HES 16 Heston & Isleworth Urban District Council. 1929. ANNUAL REPORT of the Medical Officer of Health School Medical Officer for THE URBAN DISTRICT OF HESTON AND ISLEWORTH for the Year ending 31st December, 1929. LOWE & SONS (PRINTERS) LTD. Whitton Road, Hounslow. 1929 REPORT on The Health of the HESTON & ISLEWORTH URBAN DISTRICT FOR THE YEAR 1929. by ELWIN H. T. NASH, M.R.C.S., L.R.C P.. D.P.H. Medical Officer of Health. Public Health Department, 92, Bath Road, Hounslow. July, 1930. 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 in 1925. 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 or HESTON &. ISLEWORTH URBAN DISTRICT COUNCIL For the Year 1929-30. Members of the Council:— J. J. Clements, Esq. (Chairman). W. J. R. Divine, Esq. (Vice-Chairman). H. J. Nias, Esq., m.b.e., j.p., ex-officio (Chairman of the Council). F. T. Hart, Esq., ex-officio (Vice-Chairman of the Council). J. J. Bonnett, Esq., O.B.E. R. B. Depledge, Esq. H. Collar, Esq. A. J. Fielder, Esq. C. Crush, Esq. F. C. Green, Esq. A. Dennis, Esq.. E. W. Heath, Esq. C. L. Lewis, Esq. Medical Officer of Health— Elwin H. T. Nash, m.r.c.s., l.r.c.p., d.p.h, maternity and child welfare committee. Members of the Council: E. W. Heath, Esq. (Chairman). J. J. Bonnett, Esq., o.b.e. F. W. Buckley, Esq. W. J. K. Divine, Esq. E. Walton, Esq. Co-opted Members: Miss E. A. Ankritt. Mrs. E. Chedgey. 6 STAFF The following persons constituted the Staff of the Health Department during 1929:— Medical Officer of Health— Elwin H T. Nash, M.R.C.S., L.R.C.P., D.P.H. Assistant Medical Officer of Health— Mrs. E. Louise Roberts, M.B., Ch. B., D.P.H. Assistant Medical Officer (Half-Time)— Duncan Gerard Leys, B.A., MB., B.Ch., M..R.C.P. (Resigned 31/7/29) Fredk. M. M. Eyton-Jones, M.D., B.S. (Lond.), M..R.C.P. (Lond) (Appointed December, 1929). 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. G. Grieve, Cert. as S.I. and M.I. J. K. Lawson, Cert. as S.I. and M.I. (Appointed March, 1929). Disinfector and Laboratory Attendant— F. J. Cobb. Health Visitors and School Nurses— Mrs. C. E. M. Ottley, Cert. C.M.B.. H.V. and S.N., M.C.W.W. Miss B. N. Tetley, S.R.N., Cert. C.M.B., Health Visitor's Diploma, 1928. Mrs. A. E. Tyrrell, Cert. C.M.B., H.V. 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. Health Visitor's Diploma, 1928. (Resigned July, 1929). Miss M. G. Gribble, S.R.N., Cert. C.M.B., H.V. and S.N, A.R.R.C. Miss E. An.stis (half-time). (Resigned May, 1929). 7 Miss A. Bowness, S.R.N., Cert. C.M.B. Health Visitor's Diploma, 1928. (Appointed December, 1929). One Vacancy (at present filled by Temporary Appointment). Home Help— Mrs. E. Yates. Chief Cleric— B. W. Kilby, Cert. as S.I. and M.I. Clerks— Miss R. Marshall, Cert. as S.I. Miss G. E. Curtis. K. I. Bisshopp. L. Hanks (appointed January, 1929—left Nov. 1929). A. E. Black (appointed Mar., 1929). E. Cromwell. B. Garrod. R. Bulport (Resigned Jan., 1929) H. J. Aldhous (appointed Jan., 1929. F. V. Bell (appointed Nov., 1929) 9 NATURAL AND SOCIAL CONDITIONS OF THE AREA. 10 EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1929 Population— At the Census, 1921 46,664 Registrar-General's Estimate of nett 63,070 (Birth rate) Civil Population 62,240 (Death rate) Births— Male Female Total Legitimate 537 501. 1038 Illegitimate 24 16 40 Birth rate (nett) 17.09 Deaths— Male Female Total 402 367 769 Death rate (corrected) 11.5 Number of women dying in, or in consequence of, childbirth from sepsis 1 from other causes 0 Deaths of infants under one year of age per 1,000 births- Legitimate 42.38 Illegitimate 150 Infantile Mortality Rate 46.38 Deaths from Measles (all ages) 1 „ „ Whooping Cough (all ages) 7 „ „ Diarrhoea (under 2 years of age) 6 Area 6,851 acres Number of inhabited houses (Census, 1921) 8,790 „ of families or separate occupiers (1921) 9,893 Rateable value (at 31/12/29) £483,841 Sum represented by a penny rate during: the vear 1929-30 £1,928 Poor Law Relief. I am indebted to Mr. F. E. Harmsworth, Clerk to the Brentford Guardians, for information respecting the amounts paid in money and kind as out-relief to poor persons within the Parish of Heston and Isleworth during the years 1928-29:— 1928. 1929. £ s. d. £ s. d. Parish of Heston & Isleworth 4929 15 8½ 4373 11 6 11 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 457 medical orders during 1929. 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 GO beds, with a children's ward and X-Ray Department. During the year 1929, there were admitted 949 in-patients, whilst 3,893 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 indirectly under the control of the Council will be referred to under their appropriate headings. They include:— Maternity and Child Welfare Clinics (three centres). Ante-Natal Clinic. Three School Clinics (inspection and treatment of school children). Hospital provision at Mogden and M.A.B. Hospitals for infectious diseases. 12 Staff. During the year it was found necessary, owing to the growth of the work, to provide increased medical, nursing and clerical assistance. The extra medical assistance was obtained on a sessional basis pending the time when there will be sufficient work to warrant further half-time assistance. The half-time nurse resigned during the year, and was replaced by a whole-time officer.. An additional Sanitary Inspector was appointed, particularly to make it possible to deal with increased work under the Housing Act. Two additional junior clerks were also appointed; one particularly to deal with the clerical work arising out of the increased housing inspection. VITAL STATISTICS. Population. The Registrar-General's estimate for the population for 1929 is (Birth rate) 63,070—(Death rate) 62,240, despite the fact that our building activities, particularly for the last five years, have been very large, the extent of which may be demonstrated by the fact that the amount of the loans to house purchasers under the Housing and Small Dwellings Acquisition Acts at the end of 1929 amounted to £2,633,654. 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 be 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 (and 13 marriage-rate) population includes all the elements of the population contributing to the birth and marriage rates and may be represented by:— Death-rate population plus the district's proportional share of all non-civilians enlisted from this country.. The number of deaths registered in the district was 1541, but 862 of these did not belong to the district, while 20 residents died outside the district. Thus the number of deaths properly attributable to the district was 769. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 12.35 per 1,800, which is comparable with the following figures: 13.4 for England and Wales, and 13.8 for London. The death-rate corrected by the Registrar-General's factor of .931 is 11.5. The total number of births registered during the year was 1135, but 181 of these did not belong to this district, while 124 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 10.78. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 17.09 per 1,000. The birth-rate of England and Wales was 16.3 per 1,000, and for London 15.7 per 1,000. Legitimacy. Deaths. Births. The following figures give the number of births:— Legitimate. Male. Female. Total. 537 501 1038 Illegitimate. Male. Female. Total. 24 16 40 14 Table of Causes of Deaths during 1929. Causes of Death. Civil Residents all ages. Male. Female. All causes 402 367 1 Enteric Fever ... ... 2 Small-pox ... • •• 3 Measles ... 1 4 Scarlet Fever ... 1 5 Whooping Cough 5 2 6 Diphtheria 16 1 7 Influenza 15 24 8 Encephalitis Lethargica ... 1 9 Meningococcal Meningitis ... ... 10 Tuberculosis of Respiratory System 25 19 11 Other Tuberculous Diseases 1 5 12 Cancer, Malignant Disease 32 37 13 Rheumatic Fever 2 ... 14 Diabetes 4 4 15 Cerebral Haemorrhage, &c. 17 19 16 Heart Disease 54 83 17 Arterio-sclerosis 23 16 18 Bronchitis 24 24 19 Pneumonia (all forms) 35 25 20 Other Respiratory Diseases 7 8 21 Ulcer of Stomach or Duodenum 6 ... 22 Diarrhoea, etc. (under 2 years) 5 1 23 Appendicitis and Typhlitis 2 4 24 Cirrhosis of Liver 2 2 25 Acute and Chronic Nephritis 10 8 26 Puerperal Sepsis ... 1 27 Other Accidents and Diseases of Pregnancy and Parturition ... ... 28 Congenital Debility and Malformation, Premature Birth 17 8 29 Suicide 6 2 30 Other Deaths from Violence 28 13 31 Other Defined Diseases 66 52 32 Causes ill-defined or unknown ... ... According to figures furnished by the Registrar-General Infantile Mortality during the year 1929. Deaths from stated Causes at various Ages under 1 Year of Age. Cause of Death. Under week 1-2 weeks I 2-3 week 3-4 weeks Total under 4 weeks. 4 weeks and under 3 mts. 3 mts. and under 6 mts. 6 mts and under 9 mts. 9 mts. and under 12 mts. Total Deaths under 1 year. Certified 13 3 2 1 19 12 8 8 3 50 Smallpox Chickenpox Measles Scarlet Fever Whooping Cough ... ... ... ... ... ... 1 2 ... 3 Diphtheria and Croup Erysipelas Tuberculous Meningitis ... ... ... ... ... ... 1 ... ... 1 Abdominal Tuberculosis Other Tuberculous Diseases Meningitis (not Tuberculous) ... ... ... ... ... ... 1 1 1 3 Convulsions ... ... ... ... ... ... ... 1 ... 1 Laryngitis Bronchitis 2 2 Pneumonia (all forms) 1 ... ... ... 1 1 ... 2 ... 4 Diarrhœa Enteritis ... ... ... ... ... 1 2 1 1 5 Gastritis Syphilis Rickets Suffocation, overlying ... ... ... ... ... ... 1 ... ... 1 Injury at Birth Atelectasis 1 ... ... ... 1 ... ... ... ... 1 Congenital Malformations 2 ... ... ... 2 1 2 ... 1 6 Premature Birth 7 2 1 ... 10 ... ... ... ... 10 Atrophy, Debility and Marasmus ... ... 1 ... 1 6 ... 1 ... 8 Other Causes 2 1 ... 1 4 1 ... ... ... 5 13 3 2 1 19 12 8 8 3 50 Nett Births Legitimate 1038 Illegitimate 40 Nett Deaths Legitimate infants 44 Illegitimate infants 6 16 Infant Mortality. The figure obtained under this heading is regarded as a valuable index of the sanitary conditions of a district. Furthermore, as it is based on ascertained facts (i.e., the actual number of births and infant deaths), it is more reliable than the death-rate, which is calculated on an estimated population. The rate for 1929 is 46.38 per 1,000 births. The rates for England and Wales and for London during the same period were 74 and 70 respectively. PHYSICAL FEATURES OF THE DISTRICT. The Urban District comprises an irregular rectangular district of approximately eleven square miles, the average elevation lying between 16 and 104 above ordnance datum, the higher part being Osterley and Heston, and the lower part along the margin of the river from Brentford to the boundary at Twickenham. The Western end is also low lying and the water level comparatively near the surface, this part of the district being bounded by the River Crane The greater part of the district is on valley gravel with pockets of clay at the Western end. The district is bounded on the Eastern side by the River Thames, the Grand Union Canal and the River Brent, and crossed from West to South East by the River Crane. Taken on the whole, the district may be said to be comparatively flat from end to end. The district is roughly divided into two by the main Bath Road which intersects it from East to West.. Large tracts of the district are occupied by market gardens, which are being rapidly cut into by new housing schemes. There are two large parks, one surrounding the residence of the Earl of Jersey at Osterley Park, and one at Syon House, the property of the Duke of Northumberland. The greater part of the rest of the district is largely a dormitory for workers in London. 17 The industries are increasing, the chief being:— (1) Beer, etc.., brewing. (2) Boat building and pairing. (3) Colours and dyes. (4) Flour, etc., milling. (5) Gravel quarrying. (6) Market gardening. (7) Rubber Tyres, etc. (8) Pewterware & Candle Machinery. (9) Pharmaceutical istry. (10) Soaps and perfumes. (11) Sweets, Confectionery. (12) Wines. (13) Sawmills and Joinery. (14) Fire extinguishers, etc. (15) Wireless apparatus & accessories. Gramophones.. (16) Motor cars. (17) Fancy papers. (18) Aeroplanes. (19) Engineering works. (20) Disinfectants. (21) Laundries. (22) Linoleum. (23) Carbons, Stencils, Typewriter ribbons, etc.. The district is 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 and Isleworth, New Brentford, Old Brentford, Perrivale, Twickenham and West Twyford. 19 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA. 20 HOSPITALS. Hospitals provided or subsidised by the Local Authority or by the County Council:— 1. Tuberculosis.—The County Council have an institution; The Bell Road Hospital, with 16 (7 female and 9 male) beds. 2. Maternity.—There is no definite provision in the district other than the West Middlesex Hospital (Guardians) for maternity cases apart from private nursing homes charging considerable fees. There are a few beds in the Hounslow Hospital, and cases can also be dealt with at the West Middlesex Hospital, but the great majority of the cases which come under the notice of the Public Health Department are dealt with by the large London Hospitals. 3. The Hospitals in the district are the West Middlesex Hospital which is the Poor Law Infirmary. The Hounslow Hospital, with 60 beds, is entirely supported by voluntary contributions; a Children's Ward of 8 cots and 4 beds with a solarium has also been provided. The Mogden Hospital for Infectious diseases is supported from the rates by the Councils of Heston and Isleworth and Richmond. The Council annually subscribe £100 to the Hounslow Hospital, £50 to the Royal Hospital, Richmond, and £25 to the West London Hospital. The local usefulness of the hospitals is still hampered by the number of motor accident cases admitted from the Great West Road. These do not contribute their proper quota to the funds of the hospital, but what is more important, they occupy beds which were subscribed for by the charitable people of the district for the residents in this area, and some of those who subscribe feel that their charity docs not lie towards strangers whose admission from outside 21 districts to ours is often the result of either their indiscretions or infringements of the laws connected with motoring, to the exclusion of those of this district who are in need of surgical assistance. There is practically no difficulty in getting cases into the West Middlesex Hospital, but there is no out-patient department. The Hounslow Hospital has a staff of consultants, who are almost entirely concerned with in-patients, but there appears to be a preference for the larger Hospitals with national reputation, such as Great Ormond Street: Queen Square; Brompton; Chelsea Hospital for Women, and the larger hospitals. The difficulty in connection with this, however, is that it entails a considerable expense, which many of the patients can ill afford, and in other cases where specialised treatment is Wanted, there is often considerable difficulty in obtaining the necessary letters demanded by the Hospital. There is still considerable difficulty in getting satisfactory outpatient treatment for children. Things have improved somewhat since the appointment of a House Surgeon at the Hounslow Hospital, but there is a definite need in the district for a properly staffed out-patient department. There is an ever increasing demand made by Local Hospitals for payment for services rendered, and these recurrent payments have a definitely deterrent effect on the willingness with which patients seek advice, owing to the inroads on their small incomes. 4. Fever.—This district joins with Richmond in the form of a Joint Hospital Committee, which is responsible for the Mogden Hospital dealing with Scarlet Fever, Diphtheria and Enteric Fever. Arrangements have been, in operation with the Metropolitan Asylums Board, through the County Authorities, for the admission of cases of small-pox to their Hospitals, since 1st October, 1928, and Dockwell Hospital was closed on that account, 22 An arrangement exists also whereby eases of Ophthalmia Neonatorum can be admitted to the St. Margaret's Hospital of the Metropolitan Asylums Board. AMBULANCE FACILITIES (a) For Infectious Cases.— This is provided by the Joint Hospital Committee. (b) For Non-Infectious and Accident Cases.—A Wilson and Stockall Ambulance has been provided for accident cases and removal of non-infectious cases to hospitals or nursing homes within or outside the district. During the year 345 accident cases were removed to hospital, and 288 cases of non-infectious disease were removed to hospitals or nursing homes. CLINICS AND TREATMENT CENTRES IN THE DISTRICT. A third Maternity and Child Welfare Centre was opened at Heston in January, 1928. The three 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. An Ante-Natal Clinic is held at the Health Department on the first Wednesday in each calendar month. The only Day Nursery in the district was closed in 1920. There are three School Clinics, one at Heston, one at Hounslow, and one at Isleworth. At each School Clinic treatment for minor ailments is carried out on six mornings in the week, and the minor ailments treatment clinics continue open during the School Holidays. A Medical Officer attends at Hounslow School clinic twice a week, and at the Isleworth and Heston Clinics once a week each. The Tuberculosis Clinic which is part of the County machinery is situate in Hounslow in the centre of a populous district, 23 Arrangements for the treatment of Venereal Disease are made through the County at various Hospitals in London and at the Richmond Hospital. Professional Nursing in the Home. The Isleworth Nursing Association carries 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. Midwives. The inspection of Midwives is under the supervision of the County Council. It is, however, generally recognised that the authority administering a Maternity and Child Welfare Schemc should also exercise control over the Midwives practising in its area. In this district it is the practice of 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 18 Midwives practising in the district. There is now very definite difficulty in the Isleworth end of the district owing to the shortage of midwives. A number of the births are attended from a Nursing Home outside the district, and from complaints received on various matters, things do not seem to be quite satisfactory in that direction. ADOPTIVE ACTS AND BYE-LAWS IN FORCE. Adoptive Acts in force in the District. *Infectious Diseases (Prevention) Act, 1890. *Public Health Acts Amendment Act, 1890, Part III. *Public Health Acts Amendment Act, 1907, Parts II., *III., *IV., *V., VI. and VIII. *Public Health Act, 1925, Parts *II., *III., *IV. and *V. were adopted in November, 1925. Maternity and Child Welfare Act, 1918. Baths and Wash-houses Act, 1846-82. 