Heston & Isleworth Urban District Council. 1930. ANNUAL REPORT OF THE Medical Officer of Health AND School Medical Officer FOR THE URBAN DISTRICT OF HESTON AND ISLEWORTH FOR THE Year ending 31st December, 1930. LOWE & SONS (PRINTERS) LTD., 52, Hanworth Road, Hounslow. 1930 REPORT ON The Health of the HESTON & 1SLEWORTH URBAN DISTRICT FOR THE YEAR 1930. by ELWIN H. T. NASH, M.R.C.S., L R.C.P., D.P.H. Medical Officer of Health. 3 Public Health Department. 92, Bath Road, Hounslow. June, 1931. 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 a 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. 4 The health Committee. OF HESTON & ISLEWORTH URBAN DISTRICT COUNCIL Foe the Year 1930-31. Members of the Council:— E. W. Heath, Esq., j.p. (Chairman) C. J. Geary, 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. Clements, Esq. F. C. Green, Esq. H. Collar, Esq. A. L. Lang, Esq. T. W. Cox, Esq. C. L. Lewis, Esq. R. B. Depledge, Esq. G. N. Shackleton, Esq. H. Walton, Esq. Medical Officer of Health— Elwin H. T. Nash, M.R.C.S., L.R.C.P., D.P.H. 5 maternity and child welfare committee. Members of the Council:— J. J. Bonnett, Esq., o.b.e. (Chairman). J. J. Clements, Esq. E. W. Heath, Esq., j.p. A. L. Lang, Esq. G. N. 'Shacklehon, Esq. A. A. White, Esq. Co-opted Members:— Miss E. A. Ankritt. Mrs. E. Chedgey. 6 STAFF. The following persons constituted the Staff of the Health Department during 1930:— Medical Officer of Health— Elwin H. T. Nash, M.R.C.S., L.R.C.P., D.P.H. Assistant Medical Officers of Health— Mrs. E. Louise Roberts, M.B., Ch.B., D.P.H., Barrister-atLaw. Fredk. M. M. Eyton-Jones, M.D., B.S. (Lond), M.E.C.P. (Lond), D.P.H. (Part-time). Consultant in Puerperal Sepsis and Consultant in Obstetric Emergencies— J. W. Bell, L.R.C.P.I. & L.M., L.R.C.S.I. & L.M. (Part time) Consultant to Ante-Natal Clinic— J. W. Bell, L.R.C.P.I. ,& L.M., L.R.C.S.I. & L.M. (Part time). Resigned December, 1930. A. J. Wrigley, M.D. (Lond), F.R.C..S. (Eng). (Part time). Appointed December, 1930. Diphtheria Immunisation Clinics: Superintendent Medical Officer— G. W. J. Bousfield, M.B., B.S. (Part time). Medical Officers— W. W. King Brown, M.B., B.S., M.R.C.S., L.R.CJP. (Part time). Fredk. Porter Smith, M.R.C.S., L.R.C.P. (Part time). Dental Surgeon— I. Cohen, L.D.S., R.C.S. (Eng). Chief Sanitary Inspector— R. H. Butler, A.M.I.S.E., Cert. as S.I. and M.I. District Sanitary Inspectors— G. W. Ashworth, Cert. as S.I. and M.I. E. W. Barton, Cert,.as S.I. and M.I. (Resigned Feb., 1930). G. Grieve, Cert. as S.I. and M.I. (Resigned April, 1930). J. Iv. Lawson, A.M.I.S.E., Cert. as S.I. and M.I. H. E. P. Corline, Cert. as S.I. and M.I. (Appointed April, 1930; Resigned June, 1930). J. R. Glover, Cert. as S.I. and M.I. (Appointed April. 1930). A. E. Hollox, Cert. as S.I. and M.I. (Appointed June, 1930). 7 Disinfector and Laboratory Attendant— F. J. Cobb. Assistant Disinfector and Laboratory Attendant— J. Josephs. (Part time). Health Visitors and School Nurses— Mrs. C. E. M. Ottley, Cert. C.M.B., H.V. & S.N., M.C.W.W. Miss B. N. Tetley, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Soyal Sanitary Institute. Mrs. A. E. Tyrrell, Cert. C.M.B., H.V., and S.N. Miss W. E. Scott, S.E.N. Cert C.M.B., H.V. S.N. M.C.W.W. Miss M. G. Gribble, A.R.R.C., S.R.N., Cert. C.M.B,, H.V. and S.N. Miss A. Bowness, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss G. M. Clare, S.R.N. Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. (Appointed December, 1930). Also one Temporary Health Visitor. Home Help— Mrs. E. Yates. Chief Clerk— B. W. Kilby, Cert, as S.I. and M.I. Clerks— Miss R. Marshall, Cert. as S.I. E. Cromwell, Cert. as S.I. (Resigned January, 1930). P. T. H. Crandon. (Appointed February, 1930). F. Burton. (Appointed Feb. 1930, Resigned Mar., 1930). A. H. Cornhill. (Appointed April, 1930). Miss G. E. Curtis. B. P. Garrod, Cert. as S.I. K. I. Bisshopp. H. J. Aldhous. F. V. Bell. A. E. Black. (Transferred to Surveyor's Dept., Aug., 1930). E. E. Forrest. (Appointed August, 1930). Miss V. D. Nicholls. (Appointed January, 1930). o Medical Superintendent, Mogden Joint Isolation Hospital— (Joint Isolation Hospital, Richmond with Heston. and Isleworth) John Ewinq Adam, M.D., F.R.C.S., D.P.H. 9 NATURAL AND SOCIAL CONDITIONS OF THE AREA. 10 EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1930. Population— At the Census, 1921 46,&64 Registrar-General's Estimate of nett 63,070 (Birth rate) Civil Population (to mid. 1929) 62,240 (Death rate) Local Estimate of Population 80,000 Births— Total Male Female Live Births—Legitimate 1167 625 542 Illegitimate 39 25 14 Birth Rate— On Registrar-General's population figure 19.12 On local estimate population figure 15.07 Total Male Female Still births 44 24 20 Rate per 1000 total births 36.48 Deaths— Total Male Female 647 328 319 Death Rate (corrected)— On Registrar-General's population figure 9.59 On local estimate population figure 7.52 Percentage of total deaths occurring in public institutions 42.65 Number of women dying in, or in from sepsis 6 consequence of, childbirth ) from other causes 2 Deaths of infants under one year of age per 1,000 births— Legitimate 44.55 Illegitimate 205 Infantile Mortality Rate 49.75 Deaths from Measles (all ages) 8 „ „ Whooping Cough (all ages) 0 „ „ Diarrhoea (under 2 years of age) 14 Area 6,851 acres Number of inhabited houses (Census, 1921) 8,790 „ 31/12/30 17,471 „ of families or separate occupiers (1921) 9,893 Rateable value (at 31/12/30) £508,245 Sum represented by a penny rate during the year 1930-31 £2,003 11 Poor Law Relief. I am indebted to Mr. F. E. Harmsworth, Local Public Assistance Officer, for information respecting the amounts paid in money and kind as out-relief to poor persons within the Parish of Heston and Islewortih during the years 1928-29-30:— 1928. 1929. 1930. £4929: 15: 8½ £4373: 11:6 £3947:9:3 VITAL STATISTICS. Population. The Registrar-General's estimate of 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 193.0 amounted to £2,902,01:6. This estimate has a considerable 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 deatlh-rate population excludes all non-civilian males, whether serving at home or abroad; whilst the birth-rate (and 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. Owing to the comparative nearness of the Census, the Registrar-General's estimate of the population up to the middle of 1930 was not issued, and the various rates have therefore been worked out on the last figure supplied by him for 1929. In addition, for the purpose of comparison, and to show to some extent how the population figure affects the birth and death rates, they have also been worked out on an estimated population figure of 80,000. 12 Deaths. The number of deaths registered in the district was 1310, but 737 of these did not belong to the district, while 74 residents died outside the district. Thus the number of deaths properly attributable to the district was 647. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 10.31 per 1,000, which is comparable with the following figures: 11.4 for England and Wales, and 11.4 for London. The death-rate corrected by the Registrar-General's factor of .931 is 9.59. The corrected death-rate worked out on an estimated population figure of 80,000 is 7.52. Births. The total number of births registered during the year was 1291, but 223 of these did not belong to this district, while 138 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 1206. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 19.12 per 1,000. The birth-rate of England and Wales was 16.3 per 1,000, and for London 15.7 per 1,000. The birth-rate worked out on an estimated population figure of 80,000 is 15.07. Legitimacy. The following figures give the number of births:— Legitimate. Male 625 Female. 542 Total 1167 Illegitimate. Male 25 Female. 14 Total 39 13 Table of Causes of Deaths during 1930. Causes of Death. Civil Residents all ages. All causes Male. Female. 328 319 1 Enteric Fever ... ... 2 Small-pox ... ... 3 Measles 3 5 4 Scarlet Fever 2 2 5 Whooping Cough ... ... 6 Diphtheria 5 14 7 Influenza 2 2 8 Encephalitis Lethargica ... 2 9 Meningococcal Meningitis ... ... 10 Tuberculosis of Respiratory System 27 13 11 Other Tuberculous Diseases 4 4 12 Cancer, Malignant Disease 25 50 13 Rheumatic Fever 1 2 14 Diabetes 2 2 15 Cerebral Hemorrhage, &c. 10 18 16 Heart Disease 66 81 17 Arterio-sclerosis 11 6 18 Bronchitis 10 4 19 Pneumonia (all forms) 21 17 20 Other Respiratory Diseases 5 3 21 Ulcer of Stomach or Duodenum 5 2 22 Diarrhoea, etc. (under 2 years) 7 7 23 Appendicitis and Typhlitis 1 3 24 Cirrhosis of Liver 2 ... 25 Acute and Chronic Nephritis 9 12 26 Puerperal Sepsis ... 6 27 Other Accidents and Diseases of Pregnancy and Parturition ... 2 28 Congenital Debility and Malformation, Premature Birth 20 6 29 Suicide 5 3 30 Other Deaths from Violence 21 10 31 Other Defined Diseases 64 43 32 Causes ill-defined or unknown ... ... According to figures furnished by the Registrar-General. 14 Motor Traffic. In dealing with the causes of death in the district, it seems to me that the time has come when the record of deaths caused by modern motor traffic should be put in its proper perspective. Appended are the actual numbers of the deaths which have occurred in this district over the last five years, the particulars having been furnished by the kindness of the Commissioner of Police at New Scotland Yard. Nearly half the accidents have occurred on the Great West Road, and it will be seen how great a menace one road with fast moving traffic can be to a neighbourhood. A further list, also furnished by the kindness of the Commissioner, gives the number of non-fatal accidents during the past five years. These lists, considered together, show how our hospital beds are being occupied to the exclusion of local residents. Return showing the number of persons killed by private motor cars in the Hounslow District and Great West Road. Date. Day or Night. Locus. Person Killed. 16/6/26 Night Great West Road, Hounslow Passenger in Car. 5/11/26 Night Great West Road junction, Bath Road Pedestrian. 3/12/26 Night London Road, Hounslow Pedestrian. 13/6/27 Day Bulstrode Road, Hounslow Pedal Cyclist 20/6/27 Night Great West Road, Heston Pedal Cyclist 26/7/27 Day Great West Road, Hounslow Pedestrian. 21/8/27 Night Great West Road, Isleworth Passenger in Car. 30/10/27 Night Great West Road, Hounslow Pedestrian. 16/10/27 Night Great West Road, Hounslow Pillion Rider 6/6/28 Day Great West Road, Houslow Motor Cyclist 24/7/28 Night Great West Road, Isleworth Motor Cyclist and Pillion Rider 1/8/28 Day Bath Road, Heston Pedestrian. 11/5/29 Day High Street, Hounslow Pedestrian. 10/5/29 Day Martindale Road, Hounslow Pedestrian. 19/6/29 Day London Road, Isleworth Pedal Cyclist 12/6/29 Day Twickenham Road, Isleworth Pedestrian. 24/9/29 Night Great West Road, Hounslow Pedestrian. 26/9/29 Day Great West Road, Heston Motor Cyclist 7/10/29 Night Great West Road, Hounslow Pedestrian. 26/10/29 Night Great South West Road, Hounslow Passenger in Car. 23/12/29 Night Staines Road, Hounslow Pedestrian. 23/12/29 Night Whitton Road, Hounslow Pedestrian. 26/12/29 Night Great West Road, Isleworth Pedestrian. 8/3/30 Day London Road, Isleworth Pedestrian. 9/10/30 Night Bath Road, Hounslow Motor Cyclist 12/11/30 Night Great West Road, Isleworth Passenger in Car. 15 Return showing the number of persons killed by motor cycles in the Hounslow District and Great West Road. Date. Day or Night. Locus. Person Killed. 2/3/26 Day Bath Road, Hounslow Motor Cyclist 17/4/26 Day Bath Road, Hounslow Motor Cyclist 2/4/26 Day Great West Road, Hounslow Motor Cyclist 8/5/26 Day Staines Road, Hounslow Motor Cyclist 25/11/26 Day Barrack Road, Hounslow Motor Cyclist 6/3/27 Day St. Margarets Road, Isleworth Motor Cyclist 14/4/27 Night Great West Road, Hounslow Motor Cyclist 23/7/27 Day Bath Road, Hounslow Motor Cyclist 28/2/28 Night Park Road, Isleworth Motor Cyclist 28/4/28 Day Wellington Road South, Hounslow Pedestrian. 11/7/28 Night Great West Road, Hounslow Passenger in Car. 30/6/28 Day London Road, Hounslow Motor Cyclist 19/8/28 Night Great West Road, Osterley Motor Cyclist 20/8/28 Day Staines Road, Hounslow Motor Cyclist 26/8/29 Day Jersey Road, Heston Pedestrian. 27/9/29 Day Twickenham Road, Isleworth Motor Cyclist 10/8/29 Day Hanworth Road, Hounslow Motor Cyclist 2/10/29 Night Great West Road, Isleworth Motor Cyclist 26/12/29 Night Great West Road, Heston Pillion Rider 2/1/30 Day Hanworth Road, Hounslow Motor Cyclist 9/2/30 Day London Road, Isleworth Motor Cyclist 11/5/30 Day High Street, Hounslow Pedestrian. 7/7/30 Night Great West Road, Osterley Motor Cyclist 10/8/30 Day Hanworth Road, Hounslow Motor Cyclist 28/10/30 Day Bath Road, Hounslow Pedestrian. 17/10/30 Day Worton Road, Isleworth Motor Cyclist 16 Return showing the number of persons killed by motor trade and commercial vehicles in the Hounslow District and Great West Road. Date. Day or Night. Locus. Person Killed. 20/5/26 Day South Street, Isleworth Pedestrian. 9/12/26 Day Great West Road, Hounslow Pedal Cyclist 3/10/27 Day Staines Road, Hounslow Pedal Cyclist 22/10/27 Day Great West Road, Hounslow Pedal Cyclist 11/11/27 Day Staines Road, Hounslow Pedal Cyclist 7/1/28 Day London Road, Isleworth Pedal Cyclist 26/5/28 Day Staines Road, Hounslow Pedestrian. 24/5/28 Day Whitton Road, Hounslow Pedestrian. 18/7/28 Day Bell Road, Hounslow Pedal Cyclist 24/9/28 Day Great West Road, Hounslow Pedestrian. 8/10/28 Day Great West Road, Hounslow Passenger in Car. 19/10/28 Night Great West Road, Hounslow Pedal Cyclist 17/1/29 Night Staines Road, Hounslow Pedestrian. 23/3/29 Night Great West Road, Hounslow Pedestrian. 20/4/29 Day Pears Road, Hounslow Pedal Cyclist 11/4/29 Day London Road, Isleworth Pedestrian. 20/4/29 Day Kingsley Road, Hounslow Pedestrian. 29/8/29 Day Martindale Road, Hounslow Pedestrian. 29/10/29 Night Bath Road, Hounslow Pedal Cyclist 2/12/29 Day London Road, Isleworth Pedestrian. 18/6/30 Day Lampton Road, Hounslow Pedal Cyclist 14/10/30 Night Great West Road, Hounslow Pedal Cyclist 12/11/30 Day London Road, Isleworth Pedestrian. 17 Return showing the number of persons killed by motor omnibuses in the Hounslow District and Great West Road. Date. Day or Night. Locus. Person Killed. 25/11/30 Night Great West Road, Hounslow Pedal Cyclist Return showing the number of persons killed by motor cabs in the Hounslow District and Great West Road. Date. Day or Night. Locus. Person Killed. 8/12/27 Night Great West Road, Isleworth Pedal Cyclist 18 19 NON-FATAL ACCIDENTS IN HOUNSLOW DISTRICTS. Year. Number of accidents. Number of persons injured. 1926 193 231 1927 266 293 1928 334 375 1929 364 371 1930 345 407 Infantile Mortality during the year 1930, Nett Deaths from stated Causes at various Ages under 1 Year of Age Cause of Death. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks. 4 weeks and | under 3 mts. 3 mts. and under 6 mts. 6 mts and : under 9 mts. 9 mts. and under 12 mts. ? Certified 20 4 6 ... 30 9 2 10 9 60 Smallpox Chickenpox Measles ... ... ... ... ... ... ... ... 2 2 Scarlet Fever ... Whooping Cough Diphtheria and Croup ... ... ... ... ... ... ... 1 ... 1 Erysipelas ... Tuberculous Meningitis ... ... ... ... ... ... ... ... 1 1 Abdominal Tuberculosis Other Tuberculous Diseases Meningitis (not Tuberculous) ... ... ... ... ... ... ... 2 ... ... Convulsions 2 1 ... ... 3 ... ... ... 1 4 Laryngitis Bronchitis ... ... ... ... ... 1 1 ... ... 2 Pneumonia (all forms) ... ... ... ... ... ... ... 2 1 3 Diarrhoea ... ... ... ... ... ... 1 ... ... 1 Enteritis ... ... ... ... ... 3 ... 5 ... 8 Gastritis ... ... 2 ... 2 ... ... ... ... 2 Syphilis Rickets Suffocation, overlying Injury at Birth ... ... 1 ... 1 ... ... ... ... 1 Atelectasis 3 ... ... ... 3 ... ... ... ... 3 Congenital Malformations 4 ... 1 ... 5 1 ... ... ... 6 Premature Birth 8 1 2 ... 11 1 ... ... ... 12 Atrophy, Debility and Maiamus 1 2 ... ... 3 2 ... ... 2 7 Other Causes 2 ... ... ... 2 1 ... ... 2 5 20 4 6 ... 30 9 2 10 9 60 Legitimate 1167 Legitimate infants? Nett Births Nett Deaths Illegitimate 39 Illegitimate infants? 21 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 definite figures (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 1930 is 49.75 per 1,000 births. The rates for England and Wales and for London during the same period were 60 and 59 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 formerly occupied by market gardens are being rapidly cut into by new housing schemes. There are two large private 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. 22 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 and 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 to £700. Great use has been made of the Small Dwellings Acquisition Act, and the Housing Act, particularly the former. 13 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA 24 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. No definite arrangements exist for nursing infectious diseases in the (home, but emergency cases which may require it are dealt with as they arise. Suitably trained nurses are put in, if necessary for day and night duty. 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 Scheme 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 22 Midwives practising in the district. There is still some difficulty in the Isleworth end of the district owing to the shortage of midwives. A number of tlhe 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. No Midwife is employed or subsidised by this Council, and I am informed by the County Medical Officer that in no instance did the County Council pay or contribute to the fee of a midwife during 1930. Medical Relief. Poor Law Medical Relief.—The Relieving Officers issued 424 medical orders during 1930. Some of these cases received also outrelief and institutional treatment. 25 COUNCIL LABORATORY, 1930. Total Positive Swabs for Diphtheria sent by Medical Practitioners 667 56 Taken from Schools, Clinics, and from Contacts 2655 61 Sub-cultures 19 3 Sent from Staines Joint Isolation Hospital 555 47 Swabs examined by Clinical Research Association or at Other Laboratories 148 16 Total cultures examined 4044 183 Virulency Tests 10 5 Blood examination for Typhoid Widal Tests 215 2 Specimens of Sputum for Tubercle Bacilli sent by Medical Practitioners 110 6 Hairs for Ringworm— Taken at Sdhools or Clinics 31 21 Other Specimens— Urine 344 Discharge 8 Milk 48 Faeces 1 Blood for Wassermann Test (sent to Clinical Research Association) 2 Special Swabs sent to Dr. Spitta for examination 13 2 Preparation of Materials— Tubes of Serum 4420 Throat Swab Outfits 4650 Sputum Outfits 315 Total 9,385 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. 26 ADOPTIVE ACTS AND BYE LAWS IN FORCE. Adoptive Acts in force in the District. *Infectious Diseases (Prevention) Act, 1890. *Public Health Acts Amendment Act, 1890, Part III. *Public Health Acts Amendment Act, 1907, Parts II., *111., *IV., *V., VI. and VIII. *Public Health Act, 1925, Parts *11., *111., *IV. and *V. were adopted in November, 1925. Maternity and Clhild Welfare Act, 1918. Baths and Wash-houses Act, 1846-82. Burial Acts, 1852-85. (Applicable to parts of the district only). Public Libraries Act, 1892. Private Street Works Act, 1892. Small Dwellings Acquisition Acts, 1899-1923. Local Government & Other Officers' Superannuation Act, 1922. Bye-Laws in force in District. *Common Lodging Houses (P.H.A. 1875, s. 80). *Cleansing, etc. and Removal of Refuse (P.H.A., 1875, s. 44). *Houses Let in Lodgings (P.H.A. 1875, s. 90). *Tents, Vans, Sheds, etc. (H.W.C.A. 1885, s. 9 (2). *Slaughter Houses (P.H.A. 1875, s. 169, and T.I.C.A., 1847, s. 128). *Prevention of Nuisances (P.H.A. 1875, s. 44). *Keeping of Animals (P.H.A. 1875, s. 44). *Removal of Offensive Matters (P.H.A.A.A. 1890, s. 26). New Streets and Buildings (P.H.A. 1875, s. 157, & P.H.,A.A.A. 1890, s. 23). Pleasure Grounds (P.H.A. 1875, s. 164). *Fislh Frying (P.H.A. 1875, s. 113). *Emission of Smoke (P.H.(S.A.)A. 1926, s. 2). 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. 27 HOSPITALS. (1) General.—Hounslow Hospital, Staines Road.—This is the only Voluntary Hospital within the district. It is a modern and well-equipped institution, with 72 beds, including a children's ward and X-ray Department. During the year 1930, there were admitted 10'83 in-patients, whilst 4,775 new out-patients received treatment. West Middlesex Hospital, Isleworth—The large public institutions formerly administered by the Brentford Board of Guardians, and now transferred by virtue of the Local Government Act, 1929, to the Middlesex County Council, are situated at the eastern end, and receive patients and inmates from the constituent parishes of: Acton, Chiswick, Ealing, Greenford, Hanwell, Heston and Isleworth, New Brentford, Old Brentford, Perivale, Twickenham and West Twyford. The County Council, however, I am informed, find that the up-to-date equipment at the West Middlesex Hospital is very convenient for dealing with cases which had formerly to be sent to London and other hospitals by the Staines and Uxbridge Unions. Patients are, therefore, received in increasing numbers from the outlying districts of Spelthorne, Staines, Uxbridge, Hayes and Southall, for medical and surgical treatment. There is practically no difficulty in getting cases into the West Middlesex Hospital. The Royal Hospital (Richmond), West London Hospital (Hammersmith) and other large General Hospitals within the Metropolitan area are within comparatively easy reach by tram, bus, 28 District Railway, or Ambulance, and although definite particulars are not available, it is certain that many people apply to these Hospitals outside this district. The Council annually subscribe £100 to the Hounslow Hospital and £50 to the Royal Hospital, Richmond. (2) Children.—The Children's Ward at the Hounslow Hospital contains 8 cots and 4 beds. A considerable number of children are also dealt with at the West Middlesex Hospital and the London Hospitals. There is still difficulty in getting satisfactory out-patient treatment for children, and there is a definite need in the district for a properly staffed out-patient department. I am glad to see from the last Annual Report of the Hounslow Hospital that this is now in view in the near future. (3) Maternity.—There is no definite provision in the district other than the West Middlesex Hospital for maternity cases, apart from private nursing homes charging considerable fees. The maternity block there, however, is being extended, and great use is made of it by mothers from this and neighbouring districts. A few cases are dealt with in the Hounslow Hospital, and some at the large London Hospitals. (4) Venereal Diseases.—The nearest (hospital for patients from this district is the West London Hospital, but treatment is also available at most of the London Hospitals. 29 (5) Tuberculosis.—The County Council has an Institution in Bell Road, Hounslow, for observation cases only. It contains 16 beds, 7 for females and 9 for males. (6) Chronic Sick.—As far as I am aware, the only Hospital for these cases is the West Middlesex Hospital. (7) Mental Deficiency.—There is no public or voluntary institution in this district. Cases are sent by the County Council and Public Assistance Authority to various Homes and Hospitals for which they are suitable. (8) Orthopaedic.—There is no special provision for orthopaedic treatment at the local Hospitals, apart from massage. Most of the patients requiring special 'advice or treatment attend at the Royal National Orthopaedic Hospital, London. (9) Ear. Nose and Throat.—The Hon. Ear and Throat Surgeon attends at Hounslow Hospital fortnightly, and in-patients are also dealt with for these conditions. The West Middlesex Hospital also deals with some cases. Otherwise patients go to one of the special Hospitals in London. (10) Puerperal Fever and Pyrexia.—-Nearly all cases requiring Hospital treatment are admitted, on the application of the Medical Practitioner attending, to the West Middlesex Hospital, where adequate treatment is available. Occasionally a case may be sent by arrangement to one of the London County Council's Hospitals. (11) Ophthalmia Neonatorum.—An arrangement exists whereby cases of Ophthalmia Neonatorum can be admitted to the St. Margaret's Hospital of the London County Council. 30 (12) Small Pox—Arrangements are in operation with the London County Council Hospitals, through the Middlesex County Authorities, for the admission of cases of small pox to their Hospitals. Dockwell Hospital, the old Small Pox Hospital, situate in this district, was closed on that account, but is available for re-opening at any time for possible infectious disease emergencies. (13) Fever.—This district joins with Richmond in the form of a Joint Hospital Committee, which is responsible for the Mogden Hospital, Isleworth, dealing with Scarlet Fever, Diphtheria, and Enteric Fever. Maternity and Nursing Homes. The County Council is the Supervising Authority under the Nursing Homes Registration Act, 1927. Maternal Mortality. These deaths are investigated by the Medical Officer of Health as far as possible, in conjunction with the medical practitioner in attendance, and the report is made on the prescribed form to the Maternal Mortality Committee of the Ministry of Health. Some difficulty is experienced in getting reports which are of any substantial value. Institutional Provision for Unmarried Mothers, Illegitimate Infants, and Homeless Children. There is in this district the Maddison Memorial Hostel for mothers and babies, which is maintained in connection with the "Woman's Mission to Women," and is an institution which does exceedingly useful work in helping these cases. We have no official arrangement with this institution. 31 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 435 accident cases were removed to hospital, and 340 cases of non-infectious disease were removed to hospitals or nursing homes. CLINICS AND TREATMENT CENTRES. Clinics and Treatment Centres. Address. Day. Time. Provided by Ante-Natal Clinic Public Health Department, 92, Bath Road, Hounslow. 1st & 2nd Wednesday in each month 10 a.m. Heston & Isleworth U.D.C. Diphtheria Immunisation Clinics Public Health Dept. Monday 2.0 p.m. Wednesday 2.0 p.m. ,, Isleworth Public Hall Saturday 10 a.m. Infant Welfare Centres Congregational Hall, Tuesday 2.0 p.m. Hounslow Wednesday 2.0 p.m. ,, Thursday 2.0 p.m. Village Hall, Heston Tuesday 2.0 p.m. Friday 10 a.m. ,, Isleworth Public Hall Monday 2.0 p.m. Wednesday 2.0 p.m. ,, Friday 2.0 p.m. Maternity & Child Welfare Dental Clinic Public Health Dept. As for School Dental Clinics (see below) Minor Ailments Clinics (nurse attending) Public Health Dept. Every week day 9.0 a.m. ,, Village Hall, Heston Every week day 9.0 a.m. Isleworth Public Hall Every week day 9.0 a.m. Ophthalmic Clinic Public Health Dept. Thursday 2.0 p.m. ,, Friday 2.0 p.m. 32 School Clinics (Medical Officer attending) Public Health Dept. Tuesday 10.30 a.m. Heston and Isleworth U.D.C. Friday 10.30 a.m. Village Hall, Heston Thursday 10.30 a.m. Isleworth Public Hall Monday 10.30 a.m. ,, School Dental Clinic Public Health Dept. Monday 9.30 a.m. and 2.0 p.m. Tuesday 9.30 a.m. and 2.0 p.m. Wednesday 9.30 a.m. and 2.0 p.m. Thursday 2.0 p.m. Friday 9.30 a.m. and 2.0 p.m. Saturday 9.30 a.m Tuberculosis Dispensary Bell Road, Hounslow Monday 10 a.m. Middlesex C.C. Thursday 2.30 p.m. Venereal Diseases Clinic West London Hospital, Hammersmith, and other London Hospitals Every week day 7.30 a.m. to 7.30 p.m. Sunday 10.0 a.m. to noon The 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 the Local Medical Practitioners. The only Day Nursery in the District was closed in 1920. 