compared with 2,299 in 1919. The average attendance at the Council House being 34 5 and at the Isleworth Centre 26'2. It must be recorded that, owing to the largely increased attendance at the Council House, it was found necessary to hold 22 a second clinic per week. Thursday was the day selected and on this afternoon Dr. Roberts takes charge. Doubtless the presence of a lady doctor at the Centres has encouraged mothers to attend in large numbers ; for a like reason, it may be anticipated ante-natal cases will avail themselves of the opportunity afforded to a greater extent than has been the case in the past. It must, however, be noted that ante-natal work up to the present has been sandwiched in at the ordinary clinics which are primarily for infants, and owing to lack of time it has only been possible to see one or two cases in an afternoon. As the women have shewn keen readiness to come for advice, it is highly desirable to establish this important branch on a sound basis and devote to it at least one afternoon a week. Developments in this direction have been thwarted by pressure of other work, and chiefly by the increasing demands of the School Medical Service with consequent lack of time. The arrangements with chemists for the dispensing of prescriptions, on terms similar to those under the National Insurance Act, have been continued. During the year, 4,921 lbs of Glaxo and 368½ lbs. of Virol were distributed ; besides these commodities, Extract of Malt and Extract of Malt with Cod Liver Oil have also been placed on sale at cost price and have been greatly appreciated by the mothers attending the clinics. It may be noted here that the numbers of individual mothers and children that make use of the Centres have increased, as the table hereunder shows :— Mothers Children Council House, Hounslow. Isleworth Public Hall. 1919. 199 250 1920. 315 407 1919. 139 162 1920. 170 185 The matter of treatment of dental defects in nursing and expectant mothers, and provision for the treatment of defective vision, ringworm, dental defects and minor ailments in children below the age of 5 years were considered by a special SubCommittee of the Health Committee, but upon report decision was deferred. 23 Treatment for the above defects, for enlarged tonsils and adenoids and other crippling conditions, e.g., hernias, is urgently needed, for in the interests of national health, it cannot be too strongly emphasised that if defects are present in children they should be treated as soon as possible. To wait until the child is of school age (5 years) before treatment is instituted, is an unsound and uneconomical policy and is to be absolutely condemned. Home Help for Mothers. A Home Help was appointed by the Committee in 1919 to assist mothers with their domestic work during their confinement. Her services have proved very useful and have been much appreciated. During the year she paid 328 visits to homes for the purpose of rendering assistance. Grants of Milk and Food. Much good has been done by continuing the grants of milk and food to expectant and nursing mothers and of milk to children under 5 years. During the year the scale by which grants are regulated was altered, rent being deducted before calculating the nett family income. The total nett income is then divided by the number of persons in the family, adults as well as children, the quotent being the amount per head. Scale for grants. Where the amount per head is less than 8/-, the grant is free Where the amount per head is 8/- but less than 9/-, the recipient pays quarter of the cost. Where the amount per head is 9/- but less than 10/-, the amount paid is half the cost. Where the amount per head is 10/- but less than 11/-, the recipient pays three quarters of the cost. Where the amount per head is 11/- or more, no grant is made. Furthermore, before a grant is authorised, a form of application setting forth the members of the family, their ages, occupation, name and address of employer, weekly wage of each member 21 earning, money derived from other sources, e.g., National Insurance Benefit, War Pension, rooms let, etc., weekly rent, and stating if Poor Law Relief or relief from any other source is afforded, has to be filled in by one or other patent and signed by both. Subsequently the statements are verified by inquiry from the employers and the Relieving Officers. Acknowledgement must be made of the courtesy extended to me by employers, Superintendents of Labour Exchanges and Officers of the Poor Law, for their cooperation in helping the Council to prevent abuse of their grants. During the early part of the year it was ascertained that in three instances grants had been obtained by mis-stating the amount of income, but on threatening legal proceedings the parties at fault made re-paymant. Health Yisitors. A fifth Health Visitor was appointed and took up her duties in September. As will be seen under " Home Visiting," the work performed by the Health Visitors has materially increased ; and, incidentally I believe, it has contributed not a little to the marked reduction in the infant mortality during the year. The area of the Local Authority is now divided into five districts, for each of which a Health Visitor is responsible, combining duties in connection with the School Medical Service with those relating to Maternity and Child Welfare. Each member of the staff is thus enabled to get to know intimately the mothers in her district, and, by the exercise of sympathy and tact, to achieve results that could not otherwise be obtained, whilst duplicate visiting is obviated. Home Visiting. The following table gives comparative figures for 1919 and 1920 25  1919 1920 visits to Babies under one year 667 1132 -visits to Babies and Children up to five years 3311 4715 quiries made, elicited:— Feeding—Natural 469 870 Artificial 48 59 Both 17 23 No information 133 54 Sleeping with parents 300 477 Using Comforter 182 300 Mother working during pregnancy 73 56 NURSING ASSOCIATION. Arrangements continue with the Isleworth Nursing Association whereby nursing assistance may be obtained for maternity cases and for the nursing of Measles, Whooping Cough, Epidemic Diarrhoea and Poliomyelitis in young children and cases of Ophthalmia Neonatorum. HOSPITAL ACCOMMODATION. The need for hospital accommodation for maternity cases and for sick children has again been discussed and reported on during the year, but owing to difficulties in the way of securing suitable premises, no definite steps have yet been taken in the matter. It is recognised that it would be wiser to acquire a site as nearly as possible equally accessible from the several centres of population in the district, whereon a Maternity Hostel, a Creche and a School Clinic could be erected as circumstances would permit. INFANT DEATHS, STILL BIRTHS, MEASLES, etc. Infant deaths are inquired into, 40 visits having been paid for this purpose. Still births have not yet been investigated, but 21 are noted as having occurred during the year. For the incidence of infectious disease among parturient women and children, see the table on page 41. 26 The following numbers of visits were paid in connection with infectious disease among young children:—Measles, 48; Whooping Cough, 25; Ophthalmia Neonatorum, 15. Three of the Ophthalmia cases were nursed in an Institution, and of these one was disharged blind in both eyes; the remaining cases were nursed at hotne and made complete recoveries. No special measures exist for dealing with unmarried mothers or illegitimate children as such, but cases not wholly destitute have derived benefit through the Council's scheme for grants of food and milk. VOLUNTARY SOCIETIES AND HELPERS. The Isleworth Nursing Association is the only Voluntary Society in direct contact with the Council's Maternity and Child Welfare Scheme. During the year negotiations were carried on with the Ellis Day Nursery with a view to rendering it assistance financially and otherwise, but Mrs. Ellis decided she could no longer continue the work, and much to the regret of many mothers, the Institution closed its doors after many years of usefulness. Acknowledgement must be made of the interest taken and useful help rendered by the members of the Womens' Co-operative Guild, Mrs. Dollaston and Mrs. Bartlett assisting at the Hounslow Clinic and Mrs. Tarling and Mrs. Evans at the one held at the Isleworth Public Hall. ISOLATION HOSPITALS. Isolation Hospital Accommodation. This district, with the Borough of Richmond (Surrey), maintains two Isolation Hospitals: — (1) Mogden Hospital, situate in the southern portion of the district, for Scarlet Fever, Diphtheria, Enteric Fever, etc. It has 61 beds, allowing 1,500 cubic feet of air space to each bed. (2) Dockwell Hospital, situate on the western confines of the district, for Small-Pox. It has 13 beds, allowing 1,500 cubic feet of air space per bed. 27 No definite number of beds is assigned to either Authority, but on the basis of the amount of money contributed by each for upkeep, it may be said there are 45 beds (37 at Mogden and 8 at Dockwell) for Richmond, and 29 beds (24 at Mogden and 5 at Dockwell) for Heston and Isleworth. ADOPTIVE ACTS AND BYE-LAWS IN FORCE. Adoptive Acts in force in District: •Infectious Diseases (Prevention) Act, 1890. •Public Health Acts Amendment Act, 1900, Part III. •Public Health Acts Amendment Act, 1907, Parts II., *III., *IV., *V., VI. and VIII. Maternity and Child Welfare Act, 1918. Baths and Wash-houses Act, 1846-82. Burial Acts, 1852-85. (Applicable to parts of district only). Private Street Works Act, 1892. Public Libraries Act, 1892. Bye-Laws in force in District: •Common Lodging Houses (P.H.A. 1875, 80). •Cleansing, etc., and Removal of Refuse (P.H.A. 1875, s. 44). •Houses Let in Lodgings (P.H.A. 1875, s. 90). •Tents, Vans, Sheds, etc. (H.W.C.A. 1885. s. 9 (2) ). •Slaughter Houses (P.H.A. 1875, s. 169 and T.I.C.A. 1847, s. 128). •Prevention of Nuisances (P.H.A. 1875, s. 44). •Keeping of Animals (P.H.A. 1875, s. 44). •Removal of Offensive Matters (P.H.A.A.A. 1890, s. 26). New Streets and Buildings (P.H.A. 1875, s. 157, and P.H.A.A.A. 1890, s. 23). Pleasure Grounds (P.H.A. 1875, s. 164). •Fish Frying (P.H.A. 1875, s. 113). Regulations made by Local Authority in force in District: •Dairies, Cowsheds and Milkshops (D.C.M.O. 1885, s. 13). Allotments (A.A. 1887, s. 6). •These are administered wholly or partly by the Health Committee. The unstarred are administered by other Committees of the Council. 28 COUNCIL LABORATORY. During the year 1920, there were 555 specimens examined as compared with 305 in 1919. These were as follows:— Positive. Negative. Total. Diphtheria (swabs) 93 ... 318 ... 411 Tuberculosis (sputum) 15 65 ... 80 Blood (Widal test) — 1 1 Hair for Ringworm 48 6 54 Pus for Micro-Organisms — — 9 Total 156 ... 390 ... 555 Of the 93 swabs found to be positive, 30 of these were taken from contacts with Diphtheria or from cases met with in the course of Medical Inspection at the schools or at the School Clinics. Preparation of material was as follows:— Tubes of Blood Serum 642 Throat Swab Outfits 561 Sputum Outfits 90 29 SANITARY ADMINISTRATION. Staff. The following persons constituted the staff of the Health Department on the 31st December, 1920:— Medical Officer of Health— W. A. Berry, M.D., D.P H. Assistant Medical Officer of Health— Mrs. E. Cairns Roberts, M.B., D.P.H. Inspector of Nuisances— R. H. Butler, Cert. as S.I., M.I. and S.E. District Sanitary Inspectors— G. W. Ashworth, Cert.as S.I. and M.I. S. H. Franklin, Cert. as S.I. and M.I. One vacancy. Disinfector and Laboratory Attendant— J. H. Cobb. Health Visitors— Mrs. C. E. M. Ottley, Cert. as H.V., S.N., M.C.W.W. and C.M.B. Miss B. M. Tetley, Cert. C.M.B. Miss G. P. Chatfield, Cert. as H.V., S.N. and C.M.B. Mrs. A. E. Tyrrell, Cert. C.M.B. Miss W. E. C. Scott, Cert. as H.V., S.N., M.C.W.W. and C.M.B. Midwife— Mrs. R. Barcroft, Cert. C.M.B. Home Help— Mrs. E. Yates. Chief Clerk— A. G. Hubbard. Clerks— F. G. Boto. Miss R. Marshall. A. Pound. W. I. Smith. E. Cromwell. 30 HESTON & ISLEWORTH URBAN DISTRICT COUNCIL. Health Department, Council House, Hounslow. 