24 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 Officers' Superannuation Act, 1.922. Bye-Laws in force in District. *Common Lodging Houses (P.H.A.. 1875, s. 80). *Cleansing, etc. and Removal of Refuse (P.H.A, 1875, s. 44). *Houses Let in Lodgings (P.H.A. 1875, s. 90). *Tents, Vans, Sheds, etc. (H.W.C.A. 1885, s. 9 (2). *Slaughter Houses (P.HA. 1875, s. 169 and T.I.C.A., 1847, s. 128). *Prevention of Nuisances (P.H.A 1875, s. 44). *Keeping of Animals (P.H.A. 1875, s. 44). *Removal of Offensive Matters (P.H.A.A.A. 1890, s. 26). New Streets and Buildings (P.H.A. 1875, s. 157, and P.HA.A.A. 1890, s. 23). Pleasure Grounds (P.HA. 1875, s. 164). Fish Frying (P.HA. 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 Committee. The unstarred are administered by other Committees of the Council. 25 SANITARY CIRCUMSTANCES. 26 SANITARY CIRCUMSTANCES. Water Supply. There were, as far as is known, at the end of the year 42 private wells from which the water was used for domestic purposes. In 14 other cases there are wells, but an alternative supply from the main exists for domestic purposes. In 77 instances draw-taps were placed on the main to the house, in compliance with notice from the Public Health Department, in lieu of a supply drawn from an inaccesible and improperly or uncovered cistern. Drainage and Sewerage. The sewerage of almost the whole district is arranged on the "separate" system. The following extensions to the sewerage system have been carried out during 1929:— (а) Foul Sewer 29,380 feet. (б) Surface Water Sewer 34,850 feet. Closet Accommodation. Accommodation on the water carriage system is almost general throughout the district, 99 per cent, of the houses having water closets. Scavenging. This is carried out by the Local Authority and is under the control of the Surveyor. During 1929 collection of house refuse has continued weekly as before, and was disposed of by moans of a dump in the Staines Road. The method of disposal is that each day's tipping is completely covered with earth. 27 During the year as a result of action taken there were supplied 151 new ashbins. Sanitary Inspection of District. See pages 29 to 36. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc. The number of premises on which nuisances were outstanding at the end of 1928 was 254. To these another 1261 premises whereat nuisances were recorded in 1929 were added, giving a total of 1515 premises. Of these 1006 had the nuisances remedied, leaving 509 premises at which nuisances still existed at the end of the year. During the year, nuisances at 45 houses were reported to the Health Committee, which added to the 72 brought forward from 1928, made a total of 117. Before asking the authority to serve statutory notices, the premises are inspected by the Medical Officer of Health. Statutory notices were authorised and served in most of these cases, and by the end of the year, the nuisances were remedied in 42 of the houses. In 13 cases it was decided to take no further action, and in. 2 other instances the houses ceased to be used for human habitation, leaving 60 cases to be carried forward to 1929. Comparative figures for the years 1927, 1928 and 1929, in connection with nuisances, are submitted herewith:— 1927 1928 1929 Number of complaints received 403 514 590 Premises at which nuisances were located 597 882 1261 Informal notices sent— First 493 863 1200 Second 63 158 124 Statutory notices served 17 39 90 28 The problem of dealing with property, as I said before, is extremely difficult, the Rents Restrictions Act allowing only a 40 per cent, increase in the rent to cover the cost of repairs, which is in many cases totally inadequate. As things are now, many houseare being crowded with two, three or more families. Sometimes these houses have been of the better class more commodious houses, and in the ordinary way the 40 per cent, would have been comparatively just. Where these are sub-let, often at an exorbitant profit to more families, the wear and tear on the landlord's property is not in arithmetical progression, and he is in no way recompensed 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, but as pointed out previously, considerable moral overcrowding. At 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 harassed landlord who is in certain cases deprived of his rights by statute. There is another class of property which is giving considerable difficulty, where the Landlord has don.e practically nothing for many years, particularly since the outbreak of war, and has sucked the property dry without doing anything to adequately maintain it, with the result that difficulty is experienced in getting repairs done owing to the amount that is necessary. Another class of property giving great difficulty is that in which there has been a life interest only and the property has come to the next-of-kin, where again the property has been sucked dry, and the unfortunate next-of-kin is faced with extensive repairs when the house has been inspected. 29 Proceedings. Proceedings were taken during the year in respect of: — (а) Non-compliance with a notice served under Section 94 of the Public Health Act, 1875. An order was made for defendant to abate nuisance within twenty-eight days and pay costs. (b) Non-compliance with a notice served under Council's Bye-laws with regard to Nuisances and the Keeping of Animals (pigs kept within 180 ft. of a dwelling-house). An order was made for defendant to discontinue keeping pigs within twenty-eight days. On second hearing of case defendant was fined 20s. and required to pay costs amounting to £2 2s. 0d.. SANITARY WORK, ETC. Inspections.—General: Total number of inspections and re-inspections, etc 22490 Inspections, etc. re Nuisances, Contraventions, etc.: Number of premises, etc.., inspected on complaint 717 Number of premises inspected in connection with infectious diseases 463 Total number of premises, etc., primarily inspected in connection with nuisances 1603 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920 2 Number of other visits made to premises, etc. in connection with nuisances, etc. 2141 Number of visits made to works in progress 2357 Number of interviews with owners, builders, etc. 1536 Action taken (including action taken under Housing Act, 1925, Section 3). Number of premises, etc., whereat nuisances were recorded during the year 1261 30 Number of premises, etc., on which defects, etc., were remedied— (а) by owners or occupiers 1004 (b) by local authority in default of owner or occupier 2 Number of cautionary or intimation notices given— (а) verbal 359 (b) written 841 Number of second (informal) notices given 124 Number of letters re nuisances sent 649 Number of Statutory Notices issued 90 Number of proceedings taken 2 Number of convictions obtained 2 Number of proceedings withdrawn - Number of cases dismissed - Common Lodging Houses: Number registered 2 Number of inspections made 23 Number of contraventions outstanding from previous year - Number of contraventions found 3 Number of contraventions remedied 3 Number of contraventions outstanding at end of year - Canal Boats used as Dwellings: Number of inspections made 66 Number of contraventions outstanding from previous year 3 Number of contraventions found 10 Number of contraventions remedied 8 Number of contraventions outstanding at end of year 5 Movable Dwellings, Caravans, Tents; etc. Number of inspections made 52 Number of contraventions outstanding from previous year 46 Number of contraventions found 13 31 Number of contraventions remedied 36 Number of contraventions outstanding at end of year 23 Bakehouses: Number in district (a) factories 12 (b) workshops 10 Number of underground bakehouses in district 1 Number of inspections made 131 Number of contraventions outstanding from previous year - Number of contraventions found 26 Number of contraventions remedied 26 Number of contraventions outstanding at end of year - Slaughterhouses (including Knacker's Yard): Number on register (a) registered premises 4 (b) licensed premises (including one licensed knacker's yard) 4 Number of inspections and visits made 1291 Number of contraventions outstanding from previous year 5 Number of contraventions found 9 Number of contraventions remedied 9 Number of contraventions outstanding at end of year 5 Cowsheds: Number of persons registered 5 Number of premises registered 6 Number of cowsheds on register 6 Number of milch cows in district 80 Number of inspections made 27 Number of contraventions outstanding from previous year - Number of contraventions found 10 Number of contraventions remedied 9 Number of contraventions outstanding at end of year 1 32 Dairies and Milkshops: Number of persons registered 55 Number of premises registered 35 Number of inspections made 207 Number of contraventions outstanding from previous year 6 Number of contraventions found 18 Number of contraventions remedied 17 Number of contraventions outstanding at end of year 7 Offensive Trades: Number of businesses established in district 19 Number of inspections made 147 Number of contraventions outstanding from previous year - Number of contraventions found 5 Number of contraventions remedied 4 Number of contraventions outstanding at end of year 1 Public Health (Meat) Regulations, 1924: Number of inspections made 1383 No Notice of Slaughtering given 10 Improper notice of slaughtering given 55 Insufficient periodical cleansing of shops, counters, slabs, apparatus or utensils, etc 1 No precautions taken for the prevention of contamination 7 Written, notices sent 2 Verbal notices given 63 Inspection of Food: Number of meat inspections 1810 Number of fish inspections 366 Number of provision inspections 589 Number of greengrocery and fruit inspections 620 33 Number of hawkers' foodstuff inspections 570 Number of other food inspections 202 insound Food: Number of carcases and offal surrendered 6 Number of parcels surrendered 14 Number of organs or parts surrendered during slaughtering 606 Infectious Diseases, Disinfections, etc.: Number of visits made 1725 Number of rooms disinfected (a) ordinary infectious diseases 705 (b) Tuberculosis 74 (c) Other diseases 10 Number of rooms stripped and cleansed after infectious diseases— (а) by owners or occupiers 58 (b) by local authority 6 Number of articles disinfected or destroyed 4112 Smoke Abatement: Number of observations made 42 Number of nuisances found 5 Number of nuisances abated 2 Water Supply: Number of supplies provided or re-instated 22 Number of draw taps connected direct to main 77 Number of water service pipes or taps repaired 14 Approximate percentage of houses supplied on constant system 99.95 Number of samples taken for analysis from local wells 1 Number of samples found polluted or impure - 34 Drainage and Sanitary Arrangements, etc., of existing Buildings: Water Closets: Number of water closets provided or reconstructed 25 Number of water closets provided in substitution for dry receptacles 2 Number of privies abolished 4 Number of walls, etc.. cleansed 21 Number repaired, supplied with water or otherwise improved 353 Number cleansed or unstopped 11 Approximate percentage of houses provided with water closets 99 Sinks: Number of new sinks provided 30 Number of sinks repaired or improved 11 Drains: Number examined, exposed, etc. 8 Number unstopped, repaired, trapped, etc 260 Number of waste pipes provided, disconnected, repaired trapped or unstopped 50 Number of soil pipes fixed, repaired or improved 3 Number of ventilating shafts fixed, repaired or improved 9 Number of fresh air inlets provided, repaired or improved 28 Number of rain water pipes disconnected from drain 3 Number of gully traps inserted or improved 131 Number of disconnecting traps inserted 1 Number of inspection chambers inserted 15 Number of disconnecting traps improved, sealed or cleansed 2 Number of inspection chambers repaired, improved sealed or cleansed 20 Number of drains constructed or reconstructed 24 35 Total length of drain pipes laid (4in.) 933ft. Number of tests and retests applied 8O Number of other works executed 7 Approximate percentage of houses draining into Council's sewer 99 Cesspools: Number rendered impervious, emptied, cleansed, etc. 3 Removal of Household Refuse: Number of new ashbins provided 151 Dampness: Number of roofs stripped, renewed or repaired 224 Number of gutters and rain water pipes provided, repaired or unstopped 178 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 282 Number of damp-proof courses provided 68 Number of yards paved, repaired or drained 114 Interior Work: Number of rooms stripped and cleansed (other than in connection with infectious disease) 308 Number of floors, walls & ceilings repaired or renewed 754 Number of rooms in which ventilation provided or im proved 10 Number of rooms in which lighting provided or improved 3 Number of window frames and sashes provided, repaired or unfixed 707 Number of stoves or grates provided or repaired 143 Number of instances in which ventilation under floors provided or improved 88 Number of other repairs 70 36 Sundry Nuisances, etc.: Number of instances in which domestic cleansing enforced 9 Number of foodstores provided, cleansed or improved 5 Number of washing coppers provided or repaired 102 Number of rooms sprayed for the removal of vermin by the Disinfector 68 Number of instances in which overcrowding abated 70 Number of instances of improper keeping of animals abated 15 Number of offensive accumulations removed 34 Number of urinals provided, repaired, cleansed or improved 15 Number of dungpits provided, repaired or improved 3 Number of contraventions of P.H.A., 1925, s. 73—improper hawking of toys, etc. 2 Number of other nuisances abated 36 Report on the administration of the Factory and Workshop Act, 1901, in connection with FACTORIES, WORKSHOPS AND WORKPLACES. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspection made by Sanitary Inspectors. Premises. Number of Number on Register. Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) (5) Victories (including Factory Laundries) 83 221 12 Nil. Workshops (including Workshop Laundries) 144 326 10 Workplaces (other than Outworkers' premises) 39 95 2 outworkers 34 69 . Total 300 711 24 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions Outstanding Jan. 1st. 1929. Found during 1929. Remedied during 1929. Outstanding Deo. 31st, 1929. Referred to H M. inspecto r 2 3 4 6 6 7 Nuisances under the Public Health Acts:-* Want of cleanliness 1 20 15 6 Want of ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors ... ... ... ... Other nuisances 3 30 29 4 Sanitary accommodation—† Insufficient 6 1 5 Nil. Nil. Unsuitable or defective 1 32 3° 3 Not separate for sexes 3 3 5 1 Offences under the Factory and Work- shop Act:— Illegal occupation of underground bakehouse (s.101) ... ... ... ... Breach of special sanitary requirements for bakehouses (ss. 97-100) ... 20 20 ... Other offences:— Excluding offences relating to outwork ... ... ... ... Total 8 111 100 19 Nil. Nil. Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act, 1901, and remediable under the Public Health Acts. †Section 22 of the Public Health Acts Amendment Act. 1890, has been adopted by the District Council, and the standard of sufficiency and suitability of sanitary accommodation or persons employed in factories and workshops enforced is that required by the Sanitary Accommodation Order of 4th February, 1903. 38 OUTWORK. (а) Outwork in unwholesome premises, Section 108 Nil. (b) Outwork in infected premises, Sections 109-110 Nil. PREMISES AND OCCUPATIONS CONTROLLED BY BYE LAWS OR REGULATIONS. There are 309 known places in this district which call for periodical inspection as follows:— Houses let in Lodgings, Common Lodging Houses, Bakehouses, Slaughterhouses, Cowsheds, Dairies and Milkshops, Offensive trades, Laundries (non-factory), Workshops, Workplaces and Outworkers' premises. SCHOOLS. In this district there are 13 public elementary schools and one Central school; 3 are modern buildings, the remainder being for the most part old and lacking in up-to-date hygienic conditions. 39 HESTON & ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Department, 92, Bath Road. Hounslow. 24th April, 1930.. Sir, Canal Boats Acts, 1877 to 1884. In accordance with Section 3 of the Canal Boats Act, 1884, I leg to present herewith the Annual Report for the year ended 31st December, 1929, as to the execution of the Canal Boats Acts, 1877 and 1884, and of the Regulations made thereunder, within the Urban District of Heston and Isleworth, Middlesex. Inspectors Appointed under Canal Boats Acts— R. H. Butler (Chief Sanitary Inspector). G. W. Ashworth (District Sanitary Inspector). E. W. Barton (District Sanitary Inspector). G. Grieve (District Sanitary Inspector). J. K. Lawson (District Sanitary Inspector). No special remuneration is paid for the position. Number of Inspections, etc.— Number of Inspections made 66 Number of Canal Boats inspected 65 Number of boats found in order 60 Number of boats with three infringements 1 Number of boats with two infringements 3 Number of boats with one infringement 1 Nature of Contraventions,, etc.— Overcrowding 2 Cabins not in a cleanly and habitable condition 4 No proper water vessels provided 2 Paintwork of internal surfaces of cabin requiring renewing 1 Registration certificate dilapidated and not legible 1 40 Legal Proceedings— No legal proceedings have been taken during the year. Infectious Disease— No cases of infectious disease were reported as occurring among the Canal Boat population during the year. 1 am, Sir, Your obedient servant, ELWIN H. T. NASH, Medical Officer of Health. 