HES 9 Heston & Isleworth Urban District Council. 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, 1922. 1922 REPORT on The Health of this HESTON and ISLEWORTH URBAN DISTRICT FOR THE YEAR 1922. by elwin h. t. nash, M.R.C.S., L.R.C.P.. D.P.H. Medical Officer of Health. Z 7 82. Public Health Department, Council House, Hounslow. April, 1923. To the Chairman and Members of the Heston and Isleworth Urban District Council. Ladies and Gentlemen, The Annual Eeport this year, which is designated by the Ministry an ordinary report, has been drawn up on the lines laid down in their Memorandum and reduced to the smallest compass consistent with those instructions. The work of the Department has been disorganised to a certain extent through sickness amongst the staff. During the year the work of the Department has been re-organised so as to reduce the administration expenses. By this means, the services of two clerks were dispensed with. I beg to express my appreciation to the Council for the consideration shewn to me during the past twelve months. I am, Ladies and Gentlemen, Your obedient servant, ELWIN H. T. NASH, Medical Officer of Health. THE HEALTH COMMITTEE of HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL For the Year ending April, 1923. Members of the Council:— J. J. Bonnett, Esq. (Chairman). F. W. Buckley, Esq. (Vice-Chairman). E. W. Heath, Esq. j.p. ex-officio (Chairman of the Council): S. Carter, Esq. ex-officio (Vice-Chairman of the Council. C. Crush, Esq, j.p. A. E. Hales, Esq. A. Dennis, Esq. R. Langdon, Esq. N. L. Samuels, Esq. Selected Members:— Mrs. C. W. Bezer. Mrs. W. H. Dumsday. P. Murphy, Esq., j.p. E. W. Goode, Esq. Medical Officer of Health. Elwin H. T. Nash, d.p.h. 1 SUMMARY OF VITAL STATISTICS, 1922. Population— At the Census, 1921 46,729 Registrar-General's estimate of nett 47,850 (Birth rate) Civil Population 46,330(Deathrate) Birth rate (nett) 18.7 England and Wales 20.6 London 21.0 Death rate (nett) 11.8 England and Wales 12.9 London 13.4 Infantile Mortality Rate 73.5 per 1,000 births. England and Wales 77 ,, ,, London 74 „ „ Area 6,893 acres Number of inhabited houses Not known. ,, of families or separate occupiers ,, ,, Rateable value £245,169 Sum represented by a penny rate £905 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 years 1921—22:— 1921. 1922. £ s. d. £ s. d. Parish of Heston 1493 0 11 1874 13 11 Parish of Isleworth 3891 17 8 5014 13 10 Total £5384 18 7 £6889 7 9 2 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 382 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 which was enlarged by the addition of 20 beds during the present year. Its sphere of usefulness will, it is hoped, be extended by the provision of maternity beds. During the year 19.22, there were admitted 357 in-patients, whilst 586 received treatment as outpatients. Medical relief is also given by certain voluntary organisations in the district, namely The Hounslow Central Aid Society. The Isleworth District Nuising Association. 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 1922, the estimate of nett civil population is given under two figures supplied by the Registrar-General. 3 The death-rate population (46,330) excludes all non-civilian males whether serving at home or abroad ; whilst the birth-rate (and marriage-rate) population (47,850) 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 1024, but 522 of these did not belong to the district, while 47 residents died without the district. Thus the number of deaths properly attributable to the district was 549. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 11 8 per 1,000, which is comparable with the following figures: —12.9 for England and 134 for London. 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 he found in the Infant death-rates given on page 4. Births. The total number of births registered during the year was 98G, but 102 of these did not belong to this district, while 14 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 898. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 18.7 per 1,000. The birth-rate of England and Wales is 20 6 per 1,000 and for London 21. per 1,000. Legitimacy. The following figures gives the number of births:— 4 Legitimate. Male. Female. Total.[/$$$] 434 433 867 Illegitimate. Male Female. Total. 13 18 31 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 infant deaths), it is more reliable than the death-rate which is calculated on an estimated population. The rate for 1922 is 73 5 per 1,000 births. The rates for England and Wales and for London during the same period were 7.3 and 74 respectively. In 1912 the rate for this district was 85, and in 1918,. 86. in 1920 it was 57; 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 : - During 1922. Heston 74.0 Hounslow North 73.3 Hounslow South 68.0 Isleworth North 81.6 Isleworth South 75.9 SANITARY CIRCUMSTANCES. Water Supply. There were, as far as is known, at the end of the year 41 private wells from which the water was used for domestic purposes. In nine other cases there are wells, but an alternative supply from the main exists for domestic purposes. 5 In 117 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. In the western portion of the district, there are some houses not yet linked up with the general system. The present methods of drainage employed at these houses are not satisfactory. The following extensions have been completed or were in progress during 1922:— Jersey Road.—From existing termination at "Brierley," to present termination at junction of Wood Lane, 267 yards. Jersey Road.—From existing termination approximately 100 yards west of Thornbury Road, extending in a westerly direction to Rose Farm, 486 yards. Wood Lane.—From existing termination in front of Wyke House, extending in a northerly direction to the District Railway line, 363 yards. Bath Road.— From the existing termination at Vicarage Farm Lane to the U.D. boundary at Cranford, 2,000 yards. Dockwell Lane.—From the junction with Bath Road extending southward over a distance of 96 yards. Foul sewers on the Great West Road, 7½ miles in length, work on which has been carried out during the past two years, are now approaching completion. 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. 6 During 1922, collection of house refuse has continued weekly as before, but was disposed of by means of a dump in the Staines Road instead of being dealt with in the destructor. During the year there were supplied 201 new ashbins. Sanitary Inspection of District. See pages 48—53. Nuisances, Contraventions of Bye-laws, Defective Drainage, etc. The number of premises on which nuisances were outstanding at the end of 1921 was 696. To these, other 722 premises whereat nuisances were recorded in 1922 were added giving a total of 1,418 premises. Of these 829 had the nuisances remedied, leaviug 589 premises at which nuisances still existed at the end of the year. During the year, nuisances at 59 houses were reported to the Health Committee, which added to the 19 brought forward from 1921, make a total of 78. Before asking authority to serve statutory notices, the premises are inspected by the Medical Officer of Health and Sanitary Inspector. Statutory notices were authorised and served in most of these cases, and by the end of the year, the nuisances were remedied in5L of the houses, leaving 27 cases to be carried forward in 1923. Comparative figures for the years 1920, 1921 and 1922 in connection with nuisances are submitted herewith:— 1920. 1921. 1922. Number of complaints received 598 496 460 Premises at which nuisances were located 1326 932 722 Informal notices sent— First... 1069 682 568 Second 385 213 217 Statutory Notices served 231 142 79 It is my duty once more to point out that the staff of Sanitary Inspectors is inadequate. 7 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 406 known 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, etc. SCHOOLS. In 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. FOOD. The fpllowing is the record of inspection of food premises No. of Inspections made. Meat 759 Fish 395 Provisions 522 Greengroceries and Fruit 877 Hawkers' Food Stuffs 499 Number of other Food Inspections 23 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. 219 grants were made during the year. Unofficial milk analyses are made by the Medical Officer of Health. 8 1. Meat Inspection—The Chief Sanitary and the District Sanitary Inspectors hold special certificates (or meat inspection. Slaughter-houses and butchers' shops are visited periodically, but during the year no diseased meat was seized, but 42 lbs. were surrendered. There are 8 slaughter-houses and 26 butchers' shops in the district. Each slaughter-house received on an average 179 visits 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. The Ministry's Circular number 282 with regard to the inspection of meat raised considerable difficulties owing to the nature of the district, slaughter-houses, and the class of meat dealt with. Since the war, the number of animals slaughtered in the district has diminished. The one slaughter-house which would have been ideal had it been in the centre of the town was situated at the extreme end and was therefore unsuitable from the point of view of accessability. I asked the Local Butchers' Association to call a meeting at which I attended to see what could be done to comply with the Ministry's recommendations. Owing to difficulties, I asked that one of the Ministrys' Officers might iuspect the Slaughter-houses, with a view to obtaining a solution, his conclusion coincided with mine, that it was practically impossible to alter any of the existing slaughter-houses into a central slaughter-house without raising serious difficulties, as the most likely one that could be made to conform with the requirements would necessitate all beasts being driven through the main streets, which, owing to the traffic, would be a serious drawback. 3. Action under Section 117, Public Health Act, 1875.—None during 1922. 4. Tubercular Meat.—There were none seized, but 42 lbs. were surrenered during the year. 5. The following tabular statement on slaughter-houses is required:— 9 In 1914. In January, 1922. In December, 1922.[/$$$] Registered 6 4 4 Licensed 3 4 4 Total 9 8 8 The slaughter-houses as a whole are unsatisfactory. During the year on the 1st February, the Bye-laws with regard to pig-keeping which had been relaxed during the war were put, into force again after six months' notice having been given. Sale of Food and Drug 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 1922. List of Samples purchased Article. No. taken. Adulterated. Milk 185 13 Separated milk 6 — Cream 9 8 Preserved cream 7 — Butter 9 — Cake 2 — Acetyl Salicylic Acid Powde 1 Bismuth Loz. 2 1 Chocolate 1 — Coffee 5 — Lard 5 — Self Raising Flour 1 — Vinegar 9 — Whisky 5 2 247 24 Of the 13 samples of milk reported against, 6 were informal samples. 10 Number of prosecutions 9 ,, convictions 7 Fines and costs imposed £24 UNSOUND FOOD, 1922. Tons cwts. qrs. lbs. Fish ... 3 1 18 Fruit ... 5 3 4 Meat ... 3 0 Rolled Oats ... 24 Total quantity surrendered, 10 cwts., 0 qrs., 24 lbs. Report on an outbreak of Lead Poisoning due to Beer. I beg to submit the following report on outbreak of Lead Poisoning in Heston and Isleworth, arising from contaminated beer:— On the 10th July, I was notified by Dr. Darke, one of the practitioners in the district, that he was attending a barman from one of the local Public Houses, who was suffering from lead poisoning, and that the patient had informed him that there were several other men who frequented the Public House(The " Tankerville Arms)," who were complaining of abdominal pain. The Doctor also stated that as his patient informed him that there had been new lead tanks installed, it seemed that these were the possible source of the trouble. On enquiry, another doctor- in the district also stated that he had certain cases of abdominal trouble which he suspected might be lead poisoning. On visiting the Public Houses in question, it was found that a completely up-to-date installation existed, consisting of four 54 gallon tanks. These tanks are cylindrical cast iron containers with a vitrified enamel liner. (The exterior is painted lead grey, and this apparently gave rise to the mistaken idea in the barman first diagnosed, that the tanks were made of lead). They are raised off the ground by short legs. The top is finished off as a wide flange with moveable thumbscrews by means of which an aluminium domed cover is fastened on. This cover has a rubber washer, so that it can be made air tight and is provided with a brass vent at the summit of the dome to allow the escape of the gases. At the side is a glass guage the full height of the tank. From the tank the beer is drawn through rubber tubes with brass couplings similar to a garden hose. Midway to the beer engine there is a small conical container, technically called the utilizer, which is also lined with vitrified enamel. This receives the drips from the sink beneath the beer engine tap which are filtered through a conical felt filter. From the utilizer a small rubber pipe is coupled on to a 2-way lead pipe about in diameter 2 the total length of which is about 2 feet. By this means a small amount is drawn from the utilizer at the same time as the beer is drawn from the tank. This short length of new lead piping was the only lead to be found which could possibly account for the contamination, and this appeared to be quite inadequate to account for the trouble. The classic cause of lead poisoning due to beer viz :—the barman consuming the beer that had been lying in lead pipes all night was non-existent. The tanks appeared to be everything that was satisfactory ; capable of the most perfect cleansing and considerably in advance of anything hitherto in use. Speaking generally the beer does not remain more than 4 days in the tanks, in a few rare cases it may be 7 days. On the 11th July, 1 sent out an enquiry in the following form and as the result I got some definite information:— 3 Dear Sir, "It has been reported to me that several cases have arisen in which the primary symptoms are Colic, sometimes accompanied with Jaundice and a blue line on the gums which appears to be lead poisoning. I shall be glad, if you have any cases of this description, if you will let me have particulars, and whether you have arrived at any conclusion as to the possible origin. I shall be glad of any information by return of post if possible." Yours faithfully, (Signed) Elwin H. T. Nash, Medical Officer of Health. One doctor reported as follows:— "Two of my cases recently have been definite cases of lead poisoning (chronic) with typical Colic, Icteric Conjunctivae and blue lines on the gums, a third has had some Colic but more of the intestinal obstruction type. A further case has had Colic and some yellowness of Conjunctiva. My opinion is that he is of the lead poisoning type, but I shall have further information about him to-morrow. All these cases are situated in a small area, and a number of them (including cases of similar type under other doctors) are personal friends. There seems to be an impression that those of them who frequent Isleworth Brewery Public Houses are most ill, but the different men drink different kinds of beer, and I have been unable yet to trace a very definite connection, though in my own mind this seems to promise to be the most fertile source of investigation, bearing in mind that the rest of the families of the patients are, so far, immune, and also the fact that they are all working men in the habit of taking their "glass of ale." Other doctors in the district reported on cases at first, one of whom had been a painter. Others bad seen none. Another doctor reported four cases, the details being as follows:— 4 (a). "Warehouseman; 13/7/22 complained of epigastric pain and vomiting. 