16th February, 1921. Canal Boats Acts, 1877 and 1884. Sir, In accordance with Section 3 of the Canal Boats Act, 1881, I beg herewith to present the Annual Report for the year ended 31st December, 1920, as to the execution of the Canal Boats Acts, 1877 and 1884, and of the Regulations made thereunder, within the Urban District of Heston and Isleworth, Middlesex. Inspectors. Messsrs. R. H. Butler (Inspector of Nuisances), S. H. Franklin and G. W. Ashworth (District Sanitary Inspectors) are appointed to act as Canal Boats Inspectors. No special remuneration is paid for the position. Number of Inspections, etc. During the year, 19 inspections were made of 19 boats, 17 boats were in order and on each of two boats one infringement of the Acts and Regulations was found. The nature of the contraventions were as follows:— (1) Improper marking of boat. (2) Certificate not identifying the owner. Legal Proceedings. No legal proceedings have been taken during the year. Infectious Disease. No cases of infectious disease were reported as occurring among the Canal Boat population during the year. General. It has not been possible to make an adequate number of inpections during the year, owing to the shortage of inspectorial staff in the Health Department. Difficulties of enforcing the maintenance of a proper standard of habitable condition in Canal Boats have been found to exist, owing to the duty of maintaining a habitable condition being 31 imposed under the Regulations upon the master and not upon the owner. In many cases it is found upon inspection that the master has only been in occupation for a short period and to require such a person to carry out necessary structural repairs, the renewal or repair of pump and the means for storing water is unreasonable and points to the necessity of amending the Regulations. It is to be noted that no means of proving the date on which any cabin was last painted is provided for in the Acts and Regulations, e.g., by endorsement of the Registration Certificate or by the issuing of a Special Certificate by an authorised authority or inspector. Again, no provision appears to be made for ensuring that one of the certificates shall be kept upon Canal Boats. The non-deposit of one of the certificates upon Canal Boats has, in the past, caused considerable inconvenience and delay in ascertaining whether the boat is overcrowded or properly marked. The absence of sufficient power to enforce this is to be regretted. I am. Sir, Your obedient servant, W. A. BERRY, Medical Officer of Health. The Secretary, Ministry of Health, Whitehall, S. W. 1. SHOPS ACTS. The number of contraventions of the Acts which were reported during the year was as follows:— Open on half-holiday 1 Notices not exhibited 14 Notices not exhibited in a conspicuous position Notices not in prescribed form — Notices (Assistants) not exhibited 31 Provision of seats 1 Sanitary Conveniences 5 32 PROCEEDINGS Proceedings were taken during the year in respect of:— (a) nuisances at 14 houses and (b) the sale of non-exempted articles on the legitimate weekly half-holiday. In the case of (a) costs were imposed and abatement orders made for the works to be carried out in the case of 10 houses. In the case of the 4 remaining houses the summonses were withdrawn upon payment of costs by the owners, (b) a fine of £1, including costs, was imposed. HOUSING. It was stated in the Annual Report for 1919, that the housing conditions in the district were unsatisfactory, and that provision for carrying out systematic inspection was long overdue. These statements still hold good. The numbered headings that follow are introduced by direction of the Ministry of Health in their Memorandum of Instructions as to contents and arrangements of the Annual Reports of Medical Officers of Health for 1920. I. General Housing Conditions in the District. (1) General Housing Conditions: Unsatisfactory. (2) (a) Extent of Shortage or Excess: There is a shortage, but as there has been no recent survey the precise extent is unknown. Last year the figure returned was 1064 and during 1920 34 new houses were erected. (b) Measures taken or contemplated to meet any shortage. I am indebted to the Surveyor for the following summary of Housing Schemes in hand by the Council:— Housing Schemes in hand by the Council. Warren Estate, Hounslow. Forty houses are being erected on this site which lies between Cromwell Road and Wellington Road (South). Twenty being built on each side of road known as St. Aubyn's Avenue. 33 Of these 40, 20 are Class A (Parlour, Living Room and 3 Bedrooms), 12 are Class B (Living Room and 3 Bedrooms) and 8 Class C (Living and 2 Bedrooms). Worple Estate, Isleworth. Three-hundred and four houses are being erected on this site, which lies to the east of Twickenham Road on an orchard site, of these (304) 184 are Class A, 104 are Class B and 16 are Class C. Sutton Lane Estate, Hounslow. Four-hundred and fourteen houses are planned to be erected on this site which lies to the north of Hounslow Barracks Station (District Railway). The classification of these 414 houses has not yet been completed. Advantage has been taken of the local surroundings in each case, and the houses are planned to obtain the maximum amount of sunlight in the rooms and provision is made for cross ventilation in the Living Rooms and Large Bedrooms. (3) Information as to any important changes in population during the year or anticipated in the future. There has been none and none is anticipated. II. Overcrowding. (1) Extent: Overcrowding is prevalent, but in the absence of a complete survey I am unable to say to what extent. (2) Causes: It is due to shortage of houses. (3) Measures taken or contemplated to deal with crowding: No temporary measures have been adopted. (4) Principal cases of overcrowding dealt with : 34 Ten cases remedied. In one of tbese, proceedings were instituted against the occupier, resulting in an order being made with costs of £1. III. Fitness of Houses. (1) (a) General standard of housing in the district: As already stated,the general standard is unsatisfactory. (b) General character of defects found to exist in unfit houses: Dampness due to want of proper damp-proofing, inadequate lighting and ventilation and general dilapidation are the main defects found. (c) How far defects are due to the lack of proper management and supervision by owners: The defects found are in the main, due to owners neglecting to have repairs carried out. (2) Action taken as regards unfit houses under: (a) Public Health Acts See appendices. (b) Housing Acts ,, (3) Difficulties in remedying unfitness, special measures taken and any suggestions in the matter: Principal difficulty is absence of suitable accommodation for families displaced by closing or demolition of unfit houses. Landlords give the price of materials and cost of labour as reasons for delay or neglect in the repair of repairable houses. (4) Conditions, so far as they affect housing, as regards water supply, closet accommodation and refuse disposal, together with measures taken during the year in these matters: Water supply is on the whole satisfactory. Closet accommodation is generally adequate, but defective apparatus is frequently complained of, whilst in the outlying parts of the district are some houses not yet connected with the general sewerage system. Refuse disposal:—a weekly collection is made. 35 IY. Unhealthy Areas. Information as to complaints received or representations made and action taken in regard to unhealthy areas, under Part I. or Part II. of the Housing Act of 1890: Nil. Y. Bye-laws relating to houses, houses let in lodgings, tents, vans, sheds, etc. (1) As to working of existing bye-laws: For reasons given elsewhere it has been impracticable to maintain the inspection of houses let in lodgings, etc. Probably many houses are now technically houses let in lodgings owing to the abnormal housing conditions, but are not on the register. (2) As to need for new bye-laws and revision of existing bye-laws: Some difficulty has been experienced in dealing with caravan dwellers under the existing bye-laws with regard to the disposal of refuse and closet accommodation, and a revision of these bye-laws is under consideration. YI. General and Miscellaneous. Other action taken in connection with overcrowding, insanitary property and housing Nil. YII. Appendices. Statistics for year ending 31st December, 1920. 36 APPENDICES. Housing Conditions Statistics. Year ended 31st December, 1920. 1. GENERAL. (1) Estimated population Birth Rate Death Rate 43,445 41,945 (2) General Death Rate 1091 (3) Death Rate from Tuberculosis 107 (4) Infantile Mortality 57-72 (5) Number of dwelling houses of all classes 8,848 (6) *Number of working-class dwelling houses 4,381 (?) Number of new working-class erected 5 *Number of new houses other than working-class. 29 2. UNFIT DWELLING-HOUSES. I. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1177 (2) Number of dwelling-houses which were inpected and recorded under the Housing (Inspection of District) Regulations, 1910 17 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 11 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 227 (5) Number of houses, listed for inspection under the Housing (Inspection of District) Regulations, 1910 1551 37 II. Remedy of Defects without Service of Formal Notices. Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their Officers 816 III. Action under Statutory Powers. A. Proceedings under Section 28 of the Housing, Planning, etc. Act, 1919— Town (1) Number of dwelling-houses in respect of which notices were served requiring repairs 24 (2) Number of dwelling-houses which were rendered fit— (a) by owners 22 (b) by Local Authority in default of owners nil. (3) Number of dwelling-houses in respect of of which Closing Orders became operative in pursuance of declarations by owners of intention to close nil. (4) Number of prosecutions taken for re-letting houses ordered to be closed nil. B. Proceedings under Public Health Acts— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 11G0 (2) Number of dwelling-houses in which defects were remedied— (a) by owners 947 (b) by Local Authority in default of owners 2 C. Proceedings under Sections 17 and 18 of the Housing, Town Planning etc., Act, 1909— (1) Number of representations made with a view to the making of Closing Orders 11 (2) Number of dwelling-houses in respect of which Closing Orders were made 7 38 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered tit 4 (4) Number of dwelling-houses in respect of which Demolition Orders were made nil. (5) Number of dwelling-houses demolished in pursuance of Demolition Orders nil. 3. UNHEALTHY AREAS. Areas represented by the Local Authority with a Yiew to Improvement Schemes under (a) Part I. or (b) Part II. of the Act of 1890 nil. (1) Name of area — (2) Acreage — (3) Number of working-class houses in area — W Number of working-class persons to be displaced — (*)• Number of houses not complying with the building bye-laws, erected with consent of Local Authority under Section 25, of the Housing, Town Planning, etc., Act, 1919 10 (5). Staff engaged on housing work with, briefly, the duties of each officer (6). Staff engaged in housing work:— The outdoor staff of the Health Department consists normally of one Chief Inspector and three District Inspectors. During the War, two of the District Inspectors joined the Army and the third left to take up a position elsewhere, whilst the Chief Inspector carried on as best he could. Upon their discharge from the Army the tvvo District Inspectors resumed duty, but sanction to till the vacancy for a third Inspector has not been granted by the Council, notwithstanding representations made by the Health Committee. There is no officer appointed wholly for housing duties, which are carried out by the above staff in conjunction with their other duties. 39 Table I. shewing dwelling-houses represented as unfit for human habitation. Premises. No. of houses represented by M.O.H. Date Closing Orders made Date Closing Orders determined. Date Demolition Orders made. Date Demolition Orders obeyed. Date Demolition enforced. Br't forw'd from 1919- *1-3, Poplar Cottages 3 24/2/14 22/12/14 115, South Street 1 27/4/15 23/11/15 l-4,Baker'9 Cotts 4 23/11/15 24, Lampton Road 1 27/3/17 25/5/20 ... 26„ „ 1 »» 28/9/20 ... 28„ „ } I 26/10/20 ... 