'The Secretary, Ministry of Health, Whitehall, S.W.I. 41 HOUSING. 42 Housing conditions are improving as a result of the policy of the Council, which is to re-house those people whose houses have been closed as unfit, or found to be overcrowded. Up to the end of the year the Council have built in all 541 houses for letting purposes. At the same time, rapid progress has been made with building houses for sale, the total number purchased during the year under the Small Dwellings Acquisition Act was 1008, and the total amount of loans under the Small Dwellings Acquisition Act up to the end of 1929 was £2,633,654. The plight of a family with children in their search for accommodation is still lamentable. They have only to mention the fact that there are children, and the door is closed on. their enquiries. There is a long list waiting for Council houses as they become vacant. In the meantime van dwellers increase and are becoming a great difficulty in the district. With respect to Van Dwellers, the time is rapidly approaching, in my opinion, when the comparative immunity which this class of population has secured must be reconsidered. I have yet to meet the Medical Officer of Health who has had much to do with this class of population, who does not regard them as an unmitigated nuisance. True there is a certain proportion of the better class who are law abiding citizens, but there is a considerable number subversive of discipline, rowdy, threatening to those who interfere with them, dirty in their habits, and generally undesirable in. any district. I am, as I said last year, constantly being appealed to to assist in getting a "Council House." In almost every case the applicants are decent working class families with their own furniture, and in steady work, who can afford to pay a reasonable rent. Some have offered up to 20/- per week. These, even if they can get 43 rooms, are at the mercy of the profiteering landlord. It is melancholy work listening to the tale of the many trampings of the mother of a family to whom every door is shut directly she admits the existence of a family. I. Fitness of Houses. (1) (a) General standard of Housing in the district: The general standard is steadily improving. (b)General character of defects found to exist in unfit houses: Dampness due to want of proper damp-proofing, inadequate lighting and ventilation and general dilapidaton are the main defects found. (c) How far defects are due to lack of proper management and supervision by owners: The defects found are mainly due to owners neglecting to have repairs carried out. (2) Action taken as regards unfit houses under: (a) Public Health Acts See appendices. (b) Housing Acts „ (3) Difficulty in remedying unfitness; special measures taken and any suggestions in the matter: Landlords give the price of materials and the cost of labour as reasons for delay or neglect in the repair of reparable 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. 44 Closet accommodation is generally adequate, but defective apparatus is frequently complained of, whilst in the outlying parts of the district air 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. 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) As to need for new Bye-laws and revision of existing Bye-laws : Some difficulty has been experienced in dealing with caravan dwellers under the existing bye-laws with regard to the disposal of refuse, and closet accommodation, and a revision of these bye-laws is under consideration. IV. General and Miscellaneous. Other action taken in connection with overcrowding. Insanitary property and housing NIL. 45 V. Appendices, Statistics for year ending 31st December, 1929. APPENDICES. Housing Conditions Statistics. Year ended 31st December, 1929. I. GENERAL. (1) Estimated population—Birth rate 63,070 Death rate 62,240 (2) General Death rate (corrected) 11.5 (3) Death rate from Tuberculosis (all forms) 0.8 (4) Infantile Mortality 46.38 (5) Number of dwelling-houses of all classes 15,220 Total number of new houses erected of all classes 1,551 Number of New Houses erected during the year:— (a) Total (including figures given below) 1,551 (b) With State assistance under the Housing Acts:— (1) By the Local Authority 181 (2) By other Bodies or Persons — 2. UNFIT DWELLING HOUSES. I. Inspection. (1) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 1104 (2) Number of dwelling-houses which were inspected and recorded under the Housing Consolidated Regulations, 1925 227 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 47 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-heading) found not to be in all respects reasonably fit for human habitation 488 46 (5) Number of houses, listed for inspection under the Housing Consolidated Regulations, 1925, at end of year 1308 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 330 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 39 (2) Number of dwelling-houses which were rendered fit after service of formal notices— (a) by owners 5 (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 27 (2) Number of dwelling-houses in which defects were remedied— (а) by owners 9 (b) by Local Authority in default of owners 2 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 47 47 (2) Number of dwelling-houses in respect of which Closing Orders were made 48 (3) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit Nil. (4) Number of dwelling-houses in respect of which Demolition Orders were made 2 (5) Number of dwelling-houses demolished in pursuance 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 9 (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 The Inspectorial staff of the Health Department consists of one Chief Inspector and four District Inspectors. There is no officer appointed wholly for housing duties, which are carried out by the staff in conjunction with their other duties. Table shewing dwelling-houses represented as unfit for human habitation. Premises. No. of houses represented by M.O.H. Date of representation. Date Closing Order made. Date Closing Order determined. Date Demolition Order made. Date Demolition Order obeyed. Date Demolition Order enforced. Br'f forW'd from 1928— *1-3, Poplar Cottages, Town Wharf, lsleworth 3 8/1/14 24/2/14 ... 22/12/14 *15, South Street, lsleworth l 11/1/15 27/4/15 ... 23/11/15 14-34, London Road, Brentford End 11 12/5/19 22/7/19 10/6/29 23/7/29 1-10, Syon Place, London Road, Brentford End 10 12/5/19 22/7/19 10/6/29 23/7/29 65-75, Hanworth Road, Hounslow 6 12/1/20 23/11/20 13/5/29 25/6/29 175, Twickenham Rd., lsleworth 1 12/1/20 26/4/21 177 ,, ,, 1 12/1/20 1 & 3, Wellington Road North, Hounslow 2 13/5/29 25/6/29 9/2/20 Cottage situated in the Farm Buildings, Wood Lane Farm, Wood Lane, lsleworth l 13/5/29 25/6/29 13/7/25 22/9/25 Promises No. of houm repretented by M.O.H. Date of representation. Dale Closing Order made Date Closing Order determined. Date Demolition Order made. Date Demolition Order oboyed. Date Demolition Order anforood. Losbey Cottage, Wellington House not demolished —written undertaking Road South, Hounslow l 12/12/27 24/1/28 given by owner that it will not again be used for human habitation. 335, London Road, Isleworth l 5/4/28 22/5/28 27/11/28 ditto 4, Barnfield Cottages, Spring- well Road, Heston 1 7/5/28 26/6/28 23/7/29 17, Bell Road, Hounslow 1 10/12/28 22/1/29 23/7/29 Cottage, Brentside, London Road, Brentford End l 10/12/28 22/1/29 Premises converted in to stables. Dealt with in 1929— Woodbine Cottage, Bath Road, Hounslow l 11/3/29 23/4/29 34, Holly Road, Hounslow I 8/4/29 28/5/29 Premises d emolished 2 -9-29 Cottage in grounds of Heston Lodge, New Heston Road, Heston l 8/4/29 28/5/29 House not demolished—written undertaking given by owner that it will not again be used for human habitation. 240 & 242, London Rd.,Isleworth 2 11/11/29 17/12/29 11, 13 & 11, Syon Cottages Svon Lane, Isleworth 3 11/11/29 17/12/29 123,"125, 127, East and West, Vicarage Farm Road, Heston 4 11/11/29 17/12/29 6, London Road, Brentford End 1 9/12/29 8, London Road, 1 26/11/29 10 i: 12, London Rd., 2 26/11/29 17/12/29 36, Holly Road. Hounslow 1 26/11/29 17/12/29 *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 1810 Fish 366 Provisions 589 Greengroceries and Fruit 620 Hawkers' Food Stuffs 576 Number of other Food Inspections 202 Milk. There has been a very definite improvement in milk vending. The standard of a milk shop is also steadily improving. The popular demand for a cream line is producing a simultaneous demand for efficient pasteurising owing to the lack of cream line as a result of flash pasteurising. Much of the advantage of a clean milk supply is lost by the decanting of the milk when delivered 'rom the bottle into unsterilised containers. It is far hotter in the smaller homes if they would retain the milk in the bottles as delivered, keeping something over the top to ensure the absence of flies and dust. The demand for the cream line produces difficulties, particularly with infant feeding, as unless the bottle is very well shaken and can be shaken after each time it is set aside to stand, there is a very definite deterioration in. the cream content of the later samples in the bottle. What so often happens is that the first user in the morning has a surplus of cream in the milk and that those using the bottle (particularly quart bottles) get progressively less and less cream as the bottle empties. From the point of view of general utility, there would appear to be no doubt that homogenisation would definitely improve things by giving a milk with practically a standard fat content, but the trade value of the cream line would probably be the chief obstruction to getting an homogeneous milk. 53 234 inspections were parried 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 3 firms have applied for a Licence to sell "pasteurised" milk under the Milk (Special Designations) Order, 1923. Number of firms in the district licensed to sell— " Certified " milk 5 (16 shops) " Grade A (Tuberculin Tested) " 6 (17 shops) " Grade A" — "Pasteurised" 3 (12 shops) All the milk shops are being brought up-to-date to ensure complete cleanliness in dealing with their utensils, and under the latest Regulations it is to be hoped that a really satisfactory standard will be reached and maintained. Meat Inspection. 1. jMeat Inspection.—This is still kept at a very high pitch of efficiency. The Chief Sanitary Inspector and the District Sanitary Inspectors hold special certificates for the meat inspection Slaughter-houses and butchers' shops are visited periodically. During the year 3390} lbs. of diseased meat were surrendered. There are 7 slaughter-houses in use in the district and each slaughter-house received on an average 15.4 visits per month. There were 45 butchers' shops in the district at the end of 1929. 2. Public Abattoir.—There is no public alattoir in the district. Slaughtering may take place at. 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 occasion advised against it, on the 54 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 in.to 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 1929. 4. Tubercular Meat—There was none seized, but 2252J lb?, were surrendered during the year. 5. The following is a tabular statement on slaughter-house?: 1920 In January 1929 In December, 1929 Registered 4 4 4 Licensed 4 3 3 Total 8 7 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 v.ears Number of Inspections, etc., made. 1924| 1925 1926 1927 1928 1929 Meat—Inspections made 556 1513 1790 1820 1985 1810 Slaughter-houses—Inspections and visits made 204 1131 1106 1400 1463 1291 Most of the butchers have loyally fallen into line with regard to giving notice of slaughtering, but in 76 instances no notice+ 55 or insuffieient notice of slaughtering was given, a large number of which could be avoided with a little forethought. When new butchers' shops are opened every effort is made to obtain fixed windows. There are in all 45 Butchers' shops in the district. Up to the present, 28 have been provided with fixed windows, of which number 3 were new shops in 1929, one is provided with one fixed window and one window made to open, 2 have one fixed window and two windows made to open, and the remainder have windows made to open. 56 Meat setzecf Of stsrrenc/brec/ ancf inspections made dur,ng 1924-25-36-27- 23 29 number of fts cr mspecCtons MumbQrof 'bs. or <nsfieet/ons 7000 6000 SOOO SOOO JSOO 3QQO 2S00 2500 tSOO /ooo Mat Seized Of surrendered /n 1(3$ —— Mc&C /njjpfct/j/hi 57 INSPECTION OF OTHER FOODS. Section 72 of the Public Health Act, 1925, provides, in some measure, for the prevention of contamination of food stuffs (other than meat) when stored or kept on enclosed premises; but there appear to be no provisions made for dealing with the contamination of foodstuffs deposited for sale, in an open manner, on forecourts to shops and on stalls and barrows standing or moving about the roadways of a district. I wish again. to draw attention to the want of perspective in the way in which meat is dealt with, and such things as figs, dates, sweets and biscuits, which are eaten raw, are exposed in open shop fronts, barrows, and on street vendors' trays, on which horse dung and other filth has blown, whereas meat is cooked before being eaten. The time has come when legislation should be provided to insist that all such foods should be kept inside, and if possible under cover. 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 1929 : Article Taken Adulterated Milk ... 238 7 Cream 2 — Gin 3 — Meat 6 — Minced Beef 2 — Rum 2 — Sausages 5 — Whisky 4 1 262 8 The unsatisfactory samples of milk were informal samples in which small deficiencies in fat were reported. No formal sample was reported as adulterated. The unsatisfactory sample of whisky was also an informal sample. Subsequent formal samples from the same vendor were satisfactory-. UNSOUND FOOD, 1929. Tons. Cwts. Qrs. lbs. Fish 2 1 9½ Meat 1 10 1 2⅓ Rabbits 2 9 Vegetables 1 12½ Fruit 22⅓ Total 1 13 3 0½ 59 INFECTIOUS DISEASES. 60 INFECTIOUS DISEASE. Scarlet Fever and Diphtheria. There were 14 "return" cases of Scarlet Fever and fi of 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 2s days after the release of a case from isolation at home. Two of the return cases of Diphtheria occurred after a ca« nursed at home had been declared free from infection. 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 223 No. of civil cases removed to Hospitals 192 Percentage of cases removed to Hospitals 84.2 The incident rate of Scarlet Fever in the civil population was 3.66 per 1,000. One death 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 370 No. of civil cases removed to Hospitals 344 Percentage of cases removed to Hospitals 92.9 61 The incident rate per 1,000 of the civil population was 5.94. Eighteen cases occurred in institutions during the year. 23 deaths took place from this disease, i.e., a case mortality rate of 6.21 per cent. The deaths occurred in the following age groups :— Age. No. of deaths. 2 1 3 1 4 3 5 2 6 4 7 4 8 2 9 4 10 — 11 2 And in the following months: — January 2 February Nil March 1 April Nil May 1 June 3 July 3 August 2 September 2 October 5 November 3 December 1 Diphtheria during 1929 gave the Public Health Department not only a great deal of anxiety, but an enormous amount of work. Speaking broadly the disease started in the early part of the year in the eastern end of the district, and spread gradually across from east to the west, 62 The incidence of the disease gradually became greater as the year progressed, as is shown by the figures on the accompanying graph. During the summer holidays the numbers as will be seen, diminished considerably, and one hoped that the Autumn would prove that the outbreak had substantially diminished or was over. This unfortunately proved not to be so, and there was a steady progress upwards from September. In the early part of the year the outbreak was principally confined to the congested part of the Isleworth North Ward. The children from this area attend the Isleworth Town School, and a considerable number of cases were notified from the various class; in that school. A strict watch was kept on the classes and any suspicion! cases swabbed, but it was impossible to convict the school as a factor in the spread. This was borne out by the fact that in the Junior School the classes affected, mixed with portions of two classes for handwork lessons with what is known technically as "free discipline," and despite the mixing of children with the classes amongst whose pupils cases kept cropping up in the half of the class that remained in their original room, no cases occurred amongst the pupils of the two other classes with whom they mixed. In order to clear the matter up, eventually the whole school was swabbed, including the teachers and the caretakers, and cultures were taken from the drinking apparatus, but it was clear that the spread was taking place outside the school. Despite everything that was done to limit the outbreak, the disease progressed, and one could only come to the conclusion that one had to deal with an "unsalted" population. This district has been growing enormously, and a considerable proportion of the population have come out from more congested areas into a district in which practically all the new houses are 63 semi-detached with ample gardens, and it appeared that the reason for the inability to control the situation was the fact that the population had largely lost its immunity. (This has been borne out in 1930 at the diphtheria immunisation clinic where every case has been Schick tested. The proportion of immunes has been found to be only 16 per cent.) All contacts were swabbed, both nose and throat, and the same process had been carried out in school investigations. This, as may be realised, gave an