HES 10 Henston & Isleworth Urban District Council. 1923. ANUAL REPORTS of the ledical Officer of Health and School Medical Officer for the URBAN DISTRICT OF 1ESTON AND ISLEWORTH for the Year ending 31st December, 1923. 1923 REPORT ON The Health OF THE HESTON and ISLEWORTH URBAN DISTRICT FOR THE YEAR 1923. 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, 1924. To the Chairman and Members of the Heston and Isleworth Urban District Council. Ladies and Gentlemen, The Annual Report 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. 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 1923. Members of the Council:— F. W. Buckley, Esq. (Chairman). J. J. Bonnett, Esq. (Vice-Chairman). E. W. Heath, Esq., j.p. ex-ofjicio (Chairman of the Council). S. Carter, Esq.. ex-ofjicio (Vice-Chairman of the Council). C. Crush, Esq., j.p. A. E. Hales, Esq. A. Dennis, Esq. F. T. Hart, Esq. C. J. Geary, Esq. A. L. Lang, Esq. J. A. Jessop, Esq. R. Langdon, Esq. Medical Officer of Health Elvvin H. T. Nash, d.p.h. MATERNITY AND CHILD WELFARE COMMITTEE. Members of the Council:— N. L. Sammels, Esq. (Chairman). J. J. Bonnett, Esq. F. W. Buckley, Esq. E. W. Heath, Esq. A. L. Lang, Esq. R, Langdon. Esq. Co-opted Members:— Mrs. C. W. Bezer. Mrs. E. Chedgey. 6 STAFF. The following persons constituted the Staff of the Health Department on the 31st December, 1923. Medical Officer of Health — Elwin H. T. Nash, M.R.C.S., L.R.O.P., D.P.H. Assistant Medical Officer of Health — Mrs. E. Louise 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. Ash worth, 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. N. Tetley, 3 years childrens' training. Cert. C.M.B. 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. Miss J. D. Law, 4 years general training, Cert. C.M.B., M.C.W.W., H.V. Home Help— Mrs. E. Yates. Chief Clerk— B. W. Kilby, Cert. S.I.E.B. and R.S.I. (M.l.) Clerks— A. G. Hubbard. Miss R. Marshall, Cert. R.S.I. E. Cromwell. J. Holmes. 7 SUMMARY OF VITAL STATISTICS, 1923. Population— At the Census, 1921 46,729 Registrar-General's estimate of nett 48,030 (Birth rate) Civil population 46,505 (Death rate) Birth rate (nett) 17.45 England and Wales 19.7 London 20.2 Death rate (nett) 9.8 England and Wales 11.6 London 11.2 Infantile Mortality Rate 54.89 per 1,000 births. England and Wiles 69 „ London 60 „ Area 6,893 acres. Number of inhabited houses (Census 1921) 8,790 „ of families or separate occupiers (1921) 9,893 Rateable value £249,765 Sum represented by a penny rate £918 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 1922—23:— 1922. 1923. £ s. d. £ s. d. Parish of Heston 1874 13 11 1825 8 7 Parish of Isleworth 5014 13 10 4081 16 2 Totals £6389 7 9 £5907 4. 9 8 Medical Relief. Particulars as to the extent to which hospitals and other forms of gratuitous medical relief are utilised are not available, save in a few instances, as many people apply to hospitals outside tha 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 510 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 in 1922, making a total of 47. Its sphere of usefulness will, it is hoped, be extended by the provision of maternity beds. During the year 1923, there were admitted 512 in-patients, whilst 2,638 new out-patients received treatment. Medical relief is also given by certain voluntary organisations in the district, namely:— The Hounslow Central Aid Society. The Isloworth District Nursing 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 Dockvvell for infectious diseases. VITAL STATISTICS. Population. For the year 1923, the estimate of nett civil population is given under two figures supplied by the Registrar-General. The death-rate population (46,505) excludes all non-civilian males whether serving at home or abroad; whilst the birth-rate A 9 (and marriage-rate) population (48,030) 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. The number of deaths registered in the district was 971, but 564 of these did not belong to the district, while 49 residents died without the district. Thus the number of deaths properly attributable to the district was 456. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 9.8 per 1,000, which is comparable with the following figures:—11.6 for England and 11.2 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. The total number of births registered during the year was 918, but 121 of these did not belong to this district, while 41 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 838. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 17 45 per 1000. The birth-rate of England and Wales is 19 7 per 1,000, and for London 20 2 per 1,000. Legitimacy. The following figures give the number of births:— Legitimate. Male. Female. Total. 435 380 815 Illegitimate. Male. Female. Total. 8 15 23 Deaths. Births. 10 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 1923 is 54 89 per 1,000 births. The rates for England and Wales and for London during the same period were 69 and 60 respectively. The infantile mortality figure, 54 9, is the lowest in the history of the district. Less than 15 years ago, one Medical Officer who ventured to hold up an infantile mortality of 60 per 1,000 as the goal to be aimed at, a goal unbelievable, and undreamt of, was looked upon as a visionary and a dreamer. Of a truth " Peace hath its victories." Previous low figures were:— 1912 85.0 1918 86.0 1920 57.0 1921 69.4 1922 73.5 SANITARY CIRCUMSTANCES. Water Supply. There were, as far as is known, at the end of the year 42 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. In 108 instances draw-taps were placed on the main to the bouse, in compliance with notice from the Health Department, in lieu of a supply drawn from an inaccessible and uncoverd cistern. Drainage and Sewerage. The sewerage of almost the whole district is arranged on the " separate " system. 11 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 1923:— Jersey Road.— From "Rose Farm," Scrattage to the Great West Road. This work is wearing completion. Wood Lane.—(a) From Borough Road extending for a length of 167 yards in a southerly direction. (b) From London Road extending in a northerly direction for a distance of 394 yards. This work is nearing completion. Bath Road.—The extension of this sewer from Vicarage Farm Lane to Cranford (1,937 yards in length) was completed during the course of the year. Great West Road.—The foul and surface water sewers to that portion of the road situated within the Urban District were completed during the course of the year. 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. During 1923, collection of house refuse has continued weekly as before, but was disposed of by means of a dump in the Stainas Road instead of being dealt with in the destructor. During the year there were supplied 246 new ashbins. Sanitary Inspection of District. See pages 50—55. 12 Nuisances, Contraventions of Bye-laws, Defective Drainage, etc. The number of premises on which nuisances were outstanding at the end of 1922 was 589. To these another 740 premises whereat nuisances were recorded in 1923 were added, giving a total of 1,329 premises. Of these S32 had the nuisances remedied, leaving 497 premises at which nuisances still existed at the end of the year. During the year, nuisances at 67 houses were reported to the Health Committee, which added to the 27 brought forward from 1922, make a total of 91. 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 in 48 of the houses, leaving 46 cases to be carried forward in 1924. Comparative figures for the years 1921, 1922 and 1923 in connection with nuisances are submitted herewith:— 1921 1922. 1923. Number of complaints received 496 460 459 Premises at which nuisances were located 932 722 740 Informal notices sent— First 682 568 636 Second 213 217 190 Statutory notices served 142 79 114 It is my duty once more to point out that the staff of Sanitary Inspectors is inadequate. 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 408 known places in this district which call for periodical inspection as follows:— 13 Houses let in Lodgings, Common Lodging Houses, Bakehouses, Slaughter-houses, Cow-sheds, Dairies and Milkshops, Offensive Trades, Laundries (non-factory), Workshops, Workplaces and Outworkers. 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 following is the record of inspection of food premises:— No. of Inspections made. Meat 960 Fish 519 Provisions 553 Greengroceries and Fruit 856 Hawkers' Food Stuffs 417 Number of other Food Inspections 31 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. 197 inspections were carried out in respect of dairies and milkshops. 125 grants were made during the year. Unofficial milk analyses are made by the Medical Officer of Health. A serious complaint was made by one of the dairymen in the district, that his well, used for cooling purposes, was contaminated and that he had had to put in 2 pumps, and a new draw pipe and strainer owing to the corrosion taking place. Examination of the well and pumping gear, showed that the water had a faint yellowish colouration, probably due to iron, and that the whole of the end of the draw pipe in the well was eaten away. The dairyman expressed a fear that his coolers might be perforated and his milk damaged. 14 Chemical examination of the water showed a definite acidity. Investigation showed that a manufacturing concern in the neighbourhood had as the result of one of their largest manufacturing processes a highly coloured acid effluent, the acidity at times being as high as 25%. This effluent could not be taken into the sewers either on account of the acidity or the colour. Nor could the colour be separated by any then known process, so that the acid content could be utilized or even neutralized and discharged into the sewers. In order to overcome the difficulty, the effluent was discharged into a deep soak away in the gravel, as it was found that the action of the effluent on ordinary soil was to produce a colloidal film and ponding without percolation. Gravel alone seemed to have the capacity to discharge the colour. As the result of the pumping there was no doubt that flow had been produced in the subsoil water from the works involved, and the acid had caused the trouble complained of. The firm involved solved the dairyman's difficulty, by installing a complete refrigerating plant. The dairyman's need of his well for cooling is due to the fact that in the summer the temperature of the water in the mains is such that it is impossible to use it for cooling purposes. The firm involved commenced a special research to find some n.eans of discharging the colour which was ultimately successful, and a plant is being designed to accomplish this and neutralize the acidity with another alkaline by-product and so produce an innocuous effluent. 1. Meat Inspection.