30,„ „ 1 »i 28/12/20 .. • †14-34, London Road 11 22/7/19 † 1-10, Syon Place 10 »» The Depot, North Hyde „ „ 1 23/12/19 Inspected in 1920— 165-75, Hanworth Road 6 23/11/20 175 & 177, Twickenham Road 2 1, Wellington Road North 1 3, „ „ 1 5, „ „ 1 28/7/20 *17/4/14 Notices served on tenants of Nos. 1, 2 and 3 and complied with. 16/3/16 Demolition ordered in default of owner. 16/10/17 Notices served on new tenants of Nos. 1 & 3. 31/12/20 Nos. 1, 2 A 3 occupied. †Closing Orders not served. Demolition deferred until after the War. 40 Table II. Causes of Death during 1920. Causes of death. Civil Residents all ages.* All causes I Certified 458 Uncertified — 1 Enteric Fever 1 2 Small-Pox — 3 Measles 9 4 Scarlet Fever 2 5 Whooping-cough 5 6 Diphtheria and Croup 4 7 Influenza 9 8 Erysipelas — 9 Phthisis (Pulmonary Tuberculosis) 40 10 Tuberculosis Meningitis 1 11 Other Tuberculous diseases 3 12 Cancer, malignant disease 56 13 Eheumatic Fever 4 14 Meningitis 2 15 Organic Heart Disease 51 16 Bronchitis 43 17 Pnoumonia (all forms) 29 18 Other Diseases, Respiratory Organs 3 19 Diarrhoea and Enteritis 7 20 Appendicitis and Typhlitis 6 21 Cirrhosis of Liver — 21a Alcoholism — 22 Nephritis and Bright's Disease 13 23 Puerperal Fever — 24 Other accidents and diseases of Pregnancy and Parturition 1 25 Congenital Debility and Malformation includining Premature Birth 25 26 Violent Deaths, excluding suicide 13 27 Suicide 2 28 Other defined diseases 128 29 Diseases ill-defined or unknown 1 458 Table III. Infantile Mortality during the year 1920. Nett Deaths from stated Causes at various Ages under i Year of Aee Cause of Death. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks. 4 week* and under 3 mts. 3 mts. and under 6 mts. 6 mts. and 1 under 9 mts.l 9 mts. and under 12 mts. Total Deaths under 1 year. All causes Certified 16 1 4 3 24 16 io 5 7 62 Uncertified Smallpox Chickenpox Measles ... ... ... ... ... ... ... ... 2 2 Scarlet Fever Whooping Cough ... ... ... ... ... 2 ... ... ... 2 Diphtheria and Croup Erysipelas Tuberculous Meningitis Abdominal Tuberculosis Other Tuberculous Diseases ... ... ... ... ... ... 1 ... ... 1 Meningitis (not Tuberculous) Convulsions 1 ... ... 1 2 1 2 ... ... 5 Laryngitis Bronchitis ... ... 2 ... 2 1 2 1 2 8 Pneumonia (all forms) ... ... ... ... ... 3 2 3 2 10 Diarrhoea ... ... ... ... ... 2 1 ... ... 3 Enteritis 1 ... ... ... 1 1 ... ... ... 2 Gastritis Syphilis Rickets Suffocation, overlying Injury at Birth Atelectasis 1 1 2 1 ... ... ... 3 Congenital Malformations Premature Birth 11 ... ... 2 13 2 ... ... ... 15 Atrophy, Debility and Marasmus ... ... ... ... ... ... 1 ... ... 1 Other Causes 2 1 1 4 3 1 1 1 10 16 1 4 3 1 24 16 10 5 7 62 Nett Births Legitimate 1008 Nett Deaths Legitimate infants 51 Illegitimate 36 Illegitimate infants 11 42 table iv. Infectious Diseases, 1920. Cases Notified. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Cerebro-spinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Malaria. Pulmonary Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Dysentery. January 9 11 4 2 6 2 5 February 8 3 2 1 7 5 ... Marcb 12 13 3 4 2 4 April 4 11 1 2 5 i 1 1 May 33 12 1 7 2 June 5 7 1 1 3 i July 10 1 1 4 August 16 4 4 September 24 2 1 2 2 October 23 4 2 1 3 1 November 35 13 1 1 2 6 4 December 30 10 1 1 1 1 3 Totals 209 91 8 13 1 2 25 3 49 6 8 1 Report on the administration of the Factory and Workshop Act, 1901, in connection with FACTORIES, WORKSHOPS, WORKPLACES AND HOMEWORK. Table V.—INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Number of Premises. (1) Inspections. (2) Written Notices. (a) Prosecutions. (4) Factories (including Factory Laundries) 12 5 Nil Workshops (including Workshop Laundries) 173 Workplaces (other than Outworkers' premises included in Table VII. 13 Total 198 5 Nil. Table VI.—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. (i) Number of Defects. Number of Prosecutions. (5) Found. (2) Remedied. (3) Referred to H.M. Inspector. (4) Nuisances under the Public Health Acts:Want of cleanliness c 5 Want of ventilation 1 Overcrowding Want of drainage of floors i Other nuisances 5 3 fSanitary accommodation— Insufficient 1 2 Nil Nil Unsuitable or defective 2 1 Not separate for sexes 1 2 Offences under the Factory and Workshop Act: — Illegal occupation of underground bakehouse (s.101) Breach of special sanitary requirements for bakehouses (ss. 97-100) Other offences ("excluding offences relating to outwork which are included in Table VII 2 2 Total 17 16 Nil. Nil. Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by the district Council, and the standard of sufficiency and suitability of sanitary accommodation or persons employed in factories and workshops enforced is that required by the Sanitary Accommodation Order of 4th February, 1903. 44 Table VII.—HOMEWORK. NATURE OF WORK. OUTWORKERS' LISTS, SECTION 107. Outwork in unwholesome premises, Section 108. Outwork in infected premises, Sections 109, 110. Lists received from Employers. Notices served on Occupiers as to keeping or sending lists. Prosecutions. Instances. Notices Served. Prosecutions. Instances. Orders made (s. 110). Prosecutions (Sections 109, 110). Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send lists. Lists. Outworkers. Lists. Outworkers. Contractors Workmen. Contractors Workmen. (1) (2) (8) (4) (5) (6) (7) (8) (9) (10 (11) (12) (13) (14) (15) (16) Wearing Apparel— making, &c. *6 5 1 cleaning & washing I 2 ... Household linen I Furniture and upholstery I Brush making †1 Total 6 7 I 2 1 1 *Two lists recorded in column 2 contained information of other classes of outworkers as shown in column 4. †A Closing Order has been made with respect to the premises occupied by this outworker. ‡A resident at the premises occupied by this outworker has been notified as suffering from Tuberculosis. Number of outworkers on register, 24. Inspections made, 34. Number of Lists received from other Sanitary Authorities, 17. 45 Table VIII.—REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. (1) Number. (2) 'Bakehouses (Retail)—Workshops 16 Laundries (non-factory) 23 Workshops 150 Workplaces 28 Total number of workshops on Register 217 •In addition there are in the district 8 Retail—Factory Bakehouses. Table IX.—OTHER MATTERS. Class. Number. (0 (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Acts, (s.133, 1901) — Action taken in matters referred by H.M. Inspector as remediable under the Public Health Acts, but not under the Factory Acts (s. 5, 1901)— — Notified by H.M. Inspector 1 Reports (of action taken) sent to H.M. Inspector __ Other t ndergrouud Bakehouses (s. 101) .— *In use at the end of the year I †Retail—Factory Bakehouse. 46 SANITARY WORK. Inspections—General: Total number of inspections and re-inspections 9769 Inspections &c. re Nuisances and Contraventions: Number of premises inspected on complaint 939 Number of premises inspected in connection with infectious diseases 138 Number of smoke observations taken 7 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920 ... 7 Number of other premises on which nuisances were observed 242 Total number of premises primarily inspected in connection with nuisances 1326 Number of visits made to works in progress 703 Number of interviews with owners, builders, etc., re abatement of nuisances 337 Action taken (other than under Housing Acts, 1909-1919) : Number of premises, etc. in respect of which notices etc., were served requiring defects to be remedied (including 57 verbal notices 1275 Number of premises, etc , on which defects were remedied— (a) by owner 1361 (b) by Local Authority in default of owner 2 Number of cautionary or intimation notices given (a) verbal 57 (b) written 1069 Number of second (informal) notices given 385 Number of letters re nuisances sent 270 Number statutory notices issued 23 L Number of proceedings taken 14 Number of convictions obtained 10 Number of proceedings withdrawn 4 Number of cases dismissed — Common Lodging Houses: Number registered 2 Number of inspections made 11 47 Canal Boats used as Dwellings: Number of inspections made 19 Number of contraventions found 2 Movable Dwellings, Caravans, Tents, etc: Number observed during the year 11 Number of inspections made 67 Number of contraventions and nuisances found 12 Number removed from district 11 Bakehouses: Number in district workshops 12 Number of Inspections made 38 Number of contraventions found 6 Number constructed or re-constructed 1 Number repaired or improved 3 Number cleansed 2 Slaughterhouses: Number on register — (a) Registered premises 4 (b) Licensed premises 4 Number of inspections made 127 Number of contraventions found 9 Number repaired or improved 1 Number cleansed 4 Number improperly used 2 Non-removal of offal 2 Cowsheds: Number of persons registered 11 Number of cowsheds on register 17 Number of inspections made 20 Number of milch cows in district 79 Dairies and Milkshop: Number of persons registered 44 Number of premises registered 30 Number of inspections made 104 Number of contraventions found 4 Number repaired or improved 4 48 Offensive Trades: Number of businesses established in the district 10 Number of businesses newly established during the year 2 Number of inspections made 86 Inspection of Food: Number of meat inspections 307 Number of fish inspections 205 Number of provision inspections 145 Number of greengrocery and fruit inspections 399 Number of hawker's foodstuff inspections 184 Number of other premises inspected 11 Unsound Food: Number of articles (233) and parcels (26) surrendered 309 Number of organs or parts surrendered during slaughtering 15 Water Supply and Water Service: Number of supplies provided 2 Number of cisterns cleansed, repaired, covered, etc. 12 Number of draw taps connected direct to main 104 Number of water service pipes or taps repaired 16 Approximate percentage of houses supplied on constant 99 95 system Drainage and Sanitary Arrangements etc., of existing buildings: Water Closets: Number of water closets provided or re-constructed 2 Number of walls, etc. cleansed 99 Number repaired, supplied with water or otherwise improved 203 Number of apparatus cleansed or unstopped 51 Approximate percentage of houses provided with water closets 98 Sinks: Number of new sinks provided 5 Number of sinks repaired, improved or trapped 27 49 Drains: Number examined, exposed, etc. 8 Number unstopped, repaired, trapped, etc. 133 Number of waste pipes provided, dis-connected, repaired, trapped or unstopped 60 Number of soil pipes (8) or ventilating shafts (27) fixed, repaired or improved 35 Number of fresh air inlets provided, repaired or improved 32 Number of gully traps inserted or improved 97 Number of dis-connecting chambers inserted 5 Number of dis-connecting chambers repaired, improved, sealed or cleansed 40 Number of drains constructed or re-constructed 6 Total length of drain pipes laid (4"-224", 6"-127') 351 Number of tests and retests applied 58 Number of other works 5 Approximate percentage of houses draining into Council's sewer 98 Infectious Diseases, Disinfection, &c.: Number of visits made 975 Number of rooms disinfected— (a) ordinary Infectious diseases 290 (b) Tuberculosis 61 Number of rooms stripped and cleansed after infectious diseases— (a) by owners or occupiers 58 (6) by Local Authority 28 Number of articles disinfected or destroyed 2679 Removal of Household Refuse: Number of new ashbins provided 453 Number of ashpits abolished 3 Number of complaints of non-removal received 10 Dampness: Number of roofs striped, renewed or repaired 212 Number of gutters and rain water pipes provided, repaired or unstopped 201 Number of rain water pipes disconnected from drain 32 50 External brickwork, sills, etc., repaired, renewed or rendered impervious 176 Number of damp-proof courses provided 34 Number of yards paved, repaired or drained 136 Interior Work: Number of rooms striped and cleansed (other than in connection with infectious diseases) 3S8 Number of floors, walls and ceilings repaired or renewed 530 Number of rooms in which ventilation provided or improved 13 Number of rooms in which lighting provided or improved 3 Number of window frames and sashes provided, repaired or unfixed 98 Number of stoves or grates provided or repaired 76 Number of instances in which ventilation under floors provided or repaired 43 Number of other repairs 102 Sundry Nuisances: Number of instances in which domestic cleansing carried out 7 Number of food stores provided, cleansed or improved 8 Number of washing coppers provided or repaired 58 Number of verminous conditions abated 47 Number of rooms sprayed for the removal of vermin by the Disinfector 174 Number of overcrowding abated 10 Number of keeping animals abated 21 Number of offensive accumulations removed 29 Number of urinals cleansed, repaired or improved 4 Number of dungpits provided, repaired or improved 1 Number of other nuisances 2 OTHER WORK. Shops Acts 1912-13: Number of inspections made 242 Number of contraventions found 52 51 Number of contraventions remedied 29 Number of warning notices sent 46 Number of proceedings taken 1 Number of convictions obtained 1 Petroleum Acts, 1871-1881: Number of premises licenced 34 Number of inspections made 86 Number of contraventions found 17 Number of contraventions remedied 12 Number of new stores provided 3 Number of warning notices sent 2 HESTON and ISLEWORTH URBAN DISTRICT EDUCATION COMMITTEE. thirteenth ANNUAL REPORT OF THE School Medical Officer FOR THE Year ending 31st December, 1920. 