HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL HESl3 1926 ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE URBAN DISTRICT OF HESTON AND ISLEWORTH FOR THE Year ending 31st December, 1926. 1927. ???. LOWE & SON, Printers, Whiiton Road, Hoonslow. 73684 1926 REPORT ON The Health OF THE HESTON & ISLEWORTH URBAN DISTRICT FOR THE YEAR 1926. BY ELWIN H. T. NASH, M.R.C.S.. L.R.C.P., D.P.H. Medical Officer of Health. Public Health Department, Council House, Hounslow. June, 1927. To the Chairman and Members of the Heston and Isleworth Urban District Council. Gentlemen, The Annual Report this year is designated by the Ministry as an ordinary report of a more simple character than the full survey report which was required last year. * I beg to express my appreciation to the Council for the consideration shewn to me during the past twelve months. I am, 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 1926—27. Members of the Council: A. E. Hai.es, Esq. (Chairman). G. Newell, Esq. (Vice-Chairman) S. Cakter, Esq. j.p. ex-officio (Chairman of the Council). A. L. Lang, Esq. ex-officio (Vice-Chairman of the Council). H. Collar, Esq. C. J. Geary, Esq. J. J. Clements, Esq. F. T Hart, Esq. C. Crush, Esq. j.p. E. W. Heath, Esq. A. Dennis, Esq. H. F. Metcalfe, Esq. m.b e. C. M. Robinson, Esq. Medical Officer of Health:— Elwin H. T. Nash, d.p.h. MATERNITY AND CHILD WELFARE COMMITTEE. Members of the Council: .F. W. Buckley, Esq. {Chairman). J. J. Bonnett, Esq. o.u.e. J. J. Clements, Esq. A. E Hales, Esq. E. W. Heath, Esq. C. M. Robinson, 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, 1926 :— Medical Officer of Health— Elwin H. T. Nash, M.R.C.S., L.R.C.P., D.P.Ii. 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. Ashworth, Cert, as S.I., and M.I. E. W. Barton, Cert, as S.I., and M.I. One vacancy. Disinfector and Laboratory Attendant— J. H. Cobb. Health Visitors and School Nurses—- Mrs. C. E. M. Ottley, Cert. C.M.B., II.V. and S.N., M.C.W.W. Miss B. N. Tetley, S.R.N., Cert. C.M.B. Mrs. A. E. Tyrrell, Cert. C.M.B., H.Y. and S.N. Miss W. E. Scott, S.R.N., Cert. C.M.B. H.V. S,N.. M.C.W.W. Miss B. G. Sorlie, S.R.N., Cert. C.M.B., Cert. R.S.I. Home Help— Mrs. E. Yates. Chief Clerk— B. W. Kilby, Cert. S.I.E.B. and R.S.I. (M.I.) Clerks— A. G. Hubbard. Miss R. Marshall, Cert. R.S.I. E. Cromwell. J. Holmes. 7 NATURAL AND SOCIAL CONDITIONS OF THE AREA. 8 EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1926. * Population—- At the Census, 1921 46,664 Registrar-General's Estimate of nett 52,110 (Birthrate) Civil population 51,240 (Death rate) Births— Male. Female. Total. Legitimate 432 436 868 Illegitimate 16 22 38 Birth rate (nett) 17.38 Deaths— Male. Female. Total. 259 241 500 Death rate (corrected) 9.08 Number of women dying in, or in consequence of, childbirth from sepsis 1 from other causes 1 Deaths of infants under one year of age per 1,000 births- Legitimate 53 Illegitimate 131.6 Infantile Mortality Rate 56.29 Deaths from Measles (all ages) 10 „ „ Whooping Cough (all ages) 2 „ „ Diarrhoea (under 2 years of age) 5 Area 6,851 acres. Number of inhabited houses (Census 1921) 8,790 „ of families or separate occupiers (1921) 9,893 Rateable value £310,230 Sum represented by a penny rate £1,186 Poor Law Relief. I am indebted to Mr. F. E. Harmsworth, Cerk 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 1'925—1.926 :— 1925. 1926. Parish of Heston 1996 6 3 1611 18 8 Parish of Islewofth 4759 11 6¾ 4280 0 11 £6755 17 93 5891 1.9 7 9 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 the hospitals outside the district, as for example, the Royal Hospital, Richmond, the West London Hospital, Hammersmith, and other General Hospitals within the Metropolitan area. Poor Law Medical Relief.—The Relieving Officers issued COS medical orders during 1926. Some of these cases received also outrelief and institutional treatment. The Hounslow Hospital is the only voluntary Hospital within the district; it is a modern and well equipped institution with 54 beds. Its sphere of uselfulness has been extended by the provision of a children's ward. During the year 1926, there were admitted 718 in-patients, whilst 2,795 new out patients received treatment. Medical relief is also given by certain voluntary organisations in the district, namely The Isleworth District Nursing Association. The Osterley, North Hounslow and Heston Nursing Association. Curative Agencies directly or inderectly under the control of the Council will be referred to under their appropriate headings. They include :— Maternity and Child Welfare Clinics (two centres). School Clinics (inspection and treatment of school children). Hospital provision at Mogden and Dockwell for infectious diseases. VITAL STATISTICS. Population. The Registrar-General's estimate for the population for 1926 is (Birth rate) 52,110—(Death rate) 51,240, despite the fact that our building activities for the last three years particularly have been 10 very large, the extent of which may be demonstrated by the fact that the amount of the loans under the Housing and Small Dwellings Acquisition Acts at the end of 1926 amounted to £966,934. This estimate has a detrimental effect on all the vital statistics, in that they appear larger than they really should be owing to being based on a smaller population. This however cannot be avoided in intercensal periods as the figures throughout the Country must lie taken on a uniform basis, and the fact that our housing activities are producing a large influx of population, does not appear in the figures supplied to us by the Registrar-General which are based on a definite mathematical basis used uniformly. The death-rate population excludes all non-civilian males whether serving at home or abroad; whilst the birth-rate (aivl marriage-rate) population includes all the elements of the population contributing to the birth and marriage rates and may he represented by : — Death-rate population plus the district's proportional share of all non-civilians enlisted from this country. Deaths. The number of deaths registered in the district was 1,090, but 651 of these did not belong to the district, while 61 residents die.J without the district Thus the number of deaths properly attribut able to the district was 500. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 9.75 per 1,000, which is comparable with the following figures :— 1.1.6 for England and 11.6 for London. The death-rate corrected by Ihe Registrar-General's factor of .931 is 9.08. Births. The total number of births registered during the year was 101.0, but 158 of these did not belong to this district, while 51 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the dis- 11 triot is 906. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 17.38 per 1,000. The birth-rate of England and Wales was 17.8 per 1,000, and for London 17.1 per 1,000. Legitimacy. The following figures give the number of births : — Legitimate. Male. Female. Total. 432 436 868 Illegitimate. Male. Female. Total. 16 22 38 Table of Causes of Deaths during 1926. Causes of Death. Civil Resident— all ages. Male. Female All causes 259 241 1 Enteric Fever 2 Small-pox 3 Measles 6 4 4 Scarlet Fever 5 Whooping Cough 1 1 6 Diphtheria 2 1 7 Influenza 4 4 8 Encephalitis Lethargica 1 3 9 Meningococcal Meningitis 3 10 Tuberculosis of Respiratory System 20 17 11 Other Tuberculous Diseases 6 1 12 Cancer, Malignant Disease 38 33 13 Rheumatic Fever 1 ] 4 Diabetes 5 15 Cerebral Haemorrhage, Ac. 12 14 16 Heart Disease 31 40 17 Arterio-sclerosis 11 7 18 Bronchitis 10 15 19 Pneumonia (all forms) 16 16 20 Other Respiratory Diseases 2 2 21 Ulcer of Stomach or Duodenum 2 22 Diarrhoea, etc. (under 2 years) 4 1 23 Appendicitis and Typhlitis 5 1 21 Cirrhosis of Liver 25 Acute and Chronic Nephritis 4 11 26 Puerperal Sepsis 1 27 Other Accidents and Diseases of Pregnancy and Parturition 1 28 Congenital Debility and Malformation, Premature Birth 17 6 29 Suicide 7 2 30 Other Deaths from Violence 11 7 31 Other Defined Diseases 46 47 32 Causes ill-defined or unknown According to figures furnished by the Registrar-General. Infantile Mortality during the year 1926. Deaths from stated Causes at various Ages under I Year of Age. Cause of Death. Under 1 week 1-2 weeks j 2-3 weeks 3-4 weeks Total under 4 - weeks. 4 weeks and under 3 mts. 3 mts. and under 6mts. 6 mts. and under 9 mts. 9 mts. and under 12 mts. Total Deaths under 1 vear. Certified 14 3 6 ... 23 5 7 9 7 51 mallpox hickenpox leasles ... ... ... ... ... ... 1 1 1 3 oarlet Fever Hooping Cough ... ... ... ... ... ... 2 ... ... 2 iphtheria and Croup Crypspelas uberculous Meningitis dominal Tuberculosis ... ... ... ... ... ... ... 1 ... 1 ther Tuberculous Diseases Meningitis (not Tuberculous) ... ... ... ... ... ... ... 1 1 2 convulsions aryngitis ronnchitis ... ... 1 ... 1 ... ... ... ... 1 neumouia (all forms) ... ... ... ... ... 1 1 2 4 8 iarrhcea ... ... ... ... ... ... ... 1 ... 1 cnte ritis ... ... ... ... ... ... 2 2 ... 4 Btritis ... ... ... ... ... ... ... 1 ... 1 Syphilis ... 1 ... ... 1 ... ... ... ... 1 liqkets Suffocation, overlying njLry at Birth 3 ... ... ... 3 ... ... ... ... 3 atelectasis congenital Malformations 1 1 2 ... 4 1 ... ... ... 5 premature Birth 7 ... 1 ... 8 2 ... ... ... 10 tophy, Debility and Marasmus 2 1 1 ... 4 1 ... ... 1 6 Her Causes 1 ... 1 ... 2 ... 1 ... 3 14 3 6 ... 23 5 7 9 7 5 Nett Births Legitimate 868 Nett Deaths Legitimate infants 46 Illegitimate 38 Illegitimate infants 5 14 Infant Mortality. The figure obtained under this heading is regarded as a vali able index of the sanitary conditions of a district. Furthermori as it is based on ascertained facts (i.e., the actual numbers of birt! and infant deaths), it is more reliable than the death-rate which caculated on an estimated population. The rate for 1926 is 56.29 per 1,000 births. The rates fo England and Wales and for London during the same period we 70 and 64 respectively. PHYSICAL FEATURES OF THE DISTRICT. The Urban District comprises an irregularly rectangul: district of approximately eleven square miles, the average elevatio lying between 16 and 104 above ordnance datum, the higher pa being Os'terley and Heston, and the lower part along the margi of the river from Brentford to the boundary at Twickenham. Tli Western end is also low lying and the water level comparativel near the surface, this part of the district being bounded by th River Crane. The greater part of the district is on valley gravt with pockets of clay at the Western end. The district is bounde on the Eastern side by the River Thames, the Grand Junctio Canal and the River Brent, and crossed from West to South E& by the River Crane. The district is roughly divided into two by the main Bat Road which intersects it from East to West. Large tracts of th district are occupied by market gardens, which are being rapidl cut into by new housing schemes. There are two large park: one surrounding the residence of the Earl of Jersey at Osterlp Park, and one at Syon House, the property of the Duke of North umberland. The greater part of the rest of the district is largely a dormi tory for workers in London. The industries are few, the chief being : — (1.) Beer etc., brewing. (2) Boat buiding and repairing. 15 (3) Colours and dyes. (4) Flour etc., milling. (5) Gravel quarrying. (6) Market gardening. (7) Patent Animal foods. (8) Pewter ware and candle machinery. (9) Pharmaceutical Chemistry. (10) Soaps and perfumes. (11) Sweets, Confectionery. The district is now rapidly developing in nearly all directions, the great majority of houses that are going up being of the working class type, valued round about £600. Great use is being made of the Small Dwellings Acquisition Act, and the Housing Act, particularly the former. The large buildings of the Brentford Board of Guardians are situate at the Eastern end, and receive inmates from the constituent parishes of : — Acton, Chiswick, Ealing, Greenford, Hanwell, Heston, New Brentford, Old Brentford, Isleworth, Perryvale, Twickenham and West Twyford. Taken on the whole the district may be said to be eomparatively flat from end to end. 17 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. 18 HOSPITALS. Hospitals provided or subsidised by the Local Authority or ??? the County Council:— 1. Tuberculosis.— The County Council have an institi??? tion; The Bell Road Hospital, with 16 (9 male and 7 female??? beds. 2. Maternity.— There is no definite provision in tl??? district other than the West Middlesex Hospital (Guardian??? for maternity cases apart from private nursing homes chargin??? considerable fees. There are a few beds in the Hounslo??? Hospital and cases can also be dealt with at the West Middli??? sex Hospital, but the great majority of the cases which con??? under the notice of the Public Health Department are ded??? with by the large London Hospitals. 3. The Hospitals in the district are the West Middlese??? •Hospital which is the Poor Law Infirmary. The Hounsloi??? Hospital with 54 beds, is entirely supported by voluntar??? contributions. A Children's Ward of 8 cots with a solariur??? has also been provided. The Mogden and Dockwell Hospital??? for Infectious diseases and Small Pox are supported from th??? rates by the Councils of Heston and Isleworth and Richmond There is practically no difficulty in getting cases into the We??? Middlesex Hospital, but there is no out-patient department. The Hounslow Hospital has a staff of consultants, but then??? appears to be a feeling for preference for the larger Hospitals wit??? national reputation such as Gt. Ormond Street, Queen's Squarr??? Brompton, Chelsea Hospital for Women and the larger hospital;??? The difficulty in connection with this however, is that it entails I??? considerable expense, which many of the parents can ill afford an??? in other cases where specialised treatment is wanted, there is oftci??? considerable difficulty in obtaining the necessary letters demands??? by the Hospital. 19 There is considerable difficulty in getting children out-patient or ??? tcatment in the district. The medical practitioners of the district on the staff of the Hospital take a month on duty in rotation to see out patient eases. As can well be imagined this is a thoroughly ??? nsatisfactory system in that the doctor coming on duty has the ???remains of one, two, three or more doctor's leavings to carry on with, cases which he has not seen from the beginning when they ???were of some interest compared with what they are when he sees ??? them. In the same way his leavings are handed on to his succes???sor, and as they admit, this system is entirely unsatisfactory. It ???might be said that these cases should go to a Poor Law Medical ???iddla Officer kut there are a considerable number of the cases which ???want special investigations which it would not be fair to expect a ???Poor Law Medical Officer to carry out, and which can only be done where all the facilities of a Hospital exist. The appointment of a House Surgeon has improved matters somewhat. I have person??? ally been able to get a great deal done as I have many friends on ???the staffs of the London Hospitals, general and dental, but it ???intailjhould not be that the personality of the Officer in charge of the ???ariuwork slfould be able to obtain treatment which should be available for any child, no matter who the Officer in charge is. 4. Fever.— This district joins with Richmond in the from of a Joint Hospital Board, which is responsible for the Mogden Hospital dealing with Scarlet Fever, Diphtheria and Enteric, and the Dock well Hospital with 13 beds for the ???there accommodation of Smallpox. Arrangements have been made to substantially improve pi tall the Mogden Hospital. Central heating has been installed to ??? I replace the previous unsatisfactory isolated units, and the ??? Administration Block has also been increased to adequately ofter house the Staff. Plans were also prepared for an Observation and ??? Block, but this was postponed for a period of one year. The+ Hospital Committee were approached with a view to arrang- 20 ing for the admission of cases of Puerperal Fever and Oph thalmia Neonatorum, but consideration was adjourned unti the additional accommodation has been provided. AMBULANCE FACILITIES. (a) For Infectious Cases.—This is provided by the Join??? Hospital Board. (b). For Non-Infectious and Accident Cases.— There an??? none in the district, but arrangements have been made with the??? Board of Guardians whereby their ambulance is available at call. A contract is being entered into for the provision of a rnotoi??? ambulance for the district. 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 once 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 in part of the district, and the Osterley, North Hounslow and Heston Nursing Association deals with the cases in the remaining area. It was found that nursing assistance in the Northern part of the district was sadly deficient, and the new Nursing Association was formed in 1925 to remedy the defect. 21 The demand for nursing assistance was found so great that it has been found necessary to provide further assistance for the winter months, as the first nurse was being seriously over-worked. Widwives. The inspection of Midwives is under the supervision of the dounty Council. It is, however, generally recognised that the luthority administering a Maternity and Child Welfare Scheme should also exercise control over the Midwives practising in its area. In this district it is the practice of the Health Visitors not to visit the newly-born till 11 days after the birth, in order not to interfere with the Midwife. According to the County Medical Officer's last list, there are 15 Midwives practising 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., *1V., *V., VI. and VIII. *Public Health Act 192*5, Parts *11., *111., *IV. and *V. were adopted in November, 1925. Maternity and Child Welfare Act, 1918. Baths and Wash-houses Act. 1846-82. Burial Acts, 1852-85. (Applicable to parts of the district only). Public Libraries Act, 1892. Private Street Works 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). 