—The Chief Sanitary and the District Sanitary Inspectors hold special certificates for meat inspection. Slaughter-houses and butchers' shops are visited periodically, but during the year no diseased meat was seized, but 117 lbs. was surrendered. There are 8 slaughter-houses and 27 butchers' shops in the district. Each slaughter-house received on an average 2.55 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. 3. Action under Section 117, Public Health Act, 1875.—None during 1923. 15 4. Tubercular Meat.—There was none seized, but 117 lbs. were surrendered during the year. 5. The following tabular statement on slaughter-houses is required:— In 1914. In January, 1923. In December, 1923. Registered 6 4 4 Licensed 3 4 4 Total 9 8 8 The slaughter-houses as a whole are unsatisfactory. Two licenced slaughter-houses have been improved during 1923. During 1922, 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 Drugs Act. I am indebted to Dr. J. Tate, 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 1923. List of Samples purchased Article. Taken. Adulterated. Milk 153 2 Milk, separated 8 — Milk, condensed 2 — Cream 5 2 Cream, preserved 8 — Cream, pastry 2 — Beer 2 — Butter 11 — Cream of Tartar 2 — Flour, self-raising 5 — Olive Oil 2 — Zinc Ointment 2 — 202 4 16 UNSOUND FOOD, 1923. cwts. qrs. lbs. Fish 1 3 5 Meat 1 0 5 Total quantity surrendered 2 3 10 INFECTIOUS DISEASE. General Remarks. Scarlet Fever incidence was comparatively low. That of Diphtheria on the other hand was considerably higher than last year. Heston had a comparatively larger proportion of cases, many of which were discovered aa the result of swabbing. Six cases of Enteric Fever were reported, but investigation failed to reveal any positive source of infection. The one case of Anthrax occurred in a soldier who was transferred from Feltham to the Hounslow Barracks, en route for Millbank. 17 The table hereunder gives the number of cases of infectious diseases that occurred in the several Institutions in the district ENTERIC FEVER. SCARLET FEVER. DIPHTHERIA PNEUMONIA (all forms). ERYSIPELAS. PUERPERAL FEVER. CEREBRO SPINAL FEVER. OPHTHALMIA NEONATORUM. ENCEPHALITI8 LETHARGIC A. PULMONARY TUBERCULOSIS. OTHER TUBERCUL08IS. POLIOMYELITIS TOTAL. West Middlesex Hospital 2 5 22 67 9 15 ... 2 1 ... ... ... 123 Hounslow Barracks ... ... 2 ... ... ... ... ... ... ... 2 Hounslow Hospital ... 1 ... 2 ... ... ... ... ... 1 4 Dundee House ... ... 7 ... ... ... ... ... ... ... ... ... 7 North Hyde Schools ... 1 13 ... ... ... ... ... ... ... ... 14 Totals 2 7 44 69 a 15 ... 2 1 ... ... 1 150 Also 1 case of Anthrax at the R.A.S.C. Depot, Feltham. This case was notified from the Barracks, Hounslow, where it was sent pending its removal to Millbank. 18 Scarlet Feyer. The following table shows the number of cases which have been notified, and the number and percentage of cases which have been removed to Hospital:— No. of civil cases notified 92 ,, „ removed to Mogden Hospital... 84 Percentage of cases removed to Hospital 91 The incidence rate of Scarlet Fever in the civil population was 197 per 1,000. One death took place from this cause during the year. The mortality rate was 1 08 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 105 „ „ removed to Mogden Hospital 60 Percentage of cases removed to Hospital 57 In addition to these cases one military case was reported. The incidence rate per 1,000 of the civil population was 2.25. Forty-four cases occurred in public institutions during the year, 11 of the persons affected being non-residents. 10 deaths took place from this disease, i.e. a case mortality rate of 9.5 per cent. Diphtheria Antitoxin. During 1923, 31 vials of Antitoxin were supplied to medical practitioners. (18 of 2000 units and 13 of 4000 units). Typhoid Fever. There were six cases notified during the year. Two of these were non-residents, notified from the West Middlesex Hospital. Dysentry. None were notified. Erysipelas. 15 cases of this disease were notified, of whom 9 were West Middlesex Hospital cases, the persons affected being non-residents, with the exception of 1. No deaths were recorded from this disease. 19 Puerperal Fever. 17 cases of this disease were notified, 15 were institution cases, 14 of the persons affected being non-residents. Ophthalmia Neonatorum. Four children were notified as suffering from this disease. One was notified from Warkworth House, and 1 non-resident from the West Middlesex Hospital. Encephalitis Lethargica. There was one case notified of this disease. Cerebro-Spinal Fever. No cases of this disease were notified. Acute Poliomyelitis. There was one case notified. Pneumonia. 99 cases were notified, 49 being non-residents in the Infirmary. Malaria. There were no cases notified during the year. Anthrax. One case notified. See previous table. Pulmonary Tuberculosis. The number of new cases notified during the year wan 57. Twenty-eight cases (or nearly 50%) were notified from Institutions:— Sanatoria 9, Poor Law Institutions 12, General Hospitals 2. Mental Hospitals 3, T B. Dispensary 2. Naval and Military cases 3. Total number of cases admitted to Sanatoria, etc. 71. Of the new cases notified 45 received Institutional treatment during the year and 10 died in Institutions. 20 Other Forms of Tuberculosis. The number of new cases notified during the year was 11. Nine of them were notified as receiving institutional treatment. Nine cases were notified from Institutions. Deaths from Tuberculosis. Tuberculosis of Respiratory system 35. (15 were primary notifications and 6 were not notified at all). Other Tuberculosis 6. (3 were not notified). 21 TUBERCULOSIS. Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 ... ... ... ... ... ... ... 1 ... ... 1 ... ... ... 1 ... 5 3 ... 1 ... 1 ... ... ... 10 1 2 1 ... ... 1 ... ... 15 4 2 1 ... 2 2 ... ... 20 6 2 ... ... 3 1 2 ... 25 4 7 2 ... 3 3 1 ... 35 6 6 1 1 5 7 ... ... 45 6 3 ... ... 3 ... ... ... 55 2 1 ... ... 3 i 1 ... 65 and upwards ... 1 ... ... ... ... ... ... Age not known 1 ... ... ... ... ... ... ... Totals 33 24 7 4 20 15 5 1 Six of the deaths from Pulmonary Tuberculosis were not notified and three of the deaths from Non-Pulmonary Tuberculosis were not notified. 22 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 3 German Measles 5 Chicken Pox 62 Mumps 111 Whooping Cough 63 Upon receipt ot information ol the existence of a case, inquiry is made by a Health Visitor to obtain all necessary facts. Influenza. The mortality from Influenza was 012 per 1,000. Smallpox. No case occurred during the year. In September information was received from the County Medical Officer of Health, that a contact of a Smallpox case in London was residing in the District. The whole family was, in consequence, kept under observation, and several children vaccinated. Another possible contact (a shop assistant) of the original Smallpox patient in London was also visited. No case resulted. No vaccinations were performed by the Medical Officer of Health under the Public Health (Smallpox Prevention Regulations, 1917) during the year under review. Cleansing of Yerminous Persons. Particulars are asked for as to the facilities available in the district for the cleansing and disinfection of verminous persons and their belongings. Neither the Education Authority nor the Sanitary Authority possesses a cleansing station. This matter has been brought to the notice of the Education Committee on many occasions. Where application is made, the Health Department undertakes the spraying of rooms for the removal of bed bugs, and bedding and clothing generally can be disinfected by steam at Mogden Isolation Hosuital. 23 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 practicing 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. According to the County Medical Officer's last list, there are 14 midwives practising in the district. 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 8,322 for the year as compared with 8,398 in 1922. The average attendance at the Council House was 32 and at the Isleworth Centre 34 4. The number of individual mothers and children attending the Clinics is shewn hereunder:— Council House, Hounslow. Isleworth Public Hall. 1920. 1921. 1922 1923. 1920 1921. 1922 1923 Mothers 315 538 541 525 170 268 278 270 Children 407 774 726 646 185 296 350 330 Sales at Clinics. Quantity. Receipts. £ s. d. Glaxo 6948 lbs. 538 18 0½ Virol 4521/16 lbs. 37 17 1 Malt 272½ lbs. 21 6 8 Oil and Malt 194¾ lbs. 14 6 4½ Marylebone Cream 285/8 lbs. 2 6 10½ Lactagol 142 pkts 8 5 8 Total Receipts £623 0 8½ Ihe arrangements with chemists for the dispensing of prescriptions on terms similar to those under the National Insurance Act, have been continued. 24 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. 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. 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 existence 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. Negotiations are taking place with respect to premises which would give much better facilities for the Maternity and Child Welfare Work generally. 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 180 visits during the year and her work was found of considerable value. 25 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 of 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. The presence of this service acts in another way, in that if a case is taken before the Magistrates the fine is 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 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 ]/- and get the head clean, than run the risk of a substantial tine by the bench. During the year, 168 children have been cleansed. 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. Number of grants made during the year was 125. 26 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. 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 Yisiting. The visits by the Health Visitors in connection with the Maternity and Child Welfare work are shown in the following table :— 1920. 1921. 1922. 1923. 1st visit to babies under one year 1132 1029 913 803 Re-visits to babies and children up to five years 4715 4484 4241 4150 Inquiries made, elicited— Feeding—Natural 870 631 536 516 Artificial 59 54 43 61 Both 23 51 41 42 Sleeping with parents 477 354 319 282 Using Comforter 300 236 198 285 Mother working during pregnancy 56 45 56 44 27 Ante-Natal. First visits 120 Subsequent visits 92 Infant Deaths. Visits paid 17 Ophthalmia Neonatorum 1 Infantile Diarrhoea 2 Puerperal Fever 5 Measles and German Measles 4 Children under 5 years. Whooping Cough 29 Mumps 6 Chicken Pox 16 Pneumonia 5 Bronchitis 1 Milk and Food cases 57 Home Help 23 Social conditions 32 Milk samples 12 Other visits 16 Number of live births notified during the year 924 „ „ still births notified ,, ,, 24 Notified by Midwives 588 Notified by parents or doctors 360 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 bs made of the services rendered at the Welfare Clinics, by the members of the Women's Co-operative Guild, Miss Clements, Hounslow, and Mrs. Evans, Isleworth. The Council in January, 19V3, placed on record their appreciation of the valuable services rendered by the voluntary helpers. 