50 (m.o h.) 50 (s.m.o.) Z 7.82. To the Chairman and Members of the Heston and Isleworth Urban District Education Committee. Ladies and Gentlemen, I beg to present the Annual Report of the School Medical Service for the year ending 31st December, 1920. The arrangement is somewhat different to that of previous years and follows the lines suggested by the Board of Education in their circular letter dated December, 1920. During the year Dr. Simpson, resigned his position as Assistant School Medical Officer, and Dr. Eva Cairns Roberts was appointed as his successor. Her work among the children has been very successful and she has contributed largely to the popularity of the school clinics. The appointment of an additional Health Visitor, has proved a great help and it may be anticipated that the numbers of children treated will continue to grow. During the year the number of special cases seen was 2,041, necessitating 6,681 consultations, compared with 1,586 involving 5,236 consultations in 1919. Thus the numbers passed through the clinics have increased. It will also be observed that the number treated at the Dental Clinic has been considerably augumented. Expansion to this extent has not taken place without taxing very severely the clerical staff in the Health Department, and they deserve the highest praise for the manner in which the medical records have been kept. I would remind the Committee that the clerical staff stands numerically as it did in April, 1919, when Dental Inspection and Treatment were in their infancy, certificates for employed children were not needed, there were fewer Eye Clinics and the Inspection and Treatment Clinics were held only thrice, instead of seven times weekly. Nominally the clerical work of the School Medical branch is performed by two clerks, but in reality it requires three, so that a revision of the amount of remuneration paid for this service seems indicated. 2 It will be observed on reference to Table I. that roughly 3/7ths of the total elementary school population come under medical review during 1920. The figures do not of course include children inspected or swabbed in classes where there has been recurring cases of infectious diseases, nor children dentally inspected. I wish to express my thanks to the members of the Committee for the kindness and support they have shewn me. 1 am, Ladies and Gentlemen, Your obedient servant, W. A. BERRY. MEMBERS OF EDUCATION COMMITTEE, 1920-21. E. W. GOODE, Esq (Chairman). G. A. GRIFFITH, Esq. (Vice-Chairman). Members o) the Council:— C. CRUSH, Esq., j.p., ex-officio (Chairman of the Council). F. W. LANGSTONE, Esq., ex-officio (Vice-Chairman of the Council). G. A. GRIFFITH, Esq. (Vice-Chairman of the Education Committee). S.BARTHOLOMEW, Esq. R. LANGDON, Esq. J. J. BONNETT, Esq. W. G. LOBJOIT, Esq., o.b.e., j.p., c.a. E. W. HEATH, Esq. H. J. NIAS, Esq., m.b.e., j.p. A. L. LANG, Esq. N. L. SAMMELS, Esq. J. WEATHERS, Esq. Selected Members— Mrs. W. H. DUMSDAY. Mrs. C. F. EVA. E. W. GOODE, Esq. W. DIVINE, Esq. P. MURPHY, Esq. School Medical Officer: W. A. BERRY, m.d., d.p.h. STAFF. Clerical Staff— A. G. Hubbard (Chief Clerk). F. G. Boto. Miss R. Marshall. A. Pound. W. Smith. E. Cromwell. Health Visitors— Mrs. C. E. N. Ottley. Miss B. N. Tetley. Miss G. P. Chatfield. Mrs. A. E. Tyrrell. Miss W. E. Scott. Dentist—I. Cohen, L.D.S. Radiographer—D. Arthur, M.D., D.P.H. Ophthalmologist—A. E. Loosely, F.R.C.S. Assistant School Medical Officer— Mrs. Eva Cairns Roberts, M.B., D.P.H. School Medical Officer—W. A. Berry, M.D., D.P.H. 5 CO-ORDINATION. The administrative work of the School Medical Service is carried out in the Health Department, under the supervision of the School Medical Officer who is also Medical Officer of Health with charge of the Council's scheme for Maternity and Child Welfare. The Assistant Medical Officer, whose duties are mainly in connection with school children, also gives assistance in public health matters generally, and has charge of one Maternity and Child Welfare Clinic, where ante-natal work in particular is dealt with. The Health Visitors act also as School Nurses, each being responsible for a district and the schools therein. Conference with the Education Office is facilitated, as it is housed in the same building as the Health Department. Finally, the year 1920 has seen greater unification of Health Services, inasmuch as matters pertaining to the School Medical Service, Maternity and Child Welfare and Public Health generally, are now reported monthly to the same Health Committee. (a). Infant and Child Welfare. There are two centres in the District. These with the School Clinics share the same medical and nursing staff, and the record cards are available for school medical purposes. Occasionally a case of ringworm receives x-ray treatment by arrangement with the Education Committee, but there is no general scheme for remedying dental, visual and other defects in children below the age of 5 years. Proposals to this end have been put forward ; their consideration, has however, been deferred. (b). Nursery Schools. There is none in the district. (c). The Care of Debilitated Children under School Age. Children up to the age of five years have access to the centres above mentioned. Arrangements have also been made with the Isleworth Nursing Association for the nursing of measles, whooping cough, etc. 6 The School Medical Service in relation to Public Elementary Schools. School Hygiene. It has not been found possible to make detailed inspections of the school buildings as a whole and their equipment. Attention has, however, been bestowed on the sanitary arrangements, and a resumé of the findings is submitted. Sanitary Arrangements at Schools. During the year detailed inspections were carried out with regard to the sanitary conveniences, lavatories, supplies of drinking water and condition of playgrounds. Full reports were submitted to the Health Committee and the matters were referred to a Sub-Committee with a view to their being remedied. Below is given a list of the schools and departments with the more importtant defects. Those marked with an asterisk have since received attention. ALEXANDRA SCHOOL. Boys' Department. Urinal.—*Flushing pipe from cistern is badly holed and is useless. Grids are missing from the outlets of the urinal channels. W.c's.—The number of apartments is insufficient by four. Doors of apartments not provided with inside fastenings. *Three Hushing cisterns are out of order. *The joint between the flushing pipe and pan is defective in two instances. * All the pans are furred. The glass roof over one apartment is broken. Lavatory.—*One waste plug in the west cloak room is defective. Ashbin.—Defective. Drinking Water.—Supply drawn from tank. Inconvenient position of fountain. Playground.—Asphalt requires repairing and should be extended to cover the large sections of exposed drain pipes. 7 Girls' Department. W.c's.—*Three flushing cisterns are out of order. *There is one defective joint between flushing pipe and pan. *The pans are furred. The glass roof is smashed over two of the apartments. Lavatory.—One roller towel for each cloak room is inadequate. Ashbin.— Defective. Drinking Water.—*The iron receiver for waste water is defective. The supply is not drawn direct from the main. Brentford End Infants' School. Fore court.—The paving is laid with an insufficient fall and in wet weather becomes flooded. Playground.—This has an uneven gravelled surface. W.c's.—Lighting deficient. One seat is defective. Teachers' w.c.—No provision is made for lighting. The closet seat is defective. Drainage.—The collar atid joint at foot of ventilating pipe are defective. GROVE ROAD SCHOOL. Boys' Department. Playground.—Portions of the asphalt need repairing. Urinal.—This is not sufficiently long by about 7 feet. The cement rendering is much cracked and the brickwork is become foul. The automatic flush is insufficient. The floor is rough and not easily cleansed. W.c's.—There are only four apartments; there should be eight. Of the doors two are missing and two are defective. All the seats are dirty and one is defective. Drinking Water.—The tap of the fountain external to the cloakroom on the north side is defective. Lavatory.—Three basins are supplied (number insufficient). Two are without waste plugs. One towel is not enough for a department of this size. 8 Girls' Department. Playground.—There are defective areas in the asphalt; and the paving at the entrances and along the front of the building needs attention. W.c's.—There are seven apartments; six more are indicated. The doors have no inside fastenings and are not self-closing, and five are defective. Lavatory.—Of six taps supplying basins four are defective. Four waste plugs are missing. Drinking Water.—There is no gully trap to receive surplus water from the fountain in the playground. Infants' Department. Urinal.—The cement rendering is cracked. About 12 feet of the sparge pipe are missing. The floor has an insufficient fall towards the channel. W.c's.-'The doors are not self-closing and three are defective. The floors are laid with an insufficient fall. Drinking Water.—*The tap of the fountain external to the teachers' room is defective and the supply is cut off. HESTON SCHOOL. Boys' Department. Urinal.—*Sparge pipe defective. Channel insufficient to accommodate the flush. W.c's.—* Seats dirty. Walls dirty. *No fastenings provided inside the doors. Lavatory.—One basin broken ; paving of floor defective. Ashbin.—*Defective, having neither bottom nor cover. Male. Teachers' Lavatory.—Flushing cistern defective, lighting and ventilation deficient. Walls of apartment are dirty. Girls' Department. W.c's.—*Seat8 dirty. *Four doors unprovided with inside fastenings. 9 Lavatory.—Walls dirty. A range of four basins is provided but only one tap is in working order. Eaves guttering missing in part. Ashbin.—*Defective. Drinking Water.—Supply is drawn from a tank; no cups provided. Infants' Department. Urinal.—Sparge pipe defective. W.c's.— Walls dirty. Inside fastening of door absent or defective. Lavatory.—All the basins are cracked and will not hold water. One tap is defective. *Eaves guttering is absent. Drinking Water.— Supply is drawn from a tank; no cups provided. HOUNSLOW HEATH SCHOOL. Boys' Department. Urinal.—The flush is inadequate. The outlets to channel are unprovided with grids. The concrete floor is defective. W.c's.—The doors are not self-closing. *Inside fastenings of doors are defective. Lavatory.—The plugs to the waste pipes are unsuitable. Drinking Water.—The supply is from an uncovered cistern and the drinking cups have been removed. Girls' Department. W.c's.—One seat is defective. The joint between pan and flush pipe is defective in three instances. The inside fastenings of the doors in some cases are defective. Drinking Water.—The supply is from a cistern unprotected against contamination. Infants' Department. W.c's.—Inside fastenings of doors defective. Joint between flush pipe and pan defective in two instances. 10 Drinking Water.—The supply is drawn from a tank not adequately covered. ROMAN CATHOLIC SCHOOL. Boys' Department. Urinal.—Cement rendering much cracked and a portion about two feet in diameter has fallen from the wall. Sparge pipe badly choked. Floor cracked and has an insufficient fall. W.c's.