22 *Tents, Vans, Sheds, etc., (H.W.C.A. 1885, s. 9 (2) ). *Slaughter Houses (P.H.A. 1,875, s. 169 and T.I.C.A. 1847 s. 138). *Prevention of Nuisances (P.H.A. 1-875, 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, am P.H.A.A.A. 1890, s. 23). Pleasure Grounds (P.H.A. 1875, s. 104). *Fish Frying (P.H.A. 1875, s. 113). Regulations made by Local Authority in force in District. Allotments (A.A. 1887, s. 6). Allotment Regulations, 1922 These are administered wholly or partly by the Health Coimmittee The unstarred are administered by other Committees of the Council 26 During 1926, collection of house refuse has continued week??? as before, and was disposed of by means of a dump in the Staine??? Road. In addition to this, a large gravel pit on the Worp??? Estate which was frequently being complained of in the past ??? a breeding ground for mosquitoes, was utilised as a dum??? During hot weather this caused numerous complaints from til??? inhabitants particularly in Crane Avenue, and also in Haliburt??? Road. Apart from the smell the chief complaint was of a plag??? of flies. I inspected the houses on both sides of the river.??? the Haliburton Road side some of the houses were comparative??? free, others were suffering from the plague of flies. In Crai??? Avenue the condition was intolerable. The majority of the ??? houses even though well kept were swarming with flies. In son??? cases the marks of the flies on the walls were so numerous tha??? the tenants demanded that they should be redecorated. On in??? specting the houses further away from the river there was a ??? question that the fly trouble was arising from the dump. The ??? East side of Crane Avenue was actually considerably less trouble??? than the West side, and in Worple Avenue and the road approach??? ing Twickenham Road there was nothing to be complained o??? I arranged with the Surveyor at once to spray every load that wa??? tipped with Chloros and later with Izal, and this eased the situa??? tion. There was no doubt that a certain amount of the troub??? had been caused by the Surveyor's instructions not being strict??? carried out, in that during the tipping the earth covering wa??? broken through by the horses in manipulating the carts-, and ii??? some cases by the wheels getting off the sleeper track laid for th??? purpose of tipping. During the year as a result of action taken there wev??? supplied 87 new ashbins. Sanitary Inspection of District. See pages 29—34. 27 Nuisances, Contraventions of Byelaws, Defective Drainage, etc. The number of premises on which nuisances were outstanding ???at the end of 1925 was 463. To these another 55'8 premises where???at nuisances were recorded in 1926 were added, giving a total of ???1021 premises. Of these 502 had the nuisances remedied, leaving ???519 premises at which nuisances still existed at the end of the year. During the year, nuisances at 27 houses were reported to the ???Health Committee, which added to the 25 brought forward ???from 1925, made a total of 52. Before asking the authority to ???serve statutory notices, the premises are inspected by the Medical ???Officer of Health and Chief Sanitary Inspector. Statutory notices ???were authorised and served in most of these cases, and by the end ???0f the year, the nuisances were remedied in 20 of the houses, and ???in one case the house ceased to be used for human habitation, ???leaving 31 cases to be carried forward to 1927. Comparative figures for the years 1924, 1925 and 1926, in Connection with nuisances, are submitted herewith:— 1924 1925 1926 Number of complaints received 381 366 415 Premises at which nuisances were located 470 472 558 Informal notices sent— First 402 368 503 Second 110 60 114 Statutory notices served 44 37 43 It is my duty once more to point out that the staff of Sanitary Inspectors is inadequate. 28 It must be placed on record that twice during 1920, recom??? mendations urging the appointment of a District Sanitar??? Inspector to fill the existing vacancy, were sent forward by th??? Health Committee to the Council, but were defeated. In Octobei 1925 I again reported on the inadequacy of the staff to carry on??? During the last five years, the Department has been definitel??? understaffed, and it has been quite impossible to deal with any thin;??? except complaints. District inspection has been quite out of thi??? question. The extra work necessitated by the Public Healtl (Meat) Regulations, 1924, made matters worse. In order to eaa the situation which was becoming acute, the work under the Shop Act was ceased by the Public Health Committee and turned over ti the Police. In addition to this, all the work under the Petroleun Acts which involved a considerable amount of work was transferre to the Fire Brigade. The problem of dealing with property as I said last year is ex??? tremely difficult, the Rent Restrictions Act allowing only a 40 pe:??? cent, increase in the rent to cover the cost of repairs, which is in??? many cases totally inadequate. As things are now, many houses are being crowded with two, three or more families. Sometime these houses have been of the better class more commodious houses and in the ordinary way the 40 per cent, would have been compared??? tively just. Where these are sublet, often at an exhorbitant profi??? to more families, the wear and tear on the landlord's property is??? not in arithmetical progression, and he is in no way recompense??? by the limited increase in the rent which he is allowed to charge??? His tenant profiteers unblushingly and the landlord has to bear the??? burden, and has no remedy whatever unless legal overcrowding occurs. In nearly every case there is no legal overcrowding, bul??? as pointed out elsewhere considerable moral overcrowding. A;??? the same time there are landlords who are hard put to it, and the??? tenants have a great difficulty in getting anything done. It is very difficult at times to hold the scales justly between the tenant who has certain rights, and a harrassed landlord who is in certain cases deprived of his rights by statute. 29 SANITARY WORK, ETC. Inspections-General: Total number of inspections and re-inspections, etc. 12886 Inspections, etc. re Nuisances, Contraventions, etc.: Number of premises, etc., inspected on complaint 470 Number of premises inspected in connection with infectious diseases 73 Total number of premises, etc., primarily inspected in connection with nuisances 658 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920 3 Number of smoke observations made 3 Number of other visits made to premises, etc., in connection with nuisances etc 754 Number of visits made to works in progress 952 Number of interviews with owners, builders, etc. 439 Action taken (other than under Housing Act 1925). Number of premises, etc., whereat nuisances were recorded during the year 558 Number of premises, etc., on which defects, etc., were remedied— (а) by owners 502 (б) by local authority in default of owner or occupier — Number of cautionary, or intimation notices given— (а) verbal 126 (б) written 377 Number of second (informal) notices given 114 Number of letters re nuisances sent 148 Number of Statutory Notices issued 43 Number of proceedings taken — Number of convictions obtained — Number of proceedings withdrawn — Common Lodging Houses: Number registered 2 Number of inspections made 17 30 Number of contraventions found ??? Number of contraventions remedied ??? Canal Boats used as Dwellings: Number of inspections made 5??? Number of contraventions found 13??? Movable Dwellings, Caravans, Tents, etc.: Number of inspections made ... 47??? Number of contraventions found 7??? Number of contraventions remedied 2??? Bakehouses: Number in district (a) factories 1??? (6) workshops 1??? Number of underground bakehouses in district Number of inspections made 78??? Number of contraventions found 1??? Number reconstructed, repaired or improved Number cleansed 14??? Slaughterhouses: Number on register (a) registered premises 3??? (b) licensed premises 4??? Number of inspections made 110??? Number of contraventions found ??? Number reconstructed, repaired of improved ??? Number cleansed ??? Cowsheds: Number of persons registered ??? Number of premises ??? Number of cowsheds on register 1??? Number of milch cows in district 12??? Number of inspections made 3??? Number of contraventions found ??? 31 Dairies and Milkshops: Number of persons registered 29 Number of premises 33 Number of inspections made 360 Number of contraventions found 7 Number cleansed 6 Offensive Trades: Number of businesses established in district 18 Number of businesses newly established during the year 1 Number of inspections made 265 Number of contraventions found 2 Number of premises repaired or improved 1 Number cleansed 1 Public Health (Meat) Regulations, 1924: Number of inspections made 1110 No notice of slaughtering given 2 Imprdper notice of slaughtering given 123 Water closet communicating directly with shop 1 No precautions taken for the prevent of contamination 11 Verbal notices given 8 Written notices given 20 Inspection of Food: Number of meat inspections 1.790 Number of fish inspections 496 Number of provision inspections 640 Number of greengrocery and fruit inspections 686 Number of hawkers foodstuff inspections 429 Number of other food inspections 285 Unsound Food: Number of carcases and organs surrendered 24 Number of parcels surrendered 7 Number of organs or parts surrendered during slaughtering 182 43 (c) How far defects are due to 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 house under: (а) Public Health Acts See appendices. (б) Housing Acts „ (3) Difficulty in remedying unfitness, special measures taken and any suggestions in the matter: Principal difficulty is absence of suitable accommodation for families displaced by closing or demolition of unfit houses. Landlords give the price of materials and the cost of labour as reasons for delay or neglect in the repair of repairable houses. (4) Conditions so far as they affect housing, as regards water supply, closet accommodation and refuse disposal, together with measures taken during the year in these matters: Water supply is on the whole satisfactory. Closet accommodation is generally adequate, but defective apparatus is frequently complained of, whilst in the outlying parts of the district are some houses not yet connected with the general sewerage system. Refuse disposal:—a weekly collection is made. II. Unhealthy Areas. Information as to complaints received or representations made and action taken in regard to unhealthy areas. under Part II. of the Housing Act of 1925. Nil. 44 III. Bye-laws relating to houses, houses let in lodgings, tents, vans, sheds, etc. (1) As to working of existing Bye-laws: For reasons given elsewhere it has been impracticable to maintain the inspection of houses let in lodgings, etc. Probably many houses are now technically houses let in lodgings owing to the abnormal housing conditions, but are not on the register. (2) .4s to need for new byelaws and revision of existing byelaws: Some difficulty has been experienced in dealing with caravan dwellers under the existing bye-laws with regard to the disposal of refuse, and closet accommodation, and a revision of these bye-laws is under consideration. IV. General and Miscellaneous. Other action taken in connection with overcrowding, insanitary property and housing Nil. V. Appendices, Statistics for year ending 31st December, 1926. APPENDICES. Housing Conditions Statistics. Year ended 31st December, 1926. 1. GENERAL. (1) Estimated population Birth rate 52,110 Death rate 51,240 (2) General Death rate (corrected) 9.75 (3) Death rate from Tuberculosis (all forms) 0.86 (4) Infantile Mortality 56.29 (5) Number of dwelling-houses of all classes 11,285 (6) *Number of working-class dwelling-houses 6,214 (7) Number of new working-class houses erected 900 *Number of new houses other than working-class 168 Total number of new houses erected of all classes 1,068 45 Number of New Houses erected during the year: — (a) Total (including figures given below) 1068 (b) With State assistance under the Housing Acts: — (1) By the Local Authority 0 (2) By other Bodies or Persons 767 2. UNFIT DWELLING-HOUSES. I. Inspection. (1) Total number of dwelling houses inspected for housing defects (under Public Health or Housing Acts) 446 (2) Number of dwelling houses which were spected and recorded under the Housing Consolidated Regulations, 1925 2 (3) Number of dwelling houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 2 (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 241 (5) Number of houses, listed for inspection under the Housing Consolidated Regulations, 1925, at end of year 1543 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 174 46 III. Action under Statutory Powers. A. Proceedings under Section 3 of the Housing Act, 1925— (1) Number of dwelling houses in respect of which notices were served requiring repairs 15 (2) Number of dwelling houses which were dered fit after service of formal notices— (a) by owners 1 (b) by Local Authority in default of owners NIL (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intentions 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 14 (2) Number of dwelling houses in which defects were remedied— (a) by owners 11 (b) by Local Authority in default of owners NIL C. Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925— (1) Number of representations made with a view to the making of Closing Orders 2 (2) Number of dwelling houses in respect of which Closing Orders were made 1 (3) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 1 47 (4) Number of dwelling houses in respect of which Demolition Orders were made NIL (5) Number of dwelling houses demolished in suance of Demolition Orders NIL D. Proceedings under Section 12 of the Housing Act, 1925— 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 10 (2) Number of dwelling houses demolished voluntarily 10 3. UNHEALTHY AREAS. Areas represented by the Local Authority with a view to Improvement Schemes under Part II of the Act of 1925 Nil. (1) Name of area — (2) Acreage — (3) Number of working-class houses in area — (4) Number of working-class persons to be dis placed — (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. 48 During the War, two of the District Inspectors joined the Army and the third left to take up a position elsewhere, whilst the Chief Inspector carried on as best he could. Upon their discharge from the Army the 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. 49 Table shewing dwelling-houses represented as unfit foiHiuman habitation. Premises. No. of houses represented by M.O.H. Date of representation. Date Closing Order made. Date Closing Order determined. Date Demolition Order made. Date Demolition Order obeyed. Date Demolition Order enforoed. Br't forw'd from 1925— †*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 Road 11 12/5/19 22/7/19 ... ... ... ... †1-10, Syon Place, London Road 10 „ „ ... ... ... ... †65-75, Han worth Road 6 12/1/20 23/11/20 ... ... ... ... 175, Twickenham Road 1 „ 26/4/21 ... ... ... ... 177, „ „ 1 „ ... ... ... ... ... 1 & 3, Wellington Road North 2 9/2/20 ... ... ... ... ... 5, „ „ „ 1 „ 28/7/20 ... ... ... ... 2, Forman's (or Field's) Cotts., North Hyde Lane Cottage situated in the Farm 1 10/7/22 ... 12/4/26 dwelling-house rendered fit pro tem. Buildings, Wood Lane Farm, Wood Lane, Isleworth 1 13/7/25 22/9/25 1926— Quinion's Cottage, Fern Lane, Heston 1 8/2/26 23/2/26 28/9/26 13, North Street, Isleworth 1 8/3/26 Demolished voluntarily 12/4/26 *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 and 3. 31/12/26 Nos. 1, 2 and 3 occupied. †Closing Orders not served. ††Closing Orders re-made. ‡Demolition deferred. 51 INSPECTION AND SUPERVISION OF FOOD. 52 INSPECTION AND SUPERVISION OF FOOD. The following is the record of inspection of food premises:— No. of Inspections made. Meat 1790 Fish 496 Provisions 640 Greengroceries and Fruit 686 Hawker's Food Stuffs 429 Number of other Food Inspections 285 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. 394 inspections were carried out in respect of cowsheds, dairies and milkshops. Unofficial milk analyses are made by the Medical Officer of Health. The standard of the milk supply in the district on the whole has improved. Very little of the milk which is sold in the district now is not pasteurised, although only two firms have applied for a Licence to sell "pasteurised" milk under the Milk (Special Designations) Order, 1923. No. of firms in the district licensed to sell— "Certified" milk 3 (6 shops). "Grade A (Tuberculin Tested)." 2 (5 shops). "Grade A" — "Pasteurised" 2 (5 shops). All the milk shops are being brought up to date to ensure complete cleanliness in dealing with their utensils, and under the new Regulations it is to be hoped that a really satisfactory standard will be reached and maintained. It should again be pointed out that it is of little value providing a satisfactory milk supply to the consumer's door if the consumer does not take precautions to see that Meat seized or surrendered and inspections made during 1923-24-25-26 Meat seized or surrendered in lbs. Meat Inspections 53 the milk is not contaminated by flies or dust, or decanted into dirty jugs. If it is imperative for the milk vendor to ensure that his utensils are sterilised so as to be thoroughly clean, it is equally important for the consumer, and the Milk Retailers Association point out with a certain amount of truth that a large proportion of the blame for dirty milk which causes trouble with the children is produced by contamination after the milk reaches the home. The reason why so many Maternity and Child Welfare Clinics use large quantities of dried milk is that they thus ensure for the child a perfectly clean sterile milk, which has the least possible chance of contamination in the home. Meat Inspection. 1. Meat Inspection.—The Chief Sanitary Inspector and the District Sanitary Inspectors hold special certificates for meat inspection. Slaughter-houses and butcher's shops are visited periodically. During the year no diseased meat was seized, but 7027¾ lbs. were surrendered. Until June there were 8 slaughter-houses in use, one registered slaughter-house then closed down leaving 7 still in use, and there are 34 butcher's shops in the district. Each slaughter-house received on an average 12.3 visits per month. 