28 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 47 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. 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. 29 AMBULANCE FACILITIES. (a). For Infectious Cases.—This is provided by the Joint Hospital Board. (b). For Non-Injections 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., *111., •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. Small Dwellings Acquisition Acts, 1899-1923. Local Government and other Officer's Superannuation Act, 1922. 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, 5. 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). 30 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. 1835, s. 13). Allotments (A.A. 1887, -s. 6). Allotment Regulations, 1922. •These are administered wholly or partly by the Health Committee. The unstarred are administered by other Committees of the Council. 31 COUNCIL LABORATORY, 1923. (a) Swabs for Diphtheria sent by Medical Practitioners Total. Positive. 133 ... 10 Sub-cultures 11 2 Taken from Schools, Clinics and from Contacts 581 ... 31 Scraping from finger 1 1 Sent from Staines Joint Isolation Hospital 569 ... 127 Sub-cultures 6 6 Total cultures examined 1306 ... 177 Virulency Tests 3 2 (b) Blood Examination for Typhoid Widal Tests 2 1 (c) Specimens of Sputum for Tubercle Bacilli — Sent by Medical Practitioners 73 ... 18 Sent by M.O.H 1 0 74 18 (d) Hairs for Ringworm— Taken at Schools or Clinics 42 29 (e) Other Specimens— Urine 32 Discharge 12 Film 1 (f) One sample of water examined for acidity. (g) 6 analyses of milk—shewed no added water. 2 analyses of Glaxo. Preparation of Materials — Tubes of Serum 1660 Throat Swab Outfits 1300 Sputum Outfits 96 Typhoid Outfits 12 32 The work done shows a slight increase over 1922, chiefly due to the large number of swabs examined for Diphtheria during the first quarter of the year. The bacteriological work of the Staines Joint Isolation Hospital continues to be done in the Council Laboratory following the arrangement made last year. We also continue to supply the Mogden Isolation Hospital Diphtheria Culture Tubes. The Virulency and Widal Tests were carried out for us by Dr. Harold Spitta at St. George's Hospital. 33 HESTON & ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Derartment, Council House, Hounslow. 22nd January, 1924. Canal Boats Acts, 1877 to 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 31sJ December, 1923, 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. U. H. Butler (Chief Sanitary Inspector), G. W. Ashworth and F. Humphries (District Sanitary Inspectors), were appointed to act as Canal Boat Inspectors. No special remuneration is paid for the position. Number op Inspections, etc. During the year 55 inspections were made of 48 boats, 46 boats were in order, whilst in the case of the other two boats, one wax found to have two infringements, and the other one infringement of the Acts and Regulations. The nature of the contraventions were as follows:— (a). Interiors of fore and aft cabins require re-painting 1. (b). Cabins not in a habitable condition 2. 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. 34 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 a special report on all known cases was presented. The Public Health Committee recommended the appointment of a special Officer for a period of three months, to leport on certain areas, in order to get a real picture of the overcrowding. This was negatived by the Council. 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 tKe health of the children. I. Fitness of Houses. (1) (a) General standard of Homing in the district: As already stated,the general standard is unsatisfactory. (b) General character of defects found to exists 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 ... ... ,, 35 (3) Difficulty in remedying unfitness, special measures taken and any suggestions in the matter : Principil 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 ivatcr 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) /is to working uf existing Bye-laws : For reasons given elsewhere it has been impracticable to maintain the inspection of houses let in lodgings, etc. Probably many houses are now technically houses let in lodgings owing to the abnormal housing conditions, but are not on the register. 36 (2) As to need for new bye-laws and revision of existing bye-laws : Some difficulty has been experienced in dealing with caravan dwellers under the existing bye-laws with regard to the disposal of refuse, and closet accommodation, and a revision of these bye-laws is under consideration. IY. General and Miscellaneous. Other action taken in connection with overcrowding, insanitary property and housing Nil. Y. Appendices, Statistics for year ending 31st December, 1923. SHOPS ACT. The number of contraventions of the Acts which were reported during the year was as follows:— Open on half-holiday 2 Open after evening closing hour 9 Prescribed form of notices not exhibited (exempted articles afternoon) 14 Prescribed form of notices not exhibited (exempted articles evening) 22 Prescribed form of notices not exhibited (assistants half-holiday) 6 Provision or improvement of sanitary conveniences (P.H.A.A.A. 1890, s. 22) 10 PROCEEDINGS. Proceedings were taken during the year in respect of nuisances at two houses, but the summonses were withdrawn on the completion of the necessary work by the owners. 37 APPENDICES. Housing Conditions Statistics. Year ended 31st December, 1923. 1. GENERAL. (1) Estimated Population Birth rate 48,030 Death rate 46,505 (2) General Death rate 9'8 (3) Death rate from Tuberculosis (all forms) 0 88 (4) Infantile Mortality 54 9 (5) Number of dwelling houses of all classes 9,307 (6) ^Number of working-class dwelling houses 4,698 (7) Number of new working-class houses erected 16 *Number of new houses other than working-class 73 Total number of new houses erected of all classes 89 2. UNFIT DWELLING-HOUSES. I. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts 497 (2) Number of dwelling-houses which were inspected and recorded under the Housing (Inspection of District) Regulations, 1910 nil. (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation ... nil. (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 180 (5) Number of houses, listed for inspection under the Housing (Inspection of District) Regulations, 1910, at end of year 1547 33 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 ... 202 III. Action under Statutory Powers. A. Proceedings under Section 28 of the Housing Toun Planning, etc., Act, 1919— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 16 (2) Number of dwelling-houses which were rendered fit— (a) by owners 5 (b) by Local Authority in default of owners 2 (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 43 (2) Number of dwelling-houses in which defects were remedied — (a) by owners 33 (b) by Local Authority in default of owners nil. C. Proceedings under Sections 17 and 13 of the Housing Town Planning, etc., Act, 1909— (1) Number of representations made with a view to the making of Closing Orders nil- (2) Number of dwelling-houses in respect of which Closing Orders were made nil 39 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit nil. (4) Number of dwelling-houses in respect of which Demolition Orders were made nil. (5) Number of dwelling-houses demolished in pursuance of Demolition Orders nil. D. Proceedings under Section 32 of the Housing, Totun Planning, etc. Act, 1919— Number of prosecutions taken for letting, attempting to let, occupying or permitting to occupy houses ordered to be closed nil. E. Other matters — (1) Number of dwelling-houses closed voluntarily 8 (2) Number of dwelling-houses demolished voluntarily 6 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 — (5) Staff engaged on housing work with, briefly, the duties of each officer. The outdoor staff of the Health Department consists normally of one Chief Inspector and three District Inspectors. 40 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. j No. of houses represented by M.O.H. Date of -5 representation. Date CloRing Order made Date Closing Order determined. Date Demolition Order made. Date Demolition Order obeyed. Date Demolition Order enforced. Br't forw'd from 1922— 1*l-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 Boad 11 12/5/19 22/7/19 ... ... ... ... † 1-10, Syon Place 10 „ ... ... ... ... †65-75, Han worth 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 ... ... ... ... 1 9/2/20 ... ... ... ... 5, ,, , ,, 1 9/2/20 28/7/20 ... ... ... ... 10, South Street 1 10/10'21 22/11/21 ... ... ... ... 2, Forman's (or Field's) Cotts., 1 10/7)22 ... ... ... ... North Hyde Lane, Heston . ... ... ... ... †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. 16/3/16 Demolition ordered in default of owner. 16/10/17 Notices served on new tenants of Nos. 1 & 3. 31/12/23 Nos. 1, 2 A 3 occupied. fClosing Orders not served. ; Demolition deferred until after the War. 42 Table II. Causes of Deaths during 19 23. Causes of Death. Civil Residents all ages. Male. Female. All causes 240 216 1 Enteric Fever ... ... 2 Small-pox ... ... 3 Measles ... ... 4 Scarlet Fever 1 5 Whooping Cough 2 1 6 Diphtheria 4 6 7 influenza 3 3 8 Encephalitis Lethargica ... ... 9 Meningococcal Meningitis ... ... 10 Tuberculosis of Respiratory System 20 15 11 Other Tuberculous Diseases 5 1 12 Cancer, Malignant Disease 24 24 13 Rheumatic Fever ... ... 14 Diabetes 2 2 15 Cerebral Haemorrhage, &c. 16 15 16 Heart Disease 34 47 17 Arterio-sclerosis 3 6 18 Bronchitis 24 11 19 Pneumonia (all forms) 18 9 20 Other Respiratory Diseases 3 3 21 Ulcer of Stomach or Duodenum 5 1 22 Diarrhoea, etc. (under 2 years) 3 4 23 Appendicitis and Typhlitis 2 ... 21 Cirrhosis of Liver 1 ... 25 Acute and Chronic Nephritis 3 4 26 Puerperal Sepsis ... 2 27 Other Accidents and Diseases of Pregnancy and Parturition ... 5 28 Congenital Debility and Malformation, Premature Birth 13 10 29 Suicide 1 ... 30 Other Deaths from Violence 10 7 31 Other Defined Diseases 44 38 32 Cautfes ill-defined or unknown ... 1 According to figures furnished by the Registrar-General. Table 11T. Infantile Mortality during the year 1923. Nett Deaths from stated Causes at various Ages under 1 Year of Age Cacse of Dkath. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks. 4 weeks and under 3 rats. 3 mts. and uuder 6m ts. 6 mts. and under 9 mts. 9 mts. and under 12 mts. Total Deaths under 1 vear. Certified 18 1 2 1 22 9 7 6 2 46 Smallpox Chickenpox Measles Scarlet Fever Whooping Cough Diphtheria and Croup Erysipelas Tuberculous Meningitis Abdominal Tuberculosis Other Tuberculous Diseases Meningitis (not Tuberculous) Convulsions 1 ... ... ... 1 1 1 ... 3 Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... 1 ... 