33 34 LOCAL GOVERNMENT ACT, 1929. On the 1st April, 1930, the work in connection with Infant Life Protection was transferred from the Board of Guardians to the Local Authority, and it has become a purely public health matter, whereas previously the Guardians assumed other functions in tracing out the father and exacting payment where it could be obtained. The transfer of duties was made known by notices in the local press, by sending a circular letter and brief details of the law to all the known foster-mothers, and by information supplied at the Council's Maternity and Child Welfare Centres. No special Infant Protection Visitors have been appointed, but the work has been divided amongst the existing staff of Health Visitors, who have paid 338 visits to foster-children between the 1st April and 31st December. Many of the foster-children have also been brought regularly to the Maternity and Child Welfare Centres. The work has progressed smoothly, and the foster-mothers generally have proved satisfactory. In one case only was it found necessary to take any action, and here the foster-mother's name was removed from the Begister as the accommodation was unsatisfactory. It was found that all the upstair rooms were sub-let, and the family (5 in all) were sleeping in one room. The child is now with another foster-mother in the district, and has a room to himself. No new foster-mother is registered until she has supplied full details of her circumstances, etc., and the home has been found satisfactory by the Visitor. When a foster-child removes to an address outside the area, full details are sent immediately to the appropriate authority, and any foster-child arriving in this area, whether it is reported to have come to its parents or not, is visited to see that all is satisfactory. 35 Three foster-children died between 1st April and 31st December. One, aged 8 months, died in hospital from gastro-enteritis and marasmus. The second death, a child of 1.7 months, was due to miliary tuberculosis; and the third child, aged 5 months, died from "asphyxia due to regurgitated food in the gullet." An inquest was held in this case. No. of Foster-Mothers and Children in the 'Register. At 1st April, 1930. At 31st December, 1930. Foster-mothers 50 74 Foster-children 60 63 No. of Visits paid by Visitors (April to December inclusive) 338 . 37 SANITARY CIRCUMSTANCES. 38 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 103 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 inaccessible 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 1930: — (a) Foul Water Sewers 31,067 feet. (b) Surface Water Sewers 30,904 feet. During 1930 negotiations have been pending for a complete West Middlesex Sewage Scheme which should pick up the sewage of this district. Alternative sites were suggested, but ultimately a site adjacent to and including our own Sewage Works was selected, and the Bill promoted by the Middlesex County Council. (This Bill was read a third time in the House of Commons in May, 1931.) 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 1930 collection of house refuse has continued weekly as before, and was disposed of by means of a dump in the Staines Road. The method of disposal is that each day's tipping is completely covered with earth. Four low loading electric collecting vehicles have replaced old-type lorries. 39 During the year, as a result of action taken there were supplied 189 new ashbins. Sanitary Inspection of District. See pages 41 to 48. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc. The number of premises on which nuisances were outstanding at the end of 1929 was 509. To these another 902 premises whereat nuisances were recorded in 1930 were added, giving a total of 1411 premises. Of these 977 had the nuisances remedied, leaving 434 premises at which nuisances still existed at the ,end of the year. During the year, nuisances at 94 houses were reported to the Health Committee, which, added to the 60 brought forward from 1929, made a total of 154. 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 101 of the houses. In 8 cases it was decided to take no further action, leaving 45 cases to be carried forward to 1931. Comparative figures for the years 1928, 1929 and 1930, in connection with nuisances, are submitted herewith:— 1928 1929 1930 Number of complaints received 514 590 566 Premises at which nuisances were located 882 1261 902 Number of First Informal Notices 863 1200 905 Number of Reminders and Letters 158 124 861 Number of Statutory Notices 39 90 230 40 The housing problem, as I have said in previous reports, is one of extraordinary difficulty from many points of view. One is bound to admit that the removal of the Rent Restriction Act would, in many cases, create immense hardship. For example, one street of houses—the average rent of which is in the region of 13/6—directly one becomes de-controlled the rent that is obtained is 32s. per week. In the case of two semi-detached cottages, identically the same, let at 13s. a week, one became de-controlled, the rent now obtained being 35s. a week. On the other hand, the more one sees of the Rent Restriction Act and sub-letting, and the wear and tear of premises, particularly where there is more than one sub-tenancy, the more one feels that the landlord, in these cases, is not getting a square deal. The amount which he receives is 40 per cent., which in the case of sub-letting is quite insufficient to cover the increased wear and tear, and there is a certain class of tenant who insists on the last letter of the law in respect of repairs, which they have brought about by their profiteering. Proceedings. Proceedings taken during the year were as follows: — {a) Proceedings for non-compliance with notices served under Section 94 cf the Public Health Act, 1875, were instituted in 19 instances. Summonses were withdrawn in 6 cases where work was in progress or had been completed. In the remaining 13 instances Orders to abate the nuisances were made, and in addition the following Fines and Costs were imposed in 7 of these instances Fine £2, and Costs £2 2s. in two instances. Costs £2 2s. in three instances. Costs 11s. in two instances. (b) Non-compliance with notices to vacate premises after Closing Orders had become operative. In 18 instances proceedings were taken and an Order for possession was made in each case. 41 (c) Contravention of the Public Health (Meat) Regulations, 1924. In this case a summons was taken out for constantly repeated neglect to notify the time of slaughtering. The butcher claimed that he had the right, under a notice given of customary slaughtering at a specified time, to delay the actual slaughtering if necessary in some cases several hours after the time given. The summons was withdrawn after an adjournment, defendant having undertaken to carry out the requirements of the Regulations in the, future. £2 2s. costs were imposed. Milk and Dairies (Amendment) Act, 1922. Section 2. An appeal was made against the decision of the Council to remove from the Register the name of a purveyor of milk, owing to the unsatisfactory state of his premises. The appeal was dismissed, the appellant being allowed to sell bottled milk in unopened bottles purchased from another vendor. SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc. 22415 Inspections, etc., re Nuisances, Contraventions, etc.: Number of premises, ctc., inspected on complaint 522 Number of premises inspected in connection with infectious diseases 338 Total number of premises, etc., primarily inspected in connection with nuisances 1164 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920 17 Number of other visits made to premises, etc., in connection with nuisances, etc. 3677 Number of visits made to.works in progress 3104 Number of interviews with owners, builders, etc. 1687 42 Action taken (including action taken under Housing Act, 1925, Section 3). Number of premises, etc., whereat nuisances were recorded during the year 902 Number of premises, etc., on which defects, etc., were remedied— (a) by owners or occupiers 977 (b) by local authority in default of owner or occupier 22 Number of cautionary or intimation notices given— (a) verbal 202 (b) written 703 Number of letters and reminders re nuisances sent 861 Number of Statutory Notices issued 230 Number of proceedings taken 38 Number of convictions obtained 31 Number of proceedings withdrawn 7 Number of cases dismissed Number of appeals made against decision of Council 1 Number of appeals dismissed 1 Common Lodging Houses: Number registered 2 Number of inspections made 15 Number of contraventions outstanding from previous year Number of contraventions found Number of contraventions remedied Number of contraventions outstanding at end of year Canal Boats used as Dwellings: Number of inspections made 59 Number of contraventions outstanding from previous year 5 Number of contraventions found 13 Number of contraventions remedied 7 Number of contraventions outstanding at end of year 11 43 Movable Dwellings, Caravans, Tents, etc. Number of inspections made 70 Number of contraventions outstanding from previous year 23 Number of contraventions found – Number of contraventions remedied 10 Number of contraventions outstanding at end of year 13 Bakehouses: Number in district (a) factories 13 (6) workshops 9 Number of underground bakehouses in district 1 Number of inspections made 84 Number of contraventions outstanding from previous year – Number of contraventions found 22 Number of contraventions remedied 18 Number of contraventions outstanding at end of year 4 Slaughterhouses (including Knacker's Yard): Number on register (a.) registered premises 4 (6) licensed premises (including one licensed knacker's yard) 4 Number in inspections and visits made 1030 Number of contraventions outstanding from previous year 5 Number of contraventions found 6 Number of contraventions remedied 6 Number of contraventions outstanding at end of year 5 Cowsheds: Number of persons registered 5 Number of premises registered 5 Number of cowsheds on register 8 Number of milch cows in district 67 Number of inspections made 59 44 Number of contraventions outstanding from previous year 1 Number of contraventions found 6 Number of contraventions remedied 6 Number of contraventions outstanding at end of year 1, Dairies and Milkshops: Number of persons registered 54 Number of premises registered 33 Number of inspections made 322 Number of contraventions outstanding from previous year 7 Number of contraventions found 24 Number of contraventions remedied 29 Number of contraventions outstanding at end of year 2 Offensive Trades: Number of businesses established in district 19 Number of inspections made 125 Number of contraventions outstanding from previous year 1 Number of contraventions found 5 Number of contraventions remedied 6 Number of contraventions outstanding at end of year – Ice Cream Vendors: Number of contraventions found 1 Number of contraventions remedied 1 Public Health (Meat) Regulations, 1924: Number of inspections made 987 No notice of slaughtering given 10 Improper notice of slaughtering given 35 No precautions taken for the prevention of contamination 4 Written notices sent 4 Verbal notices given 49 45 Inspection of Food: Number of meat inspections 1065 Number of fish inspections 122 Number of provision inspections 169 Number of greengrocery and fruit inspections 202 Number of hawkers' foodstuff inspections 181 Number of other food inspections 26 Unsound Food: Number of carcases and offal surrendered 12 Number of articles surrendered 11 Number of parcels surrendered 10 Number of organs or parts surrendered during slaughtering 378 Infectious Diseases, Disinfections, etc.: Number of visits made 1301 Number of rooms disinfected— (a) Ordinary infectious diseases 470 (b) Tuberculosis 76 (c) Other diseases 6 Number of rooms stripped and cleansed after infectious diseases— (a) by owners or occupiers 37 (b) by local authority 1 Number of articles disinfected or destroyed 2256 Smoke Abatement: Number of observations made 36 Number of nuisances outstanding from previous year 3 Number of nuisances found 1 Number of nuisances abated 4 Number of nuisances outstanding at end of year – Water Supply: Number of supplies provided or reinstated 13 Number of cisterns cleansed, repaired, covered, etc. 1 46 Number of draw taps connected direct to main 103 Number of water service pipes or taps repaired 4 Approximate percentage to houses supplied on constant system 99.95 Number of samples taken for analysis from— (а) Local wells 1 (b) Public supply 1 Number of samples found polluted or impure Drainage and Sanitary Arrangements, etc., of existing Buildings: Water Closets: Number of water closets provided or reconstructed ... 43 Number of water closets provided in substitution for dry receptacles 1 Number of walls, etc., cleansed 26 Number repaired, supplied with water or otherwise improved 362 Number cleansed or unstopped 6 Approximate percentage of houses provided with water closets 9'9 Earth or Chemical Closets: Number provided or reconstructed 1 Number repaired or supplied with deodorants 1 Sinks: Number of new sinks provided 113 Number of sinks repaired or improved 80 Drains: Number examined, exposed, etc. 4 Number unstopped, repaired, trapped, etc. 215 Number of waste pipes provided, disconnected, repaired trapped or unstopped 58 Number of soil pipes fixed, repaired or improved 1 Number of ventilating shafts fixed, repaired or improved 18 Number of fresh air inlets provided, repaired or improved 25 47 Number of rain water pipes disconnected from drain 4 Number of gully traps inserted or improved 160 Number of disconnecting traps inserted 1 Number of inspection chambers inserted 5 Number of disconnecting traps improved, sealed or cleansed 3 Number of inspection chambers repaired, improved sealed or cleansed 13 Number of drains constructed or reconstructed 11 Total length of drain pipes laid (4in.) 322ft. Number of tests and re-tests applied 30 Number of other works executed 7 Approximate percentage of houses draining into Council's sewer 99 Cesspools: Number rendered impervious, emptied, cleansed, etc. 2 Removal of Household Refuse: Number of new ashbins provided 189 Number of ashbins repaired 3 Dampness: Number of roofs stripped, renewed or repaired 419 Number of gutters and rain water pipes provided, repaired or unstopped 391 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 566 Number of damp-proof courses provided 225 Number of yards paved, repaired or drained 235 Interior Work: Number of rooms stripped and cleansed (other than in connection with infectious disease) 552 Number of floors, walls & ceilings repaired or renewed 1770 48 Number of rooms in which ventilation provided or improved 28 Number of rooms in which lighting provided or improved 9 Number of window frames and sashes provided, repaired or unfixed 1269 Number of stoves or grates provided or repaired 389 Number of instances in which ventilation under floors provided or improved 194 Number of other repairs 249 Sundry Nuisances, etc.: Number of instances in which domestic cleasing enforced 11 Number of foodstores provided, cleansed or improved 27 Number of washing coppers provided or repaired 176 Number of rooms sprayed for the removal of vermin by the Disinfector 60 Number of instances in which overcrowding abated 43 Number of instances of improper keeping of animals abated 21 Number of offensive accumulations removed 23 Number of urinals provided, repaired, cleansed or improved 4 Number of other nuisances abated 49 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) Factories (including Factory Laundries) 88 117 8 Nil. Workshops (including Workshop Laundries) 144 195 13 Workplaces (other than Outworkers' premises) 38 25 7 Outworkers 36 32 ... Total 306 369 28 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecutions. Outstanding Jan. 1st. 1930. Found during 1930. Remedied during 1930. Outstanding Dec. 31st, 1930. Referred to H.M. Inspector 2 3 4 5 6 Usances under the Public Health Acts:-* Want of cleanliness 6 11 15 2 Want of ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors ... ... ... ... Other nuisances 4 18 15 7 Sanitary accommodation—† Insufficient 5 3 7 1 Nil Nil. Unsuitable or defective 3 21 1 3 Not separate for sexes 1 ... 1 ... 1 fences under the Factory and Workshop Act: — Illegal occupation of underground bakehouse (s.101) ... ... ... ... Breach of special Sanitary requirements for bakehouses (ss. 97-100) ... 14 13 1 Other offences:— Excluding offences relating to outwork ... ... ... ... Total 19 67 72 14 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 for persons employed in factories and workshops enforced is that required by the Sanitary Accommodation Order of 4th February, 1903. 50 OUTWORK. (a) 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 308 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. There are 14 public elementary schools and one central school. Some are modern up-to-date buildings, and others of the transitional period and not up to modern standards; some are considerably older and unsatisfactory from a hygienic point of view. These are being brought up-to-date so far as their structure allows. 51 COPY OF REPORT FORWARDED TO THE MINISTRY OF HEALTH DATED 27th JANUARY, 1931, WITH REGARD TO CANAL BOATS. Canal Boats Acts, 1877 to 1884. In accordance with Section 3 of the Canal Boats Act, 1884, I beg to present herewith the Annual Report for the year ended 31st December, 1930, as to the execution of the Canal. Boats Acts, 1877 and 188k, and of the Regulations made thereunder, within the Urban District of Heston and lsleworth, Middlesex. Inspectors Appointed under Canal Boats Acts— R. H. Butler (Chief Sanitary Inspector). G. W. Ashworth (District Sanitary Inspector). J. K. Lawson (District Sanitary Inspector). J. R. Glover (District Sanitary Inspector). A. H. Hollox (District Sanitary Inspector). No special remuneration is paid for the position. Number op Inspections, etc.— Number of Inspections made 59 Number of Canal Boats inspected 59 Number of boats found in order 47 Number of boats with two infringements 1 Number of boats with one infringement 11 Nature of Contraventions, etc.— Overcrowding 4 Cabins not in a cleanly and habitable condition 2 Paintwork of internal surfaces of cabin requiring renewing 2 Registration certificate not in order 5 Legal Proceedings— No legal proceedings have been taken during the year. Infectious Disease— Nine cases of smallpox and one case of scarlet fever were reported as occurring among the Canal Boat population during the year. 53 HOUSING. 54 Housing. 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 667 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 458, and the total amount of loans under the Small Dwellings Acquisition Act up to the end of 1930 was £2,902,016. Despite a slight easing of the problem, there is still great difficulty with regard to accommodation in the case of a family with small children. A point that seems to arise from the necessity of purchasing a house in order to find accommodation, is that people are purchasing houses, the weekly re-payments of which are far beyond the limit which their means justify. One comes across cases where the amount of the re-payments, which of course stand in the place of rent, are as high as 40 per cent. of the total earnings. What is going to happen to these houses when repairs become necessary, one scarcely likes to contemplate. All this is bad enough where the occupier is in regular work, but one repeatedly comes across cases where, after having entered into obligations of this kind, work fails, and then the plight of these harassed people vainly endeavouring to make the ever-widening ends meet is deplorable. Again I wish to draw attention to the question of Van Dwellers. The profits on pieces of land let to these people is such that in the absence of adequate powers by the Local Authority, no district can be free from what is often—as a result of the habits of the people—an intolerable nuisance. Year by year the class of Van Dweller is growing owing to the housing shortage, being recruited from a different class altogether from the original van dweller, some of whom are maintaining their respectability and 55 cleanly habits, others of whom are definitely degenerating. The condition of some of these places in the wet weather is hopeless from the point of view of cleanliness. The surface of the ground becomes a quagmire, the children's boots get filthy, and the dirt is trodden into the caravans. Not only are these people a nuisance from the point of view of their habits, rowdiness and such-like, but their method of earning a living is mainly accompanied by noise. There should be some protection for the general public from the deafening din produced by merry-go-rounds and all the noisy accompaniments of fairs. It is the introduction of the steam organ, whose brazen reiteration of popular tunes can be heard for very long distances, which creates the chief difficulty. The city of New York has taken the lead in appointing a Commission to deal with noise. The time has surely come when something should be done in this country to deal with noise. From the point of view of the individual, the necessity of working under noise increases the daily nervous wear and tear. The noise of motor traffic, and now the incessant noise of aeroplanes in the neighbourhood of aerodromes, particularly at week-ends, is producing a new worry in the daily life of certain classes of people. I have received various complaints with regard to the noise from aeroplanes, particularly from women, who, being at home all day, get more of it than the men. I see no reason, if we insist on the silencing of motor vehicles and the progressive use of pneumatic tyres to decrease noise, why we should not equally insist—and more emphatically to my mind—on the silencing of aeroplanes flying round residential areas, for this reason : that whereas the noisee of a motor lorry is a matter which lasts but a few seconds, the noise of an aeroplane is heard persistently for long distances, and where several machines are circling round an aerodrome, the area is never free from noise. And noise, 56 moreover, of a peculiarly irritating character if stunting is going on, as the variations in noise, for instance, when looping the loop are arresting and penetrating. That the noisy aeroplane is necessary is disproved by the quietness of some. 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 dilapidation are the main defects found. (c) How far are defects 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 given the price of materials and the cost of labour as reasons for delay or neglect in the repair of repairable houses. (4) Conditions so far as they affect housing, as regards water supply, closet accommodation and refuse disposal, together with measures taken during the year in these 'matters: Water supply is on the whole satisfactory. 57 Closet accommodation is generally adequate, but defective apparatus is frequently complained of, whilst in the outlying parts of the district are some houses not yet connected with the general sewerage system. Refuse disposal: A weekly collection is made. II. Unhealthy Areas. Information as to complaints received or representations made and action taken in regard to unhealthy areas, under Part II. of the Housing Act of 1935. 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 arc 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: Difficulty is still experienced in dealing with caravan dwellers and the existing bye-laws, as mentioned elsewhere. IV. General and Miscellaneous. Other action taken in connection with) overcrowding: Insanitary property and housing Nil. 58 V. Appendices, Statistics for year ending 31st December, 1930 APPENDICES. Housing Conditions Statistics. Year ended 31st December, 1930 I. GENERAL. (a) Registrar-General's estimated population to middle of 1,929 Birth Rate 63,010 Death Rate 62,240 (b) Local estimate of population (31/12/1930 80,000 General Death rate (corrected on population figure of 80,000) 7.5 Death rate from Tuberculosis, all forms (on population figure of 80,000) 0.6 Infantile Mortality 49.75 Number of dwelling-houses of all classes according to rate books 17,471 Total number of New Houses erected of all classes 1,734 Number of New Houses erected during the year:— (a) Total (including figures given below) 1,734 (b) With State assistance under the Housing Acts:— (1) By the Local Authority 126 (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) 860 (2) Number of dwelling-houses which were inspected and recorded under the Housing Consolidated Regulations, 1925 170 53 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 1 (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 463 (5) Number of houses listed for inspection under the Housing Consolidated Regulations, 1925, at end of year 1310 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 422 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 28 (2) Number of dwelling-houses which were rendered fit after service of formal notices— (a) by owners 28 (6) by Local Authority in default of owners 21 (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 Section 17 of the Homing Act, 1930:— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 11 60 (2) Number of dwelling-houses which were rendered fit after service of formal notices— (a) by owners 2 (b) by Local Authority in default of owners Nil C. Proceedings under Public Health Acts— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 72 (2) Number of dwelling-houses in which defects were remedied— (a) by owners 62 (b) by Local Authority in default of owners 1 D. 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 Oraers l (2) Number of dwelling-houses in respect of which Closing Orders were made 2 (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 (H.A. 1.925, 22; H.A. 1930, 20) 42 (5) Number of dwelling-houses demolished in pursuance of Demolition Orders ... 4 E. 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 61 F. Other matters:— (1) Number of dwelling-houses closed voluntarily 14 (2) Number of dwelling-houses demolished voluntarily 14 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 at present appointed wholly for housing duties, which are carried out by the staff in conjunction with their other duties, but the appointment of one of the District Sanitary Inspectors, solely for duties under the Housing Acts, is being considered. 62 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't forw'd from 1929— *1-3, Poplar Cottages, Town Wharf, lsleworth 3 8/1/14 24/2/14 ... 22/12/14 *15, South Street, lsleworth 1 11/1/15 27/4/15 ... 23/11/15 14-34, London Road, Brentford 11 12/5/19 22/7/19 End 10/6/29 23/7/29 ... 25/3/30 1-10, Syon Place, London Road, 10 12/5/19 22/7/19 Brentford End 10/6/29 23/7/29 ... 25/3/30 65-75, Hanworth Road, 6 12/1/20 23/11/20 slow 13/5/29 25/6/29 ... 28/10/30 175, Twickenham Rd., lsleworth 1 12/1/20 26/4/21 ... 28/10/30 177, „ „ 1 12/1/20 13/5/29 25/6/29 ... 28/10/30 1 & 3, Wellington Road North, Hounslow 2 9/2/20 13/5/29 25/6/29 Cottage situated in the Farm Buildings, Wood Lane Farm, Wood Lane, Isleworth 1 13/7/25 22/9/25 ... 25/2/30 10/12/30 * Demolition deferred. 64a HOUSING. (1) GENERAL OBSERVATIONS AS TO HOUSING CONDITIONS, including the standard of houses, the prevalent types, age, and approximate number and general soundness of the several types— any information as to prevailing forms of defects and of prevailing bad conditions resulting from overcrowding. Number of houses of all classes according to rate books - 17,471. Approximately 80% are occupied by persons of the working and middle classes and 20% by the higher class. Approximately half of the working and middle class houses are of the Terrace type, and most of these are upwards of 50 years old— some in the vicinity of 100 years old. The remainder are mostly of the semi-detached type. A considerable number of houses require renovation. Dampness due to lack of proper dampproofing, inadequate lighting and ventilation and general dilapidation are the principal defects found. (2) SUFFICIENCY OF SUPPLY OF HOUSES. (a) Extent of shortage, if any, of houses available at reasonable rents, and the measures taken or contemplated to meet any shortage. There is still a shortage of houses available at rents within the compass of the financial resources of those most in need of them. There are approximately 1,500 applicants on the register for houses on the Council's Estates. The number of houses erected by the Council during the year is 126, making a total of 667 since 1921. The Council's Quinquennial Housing Programme includes the erection of a further 2,000 houses to meet the present shortage. (b) Information as to any important changes in population during the period under review, or anticipated in the future. The present population shows an increase of 61 % on the 1921 Census figures. (c) Any special difficulties in the way of providing suitable sites for new houses. No special difficulties encountered. (3) OVERCROWDING. (a) Extent. The basis on which the estimate has been made should be stated. Approximately 13% of the working class houses are overcrowded. (Basis of estimate: Out of 1,345 houses visited during the year for the purpose of making up the 5 years housing programme, 179 were estimated to be overcrowded). 