2. Public Abattoir.—The is no public abattoir in the district. Slaughtering may take place any time, subject to the requisite notice being given. From time to time suggestions have been brought forward as to the possibility of establishing an abattoir. I have on every occassion advised against it, on the grounds that I do not think that at the present time the expense is justified, owing to the fact that by far the greater part of the meat coming into the district is bought at Smithfield and inspected there. There does not seem to be with the growth of the district any demand for further facilities for slaughtering at present. 3. Action under Section 117, Public Health Act, 1875.— None during 1926. 54 4. Tubercular Meat.—There was none seized, but 5165½ lbs. were surrendered during the year. 5. The following is a tabular statement on slaughter-houses. In 1920. In January. 1926. In December. 1926. Registered 4 4 3 Licensed 4 4 4 Total 8 8 7 The slaughter-houses as a whole are unsatisfactory. The additional work thrown on the staff by the Public Health (Meat) Regulations, 1924, has been considerable and is best shown by the number of inspections as compared with previous years. Number of Inspections made. 1922 1923 1924 1925 1926 Meat 759 960 556 1513 1790 Slaughter-houses—Inspections made (not included in above) 172 245 204 1131 1106 The majority of butchers have loyally fallen into line with regard to giving notice of slaughtering, one notable exception being an individual who seems to take a delight in giving the officers endless trouble as to the times of slaughtering. The requirements with regard to ensuring freedom from contamination have been in most cases satisfactorily followed by the provision of windows. The Regulations are in many ways entirely unsatisfactory. It is only necessary to take a bus ride from Hounslow to Hammersmith to see how extremely difficult it is for a Medical Officer in a district such as this with practically artificial boundaries, to deal with the problem in his own district if his near neighbours are failing to get the Regulations satisfactorily carried out. Directly 55 he asks for the satisfactory arrangements foreshadowed in the Regulations, he is faced by the reply that neighbouring Authorities are doing little or nothing as compared with the demands which he thinks necessary. At the same time that the rigid inspection of meat, and its protection from contamination is demanded, we have side by side in the same street exposed to all the desiccated horse dung, dried sputum, and other things from the street, such things as dates, figs, and fresh fruit which are consumed raw, and sweets sold from barrows and pedlar's trays, which are unprotected and are all liable to be contaminated. In view of the fact that practically every article of meat is only surface contaminated, and is submitted to adequate heating to ensure the sterilisation of the outside of the joint, it is surely straining at the gnat and swallowing the camel when we allow such things as fruits, sweets, etc., above-mentioned, to be exhibited without any form of protection. Sale of Food and Drugs Act. I am indebted to Dr. J. Tate, County Medical Officer, for the following report prepared by the Chief Officer of the Public Control Department, as to the samples purchased in this area during 1926. Article. Taken. Adulterated. Milk 223 5 Apples 2 2 Cream 6 — Butter 10 — Beer 2 — Condensed Machine-skimmed Milk 2 2 Fish Paste 1 — Oatmeal 1 — Fruit, tinned 2 — Gin 5 1 Vinegar 3 — Mustard 2 — Whisky 3 — 262 10 56 The figures given for adulterated samples include some adulterated informal samples in respect of which no proceedings could be taken. Prosecutions for Milk 2 Prosecutions for arsenical apples 1 Fines and Costs imposed £1,6. 15. 0. UNSOUND FOOD, 1926. Tons. Cwts. Qrs. Lbs. Fish — 2 0 0¾ Meat 3 2 2 27¾ Corned Beef — — — 12 Total 3 4 3 12½ 57 INFECTIOUS DISEASES. 58 INFECTIOUS DISEASE. Scarlet Fever and Diphtheria. There were no "return" cases of Scarlet Fever or Diphtheria during the year. The usual period allowed when speaking of a "Return Case" is 28 days after the return home of a case from Hospital, or 28 days after the release of a case from Isolation at home. No cases of Diphtheria were notified from North Hyde School during the year. There does not appear to be any use made of the Dick reaction. Scarlet Fever serum is being used at the Isolation Hospital in emergencies. The Staff is not being Schick tested or immunized. Scarlet Fever. The following table shows the number of cases which have been notified, and the number and percentage of cases which have been removed to Hospital:— No. of civil cases notified 63 No. of civil cases removed to Hospitals 59 Percentage of cases removed to Hospitals 93.6 The incident rate of Scarlet Fever in the civil population was 1.22 per 1,000. No deaths took place from this cause during the year. Diphtheria. The following table shows the number of notifications received and the percentage of cases of Diphtheria removed to Hospital: — No. of civil cases notified 68 No. of civil cases removed to Hospitals 67 Percentage of cases removed to Hospitals 98.5 The incident rate per 1,000 of the civil population was 1.3 Twelve cases occurred in institutions during the year. Three deaths took place from this disease, i.e., a case mortality rate of 4.4 per cent. 59 Diphtheria Antitoxin. Boxes containing Sterile Antitoxin, syringe and the necessary dressings, etc., are kept at the two Police Stations so as to be available in case of emergency. During 1926, 25 vials of Antitoxin were supplied to medical practitioners. (5 of 2,000 units and 20 of 8,000 units). Enteric Fever. There were 2 cases notified during the year, 1 being a military case. Erysipelas. 16 cases of this disease were notified, of whom 5 were West Middlesex Hospital cases. Ophthalmia Neonatorum. See pages 96—99 and 107. Puerperal Fever. 4 cases of this disease were notified; 3 were notified from the West Middlesex Hospital, 2 of these patients were not resident in this district. See also pages 96—99. Puerperal Pyrexia. Became notifiable on 1st October, 1926. 3 cases were notified between that date and December 31st, but no special action was required is any of these cases. See also pages 96—99. Encephalitis Lethargica. See also special report, pages 69—89. There were 22 cases notified this year. 60 Cerebro-Spinal Fever. 3 cases of this disease were notified. (Two were children under 1 year of age who both died). In addition a man aged 33 died of this disease but was not notified . Acute Poliomyelitis. 3 cases were notified. Pneumonia. 84 cases were notified. 48 notifications were from the West Middlesex Hospital. Malaria. There were no cases notified during the year. 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 forlh the numbers of such cases for the last five years :— 1922 1923 1924 1925 1926 Measles 413 3 563 239 497 German Measles 1 5 30 43 75 Chicken Pox 64 62 100 243 408 Mumps 256 111 308 266 246 Whooping Cough 88 63 67 213 131 822 244 1068 1009 1357 Upon receipt of information of the existence of a case, inquiry is made by a Health Visitor to obtain all necessary facts. 61 Influenza. The mortality from Influenza was 0.15 per 1,000 Cleansing of Verminous Persons. Particulars are asked for as to the facilities available in the district for the cleansing and disinfection of verminous persons and their belongings. Neither the Education Authority nor the Sanitary Authority possesses a cleansing Station. This matter has been brought to the notice of the Education Committee on many occasions. Where application is made, the Health Department undertakes the spraying of rooms for the removal of bed bugs, and bedding and clothing generally can be disinfected by steam at Mogden Isolation Hospital. Notifiable Diseases during 1926. DISEASE. TOTAL CASES NOTIFIED. CASES ADMITTED TO HOSPITAL. under 1 year. 1-2 years 2-3 years 3-4 years 4-5 years 5-10 years 10-15 years 15-20 year. 20-35 years 35-45 years 45-65 years 65 years and over. MOGDEN. OTHER HOSPITALS Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever ... ... ... ... ... ... ... ... 2* ... ... ... ... 1* Scarlet Fever ... 3 3 4 3 21 19 5 3 2 ... ... 56 7 Diphtheria ... 3 1 6 9 27 15 3 4 ... ... ... 58 9 Erysipelas 1 ... ... ... ... ... 2 ... 1 2 8 2 ... 8 Puerperal Fever ... ... ... ... ... ... ... ... 3 1 ... ... ... ... Puerperal Pyrexia ... ... ... ... ... ... ... ... 3 ... ... ... ... ... Ophthalmia Neonatorum 7 ... ... ... ... ... ... ... ... ... ... ... ... ... Poliomyelitis ... 2 ... ... 1 ... ... ... ... ... ... ... ... 3 Cerebro Spinal Fever 2 ... 1 ... ... ... ... ... ... ... ... ... ... 3 Pneumonia 8 12 9 4 ... 7 1 1 12 11 10 9 ... 57 Dysentery ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... 1 2 4 4 8 3 ... ... ... Infectious Diseases, 1926. Cases Notified. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Cerebrospinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Malaria. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Dysentery. Puerperal Pyrexia. Small-pox. January 5 9 ... 1 4 ... 8 ... 11 ... 5 4 1 ... ... ... February 5 4 1 ... ... ... 5 ... 18 ... 3 1 ... ... ... ... March 9 6 ... ... 4 ... 2 ... l6 ... 6 3 ... ... ... ... April 7 6 1 1 1 ... 1 ... 6 ... 5 1 ... ... ... ... May 5 1 ... ... 1 ... 4 ... 12 ... 2 1 ... ... ... June 4 4 ... ... 2 2 1 ... 3 ... 7 1 ... ... ... ... July 11 2 ... 1 1 ... ... ... 1 ... 6 2 ... ... ... ... August 4 4 ... ... ... ... ... ... 1 ... 4 1 ... ... ... ... September 2 4 ... ... ... ... 1 1 2 ... 4 ... 2 ... ... ... October 2 18 ... 1 ... 1 ... 1 4 ... 4 2 ... ... 2 ... November 4 3 ... ... 3 ... ... 1 6 ... 8 1 1 ... 1 ... December 5 7 ... ... ... ... ... ... 4 ... 3 ... 2 ... ... ... Totals 63 68 2 4 16 3 22 3 84 ... 57 16 7 ... 3 ... 64 Deaths from Notifiable Infectious Diseases, 1926. Age Groups. Under 1 year. 1 year. 2 years. 3 years. 4 years. 5 years. 10 years. 15 years. 20 years. 35 years. 45 years. 65 years and over Small Pox ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria ... ... ... 2 ... 1 ... ... ... ... ... ... Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... 1 ... ... ... Pneumonia 8 4 1 ... 1 ... ... ... 1 4 4 9 Encephalitis Lethergica ... ... ... ... ... ... ... 2 2 ... ... ... Cerebro Spinal Fever 2 ... ... ... ... ... ... ... 1 ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... 1 ... Total 10 4 1 2 1 1 ... 2 5 4 5 9 For Tuberculosis Deaths—see other Table. The table hereunder gives the number of cases of infectious diseases that occurred in the several Institutions in the district during 1926:— SMALLPOX. ENTERIC FEVER. SCARLET FEVER, DIPHTHERIA. PNEUMONIA (all forma). ERYSIPELAS. PUERPERAL FEVER. CEREBRO SPINAL FEVER. OPHTHALMIA NEONATORUM. ENCEPHALITIS LETHARGICA. PULMONARY TUBERCULOSIS. OTHER TUBERCULOSIS. POLIOMYELITIS. TOTAL. West Middlesex Hospital ... ... 1 9 42 6 3 ... ... ... 5 ... 1 67 Mogden Hospital ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 Military Hospital ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 Hounslow Hospital ... ... ... 1 1 1 ... 3 ... ... ... ... ... 6 Nazareth House ... ... ... 1 ... ... ... ... ... ... 1 ... ... 2 North Hyde Schools ... ... ... ... ... ... ... ... ... ... 2 2 ... 4 Royal Naval School ... ... 3 ... ... ... ... ... ... ... ... ... ... 3 ... ... 5 12 43 7 3 3 ... ... 8 2 1 84 66 COUNCIL LABORATORY, 1926. Total Positive. (a) Swabs for Diphtheria sent by Medical Practitioners 163 19 Sub-cultures 0 0 Taken from Schools, Clinics and from Contacts 744 29 Sub-cultures 4 1 Sent from Staines Joint Isolation Hospital 255 12 Sub-cultures 0 0 St. Mary's School, North Hyde 0 0 Sub-cultures 0 0 Total cultures examined 1166 61 Yirulency Tests 9 6 (b) Blood examination for Typhoid Widal Tests 1 0 (c) Cerebro Spinal Fluid Examinations 3 2 (d) Specimens of Sputum for Tubercule Bacilli:— Sent by Medical Practitioners including 1 from Staines Isolation Hospital 68 12 Total 72 14 (ie) Hairs for Kingworm— Taken at Schools or Clinics 21 13 (f) Other Specimens— Urine 130 Discharge 16 5 Specimen examined for Dysentery 1 Pathological Specimen 1 Milk 11 67 Preparation of Materials— Total. Tubes of Serum 1980 Throat Swab Outfits 940 Sputum Outfits 130 Typhoid Outfits 0 The bacteriological work of the Staines Joint Isolation Hospital continues to be done in the Council Laboratory. We also continue to supply the Mogden Isolation Hospital with Diphtheria Culture Tubes. The Virulency and Widal Tests were carried out for us by Dr Harold Spitta at St. George's Hospital. 69 ENCEPHALITIS LETHARGICA. Twenty-two cases of this disease were notified, some of which really arose in 1925, but were notified in the early part of 1926. The notes of the cases notified in 1926, (beginning with Caseserial No. 58), are as follows. Case No. 58. (First case—year 1926). F. 17. Onset 10/10/25. For 7 days previous to being seen by the doctor, and more particularly during the last 3 days had been frightened to enter bedroom at night, and was afraid to go to sleep. Otherwise quite alright. 19th October—Headache. Feverish. Anorexia. 26th October—Not been sleeping at night, very sleepy in daytime. Still frightened to go into room. Headache over both eyes into temples. Was sick the previous night. Retching for 3 days. No appetite. Nystagmus R ,& L. Pulse 80. Temp. 99 degrees. No giddiness. 70 27th October—P. 80. T. 98.6 degrees. Broken sleep. No p.s. C.N.S.—Nil except slight nystagmus. 29th October—Keeping well. Much better. Still headache. Can see clearly. 2nd November—Nystagmus marked. Sleeps more heavily and after meals. In bed for? 11 weeks. Now up. Still has headaches and giddy attacks. When seen later on 14th June, 1926, patient had had to give up her work as a domestic servant, having been in a very light place where the mistress was a trained nurse, and working only until lunch time, then going home and sleeping till about 5, returning to work at 5.30, and leaving about 8.30. This she had to give up three days before being seen. She is still very drowsy during the day, and complains of always feeling tired. Still lias frontal headache which is not in any way relieved by glasses. Face is somewhat expressionless, and there is still slight lateral nystagmus. Her condition was such that whilst she was at work she was constantly worrying over the possibility of dropping things, and things not turning out right which she had to cook. She is still unable to face a crowd, and has not travelled anywhere since her illness. Case No. 59. M. 20. Shipping Clerk. Onset 10/10/25. The illness commenced with diarrhrea, after which he felt ill but continued working. Whilst at work he felt dizzy, and felt as If he would faint. Had recurrent attacks of palpitation. The Chief Clerk in the office. died and this upset him considerably. He 71 became worse, could not keep still—had to keep walking about. On 29th October he went to business but could not write, felt so ill that he was brought home by a fellow clerk, as he could not trust himself. Seen by a doctor on 31st October. Pulse 120. Temp. 99.4. Could not concentrate. Depressed. Anorexia. Weak. No p.s. 1st November—Pulse 66. Temp. 97.8. Felt well. 10 p.m. Had an attack of shaking with tachycardia. Felt as if he was going to die after waking up from sleep and had a bad dream. No nystagmus or abnormal physical signs. 2nd November—Slight nystagmus. Had a little sleep. 4th November—Pulse 66. Temp. 97.4. Slightly jaundiced, but no bile in urine. No headache. Not giddy in bed. After that he varied from day to day, sometimes feeling well, sometimes giddy and too weak to move. Had tremors of hands at times. Gradually improved and could walk about 10 miles. One of his periodic complaints was that at times everything he saw used to annoy him. The boy was very nervous, working a lot in the ings as a student, but had no worries either at home or at his work. 21st January, 1926—When seen on this date, pupils were much dilated, 3rd nerve affected. No nystagmus. Slight tremor of hands Knee jerks brisk. Recovery in this case was complete, and he has since been promoted in the Office. Case No. 60. F. 18. Domestic Servant, Onset 11/11/25. The initial symtoms were headache, lethargy, giddiness and some retching. These symtoms persisted for nearly three weeks. Later was costive. No ocular symtoms. Recovered. 72 Case No. 61. F. 11. School-girl. Onset 16/10/25 In September, 1925, this child had been transferred to a new school. Seemed upset by the change, had headaches and some loss of appetite. Was seen by the family doctor and kept away from school until November 11th, on which evening she complained of seeing stars and black specks in front of her eyes, and mistook her bedroom, going into another room. When going to bed she complained that her right arm felt weak. The mother left her in bed and returned in a few minutes to find the child very distressed, trembling all over, tears rolling down her face, and trying to speak but unable to do so. After 15 minutes speech returned, was very jerky, but gradually improved. Later that evening the child vomited. The arm was still weak but recovered next day. She was kept in bed for fourteen days, had slight headache, slept fairly well, and appetite was fair, slight giddiness, bowels and bladder normal, after getting up kept fairly well, but was very nervous and seemed terrified of another attack. 21st January, 1926—Speech still slow. Some slight asymmetry of face, weakness on one side. Recovered. Case No. 62. F. 44. Housewife. Onset, September, 1925. The patient had been sleepy apparently for one month or so before she saw the doctor. Would go up to bedroom and go to sleep on the bed. Initial symptoms—pains in back and neck, bad headaches and lethargy. Towards the end of October she fainted, and afterwards vomited, and vomited again later in the day. Felt very ill all the next day and went to the doctor, 30/10/25. Temperature was 101-4. Pulse 84. Dirty white tongue. 