enormous amount of work to the department, as will be seen by the fact that the total number of swabs examined during the year was 6021, and this, as would be expected, resulted in the finding of a considerable number of positive nasal cases. Doubts of course arise on these occasions as to whether the bacterial cases which are being picked up are sources of danger—in other words whether they are virulent or not. In order to see how things were going, random samples of cases were sent for virulency tests. Dr. O'Brien, the director of the Wellcome Research Laboratories, kindly undertook to do this work for me, so that there can be no doubt as to the accuracy of the results. A series of cases were sent, the first of which we regarded as doubtful as being a true Kleb-Leoffler's Bacillus. The virulency reports were, with the exception of this first one which was returned as non-virulent, virulent in every case. On the face of that, and what one took to be the unsalted condition of the population, despite what some other Authorities say, there appeared to be no alternative but to pursue the same course and to pursue it diligently. The bacteriological conditions were peculiar during a portion of the year, in that the confirmatory Neisser staining was extremely poor. There appeared to be no doubt whatever about the character of the organism stained with the usual stains, either Loelfler, 64 Muir or Ponder, but in the ease of the Neisser stain the polar bodies only showed extremely faintly, in fact at times scarcely diseernable, a condition which, speaking with 25 years' experience, 1 had never come across before. I put the matter up to Dr. O'Brien, who reported that he did not think "there was any special significance to be attached to this very poor polar staining," as from time to time he came across "virulent cultures typical in every other respect which did not stain deeply by Neisser." This was borne out by the fact that the cases which were sent for virulence tests and stained in this particular manner, were Teturned as virulent. The bacterial cases were, when possible, isolated at home, but the crowded condition of many houses rendered it imperative in view of these findings, that they should be accommodated in the Isolation Hospital. The difficulty of dealing with them is illustrated very well by the case of a boy who was picked up in the course of contact swabbing at school, a big, lusty lad of 13, and the picture of rude health. His right tonsil was slightly enlarged, and appeared 'o have a patch of thickening in, its centre, but nothing more. His culture was abundantly positive. He was isolated at home and treated, and despite all methods of treatment remained positive, and when tested for virulency was returned as virulent. He was eventually removed to the Hospital, and until his tonsils were removed he returned positive cultures. The type of disease seemed to get progressively worse as the year went on. Our Isolation Hospital accommodation, which had been getting more and more inadequate owing to the continual growth of the district, was now absolutely incapable of meeting the situation, and on the 20th May I was compelled to send cases to the 65 Metropolitan Asylums Board Hospitals, and later, when they were unable to help owing to their own difficulties, to the Staines Rural District Hospital. 62 cases were sent to the M.A.B. Hospitals and 18 to the Staines Isolation Hospital. Ultimately, in December, when one's borrowing powers had been exhausted, I was compelled to seek other means. I got such information as could be obtained with regard to large empty houses in the district. The only one which appeared suitable being one in the Brentford Area. The Chairman and I had an interview with the Chiswick and Brentford Council, but were unable to obtain their permission to utilise the building, as it would mean taking cases of infectious disease into their area. The old Dockwell Smallpox Hospital had been closed since October, 1928, when we agreed to go into the County Scheme for treatment of smallpox, and attempts had been made to sell the site. As there appeared no possible accommodation elsewhere, I went to inspect, and found the place more or less derelict, the grounds having been turned by the caretaker into a pig farm. I took the Chairman down to inspect the place, and he agreed that it must be utilized as the only solution of the difficulty. The matter was reported to the Public Health Committee which met two days later. The account of subsequent happenings is embodied in the accompanying report, which was presented to the Committee at their January meeting. " Re-opening of Dockwell Isolation Hospital for Diphtheria Cases. Anticipating the possibility of the sanction for opening Dockwell Hospital, I had made arrangements previous to the meeting on the 9th December, for a Disinfector to be in attendance. Directly the motion was passed the word was sent out and two Sanitary Inspectors were picked up, and before the termination of the meeting the Hospital was disinfected. 66 Arrangements had also been made in case sanction was given that workmen should be on the premises first thing in the morning. This was done, and the work was pushed on with all the expedition possible. I saw the Chairman of the Joint Board the following morning and got his approval to the co-operation of the Mogden staff with respect to housing and feeding the nurses. Difficulty was experienced in obtaining the delivery of the necessary cots; none of the firms first interviewed could give delivery under ten days. Eventually one firm promised delivery in five days. The Surveyor's staff were working continuously there until Saturday morning. It was arranged that the necessary equipment should be delivered between 10 a.m. and 1 p.m. on the Saturday morning. In order to do this the firm delivering the cots despatched them at 3 a.m. by road from Birmingham. Practically everything arrived to time. The Nurses reported for duty at 9.30 a.m. on Saturday morning and worked like Trojans to get the place ship-shape. Admission of the first batch of patients had been arranged for 3 o'clock on the Sunday following the meeting, and within a few minutes of that time the first six patients had arrived. Arrangements were made that the night and day Nurses slept at Mogden, and that the washing for the whole Hospital was done at the Mogden Laundry. The night Nurse was brought down by the Ambulance, and the day staff were taken back. I was fortunate in obtaining as cleaner a woman who has worked for my family for some time, and upon whom 1 could absolutely rely. 67 The first two wards filled directly, and as more accommodation was necessary, the Chairman authorised the addition of a sanitary annexe to the second block, in order to enable a further five cases to be taken. This meant strenuous work by the Surveyor's staff, who were working on Sunday, and up till dinner time on Christmas Day. I should like to place on record my appreciation for the way they got through the necessary work in order to enable the patients to be admitted at the earliest possible moment. These extra cots were soon filled, and we have been continuously full ever since. We have had to discharge 17 patients owing to pressure at Mogden. This has meant that whenever the call for beds has come, I have had to arrange for the removal of such cases as could best be dealt with at home, mainly on the grounds of lack of overcrowding. During the last week, however, the pressure has been such that I have had to send out into crowded homes, children who were not yet fit to be up. In two cases I have had to send out children whom I could not certify as free from infection, but they were over the acute stage of their illness, and were isolated at home. It should be understood that this is a serious anxiety, in that if not properly handled at home, there is the possibility of complications arising which may have serious results. I think, however, that it is far more important to have the children in Mogden during the acute stage of their illness, and for that reason I am making room in Dockwell. When an emergency case of diphtheria occurs, I have to sort out at Dockwell the patients I think fit to send home, and inform the G8 parents they are coming. In several instances I have had top myself, as the demand has been urgent after office hours, and sometimes late in the evening. The cases have to be sent home from Dockwell, cases have to be transferred then from Mogden to fill these beds, and then, and then only, the patient who has been notified can be admitted to Mogden. In one case I had to arrange for the removal of a patient late at night, and twice visited the home but found nobody there, so having made arrangements for the admission of the case, and the transfer of others from Mogden, I had to sleep one patient on the floor over night, to be sent home early the next morning. It was necessary with the opening of the other ward to engage a second night Nurse who is being housed in the cottage at Dockwell, and it was also necessary to engage a relief Nurse, as none of the day staff had had any time off duty since the opening of the Hospital. The piggery which existed when we took over was demolished, and the pigs sold at the earliest possible moment. One great difficulty has been the question of lighting, ns owing to the sudden emergencies which arise in the case of diphtheria, it is imperative that the Hospital shall be capable of being well lit. I installed "Aladdin" Lamps, and owing to the necessary use of these and many smaller lamps, I doubled the fire' precautions, but despite this and careful handling of the lamps, we have had two slight accidents. As a result I obtained estimates for electric lighting from the Electrical Engineer. The installation was sanctioned by the Chairman. The idea had been to take the current from the Great West Road Extension Sand and Gravel Co. At the last minute they demanded £25 for this facility. 69 I hung up the work pending the Chairman's decision, but in view of the need for safety and the light, he authorised the continuance of the working, which is now in hand. The place is running smoothly and efficiently. The Hospital was visited on Christmas Day by the Chairman of the Health Committee, Mr. Hart, Mr. Green and Mr. Divine, and since then by Miss Ankritt and Dr. Brebner. If this present pressure continues, it will be imperative to consider the immediate extension of the second block to give another five or six beds, which will have to be of a larger size than at present, to accommodate older patients. So far we have managed to carry on by only admitting the small children that can be got into cots. One of the difficulties has been that we are only working with about 500 cubic feet of air space per bed, which is only one quarter of the proper amount. This necessitates extra ventilation, and therefore extra heating. This latter has been got over by utilising large water cauldrons on the coal stoves in the centre of the ward to provide the necessary hot water for the evening baths and other work, and also to act as accessory radiators. I wish to place on record my great appreciation of the helpful way in which the Matron at Mogden has stepped into the breach and facilitated in every way possible the inter-working of the two Institutions. I also wish to place on record my approval of the way that Miss Gribble, one of our Health Visitors, who has been acting as Matron at the Hospital, and the two temporary Nurses worked to get the place in order, and put up with inconveniences inseparable from such an Institution, cheerfully and willingly in order to make the thing a success. 70 It was found that Mr. Crosswaites, who, with his wife, his been acting as caretakers under the old scheme, and was responsible for keeping the grounds in order, was, throng advanced bronchitis, quite unable to carry out any duties, and therefore arrangements had to be made for the temporary stoke doing duty at Clipstone House, to divide his time between Clipstone House and Dockwell Hospital. There is a considerable amount to be done in, the grounds together with the necessary filling of coal bunkers, emptying and filling earth closets, and various odds and ends which arise in such an Institution. Mrs. Crosswaites has been retained, and is doing excellently as cook to the Institution, attending to the gate, and relieving the cleaner in the wards during her time off. Readjustments of the remuneration for their service has been made on the basis of the inability of the husband and lie extra duties carried out by Mrs. Crosswaites. I also wish to place on record our thanks to those was generously contributed to provide toys and other things for the children at Christmas. They had quite a happy little time with a well covered Christmas Tree on Christmas Day, and also another on Net Year's Day. Figures with regard to the cost of opening and equipping, and with regard to the running expenses, will be reported to the Committee at the meeting on Monday evening, 13th January, 1930." In all 52 bacterial cases were dealt with, but these were not returned to the Ministry as cases of diphtheria. With these, the total number dealt with for the year was 422, and the following table shows the distribution in, their various wards, and the months in which they occurred, which are also shown on the graph. 71 DIPHTHERIA YEAR, 1929 (including Bacterial cases, 52 in November). Month. WARD. Elem. School Children. Other School Children. Other Cases. Total. Heston. Hounslow Nth. Hounslow Sth Isleworth N. Isleworth S. January 24 — 3 2 11 8 15 1 8 February 12 — — 2 9 1 6 — 6 March 17 1 1 7 7 1 9 — 8 April 18 3 3 4 6 2 8 — 10 May 42 8 4 10 19 1 32 — 10 June 48 5 8 10 14 11 30 6 12 July 46 12 10 9 10 5 3S 1 7 August 18 3 1 8 4 2 9 — 9 September 38 8 7 14 8 1 30 1 7 October 56 6 10 17 19 4 38 3 15 November 46 8 5 16 6 11 30 — 16 December 57 7 7 38 4 1 41 2 14 Totals 422 61 59 137 117 48 286 14 122 72 It was fortunate as far as Mogden Hospital was concerned that the increase of diphtheria which occurred later in Kichniond did not. coincide with ours, otherwise the position would have been more difficult than it was. In a stable district with a stationary "salted" population it may be possible to sit with folded hands and confine swabbing to within narrow limits, and more or less disregard the carrier who may or may not be virulent, with the knowledge that to difference it is going to make is not going to be material, but in the cases of populations of children "unsalted" and susceptible, and a rising toll of deaths, one cannot refuse to utilise any or every method which may help to minimize the outbreak, no matter how much work or embarrassment it may give to the Public Health Department of the district. Owing to the widespread outbreak I suggested to the Council that early steps should be taken to institute an Immunisation Campaign, and on 2'Gth July, 1929, Dr. Lethem kindly came down from the Ministry of Health and gave an address to the members of the Council. Difficulties and doubts were raised as to the possible dangers. In November, as the Council were sending a deputation to Birmingham on the matter of sewage, knowing that immunisation was being carried out extensively in that city, 1 got in touch with Dr. Newsholine, who very kindly arranged a special immunisation clinic on that day, so that the members of the deputation could see the work actually in progress on a large scale. The members were profoundly impressed by the work which was being done in Birmingham, and two of them were Schick tested at the Clinic (one proving immune and one non-immune). The result was that a definite campaign was entered into and arrangements were made for public meetings and propaganda early in the new year. 73 It is difficult to describe the amount of work which the outbreak threw on the medical staff, as all the bacteriological work is done in our own laboratory. In addition to which we do the bacteriological work for the Staines Rural District. This work has to be done before the normal day's work is commenced. The increased work necessitated the employment of increased staff, which was accomplished by temporary part time assistants carrying on the various clinics to relieve the permanent staff. One of the greatest difficulties on occasions like these is to prevent certain sections of the laity from stampeding and demanding things which are perfectly useless when dealing with theria. The old ideas still stick, and one has to hammer repeatedly at the fact that diphtheria is a personal disease and not a general diffusible miasma. Diphtheria Antitoxin. Boxes Containing a Sterile Antitoxin syringe and the sary dressings, etc., are kept at the two Police Stations so as to be available in case of emergency. During 1929, 117 vials of Antitoxin of 8,000 units each were supplied to Medical practitioners. Enteric Fever. There were 6 cases notified during the year, the majority of which were Para-typhoid B. Erysipelas. 39 cases of this disease were notified, of whom 26 were West middlesex hospital cases. 19 were non-residents in this district. Ophthalmia Neonatorum. See page 92. Puerperal Fever. 6 cases of this diseases were notified; 3 of these were notified from the west Middlesex Hospital. These were patients not usually resident in this district. 74 Puerperal Pyrexia. 13 cases were notified; 5 of these notified from the West Middlesex Hospital were of patients not usually resident in this district. In one case, which was nursed at home, the mother died. Encephalitis Lethargica. There were 2 cases notified this year. Loth were notified from the West Middlesex Hospital; the patients were not usually resident in this district. Cerebro-Spinal Fever. 2 cases of this disease were notified. Both were notified from the West Middlesex Hospital, but only one of the patients was usually resident in the district. Acute Poliomyelitis. No cases were notified. Pneumonia. 216 cases were notified. 173 notifications were from the West Middlesex Hospital. 