1 Pneumonia (all forms) ... ... ... ... ... 1 2 1 ... 4 1 Diarrhoea ... 1 ... ... 1 ... ... 1 ... 2 | Enteritis ... ... ... 1 1 1 1 1 1 5 Gastritis ... ... ... ... ... 1 ... ... ... 1 Syphilis Rickets Suffocation, overlying Injury at Birth 4 – – – 4 – – – – 4 Atelectasis – – – – – – – – – – Congenital Malformations 1 – – – 1 1 2 – – 4 r Premature Birth 12 – – – 12 3 – – – 15 ^ Atrophy, Debility and Marasmus – – – – – 2 1 – – 3 Other Causes – – 2 – 2 ... – 1 1 4 18 1 2 1 22 9 7 6 2 46 Nett Births Legitimate Illegitimate 815 23 Nett Deaths Legitimate infants Illegitimate infants 41 5 table iv.—a. Infectious Diseases, 1923. 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. Anthrax. January 12 17 ... 3 1 ... ... ... 2 ... 3 ... ... ... ... February 7 14 ... 2 1 ... 1 ... 3 ... 8 ... ... ... ... March 5 ii 2 3 1 ... ... ... 14 ... 6 1 1 ... 1 April 8 7 ... 1 2 ... ... ... 9 ... 6 1 1 ... ... May 7 S ... 1 1 ... ... ... 9 ... 7 1 1 ... ... June 9 5 ... ... 5 ... ... ... 9 ... 6 ... ... ... ... July 5 6 1 ... ... ... ... 6 ... 6 ... 1 ... ... August 10 8 3 ... ... ... 1 5 ... 7 1 ... ... ... September 6 2 ... 2 ... ... ... 16 ... 2 3 ... ... ... October 11 3 ... 1 1 ... ... ... 11 ... 3 1 ... ... ... November 5 11 ... 1 1 ... ... ... 4 ... 1 ... ... ... ... December 7 14 ... 3 2 ... ... ... 11 ... 2 3 ... ... ... Totals 1 92 *106 6 17 15 ... 1 1 99 ... 57 11 4 ... †1 *i Military case. †MIL 44 45 Table IV.-B. Cases of Infectious Disease notified and Cases removed to Mogden Isolation Hospital during 1923. Disease. Notified. Admitted to Hospital. Deaths. Small-pox ... ... ... Enteric Fever 6 4 ... Scarlet Fever 92 84 1 Diphtheria 106 60 10 Erysipelas 15 ... ... Puerperal Fever 17 ... 2 Ophthalmia Neonatorum 4 ... ... Acute Poliomyelitis 1 ... ... Cerebro Spinal Fever ... ... ... Pneumonia 99 ... 27 Malaria ... ... ... Encephalitis Lethargica 1 ... ... Table IY.—C. Deaths from Notifiable Infectious Disa&es, 1923. Age Groups. Under 1 year. 1 year. 2 years. 3 years. 4 years. 5 years. 10 years. 15 yearn. 20 years. 85 years. 45 years. 65 years and over Scarlet Fever ... ... ... ... ... ... l ... ... ... ... ... Diphtheria ... ... 3 3 2 2 ... ... ... ... ... ... Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... 2 ... ... ... Encephalitis ... ... ... ... ... ... ... ... ... ... ... ... Lethergica Pneumonia 4 l 1 1 ... ... l ... 1 5 10 3 Cerebro Spinal Fever ... ... ... ... ... ... ... l ... ... ... ... Pulmonary Tuber. ... ... ... ... ... 1 l 4 10 12 7 ... Other Tuberculosis ... l ... ... ... ... l ... 3 ... 1 ... Report on the administration of the Factory and Workshop Act, 1901, IN CONNECTION WITH FACTORIES, WORKSHOPS, WORKPLACES AND HOMEWORK. Table V.—INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspections made by Sanitary Inspectors. Premises. Number of Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) Factories (including Factory Laundries) 65 Nil. Workshops (including Workshop Laundries) 149 3 Workplaces (other than Outworkers' premises included in Table VII 28 ... Total 242 3 Nil. Table VI.—DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions. Outstanding Jan. 1st. 1928. Found during 19-28. Remedied during 1923. Outstanding Dec. 31st, 1923. Referred to H.M. Inspector. 1 2 3 4 5 6 7 Nuisances under the Public Health Acts:Want of cleanliness 1 1 2 Want of ventilation Overcrowding Want of drainage of floors Other nuisances i I fSanitary accommodation— Insufficient I I 2 2 £ Unsuitable or defective 3 2 5 Not separate for sexes 2 1 I Offnett wider the Factory and Workshop Act : — Illegal occupation of underground bakehouse (s.101) Breach of special sanitary requirements for baikehouses (ss. 97-100) 4 3 5 2 Other offences (excluding offences relating to outwork which are included in Table VII Total 10 9 16 3 Nil. Nil. †Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by the District Council, and the standard of sufficiency and suitability of sanitary accommodation for persons employed in factories and workshops enforced is that required bv the Sanitary Accommodation Order of 4th February, 1903. Table VII.—HOMEWORK. NATURE OF WORK. OUTWORKERS' LISTS, SECTION 107. Outwork in unwholesome premises, Section 108. Outwork in infected premises, Sections 109, 110. Lists received from Employers. Notices served on Occupiers as to keeping or sending lists. Prosecutions. Instances. Notices Served. Prosecutions. Instances. Orders made (s. 110). Prosecutions (Sections 109, 110). Sending twice in the year. Sending once in the year. Failing to keep or permit inspection of lists. Failing to send lists. Lists. Outworkers. Lists. Outworkers. Controctors Workmen. Contractors Workmen. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Wearing Apparel— making, Ac. 1 ... 2 4 ... 7 ... ... ... ... ... ... ... ... ... cleaning & washing 1 1 ... 1 1 ... ... ... ... ... ... ... ... ... ... Furniture and upholstery 1 ... 2 ... ... ... ... ... ... ... ... ... ... ... ... Brush making ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... Total 3 1 4 5 1 7 ... ... ... 1 ... ... ... ... ... †A Closing Order has been made with respect to the premises occupied by this outworker. Number of outworkers on register, 31. Inspections made 28. Number of Lists received from other Sanitary Authorities twice in the year, 4 ; once in a year, 4. 49 Table VIII.—REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year. Number. (1) (2) 'Bakehouses—Workshops 16 Laundries (non-factory) 21 Workshops 214 Workplaces 36 Total number of workshops on Register 287 *In addition there are in the district 10 Factory Bakehouses. Table IX.—OTHER MATTERS. Class. Number. (1) ] 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 (8.5, 1901)— Notified by H.M. Inspector 4 Reports (of action taken) sent to H.M. Inspector Other 4 Underground Bakehouses (s. 101) .— In use at the end of the year i *Retail—Factory Bakehouse. 50 SANITARY WORK, ETC. Inspections—General : Total number of inspections and re-inspections, etc. (excluding shops and petroleum) 10797 Inspections, etc. re Nuisances, Contraventions, etc. : Number of premises, etc., inspected on complaint 505 Number of premises inspected in connection with infectious diseases 122 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920 4 Number of other visits made to premises, etc., in connection with nuisances, etc. 142 Total number of premises, etc., primarily inspected in connection with nuisaoces 857 Number of visits made to works in progress 836 Number of interviews with owners, builders, etc., re abatement of nuisances 544 Number of premises, etc , whereat nuisances were recorded during the year 740 Number of premises, etc., on which defects, etc., were remedied— (a) by owners 808 (b) by local authority in default of owner or occupier 24 Number of cautionary or intimation notices given— (a) verbal 71 (b) written 565 Number of second (informal) notices given 190 Number of letters re nuisances sent 300 Number of Statutory Notices issued Number of proceedings taken Number of convictions obtained — Number of proceedings withdrawn 2 Common Lodging Houses : Number registered 2 Number of inspections made 10 Number of contraventions remedied 1 51 Canal Boats used as Dwellings: Number of inspections made 55 Number of contraventions found 3 Movable Dwellings. Caravans, Tents, etc.: Number observed during the year 55 Number of inspections made 67 Number removed from district 50 Number of contraventions found 5 Number of contraventions remedied 5 Bakehouses: Number in district (a) factories 10 (b) workshops 16 Number of underground bakehouses in district 1 Number of inspections made 111 Number of contraventions found 3 Number cleansed 6 Slaughterhouses: Number on Register (a) registered premises 4 (b) licenced premises 4 Number of inspections made 245 Number of contraventions found 5 Number cleansed 3 Number re-constructed, repaired or improved 3 Cowsheds: Number of persons registered 10 Number of premises registered 11 Number of cowsheds on register 20 Number of milch cows in district 136 Number of inspections made 72 Dairies and Milkshops: Number of persons registered 46 Number of premises on register 34 Number of inspections made 197 52 Offensive Trades : Number of businesses established in district 16 Number of inspections made 264 Inspection of Food : Number of meat inspections 960 Number of fish inspections 519 Number of provision inspections 553 Number of greengrocery and fruit inspections 856 Number of hawkers foodstuff inspections 417 Numbers of other food inspections 31 Unsound Food : Number of carcases surrendered 1 Number of parcels surrendered 2 Number of organs or parts surrendered during slaughtering 5 Infectious Diseases, Disinfection, etc. : Number of visits made 423 Number of rooms disinfected (a) ordinary infectious diseases 197 (b) Tuberculosis 73 Number of rooms stripped and cleansed after infectious diseases— (a) by owners or occupiers 3 (b) by local authority 9 Number of articles disinfected or destroyed 1330 Water Supply : Number of supplies provided 1 Number of cisterns cleansed, repaired, covered, etc. 3 Number of draw taps connected direct to main 108 Number of water service pipes or taps repaired 31 Approximate percentage of houses supplied on constant system 9995 Number of samples taken for analysis from local wells 2 Drainage and Sanitary Arrangements, etc., of existing Buildings: Water Closets: Number of water closets provided or re-constructed 16 Number of privies abolished 1 53 Number of walls, etc., cleansed 34 Number repaired, supplied with water or otherwise improved 288 Number of apparatus cleansed or unstopped 23 Approximate percentage of houses provided with water closets 98 Sinks. Number of new sinks provided 22 Number of sinks repaired or improved 53 Drains : Number examined, exposed, etc. 1 Number unstopped, repaired, trapped, etc. 137 Number of waste pipes provided, dis-connected, repaired, trapped or un-stopped 38 Number of soil pipes fixed, repaired or improved 3 Number of ventilating shafts fixed, repaired or improved 19 Number of fresh air inlets provided, repaired or improved 29 Number of rain water pipes dis-connected from drain 39 Number of gully traps inserted or improved 37 Number of dis-connected traps inserted 2 Number of inspection chambers inserted 5 Number of dis-connecting traps improved, sealed or cleansed 1 Number of inspection chambers repaired, improved, sealed or cleansed 9 Number of drains constructed or re-constructed 20 Total length of drain pipes laid (4" = 419') (6" = 24') 443 ft. Number of tests and re-tests applied 27 Number of other works executed 47 Approximate percentage of houses draining into Council's sewer 98 Cesspools: Number rendered impervious, emptied, cleansed, etc. 2 Removal of Household Refuse : Number of new ashbins provided 246 54 Dampness : Number of roofs stripped, renewed or repaired 253 Number of gutters and rain water pipes provided, repaired or unstopped 284 Number of instances