14/7/22 above persistent, also colic, mild degree of jaundice and blue line on gums. (b). Warehouseman; Not concerned with lead in any shape or form, 10/7/22. Complained of epigastric pain with colic. Constipation, loss of appetite. Facies suggest excess alcohol. Admits moderate consumption of Isleworth beer, mostly at the " Rose and Crown," states potman has similar condition. 13/7/22. Well marked jaundice, stools dark, urine contains bile, no paralysis. Well marked blue line on gums. Some tenderness calf muscles. (c). Clerk ; 14/7/22 states was taken bad on 10th inst. I was first consulted on 14th. First 'symptoms were paiu in stomach and vomiting. Now has constipation, pain and tenderness, epigastrium, tenderness in calves, well marked blue line. Heavy beer drinker at " Duke of Cornwall." (d). Labourer ; No connection with lead. Complained of stomach and sickness on 12th. 15/7/22 first seen by me. Epigastric tenderness and pain vomiting, no paralysis. Well marked blue line. Tenderness calf muscles. Frequents " Duke of Cornwall." Further cases were reported from different doctors nearly all with pronounced colic and a considerable number of them with symptoms of obstruction. A few of the cases which I saw had a pronounced blue line, one very marked case being an extremely moderate drinker whose usual habits were half a pint in the middle of each day and rather more at the week end, making up an average of 5 pints a week. Others reported were heavy drinkers. On the notification to me of the first case, I at once communicated with the Manager of the Brewery suspected (Isleworth Brewery Company). As things seemed to point to the beer in some way being involved, I had 14 samples taken on the 12th from four Public Houses and submitted for analysis. The results 5 of the analyses received on the morning of the 17th July were striking. The samples were submitted to Messrs. Eynon & Lane as the County Authorities refused to undertake the analysis. Their report was as follows :— (1) "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Saloon Bar at the " Red Lion Hotel," High Street, Hounslow," contains 08 grain per gallon. (2) "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar at the " Red Lion Hotel," High Street, Hounslow," contains 10 grain per gallon. (3) "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the " Red Lion Hotel," High Street, Hounslow, (west pump)" contains 0 9 grain per gallon. (4) "Sample of Mild Ale from the Beer Engine in the Public Bar at the "Red Lion Hotel," High Street, Hounslow on 12/7/22 (east pump) " contains 1-2 grains per gallon. (5) "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar at the " Rose & Crown " Public House, London Road, Isleworth. Ale had been drawn before sample was taken," contains no lead (less than 01 grain per gallon). (6) "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the " Rose & Crown " Public House, London Road, Isleworth (front north pump). Ale had been drawn before sample was taken," contains 12 grains per gallon. (7) "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the " Rose & Crown " Public House, London Road, Isleworth, (rear south pump)," contains 1.5 grains per gallon. (8) "Sample of Bitter Ale from the Beer Engine in the Public Bar, " Bell" Public House, Staines Road, Hounslow, on 12/7/22," contains no lead (less than 01 grain per gallon) (within the margin of experimental error). 6 (9) "Sample of Bitter Ale from the Beer Engine in the Saloon Bar, "Bell" Public House, Staines Road, Hounslow, on 12/7/22" contains no lead (less than 0.1 grain per gallon). (10) "Sample of Mile Ale 12/7/22 from the Beer Engine in the Public Bar, "Bell" Public House, Staines Road, Houuslow, (west pump)," contains no lead (less than 01 grain per gallon). (11) "Sample of Mild Ale from the Beer Engine in the Public Bar, "Bell" Public House, Staines Road, Hounslow, on 12/7/22 (east pump)," contains no lead (less than 0.1 grain per gallon). (12) "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar at the " Tankerville Arms," Hanworth Road, Hounslow," contains 0.1 grain per gallon. (13) "Sample of Mild Ale 12/7/22 from the Beer Egnine in the Public Bar of the "Tankerville Arms,"Hanworth Road, Hounslow (west pump)," contains 0 8 grains per gallon. (14) " Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the " Tankerville Arms," Hanworth Road, Hounslow, (east pump)," contains 12 grains per gallon. It will be seen that in the samples from the "Red Lion" Public House, samples 1, 2, 3 and 4 all contained heavy percentages of lead. In those from the "Rose and Crown" (samples 5, 6 and 7) it will be seen that number 5 contains no lead (i.e. within the margin of experimental error). This, on investigation, proved to be due to the fact that this particular bitter ale was drawn direct from the cask. In samples 6 and 7 it will be seen that there is a heavy percentage of lead. In the case of the " Bell" Public House (samples 8, 9, 10 and 11) there was no lead. In this house there are no tanks installed. In the " Tankerville Arms " (samples 12, 13 and 14) it will be seen that in 12 there is a very small quantity of lead, and in 13 and 14 there is again a heavy percentage. 7 The Brewery Company took the second samples which they submitted to an eminent analyst (Mr. A. C. Chapman, F.I.C., F.R.S.) Mr. Chapman's detailed report was as follows: — No. 1. "Sample of Mile Ale from the Beer Engine in the Public Bar at the " Bed Lion Hotel," High Street, Hounslow, on 12/7/22 (east pump)." No. 2. "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar at the " Red Lion Hotel," High Street, Hounslow." No. 3. "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the " Bed Lion Hotel," High Street, Hounslow (west pump)." No. 4. "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Saloon Bar at the " Red Lion Hotel," High Street, Hounslow." No. 5. "Sample of Mild Ale on 12/7/22 from the Beer Engine in the Public Bar at the " Rose and Crown" Public House, London Road, Isleworth (rear south pump)." No. 6. "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the " Rose and Crown" Public House, London Road, Isleworth, front north pump. Previous drawings taken before sample." No. 7. "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar at the " Rose and Crown " Public House, London Road, Isleworth. Ale had been drawn before sample was taken." No. 8. "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the "Tankerville Arms," Hanworth Road, Hounslow (east pump)." No. 9. "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar at the "Tankerville Arms," Hanworth Road, Hounslow (west pump)." No. 10. " Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar at the "Tankerville Arms," Hanworth Road, Hounslow." 8 No. 11. "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar, "Bell" Public House, Staines Road, Hounslow (west pump)." No. 12. "Sample of Mild Ale 12/7/22 from the Beer Engine in the Public Bar, "Bell" Public House, Staines Road, Hounslow (east pump)." No. 13. "Sample of Bitter Ale 12/7/22 from the Beer Engine in the Public Bar, "Bell" Public House, Staines Road, Hounslow." No. 14. "Sample of Bitter Ale from the Beer Engine in the Saloon Bar at the " Bell " Public House, Staines Road, Hounslow, on 12/7/22." The numerical markings are mine and have been added for the purpose of laboratory identification. The samples will be referred to below under these numbers. I have examined these very carefully and give you below the results so far as lead alone is concerned:— No. 1 126 grains per gallon. „ 2 100 „ „ „ 3 1.32 „ „ „ 0.87 „ „ ,, 5 l.70 „ „ „ 6 1.92 „ „ „ 7 0.09 „ „ „ 8 1.68 „ „ „ 9 0.80 „ „ „ 10 0.15 „ „ „ 11 Not detectable. „ 12 „ ,,13 „ „ 14 „ Yours faithfully, (Signed) A. Chaston Chapman. Thus confirming Messrs. Eynon and Lane's results. 9 The Brewery Company's first analytical report was in their hands on the Sunday afternoon, July 16th. Mr. Chapman realising that the matter was so serious to the Company, he personally visited the Brewery the same afternoon to investigate further. He was able then by rubbing a solution of a sulphide on the enamel of the tanks to get a "lead reaction." The Brewery Company immediately got into touch with all their houses where these tanks were installed and stopped any further sales that evening. I advised the immediate and ostentatious removal of the tanks and on the 17th July, the following day, the Company commenced to remove them and by the evening of the 19th every single porcelain lined vessel had been removed. I satisfied myself on the morning of the 17th that the tanks were out of use, the Brewery having supplied all the houses with beer in casks. In the light of my circular letter, notifications of cases began to arrive in increasing numbers, some of them fairly severe, and at the time of this report 93 definite cases have been notified. The Brewery Company were anxious to compensate any sufferers and have not only asked for all names of definite cases, but have authorised the provision of any Specialist services or treatment should any case require it. Early in the investigation, I consulted the Chief Chemist of one of the biggest Brewery firms in the country, as to the possibility of lead being found, and the idea was regarded as impossible. The only possible source of metallic contamination that was suggested was an infinitesimal amount of copper from the brewing vats. I could find no evidence of any previous outbreak of Lead Poisoning arising on a wide scale from beer, and in an interview with Mr. Chapman, the President of the Institute of Chemists, he was uuable to recall in the 30 years that he had been connected with the industry of fermentation, any case where lead had been found in beer other than the well-known but rare cause, arising from the lead pipes previously in universal use. 10 Directly I notified the Brewery Company on the 12th July, that their tanks were suspected, they passed the information on to the firm from whom they had obtained the tanks, Messrs. Hopkins & Sons, 52, Holloway Road, N. 7., who passed the information on to the makers, Messrs. W. Macfarlane & Co., Saracen Iron Works, Possil Park, Glasgow, on the 13th July. On July 17th, the Brewery Co. notified Messrs. Hopkins definitely that the tanks were the source of contamination, and the information was immediately passed on to the makers. The enamelled container is made by Messrs. Macfarlane, but the cover and all other fittings are made and fixed, and the whole apparatus put on the market by Messrs. Hopkins & Sons. In order to ensure that every tank was withdrawn, the Factors were visited and it was ascertained that, with the exception of three tanks which had been supplied to the City of London Brewery Company, Messrs. Barclay and Perkins, and Messrs. Taylor, Walker & Co., of Limehouse, respectively, all the tanks that had been made had been supplied to the Isleworth Brewery Company. Of the three supplied to other firms, only that supplied to Messrs. Taylor, Walker & Co., had been in use. I communicated with the Medical Officer of Health for the distiict, and he reported that no trouble had been traced to the tank although in use for throe months. I also got into communication with the Medical Officers of Health of the districts in which tanks had been installed prior to and contemporaneously with those in our district. None of them at first could trace any trouble to the Public Houses in which these tanks were installed. The following list shows the number of houses belonging to the Brewery in which these tanks to the number of 162 had been installed, together with the first delivery of beer into them has had been used. The beer is delivered in large iron tanks on motor lorries similar in appearance to those used for petrol, oil, etc., but with a copper lining insulated from the iron casing, and is delivered direct to the tanks through rubber pipes. Hitherto, all the tanks supplied in this way have been earthenware:— 11 Dates of first delivery of beer to small beer containers. House. District. Date of Delivery. Raven Hammersmith May 16th. Hampshire Hog ” May 20th. Maltman and Shovel ” May 11th. Windsor Castle ” May 19th. Greyhound Shepherd's Bush No delivery. Blue Anchor Acton 11 Goldsmiths' Arms ” 11 Bell Ealing May 24th. Coach and Horses ” May 24th. Burlington Arms Chiswick No delivery. Feathers ” 11 Rose and Crown Isleworth May 27th. Iron Bridge ” June 1st. Duke'of Cornwall ” June 3rd. Red Lion Hounslow June 3rd. Bulsfcrode ” No delivery. Railway Inn ” June 3rd. Coach and Horses ” June 14th. Tankerville Arms ” June 3rd. Old George Heston June 24th. Rose and Crown ” June 30th. South-Western Hotel Whitton June 22nd. Duke of Cambridge ” June 23rd. Hope and Anchor Sutton No delivery. Duke of York Hanwell June 2nd. Duke of Wellington ” No delivery. Plough South all June 20th. Black Horse Lampton July 5th. Ailsa Tavern St. Margaret's Juno 30th. St. Margaret's Hotel ” July 6th. Royal Arms Richmond July 4th. Bricklayers' Arms ” June 28th. Anglers Kingston July 4th. Wheelwrights' Arms ” July 7th. 12 House. District. Date op Delivery. Borough Arms Norbiton No delivery. Bailway Inn ” Jfuly 4th. Norbiton Hotel ” July 11th. Crown and Anchor Ditton No delivery. Paragon Arms Surbiton July 14th. White Hart Hampton No delivery. Bailway Inn ” July 8th. Queons' Arms Hampton Court No delivery. Bailway Inn Worcester Park July 14th. Bising Sun Twickenham July 8th. Masons' Arms Teddington No delivery. Adelaide ” ” Kings' Arms ” ” Queen ” ” Boebuck ” ” Earl Spencer Boehampton ” Cambridge Arms Norbiton July 14th. It will be seen that Ealing, Hanwell and Hammersmith were using the tanks for some two to three weeks before there use commenced in our district, the earliest tank in our district being put into use on May 27th. Three cases in Ealing were brought to my notice and the Brewery Company state that the tenant in one of their houses in another area reports a considerable amount of trouble. From the details supplied of the patients illness, it appears, on comparing them with the first delivery of beer into the tanks, that the onset of symptons arose in most cases, just under three weeks from the first use of the tanks. Credit must be given to Dr. Darke, of Pownall Gardens, Hounslow, who first diagnosed the condition of his patient as Lead Poisoning. Mr. Chapman had analysed two samples of enamel one from a new tank and a second from one that had been used with the following result:— 13 New Tank. Oxide of Lead 41.35 Oxide of Aluminium 3.08 Oxide of Iron 5.88 Oxide of Calcium 6.44 Oxide of Magnesium 0.50 Oxide of Zinc 2.76 Silica 19.54 Used Tank. Oxide of Lead 41.08 Oxide of Aliminium 3.08 Oxide of Iron 5.96 Oxide of Calcium 6.41 Oxide of Magnesium 0.48 Oxide of Zinc 2.42 Silica 19.68 I had a consultation with Mr. Chapman and the Director of the Brewery Company, and suggested certain experimental investigations to confirm the findings. Beer was allowed to stand in one of these tanks and examined after 24 hours and 48 hours with a control sample from the "racker" from which the beer was drawn with the following results:— From racker From tank after 24 hours From tank after 48 hours Lead. Not detectable. 0.84 grain per gallon. 126 A further experiment was carried ouc, a sample was taken after being left in a tank for five days, with a control from the racker, with the following results :— From a racking vessel From tank Lead. Not detectable. 