—There are three apartments from which the doors are missing. Lighting and ventilation unprovided for save through door openings. Internal walls dirty. Seat3 filthy ; two are defective. Roof overgrown with ivy and not fitted with eaves guttering. Drainage.—Cover of inspection chamber defective. Lavatory.—None provided for the boys and girls. Ashbin.— Not sufficiently large Drinking Water.—No cups provided. Girls' Department. W.c's.—No screen wall provided. Doors not provided with inside fastenings. Internal walls dirty. Seats in a filthy condition. Lavatory.—None provided. Drinking Water.—There is a supply but there are no drinking cups. Infants' Department. Lavatory.—There are two basins provided but both are defective. In addition to the structural defects noted, the attention of the Committee was drawn to the lack of cleanliness with regard to the sanitary arrangements at this School. Upon re-inspection four months later there was no improvement in this respect. HOUNSLOW TOWN SCHOOL. Boys' Department. Old Urinal.— *Defective sparge pipe. 11 New Urinal.—Uneven floor, and excessive fall at one end. Wc's.—*Several doors missing from apartments. *Excessive flush of water causing overflow of pans. Drinking Water Supply.—*Standard fixed to screen wall of latrine and supply apparently drawn from a cistern. Girls' Department. W.c's.—*Doors of apartments improperly fitting ; live are without self-closing appliances. Lavatory.—*Certain taps defective. Ashbin.—Defective and lid missing. Drinking Water.—There is a standard fixed to the wall of the latrine but there is no water supply. Infants' Department. Urinal.—*Sparge pipe defective at either end. W.c's.—Unsuitable form of flush to pans. Ashpit.—This devoid of a door opens off urinal and hence is accessible to the small boys ; it should be abolished Drinking Water.—None supplied. ISLEWORTH BLUE BOYS' SCHOOL. Playground.— This is detached from the school and is only about half the size required for a roll of 193 boys. Latrine.—This is situated on the ground floor and immediately beneath the class rooms. The floor of the urinal permits water to lie on it. Lavatory.—Of four basins one is broken and all are without waste plugs. Teachers' W.c.—Flush is weak. Ashbin.—Two are provided but are defective and have no covers. Hot Water Pipes.—Those in the entrance hall, which is rather narrow, should be protected in order to prevent accidental burning as occurred this year. 12 ISLEWORTH BLUE GIRLS' SCHOOL Playground.—The asphalted portion is defective in parts. W.c's.—*Two of the doors are defective. There are no inside fastenings. Automatic flushing apparatus out of order. Lavatory.—The gully receiving waste water is situated in the cloak room. Ashbin.—Defective and insufficiently large. Drinking Water.—*There are no cups provided. ISLEWORTH INFANTS' SCHOOL Urinal.—One rose is not working properly. W.c's.—Self-closing springs defective. Children are not allowed to operate the flush on the plea that they put the apparatus out of order. The flushing cistern in one apartment is defective. Drinking Water.—This is drawn from the main but there are no drinking cups provided. ISLEWORTH TOWN SCHOOL. Boys' Department. W.c.'s.—*Seats are missing from two pans. The joint between flush pipe and pan is defective in four instances. Inside fastening are defective on three doors. Drinking Water.—The supply is said to be from a cistern placed in the roof of the building. The flow is very poor. Girls' Department. Playground.—The asphalt is defective in places. Also the fall is such that water drains to the main wall of the building. W.c.'s.—The inside fastenings are defective on six doors. Seats are absent from four pans and defective on three. Lavatory.—Two roller towels per week for 275 girls are not enough. Drinking Water.—The supply is from a cistern. The iron receiver is defective, allowing water to discharge on to the floor of the cloak-room. 13 St. MARY'S SCHOOL. Boys' Department. The pathway leading to this school needs attention. Urinal.—There is no automatic flushing apparatus and the periodic flushing obtained is inadequate. W.c's.—Lighting and ventilation are insuffioient. Fastenings are absent from the doors. The walls are dirty. Two seats are defective. *The seats and the pans are filthy. Teachers' Lavatory.—There is none, but one w.c. apartment is set apart for the staff (a mixed one) in the boys' latrine. Girls' Department. Playground —This has a gravel surface and provides about 18 sq. ft. per pupil, whereas there should be thirty. W.c.'s.—Only two are provided ; there should be five. Door fastenings defective. Walls are dirty and roof defective. Eaves guttering and rain water pipes back and front are missing. One pan is cracked. *Both seats are missing. Girls' Lavatory.—Three wash basins are provided in a very dark and unsatisfactory cloak-room. Teachers' Lavatory.—None provided. Drinking Water.—No proper provision made. Ashbin.—Defective. ST. MARY'S SCHOOL. Infants' Department. The entrance path to this requires attention. Playground.—Defective surface. Latrine.—The urinal and boys' and girls' w.c's. are situated under the roof covering in part of the playground, and consequently the lighting is extremely bad. Urinal.—This being hand flushed is rarely in a satisfactory state of cleanliness. 14 Boys' w.c's.—Walls of apartments require lime washing. *Flushing apparatus is out of order in one. Seats are defective in two. Girls' w.c's.—Walls of apartments are dirty. Drinking Water.—This when required is obtained from adjoining premises. SPRING GROVE SCHOOL. Boys' Department. Urinal.—Requires extending by four feet. W.c's.—*Pans fouled and seats missing from all. *Absence of two doors. Insufficient top ventilation. Defective roof. The broken glass has been replaced by corrugated iron, resulting in three of the apartments being insufficiently lighted. Girls' Department. W.c's.—*From five pans the seats are missing, and on three they are detached; *these are dirty. Insufficient ventilation. Joint between pan and flush pipe defective. Lavatory. —*Two waste plugs are missing and one tap is defective. Playground.—Defective in several large areas. Infants' Department. Urinal.—Flush inadequate. Roof defective. W.c.'s.—Pans unsuitable inasmuch as the seats, rough and unglazed, cannot be cleansed by ordinary means. *Three defective joints between pan and flush pipe. Ash pit— This brick built structure was condemmed in 1910, (vide report of School Medical Officer for that year); it is still in use. It should be abolished. Lavatory.—Basins dirty and glaze much chipped, walls dirty and require cleansing. Drinking Water.—This is drawn from an uncovered tank placed under the roof and immediately above the teachers' closet. 15 WOODLANDS ST. JOHN'S SCHOOL. Playground.—The asphalted area should he repaired and extended. Means of drainage should be provided. W.c's.—Ventilation is insufficient. The lighting of three apartments is inadequate. One seat is detached. The joint between flush pipe and pan is defective in three cases. The floor is laid with an insufficient fall. The walls are dirty. The roof is defective. Drinking Water.—A tap from the rising main is placed about 18" from the floor. There is no drainage to carry off surplus water, and there are no drinking cups. WORPLE ROAD SCHOOL. Boys' Department. Urinal.—Slate back broken exposing bricks. Sparge pipe insufficient. W.c's.—Insufficient in number. Doors not provided with inside fastenings. Drainage.—*No cone to vent pipe. Periodic obstruction of drain. Drinking Water.—No cups provided. Girls, Department. W.c's.—Automatic flushing tank out of order Doors not provided with inside fastening or self-closing appliances. Drinking Water.—*The standard against screen wall of latrine is defective. The supply is drawn from an imperfectly covered tank. Infants' Department. Urinal.—The condition of surface indicates that hand flushing used here is inadequate. W.c.'s.—Automatic flushing tank out of order, doors defective. Lavatory.—: Five taps out of eight are defective. 16 Drinking Water.—*The fitting placed against external wall of urinal is defective. The supply is drawn from an imperfectly covered tank. In regard to the foregoing, the defects were located by the District Sanitary Inspectors and subsequently were confirmed by the Medical Officer. At none of the schools was there found any attempt to provide toilet paper in the w.c's. It is plain that instructions given by the teachers on personal hygiene is waste of time, unless facilities be given for the practice of elementary cleanliness, and teachers be instructed to see it is enforced. I therefore suggest that the Committee give orders for toilet paper to be provided in each department, and that head teachers be asked to appoint one or more sanitary monitors, to see that elementary cleanliness is observed. As a natural sequence, instructions will also be required to ensure that hand basins be kept clean and serviceable, and for the supply of an adequate number of clean towels in each cloak room. Some maintain that the schools cannot properly inculcate the principles and habits of a hygienic life when it is borne in mind what are the children's own experiences in the slums. Happily in this district slums do not predominate, and even so, the Education Authority should not be found wanting in putting into practice what is preached in the schools. Education being now compulsory schools have with some justification been described as prisons. We should see to it that they are maintained in a state of sanitary efficiency. MEDICAL INSPECTION. The following short resume describes the arrangements made for the medical inspection of the children. The afternoon sessions are chosen as it is found to be more convenient for those parents who desire to be present. The suggested dates are submitted to the teachers, and if found convenient, are intimated to the Secretary who informs His 17 Majesty's Inspector of Schools. Formal notice of the inspection is sent to the school, together with cards inviting the parents to be present. These cards are all ready filled in save for the hour of attendance to be entered and the teacher's signature. Parents whose children are found to be defective and who require medical treatment, are duly informed of the necessity of medical advice being sought. If the parents fail to attend, notices of the defects are subsequently delivered at the homes by the Health Visitors who explain to the parents how they should proceed in order to have the defects remedied. (a). Age Groups Inspected. The selection of children due for routine medical inspection during 1920, includes those children born during the years, 1908, 1911 and 1914, together with those absent at the previous medical inspection. (b). Board's Schedule. In all cases the Board's Schedule of medical inspection has been followed. (c). Crippling Defects. No special steps beyond those outlined on page 33, have been taken to secure the early ascertainment of crippling defects. (d) Disturbance of School Arrangements. The accommodation available for the purpose of medical inspection varies in different schools. In some the head teachers' rooms are used, but as a rule they are insufficiently large for vision testing; in others a class room or part of a class room, more or less screened off has to serve. Where it is necessary to utilise a class room for this purpose, it is evident there results crowding, with some disturbance of the school arrangements, but it is endeavoured in all cases to cause as little interference as is practicable with ordinary school routine. 18 FINDINGS OF MEDICAL INSPECTION, 1920. Uncleanliness. Out of 1,969 children examined at routine medical inspection, 29 were excluded on account of nitty or verminous conditions, whilst 44 were marked to be kept under observation. Apart from these cases other 391 were seen at the school clinics and were referred for treatment, and 89 were kept under observation. Further reference to this subject will be found on page 36. Tonsils and Adenoids. Out of 1,969 children examined at the routine inspections, 489 had enlarged tonsils, 189 of which were referred for treatment, 300 being kept under observation. 