in which external brickwork, sills, etc. repaired, renewed or rendered impervious 328 Number of damp-proof courses provided 37 Number of sites covered with impervious material 6 Number of yards paved, repaired or drained 122 Interior Work : Number of rooms stripped, and cleansed (other than in connection with infectious disease) 462 Number of floors, walls and ceilings repaired or renewed 702 Number of rooms in which ventilation provided or improved 30 Number of rooms in which lighting provided or improved 3 Number of window frames and sashes provided, repaired or unfixed 454 Number of stoves or grates provided or repaired 144 Number of instances in which ventilation under floors provided or improved 55 Number of other repairs 63 Sundry Nuisances, etc.: Number of instances in which domestic cleansing enforced 11 Number of food stores provided, cleansed or improved 1 Number of washing coppers provided or repaired 83 Number of rooms sprayed for the removal of vermin by the disinfector 66 Number of instances in which overcrowding abated 23 Number of instances of improper keeping of animals abated 29 Number of offensive accumulations removed 13 Number of urinals provided, repaired, cleansed or improved 4 Number of dung pits provided, repaired or improved 1 Number of other nuisances abated 24 55 OTHER WORKS. Shops Acts: Number of shops on register 868 Number of inspections made 995 Number of contraventions found 63 Number of contraventions remedied 111 Number of warning notices sent 58 Petroleum Acts. 1871-1881 : Number of premises licensed 45 Number of inspections made 259 Number of stores dis-continued 2 Number of contraventions found 3 Number of contraventions remedied 9 Number of new stores provided 1 Number of warning notices given 3 HESTON and ISLEWORTH URBAN DISTRICT EDUCATION COMMITTEE. SIXTEENTH ANNUAL REPORT OF THE School Medical Officer FOR THE Year ending 31st December, 1923. 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, 1923. 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, 1923-24. II. J. NIAS, Esq., m.b.e., j.p. (Chairman). W. J. R. DIVINE, Esq. (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, E,q. D. BONNETT, Esq. A. E. HALES, Esq. F. W. BUCKLEY, Esq. A. L. LANG, Esq. W. D. COWELL, 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— B. W. Kilby, (Chief Clerk). A. G. Hubbard. Miss R. Marshall. E. Cromwell. J. Holmes. Health Visitors— Mrs. C. E. N. Ottley. Miss B. N. Tetley. Mrs. A. E. Tyrrell. Miss W. E. Scott. Miss J. D. Law. Dentist—I. Cohen, L.D.S., R.C.S. Eng. Radiographer—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 Louise 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. (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. The School Medical Service in relation to Public Elementary Schools. School Hygiene. The school buildings and the sanitary arrangements are periodically inspected. 6 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 1923, includes those children born during the years 1911, 1914 and 1917, 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. In 1922, 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. Whilst this arrangement undoubtedly provides better accommodation, it has not proved as advantageous as was hoped, owing to tbe difficulty experienced by the head teachers in being present at an Inspection held away from their own school. FINDINGS OF MEDICAL INSPECTION, 1923. Uncleanliness. Out of 2,042 children examined at routine medical inspection, 54 were excluded on account of nitty or verminons conditions, 7 whilst 130 were marked for observation. Apart from these cases other 377 were seen at the school clinics and were excluded, and 215 were kept under observation. Further reference to this subject will be found on page 31. Tonsils and Adenoids. Out of 2,012 children examined at the routine inspections, 57 had enlarged tonsils, 16 of which were referred for treatment, 41 being kept under observation. 40 children had adenoids only, of which 22 required treatment, and 18 were for observation, whilst 23 children bad both enlarged tonsils and adenoids, 12 requiring treatment, and 11 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 general improvement in the hygiene of the nose and mouth. At the special clinics 18 other children were found to have enlarged tonsils, 1 adenoids only, whilst 3 suffered from both conditions. Tuberculosis. Out of 2,012 children examined at the routine inspection there were 4 cases of suspected pulmonary tuberculosis requiring to be kept under observation. At the special clinics, 27 were found to be suffering from suspected pulmonary tuberculosis, whilst 2 children had tubercular glands. Skin. At the routine inspections, out of 2,042 children examined, 2 were found to be suffering from skin trouble. At the special clinics there were 509 children suffering from various skin complaints, including scabies and impetigo (see Table II- for analysis of figures), 27 cases of ringworm of scalp and 26 cases of ringworm of body. 8 External Eye Disease. Out of 2,042 children examined at the routine inspections, 14 were found to have minor eye diseases including blepharitis and conjunctivitis, whilst 1 had a squint. In addition 51 were found at the special clinics to suffer from the " minor " eye diseases, and 9 had squint. Vision. Out of 2,042 children examined at the routine inspections, 140 were found to have defective vision, 118 of which were referred for treatment, 22 being kept under observation. At the special clinics 43 children were referred for treatment for defective vision. Ear Disease and Hearing. Out of 2,042 children examined at the routine inspections, 36 were found to be suffering from defective hearing or ear disease, whilst an additional 116 were discovered at the special clinics. Dental Defects. Out of 2,042 children examined at the routine inspections, 763 had carious teeth and were referred for treatment, whilst 141 had slighter caries and were marked for observation. At the special clinics a further 104 were discovered and rtfei red for treatment. Dental inspections, 3,095 children were referred for treatment out of 3,835 inspected (for further particulars see Table IV. Group 4). Crippling Defects. Out of 2,042 children examined at the routine inspections, there were 5 found to be suffering from deformity, including 1 case of rickets and 4 other forms. 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. 9 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 1923, the following cases of infectious disease occurred among children attending public elementary schools in this district:— Scarlet Fever 44 Diphtheria 34 Measles 3 Rubella 5 Mumps 111 Chicken Pox 62 Whooping Cough 63 Total 322 Measles. This is the smallest number of cases in the last 10 years. The nearest to it being 4 cases in 1914. The incidence of infectious diseases generally, is much lower this year. The total number of cases being less than 1/3 of the number in 1922. 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 Cases of infectious disease have occurred during the year among school children as follows:— SCHOOL. SCARLET FEVER. DIPHTHERIA. MEASLES. GERMAN MEASLES. MUMPS. CHICKEN POX. j WHOOPING COUGH Alexandra Boys 3 1 ... 1 ... 21 5 „ Girls 3 1 ... ... 2 1 3 Brentford End Infants ... ... ... ... 1 3 Grove Road Boys 2 1 ... ... ... 1 1 „ „ Girls 3 1 1 ,, „ Infants ... ... ... ... 1 6 24 Heston Mixed ... 9 ... ... ... 2 ,, Infants ... 1 ... ... ... 2 1 Hounslow Heath Boys 3 ... ... ... ... 1 1 ,, ,, Girls ... 5 1 1 ,, ,, Infants ... 1 ... 1 ... 1 13 Hounslow R.C. Mixed 1 1 „ „ Infants Hounslow Town Boys 1 ,, ,, Girls 4 ... ... ... 1 1 ,, ,, Infants 1 ... ... ... ... 9 8 Isleworth Blue Boys 1 ... ... ... 1 1 ,, ,, Girls ... 2 ... ... 3 ... 1 „ ,, Infants 1 4 ... ... 3 1 1 Isleworth Town Boys 1 2 ... 1 1 „ ,, Girls 1 1 ... ... 3 St. Mary's Boys 1 ... ... ... 23 ,, Girls 1 ... ... ... 27 2 2 „ Infants 4 ... ... ... 40 ... 1 Spring Grove Boys 1 1 ,, ,, Girl 2 ... ... 1 ,, „ Infants 6 ... ... ... ... 1 1 Woodlands St. John's Infants ... ... ... ... 2 ... 1 Worple Road Mixed 1 1 ... ... 2 2 ,, „ Infants 3 2 1 ... 1 7 Total 44 34 3 5 111 62 63 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 1923. 178 attendances at School Inspection Clinics. 177 ,, ,, Dental Clinics. 22 ,, ,, Eye Clinics. 17 ,, ,, Ringworm Clinics. 372 „ „ Minor Ailments Clinics. 7 ,, ,, School Sports. 12 129 visits to schools for medical inspections. 28 „ ,, ,, ,, re-inspections. 68 „ „ „ dental inspections. 15 ,, ,, „ cleansing surveys. 1569 „ homes in connection with following-up. 667 „ ,, ,, „ ,, infectious diseases. 950 other visits (clinic absentees, dental visits, etc.) The following cases illustrate the necessity for persistent " following up," and the results that can only be obtained by so doing. Case 1. 1/5/19—the child was first noted as suffering from double otitis media. It should be mentioned that the mother is a hopeless person and the family neglected. Daily treatment was carried out at the Clinic. 29/5/19—she was recommended for hospital treatment and eventually on 25/7/19 she was attending Hounslow Hospital. 8/9/19—she was re-admitted to school, having been excluded on 1/5/19. She re-appeared at the Clinic, the note being, " To be allowed irregular attendance, is attending Hounslow Hospital." 27/5/20—Profuse discharge. Tonsillitis. Excluded. 3/6/20—Mother contemplates taking her to Richmond Hospital. 7/6/20—Re-admitted to school. Then ensued a spell of neglect to attend the Clinic for treatment and of visits by the Health Visitor to ensure attendance. 19/7/20—Not attending hospital. Then things were quiescent for a time. 12/5/21—R. ear discharging—commenced again. Daily treatment at Clinic. 20/6/21—Still discharging—very unsatisfactory as does not attend regularly and mother will not take child to hospital. 13 7/7/21—Has letter for hospital. 14/7/21—Attending hospital. 22/9/21—Attends hospital once a fortnight. 3/10/21—Both ears discharging now—attending Hounslow Hospital. Does not attend for daily treatment in interval of visiting hospitals. 27/10/21—R. still discharging. Pain over Mastoid, Post occipital glands enlarged. Temperature 99. Continue treatment. This brought about the following correspondence :— 29/10/21 — Letter to Secretary, — Hospital. "I saw this child at our Clinic, who stated that she had been told not to come to the hospital any more. She still has a discharging ear requiring treatment. She had when I saw her last, pain over the mastoid, with enlarged occipital glands with a temperature of 99, and was certainly a case, which in my opinion, should have been kept under observation. However, one is chary of taking the statement by children even at this age as accurate, but I thought it was a case which ought to be looked into, in view of the possibility of grave danger to the child." Letter from Secretary, — Hospital. " I have made enquiries re the above child and cannot find that she was told to leave off attending May I ask you to send her here any morning at 10 o'clock, when she will be attended to and perhaps she may be able to enlighten us as to who told her to cease her visits." After this she attended the Clinic regularly and things quietened down again. Her hearing meantime was getting worse. 