2 38 grains per gallon. A further experiment was carried out to ascertain the daily increase in the amount of Lead in solution. Mr. Chapman's report was as follows:— 14  Lead. X 22 from racker Not detectable. X 22 from tank after 24 hours 0.84 grain per gallon. X 22 „ „ 48 „ 1.26 ,, „ X 22 „ „ 72 „ 2.66 ,, „ X 22 „ „ 96 „ 3.08 ,, „ X 22 „ 120 „ 2.24 ,, „ X 22 „ „ 144 „ 2.52 ,, „ X 22 „ „ 168 „ 2.80 ,, „ X 22 „ „ 192 „ 3.36 ,, „ You will see that at the end of 120 hours the amount of Lead in solution had undergone diminuation, owing no doubt to some precipitation. It subsequently, however, increased again to rather more than 3 grains. It would appear from this that between three or four grains per gallon may well represent the maximum solubility, and when this is reached, precipitation of some of the dissolved lead—possibly in combination with nitrogenous matters in the beer—takes place. Yours faithfully, (Sgd.) A. Chaston Chapman. Samples were also taken from stoneware tanks in use, but no trace of Lead detected. It would have been thought that these results were definite enough, but despite these facts, the firm refused to believe that the tanks were the source of the trouble, and wrote to Messrs. Hopkins & Sons, to the effect that some other source must be looked for and suggested an independent set of experiments and analyses, as there was not sufficient lead in the enamel to produce any untoward effect. This at onca raised the possibility of two alternatives. The one, of disobedience of orders by subordinates in the firm, so that the enamel was not made according to the instructions of the management, the other, that the firm had been "put wise " to the effect that lead was an undesirable constituent, and that later samples might show freedom from lead. 15 It was still possible that there might have been some tampering with the beer in the tanks before the samples were taken. In view of this and the fact and the results of the analysis of the specimens sent by the Brewery Company, I took samples under test conditions and personally supervised every step, although it was practically certain in view of the fact that the Brewery Co. were co-operating in every way, that everything was straight and above board. First, a sample was taken of the beer standing in the tank. The tank was then thoroughly flushed out with water three times and a sample of the last flushing taken. A sample of beer was then taken from the racker, but it was found impossible to put the beer direct from the racker into the tank, so that two casks 36 and 18 gallons respectively, had to be filled from the racker and poured into the tank. In order to make certain that there was no possible contamination, a sample was taken from each barrel as it was being poured into the tank. The tank having beeu filled was sealed up in every possible way and left for three days, and four samples of beer were taken. One from the centre by dipping in two 1J inch gauge glasses. The idea being, that if it was possible to obtain an undisturbed sample from the centre where it had not been in contact with any part of the tank, the beer would show little, if any, contamination. The tubes were first put in without corks, but that was found to be fallacious as the majority of the sample was the upper portion of the beer. The tubes were removed and sealed by corking and then reinserted into the centre of the tank and the corks withdrawn. Unfortunately the withdrawal of the corks produced a strong upward rush. The tubes were re-corked but it was found on removing the tubes that the corks did not support a sufficient volume of beer for analysis so that a second dipping was made. It would appear that the sudden upward rush had drawn some of the beer from the lower part of the tank. The cock at the bottom was then opened and a sample taken from the bottom of the tank. The tank was then half emptied. Then another sample was taken and then practically emptied and a sample taken from 16 the remainder. These were submitted to Messrs. Eynon & Lane and their report was as follows:— Etnon & Lane. Laboratories—7 & 8, Idol Lane, —— Great Tower Street, E.C. 3. LONDON. 14th August, 1922. Elwin H. T. Nash, Esq., D.P.H., Medical Officer of Health, Heston & Isleworth Urban District Council, Council House, Hounslow. Dear Sir, We have examined the 8 samples of Mild Ale, 1 sample of Wash Water, 1 sample of tank deposit, and 1 sample of fixing material which you handed to us on the 8th inst., and have to report as follows :— (1). “No. 2, sample of Mild Ale drawn from the Mild Ale Eacker (direct), on the 5Lh August, 1922, contains no lead (less than 1/20th grain per gallon).” (2). “Sample No. 3 of Mild Ale from the Mild Ale Racker, and drawn from the 36 gals, barrel used to fill tank, 5th August, 1922, contains no lead (less than 1/20th grain per gallon).” (3). “Sample No. 4 of Mild Ale from the Mild Ale Eacker and drawn from the 18 gals., barrel used to fill the tank, 5th August, 1922, contains no lead (less than 1/20th grain per gallon).” (4). “No 1 sample of Mild Ale drawn from the 54 gals, vertical enamelled lined tank on the 5th August, 1922, Number on foot of tank, 69.0 D—contains 1.1 grain of lead per gallon.” (5). “No. 1 sample of Mild Ale drawn from the centre of the tank by means of a draw tube, on the 8th August, 1922. (Tank filled and sealed on the 5/8/22). Contains 0.4 grain of lead per gallon.” 17 (6). “No. 2 sample of Mild Ale drawn from the bottom of the tank by means of the draw-off cock, on the 8th August, 1922. (Tank filled and sealed on the 5/8/22)—contains 0.9 grain of lead per gallon.” (7). “No. 3 sample of Mild Ale drawn from the middle of the tank by means of the draw-off cock on the 8th August, 1922. (Tank filled and sealed on the 5/8/22)—contains 0.2 grain of lead per gallon.” (8). “No. 4 sample of Mild Ale drawn from the top of the tank by means of the draw-off cock, on the 8th August, 1922. (Tank filled and sealed on the 5/8/22)— contains 0.6 grain of lead per gallon.” (9). Sealed sample labelled “No 5 sample of water drawn from the 54 gals, tank after thorough washing of the tank on the 5th August, 1922. Number on foot of tank 690 D—contains no lead (leas than 1/20jth grain per gallon.” (10). Sample marked “sample of crystallization inside used, tank shaken out. Taken August 5th by Dr. Nash ; may be some chips of enamel as the tank had had some chipped off for examination. Crystallized salt of lead—consists substantially of silicates of lead and other bases, and contains 17% of lead.” N.B.—Before the analysis, the hard chips were removed, the analysis being made on the glistening flakes of which the sample chiefly consisted). (11). Sample marked “sample of fixing material for the Junction at the bottom of the utilizer ? Plaster of Paris ? White Lead. Taken by Dr. Nash, 5th August at Isleworth Brewery—consists of Calcium Sulphate (Plaster of Paris) and contains no lead." Yours faithfully, Eynon & Lane. 18 Two other samples were submitted in addition to the samples of beer. On visiting Messrs. Hopkins & Sons, my attention was drawn to the fact that in certain of the tanks that has been used there was a crystaline powder, which was thought to be the enamel flaking off. In addition, on examining certain of the tanks that were remaining at the Brewery, it was found that the junctions were packed with a white substance presumably Plaster of Paris. In order to be perfectly certain, I had samples of these analysed for the presence of lead. It will be seen from Messrs. Eynon & Lane's analysis that the salt of lead contained in the sample of powder from the tank is that which occurs in enamel, viz.: the Silicate of Lead, and it was thought that this might be the actual solution of the lead salt of enamel in the beer which had re-crystalized on drying. Examination under the microscope, however, revealed the fact that these were merely flakes of the enamel which had disintegrated as the result of the action of tlie beer and did not show any definite crystaline form. In order to pin the matter down still further, it was necessary to find whether the tanks which were known to be affected were in the house where the trouble had taken place or not. To this end, I obtained the serial number list of the tanks installed in all the firms premises. Analysis of these figures showed that with the exception of the first thirteen which were installed in the Hammersmith Houses, there was evidence that the earlier batches stood condemned. The samples of enamel which were examined by Mr. Chapman were taken from tanks No 21 and 97. These together with the history of the outbreak proved that with the exception of the first thirteen tanks, the first hundred contained large quantities of lead. In view of this, the Brewery Company undertook to get specimens of the enamel from one of the tanks supplied to one of the Hammersmith Houses and have that examined for lead. A sample from No. 8 that had been in use in the “Hampshire Hog” was chosen, and Messrs. Eynon and Lane's report is as follows:— 19 Eynon & -Lane. Laboratories—7 & 8, Idol Lane, —— Grkat Tower Street, E.C. 3 LONDON. 19th August, 1922. Elwin T. Nash, Esq., D.P.H., Medical Officer of Health, Heston & Isleworth Urban District Council, Council House, Hounslow. Dear Sir, We received this morning by post, from Messrs. G. Hopkins & Sons, (Clerkenwell), Ltd., a sample of enamel which they certify to have been chipped from No. 8 tank. The sample consisted of hard flakes of cream-coloured enamel, most of which had black patches of adhering metal on one side. We used for analysis flakes which were quite free from these patches. We find that the enamel contains 42.0 per cent, of lead. Yours faithfully, Eynon & Lane. In order to close the door absolutely, I visited Messrs. Hopkins and took a sample of enamel from one of the last tanks delivered, which had never been set up, the number being 190 on the serial delivery list. Messrs. Hopkins submitted their samples of beer which had been left in the tanks and also of the crystaline flakes and enamel to Messrs. Heron & Son, the well-known analysis. Their report is as follows:— John Heuon <fc Son, Laboratories, 129, Minories, LONDON, E. 1. 14th August, 1922. Mebsks. G. Hopkins & Sons, Ltd , 40/52, Holloway Road, N. 7. Dear Sirs, We have made a very careful determination of the lead contained in the enamel which was chipped off from the 20 porcelain enamelled iron tank, which was intended to contain beer, marked “No 167,” and also in the powder which was brushed off the surface of a similar tank marked “No. 3,” which had been in use some little time, and beg to submit our report as follows:— Enamel from Tank No. 167.— Lead as lead oxide (PbO)—24.90 per cent. Powder from surface of Tank No. 3.— Lead as lead oxide (PbO)—15.82 per cent. We have also made a very careful determination of the amount of lead extracted by the beer stored for varying periods in one of the porcelain enamelled tanks at your Works, and beg to report as follows:— 18 gallons of bright beer from the fsleworth Brewery, marked “19 x 5d,” were run in a new porcelain enamelled tank, the cover was screwed on, the samples were drawn through the run-off cock at the bottom of the tank after the beer had been well roused, (1) 24 hours, (2) 4 days, (4) 10 days, after the beer had been run into the tank. An examination of these samples gave the following results:— (2) Sample of Beer after 4 days in Tank.— Lead as lead oxide (PbO)—0.15 grain per gallon, (21.90 milligrams per litre.) (3) Sample of Beer after 7 days in Tank.— Lead as lead oxide (PbO)—0.18 grain per gallon, (25.55 milligrams per litre ) (4) Sample of Beei after 10 days in Tank.— Lead as lead oxide (PbO,)—0.28 grain per gallon, (40.15 milligrams per litre.) A sample of beer drawn from a tank used at the “Maltman and Shovel” after it had been in the tank for three days was also examined with the following results :— Lead as lead oxide (PbO)—0.11 grain per gallon (16.25 milligrams per litre). 21 Our examination of the sample of beer taken before it was run into the tank, and also the sample after it had been in the tank 24 hours is not yet completed, and our report on these will be submitted later. We are, Yours faithfully, (Signed) Harold Heron. (Signed) John Heron & Son. N.B.—In these cases the beer had been roused before samples were taken, in the others the samples were drawn in the ordinary way. It will thus be seen that the percentage of lead varies somewhat in various batches of tanks. The firm who supplied the tanks, faced with the analyses, alternatively deny liability as they stated that they did not understand that the tanks were to be used for beer. I was shown a copy of an order from Messrs. Hopkins to the firm in question in which it specifically states for what purpose they were to be used. This defence, therefore, would seem to carry no weight. The Brewery Company and the Medical Officer of Health for Hammersmith report that they have had no trouble with their Hammersmith Houses in which the first batch of tanks were installed. In order to ascertain if there was any alteration in the trade which might show whether there was any trouble in the firm's other houses, especially in those four in the Hammersmith area where the iron tanks were installed, I got the Brewery Company to supply me with a certified copy of the deliveries to all their houses in those districts and in our own. Analysis of these showed that whereas there had been a definite diminution in the roild ale trade in tho houses in our district with the iron tanks this was not so in the other districts. It revealed the fact, however, that the daily actual consumption in the houses in our district was, as a mle, less per house than in the larger houses 22 outside, but that there was little difference on the average in the ' O time between the houses during which the beer stood in the tanks. As this did not throw sufficient light on the difference between Hammersmith and our own district. I visited all four of the Hammersmith Houses with the Brewery Company's Representative. At numbers 1 and 2 no trouble whatever could be traced. At No. 2 the Potman and three customers had been affected. Two of the customers so severely that they were in the Infirmary for a fortnight, but beyond that nothing can be traced although there seems to be a considerable number of what may he described as fairly heavy drinkers. At No. 2 it was almost entirely a "Local Trade." At No. 1 the trade was found to be very largely "in and out." Amongst the regular customers were about a dozen coal-heavers working in a local coal yard. These men were practically all steady, heavy drinkers, but none of these appear to have been affected. At No. 3 which had a very large trade in mild ale, there were no complaints whatever, although this was very largely a " Local Trade." At No. 4 only one case was discovered despite the fact that this house was doing the largest mild ale trade and had a considerable number of steady drinkers. In all these houses, however, there was a marked week-end trade and the tanks were supplemented by one, two or even three wooden barrels. In No. 3 for instance the beer was delivered on Saturday morning and one tank and nearly half a second one were finished the same day. During the week the average duration of time in which the beer remained in the tanks was two days and in some cases rather longer. In three of the four houses there were two periods in which the beer had remained a week before being replenished, so that from the analyses from similar tanks it would appear that the beer must have been highly contaminated. On interrogating one of the publicans in our district in the same way, he stated that within a fortnight of the installation of the tanks, his customers in large numbers were complaining of stomach trouble and that several of them had been fairly ill. In addition 23 to which his trade had been very largely lost owing to the number affected. On cross examination, however, it appeared manifest that there was a larger number of heavy drinkers in the house, than in the Hammersmith houses. I am at a loss to account for the fact that the four Hammersmith houses escaped comparatively free, despite that the tanks were installed from two to three weeks before those in this district, and that the analysis of the enamel shows 42% of Lead, apart from the fact that the week-end draw appears to be more rapid. The only other reason would appear to be that in our district the customers are more