73 31st October—Temp. 100.2. Pulse 84. Had a bad night. Headache rather less. 1st November—Temperature 100.6. Pulse 72. Marked nystagmus. 2nd November—Nystagmus marked. No giddiness. Diplopia. Slight headache. No appetite. Nasty taste. Complains of pain in legs. 4th November—Temperature 99.2. Pulse 84. Urticarial rash on fore-arms only. Complained of pain in eyes and stiff neck. 5th November—Nystagmus present. Tongue cleaning. Eating a little but without appetite. Whilst in bed perspired very freely. Brain condition fairlyclear. In bed for about a week. Periods had been rather irregular during illness. Had always had bad headaches during the periods. Was very weak for some weeks afterwards, but no dizziness. She did no housework from the begining of November until December 18th. 21st January, 1.925—Nystagmus had gone. Felt quite well. Two weeks previously had been sick and had an attack of giddiness. Two children in the house had had headaches and sore throats. Previous health had always been good. Recovered. Case No. 63. F. 54. Housewife. Onset 12/12/25. 10th January, 1926—Patient had not been well for a year. 74 About Christmas time had pain in the back for four days, and could not turn in bed. Had been ill since then, but eating ordinary food. Complained of headache, gidddiness, and bad dreams. This was the first day on which she was seen by the doctor. Tongue was clean. Pulse about 70. Had some diarrhrca, which was probably due to castor oil. 11th January—Pulse 92. Temperature 99. No appetite. Clean tongue. Eyes kept closed. Had been like this for several days. In bed in darkened room. Complained of heaviness of the head. Felt as if she was going up and down (stated that she had felt like this for several weeks.) Also stated that for two months she had been unable to see things clearly with her glasses, and complained of black spots and bright lights in front of eyes. Patient also had horrible dreams. 12th January—Was slightly better. 13th January—Had a good night. No headache, but felt heavy. No Nystagmus. 15th January—Complained of feeling giddy. 17th January—Muddled and drowsy, but better. Tongue clean. 21st January—Conjunctivitis. Double ptosis. Photophobia. Typical speech. Some irritability and obtuseness. Six months later—Now memory very bad. Head still bad. Can see better, ? glasses want altering. Still bothered by things but improving steadily. Has had a month's good holiday. House-j work more bothering than before, much more bothered by a definite job that has to be done. Gets on her nerves. Looks worried, Parkinsonian attitudes, 75 Case No. 64. F. 44. Housewife. Onset 11/12/25. For about a week before calling in the doctor, patient had had some soreness of the throat. She was first seen by the doctor on 15th January, 1926. Was stated to have been ill since two weeks before Christmas— headaches, weakness, depression with bad nights, nightmares. Sleepy by day. Pain in the right side of the head (front, top and back), and back of the right shoulder. Appetite had been poor, but patient had been eating until this date. Some smarting on micturition. Sight for near things had been worse for the last few weeks. Could not do needlework. Bright lights in front of eyes. Patient could cry easily. Pulse 77. Temp. 98.4. Heart, lungs and abdomen normal. Slightly tender right iliac fossa. Knee jerks slight. No A.C. Flexor plantar reflexes. Left abdominal reflex not obtained. No nystagmus. 16th January—Had a better night. Head swimming a little. Better. Headache still present. No abdominal pain. 17th January—Head very bad, very swimming. Smarting on micturition. 21st January—Coarse nystagmus. Tired, lethargic. Said she seemed to be floating in mid air. Euphoria. In bed 1.2 weeks all but 2 days. Memory very bad indeed. Headaches were very bad. Pains round stomach and back, almost as bad as labour pains. Dr. had to be sefit for specially. Recurrent attacks, not giddiness, but something seemed to come over brain, just like a wave. For a few seconds seemed to lose power, a sense of pressure on the brain. The attack leaves her quite prostrate for a few minutes. 76 Now six months since the commmencement of illness, very weak, with constant pains in middle of back. Has pains in hands, arms and hips like rheumatism. Still sleeps, very badly. Always tired in day but can't sleep. Can't settle to anything or rest properly, appetite very poor. No taste since illness. Very irritable with little things. Daughter says mother now bad tempered, before was a very patient kindly woman. Now wearing glasses, as gets headaches without. Eyes very painful especially left which gets quite misty at times. Previous to her illness patient had mastitis both breasts at 2 year intervals. Intense worry, due to desertion by husband. Patient thinks condition largely due to nervous breakdown from worry. Case No. 65. M. 40. Fishmonger. Onset 1/1/26. Was quite alright when he went to bed on December 31st. Woke in the morning with very bad frontal headache. Is subject to occasional headaches which clear up rapidly after a cup of ten. In this case, headache continued all day, and for several subsequent days. About dinner time on the day of onset he felt as he was bending down as if something seemed to strike him at the bottom of the spine. He described it "Like the kick of a mule." The pain seemed to travel right up the back to the head. He went very dizzy, everything seemed to be moving round. No sickness, no pain, other than in the head. He was got to bed and the doctor called in. He slept a considerable portion of the time whilst in bed, except during the first week. Whilst awake during the day he felt exactly as if someone was pulling the top of his head off. Two or three days after being in bed he noticed things went misty at 77 times and always when he tried to read, the letters ran into one another. He could not bear the light on his eyes at all. He was very shaky the first week he was up, and had difficulty in standing. Pain in the hamstrings after walking. He had well marked vertical and lateral nystagmus, especially lateral. Convergence good. Knee jerks slightly increased but sluggish. Bi-lateral ptosis together with some 3rd nerve paralysis. Great toe extensor reflex. Recovered. Case No. 66. M. 35. School teacher. Onset 1/2/26. Subject to Rheumatism. Had occasional pain in legs since going into a new house which was not completely dried out. Headache commenced 30/1/26, mostly in occipital region, severe. He laid down and the headache went away. Next morning he felt better and went to work. At noon the pain re-commenced but he carried on until he came home and went to bed early. No sickness, no dizziness. Put on an extra blanket and sweated profusely, and pain left his head and commenced in the legs and arms. Went to work the next day with a certain amount of pain. Headache came on again during the day, more severely than the day before. Went to work the following day, the headache started almost as soon as he left Hounslow, and became so bad that he came home. The headache was behind the eyes and nose, and also in the occipital region. No history of visual troubles. Pain in the head was very acute next day, and the doctor was sent for. The next day the pain in his head lasted for 5 to 6 hours in the middle of the day, after which he felt alright. It was the same on the following day but gradually getting less. He managed to take his food alright all the time except on two days. Bowels regular. No 78 ations. Said he felt himself a fraud. When seen had definite Nystagmus, rather less in the upward direction. Recovered. Case No. 67. M. 6. School. Onset 11/12/25. This boy appeared at the Clinic on the 29th January, 192(i. His illness started 3 weeks before Christmas. He came homo feeling very drowsy and went to sleep directly. Complained of great frontal headache for two or three days. No sickness. There was a doubtful history of ptosis. He did not attend school as he could not keep awake. He was more or less drowsy all the holidays, but improved towards the end and went back to school. He was only in school a week before the headache commenced again. After that he became very drowsy again, sleeping at odd times, once or twice going off to sleep in the middle of a meal. Speech was slow. There was some weakness of the left side of the face. He had got very irritable with the children. When seen again on the 12th February, he was much better; the headache had disappeared, and he was less irritable. On the 12th March he had considerably improved generally, was sleeping and eating well and not so irritable. He still complained of headache. On the 30th April the boy was much better on the whole, no headache, no irritability. Had definite weakness and loss of tone of muscles of whole of left side of face. On the 28th May he was greatly improved, in the mother's words was "Wonderful this last four weeks." The condition of the left side of the face was much the same. There is a question as to whether a part of this difference is not a congenital asymetry. 79 Case No. 68. F. 39. Onset 15/1/36. Patient was quite alright up to the middle of January, 192-3, when the neighbour noticed that she looked very strange (vacant) She used to say she coud not see the neighbour properly, and turn her head away. Used never to go out without speaking to neighbour, but lately had not done so, which was a most unusual state of affairs. She became very uneven in temper. During the middle of February her condition altered for the worse, was very poorly all day and her head ached terribly. She complained that she could not see properly, and staring at anything made her giddy. For a week or two before this stated that she could see two of everything when she was reading, but there was no complaint of diplopia otherwise. Also said she felt a bit funny lately. Went to the doctor, and completely collapsed on her return, trembling all over. The neighbour said in describing it that she had never seen anything like it in such a short time. This apparently resulted from the fact that the doctor had told her that she had got Encephalitis, and must go home and go to bed at once. She apparently fainted when she got upstairs, and was more or less unconscious save for short intervals, for a week. The main symtoms which developed were lethargy, mask like face, insomnia, loss of appetite, giddiness, and she also developed athetosis, plucking at the bedclothes, definite intention tremors, with a certain amount of tremor at rest. Recovery was slow, the patient complaining of headaches and difficulty in walking. Daughter of case No. 53. When last seen (14/6/26) patient was still complaining of black specks in front of her eyes, and if she is walking along and meets anyone, she describes it as though their face was one blank. She still feels very weak and has to lie down, as her back is so bad. The only work she is capable of is dusting out a room, and cooking. 80 Case No. 69. F. 43. Nurse. Onset March, 1925. The initial symtoms were intense headache—particularly in back of head and neck, some stiffness of neck, marked photophobia, and some diplopia, and severe and intractible insomnia. Slight rise of temperature, occasionally up to 100, pulse rate not slowed. Ali reflexes present, but somewhat exaggerated (this the medical attendant thought to be normal for this patient, as she is very neurotic). Some slight change of mentality—tending to irritability. The most prominent and persistent symptoms were the pain in the head and insomnia. The patient subsequently had an attack characterised by persistent pain in the back and headache, with some nervous symptoms which looked very like a relapse, but in view of the patient's neurotic temperament there was considerable difficulty in making an accurate diagnosis. She was transferred to St. Thomas's Hospital under Dr. Buzzard, when the conclusion was come to that the symptoms were considered not to be due to encephalitis. After leaving the Hospital the head ache and pain persisted, and she was seen by another doctor. It was found that she had multiple tumours iu both breasts which were removed. Subsequent history will be watched. Case No. 70. M. 14. School. Onset 19/2/26. The symptoms given by the Medical Attendant were Lethargy bi-lateral ptosis, 3rd nerve paralysis, squint, insomnia. Great toe extensor reflex. Recovery apparently complete. 81 Case No. 71. F. 47. Onset 14/1/26. The illness commenced with pain in the back and great depression, and the patient was afraid to go anywhere. Could get no sleep at night, and gradually got extremely drowsy during the day. Headache mostly at the back, and later she was unable to read or knit, and developed definite diplopia which lasted for 6 or 7 weeks. This was accompanied by definite squint. She was in bed for two weeks, and then about the house for some time. Was under the doctor for three months in all. In the early part or the illness she vomited on and off for about one month. During that time she had no appetite whatever. On the 4th June, 1926, when seen she stated that she still gets headaches, often feels very languid and depressed, and feels as if it is the old trouble coming on again. She is able to do her housework with difficulty. Case No. 72. F. 57. Midwife. Nurse. Onset, about 15/2/26. Feeling terribly run down before Christmas, 1925 Had been attending a case of Cancer which had been dying all the summer. Complained of feeling terribly tired, as she put it "out of the way tired" compared with what she had done. She used to feel as if she could lie down and sleep for ever. She never gave way, but was unable to sleep at night, would sit up until 2 a.m. sewing or reading, but could not go to sleep. This went on until February, and she was getting more and more tired everyday. On 12/2/26, she was taken suddenly ill with great pains in the side of neck and back with intermittent diplopia. The pains in the neck she said were terrible. The pains lasted 4 days and seemed to drag her head 82 forward. Diplopia lasted oil and off for two weeks, (two days on and then a day or so free). On the whole, the chief difficulty later on was her back, which she could not bear to be touched, and could not lie down. When she could lie down, she had great difficulty in getting up again as her neck and back seemed so stiff. Had a good deal of constipation for two weeks. No sickness. Felt very faint when she began to sit up and very weak. As she put it she felt "really ill" for a week. Two months later there was no Parkinsonism, but the patient still felt shaky. Case No. 73. F. 22. Onset ? 1/4/26. This patient met with an accident on the 19th December, 1925, crushing her finger at a factory. The finger was amputated the same day at the West London Hospital where she attended daily until 19th January. The hand by this time was getting septic—profuse, discharge—the patient being very ill. Three incisions were made one in the stump of the finger, and two in the back of the hand.Owing to her condition, in order to avoid the daily journey to the West London Hospital, she was admitted to the Hounslow Hospital and was in bed for three weeks. The condition cleared up and she came home and attended daily. The mother at this time noticed a difference in the daughter who complained of bad headaches, and irritating cough. She became very languid, lying about, and had no energy. She was treated by the doctor for the general condition. On 1/4/26, she was very languid and off her food. 4th April.—Went out for a walk. Came home very tired. Seemed worse. Still complained of headache. Vomited later in the day. The headache got much worse all that night. 5th April.—Head worse. Not so very drowsy. 83 6th.—Doctor was called in again. Patient was then in a very lethargic condition, lying all day with eyes closed. Rambling towards night, answered quite intelligently when spoken to. No incontinence. Remained much the same as this until April 9th. Complete constipation for six days. 10th April.—Bowels moved. Got out of bed herself whilst the mother was downstairs. Had apparently soiled herself considerably and was found getting into bed in a clean nightdress, and had no knowledge of what she had done. From thence onwards she was quite helpless, took food fairly well until April 12th, when she had to be fed. Became more and more lethargic and could not answer questions intelligently. 1.6/4/26—I saw the patient on this day at the request of the medical attendant as a possible case of Encephalitis Lethargica. She had obvious squint (commenced on 13th April), incontinence from the 15th April, opened her eyes and looked around but could not recognise anyone. She was gradually getting more and more drowsy. The condition seemed very serious and I advised her removal to the West Middlesex Hospital, the condition appearing to be one of Encephalitis. She was removed to the Hospital and died the next day. In view of the injury and long protracted sepsis one ought to bear in mind such conditions. The Medical Superintendent at the Hospital considered after careful consultation with his colleague that there was no doubt that this patient was suffering from encephalitis. Case No. 74. F. 17. Onset 11/1/26. During the middle of December, 1925. this patient complained of being cold and sleepy. 84 12th January, 192(j-Took a definite turn for the worse, was very drowsy and wanted to keep crying. Had slept very heavily the night before. Her appetite disappeared and she vomited. Tongue clean. No fever, giddiness, or headache. Slight nystagmus to the left. 14th January.—Complained that her vision had been hazy for the past two days. 18th January. Felt alright except for her head—complained of a dull pain across the eyes. Continuous feeling of nausea. Felt irritable and angry and has done so for a week. Everything seemed to annoy her, and she wanted to have a good cry. Nystagmus was then well marked to right and left. 21st January.