64b (b) Causes—how far is it due to inability to pay the rents of available houses. The chief cause of overcrowding appears to be the lack of houses available for letting at rents within the capacity of the humbler section of the community. (c) Example of special action taken during the year 1930 to deal with overcrowding. No special action taken. Where overcrowding is found to exist, preliminary notices are served, but tenants are not pressed to find other accommodation as this is not available for the reason given under 3 (b). (4) FITNESS OF HOUSES. (See Manual of Unfit Houses and Unhealthy Areas, 1919 (1), p. 10). (a) Difficulties found in action under the Public Health Acts or under Section 3 of the Housing Act, 1925. No special difficulties have arisen in the administration of these Acts. (b) Special measures taken or suggested, e.g. in relation to particular types of insanitary property or in regard to arrangements for the gradual carrying out of programmes of repair. Arrangements have been made whereby all dwelling-houses of the working class type will be systematically inspected. During the next five years the Council propose to deal with 1,345 houses under the provisions of the Housing Act, 1930. (c) Extent to which houses have not an adequate internal water supply, distinguishing those houses supplied by (a) private and (b) common supplies. The percentage of houses without an internal water supply is very small—approximately 60 houses are supplied from common supplies. (d) Extent to which houses have no water closet or other adequate sanitary accommodation within their curtilage, distinguishing those having (a) private and (b) common accommodation. Nearly all the houses have separate closet accommodation. About 70 houses have common accommodation. (If exact information is not available in regard to sub-headings (c) and (d), estimated figures will be sufficient). (5) UNHEALTHY AREAS. Extent to which areas of the district are unhealthy, with information as to complaints received or representations made, and action taken, in regard to any of these areas. NIL. 61c (6) BYELAWS RELATING TO HOUSES, TO HOUSES LET IN LODGINGS, AND TO TENTS, VANS, SHEDS, ETC. Adequacy of existing Byelaws of each class, and special difficulties in or limits upon their enforcement. No byelaws have been made under the Housing Act, 1925, relating to houses. Byelaws relating to houses let-in-lodgings were made in January, 1884, and are inadequate for the conditions at present prevailing. Byelaws relating to Tents, Vans and Sheds, etc., were made in January, 1898. Some difficulty has been xperienced in dealing with caravan dwellers—who are steadily increasing— under the existing byelaws with regard to the disposal of refuse, closet accommodation and water supply. (7) GENERAL OBSERVATIONS ON HOUSING MATTERS NOT ALREADY COVERED, and any difficulties experienced in housing administration, and the measures taken to meet them. See paragraph 4 on Page 54 of Report. One great difficulty amongst the humbler folk who are suddenly provided with a house after living for long periods in one or two rooms is that they are suddenly confronted with furnishing the more ample accommodation they have acquired, and in some cases this is a very real hardship indeed, and where means are already small there is no alternative but to reduce the amount spent on food and clothing, and it is doubtful whether the increased light and air counterbalances the dietetic restrictions. POPULATION. Since the Report was printed, the Registrar-General has supplied his estimate of the population at Mid-Year—1930, which is as follows:— For calculation of the Birth Rate 70,420 For calculation of death and general rates (Net Civil Population) 69,610 ERRATUM.—Page 54, Line 5: The figures 541 should read 667. 63 Table shewing dwelling-houses represented as unfit for human habitation. Premise. No. of houses represented by M.O.H. Date of representation. Date Closing Order made. Date Closing Order determined. Date Demolition Order made. Date Demolition Order obeyed. Date Demolition Order enforoed. 4, Barnfield Cottages, Springwell Road, Heston 1 7/5/28 26/6/28 23/7/29 2/6/30 17, Bell Road, Hounslow 1 10/12/28 22/1/29 23/7/29 13/2/30 Woodbine Cottage, Bath Road, Hounslow 1 11/3/29 23/4/29 House not demolished 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 ... 28/10/30 *11, 13 & 14, Syon Cottages Syon Lane, lsleworth 3 11/11/29 17/12/29 ... 28/10/30 123, 125, 127, East and West, No. 123 Vicarage Farm Road, Heston 4 11/11/29 17/12/29 ... 28/10/30 1/9/30 6, London Road, Brentford End 1 9/12/29 28/1/30 ... 28/10/30 8, London Road, „ 1 26/11/29 25/2/30 10 & 12, London Rd., „ 2 26/11/29 17/12/29 ... 28/10/30 36, Holly Road, Hounslow 1 26/11/29 17/12/29 House demolished 7/5/30 Dealt with in 1930— The Hut at the rear of Sunny- holme, Wellington Road South, Hounslow 1 7/7/30 * Demolition deferred. 65 INSPECTION AND SUPERVISION OF FOOD. 66 INSPECTION AND SUPERVISION OF FOOD. The following is the record of inspection of food premises :— Meat 1065 Fish 122 Provisions 169 Greengroceries and Fruit 202 Hawkers' Food Stuffs 181 Number of other Food Inspections 26 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 from the bottle into unsterilised containers. It is far better 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. 381 inspections were carried out in respect of cowsheds, dairies and milkshops. Unofficial milk analyses are made by the Medical Officer of Health. The standard of the milk supply in the district on the whole has improved. Very little of the milk which is sold in the district now is not pasteurised, although only 3 firms were licensed to sell "pasteurised" milk under the Milk (Special Designations) Order, 1923, during the greater part of the year, and 1 other firm towards the end of the vear. Number of firms in the district licensed to sell— "Certified" milk 5 (8 shops) "Grade A" (Tuberculin Tested) 7 (11 shops) "Grade A" — "Pasteurised" 4 (13 shops) 67 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. Meat 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, 3343¼ lbs. of diseased meat were surrendered. There are 7 slaughter-houses in use in the district, and each slaughter-house received on an average 12.26 visits per month. There were 50 butchers' shops in the district at the end of 1:930. 2. Public Abattoir.—There is no public abattoir 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 grounds that I do not think that at the present time the expense is justified, owing to the fact that by far the greater part of the meat coming into the district is bought at Smithfield and inspected there. There does not seem to be with the growth of the district any great demand for further facilities for slaughtering at present. 3. Action under Section 117, Public Health Act, 1875. — None during 1930. 4. Tubercular Meat.—There was none seized, but 2330^ lbs. were surrendered during the vear. 5. The following is a tabular statement on slaughter-houses : 1920 In January, 1930 In December, 1930 Registered 4 4 4 Licensed 4 3 3 Total 8 7 7 68 The slaughter-houses as a whole are not very satisfactory. More and more the butchers are buying in the London markets and slaughtering less. The additional work thrown on the staff by the Public Health (Meat) 'Regulations, 1924, has been considerable, and is best shown by the number of inspections as compared with previous years:— Number of Inspections, etc., made. 1924 1925 1926 1927 1928 1929 1930 Meat—Inspections made 556 1513 1790 1820 1985 1810 987 Slaughter-houses —Inspections and visits made 204 1131 1106 1400 1463 1291 1030 Most of the butchers have loyally fallen into line with regard to giving notice of slaughtering, but in 45 instances no notice or insufficient 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 50 Butchers' shops in the district. Up to the present, 32 have been provided with fixed windows, of which number 4 were new shops in 1930, 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. 69 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 he 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 1930. Article Taken Adulterated Milk 19.2 4 Chocolate 1 — Dripping 1 — Gin 3 — Lemon Squash 2 — Meat 15 — Minced Beef 2 — Sausages 4 — Whisky 4 — 224 4 The unsatisfactory samples of milk were informal samples in which small deficiencies in fat were reported. No formal sample was reported as adulterated. b UNSOUND FOOD, 1930. Tons. Cwts. Qrs. lbs. Crabs 1 0 17 Corned Beef 1 8 Meat 1 9 3 11¼ Rabbits 23 Total 1 11 2 3¼ 71 INFECTIOUS DISEASES. 72 INFECTIOUS DISEASE. Scarlet Fever and Diphtheria. There were 8 "return" cases of Scarlet Fever and 1 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 28 days after the release of a case from isolation at home One of the return cases of Scarlet Fever occurred after a case 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 of Mogden Hospital 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 209 No. of civil cases removed to Hospitals 160 Percentage of cases removed to Hospitals 76.5 The incident rate of Scarlet Fever in the civil population (taken as 80,000) was 2.6 per 1,000. Four deaths took place from this cause during the year, i.e., a case mortality rate of 1.9 per cent, Diphtheria. The following table shows the number of notifications received and the percentage of cases of Diphtheria removed to Hospital No. of civil cases notified 165 No. of civil cases removed to Hospitals 152 Percentage of cases removed to Hospitals 92.1 73 The incident rate per 1,000 of the civil population (taken as 80,000) was 2.0. Twenty-two cases occurred in institutions during the year. 19 deaths took place from this disease, i.e., a case mortality rate of 11.5 per cent. The deaths occurred in the following age groups:— Under 1 year 1 1—2 years 1 2—3 years 1 3—4 years 1 4—5 years 1 5—10 years 10 10—15 years 2 15—20 years 1 20—35 years — 35—45 years — 45—65 years 1 Over 65 years — And in the following months:— January 5 February 2 March 3 April 1 May 2 June 2 July 2 August 1 September — October 1 November — December — 7 A DIPHTHERIA, 1930 (including Bacterial cases, 39 in number). Month. WARD. Elem. School Children. Other School Children. Other Cases. Total. Heston. Hounslow Nth. Hounslow Sth. Isleworth N. Isleworth S. January 32 4 4 19 3 2 17 2 13 February 26 1 3 9 12 1 8 2 16 March 32 3 5 8 12 4 16 2 14 April 16 3 2 5 3 3 9 1 6 May 18 1 1 4 9 3 6 2 10 June 10 1 1 3 3 2 4 — 6 July 19 1 1 6 9 2 11 — 8 August 11 — 2 3 4 2 6 - 5 September 15 2 1 2 7 3 7 2 6 October 12 3 1 1 5 2 9 — 3 November 7 1 — 2 1 3 3 1 3 December 6 — — 1 4 1 — — 6 Totals 204 20 21 63 72 28 96 12 96 No. OF CASES NOTIFIED. Years 1926 notified cases of IPHTHERIA IOLOGICAL 75 Diphtheria continued, as seen in the graph, more than usually prevalent during the early months of 1930. As stated at the end of last year's report, Dockwell Hospital was opened just before Christmas, 1929. It was found necessary, however, shortly after, of add lavatory accommodation on to the smaller block, so as to bring it into use, and the total number of cots up to 15. In the early days of its use there was no difficulty in getting the hospital filled with children small enough to go into cots, but later difficulty arose owing to the larger size of the children; and the necessity of bringing beds into use materially interfered with the floor space. In all, 53 patients were accommodated at a total cost of £1,243, of which £328 was for equipment (which is now standing ready for any future emergency), and £218 for repairs to the buildings and maintenance of the grounds. Beds had to be borrowed during the course of the outbreak from Willesden Urban District Council, Staines Rural District Council, and the Metropolitan Asylums Board, and our grateful thanks are due to those Authorities who were able to tide us over our difficulty. Without Dockwell Hospital the position would have been quite impossible, owing to the fact that the Metropolitan Asylums Board was towards the end unable to take any more cases. I wish again to express my gratitude firstly to Miss Gribble, A.R.R.C., one of our Health Visitors, whom I appointed as Matron, and to the temporary nurses, who put up with inconveniences which they would not have been expected to face in the ordinary run of their work, and who materially helped to make the hospital the success that it was. The installation of electric light into the building made a very markeddifference in the working facilities, apart from giving a sense ofsafety which before was conspicuously absent. As a result of the epidemic a campaign was set on foot to immunise as many children as possible. A Public Meeting was held in the Alexandra Schools, and a cinematograph film— 76 "Risk of Diphtheria Banished," supplied by The Community Interests Films, Ltd.—was exhibited. Dr. Lethem came down from the Ministry of Health and addressed the meeting. The place was packed, and questions were asked and answered, and literature distributed. I also arranged that, subsequent to this lecture, through the kindness of the managers of the three cinemas in the district, the film should be exhibited for a week in each, and I wish to place on record my grateful thanks to them for their assistance. The result of these efforts was an immediate response, necessitating the institution of three immunising sessions a week. Later, a meeting was arranged at Isleworth, which Dr. Bousfield addressed in place of Dr. Lethem, but there the result was nothing like as satisfactory as at the Alexandra Schools. Several members of the Council rendered valuable help in addressing meetings and in other ways, and special thanks must be given to them for their efforts on behalf of the children of the district. Although both I and my chief assistant, Dr. Boberts, have done immunisation work, I felt that in the circumstances it was wiser to put the matter in the hands of somebody who was an authority and of wide experience in the matter, and I suggested to the Council that they should put Dr. Bousfield in charge of the work; this was done, and he arranged his own team of officers who generally work with him, the fees paid being £2:2:0 per session. The success during 1930 has been, so far as I know, the most outstanding of any efforts in the country. The full details of the work for 1930 are set out in the accompanying report by Dr. Bousfield. Schick testing has been resorted to in practically every case, and every effort has been made to ensure that the work is as accurately scientific as it is possible to make it. Very careful records are kept of each case, and I have instituted a card on the lines shown, so as to ensure that as far as possible I get information in case of any possible attack which might arise at any future date in a patient who was considered to be immunised. 77 HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Office: 92, Bath Road, Hounslow. DIPHTHERIA IMMUNISATION CLINIC This is to certify that (Name) (Address).................................................................................................... was immunised and tested, and is believed to be immune to Diphtheria. to the parent or guardian. In the event of this child being ill in the future and the doctor suspects Diphtheria, please show him this certificate, when he will tear off and use the card printed below. Elwin H. T. Nash. Medical Officer of Health. This card should be retained by the parent or guardian. (Tear off here) : perforation . HESTON AND ISLEWORTH URBAN DISTRICT COUNCIL. Public Health Office: 92, Bath Road, Hounslow. DIPHTHERIA IMMUNISATION CLINIC This is to certify that (Name) (Address) was immunised and tested, and is believed to be immune to Diphtheria. Date Signed Mvdical Officer of Immunisation Clinic. To the Doctor in Attendance. If you consider this a case of definite diphtheria, I shall be glad if you will post this card with your notification to the Medical Officer of Health of the district where the case is notified. To the Medical Officer of Health concerned. If this child is definitely suffering from diphtheria, I should be glad if you would inform me, particularly indicating the character of the attack —"Mild/severe"—and enclose this certificate with your letter. Elwin H. T. Nash, Medical Officer of Health. 78 The help of the teachers was invaluable, and to them I wish to render thanks. The following list shows the percentage of scholars for whom parents have consented to immunisation during 1930. School. Percentage. Spring Grove Junior 72.47 Alexandra Girls 55.00 Alexandra Boys 47.54 Grove Road Infants 45.45 Grove Road Girls 39.81 Woodland St. John's Infants 37.70 Heston Mixed 37.32 Hounslow Heath Infants 28.17 Isleworth Town Junior 28.02 Hounslow Heath Girls 27.50 Isleworth Town Senior 25.87 Grove Road Boys 22.41 Hounslow R.C. 20.49 St. Mary's Girls and Infants 19.68 Worple Road Junior Mixed 19.05 Hounslow Heath Boys 18.61 Worple Road Infants 18.03 Spring Grove Central 17.53 Isleworth Blue Girls and Infants 15.96 Hounslow Town Girls and Infants 15.03 Hounslow Town Boys 12.62 Berkeley Junior 12.35 St. Mary's Boys 10.86 Brentford End Infants 10.00 Isleworth Blue Boys 9.45 79 Secondary Schools, Private Schools, M. & C.W. Clinics, etc. Number. Spring Grove Secondary 48 Green School 4 Isleworth County 18 Children attending Other Schools 43 M. & C.W. (Children under five years) 494 Adults 6 It should not for a moment be understood that this is a table of merit, because the different class of children at different schools, or rather the different class of parents of these children, vary considerably in their attitude to anything in the nature of an inoculation. The greatest response has come from the more educated parent. Later it was found advisable to open a clinic in the Isleworth area, owing to the distance parents had to bring their children, and the difficulty of leaving the house for the length of time necessary. The response, however, has been slow, and nothing comparable to that of the other end of the district. 80 REPORT OF MEDICAL OFFICER IN CHARGE OF DIPHTHERIA IMMUNISATION CLINICS For the Year ending December 31st, 1930. As a result of an energetic campaign instituted by the Medical Officer of Health, ably supported by the Urban District Council, I am enabled to place on record a highly satisfactory report of the first year's work in connection with active immunisation against diphtheria. The keen response of the local population affords an example Which should act as a stimulus to the general public of the Metropolis and to many public bodies. During the earlier part of the year, three sessions were provided each week at the Public Health Department Clinic at Bath Road. These were held on Monday and Wednesday afternoons and on Saturday mornings. As, however, the Monday and Saturday clinics were attended by two medical officers, there was actually the equivalent of five ordinary sessions per week. This intensive service was provided to deal with the very large number of applicants which was attracted by the announcement of the proposed facilities for protection against diphtheria. It was necessary to continue the clinics as above described until after the summer holidays, when three sessions per week were still held, but each was attended by only one medical officer. At the beginning of November it was thought advisable, in the public interest, to transfer the Saturday morning sessions to the Public Hall, Isleworth, the other clinics on Mondays and Wednesdays remaining at Bath Road. This is the arrangement which continues at the time of writing this report. The results of the year's work are possibly best appreciable in tabular form. 81 Applications for treatment received 2,952 Number Schick-tested during 1930 2,571 Number giving positive result to test 2,016 „ „ negative „ „ 454 Not read owing to various causes 101 Total Number of attendances at Clinics during 1930 11,018 The procedure adopted has been to Schick-test all subjects and then to inspect the arms one week later. Children showing positive reactions at once receive 1.0 c.c. of Toxoid-antitoxin (Burroughs, Wellcome), henceforth referred to as T.A.M. The second injection of T.A.M. is given one week later, and a third injection fourteen days after the second, the dosage being 1.0 c.c. in each case. At an interval of three or four months these subjects are again requested to attend the clinic with a view to establishing the success, or otherwise, of the immunising course, by means of a second Schick test. Up to the end of the year the figures for subjects who have reached the stage of final Schick-testing were:— Children Schick-tested, found positive originally, immunised, and re Schick-tested 993 Number of these found to have become Schick-negative at the second test 880 Number still showing varying degrees of positive reaction to the second Schick-test 109 Not read for various reasons 4 It was found that most of the children still positive at the second Schick test showed only feeble or markedly reduced positive reactions. Of the 109 subjects still considered Schick-positive or slightly susceptible after the course of three injections of T.A.M., a secondary series of injections was given to 99. Secondary Inoculation courses of T.A.M.:— Number given 1 further injection of 1 c.c. 28 Number given 2 further injections of 1 c.c. 63 Number given 3 further injections of 1 c.c. 8 Total 99 82 Of subjects receiving secondary inoculation, only 9 have so far been Schick-tested again, but in each case a negative reading has been obtained. Summarising, the total number of persons either found Schick-negative originally, or rendered so by inoculation. and issued with certificates of apparent immunity, amounted during the year to 1,343. In considering that figure, it must be borne in mind that considerable numbers of children are now becoming due for the final Schick test, so that the number of immunity certificates issued will shortly be materially increased. It has been found that persons attending the clinics have been fully prepared to persevere with the requisite number of visits. Very little trouble has been experienced in dealing with this large number of children, the natural fear of the occasional nervous child having been nearly always overcome by a little tact on the part of the clinic staff, not entirely unaided by the sweet which is provided after the injection. Actually these injections are usually almost painless, and I have occasionally injected small children while asleep without waking them up. The actual number of attendances at the clinics during the year, viz., 11,018, was a really excellent response to the facilities provided. Very few persons have shown any objectionable reactions following injections of T.A.M., and no serious phenomena have been encountered. An occasional subject may experience rather severe pain in the inoculated arm, and some slight temperature, for a day or two, but this is a peculiarity of the subject, and is not due to harmful material. This is proved by the fact that large number; of other children inoculated from the same bottle have experienced no untoward effects of any description. It is worthy of note that the Toxoid-antitoxin mixture used in this work is a safe non-toxie mixture. It is entirely free from those dangers associated with the regrettable fatalities which have been, from time to. time, reported from abroad. The careful methods of preparation, of testing, an 83 of ensuring permanent sterility, which are adopted in the laboratories where this material is prepared, preclude the slightest danger to the subject who is being inoculated. As regards the results of the work which are so far apparent in this area, it can be stated that no case of diphtheria has occurred in any person who has received a course of immunising injections and has been subsequently certified as Schick-negative. Seven children, who were found to be Schick-positive or susceptible to diphtheria originally, have contracted diphtheria prior to the completion of the immunising course. During this period, no claim is made that any protection at all has been conferred, as the development of such immunity takes an appreciable time of some weeks after the third injection of T.A.M. In the case of a child of 5 years, who had only received one injection of T.A.M.; and who must have been incubating diphtheria at the time of being brought to the clinic, the disease terminated fatally. None of the other children who contracted the disease had had more than two injections of T.A.M. No child found to be naturally Schick-negative has been notified as suffering from diphtheria. It is therefore worthy of note that the only cases of diphtheria that have arisen among children attending the clinic have been among subjects already certified by the Clinic Medical Officers as susceptible, and have occurred at a time when we knew that they could not yet be protected. The position is made clear to all parents by the posting on the clinic waiting-room wall of a notice to the following effect: — "please note that your child is not considered to be immune until you have received a certificate to that effect." Further, to prevent any sense of false security in the minds of parents, an explanatory note is issued to them as they leave the clinic for the last time after being given the immunity certificate. This is worded as follows:— 84 Please Read Carefully. heston and isleworth urban district council. Public Health Department, 92, Bath Road, Hounslow. What the Certificate Means. Most children who have had this treatment are protected for a number of years. An occasional child, however, loses the protection quickly, due to a peculiarity of the child's blood or body. If you wish to get the best out of the treatment have your child tested again in a year or two. If he or she is still safe, no further injections are necessary. If the protection has been lost, it can be restored. Although your child, if protected, is extremely unlikely to contract Diphtheria, do not assume that it is quite impossible. A very few cases of Diphtheria have occurred among immunised children. Such attacks are rarely serious but you should always get your doctor to see a sore throat. Elwin H. T. Nash, Medical Officer of Health. Anyone who has been engaged in immunological work for any length of time realises that there is no such thing as an absolutely perfect and certain process of immunisation which is applicable to every person. Owing to individual bodily peculiarities a few subjects respond poorly to injections, while a small number acquire protection which they lose rapidly as a result of this bodily peculiarity. It was with a view to reducing possible failures due to the latter cause that the above handbill was drafted. It must not be expected that no immunised child will ever contract diphtheria. A few such cases must perforce be met with in Heston and Isleworth area sooner or later. By energetic super vision of the state of immunity of subjects a year or two hence, it 85 is hoped to maintain the number of such cases at an absolute minimum. A child, on leaving the clinic, is probably at least 100 times as safe against diphtheria infection as when it was first brought there. Efforts have been directed towards immunisation of small children rather than older persons, because it is during the earlier years of life that diphtheria proves so often to be of a grave or fatal nature. Without displaying undue optimism, it would appear that shortly sufficient children in the district will have been immunised to prove that something very definite and valuable has been accomplished. It should be possible, for example, to compare the incidence of diphtheria among 3,000 children considered to be immune or immunised, with that among the remainder of the child population. Experience indicates that we may anticipate the result of such a comparison with pleasurable expectation. G. Bousfield, M.D. (Lond.). Diphtheria Antitoxin. Boxes containing a Sterile Antitoxin syringe and the necessary dressings, etc., are kept at the two Police Stations so as to be available in case of emergency. During 1930, 71, vials of Antitoxin of 8,000 units each were supplied to medical practitioners. Smallpox. Smallpox again visited us on three occasions. The first cases occurred on the 4th June. On the evening of the 3rd I was notified from Chiswick that a case of smallpox had been taken off a barge at Hemel Hempstead. I telephoned to the owners of the barge to immobilize it in the dock until I had seen the occupants in the morning. 