faithful to one house. Of the 93 cases notified to the Brewery Company, only three were women. In view of the fact that abortion is one the results of lead poisoning in women, enquiry was made of the Medical Practitioners and Midwives in the district, but no evidence of any cases could be obtained. In the majority of cases notified to the Brewery Company, the symptons have been mainly Colic with Constipation. There have been amongst them a number of cases with great muscular pain and anaemia. Some of the cases have lost as much as two stone in weight. In only one case which came to my notice were there tremors. Jaundice occurred in several cases. Neuritis tnainly in the calves but also in the arms occurred in a few cases. There have not been any cases of paralysis or the other graver nervous ocular symptoms generally associated with prolonged industrial lead poisoning. In practically all the bad cases, the men were heavy drinkers. Some, however, of those who were affected were comparatively small drinkers, but their drinking was a perfectly regular, day in, day out occurrence. The reason tliat the trouble was not discovered earlier, is that lead poisoning is what is known as a cumulative poisoning and does not show itself until a certain amount has been absorbed into the system. It has been stated in the Press, that the solution of the Lead has been brought about by the sugars in the beer. It should be slated that the beer in question is a carbonated beer. The carbonic 24 acid contents, being brought about by the re-introduction into the beer by the carbonic acid envolved during the process of brewing, thus differing from most of the carbonated beers in which the carbonic acid is introduced artificially, by which I mean that the carbonic acid is manufactured apart from the beer and then introduced. The beer thus contains three different articles which have a definite influence on the solubility of lead. Firstly, the sugars. Secondly, the acetic and lactic acids, and thirdly, the gaseous carbon dioxide. It is difficult to assign the exact proportion of the three, but the general explanation is among certain of the chemists that the sugars are largely responsible for the solution, this is equally denied by others. Before the introduction of these iron tanks, the tanks hitherto in use, of which there are about G,000 at present in constant use are manufactured by Doultons for Messrs. Lewi6, of 25, Lime Street, E.G.:— 11 On the 28tli September, 1922, one of the patients who had suffered from lead poisoning was admitted to the West Middlesex Hospital suffering with lung trouble and delirium. He was said to have had a few fits before admission. The patient (aged 42) died on the 9th October, 1922. Sir Kenneth Goadby was present at the post mortem on behalf of the Brewery Company. Sir Kenneth kindly supplied me with details of the findings of the post mortem together with an histological and chemical report. His report is as follows :— “He was admitted into the Isleworth Infirmary (West Middlesex Hospital) suffering from pains in the stomach and legs, partial paralysis of the legs, incipient wrist drop; blue line of the gums ; pain in the chest. He became violent and unable to talk clearly. Post mortem, at which I was present, there was no wasting of the tissue-fat blue line on the gums, and a well pronounced blue line at the anus. There was slight wasting of the dorsal interosseii (both hands) and muco-purrulent bronchitis, the lungs were glued together by exudate. The liver showed no obvious signs of Cirrhosis, the kidneys appeared normal, but on section the cortex was swollen. The stomach showed no haemorrhages. The small intestine showed dark staining of the muccous membrane and general oedema. The brain was normal in appearance, and there were no recent haemorrhages, but the whole of the brain was very soft. Histological Examination was made of the Kidney, Liver, Brain and Intestines. The kidneys showed general fibrosis of an old standing nature cloudy swelling, tubular and intestinal nephritis, the picture was of a chronic fibrotic kidney, complicated with a recent microbic affection. Numerous organisms (streptococci) were found present. The liver showed patches of chronic fibrosis. 12 The brain showed small cortical haemorrhages, and had appearances of degeneration, associated with an attack of inflammation, and also consonant with lead poisoning. Chemical Examination. Portions of the tissues, brain, liver, kidney, were submitted to chemical examination, and the total lead recovered was— 45 mgs. from the brain. 9.3 ,, ,, „ liver. 7.86 ,, ,, ,, kidney. making a total of 62.16 nigs. = to 0.943 grains. The findings of the jury were that death ensued from “bronchitis and broncho-pneumonia, accelerated by lead poisoning caused by drinking beer.” INFECTIOUS DISEASE. General Remarks. The chief illnesses which have affected the district have been Scarlet Fever and Influenza of a mild type. The table on page 41 sets forth by months the number of cases of infectious diseases notified during the year, 1922. It will be observed on reference to this table that there were 228 cases of Scarlet Fever notified during 1922. This disease has been more prevalent in the district in common with others in the Greater London area, since 1919. There were 14 return cases of this disease. During the year Scarlet Fever of a mild type was fairly prevalent. In the Autumn an outbreak of 45 cases in Islevvorth gave the Department a large amount of work in looking for missed cases. This outbreak overtaxed the Hospital accommodation. I" order to meet the situation, the Milne treatment was commenced. Through the kindness of Dr. Kirkhope, of Tottenham, I was able to obtain one of his nurses who had been carrying out the treatment in Tottenham. In all, 10 cases were treated before the hospital was again able to absorb the cases arising. The first nurse took up duty on October 11th, but unfortunately owing to 13 illness amongst his staff Dr. Kirkhope was compelled to recall her on October 30th. I was fortunate in obtaining one of Dr. Milne's own nurses to take over the treatment till it was concluded on November 4th. The results can only be described as entirely satisfactory. One case of Rhinorrhoea and one of enlarged glands occurred, but no secondary cases could be traced to the ones treated by this method No disinfection was carried out and no alteration made in the daily lives of the contacts. The total expenditure on these cases, including nurses salaries, travelling expenses and drugs (a considerable portion of which remain on hand) was £23:13:5, working out at £2:3:0 per case, the nurses were not working up to their full capacity, otherwise the cost per head would have been less. An instance of the difficulty of dual control in an area is shown by the fact that the County Education Committee called the County Medical Officer's attention to the fact that the rule at the County School did not permit contacts from bouses where the Milne treatment was being carried out to attend school. On the 21st June, 1922, an adult, aged 20, was notified as suffering from Scarlet Fever. On the inspector visiting the house, it was found that the patient on hearing that he had to be removed to the Isolation Hospital had decamped. Search was made, but he could not be fouud. On visiting the next morning it was found that he had returned home after having been to a cinema the previous evening, but had already decamped again. He was eventually found in the Public Recreation Ground. He was with difficulty got into the Hospital. The Council authorised the Clerk to take proceedings against the patient on his discharge from hospital. This was done and a fine of £1 inflicted. The table hereunder gives the number of oases of infectious diseases that occurred in the several Institutions in the district during 1922:— 14  ENTERIC FEVER. SCARLET FEVER. DIPHTHERIA. PNEUMONIA (All forms). ERYSIPELAS. PUERPERAL FEVER. CEREBRO SPINAL FFVER. OPHTHALMIA NEONATORUM. ENCEPHALITIS LETHARGICA PULMONARY TUBERCULOSIS. OTHER TUBERCUL08IS TOTAL West Middlesex Hospital 3 12 4 71 16 11 1 3 1 5 1 128 Hounslow Barracks 1 3 1 ... ... ... ... ... ... ... ... 5 Hounslow Hospital ... 4 ... ... ... ... ... ... ... ... 1 5 Mogden Hospital ... ... 1 ... 2 ... ... ... ... ... ... 3 Royal Naval School ... 4 ... ... ... ... ... ... ... ... ... 4 Dundee House ... ... 2 ... ... ... ... ... ... ... ... 2 Wyke House ... ... 1 ... ... ... ... ... ... ... ... 1 North Hyde Schools ... ... ... 1 ... ... ... ... ... ... ... 1 Totals 4 23 9 72 18 11 1 3 1 5 2 149 15 Scarlet Fever. 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 225 „ „ removed to Hospital 189 Pecentage of cases removed to Hospital 84 No. of cases treated by the Milne method 10 Three cases were also reported among the military population and removed to hospital. The incidence rate of Scarlet Fever in the civil population was 4 76 per 1,000. Two deaths took place from this cause during the year. The mortality rate was 087 per cent. 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 66 „ „ removed to Hospital 59 Percentage of cases removed to Hospital 89 In addition to these cases one military case was reported. The incidence rate per 1,000 of the civil population was T4. Nine cases occurred in public institutions during the year, 4 of the persons affected being non-residents. 9 deaths took place from this disease, i.e. a case mortality rate of 13.4 per cent. There was one return case. Diphtheria Antitoxin. During 1922, 20 vials of Antitoxin were supplied to medical practitioners. (12,2000 units and 8,4000 units). Typhoid Feyer. There were five cases notified during the year, one being a military case. 16 Dysentery. None were notified. Erysipelas. 29 cases of this disease were notified, of whom 16 weie West Middlesex Hospital cases, the persons affected being non-residents, with the exception of 3. No deaths were recorded from this disease. Two cases occurred at Mogden. Puerperal Fever. 12 cases of this disease were notified, all were institution cases, the persons affected being non-residents, with the exception of one. Ophthalmia Neonatorum. Five children were notified as suffering from this disease. Encephalitis Lethargica. There were three cases notified of this disease. Cerebro-Spinal Fever. Four cases of this disease were notified and one proved fatal. Acute Poliomyelitis. There was one case notified. Pneumonia. 127 cases were notified, 64 being non-residents in the Infirmary. Malaria. There were no cases notified during the year. Pulmonary Tuberculosis. The number of new cases notified during the year was ol19 cases (or over 33%) were notified from Institutions:— Sanatoria 14, Infirmary 1, General Hospitals 4. 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. 17 Other Forms of Tuberculosis. The number of new cases notified during the year was 9. Five of them were notified as receiving institutional treatment. In 25% of the deaths from Tuberculosis no notification had been received. Non-notifiable Diseases. Information respecting non-notifiable infectious diseases is usually gained through notifications by the Head Teachers and School Attendance Officers. The undermentioned table sets forth the numbers of such cases for the year:— Measles 413 German Measles 1 Chicken Pox 64 Mumps 256 Whooping Cough 88 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 32 per 1,000. Smallpox. On the 8th November, 1922, I was informed by the County Medical Officer that a case of Smallpox had arisen in Southall, and that several residents in the district had been in contact at their place of employment and an Isleworth resident had spent the evening with the patient during the initial stage of the disease. All contacts are kept under close observation during the requisite period. No case resulted. No vaccinations were performed bv 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. 18 Neither the Education Anthority 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 the County Council. It is, however, generally recognised that the authority administering a Maternity and Child Welfare Scheme should also exercise control over the Midwives practising in its area. In this district it is the practice of the Health Visitors not to visit the newly-born till 14 days after the birth, in order not to interfere with the Midwife. Considerable trouble has been experienced with regard to the delayed notifications of births by certain midwives. In one case the matter was reported to the Committee after a warning had produced no improvement. An official warning from the Committee was sent, intimating a further breach of the Act would be followed by prosecution. A further contravention occurring, the Council in November authorised proceedings to be taken against the offender. Proceedings at the same time were authorised against the Council's late midwife for similar breaches of the Act. In this case no previous warning by the Committee had been issued as owing to the fact that the midwife had been the Council's officer, her knowledge of the details of the Act were intimate. In view of the number of qualified midwives practising in the district, it was decided that it was unnecessary to retain the services of the Council Midwife, and her engagement terminated at the end of June. During the six months she attended 29 confinements and made 411 Ante Natal and 375 Post Natal visits. According to the County Medical Officer's last list, there are 16 midwives practising in the district. 19 It was necessary to report the Council's midwife in respect of a case of Ophthalmia Neonatorum in which delay occurred in carrying out the provisions of the Act. The midwife was suspended for the remaining few days of her period of service. The matter was brought before the Central Midwives' Board and the midwife placed on three and six months probationary service. One can only regard with amazement, the findings of the Board. The child in question is permanently and completely blind, apart from the life long tragedy to the child, the ratepayers are faced with the maintenance charge of £60 to £80 per annum for the child's education until it reaches the age of 16, and yet the Board allowed the midwife to continue practising. Maternity and Child Welfare Clinics. The three clinics at the Council House and two at the Isleworth Public Hall have remained open throughout the year. The attendances totalled 8,398 for the year as compared with 7,575 in 1921. The average attendance at the Council House being 33.1 and at the Isleworth Centre 33.5. The number of individual mothers and children attending the Clinics is shewn hereunder :— Council House. Hounslow. Isleworth Public Hall. 1920. 1921. 1922. 1920. 1921. 