—Still slight nystagmus. Knee jerks increased. Fixed expression. Said she still saw things mistily. Recovered. Case No. 75. F. 3G. Onset 25/3/25, about. This patient had been seen in 1925, by a medical man with an attack which had apparently been called Influenza. She had not been so well again and had been to another doctor on account of headache and dizziness. In December, 1925, she complained of being very sleepy when coming home from work and could not sleep at night. No sickness. Had curious hallucinations—when she closed her eyes thought she was looking at liver. Headache almost entirely frontal, and were so bad that she thought she was "going 85 marl." Also complained of pain in the side, but there was a history of definite pleurisy in 1925. No cough. Kept at work all through original illness, and had not complained of diplopia. Had recently been in bed for a week, and was said to have had anaemia very badly. This was due to great increase in menstrual periods which had existed during the previous 18 months. When seen later she was very trembly, with a rather twitchy face, and was very emotional. Felt as if she could not control her legs when walking and complained of getting fearfully depressed. The symptoms seemed to be definitely worse, her facial expression more or less fixed, also definite loss of memory, when seen on 21st January, 1926. Case No. 76. M. 26. Packer in Soap Factory. Onset 11/10/25. The illness commenced on the 11th October, 1925, with attacks of laughing and crying. Patient was extremely irritable, with a week's history of headache, the pain coming up from the back of the neck. During this time his character apparently changed considerably. Had a bad dream on 10th October, and woke up laughing. Had 5 attacks in 20 minutes. On examination—no diplopia, and no nystagmus. Complained of spots in the front of his eyes. Central nervous system—nil, except knee jerks very brisk and abdominal reflexes brisk. Appetite good. 12th October.—Complained that his sight was funny. There was no blurring or diplopia. Said that "People walking away appear to be running." Had terrible headache on reading, and had to fight to prevent laughing. Temperature normal. Some albuminuria. 86 14th October.—"Terrific headache'' the previous night across both eyes and over, which was worse at times and especially on stooping. No laughing or crying on this day, but still had periodic headache and could not. read for more than five minutes. Was still flying into a temper on the slightest provocation. Appetite had disappeared. Tongue was dirty. No eye signs. Felt alright between headaches. 15th October.—Had slight headache. Appetite good. Le»s irritable and sleeping alright. No laughing or crying. Reading caused severe pain in the left forehead, also in the left eye. and later in the right eye. Came over very weak when walking. Easily out of breath. Looked bright. 19th October.—Felt alright. Eating ravenously. 20th October.—Appetite lost again. 24th October.—Headache again. Great perspiration all over. Very short winded. No nystagmus. 27th October.—Eyes looked glassy. 11th November.—Felt comparatively well. 21st January, 1926.—Back at work. No physical signs. Pupils large. Recovered. Case No. 77. F. 25. Domestic Servant. Onset 2/1/26. The illness in this case commenced with neuralgia on the right side of the face and in the eye. Was seen by the doctor on the 7tli January. She fainted two days previously. 87 10th January.—Fainted again. Very trembly. 11th January. Trembling again. Had pain over right eye. No giddiness. Appetite fair. Slept poorly. Very weak by dinner time. Tongue clean. Slight nystagmus. 16th January. Had had trembling attacks daily, most mornings and evenings. Constant headache. No giddiness. Sight normal. Saw " Yellow stars " darting about in front of her eyes occasionally. Felt heavy and sick in the mornings. Sleeping better. Slight nystagmus. 21st January. Still working. Coarse nystagmus, brought out by exertion. Diplopia following prolonged gaze. Felt drowsy and fatigued. Slight tremor. Knee jerks sluggish. Memory at fault, forgot to lay things on the table. Recovered. Case No. 78. F. 15½. Onset 18/6/26. Was quite well about a week before Whit sun. Home from work. Commenced with headache—sore back from waist upwards. On Monday before Whit-Sunday taken to Doctor who treated her for Muscular Rheumatism. Next day temperature in afternoon 103. Doctor sent for, then said slight pleurisy. Still complaining of sore back. Headache all the time. Doctor attended daily for that week. Got much better over week end. Appetite better. Said she felt practically alright but didn't look at all well. Signed off by Doctor Whit-Tuesday. Didn't seem to want to go to work, remained at home '£ weeks. Certificate given in end for Influenza. Went back to work, after the strike very busy working late. Next complained of being tired and used to go to bed soon after getting home. Headache and backache commenced again, Saturday and Sunday. 88 June 19th and 20th, didn't feel well. Breath very offensive, bad headaches on 20th, got up but had no dinner. Laid in bed and went to sleep. (Tired over week end). Went to Twickenham on evening of 20th, home at 10.—Straight to bed complaining of head. (Had laid on couch most of time whilst at Twickenham). 11.30 Mother went into room, was complaining of heat—although windows open—blankets removed—drowsy, flushed. At 2 heard al Lavatory. Father found her sitting in bed—having lost articulati speech, rambling—-couldn't form her words. Signed to bring paper and pencil but couldn't form letters. Doctor fetched. No particular temperature—up one day 100—down next. Pointed to head as if in great pain. Vomiting rest of night. So bad Doctor fetched again at 6.30 by this time could not make sound and was unable to under stand many things at 11 a.m. Consultation with another Doctor Speech returned same night—had complete memory of daj happenings. No squint and no loss of sight apparent—vomitei several times—very drowsy and muddle headed. Remained in sami condition for 3 days—slept day and night. Vomiting still. Froi this got worse. 2Gth more unconscious. No speech. Could on]; make motions expressing disapproval of food. 27th about thi same. 28th Worse. Very restless—seems intelligent but purpose less movements—very restless—eyes wide open. Didn't slee] until drugged—last time she got out of bed to relieve herself 29th and 30th—worse—cannot see, quite unconscious, lost contro of bladder and rectum. Feverish. (Case in Hounslow Hospital) At the age of 8 the Child had T.B. glands and ran a tempera ture—otherwise no illness. Died on July 8th. Case No. 79. F. 42. Onset May 1926. This patient has been delicate most of her life. Is sufferin from Gastric Ulcer and Anaemia. Married. She had 3 children 89 now aged 18, 1G, 12, then 2 miscarriages then another child age 7, and had 3 miscarriages since, last in August 1925; in each case at five months. Very bad pyorrhea, had teeth all removed Christmas, 1925. This was followed by considerable hemorrhage and sockets had to be plugged. Never seemed right since miscarriage and was pulled down by dental extractions. She got on fairly well until March 1926 and then had a bad cold. Lost her voice. Very severe hrtadachep. Had a similar attack in May. Began to lose use of her legs and arms and couldn't feel the ground. No sense of pressure but felt as if she was walking backwards. Was very feverish. Severe headaches. Delirious. Aching all over body and limbs. She was in bed between 6 and 7 weeks. When told to get up her legs felt stone cold up to her knees. She was up one hour the first day and had to go back to bed as she felt so ill and terribly weak. The next day when she got up she had great difficulty in standing. She went into the next door and couldn't get back again and had to be carried back. She was under the Doctor for 10 weeks more. Partial loss of use of her hand. For some time she used to drop things. She had no sleep night or day for 5 months. Now dreams rubbish all night. Had never felt drowsy. Had 2 days diplopia at the commencement of attack. Her sight is not so good now. Now feels very weak and troubled with the feeling of walking backwards. No nystagmus. No tremors. TUBERCULOSIS. There is a definite need for an open air recovery school which will deal with convalescent, tubercular, pre-tubercular, and delicate children. I am convinced that money spent in this direction is money wisely expended. Pulmonary Tuberculosis. The number of new cases notified during the year was 57. 90 Twenty cases were notified from Institutions :— . Sanatoria 3, Poor Law Institutions 7, General Hospitals 6, T.B. Dispensary 4. Naval and Military cases 1. There were 37 deaths from Tuberculosis of the Respiratory System. The deaths of cases not notified numbered 5. Of the new cases notified 22 received Institutional Treatment during the year and 11 died in Institutions. Other Forms of Tuberculosis. The number of new cases notified during the year was 1.6. Thirteen of them were notified as receiving Institutional Treatment. Thirteen cases were notified from Institutions. Death from Tuberculosis. Tuberculosis of Respiratory System 37. (14 were primary notifications and 5 were not notified at all). Other Tuberculosis 7 (3 were not notified). Tor Table showing new cases notified and deaths in 1926 see next page. Cancer. Arrangements are being made for propaganda in connection with Cancer, the exact form of which is still under discussion. TUBERCULOSIS 1926. Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. N on-Pulmonary. M. F. M. F. M. F. M. F. 0 ... ... 1 ... ... ... ... ... 1 ... ... 1 2 ... ... 2 1 5 ... ... ... ... ... ... 1 ... 10 2 1 3 ... ... ... 1 ... 15 2 3 ... 3 2 3 ... ... 20 4 5 1 ... 3 1 ... ... 25 8 6 ... 1 9 5 ... ... 35 5 5 ... 3 ... 1 2 ... 45 3 4 1 ... 6 3 ... ... 55 3 3 ... ... ... 4 ... ... 65 and upwards 1 2 ... ... ... ... ... ... Totals 28 29 7 9 20 17 6 1 16 Five of the deaths from Pulmonary Tuberculosis were not notified and three deaths from Non-Pulmonary Tuberculosis were not notified. 93 MATERNITY AND CHILD WELFARE. 94 MATERNITY AND CHILD WELFARE. The work is expanding steadily and satisfactorily. The scheme is as follows:— Two Clinics weekly at the Congregational Hall, Douglas Road, Hounslow, on Tuesday and Thursday afternoons. Two Clinics weekly at the Public Hall, Isleworth, on Monday and Wednesday afternoons. At each of these Clinics infant consultations are carried out, regular weighing, and the sale of dried milks, malt, virol, etc. The Mothers can obtain a cup of tea and biscuits at a cost of Id. The attendances totalled 11,567 for the year as compared with 9843 in 1925, 8817 in 1924 and 8322 in 1923. The average attendance at the Douglas Road Centre was 72 and at the Isleworth Centre 40.36. The number of individual mothers and children attending the Clinics is shewn hereunder:— Douglas Road, Hounslow. 1925. 1926. Mothers 514 562 Children 608 765 Isleworth Public Hall. Mothers 288 326 Children 393 432 Sales at Clinics. Quantity. Receipts £ s d, Glaxo 4592 lbs. 284 11 5½ Virol 760¾ lbs. 63 7 6 Malt 436 lbs. 16 1 9 Oil and Malt 434 lbs. 1.6 5 6 Lactagol 239 pkts. 13 17 8 Almata 541 lbs. 41 5 0 Cow and Gate 1308 lbs. 97 12 0 Cod Liver Oil Emulsion 1110 bottles. 36 7 4 Prescription Glaxo 483 lbs. 47 6 0 £616 14 2) 95 The arrangements with chemists for the dispensing of prescriptions on terms similar to those under the National Insurance Act. have been continued. Since September 1926, the general administration of the Department has been altered and the Medical Officer of Health took aver the whole of the Maternity and Child Welfare work; the Assistant Medical Officer devoting herself mostly to Schools. The original Clinic at Hounslow was held in the Council House. Accommodation was particularly unsatisfactory as far as the waiting room was concerned. The new premises in Douglas Road are entirely satisfactory in every way giving ample accommodation for waiting, consulting room, demonstration room, kitchens and lavatories complete. There is only one drawback, and that is, that with the very large attendances that are now practically continuous week by week there is not sufficient accommodation for the number of perambulators. The average attendance which has risen from 35.6 in 1924 to 72 in 1926, is not entirely due to the new premises. There is a large influx of new mothers owing to the rapid growth of the District. Towards the end of the year the work became over-loaded, on many occasions the attendance reaching over 100, which means that a correspondingly large number had to be seen by the Medical Officer. This with a scarcity of helpers gave no time whatever for demonstrations and health talks by the Nurses. Arrangements had been made for a Sewing Class, but unfortunately our volunteer demonstrator developed Encephalitis, and we were unable to get further before the end of the year. We are getting in a new class of mother owing to the enormous expansion of the District, due largely to houses built under the Housing Acts with loans from the Council. These people with their financial restrictions owing to the purchase of their house are not in a position to spend money any more than those of the humbler classes. In fact with some of them financial stringency is considerably greater than those who have less appearance to keep up. 96 The growth of the Heston District is making it imperative to start a Clinic in that area, as the distance is too great for the mothers to come down to Douglas Road, and the transport facilities are inadequate. Negotiations are in progress for a suitable hall in that District, and it is hoped that the coming year will see something done in that direction. In addition to the Infant Welfare Centre an Ante-Natal Clinic is held on the first and third Monday in the month at the Council House, and the attendance is steadily growing. Consideration at the end of the year was given to the provision of dental treatment for mothers and children, and it is hoped that early in the new year this will become an accomplished fact. There are possibilities that something can be done to replace satisfactorily the premises used for the Infant Welfare Clinic at Isle worth. There is no possibility of any instructive work so long as we are restricted to the present unsatisfactory premises. On October 1st two important regulations—namely the Public Health notification of Puerperal Fever and Puerperal Pyrexia regulations, and the Public Health Ophthalmia Neonatorum regulations came into force. This, for the first time, made Puerperal Pyrexia, that is a rise in temperature or slight fever in a newly confined woman—a notifiable disease. "The expression 'Puerperal Pyrexia' means any febrile condition (other than a condition which is required to be notified as Puerperal Fever under the Infectious Disease (Notification) Acts) occurring in a woman within 21 days after childbirth or miscarriage in which a temperature of 100.4 degrees F. (38 degrees C.) or more has been sustained during a period of 24 hours or has recurred during that period." 97 The number of cases notified towards the end of the year had not in any way come up to the expectation that we had before the Act came into force. There still seems to be some reluctance to [notify these ' minor ailments' as they are regarded by some people. It is early yet to make any final pronouncement as to the value of the Regulations, and whether it is going to have any effect when Wealing with Puerperal Fever. The notification and treatment of Ophthalmia Neonatorum kinder the new regulations has simplified matters by placing the burden of notification solely on the Medical Practitioner in attendanee, whereas before, the Midwife had to notify as well. There were occasions on which no notification came to the Medical Officer owing to the fact that the Midwife was under the impression that the Doctor called in had notified, so that the dual system has been [finally done away with and the responsibility placed solely on the Medical Practitioner in attendance. The notification is secured by the fact that the Midwife has to send for medical assistance in any case of discharge from the eyes. The burden of notifying to the Superintendent Authority—that is the County Medical Officer, is also laid upon the local Medical Officer of Health so as to complete the machinery. There appears to be some uncertainty in [the minds of Practitioners as to whether they should notify only the severe cases of Ophthalmia Neonatorum or whether they should notify any case of discharge from the eyes. The ruling of the Ministry of Health is that there is no discretion allowed to the Practitioner, whose duty it is to notify any [ease coming within the definition under the Regulations, that is, "a purulent discharge from the eyes of an infant, commencing Kvithin 21 days from the date of its birth." In order to deal with [these two diseases efforts were made by approaching the Joint [Hospital Committee jointly with the Medical Officer of Health of [Richmond who is the other Consulting Physician to the Hospital, |and we made a report on the advisability of treating these diseases |in an Isolation Hospital, but the Committee decided against it. 98 owing to the restricted accommodation at present existing, and further discussion was postponed for a year. The Hounslow Hospital are not in a position to accept the cases. The few cases of Puerperal Fever generally find their way into the West Middlesex Hospital, but it was impossible to arrange for any accommodation for cases of Puerperal Pyrexia. Personally I am extremely averse to cases suffering from Puerperal Pyrexia or even Puerperal Fever having to go through the machinery of the Relieving Officer in order to get admission. Puerperal Fever may be, and certainly can bp, dealt with as an urgent case by the Medical Superintendent, and admitted on his responsibility, and this is done in other places, and has the sanction of the Ministry of Health. Every case of Puerperal Pyrexia notified is a potential case of Puerperal Fever and in my opinion should be regarded as an emergency, and there should be no necessity for all the Poor Law machinery for the admission of such cases to Poor Law Hospitals. I am as convinced as ever of the value of a Consulting Obstetrician in the District. It has been urged and will be urged that if a facility is provided it will create a demand. Personally