68 children had adenoids only, of which 28 required treatment, and 40 were for observation, whilst 45 children had both enlarged tonsils and adenoids, 30 requiring treatment and 15 observation. In many cases children marked for observation would probably require operative treatment, but only very well marked cases were referred for treatment on a first inspection, as the condition often clears up with removal of carious teeth and a general improvement in the hygiene of nose and mouth. At the special clinics, 22 other children were found to have enlarged tonsils, 13 adenoids only, whilst 20 suffered from both conditions. Tuberculosis. Out of 1,969 children examined at the routine inspection there were 8 cases of suspected pulmonary tuberulosis requiring to be kept under observation. At the special clinics, 3 were found to be suffering from pulmonary tuberculosis, and 12 from suspected pulmonary tuberculosis, whilst 1 child had tubercular glands. Skin. At the routine inspections, out of 1,969 children examined, 10 were found to be suffering from skin trouble, and 2 with ringworm of head. 19 At the special clinics there were 471 children suffering from various skin complaints, including scabies and impetigo, (see Table II. for analysis of figures), 52 cases of ringworm of scalp and 44 cases of ringworm of body. External Eye Disease. Out of 1,969 children examined at the routine inspections, 53 were found to have minor eye diseases including blepharitis and conjunctivitis, whilst 16 had a squint. In addition 51 were found at the special clinic to suffer from the "minor" eye diseases, and 7 had squint. Vision. Out of 1,969 children examined at the routine inspections, 195 were found to have defective vision, 125 of which were referred for treatment, 70 being kept under observation. At the special clinics 78 children were referred for treatment for defective vision. Ear Disease and Hearing. Out of 1,969 children examined at the routine inspections 74 were found to be suffering from defective hearing or ear disease, whilst an additional 50 were discovered at the special clinics. Dental Defects. Out of 1,969 children examined at the routine inspectious, 643 had carious teeth and were referred for treatment, whilst 676 had slighter caries and were marked for observation. Two-thirds of the children thus examined had carious teeth. At the special clinics a further 86 were discovered and referred for treatment. At the routine deutal inspections 1,378 children were referred for treatment out of 2,075 inspected (for further particulars see Table IV. D (1) & (2). 20 Crippling Defects. The expression "crippling defect," may include many varied pathological conditions, but in this report the definition given on page 30 is adhered to. Out of 1,969 children examined at the routine inspections, there were 34 found to be suffering from deformity, including 6 cases of rickets and 10 of spinal curvature. At the special clinics 8 more cases were discovered. In a special survey of the school children for the purpose of a report on crippling defects, 40 children were found to be affected, including those caused by tuberculosis, paralysis, rickets, trauma and congenital causes. (See Table pages 40 and 41). INFECTIOUS DISEASES. Cases of infectious disease are occasionally met with at routine inspections or at one of the school clinics. Systematic swabbing of sore throats and suspicious nasal discharges brings to light unsuspected diphtheria. All infectious cases and contacts are excluded from school till they are deemed free from infection (Joint Memorandum issued by the Local Government Board and the Board of Education). During the year 1920, the following cases of infectious disease occurred among children attending public elementary schools in this district:— Scarlet Fever 96 Diphtheria 34 Measles 517 Rubella 4 Mumps 30 Chicken Pox 64 Whooping Cough 178 Total 923 21 The non-notifiable diseases, Measles, Rubella, Mumps, Chicken Pox and Whooping Cough, are visited by the Health Visitors, and in doubtful cases by one of the Medical Officers when there is no doctor in attendance. Similar action is taken in respect of children kept at home on account of a "rash." FOLLOWING-UP. Physical defects discovered at routine medical inspection are at once notified by the examining officer to the parent, if present, and in any event a written or printed notice of the defect is subsequently delivered at the child's home by the Health Visitor, who explains to the parents what steps should be taken to have the condition treated. Re-visits are made to ascertain what action has been taken. Summary of the work undertaken by the Health Visitors in connection with the School Medical Service:— 1. They are in attendance at the Inspection (Minor Ailment) and Special Clinics. 2. They accompany the Medical Officer to the Schools for routine medical inspections, and weigh and measure children, etc. 3. They pay periodic visits to the schools for the purpose of conducting Cleansing Surveys. 4. "Following-up" as outlined above. 5. Visits are also paid to the children's homes— (a). For inquiry in connection with non-notifiable infectious diseases. (b). To swab Diphtheria contacts. (c). To obtain signatures to consent forms for operative treatment of tonsils and adenoids and dental defects. (d). To follow up cases absent or attending the clinics irregularly. 22 Summary of work by the Health Visitors during 1920. 489 attendances at School Clinics. 123 visits to schools for medical inspections. 15 „ „ „ dental inspections. 32 „ „ „ cleansing surveys. 2413 „ homes in connection with following-up. 970 „ homes in connection with infectious diseases. MEDICAL TREATMENT. Defects discovered at medical inspection are reporled to the parents, who may elect to obtain treatment either privately or through a hospital, or in certain instances may avail themselves of the facilities afforded by the School Clinics. Visual and dental defects, X-ray treatment of Ringworm, and the treatment of Minor Ailments are now undertaken by the Education Authority, whilst the operative treatment of Tonsils and Adenoids is by arrangement carried out at the local hospitals. MINOR AILMENTS. Skin. Ringworm of the Scalp.—Out of 50 cases referred for treatment 46 were successfully treated by the application of X-rays at the X-ray Clinic, 4 refusing this form of treatment. Ringworm of Body.—35 cases were successfully treated at the School Clinics. 385 children were treated at the School Clinics for other skin diseases, including 46 cases of Scabies and 248 cases of Impetigo. Ear Disease and Hearing. At the School Clinics, 34 cases of Ear Disease or Defective Hearing were seen and treated. Eye Disease. 34 cases of Eye Disease have been treated at the School Clinics. These have been chiefly Conjunctivitis, Blepharitis, with some Phylctenular and Corneal Ulcers, and suppurative conditions of the lids. 23 Tonsils and Adenoids. Out of 288 children referred for treatment, 38 received treatment either privately or through a hospital, whilst 8 were treated under the Education Authority's scheme. Arrangements have now been made whereby children requiring operative treatment for enlarged tonsils and adenoids can obtain this at one of the local hospitals, the Education Committee accepting responsibility for the fee. Re-payments are claimed from the parents in accordance with the following scale:— Weekly family income per head, less rent. Amount per case Under 8/- nil. From 8/- to 10/- 7/6 From 10/- to 12/- 15/- Above 12/- 31/6 As the arrangements did not become effective till late in the year, the number so treated was few. Before a child is sent for operation, it receives, if need be, dental treatment and is kept under observation for some weeks, as not infrequently the removal of carious teeth or the disappearance of an infective catarrh obviates the need for operative interference. Vision. 140 cases of Visual Defect were submitted for Refraction at the School Eye Clinic, whilst 1 child was treated at the local hospital. In 129 cases spectacles were prescribed and provided, and 1 case was referred to hospital for further treatment. Dental Defects. 703 children were treated by the School Dentist under the Local Education Authority's Scheme. Further, 23 attended the Dental Clinic and were referred elsewhere for treatment, e.g., hospital, and 113 attended the Clinic but refused treatment. 65 children had treatment by private dentists. OPEN-AIR EDUCATION. There are no facilities in this district for open-air education beyond the holding of playground classes, and I am not aware that this is practised to any appreciable extent. 24 During the year, I reported that there were some 60 children in the district for whom education on open-air lines was desirable, but no steps have been taken to provide the necessary accommodation. This matter was the subject of report in 1919, and also on previous occasions. PHYSICAL TRAINING. There is no Area Organiser of Physical Training for the elementary schools in this district. Whatever is done is on the initiative of the teachers, but the School Medical Officers are not consulted, save as to fitness or otherwise of a particular child to engage in drill. PROVISION OF MEALS. The systematic provision of meals to school children was not undertaken during the year under review. SCHOOL BATHS. None of the schools in this district is provided with baths. CO-OPERATION OF PARENTS. As already indicated, cards are sent to the parents inviting their attendance on the occasion of their children undergoing Medical Inspection. They are also invited to attend Dental Inspections, when the Dentist delivers a short lecture on the evils of dental caries and the need for treatment. During 1920, one or other parent attended in 1003 instances, representing a percentage of 50 9 as against 45% for 1919. Where defects are found the children are followed-up as already described. CO-OPERATION OF TEACHERS. Review of the work undertaken by Teachers in facilitating the work of (1) Medical Inspection, (2) Following-up, and (3) Medical treatment of the children. Teachers now recognise the part school medical inspection plays, and grant all the necessary facilities for the work. Mention has already been made that clerical work by the teaching staff in 25 connection with medical inspection is, by the wish of the Education Committee, reduced to a minimum. The preparation of cards, weighing, measuring and so on being performed by the staff of the Health Department. Similarly as regards following-up and the securing of medical treatment, with few exceptions the teachers do not concern themselves, mainly, it may be supposed, because they are not encouraged by the Committee to manifest any interest in the defects found, or aid in prevailing upon the parents to have them remedied. It would be a great help were the Committee to give instructions for each Head Teacher to be furnished with a medical log book, wherein might be entered the names of children in whom defects were found, and authorise a periodical muster of them and their parents for the purpose of questioning as to why medical treatment had not been forthcoming. By the adoption of some such plan considerable benefit should result, for teachers as a rule wield great influence with the parents of their charges, and can often achieve results when others fail. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. In this district there are three Attendance Officers, and they have entr6 to the Health Department where they can ascertain the health status and fitness for school of any particular child. The function of these Oflicers is to maintain attendances, consequently they take no part in aiding the work of medical inspection, nor do they engage in following-up save in the recovery of fees for the treatment of Tonsils or Adenoids or for the supply of glasses, but they do render valuable help in securing treatment for children absent from school for alleged medical reasons. If there is no doctor in attendance and the parent is unwilling to seek one, the case is referred to one of the School Clinics and a report is rendered to the Secretary of the Education Committee. Again, in instances where children are absent on account of sore throats or because of some rash, prompt reports by the Attendance Officers have frequently directed attention to early cases of infectious disease. 