86 On visiting the first thing next morning I found four cases of smallpox. The mother had evidently been entirely overlooked. She had been seen by a doctor in Brentford before the barge went to Birmingham. When at Birmingham she consulted a doctor near the docks, who treated her for "spring rash." Her journeys had been limited entirely from the barge to the doctors whom she consulted. I was given to understand that it was imperative that the cargo should be shifted down the river that night, so I arranged with the firm to remove the contacts to Dockwell Hospital. A cousin from another barge went on board, and accompanied the family to Dockwell. This was done as the family had no home except the barge. All the contacts were vaccinated the same afternoon. One of the contacts developed smallpox on the 9th, and was removed to the London County 'Council's Hospital. On the 11th the remaining cases were removed to South Wharf; the boy aged 9 then being a definite case, and the boy 18 doubtful. In all, seven cases arose from this missed case of the mother. On the 13th June, Dr. Darke notified a case of smallpox from 2, James Street. I saw this case in consultation with the doctor, and another member of the family who had been under treatment previously by another doctor, and diagnosed as chickenpox. He was now obviously convalescent from smallpox. Another boy, aged 18, was just commencing. There was a perfectly definite history of onset in all three cases. Dr. Shaw, from the Ministry, confirmed the diagnosis. All the cases were removed to hospital the same day. On the 11th September, the Deputy Medical Officer of Health, in my absence, was asked by Dr. Davey to see two cases of smallpox, in the person of two visitors to the house in question. The first case had been staying at Pitsea, where there had been staying a boy from East Ham, who was said to have "spots on his hands." Later, the housewife at the same address was removed suffering from a definite attack of smallpox. 87 Various persons had visited the house, but no further case arose. It eventually turned out from the report of the Medical Officer of Health of East Ham that the boys in the family of a contact in that area "appeared to have had a mild attack of smallpox, judging from the scars present and their distribution. The first case was two months ago, and was called chickenpox by the medical man in attendance." Enteric Fever. There were 7 cases notified during the year, the majority of which were Para-typhoid B. Erysipelas. Forty-three cases of this disease were notified, of whom 29 were of cases in the West Middlesex Hospital Eighteen were non-residents in this district. Ophthalmia Neonatorum. See page 1.10. Puerperal Fever. Twelve cases of this disease were notified; 5 of these were notified from the West Middlesex Hospital. In two of these cases the patients had been notified as suffering from Puerperal Pyrexia before admission. Two of the cases notified from this Hospital were not resident in this district. Puerperal Pyrexia. Eleven cases were notified; 5 of these were notified from the West Middlesex Hospital, including 3 who were not usually resident in this district. Puerperal Fever and Pyrexia are conditions which give rise at times to anxiety. In one small outbreak of Pyrexia, a nurse from a Home in the district appeared implicated. She was swabbed and haemolytic steptococci obtained, and she was kept off duty until she was reported free. Similarly, in the case of one of the doctors who had three unsatisfactory cases, he was swabbed and haemolytic steptococci obtained. He gave up midwifery practice, and eventually went away for a period until he was free. 88 Encephalitis Lethargica. There were 3 cases notified this year. All were treated in the West Middlesex Hospital, and 2 were not residents in this district. Cerebro-Spinal Fever. Three cases of this disease were notified. All were notified from the West Middlesex Hospital and none was resident in this district. Acute Poliomyelitis. No cases were notified. Pneumonia. There were 119 cases notified. Ninety-three notifications were from the West Middlesex Hospital. Seventy-five 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:— 1926 1927 1928 1929 1930 Measles 497 35 688 83 799 German Measles 75 7 9 344 38 Chicken Pox 408 243 265 423 392 Mumps 246 352 138 106 381 Whooping Cough 131 157 171 177 144 89 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 0.05 per 1,000 (on a population figure of 80,000). 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. SPECIAL REPORT. The following report of a widespread outbreak of Illness occurring at the Firestone Works was made to the Health Committee in July, 1930:— Public Health Department, 92, Bath Road, Hounslow. July, 1930. To the Chairman and Members of the Health Committee. Gentlemen, REPORT ON WIDESPREAD OUTBREAK OF ILLNESS AT FIRESTONE WORKS. On the 5th March I was rung up by the Engineer to the Firestone Works, notifying me of a widespread outbreak of illness at the Works, and that the Work's Medical Officer would be getting into direct communication with me, which he did shortly after; informing me of the nature and extent of the outbreak and that although it was thought that it might be some water borne trouble, the Firm were apprehensive that it might possibly be some air borne epidemic or an illness arising from some process in the Works. I visited the Works, and information was collected from all the sufferers that were available, as to their symptoms and habits in the matter of food, together with information as to the nature of their work and the departments in which they worked. The outstanding symptoms were profuse diarrhœa, with considerable abdominal pain, and a definite tendency after the original attack to relapse. These points were clearly brought out in the report by the Medical Officer to the Works. It was found that the Engineer had already had samples of the water analysed, and had informed the Metropolitan Water Board, whose officers had visited the Works and taken samples of the water. The reports of the two sets of analyses are appended. From this it appeared that there had been definite pollution of the drinking water in the factory. 2 It was unfortunate that we had not been informed at the beginning, as it was impossible for us to get any report on the bacterial content of the water actually proved to be polluted, and the investigation had to be based mainly on the bacteriological examination of the stools of sufferers, and agglutination tests of the patients' bloods against the usual organisms known to produce such outbreaks. The analysis of the sufferers revealed no common departmental aggregation, but pointed to water drinking as the common factor, as shown by the following table. First Shift (includes 6 a.m. to 2 p.m., 6 a.m. to 4.30 p.m., 7 a.m. to -6.,30 p.m.— Total Number affected 54 Total number who drank raw water 48 Total number who did not drink raw water, but drank either tea or coffee 6 Second Shift (includes 2 p.m. to 10 p.m.)— Total number affected 28 Total number who drank raw water 24 Total number who did not drink raw water but drank either tea or coffee 3 Total number who had milk only 1 Third Shift (includes 10 p.m. to 6 a.m.)— Total number affected 44 Total number who drank raw water 43 Total number who did not drink raw water but drank tea 1 Administrative and Staff— Total number affected 43 Total number who had raw water 30 Total number who did not drink raw water but drank tea or coffee 11 Total number who had typical symptoms but had no beverage of any description on premises 1 Total number who had no beverage on premises, but symptoms are not typical 1 3 The results of our investigations differ slightly from the report of the Medical Officer, but we were interrogating everyone who had been ill, whereas his report deals with those who reported sick to him. The following facts were elicited: Form of Illness. Onset was sudden with vomiting (profuse in many cases), abdominal pains (severe in, most cases) and persistent diarrhoea, with—in some cases—headache and sore throat. The average duration of the illness was three days, varying from one to seven days— with, in some cases, a recurrence after two or three days. Incidence. Approximately 80 per cent. of the cases occurred between the 26th February and the 1st March inclusive. The highest percentage of the total cases being amongst the office staff, as compared with operatives. (See graph opposite). Possible Soukces of Infection. (1) Food from Canteen.—Of the 169 cases recorded up to the 8th March, no foodstuffs could be traced which were in any degree commonly consumed by those affected. (2) Air from Factory Processing.—This can be ruled out as the Office staff, which shows the highest percentage incidence, has no direct communication with the factory processing. (3) Beverages consumed on premises, including water.—A very large percentage of the cases consumed water (98 per cent.), either raw or in coffee or tea, on the premises. Those sufferers who state they did not have any beverage on the premises had foodstuffs which were cooked in the same water. A number also drank milk on the premises, but this beverage was not to any marked degree common. 4 Water used for making coffee, tea, etc., is boiled in a galvanised iron boiler, situated in the canteen and heated in a calorifier with steam at 10 lbs. pressure. There is a constant feed, and at meal times a constant draw off from this boiler. The cooking, eating and drinking utensils are not sterilised, being washed in hot water from a special boiler, and cooled down with the addition of cold water. The water in each case being from the Metropolitan Water Board Supply. The hot coffee, tea and milk are kept in earthenware containers of jacketted copper urns. Of the 169 cases recorded, 166 drank water on the premises either in a raw state or in coffee or tea. The three remaining cases had food at the canteen which had been cooked in this same water, but in one of these cases the symptoms were not typical. The total number of cases was 169, their incidence as shown in the accompanying diagram. There were many absentees, and these were scattered in the following districts:— Eichmond. Windsor. Ealing. Twickenham. Brentford—Chiswick Lambeth. Hammersmith. Staines Rural. Westminster. Barnes. Southall. Lewisham. Chelsea. The Medical Officers of the various districts were communicated with, and kindly furnished full and careful reports on the absentees. The general history was the same. There was no extension of the disease to any other members of the sufferers' families. It was found that the Chief Engineer, suspecting water as a possible source of the trouble, had communicated with the Metropolitan Water Board, whose officials had been down and taken samples of the water entering the cisterns, the analyses of which were as follows, conforming to the standard of filtered Thames water:— 5 Results of the Chemical and Bacteriological Examination ol Samples from Firestone Rubber Works, Brentford. Description of the Sample. Day of month. Ammon- iacal Nitrogen. Albuminoid Nitrogen. Oxidised Nitrogen. Chlorine. Oxygen abs. from Permanganate 3 hrs. at 80° F. Turbidity, in terms of Sacch. Carb. of Iron. Colour m.m. brown 2ft. tube, Burgess's Tintometer. P.H. value. Hardness (permanent). 1 2 1930 Feb. 3 4 5 6 7 8 9 10 11 F. 113 from ball valve Board's water 28th 0.0022 0.0074 1.50 0.088 28 normal A mixed sample from taps inside the building gave (showing the presence of adventitious water) 2.60 Bacteriological Results. Number of bacteria, per c.c. l.l (agar 37o C). B. coli test. None in 100 c.c. Spoting anaerobes (B. Welchii etc.) None in 20 c.o. 500 c.c. were examined for paratyphoid bacteria by special methods. None found 6 At the instigation of the Chief Engineer, the Board's officials took samples from some taps throughout the building. Sir Thomas Houston's reports on these were as follows:— " M.B.W.2.—These were mixed together, and the combined chlorides (expressed in chlorine) determined and found to be 2.6, instead of 1.5, as in the case of the Board's water. This proves conclusively that some other water (? canal water) other than that of the Board was entering the system of supply." Sir Thomas Houston kindly furnished me with the analysis of the Grand Junction (Hampton) water around the period of the outbreak, which are as follows : 7 Results of the Chemical Examination of Grand Junction Works (Hampton). Description of the Sample. Day of Nonth. Ammoni- cal Nitrogen. Albuminoid Nitrogen. Oxidised Nitrogen Chlorine Oxygen abs. from Permanganate 3hrs.at 80°F. Oxygen abs. from Permanganate 5mins. at 80°F. Colour m.m. brown 2ft. tube, Burgess's Tintometer. Hardness (Total). Hardness (Permanent). 1 2 3 4 5 6 7 8 9 10 11 1930 Feb. Co. 392 20th 0.0008 0.0072 1.70 0.125 0.056 31 Co. 404 21st 0.0006 0.0069 1.63 0.134 0.052 32 Co. 417 24th 0.0004 0.0065 1.65 0.107 0.040 30 23.6 6 Co. 438 26th 0.0004 0.0052 1.61 0.093 0.029 28 Co. 451 27th 0.0004 0.0052 1.62 0.093 0.033 27 Co. 436 28th Mar. 0.0008 0.0050 1.60 0.086 0.032 25 Co. 476 3rd 0.0001 0.0042 1.60 0.076 0.023 23 26.0 6.1 Co. 497 5th 0.0009 0.0037 0.33 1.48 0.068 0.018 22 Co. 508 6th 0.0004 0.0032 1.50 0.067 0.027 20 Co. 520 7th 0.0004 0.0034 1.50 0.062 0.021 20 Co. 533 10th 0.0002 0.0038 1.50 0.059 0.025 19 25.7 6.4 Co. 554 12th 0.0C02 0.0032 1.50 0.054 0.023 20 Co. 567 13th 0.0003 0.0031 1.50 0.050 0.019 20 Co. 579 14th 0.0001 0.0038 1.50 0.047 0.023 19 8 Grand Junction (Hampton) General Well (Feb. 20th to March 14th inclusive). Day of Month. Number of Microbes per c.c. Agar at 37° counted 20—24 hours. B. Coli Test 100 c.c. 10 c.c. Presumptive Confirmatory gl. Presumptive. 1930. Feb. 20 1.6 0 21 1.2 0 24 0.5 0 25 0.8 0 26 1.4 B 0 27 2.4 B 0 28 1.2 0 Mar. 3 1.1 0 4 0.6 0 5 1.3 0 6 0.3 0 7 1.4 0 10 0.8 0 11 0.5 0 12 0.6 0 13 1.2 0 14 0.5 0 B = Lactose + Indol + Saccharose — Microbes. 9 From these it will be seen that there was no deviation from the usual standard of purity at the time of the outbreak. The Chief Engineer had submitted samples of water to an independent analyst, who had taken samples from the following sources:— (1) Representing The Metropolitan Water Board's supply entering the storage tanks on the roof. (2) From the drinking fountain on the Mezzanine floor. (3) Hot water from steam coil heater in the canteen. (4) From the cold water tap over the sink in the kitchen. The result of these analyses were:— Parts per 100,000 Sample 1 Sample 2 Sample 3 Sample 4 Total solid residue 34.20 42.40 32.80 42.76 Nitrogen as nitrates .311 .447 .585 .445 Nitrogen as nitrites 0 trace trace trace " Oxygen absorbed " in 4 hours at 26.7 C. .082 .172 .191 .175 Chlorine (combined) 1.55 2.70 3.55 2.70 Alkalinity, calculated as carbonate of lime 21.0 21.8 5.8 21.7 Total Lime CaO 13.77 14.30 7.37 14.32 Total hardness (soap test) 25.1 26.2 13.7 25.7 Lead 0 0 0 0 Zinc trace .04 trace .07 (Sample 1 was brilliant, but the others were dull.) The analyst reported that from these it was certain that "some foreign water was finding its way into the service pipes and seriously affecting the quality of the Metropolitan supply as delivered into the storage tank on the roof." This appeared impossible, but after a careful search the Chief Engineer discovered that there was a small connection whereby it was possible for some fraction of the Canal water used in various processes to get into the drinking water supply in the following manner. 10 At the top of the works is a very large container technically known as a "spreader," which as part of its function contains a highly explosive gas. In order to render this as harmless as possible, this gas is mixed with a certain proportion of CO2. The accuracy of the mixture, on which its safety depends, is ascertained by the fact that the gas in question is compressible whilst the CO2 is not at a certain pressure. The compression for this purpose is obtained by a head of water acting in the " concentration head." The concentration gauge was originally set to be used for canal water from the works' tank. At that time the drinking water in the works was obtained from their own artesian well. The canal water proved that it was not of sufficient purity to use in the concentration gauge, and for that reason the well water was coupled in. Some time after this trouble arose with the well supply owing to machinery breakdown, and the drinking water supply was changed over to the Metropolitan Water Board's supply. All the drinking water pipes are on the "well" system, so that these pipes were used for Metropolitan Board's water. The Metropolitan Board's water was supplied by a temporary pipe, and volume and pressure were very fluctuating, with the result that they were not getting a permanent supply anywhere in the factory. For this reason the supply to the concentration, gauge was recoupled to the canal water supply. The pressure in the canal water supply was greater than the Metropolitan Water Board's supply, and the result was that the valve between the two having been opened by someone, the canal water forced back the Metropolitan Water Board's supply at the lower pressure, and so gained access to the drinking water system throughout the works. This supply was immediately severed, and the service pipes emptied and flushed out with Metropolitan Water Board water before restoring the drinking water service. 11 Late in the afternoon the same day, samples were taken, giving the following results:— Chlorine in Parts per 100,000 Metropolitan supply entering storage tank 1.55 Drinking fountain on Mezzanine floor 1.55 Cold water tap over sink in kitchen 1.55 The analyst's report on the canal water was as follows, showing gross pollution :— Parts per 100,000 Total solid residue 84.96 Ammonia, free 1.75 Ammonia, albuminoid .072 Nitrogen as nitrates 1.167 Nitrogen as nitrites .030 Oxygen absorbed in 4 hours at 26.7 C .584 Chlorine (combined) 8.90 Alkalinity, calculated as carbonate of lime 27.1 Total hardness (by soap test) 32.0 turbid Some samples taken the next day showed analyses identical with the Metropolitan Water Board analysis. Traces of zinc found were less than .05 parts per 100,000, which is entirely negligible. The analyst made the following report:— " From the analyses it is possible to calculate the probable proportion of the canal water present in the drinking water services on the 1st inst., and below I give two sets of figures : "A" means of two samples taken from cold water services. "B" means the calculated composition of a mixture of 5 volumes of M.W.B. water with 1 volume of canal water. 12  Parts per "A" 100,000 "B" Total solid residue 42.58 42.66 Oxygen absorbed .173 .166 Nitrogen as nitrates .446 .453 Nitrogen as nitrites trace .003 Chlorine (combined) 2.70 2.77 Alkalinity 21.75 22.0 Total hardness (soap test) 26.0 26.2 The two columns are so very nearly alike that they prove that the drinking water on the 1st inst. was being polluted by about 17 per cent. of the canal water." The bacteriological analysis of the supply water from the Metropolitan Water Board by an independent bacteriologist gave the following result:— Source : Inlet to Tank on Roof (Metropolitan Water Board water). (Taken by W. T. Burgess, F.I.C. Witness, B. H. McCoy, 11.40 a.m., 6/3/30.) Number of organisms per cubic centrimetre of water growing upon nutrient gelatine at 20° C. in three days 102 Number of organisms per cubic centimetre of water growing upon agar at 37° C. in one day 1 Smallest quantity of water giving acid and gas in bile-salt glucose broth 100 cc. Smallest quantity of water giving gas in bile-salt lactose broth Absent in 100cc. Smallest quantity of water containing the Bacillus Coli Absent in 100 cc. Smallest quantity of water giving the reaction of the B. Welchii (Bacillus Enteritidis Sporogenes) Absent in 100 cc. 13 This is a clear and bright water free from odour and taste. It is of a very high degree of bacterial purity, and is therefore a pure and wholesome water suitable for drinking and domestic purposes. The sample from the Canal Service main gave the following results Number of organisms per cubic centimetre of water growing upon, nutrient gelatine at 20° C. in three days 320,000 Number of organisms per cubic centimetre of water growing upon agar at 37° C. in one day 16,600 Smallest quantity of water giving acid and gas in bile- salt glucose broth 0.001 cc. Smallest quantity of water giving gas in bile-salt lactose broth 0.001 cc. Smallest quantity of water containing the Bacillus Coli 0.001 cc. Smallest quantity of water giving the reaction of the B. Welchii (Bacillus Enteritidis Sporogenes) 1.0 cc. This is a grossly polluted water teeming with bacteria of which large numbers are of intestinal origin. It resembles a sewage effluent, and it would seriously contaminate any drinking water to which it gained access, even when greatly diluted. Samples of water were submitted to Mr. S. H. Johnston, M.Sc., of St. Bartholomew's Hospital, especially for the presence or absence of the Salmonella Group. His reports were as follows :— 14 Firestone Factory. Water from No. 2 Reservoir (containing Canal Water) taken 4th March. Free Ammonia 0.84 part per 100,000 Albuminoid Ammonia 0,05 „ „ Nitrites 0.09 ,, „ Nitrates 0.71 „ „ Chlorine 15.8 „ „ Oxygen absorption, 4 hr 0.65 „ „ Firestone Factory. No. 1 Drinking Fountain, taken 7th March. No. 2 Drinking Fountain in No. 17 Dept., taken 11th March. No. 1 No. 2 Free Ammonia 0.0002 none Albuminoid Ammonia 0.0044 0.003 Nitrites Trace none Nitrates 0.32 0.2 Chlorine 1.9 1.8 Oxygen Absorption, 4 hr 0.077 0.048 Poisonous Metals none none Firestone Factory. Water from Canal Intake, taken 18th March. Free Ammonia 0.34 part per 100,000 Albuminoid Ammonia 0.09 „ „ Nitrites 0.05 „ „ Chlorine 6.5 „ „ Nitrates 0.55 „ „ Oxygen absorption, 4 hr 0.5 „ „ Organisms growing at 20° 6600 per cc. Organisms growing at 37° 1930 per cc. B. Coli present in 0.01 cc., absent from 0.001 cc. Salmonella group and Alkaligenes group absent, 15 Firestone Factory. (1) Water from Grand Junction Canal, taken 5th March. Organisms present: B. Coli, Staphylocirci, diplocicci. „ absent: Salmonella. (2) Water from No. 2 Reservoir, taken 5th March. Organisms present: B. Coli; Bacillus closely allied to Faecalis Alkaligenis, but not identical with it. „ absent: Salmonella. (3) Drinking Fountain, taken 1th March. Organisms present: Water organisms not looked for. „ absent: Coli,, Salmonella. (4) Boiler in Canteen, taken 7th March. Organisms present: Water organisms not looked for. „ absent: Coli, Salmonella. Report on Specimens. From Firestone Factory Epidemic. The six specimens of Faeces did not contain the Gaertner or Salmonella group of organisms. Six specimens of Faeces from patients suffering from the disease were bacteriologically examined, with the result that they "did not contain the Salmonella Group organisms." The organism found in one of the water samples allied to the B. Faecalis Alkaligenes was not found in any of the specimens of faeces. Dr. Scott, of the Ministry of Health, kindly undertook to agglutinate some of the patients' bloods against the usual organisms known to cause such outbreaks, and also to examine some faeces and to further investigate the organism that Mr. Johnston could not pigeon-hole, with regard to which he reported that he could not identify it, stating that he did not think it was pathogenic, but probably a sewage bacterium. In the cases of the faeces, he reported that he was "not able to find any pathogenic bacteria in cultures made from the faeces." On the results of the agglutination tests, Dr. Scott reports as follows:— 16 1—20 Aertryche Gaertcner Flexner W Flexner Z Sonne Morgan A (F) Mrs. C. x trace trace trace 0 0 B (M) S. D. 0 0 trace ? trace 0 0 C (F) Mrs. N. 0 0 trace ? 0 0 0 D (M) E. O. 0 0 ? 0 ? trace 0 0 E (M) F. S. 0 0 ? 0 ? 0 0 0 F (M) A. T. 0 0 ? 0 ? 0 0 0 17 "These are the results of tests for agglutination against the most likely bacteria to cause diarrhcea in the way described. As you see, they are all negative for practical purposes. If I were to speculate on the pathology it would be that the products of bacterial growth in sewage-contaminated water are the actual irritants and not necessarily living pathogenic bacteria." In the case of E. there was "a colony of B. Dysentericus (Sonne)." A second sample of blood was taken 10 days later, on which Dr. Scott reports as follows:— "Thank you for procuring for me another sample of blood from patient F.S. It gives only a trace of agglutination with the B. Dysenteriae (Sonne) at 1-20 dilution and none higher, so one must conclude that the infection with that strain was too mild to excite a serum-reaction. I regard the traces of agglutination with the two Flexners as of no significance, as they are common in c normal' sera." As will be noticed from the analyses of the Canal water, the condition varies markedly from time to time. There is definite evidence of greater pollution at the dates nearer the outbreak than on later dates, e.g., the B. Coli figure on March 5th is 10 times greater than on the 18th; also the Free Ammonia on 5th March is 2½ times greater than on the 18th. There is no doubt that the outbreak was caused by the introduction of Canal water into the drinking water system. When that occurred the authorities cannot state definitely. The Engineer's idea is that it was only the day before. If the entry had existed some time, the odd cases of intestinal disorder may be accounted for, and the very bad analyses nearer the date of the outbreak would lend colour to the possibility of some fresh pollution gs the cause of the exacerbation, 18 The Canal draws its water supply from the River Brent, which is polluted in various ways, in addition receiving the effluents of sundry sewage works in its course. In one sense the result of the investigation is disappointing, in that no specific organism can be pilloried as responsible for the outbreak, but satisfactory in another sense in that it confirms the findings of the Poplar outbreak. It may be well to call to mind the facts of the Poplar outbreak, where it was found that the Metropolitan Water Board supply in the area adjacent to the Gas Works, in, which the cases of illness occurred, was seriously polluted. As in this case, there was valve connection between the Metropolitan Water Board supply in the Gas Works and supply from the grossly polluted River Lea on the north side of the Gas Works. In the bacteriological investigation in this case Dr. Scott " could not find any of the organisms usually associated with food poisoning epidemics in the discharges or tissues of the sufferers. Nor after a fortnight did the blood of the patients agglutinate cultures of these same microbes." In the case under discussion we were more fortunate than Poplar in that there were no fatal cases. I wish to acknowledge the ready assistance given by the firm, particularly Mr. Williamson., the Chief Engineer, and also to place on record my thanks to Sir Alexander Houston and Dr. Scott, of the Ministry of Health, for their great help willingly given. ELWIN H. T. NASH, Medical Officer of Health. 