146 were non-resident in this district. 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 forth the numbers of such cases for the last five years: — 75  1925 1926 1927 1928 1929 Measles 239 497 35 688 83 German Measles 43 75 7 9 344 Chicken Pox 243 408 243 265 423 Mumps 266 246 352 138 106 Whooping Cough 213 131 157 171 177 Upon receipt of information of the existence of a case, inquiry is made by a School Nurse to obtain all necessary facts. Influenza. The mortality from Influenza was 0.62 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. Where application is made, the Health Department undertakes the spraying of rooms for the removal of bed bugs. Bedding and clothing generally can be disinfected by steam at Mogden Isolation Hospital. Notifiable Diseases during 1929. DISEASE. TOTAL CASES NOTIFIED. TOTAL ALL AGES 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 years 20-35 years 35-45 years 15-65 years 65 years and over. MOGDEN. OTHER HOSPITALS Small-pox ... ... ... ... ... ... ... ... l ... ... ... 1 ... 1 Enteric Fever ... ... ... ... 1 1 ... 1 3 ... ... ... 6 2 2 Scarlet Fever ... 9 4 11 15 126 25 16 20 2 ... ... 228 184 8 Diphtheria 2 3 12 17 19 204 70 20 11 10 2 ... 370 264 80 Erysipelas ... 3 ... ... ... 1 2 ... 5 7 13 8 39 ... 26 Puerperal Fever ... ... ... ... ... ... ... ... 5 1 ... ... 6 ... 5 Puerperal Pyrexia ... ... ... ... ... ... ... ... 11 2 ... ... 13 ... 11 Ophthalmia 8 ... ... ... ... ... ... ... .... ... ... ... 8 ... 3 Neonatorum Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebro Spinal Fever ... 1 ... ... ... 1 ... ... ... ... ... ... 2 ... 2 Pneumonia 10 18 15 7 6 13 9 9 36 33 41 19 216 ... 182 Dysentery ... ... ... ... ... ... ... 1 ... ... ... ... 1 ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... CASES OF DIPHTHERIA OCCURRING IN THIS DISTRICT DURING-1930. JANUARY 23. FEBRUARY 22. MARCH 29. APRIL 16. MAY 13. JUNE 9. JULY 21. AUGUST SEPTEMBER 10. OCTOBER 11. NOVEMBER 7. DECEMBER 4. Infectious Diseases, 1929. Cases Notified. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever Erysipelas. Cerebro-spinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Malaria. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Dysentery. Puerperal Pyrexia. Small-pox. January 17 24 ... ... 5 1 ... ... 30 ... 1 3 1 1 ... 1 February 15 11 ... 1 ... ... ... ... 31 ... 5 1 ... ... 2 ... March 12 16 1 1 6 ... ... ... 38 ... 1 ... ... ... ... ... April 20 16 ... 1 2 ... ... ... 21 ... 6 5 1 ... ... ... May 28 40 1 2 5 1 ... ... 25 ... 5 1 ... ... 2 ... June 15 42 1 ... 2 ... ... ... 10 ... 5 2 2 ... 4 ... July 11 33 1 ... 4 ... ... ... 17 ... 3 1 1 ... 2 ... August 11 13 ... ... ... ... ... ... 6 ... 7 1 1 ... 1 ... September 15 35 2 ... 3 ... ... ... 4 ... 4 2 ... ... 1 ... October 32 44 ... 1 3 ... 1 ... 14 ... 4 ... ... ... ... ... November 22 44 ... ... 6 ... 1 ... 9 ... 5 3 ... ... 1 ... December 30 52 ... ... 3 ... ... ... 11 ... 8 ... 2 ... ... ... Totals 228 370 6 6 39 2 2 ... 216 ... 54 19 8 1 13 1 Deaths from Notifiable Infectious Diseases, 1929. 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 Total All Ages. Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... 1 ... ... ... ... ... 1 Diphtheria ... ... 1 l 3 16 2 ... ... ... ... ... 23 Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... l ... ... ... 1 Pneumonia 4 1 6 ... ... 1 3 1 4 6 18 16 60 Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 1 1 Cerebro Spinal Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... Total 4 1 7 1 3 17 6 1 5 6 18 17 86 For Tuberculosis Deaths—see other Table. The table hereunder gives the number of cases of infectious diseases that were notified from the several Institutions in the district during 1929:— SMALLPOX. ENTERIC FEVER. SCARLET FEVER, DIPHTHERIA. PNEUMONIA (all forms). ERYSIPELAS. PUERPERAL FEVER. PUERPERAL PYREXIA CEREBRO SPINAL FEVER. OPHTHALMIA NEONATORUM. ENCEPHALITIS LETHARGICA. PULMONARY TUBERCULOSIS. OTHER TUBERCULOSIS. POLIOMYELITIS. TOTAL. West Middlesex Hospital ... 3 14 13 173 26 3 5 2 2 2 10 1 ... 254 Hounslow Hospital ... 1 1 3 ... ... ... ... ... ... ... ... ... ... 5 Hounslow Barracks ... ... 7 2 1 ... 1 ... ... ... ... ... ... ... 11 Mogden Isolation Hospital ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Collingwood College ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... St. Mary's School ... ... 2 ... ... ... ... ... ... ... ... ... ... ... 2 ... 4 24 18 174 26 4 5 2 2 2 10 1 ... 272 80 COUNCIL LABORATORY, 1929. Total Positive Swabs for Diphtheria sent by Medical Practitioners 873 175 Taken from Schools, Clinics, and from Contacts 4637 96 Sub-cultures 38 5 Sent from Staines Joint Isolation Hospital 473 35 Swabs examined by Clinical Research Association 246 26 Total cultures examined 6267 337 Virulency Tests 10 9 Blood examination for Typhoid Widal Tests 19 4 Specimens of Sputum for Tubercle Baccili sent by Medical Practitioners 108 14 Hairs for Ringworm— Taken at Schools or Clinics 24 11 Other Specimens— Urine 249 Discharge 2 Milk 15 Faeces 3 Preparation of Materials— Tubes of Serum 5656 Throat Swab Outfits 5500 Sputum Outfits 160 Total 11,316 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 Widal Tests were carried out for us by the Clinical Research Association. The specimens of faeces and some swabs were also examined by the Clinical Research Association. 81 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 54. Thirty cases were notified from Institutions— Sanatoria 15, Poor Law Institutions 9, General Hospitals 6. There were 44 deaths from Tuberculosis of the Respiratory System. Thirteen of these were not notified. Of the new cases notified 47 received Institutional Treatment during the year, and eight died. Other Forms of Tuberculosis. The number of new cases notified during the year was 19. Twelve of them were notified as receiving Institutional Treatment. There were 6 deaths. All were unnotified cases. Deaths from Tuberculosis. Of the 19 deaths which occurred in non-notified cases 5 had been attended by private practitioner. 1 had only recently entered the district. 6 were transferred deaths. 1 was a case of Tuberculous Meningitis, diagnosed in Hounslow Hospital. 6 were patients who died in the West Middlesex Hospital. Tor Table showing new cases notified and deaths in 1929 see next page. 82 TUBERCULOSIS 1929. Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 ... ... ... ... ... ... ... 1 1 ... ... 4 1 ... ... 1 1 5 1 ... 4 3 ... ... ... ... 10 ... ... 1 2 ... .... ... ... 15 3 1 ... ... 3 2 ... 1 20 4 4 1 1 2 6 ... ... 25 9 9 ... 1 8 4 ... ... 35 11 4 ... ... 4 4 ... 1 45 3 ... ... ... 7 1 ... 1 55 2 3 1 ... 1 1 ... ... 65 and upwards ... ... ... ... ... 1 ... ... Totals 33 21 11 8 25 19 1 5 Thirteen of the deaths from Pulmonary Tuberculosis were not notified and six deaths from Non-Pulmonary Tuberculosis were not notified. 83 MATERNITY AND CHILD WELFARE. 84 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. One Clinic weekly at Heston Parish Hall, on Tuesday afternoons. At each of these Clinics infant consultations are carried out. Babies and toddlers are regularly weighed. Dried milks, malt, virol, etc., are on sale as directed by the Medical Officer. The Mothers can obtain a cup of tea and biscuits at a cost of 1d. The attendances totalled 17,667 for the year, as compared with 16,625 in 1928, 14,020 in 1927, 11,567 in 1926, 9,843 in 1925 and 8817 in 1924. It will be seen that the attendances have doubled in the last five years. The average attendances were as follows:— At Douglas Road Centre 95.8 At Isleworth Centre 50.1 At Heston Centre 58.1 The number of individual mothers and children attending the Clinics is shewn hereunder:— 1926 1927 1928 1929 Douglas Road, Hounslow— Mothers 562 688 605 733 Children 765 880 802 914 Isleworth Public Hall— Mothers 326 305 356 367 Children 432 414 460 452 Heston— Mothers — — 157 212 Children — — 213 253 85 The drop in the numbers at Douglas Road Centre in 1928 was due to the opening of the Heston Clinic, as the Heston people previously had to attend at Douglas Road as the nearest centre. This drop in numbers has been made up and passed by newcomers, so that the Centre is again overcrowded, necessitating long sessions. As soon as circumstances permit it is proposed to have a third session a week, on Wednesday afternoons, at Hounslow—Douglas Road Centre. Sales at Clinics. Quantity Receipts. £ s. d. Half-Cream Cow & Gate 445 lbs. 33 0 10 Cow and Gate 8767 lbs. 680 16 6 Glaxo 621 lbs. 48 4 3 Prescription Glaxo 591 lbs. 48 17 10 Virol 383½lbs. 31 13 4 Malt 58 lbs. 2 2 9 Oil and Malt 370 lbs. 13 14 9 Lactagol 957 tins. 51 0 10 Cod Liver Oil Emulsion 3980 bottles 131 9 4 Bemax 248 packets 5 2 11 Total £1,046 3 4 The work is expanding partly owing to the growth of the knowledge of the work, and partly due to the rapid increase in the district. An agreement exists with the Metropolitan Asylums Board for the admission of cases of Ophthalmia Neonatorum to St. Margarets Hospital. Dr. Bell of Ealing attends at the Ante-Natal Clinic which is held on the first Wednesday morning in each month at the Health Department. 86 The attendances during 1929 were as follows:— Number of sessions held 12 Number of expectant mothers who attended 119 Total number of attendances 169 Maternity and Child Welfare Dental Clinic. Report for Year 1929. The Dental Surgeon's report on the scheme for the year is as follows:— Visits to the Clinic— Mothers. Boys Girls. Total. .Appointments 141 106 81 328 Attendances 129 98 78 305 % Attendance 92.9 Advice was given in 24 cases, re impending irregularities, and/or re Treatment. Extractions— 12 Teeth extracted, using local spray. 307 Teeth extracted, using gas, etc. 319 „ Total. Administrations of- Gas 84 Local anaesthetic 12 96 Fillings—88. Scaling— 1. Dentures were supplied to 13 mothers. Revised Scale of Charges for Provision of Dentures. £ s. d. £ s. d. 1 Tooth 11. 0 8 Teeth . 1 10 3 2 Teeth 13 9 9 „ 1 13 0 3 „ 16 6 10 „ 1 13 0 4 „ 19 3 11 „ 1 13 0 5 „ 1 2 0 12 „ 1 13 0 6 „ 1 4 9 13 „ 1 13 0 7 „ 1 7 6 14 „ 1 13 0 87 Repayments.—In most cases the full cost of the dentures is repaid by the mother, usually by instalments of 2s. 6d. a week. In necessitous cases the charge is reduced, or no charge made. The mothers are very grateful for the opportunity of obtaining skilled treatment for their teeth, and in practically all the cases they volunteer to pay without assistance from the Committee contributions of 2s. 6d. per week towards repayment of the cost. The work at the Douglas Road Centre, as shown by the attendances, is still impossible. One cannot do duty to the cases as they arise owing to the continuous pressure. The Nurses have no time to give any instruction, and the average Clinic leaves one at the end of the afternoon absolutely dog-tired. The wonder to me is that the parents still continue to attend in such numbers, in view of the scanty time one has to give to the cases, and the crowding of the waiting hall. At Douglas Road a Mothers' Committee has been active during the year. Sewing meetings have been held; the garments are sold at various sessions at the Maternity and Child Welfare Centre. Maternity bags with complete outfits were provided for the use of the poorer members. Notification of Births. Number of live births notified during the year 1076 Number of still births notified 39 Notified by midwives 753 Notified by parents or doctors 363 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. 88 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 Miss Ankritt (Co-opted member of the Committee), Mrs. Crutchett, Mrs. Davies, Mrs. French. Mrs. Midmore, Mrs. Goff, Miss Goff and Mrs. Hogg, at the Hounlow Centre; Mrs. Chedgey (Co-opted member of the Committee), Mrs. Evans, Mrs. Watson, Mrs. Curd, and Mrs. Jones at Isleworth; Mrs. Pitkin and Mrs. Rose at Heston. Thanks are also due to the undermentioned for gifts of prams, toys, high chairs, clothing, etc., which are given to the other mothers: At Hounslow—Mrs. Brant, Mrs. Parkes, Mrs. Hill, Mrs. Midmore, Mrs. Hoddinott, Mrs. Dove. At Isleworth—Mrs. Rolfe. At the Isleworth Christmas Party Mr. and Mrs. Simms and friends organised a concert, and also kindly lent a gramophone and records. Mrs. Brown did valuable work in connection with the arrangements for the tea. Home Visiting. The visits by the Health Visitors in connection with the Maternity and Child Welfare Work are shown in the following table:— 89  1925 1926 1927 1928 1929 1st visits to babies under one year 888 1038 1020 1125 1304 Re-visits to babies and Cildren up to five years 3562 3190 4474 4204 4311 Inquiries made, elicited— Feeding—Natural 525 672 747 806 887 Artificial 104 102 41 47 44 Both 56 62 16 40 32 Stillbirths — — — 23 23 Sleeping with parents 288 202 200 247 277 Using Comforter 276 231 148 154 168 Mother working during pregnancy 84 75 36 51 48 Year 1929. Ante-natal. First visits 155 Subsequent visits 14 Infants' Deaths, and Stillbirths. Visits paid 81 Ophthalmia Neonatorum and Discharging Eyes 140 Infantile Diarrhœa 4 Puerperal Fever and Puerperal Pyrexia 16 Measles and German Measles 3 Children under 5 years. Whooping Cough 14 Mumps 4 Chicken Pox 12 Pneumonia 43 Bronchitis 4 Milk and Food Cases 42 Home Help 16 Social Conditions 34 Other Visits 310 90 Home Help for Mothers. The Home Help paid 82 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 work as Home Help, in part of her 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 Sackers' 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 cleasing 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 the parents have been very glad of the opportunity. The presence of this service acts in another way, in that if a case is taken before the Magistrates the fine is considerably heavier now that means are at the disposal of the parents, whereby the child can be re-admitted to school within 48 hours. There is 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, 41 children have been cleansed. In addition, she assists at the Maternity and Child Welfare Centres and makes dressings for the Clinics. 91 Grants of Milk. Milk is supplied free or at reduced rate to expectant mothers (during the 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 pays 1/3 cost. 5/- to 7/6 per head parent pays 2/3 cost. Where the amount is over 7/6 per head, no grant is made. The number of grants made during the year was 111. 92 OPHTHALMIA NEONATORUM year 1929. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 8 6 2 8 ... ... ... heston and isleworth urban district education committee twenty-second ANNUAL REPORT OF THE School Medical Officer FOR THE Year ended 31st December, 1929 To the Chairman and Members of the Heston and Isleworth Urban District Education Committee. Ladies and Gentlemen, I beg to present the Annual Report of the School Medical Service for the year ended 31st December, 1929. I wish to express my thanks to the members of the Committee for the kindness and support they have shown me. I am, Ladies and Gentlemen, Your obedient servant, ELWIN H. T. NASH. Members of Education Committee, 1929-30 A. A. BERGIN, Esq., j.p., c.c. {Chairman). Members of the Council: — J.J. BONNETT, Esq., O.B.E. E. W. HEATH, Esq. F. W. BUCKLEY, Esq. A. L. LANG, Esq., j.p. A. DENNIS, Esq. H. J. Nias, Esq., m.b.f.., j.p (Ex-Officio). w. j. r. DIVINE, Esq. G. R .SPEED, Esq. A. J. FIELDER, Esq. R. WALTON, ESQ. F. T. HART, Esq. (Ex-Offcio). Co-opted. Members. E. W. GOODE, ESQ. (Vice-Chairman). Miss E. A. ANKRITT. Mrs. S. SPOONER. 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). Miss R. Marshall. E. Cromwell. Miss G. E. Curtis. B. P. Garrod. K. I. Bisshopp. H. J. Aldhous F. Bell. A. E. Black. Comprising the whole Clerical Staff of the Public Health Department, part of whose duties are concerned with the School Medical Service. School Nurses— Mrs. C. E. M. Ottley. Miss b. N. Tetley (Dental Nurse). Miss b. G. Sorlie (resigned 18-7-29). Miss A. bowness (commenced 16-12-29). Dental Surgeon—I. cohen, l.d.s., R.c.s., Eng. Radiographer—D. Arthur, M.D., D.P.H. Assistant School Medical Officers— Mrs. Eva Louise Roberts, M.B., Ch. B., D.P.H. Duncan Gerard Leys, B.A., M.B., B.Ch., M.R.C.P. (halftime, resigned 31-7-29). Frederick M. M. Eyton-Jones, M.D., B.S., Lond., M.R.C.P., Lond. (half-time, appointed December 1929). 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 and acts as Deputy in the absence of the M.O.H. Conference with the Education Office is still made easy although the departments are no longer in the same building. (a). Infant and Child Welfare. There are three centres in the District, and all record cards are available for school medical purposes. Formerly 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 Officers with School Nurses. Occasionally a case of ringworm receives X-ray treatment by arrangement with the Education Committee. In 1927 a scheme was put into operation for the treatment by the School Dentist, of dental defects in children under five years, and in nursing and expectant mothers. In 1928 arrangements were made, and approved by the Ministry of Health and the Board of Education, whereby children under school age suffering from visual defects or minor ailments can be treated at the School Clinics. Such children are those seen at the Child Welfare Clinics and referred by the Medical Officer of Health as requiring treatment. (b). Nursery Schools. There are none in the district. (c). The Care of Debilitated Children under School Age. Children up to the age of five years have access to the centres above mentioned. Arrangements have also been made with the Isleworth Nursing Association for the nursing of measles, whooping cough, etc. 6 The School Medical Service in relation to Public Elementary Schools. School Hygiene. The school buildings and the sanitary arrangements are periodically inspected. A complete survey of the schools is made from time to time, and a considerable number of minor defects are remedied. Improvements have been made in the lighting of the schools, and new heating systems have been installed at Spring Grove Central School, Grove Road Schools, and at Worple Road Schools. 