I hope it will, because in return for that I can see the lives of many mothers infinitely improved. As I have said previously the whole happiness centres round the mother, and if the mother's health is undermined so that her work becomes a burden, then the whole happiness of the family is at slake. It affects not only the wife, it affects the husband; it affects the children. If by preventing a number of these accidents which occur during confinement, which has hitherto been regarded as the necessary heritage of parenthood, and thus preserving homes from the disability which arises from a fretful invalid, then much will be done, particularly from the point of view of the care of the children. Similarly I am as convinced as ever of the importance of the Ante-Natal Work being in the hands of an Obstetrician. Again it 99 may be said that the provision of skilled advice will create further demand for service of the skilled adviser. Again I hope so, as from experience one sees how much can be done to prevent trouble at the confinement, and how much more easily these things can be done by one who makes it their special vocation. Further if a person with a reputation in this particular class of work is conducting the Clinic, mothers will come with less reluctance, in fact with keenness because of the reputation of the Obstetrician concerned. We are gradually passing through a new stage in which it is gradually dawning on the mothers that the disabilities—pains, back-aches and various other things which are regarded as almost part of their everyday life as a result of a family, are not their normal lot, but unfortunately it is difficult to make the men folk understand—unless they are medical men—how much can be done and how important is the doing of it. During the year under review, a number of psychological cases have come under my notice, mainly in chidren. As an example, a batch occurred showing the different types one has to deal with. In one case, a child about 3 ½ years was brought with the following history. Three months before she was quite alright one day and the next day was crying, and used to cry in her sleep. Nothing special could be gathered from the jumble of words, but "Mother" was constantly occurring. By this time she was eating hardly anything at all, and was steadily losing weight. Her weight had been 35 lbs. 2 ozs. four months before, and 34 lbs. on the first date when seen, 33.8 lbs. the following week. One day, the mother having gone out, came back and as she put it "thought the whole of Isleworth was out in her street." The child was rushing up and down the road screaming. It appeared that the child had been refusing to allow the mother to go out, and screamed whenever she had, with the result that the mother had been practically unable to go anywhere without the child. The child was ralher a quiet type and was the only child in the family. After two confidential 100 views with her, I ascertained that the cause of the trouble was that the child was being terrorized by a girl of 8 in the flat below with whom she used to play. It appeared that this took the form of dinning into this small mind that if the mother went out "the bogies would take her away," and this unfortunate little person had become so obsessed with this that on any attempt of the mother to go out shopping or anything of that sort without her, or if she left her asleep and had managed to slip out and the child awakened before she got back, the child screamed in such a manner that the neighbours used to say she must knock the child about or she wouldn't scream so. After three therapeutic interviews it was arranged that the mother should go out alone to the pictures on the Saturday. This was successfully accomplished and the child cried—according to the mother's story —not because the mother had gone out but to come down to see me on the following Monday to tell me that not only had the mother gone to the pictures on Saturday, but that she had "let her go out to see Grannie on the Sunday." This little person was quite alright as soon as the cause was discovered and peace of mind established, and commenced to put on weight steadily. She is now perfectly alright and has never had any recurrence of nervous manifestations whatever. Another interesting case was a child much about the same age—3 A years who was brought to me with a diurnal incontinence for a period of about three weeks. The history was that she had commenced to wet herself during the day; had never wet herself at night, and had been—before she was brought to me—taken to a private practitioner who treated her as a case of ordinary incontinence. It was obvious that this was something out of the ordinary, as cases of diurnal incontinence are, as a rule the later and worse stage of a case which has commenced as nocturnal incontinence only. On attempting to get the history, it was pointed out to the mother that there must be some mental conflict, of which no evidence was obtained for some time, but after continued pressing, 101 the mother admitted that she had slapped the child very severely three weeks before. Here it was again obvious that the mother's defensive mechanism was in process owing to the punishments of the child. It appeared that the child had been punished because she had bitten the new baby so badly that the marks on the fingers showed the next day. It was later elicited that she was also found trying to suffocate the baby with the bedclothes, and as the mother said "the look on her face was fiendish." Further it was found that the child had been made to wear her wet clothes as a punishment in order to see if that would make any impression on the child, but with no results whatever. Here obviously was a case of one of those intense jealousies which are to be found and which are much more common than usually supposed of the new baby. The child being unable to attract attention to herself—having for three-and-a-half years been the only pebble on the beach, apparently conceived this manner of attracting the mother's attention from the baby, which had had effect, but in the wrong way. The mother's primary forgetfulness was obviously due to hostility born of the fact that she was not quite sure what attitude would be taken towards her manner of dealing with the child. As soon as it was found that my only effort was to help and not to blame the mother although she had unconsciously been the cause of the condition, both she and her father were ready to help. I ascertained later through another source that the child had been constantly saying to the mother when she was attending to the small baby "Mummie, you do love me now baby's come, don't you?'' The parents were intelligent people and saw the reasonableness of the analysis, and within three weeks the child was crying if it couldn't do things for the new baby. All hostility had vanished and the child is a different creature altogether. In two other cases which occurred much about the same time, of the same jealousy, one was found hitting the new baby on the head with a powder tin, and the other sticking a fork into it. 102 Curiously enough, much about the same time I happened to go away to a relation, and was asked what was the matter with the boy of about 3 years whose character had entirely altered. On investigation this proved to be another case of those intense jealousies of the new arrival. These are much more common than are usually believed, and much of a later child's character may depend on how this phase is dealt with. Another interesting case occurred in a child of 2, who passed out of my hands before I could find how to deal with it, but the history is so enlightening as showing the influences of frights on these small minds. The mother happened to be a very intelligent woman and brought the child with the history that from a certain date the child's character appeared to have entirely altered. Careful investigation of the history brought out the following facts. The child appeared to have been invariably in the habit of running upstairs or downstairs in front of everbody, always wanted to be first up or down, had had no fears of the dark, didn't mind going upstairs to the dark bedroom or into any of the cupboards, but from the date in question refused to go upstairs, was terrified of the dark, and the cupboards which it had hitherto paid no attention to. In addition except the knock of the butcher and the baker which it apparently knew, it was terrified at any strange knock. Unfortunately I have not seen the child since, but piecing the puzzle together it would appear that somebody had called in the mother's absence and knocked on the door in some way unlike the usual tradesmen that the child was accustomed to, and for whatever reason, it is impossible to say, would appear to have impressed on the child's mind some terror connected with cupboards and darkness which had apparently filled the little mind. Amongst the mothers one finds the psychological cases almost entirely confined to those with an only child, and I usually find that one is able to do a great deal by therapeutic interviews with these cases. 103 Notification of Births. Number of live births notified during the year 992 Number of still births notified 33 Notified by Midwives 685 Notified by Parents or Doctors 340 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 and the Osterley, North Hounslow and Heston Nursing Association are the only Voluntary Societies in direct contact with the Council's Maternity and Child Welfare Scheme. Special mention must be made of the services rendered at the Welfare Clinics by Mrs. Bezer (Co-opted member of the Committee) Miss K. Castell, Mrs. Chadwick, Mrs. Davis, Mrs. Hanks, Mrs. Rhodes, Mrs. Simmonds, Mrs. Steel and Mrs. Sweet at the Hounslow Centre, and Mrs. E. Chedgey (Co-opted member of the Committee), Mrs. Evans and Mrs. Watson and Miss Wotton at Isleworth. Thanks are also due to the undermentioned for gifts of prams, high chairs, clothing, etc., which are given to other mothers:— Mrs. Barnes. Mrs. Leach. „ Bircher. „ Marston. „ Botjer. „ Martin. „ Brown. „ May. „ Butler. „ Midmore. „ Carn. „ Moody. „ Cottrell. „ Mullins. „ Dearman. „ Neethan. „ Diamond. „ Palmer. „ Eames. „ Parkes. „ Edginton. Miss Rhodes. 104 Mrs. Fisk. Mrs. Rhodes. „ Fruin. Miss Rolfe. „ Gardener. Mrs. Sargeant. „ Goldrieh. „ Smith. „ Gray. „ Spofforth. „ Hall. „ Templeman. „ Hill. „ Thompson. „ Hunt. „ Unwin. „ Jeff. „ Young. „ Kingswood. Home Visiting. The visits by the Health Visitors in connection with the Maternity and Child Welfare Work are shown in the following table:— 1922 1923 1924 1925 1926 1st visits to babies under one year 913 803 754 888 1038 Re-visits to babies and children up to five years 4241 4150 3594 3562 3190 Inquiries made, elicited— Feeding—Natural 536 516 487 525 672 Artificial 43 61 59 104 102 Both 41 42 32 56 62 Sleeping with parents 319 282 248 288 202 Using Comforter 198 285 236 276 231 Mother working during pregnancy 56 44 37 84 75 Year 1.926. Ante-natal. First visits 69 Subsequent visits 18 Infant Deaths. Visits paid 48 Ophthalmia Neonatorum 58 Infantile Diarrhoea 2 Puerperal Fever 6 105 Measles and German Measles 9 Whooping Cough 7 Mumps 1 Chidren under 5 years. Chicken Pox 6 Pneumonia 22 Bronchitis 3 Milk and Food Cases 23 Home Help 13 Social Conditions 17 Other visits 70 Health Visitors attendances at the Maternity and Child Welfare Centres, Ante-Natal Clinics, etc., 431. The Health Visitors also paid 135 visits to Infectious Disease cases, and patients notified as suffering from Tuberculosis, etc. Home Help for Mothers. The Home Help paid 112 visits during the year and her work was found of considerable value. She also assists at the Centres when not occupied with her other duties. One is finding that the demand for a Home Help is not as great as it was some years ago, largely due to the work being undertaken by friendly neighbours. 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 have objected to going to the Home Help, but a considerable number of parents have been very glad of the opportunily. The presence of this service acts in 106 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 a certain class of parent who rather than face the fact of paying the 1/-, will spend more than that on various medicaments wherewith to cleanse the child's head, and run to the extreme limit of the period allowed by the Committee, and then at the last minute face the fact that it is better to pay 1/- and get the head clean, than run the risk of a substantial fine by the bench. During the year, 67 children have been cleansed. Grants of Milk. Milk is supplied free or at reduced rates to expecant mothers (during last three months of pregnancy) to nursing mothers, and to children under three. The scale of grants for provision of milk has been fixed as follows:— Where the family income after deducting rent is less than 4/- per head free. 4/- to 5/- per head parent pay ⅓ cost. 5/- to 7/6 per head parent pay 2/3 cost. Where the amount is over 7/6 per head, no grant is made. Number of grants made during the year was 116. OPHTHALMIA NEONATORUM. Notified. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Treated. At Home. In Hospital. 7 7 ... 6 ... ... 1 107 1 heston and isleworth urban district education committee nineteenth ANNUAL REPORT OF THE School Medical Officer FOR THE Year ending 31st December, 1926 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 Medic Service for the year ending- 31st December, 1926. I wish to express my thanks to the members of the Committi for the kindness and support they have shown me. I am, Ladies and Gentlemen, Your obedient servant, EI.WIN H. T. NASI Members of Education Committee, 1926-27 E. W. HEATH, Esq. (Chairman)F. T. HART, Esq. (Vice-Chairman). Members of the Council:— s. CARTER, Esq., j.p., ex-officio (Chairman of the Council). A. L. LANG, Esq., ex-officio (Vice-Chairman of the Council). A. A. BERGIN, Esq. j.p., c.c. H. F. METCALFE, Esq., m.b.e. J. J. BONNETT, Esq., o.b.e. H. J. NIAS, Esq., m.b.e., j.p. W. J. R. DIVINE, Esq. W. H. PHIPPS, Esq. A. E. HALES, Esq. C. M. ROBINSON, Esq. Selected Members:— Miss E. A. ANKRITT. Mrs. S. SPOONER. E. W. GOODE, Esq. P. MURPHY, Esq , j.p. D. RHYS, Esq., m.a. 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). Comprising the whole A. G. Hubbard. Clerical Staff of the lic Health Department, Miss R. Marshall. part of whose duties are E. cromwell. concerned with the School T HoiMES Medical Service. School Nurses— Mrs. C. E. N. Ottley. Miss R. N. tetley (Dental Nurse). Miss B. G. Sori.ie. Denial Surgeon—I. cohen, L.D.S., R.c.S., Eng. Radiographer—D. Arthur, M.D., D.P.H. 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. 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, and all record cards are available for school medical purposes. Until recently the School Clinics and Welfare Centres shared the same medical and nursing staff, but now the Welfare Centres are in the charge of the Medical Officer of Health, assisted by Nurses doing only Maternity and Child Welfare and Public Health Work, whilst the duties of the School Clinics and Medical Inspections are carried out by the Assistant School Medical Officer with School Nurses. 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. Schemes to this end have been put forward which it is hoped may mature shortly. (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 A complete survey of the schools is made from time to time, and a considerable number of minor defects are dealt with. The lighting in some of the schools, chiefly the older ones, is not altogether satisfactory, though efforts are being made to effect an improvement in this direction. In no school in the area is there any arrangement for the drying of the children's clothes and boots in wet weather. This is a matter which affects considerably the health of the children, particularly those subject to Rheumatism and Bronchitis. If such provision were made, it would be possible for many more delicate children to attend school during bad weather than do at present, and there would be a decrease of sickness during the winter months. Dinner Hour Arrangements. In one school only, Spring Grove Central, where there is a Cookery Centre attached, are children able to obtain a hot dinner at a low cost. It is fortunate that the Cookery Centre should be attached here, because the children at this school are of necessity drawn from all parts of the district, making it impossible in many cases for them to return home for a midday meal. At the other schools in the district it is only a few children who come from a distance, and in these cases the teachers are most helpful in supervising the children's food, and warming milk, etc., when required. MEDICAL INSPECTION. 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 with a view to treatment being obtained. (a). Age Croups Inspected. Following the Board's Regulations the children examined were: — 1. All new entrants, 5 year old children ; 2. Children of 8 years of age; 3. Children of 12 years of age; 7 together with those children absent at the previous medical inspection, giving secondary groups of 6, 9 and 13 years of age. The first routine medical inspection of the newly formed Central School was held last year, in which case all the children at the school were examined, the ages ranging from 11 to 15. (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; 111 others a class room or part of a class room, more or less screened off has to serve. Owing to the increased number of children in the schools, due to the expansion of the district, considerable inconvenience has been experienced in some of the schools by the holding of the medical inspection. In order to provide a room for the inspection, two classes have had to be held in one room, often only large enough for the original class. In spite of deficient accommodation however it still seems better to hold the inspection at the school. An experiment was tried a fewyears ago, by the Board's permission. Inspections were held at a nearby hall with better accommodation, but it did not prove satisfactory, and was discontinued last year. The necessary co-ordination between the Head Teacher and the Medical Inspector was lacking, as it was often impossible for the Head Teacher to be present at an inspection held outside their own school. With the provision of increased school accommodation which is to be carried out shortly, much of the difficulty should disappear. FINDINCS OF MEDICAL INSPECTION, 1926. Uncleanliness. Out of 2,613 children examined at routine medical inspection, 195 were found to have nitty or verminous condition of the head, 429 children were also seen at the school clinics. The total number of children excluded on account of nits and vermin during 1926 8 was 250. Further reference to this subject will be found on pages 26, 27, and Table IV. Tonsils and Adenoids. Out of 2,613 children examined at the routine inspections, 99 had enlarged tonsils, 41 of which were referred for treatment, 58 being kept under observation. 