1922. Mothers 315 538 541 170 268 278 Children 407 774 726 185 296 350 Sales at Clinics. Quantity. Receipts. £ s. d. Glaxo 6794 lbs. 610 5 2½ Virol 4671/8 lbs. 38 1 10½ Malt 262½ lbs. 22 16 1½ Oil and Malt 160¾ lbs. 14 0 7 Marylebone Cream 271/8 lbs. 2 3 7 Lactagol 76 pkts. 4 8 8 Total Receipts £691 16 0½ 20 The arrangements with chemists for the dispensing of prescriptions on terms similar to those under the National Insurance Act, have been continued. It was found necessary in re-organising the work of the Department to alter the days of the Maternity and Child Welfare Clinics at Isleworth from Tuesday and Wednesday to Tuesday and Friday. This resulted in a considerable drop in the attendance, as Friday was not as popular a day as Wednesday, but the attendances are steadily improving. In many ways the work can be regarded as satisfactory and particularly so under the circumstances. At the Council House the work has reached its limit of expansion. Nothing further can be accomplished until adequate accommodation can be provided. The attendance rises steadily until the accommodation becomes seriously overcrowded, when there follows a sharp drop caused apparently by the disinclination of the parents to attend under such circumstances of overcrowding and discomfort. After the drop, there is a gradual ri*e until the conditon of discomfort again becomes serious when there is again a sharp falling off in the attendance followed again by a rise until the conditions again become seriously unsatisfactory. At Isleworth, the premises are gloomy, inconvenient, smoky and difficult to ventilate. Since the Upper Hall has been re-decorated, and constantly let, the noise overhead caused by the necessary shifting of furniture in preparation of entertainments, is an additional disturbing factor. In the interests of national economy every endeavour is made to carry on under the circumstances. Personally, I regard the Maternity and Child Welfare work as. the most important of the Council's Public Health activities. It will not be long, in my opinion, before much of the importance attached to the medical supervision of the school child will pass to the child before it enters school. We more and more come to realise the importance of dealing with the beginnings of diseases in early childhood rather than the remedying of the defects during the school life, which have become thoroughly established As a business proposition to the community, the Maternity and Child Welfare work, is, in my opinion, the best investment they can 21 make, its educational value when the Medical Officers with the knowledge of this particular work have obtained the confidence of the parents, is enormous. It is impossible under the present circumstances to develop the associated activities which have such an important part in the educative value. Ante-natal work is almost negligible at Hounslow and impossible at Isleworth with the premises as they at present exist. There is ample need for this work to be developed, as by careful supervision of the mother during the latter months of pregnancy, many tragedies to the family are avoided, and the welfare of the child assured. There are not only the tragedies of loss of life, but of the mother's impaired health, which results from an unsatisfactory confinement, which are almost always accompanied by continuous pain or discomfort, the existance of which often entirely spoils the atmosphere of the home, in that the previously healthy cheerful mother tends to become an irritable semi-invalid on whom the cares of the family weigh unduly. There are no facilities at present for the treatment of dental defects in nursing and expectant mothers nor for any other treatment for children under five years of age. Home Help for Mothers. The Home Help paid 184 visits during the year and her work was found of considerable value. In addition to her ordinary work, in her unoccupied time she carries out cleansing of unclean heads, under a special scheme. She was trained at one ot the London Cleansing Stations, the Council provides the Sacker's combs and the necessary shampoo and towels. A fee of 1/- is charged for each case. By this means, any child who is excluded from school, can be back within two days, and the cleansing is not carried out by any officer of the department acting as such. There have been certain parents who objected to going to the Home Help, but a considerable number of parents have been very glad of the opportunity. In one case the mother took down two children over school age, and voluntarily paid a fee of 3/- in one 22 case and 2/- in another. Another parent stated that she would gladly pay 5/- for the services. The presence of this service acts in another way, in that if a case is taken before the Magistrates the fine is now considerably heavier now that means are at the disposal of the parents, whereby the child can be re-admitted to school within 48 hours. There is a certain class of parent who rather than face the fact of paying the 1/-, will spend more than that on various medicaments wherewith to cleanse the child's head, and run to the extreme limit of the period allowed by the Committee, and then at the last minute face the fact that it is better to pay the 1/- and get the head clean, than run the risk of a substantial fine by the Bench. Grants of Milk- Milk is supplied free or at reduced rates to expectant mothers (during last three months of pregnancy) to nursing mothers, and to children under three. The scale of grants for provision of milk have been fixed as follows:— Where the family income after deducting rent is less than 4/- per head free. 4/- to 5/- per head parent pays 1/3 cost. 5/- to 7/6 „ „ 2/3 „ „ „ Where the amount is over 7/6 per head, no grant is made. No. of grants made during the year was 219. Analysis of samples of milk supplied to the mothers under the Council's Maternity Scheme, showed one vendor with 15.7% and 14% added water successively, the information was forwarded to the County Council Authorities, who as a result of their findings prosecuted the vendor. The official sample only showed 8% added water. The vendor pleaded guilty to that and owing to the legal technicalities, the previous analysis could not be put in. The vendor was ordered to pay costs. CLINICS AND TREATMENT CENTRES IN THE DISTRICT. The two Maternity and Child Welfare Centres are kept almost entirely for consultation purposes, treatment being reduced to an absolute minimum so as not to clash in any way with local Medical Practitioners. 23 The only Day Nursery in the district was closed in 1920. There are two School Clinics at each of which the Medical Officer attends twice a week, and at which treatment for minor ailments is carried out on five mornings in the week. The Tuberculosis Clinic which is part of the County machinery is situate in Hounslow in the centre of a populous district. There is no clinic for Venereal Diseases. Professional Nursing in the Home. The Isleworth Nursing Association carried on this work throughout the district. There is an arrangement with them also for nursing Measles and Whooping Cough. No payments are made either by the County Council or by the Local Authority. Home Visiting. The visits by the Health Visitors are shown in the following table:— 1920. 1921. 1922. 1st visit to babies under one year 1132 1029 913 Re-visits to babies and children up to five years 4715 4484 4241 Inquiries made, elicited— Feeding—Natural 870 631 536 Artificial 59 54 43 Both 23 51 41 Sleeping with parents 477 354 319 Using Comforter 300 236 198 Mother working during pregnancy 56 45 56 INFANT DEATHS, STILL BIRTHS, MEASLES, etc. Infant Deaths: visits paid 64 Still Births noted 23 Measles 23 under 5 years Whooping Cough 5 Opthalmia Neonatorum 1 24 No special measures exist for dealing with unmarried mothers or illegitimate children of 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. Special mention must be made of the services rendered at the Welfare Clinics, by the members of the Women's Co-operative Guild, Mrs. Bishop and Mrs. Dollaston, Hounslow, and Mrs. Evans, Isleworth. The Council in January, 1923, placed on record their appreciation of the valuable services rendered by the foregoing helpers. HOSPITALS. Hospitals provided or subsidised by the Local Authority or by the County Council:— 1. Tuberculosis.—The County Council have two institutions : The Bell Road Hospital, with 16 beds, and a section of the West Middlesex Hospital. 2. Maternity.—There is no definite provision in the district other than the West Middlesex Hospital (Guardians) for maternity cases apart from private nursing homes charging considerable fees. There are a few beds in the Hounslow Hospital and cases can also be dealt with at the West Middlesex Hospital, but the great majority of the cases which come under the notice of the Public Health Department are dealt with by the large London Hospitals. 3. The Hospitals in the district are the West Middlesex Hospital which is the Poor Law Infirmary. The Hounslow Hospital with 40 beds, which is entirely supported by voluntary contributions and the Mogden and Dockwell Hospitals for Infectious Diseases and Smallpox supported from the rates by the Councils of Heston and Isleworth and Richmond. 25 There is practically no difficulty in getting cases into the West Middlesex Hospital, but there is no out-patient department. The Hounslow Hospital has a staff of consultants, but there appears to be a feeling for preference for the larger Hospitals with national reputation such as Gt. Ormond Street, Queen's Square, Brompton, Chelsea Hospital for Women and the larger hospitals. The difficulty in connection with this however, is that it entails a considerable expense, which many of the parents can ill afford and in other cases where specialised treatment is wanted, there is often considerable difficulty in obtaining the necessary letters demanded by the Hospital. 4. Fever.—This district joins with Richmond in the form of a Joint Hospital Board, which is responsible for the Mogden Hospital dealing with Scarlet Fever, Diphtheria and Enteric, and the Dockwell Hospital with 13 beds for the accommodation of Smallpox. AMBULANCE FACILITIES. (a). For Infectious Cases.—This is provided by the Joint Hospital Board. (b). For Non-Infectious and Accident Cases.—There are none in the district. ADOPTIVE ACTS AND BYE-LAWS IN FORCE. Adoptive Acts in force in the District: *Infectious Diseases (Prevention) Act, 1890. *Public Health Acts Amendment Act, 1890, 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. 26 Bye-Laws in force in District. *Common Lodging Houses (P.H.A. 1875, s. 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, 5. 6). *These are administered wholly or partly by the Health Committee. The unstarred are administered by other Committees of the Council. COUNCIL LABORATORY. (a). Swabs for Diphtheria. Positive. Sent by Medical Practitioners 136 26 Taken at Schools, School Clinics and from Contacts 486 8 Sent from the Staines Joint Isolation Hospital 491 119 Total 1113 153 (b). Specimens of Sputum for Tubercle Bacilli. Positive. Sent by Medical Practitioners 88 22 Sent by School Medical Officer 2 0 27 (c). Hairs fox Ringworm. Taken at Schools or School Clinics 40 34 (d). Specimens of Urine 70 ,, ,, Vaginal discharge 4 ,, „ Eye discharge 7 ,, „ Ear discharge 1 Films examined 2 Widal 3 1 Virulency test for Diphtheria Bacilli 3 1 (e). Milk Analysis. Samples taken 5 Showed added water 0 (f). Water Analysis 17 Several of the number were unsatisfactory. Preparation of Materials. Tubes of Serum 1342 Throat Swab Outfits 1210 Sputum Outfits 106 During April, 1922, arrangements were made with the Staines Joint Isolation Hospital to carry out their bacteriological work. This is a distinct advantage to them in that they could get the reports of specimens sent in one afternoon by 10 o clock the next morning. As the result of milk analysis, one vendor was reported to the County Council and ultimately dealt with at the Brentford Police Court. The virulency tests are carried out for us by Dr. Spitta, at St. George's Hospital. The work done in the laboratory has increased very greatly, as the above figures shew. This development has been possible to a very large extent owing to the intelligence displayed by Cobb, the Council's disinfector in acquiring the art of making first rate culture media. 28 SANITARY ADMINISTRATION. Staff. The following persons constituted the staff of the Health Department on the 31st December, 1922. Medical Officer of Health— Elwin H. T. Nash, M.R.C.S., L R.C.P., D.P.H. Assistant Medical Officer of Health— Mrs. E. Cairns Roberts, M.B., Ch.B., D.P.H/ Sanitary Inspector— 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. F. Humphries, Cert, as S.I., M.I. and S.E. One vacancy. Disinfector and Laboratory Attendant— J. H. Cobb. Health Visitors— Mrs. C. E. M. Ottley, Cert. C.M.B., H.V., S.N., M.C.W.W. Miss B. M. Tetley, 3 years childrens' training. Cert. C.M.B. Miss C. P. Chatfield, 3 years general training Celt. C.M.B., H.V. and S.N. Mrs. A. E. Tyrell, Cert. C.M.B, H.V. and S.N. Miss W. E. Scott, general training, Cert. C.M.B. H.V., S.N., M.C.W.W. Home Help— Mrs. E. Yates. Chief Clerk— A. G. Hubbard. Clerks— Miss R. Marshall, Cert. R.S.I. Miss W. L. Rogers. E. Cromwell. J. Holmes. 29 HESTON & ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Department, Council House, Hounslow. 31st January, 1923. Canal Boats Act, 1877 and 1884. Sir, In accordance with Section 3 of the Canal Boats Act, 1884, I beg herewith to present the Annual Report for the year ended 31st December, 1922, 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, Messrs. R. H. Butler (Chief Sanitary Inspector), G. W. Ashworlh and S. H. Franklin (District Sanitary Inspectors), were appointed to act as Canal Boat Inspectors. No special remuneration is paid for the position. Number of Inspections, etc. During the year 29 inspections were made of 29 boats, 25 boats were in order and on each of four boats one infringement of the Acts and regulations were found. The nature of the contraventions were as follows :— (a). Unregistered Canal Boats used as dwellings. (2). (b). Overcrowding. (c). Separation of the sexes. 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. I am, Sir, Your obedient servant, ELWIN H. T. NASH, Medical Officer of Health. The Secretary. Ministry of Health, Whitehall, S.W. 1. 30 HOUSING. The housing conditions in the district remain unsatisfactory. There are still a number of cases of legal overcrowding, but no remedy can be found so long as the present shortage of houses exists. These cases have been duly reported to the Public Health Committee and consideration deferred for six months. Moral overcrowding is much more frequent and produces more discontent than actual overcrowding where there is no difficulty with regard to mixing the older children with parents. There appears to be amongst a section of the population, less reluctance to live in close contact with others in small tenements than before the war, mainly brought about by the stress of war conditions. There is no doubt that in some of the families, the condition under which they live is having a really deleterious effect on the health of the children. I. Fitness of Houses. (1) (a) General standard of Housing in the district : At 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) Difficulty in remedying unfitness, special measures taken and any suggestions in the matter : 31 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. II. 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. III. 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 rr.any houses are now technically houses let in lodgings owing to the abnormal housing conditions, but are not on the register. (2) to need for new bye-laws and revision of existing bye-laws : 32 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. IV. General and Miscellaneous. Other action taken in connection with overcrowding, imanitary property and housing Nil. Y. Appendices, Statistics for year ending 31st December, 1922. During the early part of tho year, one of the local House Agents, was found to be making libellous statements about one of the Assistant Sanitary Inspectors. The Inspector put the law into action against the Agent with the result that a complete apology was recorded and all costs paid by the offending Agent. SHOPS ACTS. The number of contraventions of the Acts which were reported during the year was as follows :— Open after evening closing hour 13 Notices not exhibited (exempted articles, afternoon and evening) 78 Notices not in prescribed form (exempted articles afternoon and evening) 7 Notices (Assistants) not exhibited 8 Non-exempted articles exposed for sale 1 PROCEEDINGS. Proceedings were taken during the year in respect of:— (a) Nuisances at 11 houses. (b) Exposure in a public place of a person knowing himself to be suffering from an infectious disease. 