14 22/11/21—Large dress hook rusted and encrusted removed from ear. 11/1/22—Discharge much worse—now polypus. In order to try the possibility of ionization, I managed to get the parent to tako the child to Dr. A, at the Metropolitan Ear, Nose and Throat Hospital, but no further visits were made. 9/2/22—Meatus almost entirely blocked by large polypus which appears to rise mainly from anterior wall. Discharge now offensive. The child was still being treated every day at the Clinic. 23/2/22—Arrangements made for the child to have operative treatment. 27/3/22—Septic throat. Nothing done so far. Excluded. 10/4/22—Tonsils still enlarged but cleaner. Ears still discharging. Very unsatisfactory case. Child much thinner, white and ill. If no operative treatment advised for ear, child requires prolonged convalescent treatment. 29/4/22—Letter to Dr. " A." " You will remember the girl I sent up to you, who has a large polypus in her ear, who you suggested dealing with. The condition is perfectly hopeless without some operative interference. Could you make arrangements to deal with the case at the hospital ?." 9/5/22—Letter from Secretary, Ear, Nose and Throat Hospital. " Dr. " A " has asked me to write to you with reference to the child who attended this hospital. It will cost two guineas for an operation. She will probably be in hospital 5 or 6 days. If however, they could get an in-patients letter, ' Hospital Saturday Fund ' or ' Subscribers letter,' they would not have to pay." 15 11/5/22—Letter to Secretary, Ear, Nose and Throat Hospital. " Many thanks for letter. I am afraid it is quite out of the question for the patient to pay for the charge made for the operation. If you could put me in touch with the means of getting a 'Subscribers' or 'Saturday Fund' letter, I should be extremely obliged." Nothing, however, came of these efforts and daily treatment at the Clinic was carried out. 15/6/22—Complains of pain over Mastoid—some tenderness. Temperature normal—referred to own doctor if continuing. 19/6/22—No further pain or tenderness over Mastoid. Very little discharge. 29/9/22—Having got the people to realise the importance of the condition, I again tried to get something done. Letter to Dr. " A." :— " You remember seeing this girl, who you said required an operation. If you could possibly arrange it, they are anxious that something should be done." This, however, was fruitless. 30/10/22—I wrote to another friend, who is one of the leading Ear Specialists in London. Letter to Mr. "B":— " I shall be glad if you could see a child who has been under observation here for three years with profuse otorrhoea. It seems to me that nothing short of a radical mastoid would be of the slightest use. I have at last managed to ginger them up with regard to getting something done, and if you think it wise, I could get her sent along. The mother in this case is a perfectly hopeless person, and I have had the greatest difficulty in getting anything done at all." 16 1/11/22—Letter to parent:— " Owing to the long continued trouble of your daughter's ear and the possibility of serious consequences, I have arranged with one of the leading specialists in London to see her with a view to the possibility of a cure. Will you take your daughter to Hospital on Monday next the 6th inst., and be there at half-past one without fail." 6/11/22—Letter from Mr. "B":— "I saw the girl you sent up this afternoon, and I agree with you, that she ought to have a radical mastoid operation. I have put her name on my list for admission to hospital and will send her a card as soon as I can arrange for a bed, probably in about three weeks time. Later I think she ought to have her tonsils removed as they are very large, but I shall leave them until after the mastoid has been done." 4/12/22—Complaining of pain over R. Mastoid. Has been up to Hospital and waiting admission. Temperature 98 6. 5/12/22—Little better. 7/12/22—Moie pain—an exacerbation of discharge. 9/12/22—Letter to Mr. " B " .— " This child who is waiting admission for operation, has been up the last three days complaining of considerable pain over the mastoid. There has been, however, no temperature on the occasions on which she was seen." " I thought I had better let your know in case you could possibly expedite her admission." 19/12/22—Operation. 17 6/1/23—Returned home. Attending for daily treatment at Clinic, also attending hospital. 9/1/23—Letter to Mr. " B " : — " This child turned up at the Clinic yesterday with a verbal message asking tho Nurse to treat her ear." " I shall be glad if you will let me have detailed instructions as to what you would like done and I will see that my Nurse carries them out." 8/2/23—Doing well—just a little discharge deep inside— heariug improved. 12/3/23—Attending hospital—she reports that the Doctor she saw said she should not be at school—nothing written sent. Still slight discharge. 13/3/23—Letter to Mr. "B" " This child whom you operated on turned up at the Clinic and said she had been told not to attend school. I shall be glad to know if this is so, because the home is a particularly bad one, and in view of the fact, that the child is under our daily care at the Clinic, it appeared to me much wiser that the child should be in school and under observation. However, if you think she ought to be out of school, and will let me know, she shall be excluded." 19/3/23—Discharge ceased. Child left school at the end of that term. The duties shown above are only extracts from pages of continuous note extending on the whole period. This girl latterly had been morose and sullen, out of touch with things by reason of her defective hearing and generally below par. Some months after, she brought a younger sister to the Clinic. 1 did not recognise her at first, she looked plump, well 18 and bright and her hearing immensely improved—a different being in every way. Had she left school before I was able to get her operated on, I doubt if it would ever have been done until serious symptoms affecting life arose. Many people will be inclined to say that the time and trouble taken over discharging ears was not warranted. Apart from the danger to life that the persistence of the condition is, no one who knew the child before and saw the happy result would grudge any of the energy absorbed on her behalf. Those who are not deaf do not realise its desolating effect. I still find it very difficult to make people realise that it is far worse to be quite deaf than blind. Let anyone think it over carefully. It is very rare to find a miserable blind person. It is very rare not to find a miserable deaf person. The deaf are almost always suspicious and querulous People will always talk to the blind, but they intensely dislike having to shout at those going deaf. Intimate conversation with the deaf is an impossibility. This case, although an extreme one, illustrates the beneficent value of this complete supervision of the school child's life that exists in our district. Case 2.—That of a girl about 12 with Jacksonian epilepsy of 5 years standing, getting steadily worse. She had been attending one hospital for three years as an out-patient and had been an in-patient for three months. There were in my opinion definite localizing symptoms. I was able to get her under the care of a celebrated Neurologist and she was afterwards operated on by one of the best brain surgeons in England. A calculus which was found pressing on her brain was removed, and from that date the child has been absolutely free from fits. My last note is " Splendid !! " 19 Case 3.—A boy, aged 9, suffering from symptoms that had been put down to biliousness which commenced in 1921. He had been attending one of the London Hospitals, but more recently had been attending one nearer home as an out-patient and later on was an inpatient. He was discharged on the 29th June, 1922, nothing organically wrong having been found. His attacks got worse and at last he was seen in one. I was able to get a personal friend, Professor "X" to see him. The three following letters best describe result. Letter to Professor "X":— " I wonder if you would see this boy whom I saw yesterday at ray Clinic. He is subject to periodical attacks of pain of a very acute character localized to a very small area in the left groin. Some time after the onset of the attack, vomiting commences and continues to the end of the attack. The attacks sometimes last all day and at the end, the boy is completely exhausted. During the last attack which he had about a fortnight ago, the pain was so severe, that the mother describes the boy as "tearing his hair out." There is no doubt about the genuiness of these attacks, as my Assistant has seen him just at the termination of one. When I saw him yesterday, the boy had a curious anxious expression, much as one sees in certain cases of severe asthma or angina pectoris. The cervical glands are slightly enlarged. There is a history of periodic flatulent distension, but no enlargement of the liver has been detected. I cannot find anything abnormal in the abdomen. The only thing that I could detect was that the reflexes of the lower extremeties are extremely poor. 20 The mother states that the boy used to get over these attacks perfectly well, but now he is not recovering in the same way, the period of exhaustion seems to be getting longer and longer. He has been under treatment at Hospital and also Hospital, without the slightest benefit. I am completely at a loss to understand the location of the pain, as I can detect no abnormality in anything in that region." Letter from Professor "X":— " I could not find anything at at all by physical examination, which would explain this boy's symptoms. He is coming up to see me again and I will take him in for observation, if his attacks continue. In the meantime, he is being X-rayed, to see if there is any evidence of calculus in the ureter." Letter from Professor "X":— "The X-ray of this boy shows a big oapacity in the neighbourhood of the pelvis of the left kidney. There is either a stone in the kidney or a calcified mesenteric gland; in either ease, I feel certain it is the cause of his pain. I am getting Professor "Y" to see him, with regard to its removal, and am very delighted at getting the diagnosis after all his various adventures." The boy was operated on and a large stone removed from the kidney. He is now quite free from pain, the Clinic note being "Child quite different. Anxious look quite gone. Eating well, sleeps well." 