26 CO-OPERATION OF VOLUNTARY BODIES. During the year the National Society for the Prevention of Cruelty to Children rendered assistance in cases of neglect, but other Voluntary Bodies concerned in the welfare of school children are not conspicuous in this district. BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. (a). Periodical returns are made by the teachers of children judged to be abnormal. Arrangements are then made for a special medical examination, and based upon this a report is made. During 1920, examinations were conducted in respect of 32 children as follows:— 27 Initials. Date of Birth. Sex. Diagnosis. Recommendation. School attended. E E 28/1/12 F Mentally Backward H.M. L.M 14/11/07 F Border Line Case Special Class A.G. H.M 23/12/10 M ” ” ” ” I.T.B. E.S 27/5/12 F Epilepsy Exclusion W.R.I. S.E 22/9/12 M Border Line Case Special Class S.M.I. A.W 2/1/11 M ” ” ” ” H.H.B. D.B 6/7/11 M Mentally Backward ” ” S.M.I. W.H 22/9/12 M ” ” ” ” S.M.I. E.B 24/2/10 M Feeble Minded Special Residential School B.E.I. J.D 19/1/11 M Mentally Backward Special Class I.T.B. GF 28/8/13 M ” ” Open-air School G.R.I. E.H 6/4/11 F ” ” Special Class I.B.G. F.A 17/5/13 M Mentally Defective Special Residential School M.B 30/1/12 F Idiot H.I. M O 25/4/12 F Mentally Defective Special Residential School H.H.G. E.C 5/5/09 F ” ” ” ” ” H.R.C.M. D.D 26/7/08 F ” ” Special School W.R.I. A.E.F … F ” ” ” ” Nil. H.R.H 26/12/13 M Mongolian Imbecile Nil. M.H 23/1/11 F Mentally Defective Special Residential School I.B.G. I.M 7/6/12 F ” ” ” ” ” Nil. A.N 12/6/08 M ” ” ” ” ” G.R. . A.P 28/8/12 M ” ” ” ” ” K.R 18/8/11 F Moral Imbecile Nil. E.R 3/9/08 F Mentally Defective Special Residential School G.R.G. H.R 14/2/08 M ” ” ” ” ” I.B.B. A.F.S 24/9/06 M ” ” ” ” ” S.G.I. 28 Initials. Date of Birth. Sex. Diagnosis. Recommendation. School attended. L.T 3/11/09 F Mentally Defective Special Residential School H.R.C.M. F.W 25/10/08 M ” ” ” ” ” Nil. E.W 12/6/09 M ” ” ” ” ” I.T.B. P.H.B 9/I2/I2 M Deaf and Dumb Special School Nil. S.T 2/5/07 M Defective Speech Special Class I.B.B. Those children in whom a diagnosis of " border line " has been made will be re-examined. (b). There are no special schools in this district for defective children. NURSERY SCHOOLS. There are no nursery schools in the district, but there is no lack of material for use. Accommodation could, it is believed, be found at the Hounslow Heath Infants' Department. SECONDARY SCHOOLS, CONTINUATION SCHOOLS. The School Medical Service of the Local Education Authority does not at present extend to these. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS, (i) Employment of Children. The conditions of the employment of children and young persons in this area are regulated by Bye-Laws made under the Employment of Children Act, 1903, and the Education Act, 1918. By these certain employments are prohibited and in others the hours of employment are regulated : children between the ages of 13 and 14 employed in the sale or delivery of milk or newspapers, or in domestic work away from home, must hold a certificate from the School Medical Officer to the effect that such employment will not be prejudicial to their health or physical development and will not render them unfit to obtain proper benefit from their education. 29 (ii) Co-ordination of the work of the School Medical Service with that of the Juvenile Employment Committee and of the certifying factory Surgeon for the District. The Health Reports for Juvenile Employment cards are taken from the medical inspection records and are entered in the Health Department. Where by reason of absence at Medical Inspection, sufficiently recent medical records do not exist, the cases are summoned to the Inspection Clinics and the necessary data obtained. These represent the limits of the services rendered by the School Medical Staff I am unable to say what relationship exists between the Juvenile Employment Committee and the certifying factory Surgeon for the District. (iii) The findings of the School Medical Service as regards the physical conditions of employed children and young persons. From the time the Bye-Laws became effective in October until the end of the year there were examined 66 children and all save one were granted the necessary certificates of fitness for work. MISCELLANEOUS. Medical Examination of Teachers. During the year 24 medical examinations were made of teachers. In the majority of cases these were in connection with their appointment under the Authority. Holiday Home for Children. 42 medical examinations were of children preliminary to their going to the King Edward VII. Memorial Home, Heine Bay. Juvenile Employment. 29 special examinations were conducted in respect of children whose medical inspection records were not sufficiently recent. CRIPPLE CHILDREN. By the Education Act, 1918, Section 20, the Local Education Authority are required to ascertain what children in their area are physically defective and to make provision for them. 30 At my request, Dr. E. Cairns Roberts made a survey of all known physically defective children of school age in the district and submitted the report as follows:— Report on Cripple Children of School Age. Definition.— For the purposes of this Report the following definition of the cripple child has been taken, viz. " children who are handicapped because they lack the normal use of skeleton or skeletal muscles," and only cases of physical defect conforming to it have been included. Number of Cases.—The total number of cases examined was 43, 3 of which presented no definite deformity and are not included in the following tables and percentages. A total of 40 is equivalent to 5'7 per 1,000 children on the registers. Below are tables showing— 1. Analysis of cases. 2. Age at onset. 3. Sex incidence. Active Disease.—In one case only was there any evidence of active disease, viz., a boy, aged 12, with a Tubercular Ankle, only noticed about six weeks previously. 31 Surgical Tuberculosis. Paralysis. Deformities. Analysis. Hip. Knee and Elbow. Ankle. Infantile Paralysis. Birth Palsy. Rickets. Trauma. Congenital. Other Causes. Total. Spinal. Lower Limbs. Infective. Static. 2 1 1 9 3 4 3 4 9 3 I —40 Age at Onset. Birth ... ... ... ... 3 ... ... I 9 ... ... 13 Under 1 ... ... ... 2 ... I 2 ... ... 1 ... 6 1 ... ... ... 2 ... ... ... ... ... ... ... 3 2 ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... ... 1 ... ... ... ... ... ... ... 4 4 ... ... ... 1 ... ... ... ... ... ... 1—27 5 6 ... ... ... 1 ... ... ... ... ... 1 ... 1 2 7 ... ... ... ... ... ... ... 1 ... 1 ... 2 8 ... ... ... 2 ... ... ... ... ... ... ... 2 9 ... ... ... ... ... ... ... 1 ... ... ... 1 10 ... ... ... ... ... ... ... ... ... ... ... ... 11 ... ... ... ... ... ... ... ... ... ... ... ... 12 ... ... ... ... ... ... ... 1 ... ... ... 3 13 ... ... ... ... ... ... ... ... ... ... ... —11 Not known ... ... ... ... ... 1 1 ... ... ... ... 2— 2 Sex Incidence. Boys 2 ... 1 3 ... 3 3 4 5 1 ... —22 Girls ... 1 ... 6 3 1 ... ... 4 2 1 —l8 32 Attendance at School.—All the children are at present attending ordinary schools, with the exception of the boy with the Tuhercular Ankle previously mentioned, who is excluded. Thirteen children, however, are attending various hospitals more or less regularly for treatment, which means considerable loss of attendance. Treatment.—Out of the 40 children with defects, 30 have received treatment at some time or other, 14 of those are still receiving treatment and 2 are under medical observation. It is difficult to speak of results of treatment as only an imperfect estimate can be formed of the original condition. The only case which appears really satisfactory is that of a girl of 5½, who had a Congenital Talipes of right foot, with apparently considerable deformity. There is now no shortening of limb. The foot is in a good position with the heel on the ground, and she cat) walk well without any support. The only remaining disability being some weakness of the extensor muscles of the leg with a tendency to dropped foot. This case has had continuous treatment at Gt. Ormond Street Hospital from birth— manipulative, operative and electrical, and is still attending the hospital three times weekly for massage and electricity. Requirements for Satisfactory Treatment The requirements of satisfactory treatment of crippling are well exemplified in the case just quoted, and fall under three main headings, viz:— 1. Treatment must begin as soon as the deformity is noticed. 2. It must only be in the hands of those skilled in Orthopcedic work. 3. It must be continuous and only end with the correction of the deformity, or when further treatment is proved useless. 33 As the greater number of crippling deformities occur in children before the school age, many being present at birth, or occurring during infancy, it is plain that the closest co-operation between the Public Health and School Authorities is necessary. Early treatment requires early notification of the crippling. This is provided for in the case of infants and young children, by the Notification of Births to the M.O.H., followed by the visits of Health Nurses to the houses, until the child is five, and also by the Infant Clinics. For the children attending school there are the Routine Medical Inspections and School Clinics. The importance of Infant Welfare Clinics in any scheme for the well-being of the community cannot be over emphasized. Apart from work of a social and educational character, they provide a means of medical examination of infants, which otherwise would be impossible. Ante-natal work has also its place, for although medical science cannot speak with certainty as to the cause of Congenital Deformity, there is no doubt that attention to the pregnant woman and the child ' in utero,' by remedying or providing for defects is a sure means of minimising the risks of having children born crippled. Having discovered, the defect, the provision of adequate treatment has next to be considered. Under the present position of affairs treatment of crippling in children in this country is chiefly carried on by— (a). The large hospitals. (&). Certain voluntary organisations. (c). In a few instances by Special Clinics or Hospitals worked in conjunction with the County or Local Authorities. By far the largest number of children are treated at the hospitals, in some cases under the control of the Authority who maintains a certain number of beds for this purpose, but 34 chiefly as ordinary hospital patients, without reference to Health or School Authorities. In districts or counties where there is no special provision for the treatment of crippling, what happens is as follows:— Granted the early detection of the defect through the agencies detailed above, the mother is then told she must take the child to a hospital, either local, if treatment can be obtained there, or to the nearest large town. The unsatisfactoriness of such haphazard precedure is apparent. Practically all the large hospitals where the best treatment can be obtained have long waiting lists, therefore, if the child needs in-patient treatment, it is often many months before such is forthcoming; meanwhile the deformity increases and becomes less amenable to treatment, and often the child has left the district before its turn comes or the mother loses heart at the delay and does nothing further. Or if out-patient treatment meets the case, it is frequently necessary for the child to attend three times a week or oftener, over a long period, which is a severe tax on a working mother, particularly if living at some distance from the hospital. Also the travelling to and fro is often harmful to the child, and if the child is of school age, it means that it is forced to miss a large amount of schooling. The question of the necessary appliances must also be considered. Hospitals cannot afford to supply them free, equally the parents usually cannot afford the cost; and often the only way of obtaining them is by collecting a certain number of letters from subscribers to Societies who supply Orthopoeilic appliances, which letters are equivalent to a part or a whole of the cost. Delay is again inevitable. After treatment is equally uncertain and difficult to obtain. If, therefore, the problem of the cripple child is to be adequately solved, it seems of the utmost importance that Local Authorities, both Health and School, should formulate 35 some scheme whereby the necessary treatment could be obtained and maintained, with a minimum loss of educational training. SCHOOL CLINICS. In the early part of the year the clinic for the treatment of Minor Ailments held at Alexandra School was discontinued, it being found one such session per week was quite inadequate and frequent misunderstandings arose as to which clinic a child was to attend. Facilities having been extended at the Council House, we were enabled to hold combined Inspection and Treatment (Minor Ailment) Clinics on five mornings a week. The Clinics at the Public Hall, Isleworth, are similar in scope and are as before held on Monday and Thursday mornings. School children come under the notice of the Medical Officers in one of the following ways:— 1. They are discovered at Eoutine Medical Inspections and are perhiips marked for treatment or it may be merely for observation. 