33 (c) Re-letting of a house in respect of which a Closing Order was in force. In the case of:— (a) Costs were imposed and abatement orders made for the works to be carried out in each instance; at two houses the Council executed the necessary works in default of owners, and terms were agreed upon for the recovery of expenses incurred. In connection with five houses it was necessary to take further proceedings for disobedience of the Orders previously made, one case was adjourned for a month and the owner of the other four houses fined £5 and ordered to pay £2 : 2 : 0 costs. (b) A fine of 20/- was imposed. (See page 36). (c) A fine of £5:0:0 was imposed. 34 APPENDICES. Housing Conditions Statistics. Year ended 31st December, 1922. 1. GENERAL. (1) Estimated Population Birth rate 47,850 Death rate 46,330 (2) General Death rate 12-8 (3) Death Rate from Tuberculosis 103 (4) Infantile Mortality 73 5 (5) Number of dwelling houses of all classes 9,218 (6) *Number of working-class dwelling houses 4,682 (7) Number of new working-class houses erected by Council 74 * Number of new houses other than working-class 35 Total number of new houses erected of all classes 125 2. UNFIT DWELLING-HOUSES. I. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 400 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 (3) Number of dwelling-houses found to he in a state so dangerons or injurious to health as to be unfit for human habitation 5 (4) Number of dwelling-houses (exclusive of those referred to under the preceding subheading) found not to be in all respects reasonably fit for human habitation 267 (5) Number of houses, listed for inspection under the Housing (Inspection of District) Regulations, 1910, at end of year 1554 35 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 383 III. Action under Statutory Powers. A. Proceedings under Section 28 of the Housing Town Planning, etc. Act, 1919— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 11 (2) Number of dwelling-houses which were rendered fit— (a) by owners 11 (b) by Local Authority in default of owners 5 (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close nil. B. Proceedings under Public Health Acts— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 52 (2) Number of dwelling-houses in which defects were remedied— (a) by owners 26 (b) by Local Authority in default of owners 5 C. Proceedings under Sections 17 and 18 of the Housing, Town Planning, etc. Act, 1909— (1) J^imber of representations made with a view to the making of Closing Orders 5 (2) Number of dwelling-houses in respect of which Closing Orders were made 3 36 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered tit nil. (4) Number of dwelling-houses in respect of which Demolition Orders were made nil. (6) Number of dwelling-houses demolished in pursuance of Demolition Orders nil. D. Proceedings under Section 32 of the Housing, Town Planning, etc. Act, 1919 — Number of prosecutions taken for letting, attempting to let, occupying or permitting to occupy houses ordered to be closed 1 E. Number of dwelling-houses closed voluntarily 8 Number of dwelling-houses demolished voluntarily 8 3. UNHEALTHY AREAS. Areas represented by the Local Authority with a view 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 — (4) Number of working-class persons to be displaced — (4) Number of houses not complying with the building bye-laws, erected with the consent of Local Authority under Section 25, of the Housing Town Planning, etc. Act, 1919 . 7 (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. 37 During the War, two of the District Inspectors joined the Array 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 two District Inspectors resumed duty, but sanction to fill 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. Table I. shewing dwelling-houses represented as unfit for human habitation. Premises. No. of houses represented by M.O.H. Date of representation. Date Closing Order made Date Closing Order determined. Date Demolition Order made. Date Demolition Order obeyed. Date Demolition Order enforoed. Br't forw'd from 1921— ‡*1-3, Poplar Cottages 3 8/1/14 24/2/14 ... 22/12/14 ... ... ‡15, South Street 1 11/1/15 27/4/15 ... 23/11/15 ... ... 1-4, Baker's Cottages 4 3/6/15 23/11/15 ... ... ... ... †14-34, London Road 11 12/5/19 22/7/19 ... ... ... ... † 1-10, Syon Place 10 „ „ ... ... ... ... †65-75, Hanworth Road 6 12/1/20 23/11/20 ... ... ... ... 175, Twickenham Road 1 12/1/20 26/4/21 ... ... ... ... 177, „ „ 1 „ ... ... ... ... ... 1, Wellington Road North 1 9/2/20 ... ... ... ... ... 3 „ „ „ 1 9/2/20 ... ... ... ... ... 5 „ „ „ 1 9/2/20 28/7/20 ... ... ... ... 10, South Street 1 10/10/21 22/11/21 ... ... ... ... Inspected in 1922 — ... ... ... ... 2, Forman's (or Field's) Cotts., 1 10/7/22 ... ... ... ... ... North Hyde Lane, Heston LongCott.. Sutton Rd., Heston 1 12/6/22 house ren dered fit ...7/11/22 †20, Tivoli Road, Hounslow 1 9/10/22 28/11/22 ... ... ... ... 22 1 9/10/22 28/11/22 ... ... ... ... †24 1 9/10/22 28/11/22 ... ... ... ... *17/4/14 Notices served on tenants of Nos. 1, 2 and 3 and complied with. 16/3/L6 Demolition ordered in default of owner* 16/10/17 Notices served on new tenants of Nos. 1 & 3. 31/12/22 Nos. 1, 2 & 3 occupied. †Closing Orders not served. ‡Demolition deferred until after the war. 38 39 Table II. Causes of Deaths during 1922. Causes of Death. Civil Residents all ages. All causes Male. Female 287 262 1 Enteric Fever ... 1 2 Small-pox ... ... 3 Measles 1 6 4 Scarlet Fever ... 2 5 Whooping Cough 5 3 6 Diphtheria 5 4 7 Influenza 8 7 8 Encephalitis Lethargica 1 ... 9 Meningococcal Meningitis 1 ... 10 Tuberculosis of Respiratory System 23 18 11 Other Tuberculous Diseases 6 1 12 Cancer, Malignant Disease 19 28 13 Rheumatic Fever ... 3 14 Diabetes 2 2 15 Cerebral Haemorrhage, &c. 18 18 16 Heart Disease 37 42 17 Arterio-sclerosis 9 5 18 Bronchitis 28 25 19 Pneumonia (all forms) 17 12 20 Other Respiratory Diseases 1 1 21 Ulcer of Stomach or Duodenum 4 3 22 Diarrhoea, etc. (under 2 years) 4 4 23 Appendicitis and Typhlitis 4 21 Cirrhosis of Liver 2 1 26 Acute and Chronic Nephritis 2 4 26 Puerperal Sepsis ... 2 Other Accidents and Diseases of . Pregnane and Parturition ... 2 28 Congenital Debility and Malformation, Pre mature Birth 20 14 29 Suicide 1 ... 30 Other Deaths from Violence 20 4 31 Other Defined Diseases 49 49 32 Causes ill-defined or unknown ... 1 According to figures furnished by the Registrar-General. Table III. Infantile Mortality during the year 1922. Nett Deaths from stated Causes at various Ages under 1 Year of Age cause of death. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks. 4 weeks and under 3 mts. 3 mts. and under 6 mts- 6 mts. and under 9 mts. 9 mts. and under 12 mts. Total Deaths under 1 year Certified 22 5 3 3 33 14 7 3 9 66 Smallpox Chickenpox Measles ... ... ... ... ... ... ... 1 ... 2 Scarlet Fever Whooping Cough ... ... ... ... ... 2 ... ... ... 2 Diphtheria and Croup Erysipelas Tuberculous Meningitis ... ... ... ... ... ... ... ... 1 1 Abdominal Tuberculosis Other Tuberculous Diseases Meningitis (not Tuberculous) ... ... ... ... ... 2 ... ... 1 3 Convulsions 2 ... ... ... 2 ... ... 1 ... 3 Laryngitis Bronchitis ... ... ... ... ... 1 ... ... 1 2 Pneumonia (all forms) ... ... ... ... ... 1 1 ... 4 6 Diarrhoea Enteritis ... ... 1 ... 1 1 4 ... 1 7 Gastritis ... ... ... ... ... ... 1 ... ... 1 Syphilis ... ... 1 ... 1 1 ... ... ... 2 Rickets Suffocation, overlying ... 2 ... ... 2 ... ... ... ... 2 Injury at Birth Atelectasis 2 ... ... ... 2 ... ... ... ... 2 Congenital Malformations 1 ... ... ... 1 2 1 ... ... 4 Premature Birth 11 3 ... 2 16 2 ... ... ... 18 Atrophy, Debility and Marasmus 2 ... ... 1 3 1 ... ... ... 4 Other Causes 4 ... 1 ... 5 1 ... 1 ... 7 22 5 3 3 33 14 7 3 9 60 Nett Births Legitimate 867 Nett Deaths Legitimate infants 59 Illegitimate 31 Legitimate infants 7 table iv—a Infectious Diseases, 1922. 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 15 10 ... ... 2 ... ... ... 5 ... 2 1 ... ... February 14 9 ... 1 2 ... ... ... 49 ... 2 ... 1 ... March 13 2 ... ... 3 ... ... ... 11 ... 7 1 ... ... April 10 3 2 ... 2 1 ... ... 9 ... 5 1 1 ... May 18 ... ... 3 1 ... ... ... 13 ... 7 2 ... ... June 17 1 1 2 ... ... ... ... 6 ... 2 ... 1 ... July 21 2 ... ... 3 ... ... ... 2 ... 6 3 ... ... August 12 5 ... 1 3 ... ... 1 3 ... 9 ... ... ... September 45 ... ... 1 ... 1 1 ... 1 ... 4 ... ... ... October 32 8 1 3 5 1 ... ... 4 ... 5 1 2 ... November 15 18 1 1 2 1 1 ... 11 ... 2 ... ... ... December 16 9 ... ... 6 ... 1 ... 13 ... 6 ... ... ... Totals 228 67 5 12 29 4 3 1 127 57 9 5 ... 41 42 Table IV.—B. Cases of Infectious Disease notified and Cases removed to Mogden Isolation Hospital during 1922. Disease. Notified. Admitted to Hospital. Deaths. Small-pox ... ... ... Enteric Fever †5 1 1 Scarlet Fever 228 *‡ 189 2 Diphtheria 67 59 9 Erysipelas 29 ... ... Puerperal Fever ‡12 ... 2 Ophthalmia Neonatorum 5 ... ... Acute Poliomyelitis 1 ... ... Cerebro Spinal Fever *4 1 1 Pneumonia 127 ... 29 Malaria ... ... ... Encephalitis Lethargica *†3 ... 1 * ‡in addition, 5 Scarlet Fever cases were removed to M.A.B. Hospitals. †3 cases of Enteric Fever occurred at West Middlesex Hospital. ‡11 cases of Puerperal Fever occurred at West Middlesex Hospital and 1 was removed from this district to West Middlesex Hospital. *1 case of Cerebro-Spinal Fever occurred at the West Middlesex Hospital. *†3 cases of Ophthalmia Neonatorium occurred at the We6t Middlesex Hospital. Table IV.—C. Deaths from Notifiable Infectious Dieases, 1922. Age Groups. Under 1 year. 1 year. 2 years. 3 years. 4 years. 5 years. 10 years. 15 years. 20 years. 35 years. 45 years. 65 years and over. Scarlet Fever ... ... 1 ... ... l ... ... ... ... ... Diphtheria ... ... 2 2 ... 4 l ... ... ... ... ... Enteric Fever ... ... ... ... ... ... ... ... ... ... l ... Puerperal Fever ... ... ... ... ... ... ... ... ... l l ... Encephalitis ... ... ... ... ... ... ... ... ... l ... ... Lethergica Pneumonia 6 2 2 1 ... 2 2 ... 4 2 7 l Cerebro Spinal Fever ... ... ... ... ... ... ... l ... ... ... ... Pulmonary Tuber ... ... ... ... ... ... 1 4 14 10 12 ... Other Tuberculosis 1 1 ... ... ... 1 ... 1 2 ... ... l 43 44 Heston and Isleworth, 1922. TUBERCULOSIS N otifications. Pulmonary—New Notifications 57 Cases admitted to Sanatoria or Hospital 60 Cases discharged from Sanatoria or Hospital 43 Ten of the new notifications were admitted to Institutions during the year, two of which were discharged later. Deaths—Pulmonary. There were 41 deaths during the year. Ten were primary notifications, three of which were notified after death. Eleven cases were not notified at all. 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 madk by Sanitary Inbpkctors. Premises. Number of Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) factories (including Factory Laundries) 46 Workshops (including Workshop Laundries) 319 10 Nil. workplaces (other than Outworkers' premises I included in Table VII. 64 ... Total 429 10 Nil. Table VI.—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions Found. Remedied. Referred to H.M. Inspector. (1) (2) (3) w (5) Nuisances under the Public Health Actx:Want of cleanliness 2 1 Want of ventilation Overcrowding Want of drainage of floors Other nuisances 1 2 †Sanitary accommodation— Nil. Nil. Insufficient 2 1 Unsuitable or defective 2 3 Not separate for sexes Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouse (s.101) Breach of special sanitary requirements for bakehouses (ss. 97-100) 13 9 Other offences (excluding offences relating to outwork which are included in Table VII Total 20 16 Nil. Nil. †Section 2i 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 for persons employed in factories and workshops enforced is that required by the sanitary Accommodation Order of 4th February, 1903. 46 Table VII.—HOMEWORK. NATURE OF WORK. OUTWORKERS' LISTS, SECTION 107. Outwork in unwholesome premises, Section 108. Outwork in infected premises, Seotions 109, 110. Lists received from Employers. Notices served on Ocoupiers 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) (3) (4) (5) (6) (7) (8) (9) (10 (11) (12) (13) (14) (15) (16) Wearing Apparel— making, &c. 7 1 14 4 I 3 8 ... ... ... ... ... *1 ... ... cleaning& washing ... ... ... 4 5 ... 3 ... ... ... ... ... ... ... ... Furniture and upholstery 1 ... 2 1 ... I 2 ... ... ... ... ... ... ... ... Brush making ... ... ... ... ... ... ... ... ... †1 ... ... ... ... ... Total 8 1 16 9 6 4 13 ... ... 1 ... ... 1 ... ... *Two residents at the premises occupied by this outworker were notified as suffering from Scarlet Fever and removed to hospital. †A Closing Order has been made with respect to the premises occupied by this outworker. Number of outworkers on register, 32. Inspections made 44. Number of Lists received from other Sanitary Authorities, 16 (sent twice in the year, 6). 47 Table VIII.—REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. (1) Number. (2) Bakehouses—Workshops 17 Laundries (non-factory) 31 workshops 211 Workplaces 36 Total number of workshops on Register 295 *In addition there are in the district 9 Factory Bakehouses. Table IX.—OTHER MATTERS. Class. (1) Number. (2) Matters notified to H.M. Inspector of Factories:— Failure to affix Abstract of the Factory and Workshop Acts, (s.133, 1901) 1 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 1 Other – Underground Bakehouses (s. 101) .— In use at the end of the year 1 * Retail—Factory Bakehouse. 48 SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc. (excluding shops and petroleum) 10264 Inspections, etc. re Nuisances, Contraventions, etc. : Number of premises, etc., inspected on complaint 540 Number of premises inspected in connection with infectious diseases 132 Number of smoke observations made 8 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictione) Act, 1920 6 Number of other visits made to premises, etc., in con- connection with nuisances, etc. 956 Total number of premises, etc., primarily inspected in connection with nuisances 944 Number of visits made to works in progress 670 Number of interviews with owners, builders, etc., re abatement of nuisances 663 Number of premises, etc., whereat nuisances were recorded during the year 722 Number of premises, etc , on which defects, etc., were remedied— (a) by owners 808 (b) by local authority in default of owner or occupier 21 Number of cautionary or intimation notices given— (a) verbal 120 (b) written 568 Number of second (informal) notices given 217 Number of letters re nuisances sent 298 Number of Statutory Notices issued 79 Number of proceedings taken 16 Number of convictions obtained 16 Number of proceedings withdrawn — Number of cases dismissed — Common Lodging Houses: Number registered 2 Number of inspections made 6 Number of contraventions found 1 49 Canal Boats used as Dwellings : Number of inspections made 29 Number of contraventions found 4 Movable Dwellings, Caravans, Tents, etc.: Number observed during the year 7 Number of inspections made 12 Number removed from district 7 Bakehouses. Number in district (a) factories 9 (b) worshops 17 Number of underground bakehouses in district 1 Number of inspection made 68 Number of contraventions found 13 Number repaired or improved 1 Number cleansed 7 Slaughterhouses: Number on Register (a) registered premises 4 (b) licenced premises 4 Number of inspections made 172 Number of contraventions found 2 Number cleansed 1 Cowsheds. Number of persons registered 8 Number of premises registered 9 Number of cowsheds on register 16 Number of milch cows in district 117 Number of inspections made 40 Number of contraventions found 4 Number repaired or improved 1 Number cleansed 3 Number of other contraventions remedied 4 Dairies and Milkshops : Number of persons registered 40 Number of premises on register 35 Number of inspections made 104 50 Number of contraventions found 8 Number constructed 1 Number re-constructed, repaired or improved 4 Number cleansed 3 Number of other contraventions remedied 1 Offensive Trades: Number of businesses established in district 16 Number of inspections made 150 Number repaired or improved 2 Inspection of Food : Number of meat inspections 