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 21 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 27 cases referred for treatment 16 were successfully treated by the application of X-rays at the X-ray Clinic, 11 refusing this form of treatment. Ringworm of Body.— 26 cases were successfully treated at the School Clinics. 369 children were treated at the School Clinics for other skin diseases, including 4 cases of Scabies and 235 cases of Impetigo. Ear Disease and Hearing. At the School Clinic 35 cases of Ear Disease or Defective Hearing were seen and treated. Ear Disease. The treatment of discharging ears, occupies a very large portion of the time of the Nurses at the Treatment Clinics. There is no more unsatisfactory class of case to deal with than these 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 suppuratiou within the brain cavity and death. The number given 35, does not by any means exhibit the total number of cases existing in the schools, as a large number with a small amount of 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, 22 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. See page 12 for report of individual case. Eye Disease. 23 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 58 children referred for treatment, 11 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 accotdance with the following scale:— 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 23 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. 129 cases of Visual Defect were submitted for Refraction at the School Eye Clinic, whilst 20 children were treated privately or at hospitals. In 123 cases spectacles were prescribed and provided. Dental Defects. 819 children were treated by the School Dentist under the Local Education Authority's Scheme and 714 re-treated. Further 107 attended the Dental Clinic and were referred elsewhere for treatment, e.g., hospital and '21 attended the Clinic but refused treatment. It will be seen that 107 cases of dental defects were referred to Dental Hospital for treatment. These are almost all cases requiring orthodontic treatment. The percentage of these cases that get treated is very small, for which there are two chief reasons. 1. It is difficult in the present dentally ignorant state of the population to make many parents understand that there is need for such treatment. Even the gravely disfiguring deformity of a bad superior protrusion is often ignored, if the parent suffered from a similar condition. The argument being that what was good enough for the parent is good enough for the child. 2. Expense. Orthondontic work requires frequent visits for adjustment and supervision. The Chief Medical Officer of the Board recommends that this work should be done at a Dental Hospital. Except in rare cases in this district, this is out of the question, the rare cases being almost all the children of men working on the railways, who get special passes. What does a days' journey to a London Hospital mean? (a). Railway fares for two, mother and child, varying from 2/3 to 3/-. 24 (b). Often the expense of some food. (c). Often the carrying of a toddler or baby who cannot be left at home. (d). The loss of a mornings' or days' work, when the mother is working, and finally a thoroughly exhausting day. It is no good expecting anything much to be done—it cannot be—in the present state of unemployment, it is out of the question. If orthodontic work is to be effectually carried out, it must be done by the School Dentist acting on the advice of the consulting Orthodontist at the Dental Hospital, who could prescribe the necessary treatment in the way of extractions and/or appliances. This then could be carried out by the local School Dentist. 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 could attend such a school, with benefit from the point of view of education and also from the point 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 the district. Whatever is done is on the 25 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, and there is no machinery for enabling delicate school children to obtain milk and cod liver oil either free or at moderate prices. Such a scheme would greatly benefit many children and would not entail much organisation or expense. It is mainly a question of co-operative buying and the friendly help of the teachers. SCHOOL BATHS. No school 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 may also attend Dental Inspections. During 1923, one or other parent attended in 1197 instances, representing a percentage of 58.6 as against 61.2 for 1922. Where defects are found the children are followed-up as already described. CO-OPERATION OF TEACHERS. Review of the work undertaken by Teachers in facilitating the work of (1) Medical Inspection, (2) Following-up and (3) Medical Treatment of the children. Teachers now recognise the part school medical inspection plays, and grant all the necessary facilities for the work. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. In this district there are three Attendance Officers, and they have entre to the Health Department where they can ascertain the health status and fitness for school of any particular child. The function of these Officers is to maintain attendances, consequently they take no part in aiding the work of medical 26 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. Periodical returns are made by the teachers of children judged to be abnormal. Arrangements are then made for a special medical examination, and based upon this, a report is made. During 1923, examinations were conducted in respect of 7241 children. There are no special schools in this district for the defective. In 1922, 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. During the year, psychotherapeutic treatment has been successfully given to children with phobias and " nervous conditions. It is impossible to exaggerate the importance of a right understanding of these cases. Their whole outlook on life can be altered if properly treated, in some cases the principal factor to overcome is the mother, as she will constantly "suggest" to the child that 27 it is nervous, by talking of it to other people in the child's presence, until the unfortunate child becomes obsessed with the idea that it cannot be normal. If only we could get new mothers for some of these cases, how different their outlook on life would be. One very instructive case was a girl aged 10, who had been out of school some months. The history was given, that she was completely upset by the death of a sister in an Institution abutting on to their garden. When I first saw the child she was extremely nervous, screamed in terror every night when taken upstairs to bed, and continued to scream unless her mother stayed with her until she fell asleep. She would not go upstairs alone during the daytime, nor would she go out to the w c. at night. Her condition was such, that the family doctor had told the parents that there was nothing else for them to do, but to sell their house and get right away from the associations connected with the sister's death. Ten months after the sister's death, both mother and the patient were in deep mourning. The patient was off her food hut nutrition was quite good. Investigation showed that the phobia of the dark had nothing whatever to do with the sister's death. It was found to be due to having been terrified by tome story (? historical) told at school, wherein a little girl was taken away by robbers. This incident has become an obsession with the child, forming the foundation of the phobia. The first psychotherapeutic interview was entirely satisfactory. Arrangements were made to transfer her to another school, also I advised the mother to take her out of mourning and to remove the numerous photographs of the dead sister. At the next session, a week later, the child was very much better, my note being—"for last three nights no screaming, will now go up to bedroom with torch in the dark by herself, and by herself in the daytime." In fact, so much had she improved, that she asked to remain at her old school, which was done at once. A week later the child was quite free from terrors—no screaming, 28 only escorted to bed and left, not getting to sleep for some time after going to bed. 3 weeks later my note was—quite alright now, sleeps well at night. Shortly after this she was taken to the Isolation Hospital with Scarlet Fever, and was quite well till she came home again into the mother's influence, but soon pulled up again after two interviews. Problem cases and difficult children give rise to considerable anxiety as to what is the best thing to do. One case for example, a particularly beautiful child who could do nothing at school. Her mental examination revealed almost complete absence of memory, she would, for instance, when told to undress and get into bed, take off her knicker bockers and get, into bed with everything else on. She appeared to be a borderline case. Later examinations revealed evidence' of storage of memories which the parents were quite unable to obtain. I was fortunately able to get her into a London Hospital for observation, under the care of a Physican who makes a special study of this class of case. The Physicians' report was "she seems particularly alert and bright, as well advanced intellectually as other children of her age. On the other hand she is shy and peculiar in several respects, but all this I should attribute to neurotic trouble. The mother and to a less extent the father, seem to be provocative causes here." At her first examination, I found her about years retarded. On going into the history in the light of the parental effect, I found that the elder sister was in an Institution for Mental Defectives, and that the father, with this constantly in mind, had been extra strict with this child, and his efforts had to a large extent been backed up by the mother. Unavailing efforts were made to get the child away from the parents for a time. Home conditions are altered as the result of the parental understanding of the situation with a corresponding improvement in the child. In the case of a boy from an excellent home who is heading direct for Borstal, the same Physician reports:— 29 "I think the fact is that he has been very badly mishandled and his present temperamental peculiarities are the result of this. In this case, I can do nothing as I cannot influence the parents. 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 or 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. 45 children were examined and all were granted the necessary certificates of 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 obtained. These represent the limits of the services rendered by 30 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 3 medical examinations were made of teachers, in connection with their appointment under the Authority. Holiday Home for Children. All children recommended for the King Edward VII. Memorial Home, Herne Bay, are medically examined before being sent away. Juvenile Employment. * 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. 