116 children had adenoids only, of which 52 required treatment, and 64 were for observation, whilst 82 children had botii enlarged tonsils and adenoids, 50 requiring treatment, and 32 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 24 other children were found to have enlarged tonsils, 10 adenoids only, whilst 13 suffered from both conditions. Tuberculosis. Out of 2,613 children examined at the routine inspections there were no cases of suspected pulmonary tuberculosis requiring to be kept under observation. There were 5 definite cases of pulmonary tuberculosis found at the special clinics and 19 were found to be suffering from suspected pulmonary tuberculosis, whilst 5 children had tubercular glands, 2 tubercular hip, 3 tubercular bones and joints, 1 skin and 1 other form of tuberculosis. Skin. At the routine inspections, out of 2,613 children examined, 13 were found to be suffering from skin trouble. At the special clinics there were 604 children suffering from various skin complaints, including scabies and impetigo (see Table II. for analysis of figures), 12 cases of ringworm of scalp and 10 cases of ringworm of body. 9 External Eye Disease. Out of 2,613 children examined at the routine inspections, 24 were found to have minor eye diseases including blepharitis and conjunctivitis, whilst 5 had a squint. In addition 57 were found at the special clinics to suffer from the "minor" eye diseases, whilst 2 had squint. Vision. Out of 2,613 children examined at the routine inspections, 358 were found to have defective vision, 196 of which were referred for treatment, 162 being kept under observation. At the special clinics 49 children were referred for treatment for defective vision, 4 being kept under observation. Ear Disease and Hearing. Out of 2,613 children examined at the routine inspections, 83 were found to be suffering from defective hearing or ear disease, whilst an additional 130 were discovered at the special clinics. Dental Defects. Out of 2,613 children examined at the routine inspections 811 had carious teeth and were referred for treatment, whilst 16 had slighter caries and were marked for observation. At the special clinics a further 88 were discovered, 87 of which were referred for treatment, while one was kept under observation. Dental inspections, 2,183 children were referred for treatment out of 3,567 inspected (for further particulars see Table IV., Group 4). Deformity. Out of 2,613 children examined at the routine inspections, there were five found to be suffering from spinal curvature and one from other forms of deformity. At the special clinics none were found to be suffering from rickets, but seven other forms of deformity, and one case of spinal curvature were referred for treatment, whilst seven other forms of deformity, two cases of rickets, and three of spinal curvature were kept under observation. Physique and Nutrition. During the year, Dr. Roberts, who is responsible far the routine medical inspection has taken especial note of the height 10 and weight of the children, and has compiled tables showing:— 1. The average height and weight for the district at the different ages inspected. 2. The average height and weight for each school. 3. The relation of the individual averages of the schools to that of the whole district. In Table I. the district averages of 1926 are compared with those obtained by Drs. Tux ford and Glegg from the records taken in 1909 and 1910 of 587,635 children in 17 County and 44 Urban Districts scattered throughout England. They are, therefore, fairly representative of the country as a whole, and are further strictly comparable as they are derived from the same class of children, and taken under the same conditions, viz., in ordinary indoor clothing without shoes. In addition the figures are given for this district in 1909 and 1910, these figures forming part of the All England averages. It is satisfactory to notice that the figures for this district at both periods are generally better than the All England ones, and it would be interesting to have more recent averages with which to compare them. In Table III. the averages of the different schools are given as a percentage of the district average. Since the numbers are not large, it would be unwise to attach too much importance to any deduction obtained in this way. The following facts however emerge from this comparison of schools. Central School. In the age groups, 12 and 13 (the only years in which comparison with the ordinary Elementary Schools is possible), both boys and girls average heights and weights are above the average for the district. This is interesting in view of the fact that the children at this school are selected on account of their mental and not their physical qualifications. Isleworth Blue Schools. —The average weight of both boys and girls at all ages is well below the district average. The average height for both boys and girls is also below, except at the ages of 5, 6, and 8. 11 Worple Road Schools show somewhat similar figures. With the single exception of the age 9 group of girls, each age of both boys and girls shows an average weight well below that of the district. Heights (girls) are the same as the Blue Schools, above the average at 5, 6 and 8, below at the other ages. Heights (boys) above the average at all ages. These schools serve adjacent areas in Isleworth, and number amongst their scholars some of the poorest in the district. The Blue Schools in particular are situated in the midst of a congested low lying area near the river, where the housing conditions are bad, and there are few open spaces. The school buildings are also old and leave room for much improvement. Heston School.—This is the only other school which gives consistent figures. The Boys show a steady figure just above the district average for both height and weight at all ages, except at age 12 where the height is slightly below. The Girls (Heston) show variable figures, as indeed do all the other schools in the district. 12 TABLE 1.—Average Heights and Weights. AGE HESTON AND ISLEWORTH. ALL ENGLAND. Total number of children examined ft each age in 1926. 1926. 1909 and 1910. Averages given by Drs. Tuxlord and Glcgg, 1909 and 1910. Heights. Inches. Weights. Lbs. Heights. Inches. Weights. Lbs. Heights. Inches. Weights. Lbs. 1 BOYS 5 266 41.69 41.19 40.00 40.00 40.55 38.58 6 288 4364 4355 43.00 4450 42.52 42.55 8 216 4794 52.85 47.00 55.00 46.96 50.48 9 165 4951 56.67 4975 60.50 49.09 55.34 12 185 55.57 75.16 55.00 7675 55.03 72.97 13 66 57.36 82.11 57.00 82.50 56.10 77.60 GIRLS 5 290 42.13 39.12 39.00 39.00 40.39 37.70 6 235 43.80 42.24 42.00 41.75 42.36 41.00 8 218 48.08 52.03 46.50 52.00 46.29 48.94 9 145 49.54 56.02 48.75 5550 48.70 54.67 12 198 56.18 73.91 55.50 76.50 54.60 73.8.5 13 55 58.61 87.08 57.75 87.00 56.88 80.03 13 TABLE II.—Average Heights and Weights for each School. Boys. SCHOOL. 8 6 8 9 11 12 13 14 15 Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Brentford End I. 41.64 42.00 42.86 43.36 45.75 49.00 — — — — — — — Spring Grove Junior 42.70 42.50 43.5o 44.00 49.64 55-86 48.25 53-50 — — 54.00 69.80 — — — — — — Spring Grove Central — — — — — — 56.57 80.62 56.79 78.46 58.99 86.19 60.67 96.24 63-45 109.39 Hounslow Town 41.86 40.57 43.64 43.36 48.24 58.57 5025 59.50 — 55.94 7325 57.00 80.00 — — — — Grove Road 41.96 4'.°3 42.81 42.29 48.65 57.19 50.03 59 40 — — 55.08 7637 56.50 80.62 — — — — Alexandra 42.77 41.02 4387 45.60 49.24 54.48 5065 58.30 — — 56.94 76.09 57.00 81.07 — — — — Woodlands St. John's 42.07 42.50 42.62 42.44 45.00 46.00 — . — — — — — — — — — — Isleworth Town 43.05 41.02 45.13 45.04 48.23 52.65 49.82 56.91 — — 55 36 7489 56.50 79.00 — — — — Isleworth Blue 42.12 38.93 44.55 41.94 48.68 52.08 49.32 54.86 — — 55.23 73.65 — — — — — VVorple Road 42.12 39. 13 43.82 42.42 49.33 50.08 49.98 53.38 — — 56.00 74.19 — — — — — — St. Mary's R.C. 42.21 45.17 43.89 43.95 47.44 51.°6 48.67 55.5° — — 56.58 76.46 55.25 79.75 — — — — Heston Mixed 41.92 41.32 43.81 43.76 48.50 53.89 49.77 57.66 — — 54.94 75.43 — — — — — Hounslow Heath 41.27 38.91 43.25 43.05 47.05 51.98 49.42 59.56 — — 54.34 73.77 58.12 82.75 — — — — Hounslow R.C. 40.30 41.35 43.54 44.93 47.54 54.25 48.50 54.80 — — 55.62 79.54 59.50 87.50 — — — — Girls. SCHOOL. 5 6 8 9 11 12 13 14 15 Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Height. Inches. Weight. Lbs. Brentford End I. 42.45 41.79 42.62 41.87 48.50 60.00 — — — — — — — — — — — — Spring Grove Junior 41.30 38.40 — — 49.20 55.57 4.9.17 57.00 — — 57.50 72.00 — — — — — — Spring Grove Central — — — — — — — — 56.20 73.83 56.94 8l.22 58.71 88.00 60.22 98.08 59.80 97.20 Hounslow Town 41.99 40.84 42.93 41.29 47.04 51.27 49.60 54.63 — — 56.36 69.75 59 50 90.00 — — — — Grove Road 42.20 41.02 44.05 43.22 47.67 54.96 40.91 59.85 — — 56.78 76.56 57.00 85.90 — — — — Alexandra 44.07 38.69 43.94 42.40 48.92 52.57 50.75 53.79 — — 56.48 72.06 63.00 96.00 — — — — Woodlands St. John's 40.86 37.64 43.56 43.00 48.25 49.75 — — — — — — — — — — — Isleworth Town 43.42 38.86 43.67 42.67 47.72 49.03 51.00 57.00 — — 55 36 72.07 — — — — — — Isleworth Blue 42.30 3724 43.97 40.06 48.51 48.41 48.17 50.36 — — 55.18 68.93 — — — — — — Worple Road 42.72 38.32 43.62 39.56 48.30 50.62 49.46 58.24 — — 56.61 67.00 — — — — — — St. Marv's R.C. 41.85 40.32 43.96 45.67 47.82 52.43 48.94 55.04 — — 55.62 77.57 — — — — — — Heston Mixed 42.35 39.33 44.45 4145 47.78 50.70 49.55 54.82 — — 36.37 74.64 56.50 85.50 — — — — Hounslow Heath 41.29 38.34 43.69 42.80 47.48 51.57 49.65 57.72 — — 56.00 79.13 56.00 76.00 — — — — Hounslow R.C. 40.94 37.78 43.11 42.94 47.87 49.50 48.75 57.75 — — 55.oo 76.03 59.58 88.17 — — — — 14 TABLE III.—Averages for each School given as a percentage of the District Average. Boys. SCHOOL. 5 6 8 9 11 12 13 14 15 Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Brentford End I. 99.88 101.94 98.21 99.56 95.43 92.72 — — — — — — — — — — - - Spring Grove Junior 102.42 103.18 97.39 101.03 103.55 105.70 97.48 94.41 — — 97.15 92.87 104.39 — — — — - - Spring Grove Central — — - — - - - 100.00 100.00 102.20 102.84 104.97 100.00 100.00 100.00 - Hounslow Town 100.41 98.49 100.90 99.56 I00.62 110.82 101.49 104.99 — — 100.67 97.46 99.37 97.43 — — - - Grove Road 100.64 99.61 98.10 97.11 101.48 108.21 101.04 104.82 — — 99.12 101.61 98.50 98.19 — — - - Alexandra 102.35 99.59 100.53 104.71 102.71 103.08 102.30 102.88 — — 102.47 101.24 99.37 98.73 — — - - Woodlands St. John's 100.91 103.18 97.64 97.45 93.87 87.04 — — — — — - - — — - - Isleworth 'lown 103.26 99.59 103.41 103.42 I00.60 99.62 100.63 100.42 — — 99.62 09.64 98.50 96.21 — — - - Isle worth Blue 101.03 94.51 102.09 96.31 101.54 98.54 99.62 96.81 — — 99.39 97.99 — — — — — - Worple Road 101.03 95.00 100.41 97.41 102.90 94.76 100.14 94.18 — — 100.77 98.71 — — — - - - St. Mary's R.C. 101.20 109.66 100.57 100.92 98.96 96.6l 98.30 97.94 — — 101.82 101.73 96.32 97.13 — - - - Heston Mixed 100.55 100.32 100.16 100.48 101.17 101.97 100.53 101.74 — — 98.87 100.36 — - — - - - Hounslow Heath 98.99 94.46 99.11 98.85 98.14 98.35 97.80 105.10 — — 97.79 96.82 101.12 100.78 — - - - Hounslow R.C. 96.67 100.39 99.77 103.17 99.17 102.65 97.96 96.70 — — 100.09 105.83 103.73 106.56 — — — — Girls. SCHOOL. 5 6 8 9 11 12 13 14 15 Height. Weight. Height Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Height. Weight. Brentford End I. 100.76 106.83 97.31 99.12 100.87 115.33 — — — — — - — - — — - Spring Grove Junior 98.03 98.16 - - 102.34 106.80 99.27 101.75 — — 102.33 97.42 — - — — - - Spring Grove Central — — — — - — - - 100.00 100.00 101.35 109.89 100.17 101.06 100.00 100.00 100.00 - Hounslow Town 99.67 104.40 98.01 97.75 97.84 98.54 100.12 97.52 — — 100.32 94.37 101.52 103.35 — — - - Grove Road 100.17 104.86 100.57 102.32 99.15 105.63 100.75 106.84 — — 101.07 103.58 97.25 98.64 — — — - Alexandra 104.60 98.90 100.32 100.38 101.75 101.O4 102.44 96.02 — — 100.53 97.50 107.49 110.24 — — - - Woodlands St. John's 96.99 96.22 99.45 101.80 100. 35 95.62 — — — — - - - — — — - - Isleworth Town 103.06 99.34 99.70 101.02 99.25 94.23 102.95 101.75 — — 98.52 97.51 — — — — - - Isleworth Blue 100.40 95.14 100.39 94.84 100.89 93 04 97.23 89.90 - — 98.22 93.26 — — — — — - Worple Road 101.40 97.95 99.59 93.66 100.46 97.29 99.84 103.96 - — 100.77 90.65 — — — — — - St. Mary's R.C. 99.33 103.07 100.23 108.12 99.46 100.77 98.79 08.25 — — 99.00 104.95 — — — — — - Heston Mixed 100.52 100.54 101.41 98.13 99.38 97.44 100.02 97.86 — — 100.34 100.99 96.40 98.19 — . — - - hounslow Heath 98.01 98.01 99.75 101.32 98.75 99.12 100.22 103.03 — — 99.64 107.06 95.55 87.29 — — - - Hounslow R.C. 97.18 96.57 98.42 101.66 99.56 95.33 98.41 103.09 — — 97.90 102.87 101.69 101.25 — — - — 15 INFECTIOUS DISEASES. Cases of infectious diseases arc occasionally met with at routine inspections or at one of the school clinics. Systematic swabbing of sore throats and suspicious nasal discharges brings to light unsuspected diphtheria. All infectious cases and contacts are excluded from school till they are deemed free from infection on the general lines laid dcwn in the Joint Memorandum issued by the Ministry of Health and the Board of Education, 1925. During the year 1926, the following cases of infectious disease occurred among children attending public elementary schools in this district: — Scarlet Fever 27 Diphtheria 31 Measles 497 Rubella 75 Mumps 246 Chicken Pox 408 Whooping Cough 131 1415 The non-notifiable diseases, Measles, Rubella, Mumps, Chicken Pox and Whooping Cough, are visited by the School Nurses, 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 011 account of a " rash." 16 Cases of infectious disease have occurred during the year among school children as follows:— SCHOOL. SCARLET FEVER. DIPHTHERIA. MEASLES. " GERMAN MEASLES MUMPS. CHICKEN POX. WHOOPING COUGH. Alexandra Boys 1 ... 47 10 15 19 12 ,, Girls 1 ... 43 13 11 14 1 Brentford End Infants ... ... 4 1 ... 11 ... Grove Road Boys 3 1 4 6 4 11 1 ,, ,, Girls 2 1 5 1 9 6 ... ,, „ Infants 3 2 65 2 13 48 39 Heston Mixed 2 10 ... 1 1 4 11 ,, Infants ... ... 1 3 ... ... 9 llounslozv Heath Boys ... ... 1 1 4 9 ... Girls 1 3 5 3 8 20 ... ,, ,, Infants ... 2 55 6 28 50 2 Hounslow R.C. Mixed ... ... 2 1 16 ... ... ,, ,, Infants ... ... 2 ... ... ... ... Hounslow Town Boys ... 1 5 ... 5 4 ... ,, Girls 3 ... 29 8 45 21 1 ,, ,, Infants 1 ... 25 7 1 ... 2 Isleworth Blue Boys ... ... 3 1 ... 5 1 ,, ,, Girls & Infants ... ... 46 4 5 15 5 Isleworth Town Boys ... ... 7 ... 21 12 3 ,, ,, Girls & Infants 2 ... 4 ... 15 18 13 St. Mary's Boys ... ... 1 ... 1 2 ... ,, Girls & Infants ... ... 22 ... 2 14 1 Spring Grove Central 1 ... ... ... 7 3 ... „ Junior 3 ... 48 3 29 12 17 Woodlands St. John's Infants ... ... ... ... ... 13 1 Wor pie Road Mixed 4 1 9 ... 1 15 1 ,, ,, Infants ... 6 64 4 5 82 11 Total 2 7 31 497 75 246 408 131 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 17 to the parent. The Nurse 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, or the case closed by the Medical Officer. Summary of the work undertaken by the School Nurses: — 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 follow up cases absent or attending the clinics irregularly. Summary of work by the School Nurses during 1926. 138 attendances at School Inspection Clinics. 251 ,, ,, Dental Clinics. 55 ,, ,, Eye Clinics. 417 ,, ,, Minor Ailments Clinics. 4 ,, ,, School Sports. 147 visits to schools for medical inspections. 26 ,, ,, ,, ,, re-insp>ections. 21 ,, ,, ,, dental inspections. 15 ,, ,, ,, cleansing surveys. 3 ,, ,, ,, swabbing. 742 ,, homes in connection with following-up. 2175 ,, ,, ,, ,, ,, Infectious diseases. 187 ,, re Clinic absentees. 1204 dental visits. 166 other visits. 18 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 may avail themselves of the facilities afforded by the school clinics. Visual and dental defects, X-ray treatment of Ringworm and the treatment of Minor Ailments are now undertaken by the Education Authority, whilst the operative treatment of Tonsils and Adenoids is by arrangement earned out at the local hospitals. MINOR AILMENTS Skin, Ringworm of the Scalp.—7 Cases were successfully treated by the application of X-rays. The X-ray treatment is carried out by Dr. D. Arthur, of Ealing, at his own surgery, a fee of £\ : 1:0 per case being paid to him. A charge of 2/6 per case is made, except in necessitous cases, when free treatment may be obtained on application to the Education Committee. Treated at the School Clinic. Ringworm of the Body 8 Cases Impetigo 278 ,, Scabies 4 ,, Other skin diseases, chiefly septic sores 41 ,, Ear Disease and Hearing. At the School Clinic 70 cases of Ear Disease or Defective Hearing were seen and treated. Ear Disease. Middle ear disease, resulting often in long continued discharge from the ears, remains the most unsatisfactory ailment dealt with at the School Clinic. Only a few slight cases are cured, in others the discharge ceases for a time, to begin again later. In many the treatment is merely palliative, the cells of the mastoid bone are already infected, and nothing short of a 1 airly 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 19 of bone covering the inner ear, may lead to suppuration within the brain cavity and death. Continuous suppuration of the middle ear always causes impairment of hearing, and further affects the general health of the child, the glands in the neck behind the ear frequently become enlarged, and a general debility results. Considerable loss of attendance at school is caused by this ailment, and when in school the child does not benefit to the full by the education provided. Ionization seems to offer one of the best forms of treatment for early cases. Unfortunately such treatment is not at present available in this district, and parents often find it difficult to take the children to London. Eye Disease. 