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 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 there are only a few children who come from a distance, and in these cases the teachers are most helpful in supervising the children's tood, and warming milk, etc., when required. MEDICAL INSPECTION. Parents whose children are found to be defective and requiring 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 Clincs 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. Children at the Spring Grove Central School are examined each year. (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 schools the head teachers' rooms are used, but as a rule they are not large enough for vision testing; in others a class room or part of a class room, more or less screened off, has to serve. In most schools it is true to say that the provision of a room for Medical Inspection upsets the existing arrangements of the school. Usually, however, in order to free a room for the Inspection, two classes have to be taken in one classroom, which naturally does not tend to popularise Medical Inspection with the teachers. I should like to put on record, however, that the inspecting Medical Officer is always made as comfortable as circumstances permit. In spite of these drawbacks, however, it still seems better to hold the inspections at the schools—past experience showing that in any other arrangement the necessary co-ordination between Medical Officer and Head Teacher is lacking. FINDINCS OF MEDICAL INSPECTION, 1929. Uncleanliness. Out of 2,467 children examined at routine medical inspection, 85 were found to have nitty or verminous condition of the head, 8 and 241 similar cases were discovered at the school clinics. The total number of children excluded on account of nits and vermin during 1929 was 117. Further reference to this subject will be found on pages 30 and 31, and in Table IV. (p. 42). Tonsils and Adenoids. Out of 2,467 children examined at the routine inspections, 320 had enlarged tonsils, 102 of which were referred for treatment, 218 being kept under observation. 63 children had adenoids only, of which 24 required treatment, and 39 were for observation, whilst 104 children had both enlarged tonsils and adenoids, 57 requiring treatment, and 47 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 41 other children were found to have enlarged tonsils, 5 had adenoids only, whilst 21 suffered from both conditions. Tuberculosis. Out of 2,467 children examined at the routine inspections, there was one case of suspected pulmonary tuberculosis requiring to be kept under observation. There were 3 definite cases of pulmonary tuberculosis found at the special clinics and 6 were found to be suffering from suspected pulmonary tuberculosis, whilst 2 children had tubercular glands, 1 tuberculosis of the bones, and 1 other form of tuberculosis. Skin. At the routine inspections, out of 2,467 children examined, 28 were found to be suffering from skin trouble. At the special clinics there were 771 children suffering from various skin complaints, including scabies and impetigo (see Table II. for analysis of figures). 7 cases of ringworm of scalp and 14 cases of ringworm of body were also seen. 9 External Eye Disease. Out of 2,467 children examined at the routine inspections, 19 were found to have minor eye diseases including blepharitis and conjunctivitis, whilst 6 had a squint. In addition, 104 were found at the special clinics to suffer from the minor eye diseases, whilst 4 had squint. Vision. Out of 2,467 children examined at the routine inspections, 181 were found to have defective vision. Of these 157 were referred for treatment, 24 being kept under observation. At the special clinics 74 children were referred for treatment for defective vision. It will be seen therefore that Routine Medical Inspection still remains the way in which most of the visual defects are discovered. Below are tables shewing an analysis of the findings at the Routine Medical Inspection for this year as regards vision. The total number examined for vision is not precisely the same as the total number of children medically examined. In many cases infants are unable to have their vision tested at their first inspection—this is done at a subsequent re-inspection, but the findings have not been included, as all the re-inspections have not yet been made. The numbers in the accompanying tables therefore refer to all children of 6, 8, 9, 12 and 13 years of age examined at Medical Inspection in 1929, and in addition those of 11, 14, 15. and 16, who are at the Central School. The omission of the 5 year old children accounts for the smallness of the numbers in the Infant Schools. All testing is done with the standard Snellens Test type— infants being tested with my modification of Snellens test type using only the five vowels in the lower case type so that the child is tested on the first letters it is familiar with exhibited in the first type with which it is familiar. The conditions for testing in the different schools are not strictly comparable—light and distance varying, but the method is sufficient to detect errors of vision requiring treatment or observation—and in actual fact there is usually no important difference in the result of a test in 10 the school from that obtained when the child is seen at the Eye Clinic and tested under perfect conditions. Table I. shows the total examined with numbers requiring treatment and percentages—and the same total analysed according to age and sex. Table II. shews the numbers analysed according to sex and school. It is impossible to draw conclusions from such small numbers, but it is proposed to analyse the figures for several years, so that later conclusions may be drawn. It should be pointed out that these figures relate to children requiring treatment or observation for visual defect as found at the Medical Inspection. They are not an index of the amount of visual defect existing amongst the school children of this district as naturally children with a defect satisfactorily corrected are not included. 11 Results of Vision Testing done at the Routine Medical Inspection in 1929. TABLE 1. Total number examined. Total number -equiring treatment or observation Percentage requiring treatment or observation Percentage analysed according to age. 6 8 9 11 12 13 14 15 16 Boys & Girls 2006 166 8.27 1.30 4.24 0.60 0.05 1.55 0.35 0.20 — — Girls 976 71 7.27 1.40 3.65 0.46 0.12 1.30 0.27 0.12 — — Boys 1030 95 9.22 1.26 5.04 0.49 — 1.74 0.38 0.29 - — 12 Results of Vision Testing done at the Routine Medical Inspection in 1929. TABLE II. GIRLS. School. No. Inspected. No. requiring Treatment or for Observation. Percentage requiring treatment or Observation. Percentage analysed according to age. 6 8 9 11 12 13 14 15 16   G.R.G 80 12 15.00 - 10.00 - - 5.00 - - - - G.R.I 5 — — — — — — — — — — — A.G 95 7 7.37 1.05 3.16 1.05 — 2.10 — — — — W.S.J.I 1 - - — — — — — — — — — H.H.G 112 3 2.67 — 2.67 — — — — — — — H.H.I 33 5 15.15 15.15 — — — — — — — - H.R.C.M. 29 6 20.69 6.90 3.45 6.90 — 3.45 — — — — S.G.C 162 4 2.47 — — — 0.62 — 1.24 0.62 — — W.R.M 38 2 5.26 — 2.63 2.63 — — - — — — W.R.I 8 — — — — — — — — — — — S.M.G. & I 44 4 9.09 - 4.50 2.25 — 2.25 — — — — Heston 94 6 6.38 — 4.30 2.15 — — — — — — I.T.J 65 4 6.15 154 4.62 — — — — — — I.T.S 39 5 12.82 - — — 10.24 2.56 — — — I.B.G. & I. 46 8 17.39 6.51 8.68 — — 2.17 — — — S.G.J 25 1 4.00 — 4.00 — — — — — — — H.T.G. & I. 100 4 4.00 1.00 3.00 — — - — — - B.E.I — — - — - — — — - — 13 Results of Vision Testing done at the Routine Medical Inspection in 1929. TABLE II. BOYS. School. No. Inspected. No. requiring Treatment or for Observation. Percentage requiring treatment or Observation. Percentage analysed according to age 6 8 9 11 12 13 14 15 16 G.R.B 111 10 9.00 - 4.50 0.90 - 3.60 - - - - G.R.I 7 — — — — — — — - — — — A.B 104 15 14.42 0.90 11.52 — - 1.92 - - - — W.S.J.I 1 — — - - - - - - - - - H.H.B 129 10 7.75 - 4.66 2.33 — — 0.77 - - - H.H.I 26 5 19.23 19.23 — — — — - - - - H.R.C.M. 21 6 28.57 9.52 14.28 — — — 4.76 - - — S.G.C 144 6 4.17 - — — — 1.38 0.69 2.07 - — W.R.M 35 7 20.00 - 20.00 — - — - - - - W.R.I 16 — — - - - - - - - - - S.M.B. & I. 37 8 21.62 - 18.90 — — 2.70 - — - - Heston 90 7 7.77 1.11 6.66 - - - - - - - I.T.J 69 1 1.45 1.45 — — — — - - — — I.T.S 57 4 7.02 — — — — 7.02 - - - - I.B.B 28 7 25.00 — 7.14 3.57 — 10.71 3.57 — - - I.B.I 7 2 28.57 28.57 - - - - - - - - S.G.J 44 2 4.55 2.27 2.27 — — — — — — — H.T.B 97 5 5.15 — 3.93 — — 2.62 — — — — H.T.I 3 - - — — — — — — — — — B.E.I 2 — — — — — - - - - - - 14 Ear Disease and Hearing. Out of 2,467 children examined at the routine inspections, 84 were found to be suffering from defective hearing or ear disease, whilst an additional 122 were discovered at the special clinics. Dental Defects. Out of 2,467 children examined at the routine inspections, 1,021 had carious teeth and were referred for treatment whilst 4 had slighter caries and were marked for observation. At the special clinics a further 51 were discovered and referred for treatment, but it was not found necessary to mark any case for observation. At the dental inspections, 4,505 children were referred for treatment out of 6,736 inspected. (For further particulars see Table IV., Group 4). Deformity. Out of 2,467 children examined at the routine inspections, there were 48 found with some deformity. At the special clinics 1 was found to be suffering from rickets; 1 from Spinal curvature, and 8 from other forms of deformity, and were referred for treatment; whilst 3 were kept under observation. INFECTIOUS DISEASES. All infectious cases and contacts are excluded from school till they are deemed free from infection on the general lines laid down in the Joint Memorandum issued by the Ministry of Health and the Boaid of Education, 1927. The following table shows the infectious disease which occurred among children attending public elementary schools, during 1929, and the two previous years. 1929 1928 1927   Scarlet Fever 118 51 31 Diphtheria 239 54 29 Measles 83 688 35 Rubella 344 9 7 Mumps 106 138 352 Chicken Pox 423 265 243 Whooping Cough 177 171 157 1490 1376 854 15 The Table shows that the incidence of non-notifiable infectious disease has remained heavy, the slack Measles year being compensated by increase in other diseases. Non-notifiable diseases still continue to be visited by the School Nurses. As has been pointed out in previous years, infectious visiting takes up a very large part of the nurse's visiting time, and when the number of infections cases is large, the other work is bound to suffer; and so it has been this year. In addition there has been a substantial increase in Scarlet Fever, and a considerable outbreak of Diphtheria in the district, in which the number of school cases of Diphtheria was more than four times greater than in 1928. There has, however, been no undue preponderance of school cases; the percentage of school cases to the total civil cases being in 1927, 51.78; in 1928, 54.5, and in 1929, 56.64. As usual in cases of Diphtheria, all home contacts have been swabbed, and in cases where is was thought that the infection might be in the school, school contacts have also been examined. In one school, amongst whose pupils the largest number of cases (40) occurred, systematic swabbing was done of the nose and throat of every child in all forms where cases had occurred, and every absentee was visited and swabbed, and the relation of cases one to another was investigated; and further, every member of the staff, and the Caretakers were swabbed, and cultures were taken from the Drinking Fountain. The result was largely negative. A few children were found with Klebs-Loeffler's Bacillus in throat or nose, and were isolated and treated, but it is doubtful if they were true carriers. The whole investigation shewed that the school was not the source of infection, which in itself was valuable, as it served to allay parents' fears in this respect, and so justify the policy of keeping the schools open. Investigations in other schools gave the same result, although swabbing on such a large scale was not attempted. The amount of extra work this alone gave to the medical and nursing staff was enormous. During the year the medical staff examined 6,021 swabs. Towards the end of the year the Council decided to offer facilities to parents for free Schick testing and immunisation, and Clinics were started early in 1930. A full account of the outbreak of Diphtheria will be found in the Health Report for the year. 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 16 1 5 1 106 8 ,, Girls 1O 25 5 10 ... 22 7 Brentford End Infants ... 1 ... 1 ... 1 5 Grove Road Boys ... 11 ... 11 ... 1 1 ,, ,, Girls 2 10 3 4 ... 1 ... ,, ,, Infants 6 17 2 11 ... 7 9 Heston Mixed and Infants 4 10 ... 2 24 22 11 Hounslow Heath Boys 6 2 8 18 3 5 ... ,, ,, Girls 2 6 4 27 3 5 ... ,, ,, Infants 6 2 7 52 2 13 37 Hounslow R.C. Mixed & Infants 2 2 ... 3 29 6 ... Hounslow Town Boys 3 11 6 1 7 1 38 ... ,, ,, Girls and Infants 25 30 17 38 3 73 7 Isleworth Blue Boys ... 7 ... ... 1 ... 1 ,, ,, Girls & Infants 1 10 ... 1 4 ... 10 Isleworth Town Senior Mixed 1 3 ... 8 2 6 ... Junior Mixed 10 40 6 34 23 17 38 St. Mary's Boys ... 8 1 ... 1 10 9 ,, Girls & Infants I 6 3 3 2 19 2 Spring Grove Central 5 11 1 5 2 6 ... ,, Junior 23 7 15 41 ... 47 19 Woodlands St. John's Infants 2 1 ... 3 1 1 2 Wor pie Road Mixed 4 2 3 21 3 6 2 Infants 4 1 1 29 1 11 9 T otal 118 239 83 344 106 423 177 17 FOLLOWING-UP. Physical defects discovered at routine medical inspection are at once notified by the examining officer to the parent, if present, and in any event a written or printed notice of the defect is sent to the parent. The 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, and undertake the daily treatments at each centre. 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 Cleanliness 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 1929. 146 attendances at School Inspection Clinics. 508 ,, ,, Dental Clinics. 93 ,, ,, Eye Clinics. 781 ,, ,, Minor Ailments Clinics. 4 ,, ,, School Sports. 146 visits to schools for medical inspections. 45 ,, ,, ,, ,, re-inspections. 45 ,, ,, ,, dental inspections. 7 ,, ,, ,, cleanliness surveys. 1345 visits to homes in connection with following-up. 1868 ,, infectious diseases. 113 ,, re Clinic absentees. 212 dental visits. 126 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 carried out at the local hospitals. MINOR AILMENTS. Holiday Clinics. During the year it was decided to open the School Clinics during the holidays as it was urged that if the children required treatment during the term, they equally required it during the holidays and on Saturdays. Summer Holidays. The following report was made to the Committee as a result of the opening during the summer holidays. REPORT ON WORK AT THE MINOR AILMENTS TREATMENT CLINICS, DURING SCHOOL HOLIDAYS. " With reference to the Committee's decision that School Clinics should be opened on Saturdays and during school holidays for a time, with a view to ascertaining whether it would be an advantage to do so permanently or not, I beg to report as follows. The schools closed for the summer holidays on Thursday, 25th July, 1929, and arrangements were made for the three Minor Ailments Treatments Clinics, to continue daily except Sundays and Bank Holidays, at Hounslow, Isleworth, and Heston, from 9 a.m. to 9.30 a.m. or until the cases attending were treated. 1. Hounslow Clinic. At the commencement of the holidays, 9 cases of sores were remaining under treatment. 25 Clinics were held, and the total attendances were 53. The lowest attendances was nil on two Saturdays, and the highest four, on the first day. At two Clinics, only one child attended. The average attendance was two. Seven cases were discharged as cured. Two new cases attended for treatment. 19 2. Isleworth Clinic. There were two cases on hand at the commencement of the holidays, but neither of these continued attendance after the first day. 25 Clinics were held, and the total attendances numbered 5, which were put in by a new case which appeared for treatment, and this was the only case dealt with at this Clinic during the holiday period. At twenty Clinics there was no attendance. 3. Heston Clinic. Twelve cases were remaining under treatment at the commencement of the holidays, and five of these continued attendances. 25 Clinics were held, the highest attendance was six on the first day of the holiday. Two new cases attended for treatment, and one was cleared up before the schools re-opened. The total attendances were 36 the average being about 1.5. There were five sessions with no attendances, and at twelve Clinics only one child attended each morning. In view of the fact that this is the first experiment, and it will take time for the parents to grasp the fact, I suggest that the Clinics be opened during the remaining school holidays of this year, and I will report the result after the Christmas vacation." Half-term Holiday. During the Autumn half-term holiday, when the clinics were open on the four days that the schools were closed, the figures for the Minor Ailments Treatments Clinics were as follows: Clinics held 12 Total attendances 39 Average attendance 3.2 The average attendance at each of the clinics was as follows : Hounslow Clinic 3.5 Isleworth Clinic 5.2 Heston Clinic 1.0 20 Christmas Holidays. The results ot the opening during the Christmas Holidays are shewn below : — Each clinic was open every week day during the holidays, except Christmas Day and Boxing Day. Clinics held 36 Total attendances 69 Average attendance, approximately 2 Taking each clinic separately the average attendance per session was as under : — Hounslow Clinic .7 Isleworth Clinic 4.0 Heston Clinic 1.0 Saturdays. Analysis of the attendances on Saturdays from the end of August to the end of December gives the following figures. Clinics held 54 Total attendances 162 Average attendance 3 The average attendance at each of the clinics was as follows Hounslow Clinic 1.8 Isleworth Clinic 3.2 Heston Clinic 4.0 Apart from the fact that these holiday clinics have not been running long enough for all the parents to establish, so to speak, the holiday habit, it is demonstrated to my mind very emphatically how these cases would be neglected if the school clinics were not able to deal with them during the term time. There is unfortunate!; amongst a certain class of the population an attitude of mind which regards these minor ailments as too much trouble, regardless of what the effects may be in some cases in later life. 21 Skin. Ringworm of the Scalp.