19 APPENDIX. REPORT by Dr. M. STEEDMAN, Medical Officer to the Works. Date op Onset—Thursday, February 27th, 1930. It was first brought to my notice on Friday, February 28th, that during the last shift the day before a considerable number of men had reported sick with diarrhoea. I saw a good number of cases that day. Symptoms. The most prominent symptoms were considerable diarrhoea with abdominal pain. The onset was usually sudden. In a few cases there was vomiting, but this was not nearly so prominent a symptom as the diarrhoea. The most common history was : Feeling pretty well, suddenly taken with severe abdominal pains and feeling very ill. Almost immediately considerable diarrhoea, with frequent passage of loose, watery stools, continuation of pain and feeling of malaise. Pain of griping character, often very severe. A considerable number of the men were normal in 24 to 48 hours, but in many cases the diarrhcea continued for some days, with periods of comparative wellbeing, then sudden exacerbations of diarrhoea. In practically no cases was there pyrexia. Some cases complained of accompanying sore throat, often noticed a little while before the abdominal symptoms. Physical examination revealed very little—temperature subnormal rather than raised, pulse-rate normal. Tongue somewhat furred, but not markedly so. Some abdominal tenderness over epigastrium and over descending colon, but not very marked. Most cases not very ill, but a few looked very ill and were prostrate, and in a few cases among the female staff there were fainting attacks. 20 Course. Once the diarrhœa had stopped in most cases there was rapid recovery, but a few cases continued ill for some time—in one or two cases for about three weeks. In these cases there was usually a recurrence of the symptoms, the second attack giving noticeably more severe results in the way of prostration than the first. Kecurrences were observed in about 10 per cent. of cases, though figures are not very reliable for the reasons stated later. Treatment. All cases reporting sick were given an immediate dose of Bismuth Carb. with Chlorof. and Morph. co. and sent home with the instructions to have no solid food and to call in their own doctor at once. Steps Taken. The symptoms and sudden onset suggested some form of food poisoning, and the canteen was at once suspected. Detailed statements were taken from cases seen at once as to the food and drink they had had at the factory, and it was found at once that the food was rarely a common factor, but that drinks—coffee, tea, and water —had been taken in practically every case. The Canteen was inspected and all found in order; samples of water were taken from the Canteen hot water supply and from all the drinking taps and sent for analysis, but nothing was discovered. The Metropolitan Water Board Authorities were communicated with, but they could discover nothing abnormal. The Medical Officer of Health was informed of the outbreak and proceeded to make investigations. At about this time the Engineer discovered a possible way of entry of small quantities of canal water into the general supply. I tried to find out the probable time that elapsed before symptoms commenced after infection, but this was obviously difficult in view of the doubt as to the infection. In a large number of cases during the first day, however, the men left work about 5 p.m., and were taken suddenly ill late at night—an average of 4-6 hours after leaving work. 21 Recurrences. These occurred at intervals up to nearly a month after the original outbreak. There was no fixed period of recurrence—in some cases symptoms recurred after a day or two, in others men came back to work for some time feeling fairly well, and then went down with a recurrence of symptoms. In nearly all the cases seen temperature was subnormal (97.2°), there was rather more prostration than in the first case, and symptoms were the same as before —considerable diarrhœa and abdominal pains. Vomiting was practically absent. Physical examination revealed nothing more than before. Distribution. No department was specially picked out by the epidemic— cases occurred all over the factory from the manager downwards— and were not spread from department to department in a manner suggesting an air-borne infection. The same applies to recurrences, except that, as will be seen later, Department 14 had rather more than its share of these cases. STATISTICS. The following is an accurate record of cases reporting sick and seen at the Hospital, but is not a complete record for the reason that a number of men were taken ill after leaving work, were seen by their own, doctors, and never came under our notice at all. Some who stayed out a day or two were considered by their doctors to be suffering from an ordinary attack of the Gastric Influenza type, and therefore were not brought to my notice on resuming work. I should say that in the earlier days of the epidemic a considerable number more men were affected than are reported here. 22 Original Atacks.—Cases treated at Hospital. Feb. 27th No. of Cases 14 „ 28th „ „ 32 Mar. 1st „ „ 15 „ 3rd „ „ 11 „ 4th „ „ 11 „ 5th „ „ 7 „ 6th „ „ 7 „ 7th „ „ 1 „ 8th „ „ 2 „ 10th „ „ 6 „ 11th „ „ 3 „ 12th „ „ 3 „ 13th „ „ 5 „ 20th „ „ 1 Total 118 Recurrences—Cases treated at Hospital. March 6th Cases 1 Department—62 „ 7th „ 1 „ 14 „ 8th „ 1 „ 17D „ 10th „ 1 „ 1L „ 11th „ 2 „ 1L and 17B „ 12th „ 3 „ 17B, 17A and 14B „ 13th „ 1 „ 17B „ 18th „ 1 „ 17B „ 20th „ 2 „ 14A, 14A (?) Cases in Department 14 ... 4 „ „17 ... 6 „ „ ... 2 „ „ 62 ... 1 Number of hands in each department are appended, which shows a rather larger number of cases in Department 14 than the others. 23 These are cases of recurrence after an interval. Cases of recurrence after a day or two were impossible to tabulate as the condition ran on from the original attack and men, were usually "out" during the whole of it and not under observation. Except in the case of departmental heads, who had to carry on though feeling ill. These cases were very suggestive, though useless for statistical purposes, as it was found in several cases that having been taken ill on the Friday and Saturday of the original outbreak they recovered on Sunday, when they were not at the Factory, and on Sunday night felt comparatively well and able to take food without distress, they continued well on Monday until the evening, when they had a severe recurrence of symptoms. (Signed) M. STEEDMAN, m.r,c.s., l.r.c.p. Total Number of Employees in Departments. (Week ending 12th April, 1930) Dept. No. L 1 127 7 48 14 45 17 397 Scheduling 5 1.8 108 19 3 22-26 42 28 18 30 10 51 36 59 15 62 92 75 1 84 2 85 1 Total 950 (Female 98) — (Male 852) 91 Notifiable Diseases during 1930. DISEASE. TOTAL CA8ES 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 l5-20 years 20-35 years 35-45 years 45-65 years 65 years and over. MOGDEN. OTHER HOSPITALS Small-pox ... ... ... 1 ... 3 6 2 1 1 2 ... 16 ... 16 Enteric Fever ... ... ••• ... ... 2 ... ... 4 ... 1 ... 7 ... 6 Scarlet Fever ... 1 10 9 15 87 34 16 28 7 2 ... 209 135 25 Diphtheria 3 4 5 15 6 72 32 12 14 1 1 165 129 23 Erysipelas 2 1 ... ... ... 1 2 1 4 4 12 16 43 ... 32 Puerperal Fever ... ... ... ... ... ... ... 1 10 1 ... ... 12 ... 10 Puerperal Pyrexia ... ... ... ... ... ... ... ... 7 4 ... ... 11 ... 8 Ophthalmia 8 ... ... ... ... ... ... ... ... ... ... ... 8 ... 3 Neonatorum Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebro Spinal 1 ... ... ... ... 1 ... ... ... ... 1 ... 3 ... 3 Fever Pneumonia 5 15 5 2 4 10 3 8 22 14 22 9 119 ... 100 Dysentery ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... 2 ... 1 ... ... ... 3 ... 3 For Tuberculosis Notifications—see other Table. 92 Infectious Diseases, 1930. Cases Notified. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever Erysipelas. Cerebrospinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Malaria. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Dysentery. Puerperal Pyrexia. Small-pox. January 26 23 ... 1 3 1 ... ... 20 ... 6 1 1 ... 4 ... February 22 22 ... ... 3 1 ... ... 18 ... 3 1 1 ... 1 ... March 25 29 1 1 6 ... ... ... 23 ... 7 ... ... ... 2 ... April 20 16 1 ... 3 ... ... ... 9 ... 1 ... ... ... ... ... May 20 13 ... ... 5 ... ... ... 9 ... 7 2 1 ... ... 13 June 17 9 ... ... 2 ... 1 ... 4 ... 7 ... 1 ... ... ... July l6 13 1 1 2 ... ... ... 6 ... 11 1 2 ... ... ... August 9 8 ... 5 1 1 ... ... 8 ... 5 2 ... ... 1 ... September 12 10 1 3 4 ... 1 ... 7 ... 8 3 2 ... 1 3 October 18 11 1 1 4 ... ... ... 9 ... 4 2 ... ... 1 ... November 11 7 2 ... 5 ... 1 ... 2 ... 6 2 ... ... 1 ... December 13 4 ... ... 5 ... ... ... 4 ... 6 ... ... ... ... ... Totals 209 165 7 12 43 3 3 ... 119 ... 71 14 8 ... 11 16 93 Deaths from Notifiable Infectious Diseases, 1930. 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 ... ... l ... ... 2 ... ... ... l ... ... 4 Diphtheria 1 l l l l 10 2 l ... ... l ... 19 Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... 3 3 ... ... 6 Pneumonia 3 ... l 1 l ... ... l 2 6 10 13 38 Encephalitis ... ... ... ... ... ... 1 ... 1 ... ... ... 2 Lethargica Cerebro Spinal Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... Total 4 l 3 2 2 12 3 2 6 10 11 13 69 For Tuberculosis Deaths —see other Table. 94 The table hereunder gives the number of cases of infectious diseases that were notified from the several Institutions in the district during 1930:— SMALL-POX. 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 ... 4 11 20 93 29 4 5 3 2 3 13 3 ... 190 Hounslow Hospital ... 2 2 1 ... 1 ... ... ... ... ... 1 ... ... 7 Hounslow Barracks ... ... ... 1 2 ... ... ... 1 ... ... ... ... ... 4 Mogden Isolation Hospital ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Collingwood College ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... St. Mary's School ... ... 12 ... ... ... ... ... ... ... ... ... ... ... 12 ... 6 25 22 95 30 4 5 4 2 3 14 3 ... 213 95 TUBERCULOSIS. I still feel very strongly that an open-air recovery school is a real need in the district. One has to realise how important it is in the case of those people who-, in crowded houses, are in very intimate contact indeed with cases of open tuberculosis, to ensure that everything is done to prevent the disease becoming manifest. It is now ascertained that the average period before a child develops tuberculosis as the result of contact with a case is in the region of three years. This delay in the manifestation of disease is apt to give a false sense of security in these cases. Again, with cases of malnutrition of various kinds, a school of this type, with its rest and feeding, may mean for certain cases the difference between the life of a chronic invalid who eventually becomes a burden upon public funds, and that of a healthy selfsupporting citizen. Pulmonary Tuberculosis. The number of new cases notified during the year was 71. Thirty-nine cases were notified from Institutions— Sanatoria 19, Poor Law Institutions 13, General .Hospitals 6, and Tuberculosis Dispensary 1. There were 40 deaths from Tuberculosis of the Respiratory System. Seven of these were not notified. Of the new cases notified, 56 received institutional treatment during the year, and 13 died. Other Forms of Tuberculosis. The number of new cases notified during the year was 14. Twelve of them were notified as receiving institutional treatment. There were 8 deaths. Four of the cases which died were unnotified. 96 Deaths from Tuberculosis. Of the 11 deaths which occurred in non-notified cases, 1 was a sudden death from Miliary Tuberculosis certified by the Coroner. 5 deaths occurred elsewhere, and were transferred to this district. 1 was a case of Tuberculous Meningitis, diagnosed in the West Middlesex Hospital. 4 cases were apparently not diagnosed until just before or after death. For Table showing new cases notified and deaths in 1930 see next page. 97 TUBERCULOSIS 1930. Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 ... ... ... ... ... ... 1 ... 1 ... ... 1 2 ... ... 1 2 5 1 ... ... 2 ... ... ... ... 10 ... 2 2 1 ... ... ... ... 15 3 2 ... ... 2 1 ... 1 20 7 5 1 ... 4 ... 1 ... 25 12 8 2 2 5 5 ... 1 35 14 7 1 ... 10 3 ... ... 45 3 4 ... ... 1 2 1 ... 55 3 ... ... ... 5 2 ... ... 65 and upwards ... ... ... ... ... ... ... ... Totals 43 28 7 7 27 13 4 4 Seven of the deaths from Pulmonary Tuberculosis were not notified and four deaths from Non-Pulmonary Tuberculosis were not notified. 98 MATERNITY AND CHILD WELFARE. 99 MATERNITY AND CHILD WELFARE. The work is extending in such a way that it is difficult to keep pace with it, especially at Hounslow, despite the extra session. The sessions are still far heavier than they ought to be. There is no time for instruction during the session. The scheme is as follows:— Three Clinics weekly at the Congregational Hall, Douglas Road, Hounslow, on Tuesday, Wednesday and Thursday afternoons. Three Clinics weekly at the Public Hall, Isleworth, on Monday, Wednesday and Friday afternoons. Two Clinics weekly at Heston Village Hall, one on Tuesday afternoons, and one on Friday mornings. 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 of children at all the Centres during the last six years have been as follows:— Year. No of attendances. Year. No. of attendances. 1925 9,843 1928 16,625 192,6 11,1567 1929 17,667 1927 14,020 1930 19,222 It will be seen that the attendances have about doubled in the last six years. The average attendances during the year 1931 were as follows: At Douglas Road Centre 75.6 At Isleworth Centre 59.5 At Heston Centre 62.8 About 60 per cent. of the children born in the district attend at one of the Infant Welfare Centres before they are a year old. The number of individual mothers and children attending the Clinics is shewn hereunder:— 100  1926 1927 1928 1929 1930 Douglas Road, Hounslow— Mothers 562 688 605 733 868 Children 765 880 802 914 946 Isleworth Public Hall— Mothers 326 305 356 367 458 Children 432 414 460 452 522 Heston— Mothers — — 157 212 305 Children — — 213 253 355 It will be seen that the average attendance at Douglas Road is 75. This, towards the end of the year, was greatly exceeded, the attendances often being over 100, and on one occasion reached 128. There is no need to point out that this makes work absolutely impossible from the point of view of the nurses and also of the Medical Officer. The rapid growth of the district, with the consequent influx of families from other districts, brings to light various matters, one of which I think must be mentioned. It affects more particularly children who have attended Clinics in other parts of the County. I find a small but increasing number of children who are brought to the Clinic on account of inability to sleep soundly at night, and this group presents the same symptom, namely preputial adhesions; in most of the cases about one-third of the distance from the meatus to the glans penis, at the same time the foreskin is not in any way redundant, but rather the reverse. The mechanism is perfectly obvious; as a result of a full bladder an erection takes place, and discomfort is caused at the dragging of the preputial adhesions. It is quite a different matter to the discomfort which so many infants seem to experience as a result of a full bladder. One sees this almost every day in the clinic, and one learns what to expect from the type of infant's cry, and any abdominal manipulation immediately emphasises the wisdom of wearing washable jackets for this 101 class of work. Despite the pronouncement of some of the bestknown pædiatricians that these preputial adhesions disappear or are negligible, one finds a considerable number of reflex symptoms, particularly in older infants, which are cleared up at once by the separation of the adherent foreskin. With the complete separation of the foreskin none of these cases require circumcision. Another fact which emerges in the case of these restless infants, according to the mothers' statements, is, firstly, that without exception the infant has never had its genitals examined at the Clinic it attended; and secondly, that without exception the Medical Officer has been an unmarried woman. Sales at Clinics. Quantity. Receipts. £ s. d. Half-Cream Cow & Gate 1132 lbs. 87 9 10 Cow and Gate 9320 lbs. 714 18 3 Glaxo 165 lbs. 12 3 10 Prescription Glaxo 454 lbs. 35 15 8 Virol 859½lbs. 54 2 11 Malt 7 lbs. 5 3 Oil and Malt 328 lbs. 11 8 9 Lactagol 1117 tins. 63 8 2 Cod Liver Oil Emulsion 3580 bottles 116 17 4 Bemax 440 packets 9 3 4 Lacidac 1 packet 2 7 Total £l,105 15 11 An agreement exists with the London County Council for the admission of cases of Ophthalmia Neonatorum to St. Margarets Hospital. The appended list shows the last hundred analyses of breast milk:— 102 Particulars of the last 100 cases of Breast Milk Analyses. Mothers attending the Maternity and Child Welfare Centres. Showing Percentage of Fat. No. Per centage No. Per centage No. Per centage No. Per centage No. Per centage 1 2.6 ... 20 1.5 ... 39 3.9 ... 58 4.0 ... 77 1.0 2 3.0 ... 21 4.5 ... 40 3.0 ... 59 6.5 ... 78 2.0 R 79 2.5 L 3 3.6 ... 22 5.7 ... 41 3.0 ... 60 1.5 4 1.7 ... 23 4.0 R 42 1.7 ... 61 1.5 ... 80 3.6 24 4.0 L 5 1.0 ... ... 43 2.5 ... 62 2.0 ... 81 5.0 R 82 2.7 L 6 2.5 ... 25 2.0 ... 44 3.5 R 63 1.3 45 5.5 L 7 2.0 ... 26 2.0 ... ... 64 4.5 ... 83 2.5 R 84 2.5 L 8 20 ... 27 1.0 ... 46 2.5 ... 65 2.1 9 2.2 ... 28 3.6 ... 47 2.3 ... 66 5.2 ... 85 40 R 86 2.5 L 10 1.2 ... 29 2.0 ... 48 1.7 ... 67 6.0 ... 87 2.0 11 1.5 ... 30 2.6 ... 49 4.0 ... 68 1.1 ... 88 2.2 12 1.0 ... 31 3.0 ... 50 10 ... 69 3.0 13 4.0 ... 32 2.0 ... 51 4.5 ... 70 2.6 ... 8.9 4.0 R 90 2.4 L 14 3.0 ... 33 2.5 ... 52 1.2 ... 71 4.5 ... 91 1.5 R 92 2.5 L 15 1.0 ... 34 3.5 ... 53 30 ... 72 3.0 16 1.0 ... 35 4.5 ... 54 3.5 ... 73 2.5 ... 93 9.5 17 2.2 ... 36 3.0 ... 55 2.6 ... 74 1.0 ... 94 3.5 18 10 ... 37 2.5 ... 56 11 ... 75 10 ... 95 3.0 R 96 4.0 L 19 2.2 ... 38 1.5 ... 57 30 ... 76 6.5 ... 97 1.0 R 98 3.2 L 99 2.2 R 100 2.7 L 103 This work has been carried on for some considerable time in the laboratory, and shows how impossible it is to expect children to thrive on milk of such quality. One so often finds in these cases the amount of milk secreted is adequate and a test feed reveals nothing as to the real nature of the trouble. The majority of these analyses are on 24-hour specimens, either taken from alternate breasts as alternate feeds, or else the child is put on the bottle for 24 hours and the breast pumped. One of the striking things one finds is the frequent difference in the cream content and actual output of the two breasts. In the case of the very high cream content in most of these cases the amount is small. One of the satisfactory things is that one is able to demonstrate to the mother the necessity of making efforts to improve matters, and further one finds that this particular work enhances the reputation of the clinic, in that the mothers feel that what is done for them is done on some basis of scientific understanding; which differs markedly from a case at the other extreme, in which a mother who had recently come into the district, reported with regard to the difficulty of a wasted baby, that she had been given samples which were on the doctor's table and was told to "try these and see which suits." Despite the enormous increases which have been made in recent years in teaching the student to deal with infants, there seems to be still in tihe minds of the educating and examining bodies a want of proportion in the teaching which is necessary to a student before he qualifies. From the point of view of general practice it does not seem to be sufficiently realised that the most important person in the house is a sick infant, and that if the doctor attending exhibits a real understanding of the child his future attendance, as far as the child and mother are concerned, is secured. She is as a rule far more concerned about her infant than she is about herself. Further, there is still another point which is not dinned into students sufficiently, which is that 104 when a doctor is treating an ailing infant, he is not treating one patient but two, and very often the patient whom he is not called in to see—that is the anxious mother—is the one who wants treating most. It is an astounding thing how a fussy, anxious mother will in some way impose her state of mind on the infant, whereas the contented mother who feels that she is helping towards her infant's recovery, is a very potent assistant to the medical attendant. Some people will jeer at the idea of psychotherapy in these cases; it may be quite good medical treatment, for instance, to give a child a dose of medicine once a day, but it is rank bad therapeutics from the point of view of the anxious mother. The medicine can be given more often, or some perfectly harmless procedure can be adopted which keeps the mother's mind at rest and gives her something to do, whereby she feels that she is assisting in the child's recovery. It means an enormous amount to the sick infant not to be fussed over by a constantly anxious mother wanting to do something. Another thing that impresses me more and more with the influx of new children from other districts, is the number of breastfed children with definite signs of rickets. By this I do not mean that we do not get them amongst our own children. We do. Mothers who stay away from the clinic for long periods, bring the children up again because they are not satisfied with their progress, and again and again one is faced by definitely ricketty manifestations. Ante-Natal Clinic. This Clinic is held at 92, Bath Road, Hounslow. Owing to the increasing attendances it was necessary in July, 1930, to put on an additional session, which is held on the third Wednesday in each month. The attendances are still increasing, and it is expected that another session will be required in the near future. Dr. J. W. Bell relinquished the Ante-Natal Clinic work at the end of December, 1930, but still acts as Consultant for obstetric emergencies when required by a Medical Practitioner in a difficult 105 case, and for Puerperal Fever cases where a second opinion is desired. Mr. ,A. J. Wrigley, M.D., F.R.C.S., has been appointed to take over the Ante-Natal Clinic work at the beginning of the New Year (1931). The following are the figures with regard to the attendances at the Clinic:— Attendances by expectant mothers during the year 300 Average attendance of expectant mothers per session 16.6 Total number of expectant mothers who attended the Clinic during the year 1.87 Dental Clinic. The following is an extract from the Dental Surgeon's report for the year: — Year. Mothers. Boys. Girls. Total. Appointments were 1929 141 106 81 328 1930 165 102 122 389 Attendances 1929 129 98 78 305 1930 129 93 111 333 Details of the Work, 1930. Treated 21.0 Fillings 59 Referred for Gas 67 Extractions (Local anaesthetic) 4 Extractions (General do.) 387 Administrations of general anaesthetic 118 Advice 18 Treatment postponed 3 Refused to submit 3 Dressings 11 Impressions taken 6 Charted 31 Objector 1 Silver Nitrate treatment 25 Dentures were supplied to six mothers. 106 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 1.0 „ 1 13 0 4 „ 19 3 11 „ 1 13 0 5 „ 1 2 0 12 „ 1 13 0 6 „ 1 4 9 1.3 „ 1 13 0 7 „ 1 7 6 1.4 „ 1 13 0 Notification of Births. Number of live births notified during the year 1232 Number of still births notified 54 Notified by midwives 867 Notified by parents or doctors 419 No special measures exist for dealing with unmarried mothers or illegitimate children of such, but cases not wholly destitute have derived benefit through the Council's scheme for grants of food and milk. VOLUNTARY SOCIETIES AND HELPERS. The Isleworth Nursing Association and the Osterley, North Hounslow and Heston Nursing Association are the only Voluntary Societies in direct contact with the Council's Maternity and Child Welfare Scheme. Special mention must be made of the services rendered at the Welfare Clinics by Miss Ankritt (co-opted member of the Committee), Mrs. Cox, Mrs. Dawson, Mrs. Davies, Mrs. Killick, Mrs. Goff, Miss Goff, Mrs. Griffen, Mrs. Griffiths, Mrs. Hogg and Mrs. Horton at the Hounslow Centre; Mrs. Chedgey (co-opted member of the Committee), Mrs. Watson, Mrs. Curd, Miss Wooton and Mrs. Jones at Isleworth; Mrs. Pitkin, Mrs. Rose, Mrs. Griffiths, and Mrs. Taylor at Heston. 107 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. Dade, Mrs. Golf, Mrs. Hill, Mrs. Hoddinott, Mrs. Hogg, Mrs. Marsh, Mrs. Martin, Mrs. Midmore, Mrs. Newman, Mrs. Sandford, Mrs. Sargeant, Mrs. Yates. At the Isleworth Christmas Party, Mrs. Kenyon organised a concert, and also gave a dancing display. 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:— 1926 1927 19:28 1929 1930 1st visits to babies under 1 year 1038 1020 1125 1304 1395 Routine Re-visits to babies and Children up to 5 years 3190 4474 4204 4311 3982 Inquiries made, elicited— Feeding—Natural 672 747 806 887 980 Artificial 102 41. 47 44 77 Both 62 16 40 32 56 Sleeping with parents 202 200 247 277 260 Using Comforter 231 148 154 168 195 Mother working during pregnancy 75 36 51 48 53 Year 1930. Other Visits— Ante-natal First visits 83 Subsequent visits 15 Infants' Deaths and Stillbirths, Visits paid 61 Ophthalmia Neonatorum and Discharging Eyes 127 Infantile Diarrhoea 1 Puerperal Fever and Puerperal Pyrexia 15 Measles and German Measles 17 Children under 5 years. Whooping Cough 6 Mumps 5 Chicken Pox 6 Pneumonia 31 Bronchitis 5 Milk and Food Cases 36 Home Help 23 Social Conditions 48 108 Summary of Nurses' Visits:— Total to expectant mothers 98 „ children under 1 year of age 4156 „ children between the ages of 1 and 5 years 1,604 Miscellaneous Visits in connection with Maternity and Child Welfare work 595 Visits re Public Health matters, infectious diseases, tuberculosis, etc. 250 Total 6703 Health Visitors' attendances at the Maternity and Child Welfare Centres, Ante-Natal Clinics, etc., 431. Health Visitors' attendances at Diphtheria Immunisation Clinics, 294. Home Help for Mothers. The Home Help paid 111 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 cleansing is not carried out by an officer of the department acting as such. During the year, 66 children have been cleansed. In addition, she assists at the Maternity and Child Welfare Centres and makes dressings for the Clinics. 109 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 100. OPHTHALMIA NEONATORUM year 1930. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 8 5 3 8 ... ... ... 