2. Parents may apply to the teachers for authority to attend the Clinic. 3. The teachers may on their own initiative refer children to the Clinic either because of illness or uncleanliness. 4. The School Attendance Officers or the Attendance SubCommittees may refer children who have been absent from school on account of alleged illness. 5. The Medical Officers or the Health Visitors may discover cases casually while visiting the schools. Charges for treatment are as follows:— Spectacles Free in cases considered necessitous. Ordinary cases, 4/- per pair. When special frames ordered by parents, full cost. 36 Ringworm Free in cases considered necessitous. Other elementary school cases, 2/6. Cases from other schools, according to circumstances of parents. Dental 6d. per attendance at Clinic. Minor Ailments Free. TREATMENT OF UNCLEANLINESS. The Schools were visited by the Nurses on 32 occasions for the purpose of conducting Cleanliness Survey. At these inspections there were examined 4,181 children, of which 649 were found to be unclean. Of the latter number 237 were excluded and the remainder warned and kept under observation. In this district neither the Education Authority nor the Sanitary Authority possesses a cleansing station, consequently when children are excluded from school by reason of nitty or verminous conditions and their parents fail to cleanse them within the period of 14 days, allowed them by by-law, a prosecution may be ordered. The lack of proper facilities for cleansing was referred to in the Annual Report of 1919, and was also the subject of special report in October, 1920, but nothing has been done. During the year 1920, legal proceedings were instituted against the parents of 11 children. In two instances the summonses were withdrawn, in one an order was made and in the remainder fines were imposed as follows: 1 of 2/6 ; 3 of 5/-; and 2 of 10/-. LIST OF TABLES. 1. Number of Children Inspected. 2. Return of Defects found in the course of Medical Inspection. 3. Numerical Return of Exceptional Children. 4. Treatment of Defects of Children— A. Minor Ailments. B. Visual. Defects. C. Defects of Nose and Throat. D. Dental Defects. 5. Summary of Treatment of Defects. 6. Summary of Children examined at Routine Inspections. 37 Heston and Isleworth. Table. I.- NUMBER OF CHILDREN INSPECTED 1st January. 1920, to 31st December, 1920. A—Routine Medical Inspection. Age. Entrants. 3 4 5 6 Other ages. Totals. Boys ... ... ... 287 26 313 Girls ... ... ... 226 29 255 Totals ... ... ... 513 55 568 Age. Intermediate Group. Leavers. Other ages. Total. Grand total. 8 12. 13. 14. Boys 297 354 18 23 18 710 1023 Girls 322 318 13 24 14 691 916 Totals 619 672 31 47 32 1401 1969 B - Special Inspections. Special Cases. Re-examinations (i.e. No. of children re-examined. Children examined 2041 *810 C—Total number of individual children inspected by the Medical Officer, whi ther as Routine or Special Cases (no child being counted more than once in one, year). No. of individual children inspected '2,933. 'The figures 810 relate to children found defective at Routine Medical Inspection and subsequently re-examined in the schools. The Special Cases were, in the majority of cases, seen at the School Clinics, and for these there were 6,681 examinations, so that the total number of examinations amounts to 9.460 38 (Heston and Isleworth). Table II.—RETURN OF DEFECTS found in the Course of Medical Inspection in 1920. Disease or Defect. Routine Inspections. Specials. Number referred for treatment. Number reqniring to be kept under observation, but not referred for treatment. Number referred for treatment. Number requiring to be kept under observation, but not referred for treatment. 1 i 3 4 1 5 Malnutrition l ... ... 1 Poor Nutrition ... 40 ... ... Uncleanliness— Head 28 44 391 89 Body 1 ... 1 1 Skin — Ringworm Head ... 2 50 2 Body ... ... 35 9 Scabies 1 ... 45 ... Impetigo 2 ... 246 ... Other Diseases (non- tubercular) 2 5 89 91 Eye— Blepharitis 2 4 3 14 Conjuntivitis 9 11 5 Keratitis ... ... 1 ... Corneal Ulcer Corneal Opacities Defective Vision 125 70 78 ... Squint 3 13 7 ... Other Conditions 4 34 3 14 Ear— Defective Hearing ... 18 3 15 Otitis Media ... 6 ... ... Other Ear Diseases 20 30 14 18 Nose and Throat— Enlarged Tonsils 189 300 13 9 Adenoids 28 40 13 Enlarged Tonsils k Adenoids 30 15 5 15 Other Conditions 7 20 56 21 39 Table II—Continued. Disease or Defect. Routine Inspections. Specials. Number referred for treatment. Number reqniring to be kept under observation, but not referred for treatment. Number referred for treatment. Number requiring to be kept under observation, but not referred for treatment. 1 2 3 4 5 Enlarged Cervical Glands (non-tubercular) 1 294 13 7 Defective Speech Teeth— ... 5 1 1 Dental Diseases (see above) 643 676 86 ... Heart and Circulation— Heart Disease 11 112 5 13 Anaemia 17 13 14 8 Lungs— Bronchitis 28 18 46 8 Other Non-Tubercular Diseases ... 37 12 5 Tuberculosis— Pulmonary Definite 2 1 Suspected Non-Pulmonary ... 8 3 9 Glands ... ... 1 ... Spine Hip Other Bones and Joints ... ... ... 1 Skin Other Forms ... 1 1 ... Nervous System— Epilepsy ... 1 1 2 Chorea ... 1 15 1 Other Conditions ... 7 3 2 Deformities— Rickets ... 6 ... ... Spinal Curvature 1 9 ... 2 Other Forms 3 15 ... 6 Other Defects and Diseases 3 41 106 228 Number of individual children having defects which required treatment or to be kept under observation—2133. 40 (Heston and Isleworth). TABLE III.—NUMERICAL RETURN of all Exceptional Children in the area in 1920. Hoys. Girls. Total Blind (including partially blind) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893. Attending Public Elementary Schools ... ... ... Attending Certified Schools for the Blind ... 1 1 Not at School ... ... ... Deaf and Dumb (including partially deaf) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893. Attending Public Elementary Schools ... ... ... Attending Certified Schools for the Deaf 1 ... 1 Not at School 1 ... 1 Mentally Deficient Feebleminded Attending Public Elementary Schools 13 13 26 Attending Certified Schools for Mentally Defective Children 2 1 3 Notified to the Local (Control) Authority during the year ... 3 3 Not at School 3 3 6 Imbeciles At School ... ... ... Not at School 2 2 4 Idiots 1 1 2 Epileptics. Attending Public Elementary Schools 1 3 4 Attending Certified Schools for Epileptics ... ... ... In Instiutions other than Certified Schools ... ... ... Not at School ... 1 1 Physically Defective Pulmonary Tuberculosis Attending Public Elementary Schools 3 4 7 Attending Certified Schools for ... ... ... Physically Defective Children In Institutions other than 3 1 4 fied Schools Not at School 1 ... 1 Crippling due to Tuberculosis Attending Public Elementary 3 1 4 Attending Certified Schools for 1 ... 1 Physically Defective Children In Institutions other than Certified Schools 4 5 9 Not at School 2 ... 2 41 Table III.—Continued. Boys. Girls. Total. Physically Defective. Crippling due to causes other than Tuberculosis i.e. Paralysis, Rickets, Traumatism. Attending Public Elementary Schools 19 15 34 Attending Certified Schools for Physicallv Defective Children ... ... ... In Institutions other than Certified Schools ... ... ... Not at School 2 1 3 Other Physical Defectives, e.g. delicate & other children suitable for admission to Open-air Schools ; Children suffering from severe Heart Disease Attending Public Elementary Schools 25 35 60 Attending Open Air Schools ... ... ... Attending Certified Schools for Physically Defective Children, ... ... ... other than Open-Air Schools Not at School ... ... ... Dull or Backward Retarded two years 173 131 304 Retarded three years 43 65 108 42 (Heston and Isleworth). Table IV.—A. Treatment of Minor Ailments, 1920. Disease or Defect. Number of Children. Referred for treatment. Treated. Total. Under Local Education Authority's Scheme. Otherwise. Skin— Ringworm, Head 50 46 4 50 Ringworm, Body 35 35 ... 35 Scabies 46 46 ... 46 Impetigo 248 248 ... 248 Minor Injuries Other Skin Disease 91 91 ... 91 Ear Disease 34 34 ... 34 Eye Disease (external and other) Miscellaneous 34 34 ... 34 Total 538 534 4 538 43 Table IV.—B. Treatment of Visual Defect, 1920. Number of children. Referred for refraction. Submitted to Refraction. For whom glasses were prescribed. For whom glasses were provided. Recommended for treatment other than by glasses. Received other forms of treatment. For whom no treatment was considered necessary. Under Local Education Authority's Scheme, Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 203 140 1 (H. Hosp). 141 129 129 1 referred to Hosp. 3 Table IV. C. Treatment of Defects of Nose and Throat, 1920. Referred for treatment. Number of children. Received operative treatment Received other forms of treatment. Under Local Education Authority's Scheme, Clinic or Hospital. By Private Practitioner or Hospital. Total. 288 8 38 46 ... 44 Table IV.—D.—TREATMENT OF DENTAL DEFECTS. 1. Number of Children dealt with. Age. 5 6 7 8 9 10 11 12 13 14 Specials. Totals. a) Inspected 222 471 450 450 292 26 3 ... ... ... 121 2075 b) Referred for treatment 72 2G4 301 332 264 21 3 ... ... ... 121 1378 c) Actually treated 15 76 136 145 163 23 1 ... ... 1 55 615 d) Re-treated 1 2 18 33 24 8 ... ... ... ... 2 88 e) Attended Clinic, but referred elsewhere for treatment, e.g. Hosp. 2 4 7 5 1 ... ... ... ... 4 23 f). Attended Clinic, but refused to have treatment, "Objectors" 8 21 16 38 29 ... ... ... ... ... 1 113 (g)By Private Dentist 7 14 15 15 12 2 ... ... ... ... ... 65 45 Table IV.—D.—TREATMENT OF DENTAL DEFECTS, 1920. 2. Particulars of time given and of operations undertaken. No. of half-rlays devoted to Inspection. No. of half-days devoted to treatment. Total No. of attendances made by the children at the Clinic. No. of permanent teeth. No. of temporary teeth. Total No. of fillings. No. of administrations of general aiitesthetics included in 4 and 6. No. of other operations. Ex traded. Filled. Extracted. Filled. Permanent teeth. Temporary teeth. 1 22 2 3 4 6 6 7 8 9 10 11 110 1246 50 572 2844 Nil. 572 468 35 2 46 (Heston and Isleworth). Table V.—Summary of TREATMENT OF DEFECTS as shown in Table IV. (A, B, G, D and F, but excluding E). Disease or Defect. Number of children. Referred for treatment. Treated. Total. Under Local Education Authority's Scheme. Otherwise. Minor Ailments 538 534 4 538 Visual Defects 203 140 1 141 Defects of nose and throat 288 8 38 46 Dental Defects 1378 703 65 768 Other Defects ... ... ... ... Total 2407 1385 98 1493 47 (Heston and Isleworth). Table VI.—Summary relating to CHILDREN MEDICALLY INSPECTED at the Routine Inspections during the year 1920. (i) The total number of children medically inspected at the routine inspections 1969 (2) The number of children in (1) suffering from— Malnutrition 1 Poor Nutrition 40 Skin Disease 10 Defective Vision (including squint) 211 Eye Disease 53 Defective Hearing 18 Ear Disease 56 Nose and Throat Disease 629 Enlarged Cervical Glands (non-tubercular) 295 Defective Speech 5 Deutal Disease 1319 Heart Disease 123 Anaemia 30 Lung Disease 83 Tuberculosis— Pulmonary j Definite Suspected 8 Non-Pulmonary 1 Disease of the Nervous System 9 Deformities 34 Other Defects and Diseases 44 (3) The number of children in (1) suffering from defects (other than uncleanliness or defective clothing or footgear) who require to be kept under observation but not referred for treatment 1845 (4) The number of children in (1) who were referred for treatment (excluding uncleanliness, defective clothing, etc). 1120 (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) 973