—Four cases were successfully treated by the application of X-ray. The X-ray treatment is carried out by Dr. D. Arthur in his own surgery at Ealing, and a fee of £1 : 1 : 0: per case is paid to him. Parents are asked to pay 2/6 per case, but in necessitous cases free treatment may be obtained on application to the Education Committee. Treated at the School Clinic. Ringworm of the Body 14 Cases Impetigo 261 ,, Scabies 15 ,, Other skin diseases 45 ,, Miscellaneous, minor injuries, bruises, sores, chilblains, etc. 446 ,, Ear Disease and Hearing. At the School Clinic 80 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 fairly severe operation will cure the condition permanently. So long as this condition persists, the child is always in danger, in that any minute, any further extension of the disease to the upper plate of bone covering the inner ear, may lead to suppuration within the brain cavity, and death. Continuous suppuration of the middle ear always causes impairment of hearing, and further affects the general health of the child. 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. 22 Eye Disease. 84 Cases of Eye Disease have been treated at School Clinic. These have been chiefly Conjunctivitis, Blepharitis, with some Phlyctenular Ulcers, and suppurative conditions of the lids. Tonsils and Adenoids. Out of 248 children referred for treatment, 65 received treatment either privately or through a hospital, whilst 30 were treated under the Education Authority's scheme,' and 4 received other forms of treatment. 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 head per case Under 8/- nil. From 8/- to 10/- 5/- From 10/- to 12; 10/- Above 12/- 21/- Operative treatment of tonsils and adenoids in this district still remains unsatisfactory—the numbers receiving treatment are small and the conditions under which operative treatment is offered could be greatly improved. The greatest objection is that under the arrangement with the local hospitals, children are sent home after operation. The second is the cost—which deters many. No scheme can be considered really satisfactory which does not provide for the treatment of the child in a hospital for at least the 24 hours following the operation, and to be really satisfactory it should be 4 days, in view of the more extensive nature of the operation now considered necessary and the consequently larger surfaces liable to infection. In this district the difficulty of getting the children home after the operation is great. If the child is tiny, a pram can be usedotherwise it means walking or using a public conveyance. Neither is right—and one cannot blame parents from shrinking from having treatment under such circumstances. 23 Also the immediate after care of the child at home presents another problem—in many cases there is overcrowding, and often the mother goes out to work. The actual number treated this year is 99 out of 248 marked for treatment, making 40% against 25% last year, and 50% in 1927, and 33% in 1926. For the past few years it has been the practice to refer only well marked cases for operative treatment, although there have been many children with unsatisfactory conditions of the nasopharynx. In such cases advice is given as to the carrying out of proper nasal hygiene, and to improving the general health of the child. "Sneezing " has been tried with success in a few cases, but without the intelligent co-operation of the mother it is useless. A clinic where such treatment and instruction could be given would undoubtedly save some of the earlier cases from the need of operation. It would also be useful in helping to establish nasal breathing after operation. Unfortunately the establishment of such a clinic is at present impossible owing to the Nurses' time being fully occupied with other work. The results of operation 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 absencc 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 the 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, and it is here that a Clinic, as mentioned above, would do good work. 24 Vision. The work of the Refraction Clinic continues to increase and it has been found necessary to hold a clinic twice weekly during the year. Dr. Roberts, the Assistant Medical Officer, remains in charge. 413 cases were submitted for refraction, as against 297 in the previous year. In 344 cases spectacles were prescribed, and in 327 cases were obtained through the Education Authority. 14 children were treated privately or at hospital, and 11 children obtained spectacles privately. Spectacles are provided at an all round price of 4/6 a pair, and a definite scale of charges for repairs is issued when spectacles are prescribed. One hundred and sixty-five pairs of glases were sent for repair during the year. Necessitous cases are referred to the Medical Inspection SubCommittee, and spectacles are supplied free or at a reduced cost, according to the circumstances. An endeavour is made to see children each year who are provided with spectacles (and special cases oftener), and parents are notified at the expiration of the time, that the spectacles will probably need changing, and are asked to send the child again to be examined. The response is encouraging, and some of the children have attended regularly for years, but there are many who refuse. If the case is one of severe visual defect it is followed up furtherbut otherwise the child is left until found again either at the Routine Inspection or a Special Clinic, as times does not permit more to be done. The great improvement in this work is due in very great measure to the fact that the Assistant Medical Officer knows most of the parents and the personal factor is very markedly in evidence as contributing to the great success of the Eye Clinic compared with what it was when carried on by a visiting Ophthalmic Surgeon. Dental Defects. 3,891 Children were treated by the School Dentist under the Local Education Authority's Scheme and 1,302 re-treated, 25 Further, 81 attended the Dental Clinic and were referred elsewhere for treatment, e.g., hospital and 26 attended the Clinic but refused treatment. Dental Work. (See pages 41-51). Open Air Education. There is no open air school in the district, the only open air education being comparatively few classes held in the playgrounds in the summer. There is a great demand for an open air school, as there are a considerable number of children who would 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 lacking, and one feels that on the whole, the child is better running about in the fresh air, and even mud larking under what might be supposed to be far from ideal conditions, than sapping what energy it has by attempting to cope with the school curriculum. The presence of these children in a class also makes the work of a teacher infinitely harder, as they are apt to be a disturbing element amongst the normal children. PHYSICAL TRAINING. There is no Area Organiser of Physical Training for the elementary schools in the district. Whatever is done is on the initiative of the teachers, but the School Medical Officers are not consulted, save as to fitness or otherwise of a particular child to engage in drill. PROVISION OF MEALS. The systematic provision of meals for school children was not undertaken during the year, and there is still no machinery for enabling delicate school children to obtain milk free or at moderate prices. Since 1928, however, the Committee have allowed Cod Liver Oil and Malt to be sold at cost price at the School Clinics, in cases where it was ordered by the Medical Officer. 26 This, however, though useful, only helps a few, and there are many cases who would benefit by Cod Liver Oil who do not obtain it. 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 1929, one or other parent or relative attended in 1855 instances, representing a percentage of 75.1 as against 70% for 1928. 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. The 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 Teachers' 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. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. There are three Attendance Officers in this district and they have at any time the right to ascertain from the Health Department the condition and fitness of any school child. In the course of maintaining attendances they render valuable assistance to the Medical Department by referring to the Schoo: Clinic children who are absent from school on account of alleged illness, and who are not under private treatment. 27 Prompt notification by these Attendance Officers of a suspicious sore throat or rash has frequently directed attention to early cases of Infectious Disease. CO-OPERATION OF VOLUNTARY BODIES. During the year the National Society for the Prevention of Cruelty to Children rendered assistance in cases of neglect. In cases where further help is needed the following societies render all possible assistance: Hounslow, Heston and Whitton Philanthropic Society; The Isleworth, Spring Grove and St. Margaret's Philanthropic Society, The Shaftesbury Society and Ragged School Union, and the United Services Fund. 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 1929, examinations were conducted in respect of 45 mentally abnormal children. There are no schools in this District for the defective. During 1927 a proposal to provide a joint school for Mental Defectives in the western part of Middlesex was agreed upon by the Authorities concerned, and the proposal was submitted to the Board of Education by the Middlesex Education Committee. The matter is still under consideration by the County Council. NURSERY SCHOOLS. There are no nursery schools in this district. SECONDARY SCHOOLS. CONTINUATION SCHOOLS. The School Medical Service of the Local Education Authority does not at present extend to these. EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. (0 Employment of Children. The conditions of the employment of children and young persons in this area are regulated by Bye-Laws : Certain employments are prohibited, and in others the hours of employment are 28 regulated, and children between the ages of 13 or 14 employed in the sale or delivery of milk or newspapers, or in domestic work away from home, must, hold a certificate from the School Medical Officer to the effect that such employment will not be prejudicial to their health or physical development, and will not render them unfit to obtain proper benefit from their education. 55 Children were examined and 42 were granted the necessary certificates of fitness for work. (ii) Co-ordination of the work of the School Medical Service with that of the Juvenile Employment Committee and of the Certifying Factory Surgeon for the District. The Health Reports for Juvenile Employment cards are taken from the medical inspection records and are entered in the Health Department. Where, by reason of absence at Medical Inspection, sufficiently recent medical records do not exist, the cases are summoned to the Inspection Clinics and the necessary data obtained. These represent the limits of the services rendered by the School Medical Staff. I am unable to say what relationship exists between the Juvenile Employment Committee and the Certifying Factory Surgeon for the District. MISCELLANEOUS. Medical Examination of Teachers. During the year 34 teachers were examined in connection with their appointments under the Authority. Holiday Home for Children. All children recommended for the King Edward VII Memorial Home, Heme Bay, are medically examined before being sent away. CRIPPLE CHILDREN. 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.). There is no provision in the district for such children. 29 SCHOOL CLINICS. Hounslow. Health Department. Treatments by a nurse, 9 a.m. daily. Medical Officer in attendance Tuesdays and Fridays at 10.30 a.m. Isleworth. Public Hall. Treatments by a nurse, 9 a.m. daily. Medical Officer in attendance Mondays, 10.30 a.m. Heston. Village Hall. Treatments by a nurse, 9 a.m. daily. Medical Officer in attendance, Thursdays 10.30 a.m. As foreshadowed last year, it became necessary for a Medical Officer to attend at the Heston Clinic, and this was begun in the autumn. The new Clinic has relieved the congestion at the Hounslow Clinic to a certain extent and has also proved valuable in catering for the needs of the growing school population in Heston. 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, uncleanliness, or as urgent dental cases. 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.—4/6 per pair. 30 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 from date of payment, 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 ordered. CLEANLINESS SURVEYS, 1929. Number of visits by Nurses 7 Total number of children examined 782 ,, ,, ,, ,, given warning notices 91 ,, ,, ,, ,, excluded as verminous 3 ,, ,, ,, ,, 1. (Few) 7 2. (Bad) 78 Found to have nits— 3. (Very Bad) 6 Few Surveys have been possible during the year owing to pressure of work arising from infectious disease in the schools. The severity of the incidence of infectious disease is impossible to forecast and during the outbreak non-infectious matter sinks into the background. The number examined leaves much to be desired. The standard to be aimed at should be one survey per term in each school. 31 The work of the cleanliness survey is not only that of the actual inspection at the school. It includes also the action taken with regard to those found with dirty heads. This necessitates attendance at the clinic until the children are clean, and means a large addition to the attendance at a treatment clinic. The survey is important because— 1. The parents have no warning, and therefore, the findings are a true indication of the cleanliness of the school. 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 Teacher in maintaining cleanliness in the school. Since no 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, 41 children have been cleansed. No cleansing has been carried out by the school nurses. During the year 1929, legal proceedings were instituted against the parents of 1 child, and a fine of 10/- was imposed. LIST OF TABLES. 1. Return of Medical Inspection. 2. Return of Defects found in the course of Medical Inspection. 3- Numerical Return of Exceptional Children. 4- Treatment of Defects of Children— A. Minor Ailments. B. Visual Defects. C. Defects of Nose and Throat. D. Dental Defects. 32 TABLE 1 RETURN OF MEDICAL INSPECTIONS A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants .720 Intermediates 995 Leavers 446 Total 2161 Number of other Routine Inspections 306 B.—Other Inspections. Number of Special Inspections 1158 Number of Re-Inspections 3098 Total 4256 33 4. RETURN OF DEFECTS found by Medical Inspection In the Year ended 31st December, 1929. Defects or Diseases. Routine Inspections. Special Inspections. No. of Defect*. 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. i a 1 4 5 Malnutrition 1 8 ... ... Uncleanliness (See also Table IV., Group V.). 85 ... 241 ... Skin— Ringworm— Scalp 1 ... 7 ... Body 1 ... 14 Scabies 4 14 ... Impetigo 4 ... 258 ... Other Diseases tuberculous) 12 6 499 ... Eye— Blepharitis 3 2 13 ... Conjunctivitis 1 ... 58 ... Keratitis ... ... 4 ... Corneal Opacities ... ... 1 ... Defective Vision (excluding squint) 157 24 74 ... Squint 6 ... 4 ... Other Conditions 4 9 33 ... Ear— Defective Hearing 25 29 18 ... Otitis Media 6 ... 37 ... Other Ear Diseases 13 11 60 7 Nose and Throat— Enlarged Tonsils 102 218 40 1 Adenoids 24 39 4 1 Enlarged Tonsils and Adenoids 57 47 21 ... Other Conditions 11 19 60 28 Enlarged Cervical Glands (non-tuberculous) 20 95 26 7 Defective Speech ... 1 I ... 34 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 2 3 4 5 Teeth—Dental Diseases (see also Table IV., Group IV.) 1021 4 5i ... Heart and Circulation— Heart Disease— Organic 2 30 ... 18 Functional ... ... 1 7 Anaemia 1 11 6 1 Lungs— Bronchitis ... 3 9 2 Other Non-Tuberculous Diseases 1 30 8 6 T uberculosis— Pulmonary— ... Definite ... ... 3 ... Suspected ... 1 ... 6 Non-Pulmonary— Glands ... ... 1 1 Spine ... ... ... ... Hip ... ... ... ... Other Bones and Joints ... ... ... 1 Skin ... ... ... ... Other Forms ... ... 1 ... Nervous System— Epilepsy ... ... 5 1 Chorea ... 2 11 4 Other Conditions 5 15 6 11 Deformities— Rickets ... 1 1 ... Spinal Curvature ... 3 1 1 Other Forms 3 41 8 2 Other Defects or Diseases 9 81 95 99 35 B.—Number of individual children found at Routine Medic: Inspection to require treatment. (Excluding Uncleanliness and Dental Diseases). Group. Number of Children. Percentage of childres found to require treatment. Inspected. Found to require treatment. Code Groups— Entrants 720 IO4 14.4 Intermediates 995 197 19.8 Leavers 446 76 17.04 Total (Code Groups) 2161 377 17.44 Other Routine Inspections 306 37 12.09 36 TABLE III.—RETURN of all Exceptional Children in the area. Boys Girls Total Blind (including partially blind). (i.) Suitable for training in a School or Class for the totally blind. Attending Certified Schools or Classes for the Blind ... 3 3 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 1 1 (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind ... 2 2 Attending Public Elementary Schools 1 2 3 At other Institutions ... 1 1 At no School or Institution ... 2 2 Deaf (including deaf and dumb and partially deaf). (i.) Suitable for training in a School or Class for the totally deaf or deaf and dumb. Attending Certified Schools or Classes for the Deaf 3 4 7 Attending Public Elementary 1 ... 