110 heston and isleworth urban district education committee twenty-third ANNUAL REPORT OF THE School Medical Officer FOR THE Year ended 31st December,1930 CONTENTS page Blind children 24, 32 Clinics 20 Crippling defects 23 Deaf children 15, 22, 24, 29, 32 Dental defects and treatment 15, 30, 37, 48-71 Defective vision 15, 22, 29, 35, 40-47 Ear disease and hearing 15,22,29 Employment of children 25 Epileptics 24, 30, 32 Exclusions 14, 26 Eye defects 15, 22, 29, 34, 35, 40 Eye Clinic 7, 40-43 Findings of medical inspection 14,29 Following up 18 Infant and Child Welfare Work, Co-ordination with 12 Infectious disease 16,17, 18 Medical inspections 13, 28 Medical treatment 20, 34, 35, 36 Mentally defectives 24, 32 Minor ailments 20, 34 Nurses' work in schools 18, 26, 38 Parents, Co-operation of 23 Prosecutions 27 Ringworm 22, 29, 34 School Attendance Officers, Co-operation of 24 School Clinics 20 School hygiene 13 School Nurses' work 18, 26, 27 38 Schools in the Area 6 Skin diseases 14, 22, 34 Spectacles 8, 35, 40 Staff 5 Statistical tables 28-38, 48-51 Teachers, Co-operation of 24 ,, Medical Examination of 26 Tonsils and Adenoids 14, 21, 36 Tuberculosis 14, 22, 30, 33 Uncleanliness 14, 26, 29, 38 Voluntary Bodies, Co-operation of 24 Appendix— Report on the work of the Refraction Clinic 40 Dental Clinic Statistics 48 Report on Orthodontic work (with illustrations) 52 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, 1930. May I draw particular attention to the Report on the work of the Refraction Clinic (Page 40), my investigation into the supply of spectacles (Page 8), and the Report on Orthodontic Work (Page 52). I wish again to express my thanks to the members of the Committee for the kindness and support they have shewn me. I am, Ladies and Gentlemen, Your obedient servant, ELWIN H. T. NASH Members of Education Committee, 1930-31 A. A. BERGIN, Esq., j.p., c.c. (Chairman). Members of the Council-.— J. J. BONNETT, Esq., O.B.E. C. L. LEWIS, Esq. T. W. COX, Esq. H. J. Nias, Esq., m.b.e., j.p (Ex-Officio). A. J. FIELDER, Esq. G. N. SHACKLETON, Esq. F. T. HART, Esq. (.Ex-Officio). G. R .SPEED, Esq. E. W. HEATH, Esq., j.p. R. WALTON, Esq. A. L. LANG, Esq. Co-opted Members. E. W. GOODE, Esq. (Vice-Chairman). Miss E. A. ANKRITT. Mrs. S. SPOONER. P. MURPHY, Esq., j.p. O. WARDMAN, Esq., ph.d. School Medical Officer-.— ELWIN H. T. NASH, m.r.c.s., l.r.c.p., d.p.h. 5 1. STAFF School Medical Officer— Elwin H. T. Nash, M.R.C.S., L.R.C.P., D.P.H. Assistant School Medical Officers— Mrs. Eva Louise Roberts, M.B., Ch.B., D.P.H., Barrister- at-Law. Frederick M. M. Eyton-Jones, M.D., B.S., Lond., M.R.C.P., Lond., D.P.H. (Part-time). Dental Surgeon—I. cohen, L.D.S., R.C.S., Eng. Radiographer—D. Arthur, M.D., D.P.H. 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., New Health Visitor's Diploma of the Royal Sanitary Institute. 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., and S.N., M.C.W.W. Miss M.-G. Gribble, A.R.R.C., S.R.N., Cert. C.M.B., H.V. and S.N. Miss A. Bowness, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss G. M. Clare, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. Clerical Staff— B. W. Kilby (Chief Clerk). Miss R. Marshall. P. T. H. Crandon. A. H. Cornhill. Miss G. E. Curtis. B. P. Garrod. K. I. Bisshopp. H. J. Aldhous F. Bell. E. E. Forrest. Miss V. D. Nicholls Comprising the whole Clerical Staff of the Public Health Department, part of whose duties are concerned with the School Medical Service. Dental Clinic Assistant and Clerk— Miss P. Lee 6 ELEMENTARY SCHOOLS IN THE AREA. School Department. *Accommodation. Average Number on * Registers. Alexandra Boys' 4OO 497 ,, Girls' 4OO 433 Berkeley Junior 4OO 420 Brentford End Infants' 100 19 Grove Road Boys' 346 348 ,, Girls' 346 327 ,, Infants' 388 323 Heston Mixed and Infants' 636 581 Hounslow Heath Boys' 390 443 ,, Girls' 390 400 ,, Infants' 340 323 Hounslow R.C. Mixed and Infants' 314 245 Hounslow Town Boys' 354 427 ,, Girls' and Infants' 536 644 Isleworth Blue Boys' 248 127 ,, Girls' and Infants' 284 192 Isleworth Town Senior Mixed 440 400 ,, Junior Mixed 440 521 St. Mary's R.C. Boys' 150 137 ,, Girls' and Infants' 240 188 Spring Grove Central 392 343 ,, Junior 240 356 Woodlands St. John's Infants' 125 61 Worple Road Junior Mixed 280 270 ,, Infants' 265 246 Total 8444 8271 * These numbers are for December, 1930. 7 INTRODUCTION. In presenting the report on the School Medical Service, I want to emphasize two points particularly. Firstly, the excellent work being done by Dr. Roberts in the Ophthalmic Clinic : Secondly, the orthodontic work by the School Dental Surgeon, Mr. I. Cohen, L.D.S., Ophthalmic Work. The work in connection with visual defect in this district continues to progress and the number of refractions done this year, viz., 443, is the highest since the work began. Four hundred and five spectacles were prescribed and 392 acutally obtained before the end of the year, giving a percentage per school population which compares favourably with surrounding districts. This is partly due to the meticulous way in which Dr. Roberts follows up the cases, in addition to the fact that she is well known to the parents as a result of her activities in other directions in the school and public health work of the department. Two other factors help the efficiency: One, the flat rate charge of 4/6 for nickel frame spectacles of good quality, and the other, that the measuring for frames, etc., is done by our own nurses, and not by an optician who is out to sell the most expensive frames that he can persuade the parents to pay for. As a result of my experience, both here and elsewhere, I am of opinion that the employment of a whole-time officer at the Refraction Clinics gives definitely better results than when the work is done by a visiting Ophthalmologist. It is impossible for any outside person coming to the district for a few hours weekly to follow up and keep in touch with the children in the way that the whole-time officer is able to do. In this district this is borne out by the striking increase in the work done since 1924 when Dr. Roberts first took it over. Up to that time the refractions had been done by a Consulting Ophthalmologist. In 1923 there were 129 cases submitted to refraction; in 1924 the number rose to 183, whilst this year (1930) the total is 443, which gives a percentage of 5.3 of the whole school population, against 2.2 in 1923. In the Appendix will be found a report by Dr. Roberts on the work and aims of our School Eye Clinic. Dr. Roberts, before entering the Public Health Service, held the post of House Surgeon at the Manchester Royal Eye Hospital, and later acted as Clinical Assistant to the Ophthalmic Surgeon at Paddington Green Children's Hospital. 8 At a Conference of Medical Officers of Health held recently, the flat rate contract price at which our spectacles are supplied was somewhat severely criticised by representatives of other Authorities some of whom quoted prices as low at 1/6 per pair, against our flat rate of 4/6 for all types of lenses with nickel frames. In view of this criticism it was imperative to look into these prices closely to see if our prices could not be improved. The facts that emerged from the enquiry are interesting and illuminating. All the contracts with these very cheap prices are given to local opticians who attend the Clinics to measure the children for spectacles prescribed by the Ophthalmic Surgeon. The contracts are on sliding scales, the prices rising as the defect of vision increases : The rise taking place with simple spheres as the diopters of correction increase, but with a still further rise in cases where a cylinder has to be added to correct any astigmatism. It is interesting to see how this bait of the very cheap simple sphere works in practice. Take for example the spectacles prescribed in this area during 1930— Spheres of all grades 20.5% Spheres and cylinders 77.5% Cylinders alone 2.0% i.e., over 2/3rds of the cases are amongst the higher priced lenses, and most of the prices for this class of spectacle in the other districts approach double the flat rate price we pay. Then again, it is interesting to see how these contracts work out on the profit making side to the local opticians who attend Clinics. The following percentages show the various classes of frames supplied in my area in 1930: — Nickel at 4/6 (including lenses) 77.5% Rolled Gold at 8/- ,, ,, 16.7% Rolled Gold and Shellite rims at 9/6 ,, ,, 5.6% Contrast with this the figures from two districts: — District 1. Nickel under 2/- per pair 29% Rolled gold 12/6 per pair 19.4% Rolled gold and Shellite rims. 15/- per pair 42.0% 17/6 per pair 3.2% 21/- per pair 3.2% *25/- per pair 3.2% 9 District II. Steel at 1/6 to 5/- 21.7% Nickel at 2/-to 5/6 36.7% Rolled gold at 6/6 to 10/- 26.5% Rolled gold and Shellite at 11/6 to 15/- 15.l% The inference is fairly obvious. Where the contract price for the cheapest spectacles is considerably below ours, the percentage of these cheap glasses supplied is comparatively small, and appears to be merely a bait offered by the opticians in order to secure for themselves the higher priced work. This naturally tends to act to the detriment of the scheme. Another Authority—on the same basis as ourselves—provides practically nothing but nickel frames. Again, the following figures show the contract prices of an agricultural district: —< Lens. Nickel Steel. Frames. Nickel Plated Nickel Steel. Rolled Gold. Spheres less than 6 D. 2/6 3/6 4/6 13/6 Over 6 D. 4/6 5/6 6/6 15/6 Spheres—Cyls. or Cylinders only 5/6 6/- 7/- 16/- In this district the parents' inability to pay these prices is such that a special fund had to be raised to pay for the spectacles. It is an illuminating point that of all the districts investigated, the one with the most expensive spectacles supplied has the lowest percentage of spectacles obtained. In one case steel frames only are specified in the contract, but the parents can go to the contractor's shop and change the steel frames for more expensive frames, the prices then being almost identical with those in the district last mentioned. Instead of being able to criticise our contract, I am more than ever convinced that a flat rate is far the best from the point of view of the popularity of the service, particularly with those parents whose child has a high error, or progressive myopia, who 10 is penalized in all sliding scales. It is true that some of the frames supplied on these sliding scales are slightly better than ours, but ours are adequate in every way. Only recently a mother brought her child from one of the schools because she would not wear any spectacles except some with expensive artificial tortoiseshell frames similar to those worn by another child in the class, whose parents were in.comfortable circumstances, and who had obtained expensive frames costing 25/- from an optician. The total family income in this case was just about £3 and it needed a little fatherly advice to the child to convince her that such an amount was thoroughly unjustifiable in the parents' circumstances, and she must be content with more modest frames. The fact that in 77.5% of our 392 cases nickel frames at 4/6 were provided, shows that where pressure is not brought to bear by what we may call good salesmanship, children and parents are in the main, contented with the satisfactory nickel frame of good quality, and I am certain that this is one of the conditions which materially assist the very satisfactory result with regard to the conection of the visual errors amongst our school children. Child psychology is such that if a large number of more expensive frames are worn there is a demand amongst the other children for the same kind. Only this last week, in an adjoining district a boy of about seven got into the 'bus I was in, unkempt, almost ragged, dirty and untidy—not merely boyish dirt but that of poverty and neglect—he was wearing a pair of rolled gold frames with artificial tortoiseshell rims ! I happened to know the family circumstances, which certainly are not those that should have afforded anything but the most inexpensive frames. DENTAL WORK. Secondly, with regard to dental work, the very satisfactory percentage of attendances of those requiring treatment is shown in the Dentist's report. This is, I am convinced, in part due to the conversion from payment per attendance to the flat rate. We are finding—as in all the other departments of the Council's activities where a flat rate is in operation—that there is no longer the terror of the unknown expenditure, and this is a very material assistance. With regard to the orthodontic work, the extremely satisfactory result of the first year's (or rather six months') work is shown in the Dental Surgeon's report. 11 The difficulties of arranging the scheme, as pointed out in last year's report, were shown in the letter which governed the agreement with the Royal Dental Hospital. One of the most difficult points in completing the scheme was assessing what would be a fair payment for the parent to make. The figures given in the Dental Surgeon's report, showing that there is a balance in hand of £30 at the end of the year to finish the treatment of cases begun, would seem to indicate that our flat rate estimate of 37/- which includes the 12/- we pay the Royal Dental Hospital, was a wise one. I wish specially to pay a great tribute of thanks to the patience displayed by Mr. H. R. Evans of the Royal Dental Hospital in the negotiations. It is certainly right to say that had it not been for him there would have been no satisfactory scheme in existence. 1 also wish to emphasize one other factor which contributed largely to the success of the scheme, namely, the clarity of the reports of the Dental Surgeons who have seen the patients. There is only one note of warning. As a public authority, it is necessary to watch that enthusiasm does not outstrip judgment, and that cases which can be dealt with by a few judicious extractions to improve the condition, shall not be subjected to prolonged treatment which is cosmetic rather than utilitarian.''1 At the same time it must be understood that in certain cases of gross deformity the cosmetic result is of enormous importance to the patient. Such a scheme as this is only possible in or near large towns with established Dental Hospitals, otherwise there would appear to be no alternative but to have a peripatetic consultant visiting various clinics or schools with the patients assembled for that particular purpose, and even then the possibility of radiographic and pathologcial reports seems remote, if not out of the question. A further interesting point has emerged from the orthodontic work, which is that it has been the greatest advertisement of the Dental Clinic we have had. The radiographs and models are impressing the parents that the Dental Clinic is in a really scientific manner attempting to deal with the dental defects and diseases that afflict the children in our schools. 2 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 12 Dr. Roberts, whose duties are mainly in connection with school children, gives assistance in Public Health matters and acts as Deputy in the absence of the Medical Officer of Health, while Dr. Eyton-Jones devotes rather less than half his time to school work. (a). Infant and Child Welfare. The popularity and success of this work continues to increase, and whereas in 1926 there were two Centres each open for two afternoon sessions per week, there are now three Centres with a total of eight sessions weekly. Children may attend these Centres until they reach school age, and upon the recommendation of the Medical Officers, may attend the School Clinics for treatment of visual and dental defects and minor ailments. X-ray treatment for Ringworm can also be arranged. Children between one and five years are visited by the Health Visitors as regularly as possible. The result is that a growing number of children enter school with their medical history already available, and with such defects as have been discovered either treated or under observation: Ultimately it is hoped to find that the " Entrant " group of children examined at routine medical inspections will cease to yield the highest percentage of cases requiring treatment. This is in direct accord wich the policy of the Ministry of Health and the Board of Education who pointed out in December, 1929, that it is grossly uneconomic to allow the health and stamina of infants to deteriorate till five years old and then to spend large sums of money in trying to make good the damage between the ages of five and fifteen. (b). Nursery Schools. There are none in the district. (c). The Care of Debilitated Children under School Age. As mentioned above, children up to the age of five years have access to the Welfare Centres, and no debilitated child need go without advice and the treatment for which we have facilities. Cases of Measles, Whooping Cough, etc., if requiring to be nursed, are usually dealt with by the local Nursing Associations. There is no provision of hospital accommodation for Measles or Whooping Cough cases other than occasionally in the Public Assistance Hospital. 3.—THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. The School buildings and sanitary arrangements are periodically inspected, and a complete survey of the schools is made from time to time. Every school in the district is visited at least twice a year by a Medical Officer. Dinner Hour Arrangements. Spring Grove Central School continues to be the only school where children can obtain a hot dinner at low cost, the meal being supplied from the attached Cookery Centre. Such an arrangement here is of great value as children are drawn from all parts of the district, and it is impossible for many of them to return home for the mid-day meal. In a number of schools certain children bring food of various kinds for their midday meal, and this is consumed in the classroom or the hall. In some cases the Head Teachers give facilities for making cocoa, etc., These meals are frequently unsuitable,— in the case of the poorer children, both from the point of view of quality and sometimes quantity; and in the case of the more pampered children, unsuitable in quality, chiefly in the direction of fancy cakes, etc. 4 MEDICAL INSPECTION A routine medical inspection was carried out during the year at every school in the district, and a re-inspection followed after a period of approximately three months. The age groups selected for inspection are those laid down by the Board of Education, viz.—• 1. All new entrants (5 year old children). 2. Intermediates (8 year old children). 3. Leavers (12 year old children). 4. Other Routine Inspections. Children attending the Spring Grove Central School are examined yearly. The total number of routine medical inspections carried out during the year was 3018, compared with 2467 in 1929. The Board's schedule of Medical Inspection has been followed in all cases. 14 Disturbance of School Arrangements. No one supposes that the ordinary school curriculum is not disorganised to some extent by the needs of medical inspection, especially where all the available accommodation is required for educational purposes. The Head Teachers of the district, however, are to be congratulated upon the arrangements they make under such difficult conditions, and I should like to place on record once again my appreciation of the fact that the inspecting Medical Officer is always made as comfortable as circumstances permit. 5.—FINDINGS OF MEDICAL INSPECTIONS. (a). Uncleanliness. The number of cases discovered at routine medical inspections was 123, and special medical inspections at the Clinics revealed a further 457 cases. Two hundred and seventy children were excluded from school during the year on account of nits or vermin (£). Tonsils and Adenoids. A total of 302 children were found to be suffering from enlarged tonsils, and of these 155 were referred for operation and 147 for observation. Seventy-six children had Adenoids only, 38 being referred for treatment and 38 for observation. In a further 130 cases both conditions were present, 86 children being referred for operation and 44 for observation. (c). Tuberculosis. Five of the children examined during routine medical inspection were marked for observation as cases of suspected pulmonary tuberculosis, and one as a case of tubercular glands. Special inspections revealed 2 definite cases of pulmonary tuberculosis and 9 suspected cases; 3 cases of tubercular glands, 2 of the bones and joints, and one of the mastoid process. (d). Skin disease. A total of 429 cases of various skin diseases were reported during the year, and, with the exception of one case, all were referred for treatment. As usual, impetigo was the commonest disease, 15 accounting for nearly half of this year's total. Table II. shows that there were 177 cases of " Other skin diseases." These includc such conditions as eczema, alopecia, seborrhoea, etc. (,e). External Eye Disease. Sixteen cases of minor disease of the eye, including 7 cases of blepharitis and one of conjunctivitis, were discovered at routine medical inspections. In addition, 105 cases, including 11 of blepharitis and 30 of conjunctivitis, were discovered at the Special Clinics. (f). Defective Vision and Squint. Routine medical inspections revealed 253 cases of defective vision, 214 being referred for treatment. Seventeen cases of squint were also discovered, 9 being referred for treatment. At the Special Clinics 138 cases of defective vision and 6 of squint were referred for treatment. (g). Ear Disease and Hearing. Amongst children examined at the routine medical inspections, 60 cases of defective hearing were found, 34 of these being referred for treatment. Thirteen cases of ear disease were also discovered, 7 being referred for treatment. Special examinations at the Clinics account for 28 cases of defective hearing; and 111 cases of ear disease. (h). Dental Defects. Eight hundred and six cases of dental caries discovered at routine medical inspection were referred for treatment, and a further 87 cases were found by examination at the Special Clinics. The Dental Surgeon, in his inspections at the schools, found a total of 4632 children requiring treatment. Table IV. on page 37 gives further statistics in this connection. (i). Deformities. One hundred and sixteen cases of deformity of various degrees were discovered by inspections at the schools and at the Special Clinics. The greater number of these were cases of slight spinal curvature and flat feet. 16 6.—INFECTIOUS DISEASES. The rules as to exclusion of infected children and contacts as laid down by the Ministry of Health and Board of Education in the joint Memorandum of 1927, have been carefully followed. The following table shows the infectious disease which occurred among children attending public elementary schools during 1930, and the three previous years. 1930 1929 1928 1927 Small-pox 2 — — — Scarlet Fever 77 118 51 31 Diphtheria 88 239 54 29 Measles 799 83 688 35 German Measles 38 344 9 7 Mumps 381 106 138 352 Chicken Pox 392 423 265 243 Whooping Cough 144 177 171 157 1921 1490 1376 854 17 This table shows the incidence of infectious disease in each school during 1930: — school Small pox scarlet fever. diphtheria measles german measles mumps. chicken pox whooping couch Alexandra Boys ... 4 4 46 2 72 3 6 ,, Girls ... 3 4 68 ... 26 15 ... Berkeley Junior ... ... ... ... ... ... ... ... Brentford End Infants ... 1 ... 6 ... 1 ... ... Grove Road Boys ... 3 7 3 1 3 17 ... ,, ,, Girls ... 3 1 7 1 ... 27 3 ,, ,, Infants ... 4 6 103 6 4 104 16 Heston Mixed and Infants ... 4 1 100 4 121 37 41 Hounslow Heath Boys ... 2 1 12 2 ... 3 9 ,, ,, Girls ... 4 1 20 ... 4 6 ... ,, ,, Infants ... 5 2 120 1 2 20 46 Hounslow R.C. Mixed & Infants ... 1 ... 1 1 ... 12 ... Hounslow Town Boys 1 2 5 10 ... 8 1 1 ,, ,, Girls and Infants 1 3 15 73 ... 41 49 10 Isleworth Blue Boys ... ... 1 ... ... 2 1 ... ,, ,, Girls & Infants ... ... 1 27 ... ... 7 1 Isleworth Town Senior Mixed ... 5 4 2 ... 6 2 1 ,, ,, Junior Mixed ... 6 9 68 6 45 35 3 St. Mary's Boys ... ... 3 2 1 ... ... ... ,, Girls & Infants ... 1 4 5 ... 1 ... ... Spring Grove Central ... 3 5 2 ... 1 2 1 „ Junior ... 14 5 61 5 10 6 4 Woodlands St. John's Infants ... 2 ... 20 2 ... 22 1 Worple Road Junior Mixed ... 4 5 6 2 24 2 1 ,, ,, Infants ... 3 4 32 4 10 21 ... Total 2 77 88 799 38 381 392 144 18 The foregoing Tables show that the incidence of non-notifiable infectious disease has remained heavy. The School Nurses continue to visit all cases of non-notifiable infectious disease, and, as has been pointed out in previous years, this work takes up a very large part of the nurses' visiting time and when the number of cases is large the other work suffers to some extent. As usual in cases of Diphtheria, all home contacts have been swabbed, and in cases where it was thought that the infection might be in the school, all school contacts have also been examined. A very successful campaign has been carried on during the year with regard to immunisation against diphtheria, and a full report of this work will appear in my Annual Report as Medical Officer of Health. 7 FOLLOWING UP Every possible care is taken that no child requiring treatment shall be allowed to continue without it. Parents are notified in writing of all physical defects discovered in their children during routine medical inspection, and those parents who take advantage of our invitation and attend the inspection, receive verbal advice also. A special " Following-up " card is then made out, and one of the School Nurses visits the home and explains how treatment can be obtained. Further visits are paid from time to time as may be necessary. The great activity in the work of following-up is demonstrated by the fact that nurses paid over eighteen hundred visits in this connection during the year. The most difficult feature of this work is the wilful neglect of certain parents whose obstinacy fails to respond to persuasion: Such cases have to be referred to the Committee, who generally decide to pass the case on to the National Society for the Prevention of Cruelty to Children. The following is a list of the School Nurses' duties, with brief statistics of their activities. DUTIES. 1. Attend Routine Medical Inspections at schools with the Medical Officer, and assist in weighing and measuring children, etc. 19 2. Attend Re-inspections at schools with the Medical Officer. 3. " Following-up " as outlined above. 4. Attend Eye Clinics. 5 Attend Minor Ailments Inspection Clinics with Medical Officer. 6. Attend Minor Ailments Treatment Clinics and undertake daily treatments. 7. Attend Dental Clinics. 8. Attend Dental Inspections at Schools. 9. Visit Schools and inspect all children for uncleanliness. (Cleanliness Survey). 10. Attend Clinics for dealing with dirty children. (Cleanliness Clinics). 11. Visit children's homes for enquiries in cases of nonnotifiable infectious disease. 12. Visit homes of children who fail to attend Clinics or attend irregularly. Summary of School Nurses' work during 1930. Attendances. Routine Medical Inspections 174 Re-inspections 27 Eye Clinics 91 Minor Ailments Inspection Clinics (with Medical Officer) 181 ,, ,, Treatments Clinics 866 Dental Inspections 44 ,, Clinics 457 Cleanliness Surveys 30 Cleanliness Clinics 28 Other Attendances (School Sports, etc.) 9 Visits. Re Infectious Disease. 2605 Re Clinic Absentees 272 Following up 1817 Other Visits 45 20 8.— MEDICAL TREATMENT. (a). Minor Ailments. The Minor Ailments Clinics continue to be an important and highly successful feature of the School Medical Service for this area, as one may judge from the fact that 2036 individual children attended the Clinics during 1930, making between them over 8,000 attendances. The Clinics are open at 9 a.m. every week-day for the treatment of Minor Ailments at the following centres : — Hounslow.—Clipstone House, 92 Bath Road. Heston.—The Village Hall. Isleworth.— The Public Hall. A Medical Officer attends the Clinics on the following days : — Hounslow.—Tuesdays and Fridays at 10.30 a.m. Heston.—Thursdays, at 10.30 a.m. Isleworth.—Mondays at 10.30 a.m. In May, 1929, the Committee decided to keep the Clinics open on Saturday mornings and during the school holidays, in order to judge from the attendances the need for opening at such times. A study of the Clinic Registers for 1930 reveals a considerable drop in the attendances when schools are closed, emphasizing the fact that but for the compulsion that goes with school attendance during term time many of the cases of minor ailments would go untreated and neglected. The following are the average attendances at each of the three Clinics : — School holidays, 1930. Hounslow. Heston. Isleworth. 3.5 2.16 2.56 Saturdays (during a period of 8 months, 1930). Hounslow. Heston. Isleworth. 