759 Number of fish inspections 395 Number of provision inspections 522 Number of greengrocery and fruit inspections 877 Number of hawkers foodstuff inspections 499 Number of other food inspections 23 Unsound Food: Number of samples of beer taken 41 Number of parcels surrendered 20 Number of organs or parts surrendered during slaughtering Water Supply: Number of supplies provided 17 Number of cisterns cleansed, repaired, covered,etc. 2 Number of draw taps connected direct to main 117 Number of water service pipes or taps repaired 24 Approximate percentage of houses supplied on constant system 99.95 Number of samples taken for analysis from local wells 19 Number of samples found polluted or impure 3 Drainage and Sanitary Arrangements,etc.,of existing Buildings: Water Closets: Number of water closets provided or re-constructed 14 Number of privies abolished 2 Number of walls, etc., cleansed 56 51 Number repaired, supplied with water or otherwise improved 268 Number of apparatus cleansed or unstopped 18 Approximate percentage of houses provided with water closets 98 Sinks. Number of new sinks provided 29 Number of sinks repaired or improved 43 Drains: Number examined, exposed, etc. 5 Number un-stopped, repaired, trapped, etc. 122 Number of waste pipes provided, dis-connected, repaired, trapped or un-stopped 59 Number of soil pipes fixed, repaired or improved 5 Number of ventilating shafts fixed, repaired or improved 43 Number of fresh air inlets provided, repaired or improved 38 Number of rain water pipes dis-connected from drain 43 Number of gully traps inserted or improved 136 Number of dis-connecting traps inserted 1 Number of inspection chambers inserted 5 Number of dis-connecting traps improved, sealed or cleansed 6 Number of inspection chambers repaired, improved, sealed or cleansed 15 Number of drains constructed or reconstructed 15 Total length of drain pipes laid (4" = 331') (6"=18') 349 ft. Number of tests and re-tests applied 24 Number of other works executed 24 Cesspools: Number rendered impervious, emptied, cleansed, etc. 4 Infectious Diseases, Disinfection, etc. : Number of visits made 638 Number of rooms disinfected (a) ordinary infectious diseases 293 (b) Tuberculosis 84 Number of rooms stripped and cleansed after infectious diseases— 52 (a) by owners or occupiers 15 (b) by local authority 18 Number of articles disinfected or destroyed 2454 Removal of Household Refuse: Number of new ashbins provided 204 Number of ashbins repaired 2 Number of ashpits repaired or improved 2 Dampness: Number of roofs stripped, renewed or repaired 245 Number of gutters and rain water pipes provided, repaired or unstopped 329 Number of instances in which external brickwork, sills, etc. repaired, renewed or rendered impervious 533 Number of damp-proof courses provided 69 Number of yards paved, repaired or drained 143 Interior Work: Number of rooms stripped, and cleansed (other than in connection with infectious diseases) 574 Number of floors, walls and ceilings repaired or renewed 690 Number of rooms in which ventilation provided or improved 57 Number of rooms in which lighting provided or improved Number of window frames and sashes provided, repaired or unfixed 491 Number of stoves or grates provided or repaired 134 Number of instances in which ventilation under floors provided or improved 81 Number of other repairs 134 Sundry Nuisances etc. : Number of instances in which domestic cleansing enforced 4 Number of food stores provided, cleansed or improved 4 Number of washing coppers provided or repaired 127 Number of rooms sprayed for the removal of vermin by the disinfector 121 Number of instances in which overcrowding abated 17 Number of instances of improper keeping of animals abated 41 Number of offensive accumulations removed 9 51 Number of urinals provided, repaired, cleansed or improved 2 Number of dung pits provided, repaired or improved 1 Number of other nuisances abated 20 OTHER WORKS. Shops Acts: Number of shops on register 868 Number of inspections made 1078 Number of contraventions found 107 Number of contraventions remedied 75 Number of warning notices sent 81 Petroleum Acts, 1871-1881: Number of premises licensed 37 Number of inspections made 202 Number of stores dis-continued 4 Number of contraventions found 17 Number of contraventions remedied 10 Number of new stores provided 6 Number of warning notices given 10 HESTON and 1SLEWORTH URBAN DISTRICT EDUCATION COMMITTEE. fifteenth ANNUAL REPORT of the School Medical Officer for the Year ending 31st December, 1922. 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, 1922. I wish to express my thanks to the members of the Committee for the kindness and support they have shewn me. I am, Ladies and Gentlemen, Your obedient servant, ELWIN H. T. NASH. Members of Education Committee, 1922-23. H. J. NIAS, Esq., m.b.k., j.p. (Chairman). P. MURPHY, Esq., j p. (Vice-Chairman). Members of the Council :— E. W. HEATH, Esq., j.p., ex-officio (Chairman of the Council). S. CARTER, Esq., ex-officio (Vice-Chairman of the Council). J. J. BONNETT, Esq D. BONNETT, Esq. W. J. R, DIVINE, Esq. F. W. BUCKLEY, Esq. A. E. HALES, Esq. W. D. COWELL, Esq. R. LANGDON, Esq. A. DENNIS, Esq. F. T. HART, Esq. Selected Members— Mrs. W. H. DUMSDAY. Mrs. C. F. EVA. E. W. GOODE, Esq. P. MURPHY, Esq., j.p. J. WEATHERS, Esq. School Medical Officer : ELWIN H. T. NASH, m.r.c.s., l.r.c.p., d.p.h. STAFF. Clerical Staff— A. G. Hubbard (Chief Clerk). Miss R. Marshall. Miss W. L. Rogers. E. Cromwell. J. Holmes. Health Visitors— Mrs. C. E. N. Ottley. Miss B. N. Tetlf.y. Miss G. P. Chatfield. Mrs. A. E. Tyrrell. Miss W. E. Scott. Dentist—I. Cohen, L.D.S., R.C.S. Eng. Badiographer—D. Arthur, M.D , D.P.H. Ophthalmologist—A. E. A. Loosely, M.A., M.B., B.Ch., F.R.C.S. Assistant School Medical Officer— Mrs. Eva Cairns Roberts, M.B., Ch. B., D.P.H. School Medical Officer— Elwin H. T. Nash, M.R.C.S., L.R.C.P., 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 three Maternity and Child Welfare Clinics, at one of which, 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. Unification of Health Services is obtained 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 five years. Proposals to this end have been put forward ; their consideration, has however, been deferred. (b). Nursery Schools. There are 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. The school buildings and the sanitary arrangements are periodically inspected. MEDICAL INSPECTION. The afternoon sessions are chosen when possible, as it is found to be more convenient for those parents who desire to be present. Parents whose children are found to be defective and who require medical treatment, are duly informed of the necessity of medical advice being sought. The children are kept under observation either in the schools or at the Clinics until treatment has been obtained. (a). Age Groups Inspected. The selection of children due for routine medical inspection during 1922, includes those children born during the years,1910, 1913 and 1916, 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). 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. During the year, on the 28th August, permission was received from the Board of Education for the Routine Medical Inspection of the Isleworth Blue, Worple Road and St. Mary's Schools to be held at the Isleworth Public Hall on account of the inadequate accommodation at these schools. This is a great improvement, but unfortunately, owing to the new uses to which the Upper Hall is now being put since its re-decoration, the quiet that it 7 was hoped would be obtained has not materialised in that the work is occasionally rendered difficult, owing to tne noise of shifting furniture and equipment for the various entertainments which take place. FINDINGS OF MEDICAL INSPECTION. 1922. Uncleanliness. Out of 1,945 children examined at routine medical inspection, 246 were excluded on account of nitty or verminous conditions, whilst 85 were marked to be kept under observation. Apart from these cases other 433 were seen at the school clinics aud were referred for treatment, and 59 were kept under observation. Further reference to this subject will be found on page 19. Tonsils and Adenoids. Out of 1,945 children examined at the routine inspections, 236 had enlarged tonsils, 40 of which were referred for treatment, 196 being kept under observation. 49 children had adenoids only, of which 18 required treatment, and 31 were for observation, whilst 43 children had both enlarged tonsils and adenoids, 27 requiring treatment, and 16 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 14 other children were found to have enlarged tonsils, 1 adenoid only, whilst 2 suffered from both conditions. Tuberculosis. Out of 1,945 children examined at the routine inspection there were 7 cases of suspected pulmonary tuberculosis requiring to be kept under observation. At the special clinics, 12 were found to be suffering from suspected pulmonary tuberculosis, whilst 2 children had tubercular glands. 8 Skin. At the routine inspections, out of 1,945 children examined, 42 were found to be suffering from skin trouble. At the special clinics there were 378 children suffering from various skin complaints, including scabies and impetigo (see Table II. for analysis of figures), 26 cases of ringworm of scalp and 21 cases of ringworm of body. External Eye Disease. Out of 1,945 children examined at the routine inspections 41 were found to have minor eye diseases including blepharitis and conjunctivitis, whilst 27 had a squint. In addition 65 were found at the special clinic to suffer from the "minor" eye diseases, and 7 had squint. Vision. Out of 1,945 children examined at the routine inspections, 210 were found to have defective vision, 170 of which were referred for treatment, 40 being kept under observation. At the special clinics 34 children were referred for treatment for defective vision. Ear Disease and Hearing. Out of 1,945 children examined at the routine inspections, 46 were found to be suffering from defective hearing or ear disease, whilst an additional 97 were discovered at the special clinics. Dental Defects. Out of 1,945 children examined at the routine inspections, 939 had carious teeth and were referred for treatment, whilst 149 had slighter caries and were marked for observation. Over half of the children thus examined had carious teeth. At the special clinics a further 71 were discovered and referred for treatment. 9 At the routine dental inspections 1535 children were referred for treatment out of 2,404 inspected (for further particulars see Table IV. D (1) & (2). Crippling Defects. Out of 1,945 children examined at the routine inspections, there were 38 found to he suffering from deformity, including 8 cases of rickets and 9 of spinal curvature. INFECTIOUS DISEASES. Cases of infectious diseases 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 1922, the following cases of infectious disease occurred among children attending public elementary schools in this district:— Scarlet Fever 144 Diphtheria 39 Measles 413 Rubella 1 Mumps 256 Chicken Pox 64 Whooping Cough 85 Total 1,005 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." 10 Case of infectious disease have oceurred during the year among school children as follows:— SCHOOL. SCARLET FEVER. DIPHTHERIA. MEASLE8. GERMAN MEASLES. MUMPS. CHICKEN POX. j WHOOPING COUGH. Alexandra Boys 4 2 39 ... 40 2 10 ,, Girls 6 5 33 ... 40 3 7 Brentford End Infants ... ... 52 ... 1 1 Grove Road Boys 4 1 ... ... 1 1 „ ,, Girls 2 ... ... ... 1 1 „ ,, Infants ... 2 74 ... 6 2 7 Heston Mixed 1 6 2 ... ... 1 1 ,, Infants 1 1 ... ... ... 2 15 Hounslow Heath Boys 1 ... ... ... 3 „ ,, Girls 5 ... 5 ... 8 1 ,, ,, Infants 2 ... 63 ... 10 1 2 Hounslow R.C. Mixed ... ... 1 ... ... 1 2 ,, „ Infants ... ... 5 ... ... 2 1 Hounslow Town Boys 7 ... 3 ... 27 1 „ ,, Girls 1 ... 23 ... 27 1 2 ,, „ Infants 1 2 22 ... 24 1 2 Isleworth Blue Boys 9 1 ... ... 3 1 2 ,, ,, Girls 14 2 1 ... 21 1 1 ,, ,, Infants 4 2 3 ... 11 8 1 Isleiworth Town Boys 4 2 1 ... 7 5 „ „ Girls 2 2 ... ... 4 4 1 St. Mary's Boys 7 1 1 ... 2 3 1 ,, Girls 10 ... 1 ... ... 2 ,, Infants 5 ... ... ... 1 4 2 Spring Grove Boys 2 1 ... ... ... ... ,, ,, Girls 2 3 2 ... 6 1 1 ,, „ Infants 2 5 19 1 7 1 23 Woodlands St. John's Infants ... ... 1 ... 1 4 4 Worple Road Mixed 9 1 5 ... 2 1 „ „ Infants 9 ... 5 ... 3 8 3 Total 114 39 413 1 256 64 88 11 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 sent to the parent. The Health Visitor visits the home and explains to the parents what steps should be taken to have the condition treated. Revisits are made to ascertain what action has been taken. A " following-up " card is made out for each defect and kept " alive " until the defect is remedied. 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. Summary of work by the Health Visitors during 1922. 180 attendances at School Inspection Clinics. 141 ,, ,, Dental Clinics. 22 „ ,, Eye Clinics. 12 349 attendances at Minor Ailments Clinics. 116 visits to schools for medical inspections. 41 ,, „ „ „ re-inspections. 26 „ „ ,, dental inspections. 3 „ ,, ,, cleansing surveys. 1358 „ homes in connection with following-up. 1191 „ ,, „ ,, „ infectious diseases. MEDICAL TREATMENT. Defects discovered at medical inspection are reported 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 26 cases referred for treatment 18 were successfully treated by the application of X-rays at the X-ray Clinic, 8 refusing this form of treatment. Ringworm of Body.—21 cases were successfully treated at the School Clinics. 257 children were treated at the School Clinics for other skin diseases, including 16 cases of Scabies and 220 cases of Impetigo. Ear Disease and Hearing. At the School Clinics 63 cases of Ear Disease or Defective Hearing were seen and treated. Ear Disease. The treatment of discharging ears, occupies a very iarge portion of the time of the Nurses at the Treatment Clinics. There is no more unsatisfactory class of case to deal with than these. 13 Their treatment necessitates daily careful work which can only be "carried out properly by a nurse. In many of these cases the conditions are long standing and there is already infection of the mastoid cells and nothing short of a fairly severe operation is going to permanently cure the condition. So long as this condition persists, the child is always in danger, in that any minute, any further extension of the disease to the upper plate of bone covering the inner ear, may lead to suppuration within the brain cavity and death. The number given 63, does not by any means exhibit the total number of cases existing in the school, as a large number with a small amount af discharge, regard the matter of no importance and are not discovered until Routine or Medical Inspection, or some complaint brings the matter to notice. A very large proportion of these cases suffering from ear trouble, can be cured in the early stage by ionization but unfortunately, treatment is not available in the district, and it is difficult to induce many of the parents to take their children into the centre of London, as owing to the present prevailing unemployment, they cannot afford the necessary fare. I have been able through the kindness of Dr. Friel, to get several cases treated by ionization at the Fitzroy Square Hospital, with most satisfactory results. Eye Disease. 39 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. Tonsils and Adenoids. Out of 107 children referred for treatment, 14 received treatment either privately or through a hospital, whilst 9 were treated under the Education Authority's scheme. Arrangements have been in force since 1921, whereby children requiring operative treatment for enlarged tonsils and adenoids, can obtain this either at the Hounslow or Richmond Hospital, the Education Committee accepting all responsibility for the fee. Re-payments are claimed from the parents in accordance with the following scale :— 14 Weekly family income per head, less rent. Amount per case. Under 8/- nil. From 8/- to 10/- 5/- From 10/- to 12/- 10/- Above 12/- . 