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. 31 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 15 occasions for the purpose of conducting Cleanliness Survey. At these inspections there were examined 1,880 children, of whom 180 were found to be unclean. Of the latter number 18 were excluded and the remainding 162 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. During March of this year, this period of exclusion was shortened to 7 days, by resolution of the Education Committee. The arrangements for dealing with uncleanliness wore also modified, whereby no child is now excluded immediately except when vermin is found. In nitty cases a warning is sent to the parents, and two 32 clear days allowed to remedy the condition—failure to do so is then followed by exclusion, with prosecution after 7 days. This has proved more satisfactory than the old scheme, and there has been a reduced loss of school attendance in consequence; whereas in 1922, out of 823 children found to be unclean at Routine Medical Inspections or Clinics, 679 were excluded, and only 144 (very slight cases) marked for observation, in 1923 out of 776 cases of uncleanliness, only 209 excluded in 1924 431 were excluded in 1924. had a warning notice given. Mrs. Yates, the Home Help, still continues the work of cleansing heads begun last year, the conditions remaining the same, viz.:—the Council supplies the Sackers Combs and Shampoo and Mrs. Yates charges 1/- per case for cleansing. Attendance for cleansing is entirely voluntary, but parents as a rule are glad to avail themselves of the opportunity so as to avoid having the child excluded from school. During the year, 168 children have been cleansed. No cleansing has been carried out by the school nurses. During the year 1923, legal proceedings were instituted against the parents of 7 children (one twice). In four instances the summonses were withdrawn, and in the remainder fines were imposed as follows : 2 of 10/-; 1 of 5/- and 1 of 4/- (costs). There has been considerable improvement in the condition of the children's heads—not only in point of numbers, but also in the degree of uncleanliness. A really filthy head with the hair smothered in nits is now an exception, and it is gradually becoming understood that nits are not natural to childhood, but are the evidence of parasites which are harmful to the child's health and well being. LIST OF TABLES. 1. Return of Medical Inspection. 2. Return of Defects found in the course of Medical Inspection. 3. Numerical Return of Exceptional Children. 4. Treatment of Defects of Children— A. Minor Ailments. B. Visual Defects. C. Defects of Nose and Throat. D. Dental Defects. 33 TABLE I.—RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants 548 Intermediates 775 Leavers 719 Total 2042 Number of other Routine Inspections nil. B.—Other Inspections. Number of Special Inspections 2109 Number of Re-Inspections 2139 Total 4248 34 Table II. A. RETURN OF DEFECTS found by Medical Inspection in the year ended 31st December, 1923. Defects or Diseases. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under obr-ervation. but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. 1 2 3 4 5 Malnutrition ... 6 3 6 Uncleanliness 54 130 377 215 Skin- Ringworm— Scalp ... ... 27 ... Body ... ... 26 ... Scabies ... ... 4 ... Impetigo 1 ... 234 ... Other Diseases (non- tuberculous) 1 ... 129 69 Eye- Blepharitis 3 3 5 16 Conjunctivitis ... ... 9 6 Keratitis ... ... 1 ... Corneal Opacities ... ... ... ... Detective Vision (excluding squint) 118 22 43 ... Squint ... 1 ... 9 Other Conditions 5 3 2 13 Ear— Defective Hearing 1 22 ... 24 Otitis Media ... ... 10 18 Other Ear Diseases 10 3 14 50 Nose and Throat— Enlarged Tonsils only 16 41 8 10 Adenoids only 22 18 ... 1 Enlarged Tonsils & Adenoids 12 11 ... 3 Other Conditions 14 46 38 27 Enlarged Cervical Glands (non-tuberculous) 2 3 14 8 Defective Speech ... ... ... 1 35 Table II—Continued. Routine Inspections. Special Inspections. Defects or Diseases. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be keptiunder observation, but not requiring treatment. 1 2 3 4 5 Teeth—Dental Diseases 763 111 104 ... Heart and Circulation— Heart Disease— Organic ... 5 3 34 Functional ... ... ... ... Anaemia ... 34 5 15 Lungs— Bronchitis ... 2 21 7 Other Non-Tuberculous Diseases ... 4 12 27 Tuberculosis— Pulmonary — Definite ... ... ... 2 Suspected ... 4 10 17 Non-Pulmonary— Glands ... ... ... 2 Spine ... ... ... 1 Hip ... ... ... ... Other Bones and Joints ... ... ... ... Skin ... ... ... ... Other Forms ... ... ... 1 Nervous System- Epilepsy ... ... 2 3 Chorea ... ... 10 12 Other Conditions ... ... 3 8 Deformities— Rickets ... 1 ... 1 Spinal Curvature ... ... ... 2 Other Forms ... 4 2 14 Other Defects and Diseases 3 26 98 156 36 B.—Number of individual children found at Routine Medical Inspection to require treatment. Group. Number of Children. Percentage of children found to require treatment. Inspected. Found to require treatment. 1 2 3 4 Code Groups- Entrants 548 868 ... Intermediates 775 ... Leavers 719 ... Total (Code Groups) 2042 868 42.5 Other Routine Inspections ... ... ... 31 TABLE III.—RETURN of all Exceptional Children in the area. Boys. Girls. Total. Blind (including partially blind). (i.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind ... ... 1 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind ... ... ... Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 5 5 Deaf (including deaf and dumb and partially deaf). (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. . Attending Certified Schools or Classes for the Deaf 3 1 4 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 2 ... 2 (ii.) Suitable for training in a School or Class for the partially deaf. Attending Certified Schools or Classes for the Deaf ... ... ... Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Mentally Defective Feebleminded (cases not notifiable to the Local Control Authority. Attending Certified Schools for Mentally Defective Children 3 2 5 Attending Public Elementary Schools 10 7 17 At other Institutions 2 ... 2 At no School or Institution 2 2 4 Notified to the Local Control Authority during the year. Feebleminded ... ... ... Imbeciles ... ... ... Iiots 1 ... 1 Epileptics. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 1 1 2 In Institutions other than Certified Special Schools ... ... ... Attending Public Elementary Schools ... ... ... At no School or Institution ... ... ... Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 1 3 4 At no School or Institution ... ... ... 38 Table III.—Continued. Boys. Girls. Total. Infectious Pulmonary and Glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 1 2 At other Institutions ... ... ... At no School or Institution 1 ... 1 Non-infectious but active Pulmonary and Glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 2 1 3 At Certified Residential OpenAir Schools ... ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools 1 ... 1 At other Institutions ... ... At no School or Institution 1 1 2 Physically Defective. Delicate children, (e.g. pre- or latent Tuberculosis, Malnutrition, Debility, Anaemia, etc.) At Certified Residential OpenAir Schools .. ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools 36 37 73 At other Institutions ... ... ... At no School or Institution ... 1 1 Active nonPulmonary Tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 1 1 2 At Public Elementary Schools 2 1 3 At other Institutions ... ... ... At no School or Institution 1 ... 1 Crippled Children (other than those with active Tuberculous disease), p.g. children suffering from paralysis, &c., and including those with severe Heart Disease At Certified Hospital Schools ... ... ... At Certified Residential Cripple Schools ... 1 1 At Certified Day Cripple Schools ... ... ... At Public Elementary Schools 5 2 7 At other Institutions ... ... ... At no School or Institution 3 1 4 39 TABLE IV. Return of Defects treated during the year ended 31st December, 1923. TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness, for which see Group V. Number of Defects treated, or under treatment during the year. Diseases or Defects. Under the Authority's Scheme. Otherwise. Total. 1 2 3 4 Skin— Ringworm, Scalp 16 11 27 Ringworm, Body 26 26 Scabies 4 ... 4 Impetigo 235 ... 235 Other Skin Diseases 77 ... 77 Minor Eye Defects— (External and other, but excluding cases falling in Group II.) 23 1 24 Minor Ear Defects 35 ... 35 Miscellaneous— (eg. minor injuries, bruises, sores, chilblains, etc.) 53 ... 53 Total 469 12 481 40 TABLE IV.—Continued. Group II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group 1. Number of defects dealt with. Defect or Disease. Under the Authority's Scheme. Submitted to refraction by private practitioner or at hospital apart from the Authority's Scheme. Otherwise. Total. 1. 2. 3. 4 5. Errors of Refraction (including squint) (Operations for squint should be recorded separately in the body of the Report). 129 20 ... 149 Other Defect or Disease of the eye (excluding those recorded in Group 1.) ... ... 3 3 Total 129 20 3 152 Total number of children for whom spectacles were prescribed- (a) Under the Authority's Scheme 108 (b) Otherwise 90 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme 103 (b) Otherwise 20 41 TABLE IV.—Continued. Group III.—Treatment of Defects of Nose and Throat. Number of defects. Received Operative Treatment Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. Received other forms of Treatment. Total number treated. (1) (2) (3) (4) (5) 9 11 20 2 22 42 TABLE IV.—Continued. Group IV. —DENTAL DEFECTS. (1). Number of children who were— (a) Inspected by the Dentist: Aged. Routine age groups 5 278 Total 3443. 6 427 7 481 8 559 9 538 10 533 11 372 12 213 13 40 14 2 Specials 392 Grand total 3835 (b) Found to require treatment 3095 (c) Actually treated 819 (d) Re-treated during the year as the result of periodical examination 714 (2). Half-days devoted to Inspection 58 Total 202 Treatment 144 (3). Attendances made by children for treatment 1208. (4). Fillings Permanent teeth 966 Total 1001. Temporary teeth 35 (5). Extractions Permanent teeth 95 Total 2211. Temporary teeth 2116 (6). Administrations of general anaesthetics for extractions 582. (7). Other operations Permanent teeth Total 120. Temporary teeth 43 TABLE IV.—Continued. Group V.-UNCLEAN LINESS AND VERMINOUS CONDITIONS. (i.) Average number of visits per school made during the year by the School Nurses 115 (ii.) Total number of examinations of children in the schools by School Nurses 1880 (iii.) Number of individual children found unclean 180 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 168 (v.) Number of cases in which legal proceedings were taken— (a) Under the Education Act, 1921 — (b) Under School Attendance Bye-laws 8