2.26 1.65 0.88 Cases are referred to the Clinics from the School Medical Inspections, or are sent in by Head Teachers, Health Visitors or School Attendance Officers. The Attendance Committee also refer children who have been absent from school on account of alleged illness. 21 It will be seen therefore that the Clinics not only provide daily treatment for minor ailments, but serve as centres for more detailed examination of special cases which the pressure of routine medical inspection at schools will not permit. (b). Tonsils and Adenoids. As previously stated, 279 children were referred for treatment on account of enlarged tonsils and adenoids. Of this number, 48 were operated on at the Hounslow Hospital under the arrangements made by the Authority in 1921; 68 received operative treatment by private arrangement of the parents, and one case received non-operative treatment. The actual number treated during 1930 is therefore 117 out of 279 referred for treatment, making 42%, compared with 40% in 1929 and 25% in 1928. Our methods of arranging treatment remain the same as in past years. A child must be referred for treatment by one of the Medical Officers and the parents are then given an application form on which they are asked to state details of their income and outgoings, number in family, etc. As soon as this form is completed and returned, it is forwarded to the Education Secretary who fixes the amount the parents shall be asked to contribute towards the cost of the operation. The parents are then asked to give their written consent to the operation, and the child's name and address is sent to the Secretary of the Hounslow Hospital, who makes the appointment for operation. Every case is specially examined at the Clinic a few days after the operation. The Authority pays the Hospital one guinea for each operation. The parents' contribution is calculated in accordance with the following scale : — Weekly family income Contribution per head Under 8/- nil. From 8/- to 10/- 5/- From 10/- to 12/- 10/- Above 12/- 21/- A great deal of trouble has been experienced during the year in dealing with the children of people belonging to the Hospital Savings Association. This Association does not undertake to pay the full cost of Tonsils and Adenoids operations, and its vouchers are not accepted by the local hospital in this connection. The Association has, however, offered a repayment not exceeding 7/in each case operated on, provided the parents first pay the 22 tribution under our scale, and then produce the Authority's receipt. At the time of writing this report no official settlement has been reached. (V). Tuberculosis. Any suspicious case is immediately referred to the County Tuberculosis Officer, with whose Dispensary in Bell Road we are in constant touch. (,d). Skin Disease. Table IV. (page 34) shows that 393 cases of skin disease, and 673 miscellaneous cases of bruises, sores, chilblains, etc., were treated under the Authority's scheme during the year. Ringworm of the Scalp.—Thirteen cases were successfully treated by X-ray under our arrangements with Dr. Arthur (of Ealing) during 1930. The Authority pays Dr. Arthur's fee of £1 : 1 : o per case, but parents are asked to contribute 2/6 only; and in necessitous cases free treatment can be obtained on application to the Education Committee. (e). External Eye Disease. A total of 91 external eye defects were treated at the School Clinics during the year. These were chiefly conjunctivitis, blepharitis, with some phlyctenular ulcers and suppurating conditions of the lids. (/). Vision. (See also Appendix.) Four hundred and forty-three cases were submitted to refraction, compared with 413 in 1929, and 297 in 1928. Spectacles were prescribed in 405 cases and obtained before the end of the year in 392 cases. Twenty-five other cases were treated by private arrangement of the parents; and spectacles were obtained in 23 cases. (g). Ear Disease and Hearing. One hundred and twenty-two cases of deafness or ear disease were dealt with at the School Clinics, and 5 were treated by private arrangement of the parents. (h). Dental Defects. A full report on the work of the Dental Clinic is given in the Appendix. (See pages 48-71). 23 (i). Crippling Defects and Orthopaedics. At the time of writing this report the Authority has no definite scheme for the provision of orthopaedic treatment. We have, however, referred 36 cases of deformity of varying degree to the Royal National Orthopædic Hospital during the year under a purely unofficial arrangement. 9. 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 during the summer. 10. PHYSICAL TRAININC. There is no Area Organiser of Physical Training for the elementary schools in the district, and whatever is done is by the initiative of the teachers. The School Medical Officers however are frequently able to give advice as to the ability of certain children to engage in drill and strenuous games. 1 1 PROVISION OF MEALS. The systematic provision of meals for school children is not undertaken in this area. Since 1928, however, the Committee has allowed Cod Liver Oil and Malt to be sold at cost price at the School Clinics for children recommended by the School Medical Officers, and at the time of writing consideration is being given to the question of an arrangement whereby children may obtain milk regularly at school for a minimum payment. 12.- SCHOOL BATHS. No school in this district is provided with baths. 13 CO-OPERATION OF PARENTS. Every effort is made to secure the co-operation of parents in the work of the doctors, dentist and nurses. Parents are invited to attend all routine medical inspections, and during 1930 a parent or other relative attended in 2328 instances, representing 77.1% This compares with 75.1% in 1929 and 70% in 1928. Parents are urged also to attend the Treatment Clinics and it is gratifying to find that an increasing number of parents do attend and show their desire to obtain, and assist in the treatment of their children. 24 14.— CO-OPERATION OF TEACHERS. The assistance given by teachers is of the greatest value to the School Medical Service. They make all arrangements for routine medical inspections, and help us considerably in referring cases to the Clinics, by ensuring regular attendance there, and in their reports on backward and defective children. It is realised that this assistance involves considerable trouble and is frequently given when time is short. 15. CO-OPERATION OF SCHOOL ATTENDANCE OFFICERS. The Attendance Officers are able to render considerable assistance to the School Medical Service, and frequently refer children who are brought to their notice on account of alleged illness. Prompt notification by an Attendance Officer of a suspicious sore throat, or rash, has frequently directed early attention to a case of Infectious Disease. 16. CO-OPERATION OF VOLUNTARY BODIES. The newly constituted Public Assistance Committee has very kindly given assistance in one or two cases during the year, and the National Society for the Prevention of Cruelty to Children has continued to render valuable assistance in cases of parental neglect. The Invalid Children's Aid Association has, we know, dealt with some of our school children, and the Middlesex Edward VII. Memorial Fund from time to time provides a seaside holiday or convalescence for a few necessitous children. The following Societies render all possible assistance where required :—Hounslow, Heston and Whitton Philanthropic Society; The Isleworth, Spring Grove and St. Margaret's Philanthropic Society; The Shaftesbury Society, and Ragged School Union; The United Services Fund, and the British Legion. 17.—BLIND, DEAF, DEFECTIVE AND EPILEPTIC CHILDREN. Every effort is made to keep the list of these cases up-to-date. The Health Visitors are able to report some cases before they reach school age, others are discovered at the Infant Welfare Centres, and we never lose sight of them afterwards. Head Teachers inform us of cases, and we rely on the School Attendance Officers to bring to our notice those defective children who do not attend school. 25 There are no Special Schools in the district, and the proposal made in 1927 to provide a joint school for Mentally Defectives in the western part of Middlesex is still under consideration. At the end of 1930 there were 17 children being maintained by the Education Committee at institutions outside the district. Five were in Schools for the Blind, a further two children being admitted in January, 1931. Six were in schools for the Deaf and Dumb. Three were in schools for the Mentally Defective, a further child being admitted in January, 1931. Two children were in schools for Epileptics. One case of severe asthma and chronic bronchitis was in a sanatorium school. One child was sent to a School for Cripples in January, 1931. 18 NURSERY SCHOOLS. There are no nursery schools in the area. 19 SECONDARY SCHOOLS. 20 CONTINUATION SCHOOLS. These schools come under the Middlesex County Council. 21 EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. 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 regulated. Children between the ages of 13 and 14 employed in the sale or delivery of milk or newspapers, or in domestic work away from home, must hold a certificate from the School Medical Officer to the effect that such employment will not be prejudicial to their health or physical development, and will not render them unfit to obtain proper benefit, from their education. Forty-six children were examined and 44 were granted the necessary certificates of fitness for work. The medical history required for Juvenile Employment cards is taken from the medical inspection records in the Health Depart- 26 men:. Where, through absence,from medical inspection, up-to-date medical records do not exist, the cases are summoned to the Inspection Clinics and the necessary data obtained. Occasionally special cases are referred to the Medical Officers for advice as to physical fitness and suitable employment. 22. SPECIAL ENQUIRIES. See Tables in the Appendix giving an analysis of the results of vision testing at routine medical inspection. 23 MISCELLANEOUS. Thirty-two teachers were medically examined and 2 were reexamined during the year in connection with their appointments on the teaching staff of the Authority. Eighty-three candidates for scholarships at the Spring Grove Central School were also examined. Under an arrangement with the Middlesex County Council and the Central Association for Mental Welfare we have undertaken the annual medical inspection of children attending the Hounslow Occupation Centre. Eleven children were examined during 1930, and of these 7 were found to require treatment—4 being referred for treatment on account of dental caries and enlarged tonsils and adenoids, and 3 for dental caries only. TREATMENT OF UN CLEAN LI NESS. The Cleanliness Survey is a most important factor in maintaining cleanliness amongst school children, and although it was not found possible during the year to attain the standard of one cleanliness survey per term at each school, it was possible to examine 4211 children, compared with 782 in 1929. Number of visits to schools by Nurses 30 Total number of children examined 4211 ,, ,, ,, ,, given warning notices 288 ,, ,, ,, excluded as verminous 9 Found to have nits— 1. (Few) 228 2. (Bad) 44 3. (Very Bad) 16 27 The nurse's visit is a "surprise" visit, and every child in school is examined privately. Those children who are found to have nitty or verminous conditions are given a sealed envelope, addressed to the parent, containing (i) instructions as to the best method of cleansing the head, (2) the name and address of the Council's Home Help, who would cleanse the head in one sitting for a fee of 1 /-, and, (3) a warning that the child will be excluded from school if the head is not properly cleansed. Two clear days after the Survey, a Special Clinic is arranged for the re-examination of these children. Those who have not been properly cleansed are excluded from school. If at the expiration of seven days they are still unclean, the parents render themselves liable to prosecution under the School Attendance Bye-Laws. Mrs. Yates has done the work of cleansing heads since 1923, the Council supplying the Sackers Combs and Shampoo. As a rule, parents are glad to avail themselves of her services, so as to avoid having their children excluded from school. Sixty-six children were cleansed by Mrs. Yates during 1930. During 1930 it was found necessary to take legal proceedings in 5 cases, with the following results : 2 cases were fined 2/6 each 1 case was fined 5/- each 2 cases (one family) were fined 15/- each 28 TABLE 1 RETURN OF MEDICAL INSPECTIONS A.—Routine Medical Inspections. Number of Code Group Inspections — Entrants 951 Intermediates 1316 Leavers 426 Total 2653 Number of other Routine Inspections 325 B.—Other Inspections. Number of Special Inspections 1356 Number of Re-Inspections 2843 Total 4199 20 TABLE II. A. RETURN OF DEFECTS found by Medical Inspection in the Year ended 31st December, 1930. Defects or Diseases. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. 1 2 3 4 5 Malnutrition 10 14 6 4 Uncleanliness (See also Table IV., Group V.). 123 ... 457 ... Skin— Ringworm— Scalp ... ... 14 ... Body ... ... 17 ... Scabies 1 ... 5 ... Impetigo 4 ... 211 ... Other Diseases (nun- tuberculous) 8 ... 168 1 Eye— Blepharitis 5 2 11 ... Conjunctivitis 1 ... 29 1 Keratitis ... ... 1 ... Corneal Opacities ... ... 1 ... Defective Vision 214 39 138 2 (excluding squint) Squint 9 8 6 1 Other Conditions 5 3 60 4 Ear— Defective Hearing 34 26 24 4 Otitis Media 1 4 57 2 Other Ear Diseases 6 2 50 2 Nose and Throat— Enlarged Tonsils 96 137 59 10 Adenoids 30 38 8 ... Enlarged Tonsils and Adenoids 58 38 28 6 Other Conditions 2 9 67 16 Enlarged Cervical Glands 15 47 24 10 (non-tuberculous) Defective Speech ... 4 ... 2 30 TABLE II.—Continued. Defects or Diseases. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. I 2 3 4 5 Teeth—Dental Diseases (see also Table IV., Group IV.) 806 9 87 ... Heart and Circulation— Heart Disease— Organic ... 21 17 36 Functional 3 43 7 15 Anaemia 1 25 5 4 Lungs— Bronchitis 1 27 30 10 Other Non-Tuberculous Diseases ... 6 10 7 Tuberculosis— Pulmonary— Definite 1 ... 1 1 Suspected ... 5 3 6 Non-Pulmonary— Glands ... 1 ... 3 Spine ... ... ... ... Hip ... ... ... ... Other Bones and Joints ... ... ... 2 Skin ... ... ... ... Other Forms ... ... 1 ... Nervous System- Epilepsy ... 1 5 ... Chorea ... ... 15 12 Other Conditions 2 7 2 7 Deformities— Rickets ... 1 ... 2 Spinal Curvature ... 37 2 2 Other Forms 9 43 17 3 Other Defects or Diseases 18 51 682 59 31 B.—Number of individual children found at Routine Medical Inspection to require treatment. (Excluding Uncleanlincss and Dental Diseases). Group. Number of Children. Percentage of children found to require treatment. Inspected. Found to require treatment. Code Groups— Entrants 951 123 12.9 Intermediates 1316 229 17.4 Leavers 426 62 14.6 Total (Code Groups) 2693 414 15.4 Other Routine Inspections 325 36 11.08 32 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 ... 2 2 Attending Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 3 3 (ii.) Suitable for training in a School or Class for the partially blind. Attending Certified Schools or Classes for the Blind Attending Public Elementary ... 3 3 Schools 2 2 4 At other Institutions ... ... ... 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 3 6 Attending Public Elementary Schools 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 2 3 At other Institutions ... ... ... At no School or Institution ... ... ... Mentally Defective. Feebleminded (cases not notifiable to the Local Control Authority). Attending Certified Schools for Mentally Defective Children 3 ... 3 Attending Public Elementary Schools 6 5 11 At other Institutions ... ... ... At no School or Institution 9 3 12 Notified to the Local Control Authority during the year. Feebleminded ... ... ... -Imbeciles 2 2 4 Idiots ... ... ... Epileptics. Suffering from severe Epilepsy. Attending Certified Special Schools for Epileptics 1 1 2 In Institutions other than Certified Special Schools ... ... ... Attending Public Elementary Schools ... ... ... At no School or Institution 1 1 2 Suffering from Epilepsy which is not severe. Attending Public Elementary Schools 3 ... 3 At no School or Institution 1 2 3 33 TABLE III.—Continued, Boys Girls Total Infectious Pulmonary and Glandular Tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... 1 1 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 ... 1 1 Physically Defective. Delicate children {e.g. pre- or latent Tuberculosis, Malnutrition, Debility, Anaemia, etc.) At Certified Residential OpenAir Schools ... 1 ... 1 At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools ... 48 40 88 At other Institutions 1 1 2 At no School or Institution 3 1 4 Active nonpulmonary Tuberculosis. At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 2 ... 2 At Public Elementary Schools ... ... ... ... At other Institutions 1 ... 1 At no School or Institution ... ... ... Crippled Children (other than those with active Tuberculous disease) e.g. children suffering from paralysis, &c.t 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 21 20 41 At other Institutions 1 1 2 At no School or Institution 2 2 4 34 TABLE IV. Return of Defects treated during the year ended 31st December, 1930. Group 1.—Minor Ailments (excluding Uncleanliness, for which see Croup V.). Diseases or Defects. Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. j Total. a 3 4 Skin— Ringworm, Scalp 14 ... 14 Ringworm, Body 14 3 17 Scabies 3 3 6 Impetigo 204 11 215 Other Skin Diseases 158 18 176 Minor Eye Defects— (External and other, but excluding defective vision and squint) 91 20 111 Minor Ear Defects 122 5 127 Miscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 673 27 700 Total 1279 87 1366 35 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) 443 25 ... 468 Other Defects or Disease of the eye (excluding- those recorded in Group I.) ... ... 7 7 Total 443 25 7 475 Total number of children for whom spectacles were prescribed (a) Under the Authority's Scheme 405 (b) Otherwise 24 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme 392 (b) Otherwise 23 36 TABLE IV.—Continued. Group III.—Treatment of Defects of Nose and Throat. Number of Defects. Under the Authority's Scheme, in Clinic or Hospital. Received Operative Treatment. Received other forms of Treatment. Total number treated. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) 48 68 116 1 117 37 TABLE IV.—Continued. Croup IV.—DENTAL DEFECTS. (1) Number of children who were: (a) Inspected by the Dentist: Aged: 5 715 6 901 7 919 8 935 9 1009 Routine age groups 10 795 Total 6595 11 433 12 364 13 398 14 IOI 115 25 Specials 1353 Grand toted 7948 (b) Found to require treatment 4632 CO Actually treated 4105 (d) Re-treated during the year as the resuk of periodical examination 943 (2). Half-days devoted to Inspection 43 Total 460 Treatment 417 (3). Attendances made by children for treatment 5333 (4). Fillings Permanent teeth 3256 Total 3909 Temporary teeth 653 (5). Extractions Permanent teeth 419 Total 3435 Temporary teeth 3016 (61 Administrations of general Anaesthetic for extractions 870 (7). Other operations Permanent teeth Total 1219 Temporary teeth 38 TABLE IV.—Continued. Croup V. UNCLEANLINESS AND VERMINOUS CONDITIONS. (i) Average number of visits per school made during the year by the School Nurses 1.2 (ii.) Total number of examinations of children in the schools by the School Nurses 4211 (iii) Number of individual children found unclean 297 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 66 (v.) Number of cases in which legal proceedings were taken: — (a) Under the Education Act, 1921 - (b) Under the School Attendance Bye-laws 5 APPENDIX. 1. REPORT BY DR. ROBERTS ON THE WORK AND AIMS OF THE SCHOOL REFRACTION CLINIC (with an analysis of the results of vision testing at routine medical inspection). 2. STATISTICS FROM THE REPORT OF THE DENTAL SURGEON. 3. REPORT ON ORTHODONTIC WORK. 40 REPORT OF THE WORK OF THE REFRACTION CLINIC, The number of cases submitted to refraction this year has increased by 30 over the previous year, the figure being 433. Two sessions weekly have been held during the school terms, but these have scarcely sufficed to keep the work up-to-date, and 1930 ended with a waiting list of 79. 1578 appointments were given during the year, and 1471 attendances were made, giving a percentage of 93. Spectacles were prescribed for 405 children, and were obtained in 97% of the cases before the end of the year. All children for whom spectacles are prescribed are seen again at the Clinics so that the lenses can be checked and frames seen to be accurately fitted. It has been our constant aim, not only to provide the necessary spectacles in the first instance, but also to see that they are kept in good repair, and changed when necessary. To this end a fixed scale of charges for repairs is issued with every pair of spectades prescribed. Spectacles in need of repair or adjustment can be brought to the Health Department any day during office hours. Furthermore, no repairs are advised for spectacles which have been worn for more than 9 months without first referring the case to me, as in all probability a change of lenses or frames, or both, will be necessary. Parents are informed that the children require to be seen every twelve months in order that any necessary changes in the spectacles can be made, and children are called for re-examination at the expiration of this period. Special cases, such as myopes, etc,, are called more often. The Medical Officer or the Eye Clinic nurse can always be consulted on Saturday mornings (without appointment) and parents are encouraged to come at once and report if the child makes any complaint about its glasses. Often, there is nothing wrong with the spectacles and the child has made the complaint in order to avoid wearing them, but once this is demonstrated to a sensible mother she will then insist on the regular use of the spectacles. On the other hand, the complaint may be justified. A striking case occurred a short time ago: A mother reported that her child was getting frequent headaches and she wondered if the glasses needed changing. On investigation I found that the child 41 had been wearing lenses different from those prescribed. The mother had no knowledge of any possible change of glasses as she had only one child who wore them. The child's class at school was then examined and all children wearing glasses had their lenses checked. One child who had received spectacles was not wearing them, and when they were procured they were found to belong to the first child who had complained of headaches. Obviously the two children had inadvertently changed spectacles when in school. The prompt action of the conscientious mother who made the child wear the glasses regularly and reported his complaint at once, cleared up the matter without serious damage to either child's vision. The second child, it should be noted, had merely ceased to wear his spectacles, and this is the attitude so often adopted by parents in regard to their children's spectacles. If the child complains it is allowed to cease wearing the spectacles, and nothing further is done in the matter until the child is discovered again at the next routine medical inspection. In most of these cases the trouble is simply that the lenses need changing. The importance of systematic following up of cases of visual defect for whom spectacles are prescribed is emphasized by Sir George Newman, Chief Medical Officer to the Board of Education, in his Report for 1929, an extract from which is given below: — "It is important that a medical officer, preferably the Ophthalmic Surgeon himself, should examine the spectacles immediately after supply, in order to ascertain that the lenses conform with the prescription and that the frames are suitably fitted All children with glasses should have their visual acuity tested once a year, and if it is found there has been any change for the worse, they should be re-examined by refraction. All children suffering from myopia should be examined as a routine measure every six months or a year according to the severity or progressive nature of the defect." It is satisfactory to note that this advice of the Chief Medical Officer has been the ordinary practice for years in this area. Necessarily this detailed care involves considerable work, both medical and clerical, but the conservation of good vision in our children is of such importance, and the results achieved so encouraging, that I consider it extremely worth while. Of the 392 spectacles supplied this year, 80 were spheres only; 8 cylinders only; and 304 were cylinders + spheres; shewing that 42 a very high proportion of the children suffer from astigmatism. This high figure is doubtless due to the fact that as a general rule all astigmatic errors are corrected except in the case of young children and certain special cases. Many children need only a small cylinder, but it is just these cases with a small refractive error who suffer from eye strain with its accompanying symptoms of headache, sore eyes, general debility or nervous twitchings, and to whom a careful correction gives relief. It should, I think, always be remembered that spectacles have a two-fold object— firstly the improvement of defective vision, and secondly, the relief of strain which is most noticeable in cases where the vision is not markedly defective. On account of the large proportion of cylindrical lenses prescribed I have for some years ceased to order round lenses as a routine, and now order round lenses slightly flattened at the top and bottom, giving a larger lense surface than an oval, but preventing the possibility of the lens ever being in the frame at the wrong angle. My attention was drawn to this possibility by discovering spectacles with round lenses in which the lenses were no longer at the angle prescribed. In some cases this was due to the lens having dropped out and having been replaced by someone who has no knowledge of the required angle, and in other cases it would seem that the lens has been pushed slightly out of place in cleaning, probably due to the side screw becoming loose. For many years the measurement of frames has been done by the Eye Clinic Nurse, who has had special instruction in this work. This arrangement, common to many Eye Clinics, has been quite satisfactory. Another factor which has, in my opinion, contributed considerably to the increase in numbers attending the Eye Clinic is the flat-rate charge for spectacles. This has been in force since 1924. Before that time prices varied according to the lenses prescribed, with often a great difference in price between spectacles of different strength, and the uncertainty about the cost of spectacles undoubtedly deterred many parents from accepting treatment for their children. Also, a flat-rate prevents children with higher defects—which need more constant attention—from being penalised by the higher cost of their spectacles. Our contract prices are, nickel frames, 4/6, rolled gold frames 8/-, and rolled gold with shellite rims, 9/6. Parents are asked only to pay the actual cost of the spectacles, and in necessitous cases the spectacles are provided free or at a reduced price. Nickel frames 43 are the routine ones supplied at the Clinic—the more expensive ones are only ordered if there is a specific request by the parent. Our figures this year shew that 304 nickel, 66 rolled gold, and 22 rolled gold and shellite were provided. In conclusion I should like to emphasize the extreme importance of obtaining the intelligent co-operation of the parent in the work of the Eye Clinic. It is useless and a waste of time to prescribe spectacles unless they are worn regularly. Thus a careless mother can nullify the whole work of the Clinic in respect of her child. To avoid this I take every opportunity of explaining to parents what the spectacles do and why they are necessary, and I endeavour to make parents realise that they themselves are factors of the greatest importance in the treatment of their children's eye defects. I am convinced that the measure of this realisation by the parents is the measure of success of the work of any Eye Clinic. Although not strictly belonging to the work of the Eye Clinic I append below tables showing an analysis of the results of vision testing at the routine medical inspections this year. These have been made for three years—the previous tables having been included in the Annual Reports of 1928 and 1929. There is also an additional table giving the combined results for the 3 years. These tables show the amount of uncorrected or unsatisfactorily corrected visual defect found at the routine medical inspections, i.e., children who were found to be in need of treatment or observation at the time of examination. They are not therefore an index of the total amount of visual defect in the school children of the area. Five year old children have not been included as it is often impossible to test their vision at their first examination. This is done at the subsequent re-inspection, but the findings cannot be included as many re-inspections are made in the following year. Ages 11, 14, 15, and 16 refer only to children at the Spring Grove Central School, where all children are examined annually. The other ages are the Code Age Groups of 8 and 12 (5 being omitted) with the secondary smaller groups of 6, 9, and 13 being children absent from the previous medical inspection. E. L. ROBERTS. 