1 At other Institutions ... ... ... At no School or Institution ... ... ... (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 2 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 1 ... 1 Attending Public Elementary Schools 5 7 12 At other Institutions ... ... ... At no School or Institution 5 2 7 Notified to the Local Control Authority during the year. Feebleminded ... ... ... Imbeciles ... ... ... Idiots 1 ... 1 Epileptics. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 1 1 1 In Institutions other than Certified Special Schools ... ... ... Attending Public Elementary Schools ... ... ... At no School or Institution 1 ... 1 Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 5 1 6 At no School or Institution ... ... ... 37 TABLE III.—Continued. * Boys Girls Total Infectious Pulmonary and Glandular At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... Tuberculosis. At other Institutions ... ... ... At no School or Institution ... ... ... 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 1 ... 1 At other Institutions ... ... ... At no School or Institution ... ... ... Physically Defective. Delicate children (e.g. pre- or latent Tuberculosis, Malnutrition, Debility, Anasmia, etc.) At Certified Residential OpenAir Schools ... ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools 29 27 56 At other Institutions 2 ... 2 At no School or Institution ... 1 1 Active nonpulmonary Tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 1 1 2 At Public Elementary Schools ... ... ... At other Institutions 1 1 2 At no School or Institution ... ... ... 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 1 ... 1 At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... ... ... At Public Elementary Schools 19 12 31 At other Institutions ... ... ... At no School or Institution 1 4 5 38 TABLE IV. Return of Defects treated during the year ended 31st December, 1929. Group I.—Minor Ailments (excluding Uncleanliness, for whic see Croup V.)- Diseases or Defects. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. 1 2 3 4 Skin— Ringworm, Scalp 7 ... 7 Ringworm, Body 14 ... 14 Scabies 15 ... 15 Impetigo 261 11 272 Other Skin Diseases 45 5 50 Minor Eye Defects— (External and other, but excluding defective vision and squint) 84 8 92 Minor Ear Defects 80 7 87 Miscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 446 24 470 Total 952 55 1007 39 TABLE IV.—Continued. Group II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group 1). 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) 413 14 ... 427 Other Defects or Disease of the eye ... ... 6 6 (excluding those recorded in Group I.) Total 413 14 6 433 Total number of children for whom spectacles were prescribed (a) Under the Authority's Scheme 344 (b) Otherwise 11 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme327 (b) Otherwise 11 40 TABLE IV.—Continued. Croup III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment. Received other forms of Treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) 30 65 95 4 99 41 TABLE IV.—Continued. Croup IV DENTAL DEFECTS. (i). Number of children who were : (a) Inspected by the Dentist: Aged: t Routine age groups 5 676 Total 5788 6 772 7 849 8 833 9 797 10 491 11 419 12 425 13 399 14 108 15 19 bpecials 948 Grand total 6736 (6) Found to require treatment 4505 (t) Actually treated 3891 (d) Re-treated during the year as the result of periodical examination 1302 (2). Half-days devoted to Inspection 45 Total 466 T reatment 421 (3). Attendances made by children for treatment 4616 (4). Fillings Permanent teeth 3556 Total 4193 Temporary teeth 637 (5). Extractions j Permanent teeth 505 Total 4895 Temporary teeth 4390 (6). Administrations of general Anaesthetics for extractions 1036 (j). Other operations Permanent teeth 449 Total 449 Temporary teeth 42 TABLE IV.—Continued. Croup V. UNCLEANLINESS AND VERMINOUS CONDITIONS, (i.) Average number of visits per school made during the year by the School Nurses 5 (ii.) Total number of examinations of children in the schools by the School Nurses 782 (iii) Number of individual children found unclean 94 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 41 (v.) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 - (£) Under the School Attendance Bye-laws 1 School Dental Service YEAR 1929 STATISTICS from the Report of the School Dental Surgeon 44 INSPECTIONS FOR THE YEAR, 1929 . Age last Birthday. No. Examined No. Requiring Treatment. % Requiring Treatment 5 676 462 68.3 6 772 547 76.0 7 849 602 77.9 3 833 701 84.1 9 797 653 81.9 10 491 391 79.6 11 419 347 82.8 12 425 344 80.9 13 399 298 74.6 14 108 87 80.5 15 19 13 68.4 Specials 948 6736 4505 66.8. THE INSPECTION RESULTS (TOTALS ONLY) FOR THE PAST SEVEN YEARS -1923, 1924, 1925, 1926, 1927, 1928 and 1929. (Age Groups). Specials. Total Year. 5 6 7 8 9 10 11 12 13 14 15 1923 278 427 481 559 538 533 372 213 40 2 — 392 3835 1924 315 375 487 474 495 291 - - — — — 399 2836 1925 468 388 373 417 457 488 '261 — — — — 393 3245 1926 399 534 339 367 403 401 479 179 — — — 460 3561 1927 602 700 782 ?93 458 493 494 491 25 7 — — 245 5015 1928 571 808 825 745 485 481 501 411 453 112 24 680 6096 1929 676 772 849 833 797 491 419 425 399 108 19 948 6736 The average inspected in each of the above years = 4475 The average number of children inspected last year per session was 128. WORK OF THE DENTAL CLINIC, 1923-4 5-6-7-8-9. Derived from the School Inspections in each of the past seven fears. Year. Percentage Required treatment. Percentage actually treated. 1923 80.70 26.46 1924 68.72 47.20 1925 65.17 52.90 1926 61.30 53.00 1927 67.07 58.76 1928 72.21 70.26 1929 66.8 86.37 45 FILLINGS. Teeth Filled. Year Permanent Temporary TotaJ. 1925 1423 52 1475 1926 1665 25 1690 1927 2339 283 2622 1928 3699 202 3901 1929 3556 637 4193 EXTRACTIONS. Teeth Extracted. Year. Perm. Temp. Total Extracts Administration Ethyl Chloride & Gas No. of Gas Sessions Gas Local Anaesthetic 1925 118 2446 2564 542 — — 41 1926 221 2840 3061 719 11O 140* 54 1927 19s 3155 3350 784 317 141* 59 1928 453 4594 5047 1119 670 340* 89 1929 505 4390 4895 1036 785 296" 89 * These figures are included in the ''Gas " totals. FINANCE. In 1925 the fee for treatment was 6d. per attendance; in December, 1925, the system was re-organ ised.1/- being charged, which cover all treatment for the period of-one year from date of payment. In 1925 the fees amounted to £32 17 6 In 1926 the fees amounted to 57 l9 0 In 1927 the fees amounted to 64 10 0 In 1928 the fees amounted to *99 11 0 In 1929 the fees amounted to tioo 9 0 *Includes ,£,5 5s. paid by M. and C. W. Cases, †Includes £3 I3S- Pa'd by M. and C. W. Cases. PERCENTAGE OF ATTENDANCES FOR TREATMENT OF THOSE CHILDREN FOR WHOM APPOINTMENTS WERE MADE. School Departments. Percentage for whole School. INFANTS. UPPER. Boys. Girls. Boys. Girls. Alexandra. For ordinary treatment 79.1 79-3 79.7 72.3 76.5 For "Gas " extractions 70.2 87.3 75.0 70.7 76.8 Brentford End. For ordinary treatment 66.6 - 50.0 t'or " Gas" extractions 33.3 75.0 50.0 46 School Departments. Percentage for whole School. INFANTS. UPPER. Boys. Girls. Boys. Girls. Grove Road. For ordinary treatment 77.2 64.2 63.2 66.5 67.9 For " Gas " extractions 78.6 73.9 65.4 63.3 71.2 lieston Mixed. Fbr ordinary treatment 76.0 80.8 62.0 58.4 68.2 For " Gas " extractions 72.7 64.2 64.2 71.7 68.7 Hounslow Heath. For ordinary treatment 69.3 75.9 72.3 70.2 71.6 For "Gas" extractions 91.1 80.0 70.0 76.3 78.4 Hounslow Roman Calh. For ordinary treatment 88.8 83.3 76.9 74.0 77.3 For " Gas " extractions 57.1 66.6 50.0 60.8 59.0 Hounslow Town. For ordinary treatment 76.9 79.6 58.9 60.6 58.9 For " Gas " extractions 28.0 69.0 74.6 68.7 65.3 Isleworth Town Junior. For ordinary treatment 62.7 68.1 55.9 70.1 63.3 For " Gas " extractions 87.5 41.6 60.6 69.6 65.0 Isleworth Town Senior. For ordinary treatment 68.6 59.6 58.1 For " Gas " extractions 48.4 51.9 50.6 Isleworth Blue. For ordinary treatment 27.2 47.0 35.9 33.3 33.6 For " Gas " extractions 42.8 75.0 61.2 50. 54.8 St. Mary's R.C. For ordinary treatment 83.3 86.6 76.7 60.8 72.3 For " Gas " extractions 57.1 11.1 62.0 58.6 52.6 Spring Grove Central. For ordinary treatment 57.3 70.0 62.0 For " Gas" extractions 54.5 60.0 57.9 47 Spring Grove Junior. For ordinary treatment 83.3 90.0 67.2 63.8 69.9 For " Gas " extractions 66.6 70.5 42.8 57.1 60.0 Woodlands St. Johns. For ordinary treatment 85.7 63.1 69.2 For " Gas " extractions 45.4 71.4 55.5 Wor pie Road. For ordinary treatment 57.8 59.6 58.3 67.5 61.5 For " Gas " extractions 61.7 82.9 42.5 29.1 56.5 Note.—No order of merit is implied, nor attempted in this Table. As the whole of the school population is under survey, there will be definite statistics which will be comparable. The time has surely come when there should be dental inspectors, appointed by the Board of Education on the same lines as the medical inspectors. We who have not been trained in the dental work beyond a certain point, are not in a position to assist or criticise the treatment carried out, and unless there is some common basis on which statistics can be framed a large proportion of them are fallacious. There is a very defipite difficulty in getting the poorer children from Isleworth to the Dental Clinic on the grounds of distance and expense, and it is hoped that the institution of a Dental Clinic at Redlees will make a considerable difference in this respect. During 1928 arrangements were made for emergency cases to be dealt with every day without previous appointment, and the results have been entirely satisfactory. Four hundred and sixteen cases were sent to the Clinic during 1929, and of these 319 received immediate treatment; 71 were referred for "Gas" appointments, and were subsequently treated, whilst 26 required advice only. Emergency cases can be seen any afternodn, and are always dealt with as soon as they arrive. 48 ORTHODONTIC SCHEME. During the year negotiations had been in progress and final sanction was obtained from the Board of Education for a complete orthodontic scheme. The number of children who require deformities to be deall with in order to obtain an efficient masticating machine, and in certain cases reduce the deformities which are definitely disfiguring, is quite considerable. Hitherto the difficulty has been that the only means of getting these treated was for the parent to attend with the child at the Royal Dental Hospital, which meant that for the poorer patients this was out of the question, on the grounds of the time occupied by repeated visits, and by the necessary expenses which these visits entailed. t Negotiations had been fairly prolonged owing to the difficulty in getting a workable scheme. Hitherto dental students have been taught orthodontic treatment on lines which can only be applied to the well-to-do, and this to a considerable extent, one must say on cosmetic grounds. The point which I have taken is that with dentistry now coming into its own, there must be a refocusing of the ideas with regard to dental practice amongst those of limited means, and also of the teaching to this end. The situation as I see it, and insisted on in the negotiations is best set out in one of my letters to the Secretary of the Royal Dental Hospital. " Re Royal Dental Hospital Letters " With respect to our interview, I take it that the position is this. You will in future arrange that all cases I send up shall be seen for consultative purposes only, and the Orthodontic Specialist will prescribe on some agreed form exactly what he considers is the correct treatment for the particular case, and I would suggest here that if there is any particular reason, I should be glad if that reason could be added. 49 It is to be borne in mind that these cases are to be seen from the point of view of a Public Authority who cannot afford to treat in terms of Park Lane (a) from the point of view of cost; (b) from the point of view of time, and (c) from the point of the difficulty in getting cases to attend. It must also be borne in mind in dealing with these cases that it is quite different from a Dental Hospital where every person who comes is so to speak converted. We have unfortunately to deal with what we may call a considerable number of Dental 'sinners,' and having got them to the penitential form we want the treatment carried out as simply and as rapidly as possible. May I point out that I disagree with the view that nothing but the best must be taught to the Dental Students, and for this reason. Whilst admitting that all Students must be taught the very best and latest form of treatment, no matter how expensive or how prolonged, I think the fact should be faced that there are going to be large numbers of your Students, who are going to take up in the near future wholetime Dental appointments under Public Authorities whose method of treatment will have to be economical, rapid and based on the idea of getting the best result possible for a comparatively small outlay in money and time. Further with Dentistry coming into its own, a large number of your Students will be practising among people whose means are strictly limited, and amongst whom it will be useless to suggest expensive and prolonged treatment, when a useful denture and a satisfactory mouth can be obtained with possibly not so satisfactory an appearance but functionally sound, for a comparatively small fee, whereas if these cases are offered nothing but expensive and prolonged treatment the answer will be habitually in the negative, and will result in no treatment at all except in the bigger towns where there is a Dental Hospital. I am sure that your Students should be taught the two entirely different sets of circumstances, as if they are only going to deal with the well-to-do patients under ideal conditions they are not going to be taught how to make an income amongst those whose incomes are limited. 50 I understand that you will be 'starring' all our cases in some way so that they may be seen in the light of these circumstances. It is agreed that if the scheme goes forward, my Authority should pay the enhanced price of 10/- (ten shillings) for each ticket, which is to include any pathological report, and a print of any radiograph which may be necessary. The idea behind this is that my Authority should provide the Dental Surgeon here with mechanical assistance to make such plates and apparatus as is designated by the Orthodontic Specialist. It is understood that these increased payments for the tickets will involve no payment whatever by the patient. In the event of there being any special cases where my Dental Surgeon considers it will be advisable for a more skilled mechanic'to deal with the necessary apparatus, would it be possible for your mechanic to carry out the work at the instruction of the Orthodontic Surgeon and charge us with the cost? It is of course understood that such a scheme as this is subject to the confirmation of my Committee." The final agreement reached was that the fee of 10/- had to be raised to 12/- owing to the overhead charges of the Hospital not covering the originally suggested fee of 10/-. The greatest difficulty was found in assessing the amount which the Committee would have to pay for necessary plates, bands, etc., which would have to be made, and in many cases repeatedly remodelled for the different types of cases. After consultation with Mechanics and Dental Surgeons who are doing this class of work, it was finally agreed that the sum of 25/- per case would cover any treatment that may be required, no matter how frequently the apparatus had to be readjusted or remade. Thus the round sum of 37/- per case will be charged, irrespective of the amount of work that is to be done. The Royal Dental Hospital agree in return for 12/- to provide this Authority with an Orthodontic Surgeon's report on the case, and any radiograph and pathological reports which may be necessary for the elucidation of the defect and the treatment. 51 We undertake to provide the Hospital with models of each mouth for the Orthodontic Surgeon's use. We retain one for our own records. Thus, instead of the multitudinous journeys necessitated by many of these cases, there will be, except in the rarest instances, only one journey to Town. The rest of the work will be carried out by our own Dental Surgeon, and by the part-time Mechanic working under his direction. Arrangements have been made that the cases shall be inspected by a small Sub-Committee before being passed on for treatment. At the outset it seemed that there might be difficulty owing to possible overcrowding at the Hospital, as it appeared likely that only one Surgeon would be dealing with this work. Fortunately however, several of the Surgeons doing this class of work have entered into the scheme. Special forms are being drawn up for facilitating the work, and keeping of the records. It is proposed that the following scale shall be applied to the charges to be made to parents for orthodontic treatment. The total income is found, and this divided by the number of the family, and on the scale the charges are: — Income less than 8/- per head Free. Between 8/- and io/- per head, to pay £0 9 0 Between io/- and 12/- per head, to pay £ 0 18 0 Above 12/- per head, to pay full amount £ 1 17 0 or in cases of special difficulty to be assessed by the Chairman of the Medical Inspection Sub-Committee. I should like to place on record my thanks for the way in which the Secretary of the Royal Dental Hospital, and particularly Mr. Evans, the Surgeon to the Hospital in charge of this work, did everything they could to make the scheme workable. It is interesting to know that this is the only scheme which the Royal Dental Hospital are prepared to work, as all others that ^ have been put forward have so far been unworkable. It is interesting also to see that there is a very definite move towards educating the dental student to deal with the class of work which he is likely to meet with amongst those of more moderate means, on lines which if not producing the same cosmetic results, will produce an efficient masticating machine.