21 cases of Eye Disease have been treated at 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 180 children referred for treatment, 47 received treatment either privately or through a hospital, whilst 13 were treated under the Education Authority's scheme. Arrangements have been in force since 1921, whereby children requiring operative treatment for enlarged tonsils and adenoids, can obtain this either at the Hounslow or Richmond Hospital, the Education Committee accepting all responsibility for the fee. Re-payments are claimed from the parents in accordance with the following scale: — Weekly family income Amount per per head. case. Under 8/- nil. From 8/-to 10/- 5/- From 10/- to 12/- 10/- Above 12/- 21/- The number of cases treated is small compared with those referred for treatment. In many cases, however, treatment was considered advisable, and the parent was notified, but except in urgent cases the operation was not pressed. The results of the removal of the diseased tonsils and excessive adenoid tissue in those children who were submitted to operation, 20 have been in the main very encouraging. Improvement is not seen immediately, but at a subsequent inspection, months or even a year or two later, general improvement has been noted in physique and nutrition, and in the absence of enlarged glands of the neck. Mothers often volunteer the statement that the child has been much better since the operation, eating and sleeping better, and Head Teachers usually report improvement in school work. An essential feature in the success of operative treatment of Tonsils and Adenoids is the after treatment. This consists in giving the child a good environment, fresh air and good food, and— most important—in establishment of nasal breathing. Alas in many cases poverty and overcrowding make it difficult to obtain the first two, and the ignorance or carelessness of the parents prevents the latter. It is in these cases that there is little improvement noted after the operation. Every opportunity is taken to show parents the importance of nasal breathing in the maintenance of health, because it is in the home that good, or bad habits, are established. Breathing exercises in school and at the Clinic are helpful, but are not enough unless the good work is continued in the home. Vision. Dr. Roberts, the Assistant Medical Officer, continues in charge of the Refraction Clinic, which is held weekly. From time to time extra clinics have been necessary in order to keep the work up to date. The attendances at the Clinic remain satisfactory. 291 cases of visual defect were submitted for refraction at the Clinic, whilst 16 children were treated privately or at hospitals. In 218 cases spectacles were prescribed and provided by the Education Authority, and 14 children obtained spectacles privately. Spectacles are provided at an all round price of 5/6 a pair, and a definite scale of charges for repairs is issued when spectacles are prescribed. Necessitous cases are referred to the Medical Inspection Sub-Committee, and spectacles are supplied free or al a reduced cost, according to the circumstances. Dental Defects. 1,277 children were treated by the School Dentist under the Local Education Authority's Scheme and 541 re-treated. Further 86 attended the Dental Clinic and were referred elsewhere for 2 I treatment, e.g., hospital, and 49 attended the Clinic but refused treatment. Dental Work. A further age-group has been added, and with the growth of the work the School Nurse, who hitherto has been doing half time dental work, now devotes her whole time to the Dentist, and in addition to the actual Clinic work, is responsible for the clerical work in connection with the Dental Clinic. A very careful series of statistics has been undertaken by the School Dentist, which will next year, when the whole school population is under review, form a basis for exact statistics which will show what progress is really being made. 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 of view of their physical well-being 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 with which it is very difficult at present to deal. They cannot attend an ordinary day school and hope to cope with its curriculum. Their power of concentration is sadly Tacking, 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 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. 22 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 parents inviting their attendance on the occasion of their children undergoing Medical Inspection. They may also attend Dental Inspections. During 1926, one or other parent attended in 1,694 instances, representing a percentage of 64.8 as against 57.4 for 1925. 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. I lie School Medical Work in this District is greatly helped by the interest and friendliness of the Teachers. Not only are all facilities given for the necessary inspections at the Schools but the Teachers shew active interest in the health of the children, and encourage the parents and children to obtain treatment. Often the Teacher's influence is the paramount one in a child's life, and the parents come to them for advice, hence it is of great importance to the School Medical Service to have the Teachers as allies. Much of the improvement in the cleanliness of the school children is due to the Teachers' zealous work in this direction. 23 CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. In this district there are now two Attendance Officers, and they have the 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 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 111 cases of neglect, and help has been obtained for some cases from the Hounslow, Heston and Whitton Philanthropic Society, the Isleworth, Spring Orove and St. Margaret's Philanthropic Society, the Shaftesbury Society and Ragged School Union, and the United Services Pund. 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 1926, examinations were conducted in respect of 66 mentally abnormal 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 111 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. 24 During the year, psycho-therapeutic treatment has been successfully given to children with phobias and " nervous " conditions. 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 YOUNC PERSONS, (i) Employment of Children. The conditions of the employment of children and young persons in this area are regulated by Bye-Laws. by these, certain employments are prohibited and in others the hours ot employment are regulated; children between the ages of 13 or 14 employed 111 the sale or delivery of milk or newspapers or in domestic work away Irom home, must hold a certificate from the School Medical Officer to the eltect 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. 80 Children were examined and were granted the necessary certificates of titness for work, with the exception of one case, which was withheld. (li.) Co-ordination of the work of the School Medical service with tnat of the Juvenile Employment Committee and ot the Certifying Fastory Surgeon tor the District. The Health Reports for J uvenile Employment cards are taken from the medical inspection records and are entered 111 the Health Department. Wiiere by reason of absence at Medical Inspection, sufficiently recent medical records do not exist, the cases are summoned to the fnspection Clinics and the necessary data obtained. These represent the limits ol the services rendered by the School Medical Staff. I am unable to say what relationship exists between the Juvenile Employment Committee and the Certifying Factory burgeon for the District. MISCELLANEOUS. Medical Examination of Teachers. During the year 28 medical examinations were made of teachers, in connection with their appointment under the Authority. 25 Holiday Home for Children. All children recommended for the King Edward VII Memorial Home, Heme Bay, are medically examined before being sent away. CRIPPLE CHILDREH. By the Education Act, 1921, Section 55, the Local Education Authority are required to ascertain what children in their area are physically defective and to make provision for them. (See Table III.). 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. Since the Autumn when the work was re-arranged, the Medical Officer has only attended once a week at each Clinic. 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. 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. In other cases there is no charge for the examination of the eyes, but the parents are required to pay the cost of the spectacles, viz.—5/6 per pair. 26 Ringworm.—Free in cases considered necessitous. Other elementary school cases, 2/6. Cases from other schools according to circumstances of parents. Dental.—1/- for each child, which covers all necessary treatment within the limits of the Committee's scheme, for a period of one year, including the administration of gas when considered necessary. Minor Ailments.—Free. TREATMENT OF UNCLEANLINESS. 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 7 days allowed by by-law, a prosecution may be CLEANLINESS SURVEYS, 1926. Number of visits by Nurses 13 Total number of children examined 15 38 ,, ,, ,, ,, given warning notices 47 ,, ,, ,, ,, excluded as verminous 15 ,, ,, ,, ,, 1. (Few) 122 Found to have nits— 2. (Bad) 27 3. (Very Bad) 13 This very important work has been rather neglected of late years owing to the pressure of other things. Much unfruitful visiting has however now been cut out, and it is hoped to hold more Cleanliness Surveys in the future. The survey is important because— 1. The parents have 110 warning, and therefore, the findings arc a true indication of the cleanliness of the school. 27 2. Everyone in the school is examined, instead of only a certain group as at Routine Medical Inspection. 3. It is of great help to the Tcacher in maintaining cleanliness in the school. Since 110 one knows when the Nurse may come, it is necessary for the children to be always clean if their school is to get good marks at a Survey. Mrs. Yates, the Home Help, still continues the work of cleansing heads begun in 1923, 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, 67 children have been cleansed. No cleansing has been carried out by the school nurses. During the year 1926, legal proceedings were instituted against the parents of 4 children. Fines were imposed as follows:— 1 of 5/-; and 2 of 10/-; I was adjourned sine die. There continues to be 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 foifnd 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. 28 TABLE 1 RETURN OF MEDICAL INSPECTIONS A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants 1143 Intermediates 803 Leavers 368 Total 2314 Number of other Routine Inspections 299 B.—Other Inspections— Number of Special Inspections 1129 Number of Re-Inspections 2945 Total 4074 2Q TABLE II. A. RETURN OF DEFECTS found by Medical Inspection in the year ended 31st December, 1926. Defects or Diseases. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. 1 2 3 4 5 Malnutrition 1 4 ... 6 Uncleanliness 195 ... 429 ... (See also Table IV., Group V.) Skin— Ringworm— Scalp ... ... 10 2 Body ... ... 10 ... Scabies 1 ... 10 ... Impetigo 5 ... 316 ... Other Diseases (non- 6 1 275 3 tuberculous) Eye— Blepharitis 4 6 17 ... Conjunctivitis 1 ... 27 ... Keratitis ... ... ... Corneal Opacities ... ... ... Defective Vision 196 162 49 4 (excluding squint) Squint 5 2 ... Other Conditions 7 6 9 4 Ear— Defective Hearing 31 35 23 2 Otitis Media ... 1 33 1 Other Ear Diseases 14 2 69 2 Nose and Throat— Enlarged Tonsils only 41 58 23 1 Adenoids only 52 64 6 4 Enlarged Tonsils and 50 32 8 5 Adenoids Other Conditions 4 10 21 15 Enlarged Cervical Glands 6 21 7 14 (non-tuberculous) Defective Speech ... ... 9 3 30 TABLE II.—Continued. Defects or Diseases. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. 1 3 3 4 5 Teeth—Dental Diseases 811 16 87 1 (see also Table IV., Group IV.) Heart and Circulation— Heart Disease— Organic 1 10 2 22 Functional ... ... ... 1 Anaemia 5 6 3 4 Lungs— Bronchitis 1 ... 7 11 Other Non-Tuberculous ... 12 ... 9 Diseases Tuberculosis— Pulmonary— Definite ... ... 5 ... Suspected ... ... ... 18 Non-Pulmonary— Glands ... ... 5 ... Spine ... Hip ... ... 2 ... Other Bones and Joints ... ... 1 2 Skin ... ... ... 1 Other Forms ... ... 1 Nervous System— Epilepsy ... ... 2 5 Chorea ... ... 14 4 Other Conditions ... 2 6 11 Deformities— Rickets ... ... ... 2 Spinal Curvature ... 5 1 3 Other Forms ... 1 7 7 Other Defects and Diseases 7 16 22 171 31 Number of individual children found at Routine Medical Inspection to require treatment. (Excluding Uncleanliness and Dental Diseases). Group. Number of Children. Percentage of children found to require treatment. Inspected. Found to require treatment. Code Groups— Entrants 1143 131 11.46 Intermediates 803 156 19.42 Leavers 368 56 15.21 Total (Code Groups) 2314 343 14.82 Other Routine Inspections 299 57 19.06 32 TABLE III.—RETURN of all Exceptional Children in the area. Boys Girls Total Blind (including partially blind). (i.) Suitable fur training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind ... ... ... Attending Public Elementary Schools ... ... ... At other Institutions,, At no School or (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind ... 4 4 Attending Public Elementary Schools ... 1 1 At other Institutions ... ... ... At no School or Institution 1 ... 1 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 2 2 4 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 1 1 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 ... 1 1 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 2 1 3 Attending Public Elementary Schools 6 5 11 At other Institutions ... ... ... At no School or Institution 1 2 3 Notified to the Local Control Authority during the year. Feebleminded ... ... ... Imbeciles 1 ... 1 Idiots ... ... Epileptics. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 2 ... 2 In Institutions other than Certified Special Schools ... ... ... ... Attending Public Elementary Schools ... ... ... At no School or Institution 1 ... I Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 3 3 6 At no School or Institution ... ... ... 33 TABLE III.—Continued Boys Girls Total Physically Defective. Infectious Pulmonary and Glandular At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... 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 ... ... ... At Certified Residential OpenAir Schools ... ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools 2 ... 2 At other Institutions ... ... ... At no School or Institution 3 ... 3 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 20 27 47 At other Institutions ... ... ... At no School or Institution 1 ... 1 Active nonoulmonary Tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 1 2 3 At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 1 1 Crippled Children (other than those with active Tuberculous disease) e.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 11 11 22 At other Institutions ... ... ... At no School or Institution 1 3 4 34 TABLE IV. Return of Defects treated during the year ended 31st December, 1926. TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanl [???] see Croup V.). Diseases or Defects. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Othcjwise. Total. 1 2 3 4 Skin— Ringworm, Scalp 10 2 12 Ringworm, Body 8 2 10 Scabies 4 16 10 Impetigo 278 26 304 Other Skin Diseases 41 22 63 Minor Eye Defects— (External and other, but excluding cases falling in Group II.) 21 8 29 Minor Ear Defects 7° 18 88 Miscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 166 24 190 Total 598 108 706 35 TABLE IV.—Continued. Group II.— DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I.) Defect or Disease. Number of defects dealt with. 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 he recorded separately in the body of the Report). 291 16 ... 307 Other Defect or disease of the eye (excluding those recorded in Group I.) 1 3 8 12 Total 292 19 8 319 Total number of children for whom spectacles were prescribed— (a) Under the Authority's Scheme ... 227 (b) Otherwise 15 1 otal number of children who obtained or received spectacles— (а) binder the Authority's Scheme 218 (b) Otherwise 14 36 TABLE IV.—Continued. Croup 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) 13 45 58 2 60 37 TABLE IV.—Continued. Croup IV.—DENTAL DEFECTS. (I).- Number of children who were: (a) Inspected by the Dentist: Aged: Routine age groups 5 399 Total 3107 6 534 7 339 8 367 9 403 10 407 11 479 12 179 13 – 14 – Specials 460 Grand Total 3567 (b) Found to require treatment 2183 (c) Actually treated 1277 (d) Re-treated during the year as the result of periodical examination 541 (2). Half-days devoted to Inspection 21 Total 215 Treatment 194 (3). Attendances made by children for treatment 1996 (4). Fillings Permanent teeth 1665 Total 1690 Temporary teeth 25 (5). Extractions Permanent teeth 221 Total 3061 Temporary teeth 2840 6). Administration of general anaesthetics for extractions 719 (7). Other operations | Permanent teeth 107 Total 107 Temporary teeth – 38 TABLE IV.—Continued. Croup V. UNCLEANLINESS AND VERMINOUS CONDITIONS. (i.) Average number of visits per school made during the year by the School Nurses 1 (ii.) Total number of examinations of children in the schools by School Nurses 1538 (iii. Number of individual children found unclean 162 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 67 (v.) Number of cases in which legal proceedings were taken:— V) Under the Education Act, 1921 ... (/; Under School Attendance Bye-laws 4