21/- Under the above revised scale, which was authorised by this Committee since September, 1922, the number of cases of Tonsils and Adenoids operated on, is comparatively small. Personally, I am strongly opposed to the wholesale removal of Enlarged Tonsils, as in my experience a considerable portion of these disappear in course of time, particularly after a septic mouth has been cleaned up. I am also entirely opposed to recommending the removal of Tonsils, unless I can be assured of complete enucleation. I am bound to admit that some of the after results which I have seen do not agree with this standard. The mere slicing off of a comparatively superficial piece of an Enlarged Tonsil, does not cure the condition and with the recurrence of throat trouble, tends to bring the operation to disrepute. Vision. 155 cases of Visual Defect were submitted for Refraction at the School Eye Clinic, whilst 12 children were treated at hospitals. In 126 cases spectacles were prescribed and provided, and 2 cases referred to hospital for further treatment. Dental Defects. 1,066 children were treated by the School Dentist under the Local Education Authority's Scheme and 798 re-treated. Further 65 attended the Dental Clinic and were referred elsewhere for treatment, e.g , hospital, and 30 attended the Clinic but refused treatment. 47 children had treatment by private dentists. Open Air Education. There is no open air school in the district, the only open air education being comparatively few classes held in the playground in the summer. There is a great demand for an open air school, as there are a considerable number of children who 15 could attend such a school, with benefit from the point of view of education and also from the point of view of their physical wellbeing due to the proper feeding, rest etc., which form such an important part of an open air school curriculum. There are a considerable number of border-line cases that it is very difficult at present to deal with. They cannot attend an ordinary day school and hope to cope with its curriculum. Their power of concentration is sadly lacking, and one feels that on the whole, the child is better running about in the fresh air, and even mud larking under what might be supposed to be far from ideal conditions, than sapping what energy it has by attempting to cope with the school curriculum. The presence of these children in a class also makes the work of a teacher infinitely harder, as they are apt to be a disturbing element amongst the normal children. 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. No schoool 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 1922, one or other parent attended in 1191 instances, representing a percentage of 61'2 as against 52 2 for 1921. Where defects are found the children are followed-up as already described. 16 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. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. In this district there are three Attendance Oflicers, and they have entre to the Health Department where they can ascertain the health status and fitness for school any particular child. The function of these Officers 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. 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). Perodical 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 1922, examinations were conducted in respect of 36 children. There are no special schools in this district for the defective. 17 The Board of Education was approached to see if a concrete proposal for the formation of a Defective School in the area were brought forward, it would be considered, but the financial state of the country was such, that no hope was entertained in this direction, although the proposal put forward involved a very small outlay. NURSERY SCHOOLS. There are no nursery schools in this district. 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. 31 children were examined and all were granted the necessary certificates for fitness for work. (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 18 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. MISCELLANEOUS. Medical Examination of Teachers. During the year 10 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. 27 medical examinations were of children preliminary to their going to the King Edward VII. Memorial Home, Herne Bay. Juvenile Employment. 30 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. A special enquiry on this subject was made in 1920 and a full report submitted. There is no provision in the district for such children. SCHOOL CLINICS. There are two clinic days at the Council House and two at the Isleworth . Public Hall per week, when a Doctor is in attendance, but treatment is carried out between 9 and 10 o'clock for minor ailments on five days a week by the Nurses. School children come under the notice of the Medical Officers in one of the following ways:— 1. They are discovered at Routine Medical Inspections and are perhaps marked for treatment or it may be merely for observation. 19 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 Health Visitors may discover cases casually while visiting the schools. Charges for treatment are as follows:— Spectacles.—Free in necessitous cases. Where the total family income does not exceed 10/- per head, the spectacles are provided by the Education Authority at a reduced cost of 4/- per pair. In all other cases the full cost has to be paid. 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 3 occasions for the purpose of conducting Cleanliness Survey. At these inspections there were examined 453 children, of whom 95 were found to be unclean. Of the latter number 33 were excluded and the remainder 62 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. 20 No cleansing has been carried out by the school nurses. Mrs. Yates, the Home Help, having been trained at one of the London County Council's Cleansing Centres, commenced work in March under the following conditions:— The Council supplies the Sacker's combs and shampoo, and Mrs. Yates charges 1/- per case for cleansing. The result has been entirely satisfactory. There is only one difficulty, viz. that unless the heads are re-examined by the Nurse or Medical Officer directiy after the cleansing, there is a risk in the dirtiest houses of fresh lice being picked up in the house. This however, is the only weakness, but cannot in any way compare with the benefit. Since this work has been commenced, 145 children have been cleansed. Owing to the attitude taken by the Bench of inflicting substantial fines on cases brought before them, there has been a noticeable improvement in ihe condition of the children's heads. During the year 1922, legal proceedings were instituted against the parents of 10 children. In one instance the summons was withdrawn, in one, the case was adjourned sine die, and in the remainder tines were imposed as follows: 5 of 10/-; 3 of £1. 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 or 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 Heston and Isleworth. Table I. NUMBER OF CHILDREN INSPECTED 1st January, 1922, to 31st December, 1922. A—Routine Medical Inspection. Age. Entrants. Intermediates. Leavers. Grand Totals. 5 6 7 Totals. 8 9 10 11 Totals. 12 13 14 Totals. Boys ... 249 53 302 2 229 32 263 377 29 4 410 975 Girls 1 208 46 254 6 312 38 8 364 329 17 6 352 970 Totals 1 457 99 556 8 541 70 8 627 706 46 10 762 1945 21 B—Special Inspections. Children examined—Special Cases 1668 Re-examinations (i.e. No. of children re-examined) *867 C—Total number of individual children inspected by the Medical Officer, whether as Routine or Special Cases (no child being counted more than once in one year). No. of individual children inspected 3613 *The figures 867 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 8304 examinations, so that the total number of examinations amounts to 11,116. 22 (Heston and Isleworth). Table II.—RETURN OF DEFECTS found in the Course of Medical Inspection in 1922. Disease or Defect. Routine Inspections. Specials. Number referred for treatment. Number requiring 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 Malnutrition ... 1 ... 8 Poor Nutrition ... 24 Uncleanliness— Head 244 84 431 59 Body 2 1 2 ... Skin— Ringworm— Head ... ... 26 ... Body 1 1 20 1 Scabies ... 1 16 ... Impetigo 11 2 209 ... Other Diseases (non- tubercular) l 25 75 47 Minor Injuries ... ... 18 13 Eye- Blepharitis 7 23 4 9 Conjunctivitis 2 2 18 3 Keratitis ... ... ... ... Corneal Ulcer ... ... 2 ... Corneal Opacities ... 1 ... 4 Defective Vision 170 40 34 ... Squint 10 17 ... 7 Other Conditions 1 5 5 20 Ear— Defective Hearing 13 14 1 14 Otitis Media 3 ... 5 20 Other Ear Diseases 8 8 11 46 Nose and ThroatEnlarged Tonsils 40 196 5 9 Adenoids 18 31 ... 1 Enlarged Tonsils Adenoids 27 16 1 1 Other Conditions 7 56 41 10 23 Table II—Continued. Disease or Defect. Routine Inspections. Specials. Number referred for treatment. Number requiring 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 Inlarged Cervical Glands (non-tubercular) 2 368 12 3 Defective Speech 2 19 1 2 Teeth— Dental Diseases 939 149 71 ... Heart and Circulation— Heart Disease 1 56 5 25 Anæmia ... 38 3 6 Lungs— Bronchitis 3 1 10 3 Other Non-Tubercular Diseases 1 29 27 12 Tuberculosis— Pulmonary Definite ... ... ... ... Suspected ... 7 8 4 Non-Pulmonary Glands ... 3 1 1 Spine ... ... 2 1 Hip ... ... ... ... Other Bones and Joints ... ... ... ... Skin ... ... Other Forms ... 1 1 ... Nervous System— Epilepsy ... ... 1 1 Chorea ... 3 18 ... Other Conditions ... 14 7 5 Deformities— ... Rickets ... 8 ... 1 Spinal Curvature ... 9 ... 1 Other Forms ... 21 ... 5 Other Defects and Diseases ... 81 97 81 Number of individual children having defects which required treatment or to be kept under observation— Routine Medical Inspection 1529 *Special cases 2753 *This figure does not refer to individual children, as one child may be referred for more than one defect. 24 (Heston and Isleworth) TABLE III.—NUMERICAL RETURN of all Exceptional Children in the area in 1922. Boys. Girls. Total Blind (including partially blind) within the meaning of the Elementary Education (Blind and Deaf Children) Act, 1893. Attendiug Public Elementary Schools ... ... ... Attending Certified Schools for the Blind 2 1 3 Not at School ... 1 1 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 2 1 3 Not at School ... ... ... Mentally Deficient Feebleminded Attending Public Elementary Schools 18 17 35 Attending Certified Schools for Mentally Defective Children Notified to the Local (Control) Authority during the year 2 1 3 10 4 14. Not at School 1 1 2 Imbeciles At School ... ... ... Not at School 2 3 5 Idiots ... 2 2 Epileptics. Attending Public Elementary Schools ... 3 3 Attending Certified Schools for Epileptics 1 ... 1 In Institutions other than Certified Schools ... ... ... Not at School ... 1 1 Physically Defective Pulmonary Tuberculosis Attending Public Elementary Schools ... ... ... Attending Certified Schools for Physically Defective Children In Institutions other than Certified Schools ... ... ... ... ... ... Not at School 1 1 2 Crippling due to Tuberculosis Attending Public Elementary Schools 3 ... 3 Attending Certified Schools for Physically Defective Children In Institutions other than Certified Schools 1 ... 1 1 ... 1 Not at School 2 ... 2 25 Table III.—Continued. Boys. Girls. Total. Crippling due to causes other than Tuberculosis i.e. Paralysis. Rickets, Traumatism. Attending Public Elementary Schools 10 11 21 Attending Certified Schools for Physically Defective Children In Institutions other than Certified Schools ... ... ... ... ... ... Not at School ... 1 1 Physically Defective. Other Physical Defectives, e.p. delicate & other children suitable for admission to Open-air Schools ; Children suffering from severe Heart Disease Attending Public Elementary Schools 4 4 8 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 155 54 209 Retarded three years 67 11 78 26 (Heston and Isleworth). TABLE IV.—A. Treatment of Minor Ailments, 1922. Disease or Defect. Number of Children. Referred for treatment. Treated. Under Local Education Authority's Scheme. Otherwise. Skin— Ringworm, Head 26 18 8 Ringworm, Body 21 21 ... Scabies 16 16 ... Impetigo 220 220 ... Minor Injuries 31 18 13 Other Skin Diseases 76 76 ... Ear Disease 63 63 ... Eye Disease (external and other) 39 39 ... Miscellaneous 97 ... 97 Total 589 471 118 Table IV. B Treatment of Visual Defect, 1922. Number of children. Submitted to Refraction. Referred for refraction. Under Local Education Authority's Scheme, Clinic or Hospital. By Private Practitioner or Hospital. Otherwise. Total. 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. 320 155 12 ... 167 126 126 2 referred to Hosp. 28 (9 to continue glasses) 150 awaiting C.F. 3 Objectors. 27 Table IV.—C Treatment of Defects of Nose and Throat, 1922. Referred for treatment. Number of children. Received operative treatment Under Local Education Authority's Scheme, Clinic or Hospital. By Private Practitioner or Hospital. Total. Received other forms of treatment. 107 9 9 18 5 1 Objector. 2 Cannot afford at present. 36 Operation not necessary. 45 Awaiting receipt of C.F. 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 236 334 400 409 423 371 134 18 6 2 71 2404 (b) Referred for treatment ... ... ... ... ... ... ... ... ... ... ... 1535 (c) Actually treated ... ... ... ... ... ... 1066 (d) Re-treated ... ... ... ... ... ... 798 (e) Attended Clinic, but referred elsewhere for treatment, e.g. Hospital ... ... 65 (/) Attended Clinic, but refused to have treatment, " Objectors " ... ... ... 30 (g) By Private Dentist ... ... ... ... ... ... 47 28 Table IV. -D. —TREATMENT OF DENTAL DEFECTS, 1922. 2. Particulars of time given and of operations undertaken. No. of half-days devoted to Inspection. No. of half-days devoted to treatment. Total No. of attend ances made by the children at the Clinic. No. of permanent teeth. No. of temporary teeth. Total No. of fillings. No. of administrations of general anaesthetics included in 4 and 6. No. of other operations. Extracted. Filled. Extracted. Filled. Permanent teeth. Temporary teeth. 1 2 3 4 5 6 7 8 9 10 11 26 107 1526 126 634 2570 4 638 454 87 ... 29 30 (Heston and Isleworth). Table V.—Summary of TREATMENT OF DEFECTS as shown in Table IV. (A, B, C. D and F, but excluding E). Disease or Defect. Number of children. Referred for treatment. Under Local Education Authority's Scheme. Treated. Total. Other wise. Minor Ailments 589 471 118 589 Visual Defects 320 155 12 167 Defects of Nose and Throat 107 9 9 18 Dental Defects 1535 1066 47 1113 Other Defects ... ... ... ... Total 2551 1701 186 1887 31 (Heston and Isleworth). Table VI.—Summary relating to CHILDREN MEDICALLY INSPECTED at the Routine Inspections during the year 1922. (1) The total number of children medically inspected at the routine inspections 1945 (2) The number of children in (1) suffering from— Malnutrition 1 Poor Nutrition 24 Skin Disease 42 Defective Vision (including squint) 237 Eye Disease 41 Defective Hearing 27 Ear Disease 19 Nose and Throat Disease 391 Enlarged Cervical Glands (non-tubercular) 370 Defective Speech 21 • Dental Disease 1088 Heart Disease 57 Anæmia 38 Lung Disease 34 Tuberculosis— Pulmonary Definite Suspected 7 Non-Pulmonary 4 Disease of the Nervous System 17 Deformities 48 Other Defects and Diseases 81 (3) The number of children in (1) suffering from defects (other than uncleariliness or defective clothing or footgear) who require to be kept under observation hut not referred for treatment 223 (4) The number of children in (1) who were referred for treatment (excluding uncleariliness, defective clothing, etc.) 1267 (5) The number of children in (4) who received treatment for one or more defects (excluding uncleanliness, defective clothing, etc.) 652