44 TABLE 1. Results of Vision Testing done at the Routine Medical Inspection in 1930. Total Number examined Total number requiring treatment or observation Percentage requiring treatment or observation Percentage analysed according to age. 6 8 9 11 12 13 14 15 l6 Boys and Girls 2406 261 10.85 3.00 4.33 1.20 0.08 1.24 0.63 0.29 0.08 - Girls 1233 126 10. 22 2.68 4.14 1.05 - 1.38 0.66 0.24 0.08 - Boys 1173 135 1151 3.32 4.52 1.36 0.17 1.11 0.60 0.34 o.o9 - 45 Results of Vision Testing done at the Routine Medical Inspection in 1930. TABLE II. GIRLS. School. No. Inspected. No. requiring Treatment or for Observation. Percentage requiring treatmerit or Observation. Percentage analysed according to age. 6 8 9 11 12 13 14 15 16 G.R.G 107 6 5.60 - 2.80 - - 2.80 - - - - G.R.I 2.5 4 16.00 16.00 - - - - - - - - A.G 126 12 9.53 1.58 5.55 0.79 - 1.58 - - - - W.S.J.I 5 1 20.00 20.00 - - - - - - - - H.H.G 104 22 21.15 - 10.57 5.76 - 2.88 1.92 - - - H.H.I 22 3 13.64 13.64 - - - - - - - - H.R.C.M. 36 5 13.80 5.56 8.34 - - - - - - - S.G.C 168 9 5.36 - - - - 1.78 1.19 1.78 0.60 - W.R.M 49 7 14.29 - i0.20 4.08 - - - - - - W.R.I 19 0 - - - - - - - - - - S.M.G. & I 45 8 17.78 11.11 6.66 - - - - - - - Heston 83 6 7.23 2.41 1.20 2.41 - 1.20 - - — I.T.J 86 7 8.14 3.49 4.65 - - - - - - - I.T.S 39 3 7.70 - - - - 2.57 5.13 - - - I.B.G. & I. 59 10 16.95 8.47 5.08 - - 1.70 1.70 - - - S.G.J 50 2 4.00 - 2.00 2.00 - - - - - - H.T.G. & I. 143 12 8.39 2.10 2.79 0.70 - 2.10 0.70 - - - B.E.I 0 0 - - - - - - - - - - B.J 67 9 13.40 4.47 8.93 - - - - - - - 46 Results of Vision Testing done at the Routine Medical Inspection in 1930. 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 105 7 6.66 - 4.75 - - 1.90 - - - - G.R.I 11 3 27.27 27.27 - - - - - - - - A.B 125 13 10.40 4.00 4.00 I.60 - 0.80 - - - - W.S.J.I 5 0 - - - - - - - - - - H.H.B 93 12 12.90 - 7.52 4.30 - - 1.08 - - - H.H.I 33 5 15.15 15.15 - - - - - _- - - H.R.C.M. 37 9 24.32 8.10 8.10 5.40 - 2.70 - - - - S.G.C 157 13 8.28 - - - 1.27 1.27 2.54 2.54 0.64 - W.R.M 56 3 5.036 - 1.79 3.57 - - - - - - W.R.I 30 5 I6.67 16.67 - - - - - - - - S.M.B. & I. 36 4 i i. i i 5.56 2.78 - - 2.78 - - - - Heston 78 13 16.67 5.12 7.69 1.28 - 1.28 1.28 - - - I.T.J 99 11 i i. i i 1.01 8.08 2.02 - - - - - - I.T.S 44 4 9.09 - - 4.54 - 2.27 2.27 - - - I.B.B 32 3 9.37 - 6.25 - - 3.12 - - - - I.B.I 6 a 33.33 33.33 - - - - - - - - S.G.J 54 7 12.78 1.83 10.95 - - - - - - - H.T.B. 92 11 11.96 - 7.60 1.09 - 3.26 - - - - H.T.I. 24 5 20.83 20.83 - - - - - - - - B.E.I. 0 0 - - - - - - - - - - B.J. 58 5 8.62 5.21 3.41 - - - - - - - 47 Results of Vision Testing done at the Routine Medical Inspections in 1928, 1929, 1930. TABLE III. Total number examined. Total number j requiring treatment or observation Percentage requiring treatment or observation Percentage analysed according to age. 6 8 9 11 12 13 14 15 16 Boys & Girls 6978 721 10.33 2.73 3.82 1.22 0.05 1.42 o.73 0.18 0.05 0.01 Girls 3444 342 9.93 2.70 3.54 1.08 0.04 1.36 0.87 0.13 0.05 0.01 Boys 35.34 379 10.72 2.79 4.17 1.28 0.08 1.47 o.57 0.23 0.05 - 48 STATISTICS from the Report of the SCHOOL DENTAL SURGEON FINDINGS AT INSPECTIONS DURING 1930. Age last No. Birthday. Examined No. Requiring Treatment. Percentage Requiring Treatment. 5 715 442 61.8 6 901 564 62.6 7 919 645 70.1 8 935 684 73.1 9 1009 740 73.3. 10 795 645 81.1 11 433 308 71.1 12 364 261 71.7 13 398 250 62.8 14 101 75 74.2 15 25 18 72.0 Totals 6595 4632 70.2 Specials 1353 - - Grand Total 7948 WORK OF THE DENTAL CLINIC, 1923-4.5-6-7-8-9-30. Derived from the School Inspections in each of the past eight years. Year. Percentage found to require treatment Percentage actually treated of those found to require treatment. I923 89.8 26.4 I924 79.9 47.2 I925 74.1 52.9 1926 70.2. 58.4 1927 70.5 58.7 1928 81.2 71.1 I929 77.8 86.3 1930 70.2 88.6 49 FILLINGS. Teeth Filled. Year Permanent Temporary Total. 1925 1423 52 1475 1926 1665 25 1690 1927 2339 283 2622 1928 3699 202 3901 1929 3556 637 4193 1930 3256 653 3909 EXTRACTIONS. Teeth Extracted. Year. Perm. Temp. Total Extracts. Administration Ethyl Chloride & Gas No. of Gas Sessions Gas Local Anaesthetic I925 118 2446 2564 542 - - 41 1926 221 2840 3061 719 110 140* 54 I927 195 3155 3350 784 317 141* 59 1928 453 4594 5047 1119 670 340* 89 I929 505 4390 4895 1036 785 296* 89 1930 419 3016 3435 870 480 396* 66 *These rigures are included in the "Gas" totals. 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 90.5 86.4 75.7 80.5 81.4 For "Gas" extractions 84.3 83.3 78.5 72.7 80.4 Berkeley Junior. For ordinary treatment 82.6 88.2 - - 85.9 For "Gas" extractions 66.6 100.0 - - 81.2 Brentford End. For ordinary treatment 25.5 62.5 - - 46.6 For "Gas" extractions 42.8 - - - 42.8 50 School Departments. Percentage for whole School. INFANTS. UPPER Roys. Girls. Boys. Girls. Grove Road. For ordinary treatment 82.1 78.8 67.5 70.4 71.8 For "Gas" extractions 77.7 81.3 78.7 55.0 76.0 Heston Mixed. For ordinary treatment 85.1 75.0 70.1 81.3 77.9 For "Gas" extractions 85.0 85.7 90.9 93.5 89.1 Houtislow Heath. For ordinary treatment 82.5 83.0 86.7 84.4 85.7 For "Gas" extractions 80.5 77.2 86.9 76.0 80.6 Hounslow Roman Caih. For ordinary treatment 56.5 307 75.8 74.4 69.4 For "Gas" extractions 91.6 65.0 56.2 86.6 73.o Hounslow Town For ordinary treatment 72.5 65.5 71.5 71.1 70.8 For "Gas" extractions 67.8 72.3 73.2 88.5 77.0 Isleworih Town Junior. For ordinary treatment 91.3 77.1 69.6 61.6 69.3 For "Gas" extractions 86.6 84.2 75.0 88.8 83.8 Isleworth Town Senior. For ordinary treatment - - 62.6 68.3 65.4 For "Gas" extractions - - 83.3 94.1 88.5 Isleworth Blue. For ordinary treatment - 27.2 44.0 57.2 50.0 For "Gas" extractions 50.0 28.5 50.0 81.8 56.2 St. Mary's R.C. For ordinary treatment 90.4 68.7 48.0 60.1 57.6 For "Gas" extractions 90.0 71.4 62.5 75.0 71.9 Spring Grove Central. For ordinary treatment - - 70.7 78.5 75.2 For "Gas" extractions - - 78.5 81.4 80.4 51 School. Departments Percentage for whole School. INFANTS. UPPER. Boys. Girls. Boys. Girls. Spring Grove Junior. For ordinary treatment 60.8 76.7 86.5 76.3 78.4 For "Gas" extractions 92.8 73.0 75.0 73.9 77.3 Woodlands St. John's. For ordinary treatment 90.9 82.3 - - 85-7 For "Gas" extractions 1000 87.5 - - 94-7 Worple Road Infants. For ordinary treatment 74.5 85.4 - - 79.6 For "Gas" extractions 85.7 61.1 - - 74.3 Worple Road Junior. For ordinary treatment - - 61.2 58.8 60.0 For "Gas" extractions - - 88.8 81.8 85.0 Note.-No order of merit is implied or attempted in this Table. 52 THE ORICIN OF THE ORTHODONTIC SCHEME. It was found at the Dental Clinic here that a very great number of cases required more than the treatment usually given and sanctioned in School Clinics the conditions being—patients with : Misplaced Teeth at every angle apart from the normal it was seemingly possible to get. Jaws not in normal arch relation to each other. Teeth that did not occlude (antagonize) together. Protrusions and Retrusions of jaws and teeth. Open Bites due to Adenoids and Tonsils; the use of dummies; sucking of the lip, tongue, thumb, finger, blanket, etc. Mouth Breathers with all the usual concomitant irregularities. Impacted teeth. Teeth erupting through the centre of the palate. Teeth impacted and lying on the floor of the mouth. A Hare Lip and Cleft Palate case, previously operated upon. In short, every class and description of case one would expect to find in a large Dental Hospital. Here and there as a routine Clinic matter a few cases, could, and would, have had to be treated by extractions only, and the ultimate results left in the hands of nature. This unsatisfactory state of affairs was reported to Dr. Nash who eventually was able to frame a satisfactory scheme. For the benefit of any other School Medical Officers who may be confronted with a like problem, the steps taken are set out in full detail. Firstly —Extraction treatment—good in its place—could, but did not solve all the problem; it was useful only in a few cases, the bulk of which were met by the symmetrical extraction of all the first molars, in the majority of cases. The reasons for this decision as against Pre-Molar extractions were:— (1)-—The ^ J ^ were usually in at least two non-opposing teeth, unsaveable 53 (2).—The reluctance of parents to have teeth nearer the front extracted, in case the visible spaces did not fill up. Dr. Nash then obtained the Committee's consent to purchase a certain number of Royal Dental Hospital treatment tickets, and these were given to picked and suitable cases. In brief, as far as this Clinic was concerned this method of obtaining treatment proved a complete failure in this wise :— The ticket only stood good for ordinary treatment, but when it became necessary to have appliances made, a Dental Hospital fee was fixed, which the Hospital regulations required to be paid in one sum before the appliance was fitted. To this must be added at least another half-crown for rail and other expense on each visit. Among the class this Clinic caters for very few could stand this financial burden, hence few continued the treatment and the value of the work done up to a point, as well as the cost of the ticket, was lost. After many consultations and negotiations with every party concerned, permission was obtained from the Board of Education, for this clinic in conjunction with the Royal Dental Hospital, to establish and carry on a complete Orthondontic Scheme; and to give the necessary sessions for the purpose. Much thought was required to fix an "all-in" fee, that would, so far as one could foresee, insure the Education Committee against financial loss, be fair to the patient, and, in short, reduce the cost to the lowest amount possible without seeking to make any financial profit. The sum fixed for Orthodontic Treatment was 37/-, inclusive. As experience was gained, this had conditions attached to it: (a). It could be paid, if sanctioned by the Dental SubCommittee, in instalments, usually 2/6 per week, or as low as 1/per week. (b). No actual treatment, beyond obtaining models of the case was undertaken, or allowed by the Committee till 15/- had been paid. (c) In the event of the Consultant advising treatment by extraction only, then a total charge of 15/- was all the parent was called upon to pay. (d). In no case was the 15/- returnable. This sum it was necessary to retain to pay the agreed fee to the Royal Dental Hospital (12/-), and the cost of models. 54 (e). In a few cases where the Committee saw fit this 37/- was reduced or cancelled, and in seven cases free treatment was allowed, with rail expenses being granted in some cases to the patient. These free cases were treated exactly the same as those paying the 37/-, with the additional privilege that they had not to wait till the above 15/- was paid. (/). When the fee of 37/- was paid in one sum the Committee gave an automatic sanction for treatment: When not so paid, the Committee saw the cases and interviewed the parents before giving their decisions. Except for one visit to the Royal Dental Hospital for the Consultant's opinion, all cases are treated in our local Clinic by the School Dental Surgeon. An account of how the system works between the Royal Dental Hospital and the Clinic. The patient is seen, impressions taken, and duplicate models made. The Clinic Dental Surgeon writes a report on the case, classifying it and specifying the abnormalities as seen by him. This report, together with one set of the duplicate models (an upper and a lower) is sent to the Royal Dental Hospital and retained there. One set is retained at the Clinic, as is also a copy of the report. This enables the Consultant to be in possession of all details before he sees the patient, and facilitates any correspondence about the case. Space is left on the same sheet for the Consultant's report. A sheet is made out for the Royal Dental Hospital to fill in the Consultant's time and date of appointment, which is returned to the Clinic. The patient is warned by the Clinic to attend the Royal Dental Hospital at the appointed time. In due course the Consultant reports on the case, when treatment proceeds at our own Clinic as indicated, or in some cases, terminates—usually on the grounds that the home co-operation would not be helpful, and the prognosis is not hopeful for success, or the results that it would be possible to obtain would not be of sufficient value to justify the necessary course of treatment. In a fair percentage of cases the Consultant advises a commencing course of treatment with a view 55 to the case being sent back to him for further consideration and possible revision after a stated period of time, and for which no extra fee is charged. A point found very necessary to observe is to send for the patient and explain the intended treatment, illustrating it with the models and skiagrams, and above all to obtain the parent's signature on the case card, certifying that they have had the report explained to them and that they understand its purport. How the Scheme works, and is worked in the Clinic. When the Scheme was started it was assumed that about 50 cases in the year would pay the fee of 37/- and accept orthodontic treatment. As soon as it was announced we were ready on 5th May, 1930, we were rushed with applicants anxious to avail themselves of the facilities offered; this entailed more sessions being devoted to this work than was expected. The number of cases on the Roll at the end of the year totalled 143. The total full-time sessions (2½ hours each) given for these 143 cases was 31. It is now found that at the end of January, 1931, with over 160 cases on the roll, one session a week copes with the work and keeps it in hand. The Dental Surgeon on these sessions has the active assistance of the Dental Nurse, and Dental Mechanic who attends only on these sessions. Experience proves it is a most economical arrangement to have the Dental Mechanic present to take verbal instructions, illustrated in the mouth, and to see the patient and assist in making the progressive adjustments found necessary. Equipment. At a later date a small electric bench lathe will be necessary to polish cases that have become unhygienic. At first this is not an absolutely essential expense. Designs of the Appliances. Most of the Consultants have left these to the Clinic Dental Surgeon, contenting themselves with stating what had to be done. Appliances. These are all removable. (Fixed appliances are definitely excluded from the Clinic work, partly on the grounds of expense, 56 and partly that they require more expert manipulation, than the parents can be trusted to undertake.) These have usually been :– 1. Expansion Screws. 2. Retraction Wires. 3. Springs to move individual teeth. 4. Screws or Hickory pegs to move individual teeth. 5. Inclined planes. 6. Splint plates. 7. Labial Wires. 8. Retention plates. 9. Lip Exercisers. 10. Oral Screens. 11. Bite raising plates. In addition to the above, breathing exercises had to be explained. A certain number of cases were directed to be sent back to the Consultant in 6, 12, 18, 24 months after first being seen to enable a revision of the treatment to be considered, and such further directions as may then be found requisite. Cost of the Scheme. So far as this Clinic is concerned, the Scheme has not cost the Authority anything for the 143 cases to the end of 1930. It cost £178, which includes Mechanic's fees, cost of workroom tools, Royal Dental Hospital fees, plus miscellaneous items. The sums received totalled £208. Allowing for appliances not then made; the balance of £30 will cover their cost. It can be taken for granted that in the expenditure on appliances nothing has been stinted, although all wasteful expenditure has been.guarded against Before beginning a description of the cases met with in the Clinic work, it is well to appreciate the situation as seen by the Clinic Dental Surgeon. It had to be borne in mmd in the negotiations with the Royal Dental Hospital—Dr. Nash laid it down as an essential condition— that cases were not to be considered from the Harley Street point of view, where time and fees did not matter, but the definite aim in the Clinic work was to repair the oral defects and "sports of nature," and make the mouth fit for its proper functions of mastication and speech, and incidentally in some cases to improve appearance. This is compuisorily forced upon us through the all 57 too short time we can have these children under our control, and the necessity for saving many visits to the Clinic, and absences from school. Let it not be assumed the Clinic keeps its patients till school leaving age. Many get scholarships and at eleven years of age pass out of our control to County Schools. The County Council and other Authorities at present do not treat each others cases. Classification of Cases. As a working basis, the classification of Angle and Lischer were used. They can be roughly defined as below. A test tooth had to be taken, and from the relation of all the other teeth in the arch the classifications were founded. The first permanent molars were selected as the test teeth. The normal position of these teeth is that when they are occluded together the anterior (medial) third of the lower molar will be that amount in front of the upper molar. From this three classifications are made: — Class 1 cases.—When the first molars are in normal occlusion as above stated. The next two classes depend on the position of this anterior third of the lower first molar If it moves back in a distal direction and the anterior part of the upper first molar is in front of the lower first molar then we have Class 2—post Normal cases. Should the lower first molar have moved in a forward direction (medially) to the extent (often) of its whole width, then the case is a Class 3 Pre-Normal one. The first and second of these classes have divisions, and all three have sub-divisions. The correct diagnosis of these classes is helpful in determining, when aided by Clinical examination and Orthodontic experience, the type of problem to be solved. It has always to be kept in mind that the key teeth may be in normal occlusion, but may have moved forward in the jaw through the too early extractions of the second temporary molars. Class 1 cases can be described thus : — 1. The arches of the jaws are in normal relation to each other. 2. The test teeth are in normal occlusion. 3. All teeth anterior to (2) may be in various irregular positions. 58 Class 2 cases. Eliminating all attempts to a technical description, may be considered as those cases where the teeth in the lower arch are distal to normal, hence the condition so frequently found, and termed "inferior retrusion or post normal." Class 3 cases are the opposite to the above, where the teeth in the lower arch instead of keeping in lingual touch with the upper, the lower teeth occlude in front of the upper; and are commonly called "under" hung cases, or " Pre-normal." Unclassified.—These are cases that refuse to allow themselves to fall into any of the above classifications, and stand alone; one such, in the Consultant's decision, is under the Clinic treatment now. Dento-Facial Angle.—Too much stress is not laid on this. The avowed object of the Clinic is to obtain in the shortest possible space of time, a healthy mouth, free from irregularities, and serviceable for the vears ahead. The following defects were found in the 143 cases:— Narrow Arches 16 Labioversions 20 Linguoversions 20 General Crowding 32 Interlocked Bites 2 Suckers—.Lip 3 Finge 2 Thumb Tongue 1 Open Bite 2 Close Bite 12 Perversions 4 Torsoversions 14 Supra versions 2 Inferior Retrusions 21 Superior Protrusions 1 Impacted teeth 2 Three cases required and obtained Hospital treatment. In m cases Skiagrams were made. The cases classified were as follows : — Class 1 30. Class 2 3. Class 3 10 59 Decisions of the Consultants on the cases were as follows:— Extractions—Number of patients 70 Adenoids and Tonsils correction 5 Methods:— Bite plates 17 Expansion plates 11 Screw or peg plate 22 Oral Screens 5 Lip exercisers 4 Retractions 15 Labial wires 5 Splint plates 10 Inclined planes 5 Spring (coils) 7 Decisions postponed 4 Wish to see again in 2 months 4 months 20 6 months 12 months 18 months' 10 No treatment advised 12 No difficulty has been experienced in carrying out the instructions of the Consulting Dental Surgeons, owing to the lucid way in which their report have been made. The children come up in a large proportion of the cases unaccompanied by the parent after the first visit or so. With regard to the expansion plates and screws, the mothers in the majority of cases after a fortnight's instruction, are provided with a screw-driver and make a quarter turn every two days, or such other movements as are directed. A special Sub-Committee has been appointed which meets once a month to consider cases whose means are such that they cannot pay the whole sum. One of the most satisfactory things is the gratitude of the parents at the elimination of the deformities, which so many of them say they wish they had had the chance of getting treated in their early days. The accompanying diagrams illustrate some of the difficulties which must be met with in every Dental Clinic. I. COHEN. ORTHODONTIC CASES. Specimens of reports by the Consulting Surgeons of the Royal Dental Hospital, together with models submitted to them illustrating the conditions; and radiographs illustrating their reports. 62 Model No. 469. Male. Age 12 6/12ths. Diagnosis:— 1 Erupted in the palate. Report of the Royal Dental Hospital Orthodontic Specialist:— Treatment—advise extraction of left central incisor; 1 regulation of left upper lateral incisor. Patient to be seen again in 6 months' time with regard to 3 | 3. X-ray shows 3 | 3 presen: and left upper central incisor lying horizontally across palate. The root of this buried tooth is slightly curved. (Signed) COLEMAN. Model No. 504. Female. Age 10 2/12ths. Diagnosis:— 1|1 1 | 1 Interlocked. 1 | 1 in labial occlusion. Report of the Royal Dental Hospital Orthodontic Specialist:— Treatment in this case should be carried out on the following lines: — Extract EDC | 4. An upper plate should then be made to advance 1 | 1 and at the same tune a labial wire can be attached to the place to depress 2 | 2. The four incisors would in this way be brought into correct alignment. (Signed) A. T. PITTS. Model No. 555. Female. Age 8 10/12ths. Diagnosis:— Unilateral distoclusion. Thumb sucker. Report of the Royal Dental Hospital Orthodontic Specialist — I advise immedia:e operation of Tonsils and Adenoids. At present all that can be done is to stop the thumb sucking, and push forward the lower incisors. This might be done by using a plate which extends over the crowns of ed | de to take the bite, and is provided with screws or plugs to push out 21 | 12; or a similar plate carrying springs might serve In any case this is a difficult operation. Later, when the bicuspids are through, a small amount of expansion and a small amount of retraction of 1 j 1 might improve the appearance. (Signed) J. G. TURNER. 63 Model No. 469. Model No. 504. Before Treatment. After treatment 12 weeks. Model No. 555. 64 Model No. 408. Original condition. After extractions. After 10 weeks' treatments (treatment still proceeding), Model No. 545. Model No. 633. 65 Model No. 408. Male. Age g 9/12ths. diagnosis:— Supernumerary tooth between 1 | 1. Wide diastema 1 | 1. | 2 Linguoversion. Unilateral distoclusion. Report of the Royal Dental Hospital Orthodontic Specialist:— Immediate extraction of supernumerary and the left deciduous canine, also the right upper deciduous first molar and the left lower deciduous first molar, followed by the expansion of the arch, with apparatus to bring the central incisor over to its fellow and to push out the lateral. (Signed) F. St. J. STEADMAN. Model No. 545. Female. Age 9 3/12ths. Diagnosis:— Linguoversion 2 | 2. Torsoversion 1 |. Report of the Royal Dental Hospital Orthodontic Specialist:— I recommend immediate extraction of ED | ED | E. pushing forwards of 2 ] 2 by means of a plate which opens the bite and acts either by pegs actuated by the force of biting, or by springs or screws: when 2 | 2 are in place, straightening 1 | by means of a spring acting from inside the arch on the distal angles, e.g., to move it, from to 0<=> or as near c=c=> as possible. To free 1 | from | 1 it will probably be necessary to expand the whole arch where the 543 | 345 are erupted, but this, from an aesthetic point of view, may prove to be unnecessary. (Signed) J. G. TURNER. Model No. 633. Male. Age 9 years. Diagnosis:— Class 3. Not Hereditary. Report of the Royal Dental Hospital Orthodontic Specialist:— X-ray examination shows that all the teeth are present, but badly misplaced. Any deciduous teeth that are infected should be removed, but it would be advantageous if the upper deciduous molars could be retained until their normal time for shedding. If the patient will co-operate sufficiently, I should push the right upper central incisor over the bite at once by means of a plate. (Signed) A. C. PACKHAM. 66 Model No. 478. Male. Age 9 years. Diagnosis:— 1 | Missing. No history of extraction. No room for | 2. X-ray examination desirable. Report of the Royal Dental Hospital Orthodontic Specialist:— Radiograms show that 2 | is present: I | should be rotated, and|1 should be pushed forward and slightly rotated and the centrals then brought together; the laterals will then have sufficient space. (Signed) pp. N. G. BENNETT. H. R. EVANS. Model No. 459. Female. Age 12 5/12ths. Diagnosis:— Class 1. Neutroclusion. Contracted maxilla. | 3 crowded out labially. Proclination labially, and labioversion 2 1 | 1. 3 | not in occlusal contact. 6 | 6 considered unsaveable. It should be noted that many teeth, which could be saved in private work, cannot be done in Clinic work, due to the parent being unable to give the necessary attendances, etc. 5 | will be displaced lingually. Report of the Royal Dental Hospital Orthodontic Specialist:— This case is somewhat complicated, and after careful consideration I think that the wisest treatment will be to extract the lower first permanent molars and the upper left lateral incisor. The position of the upper left canine is favourable for a movement towards the centre and with subsequent slight alteration of the upper centrals there should be a complete closing up of the space and a respectable arch formation in the incisor region. (Signed) VIVIAN A. F. GREENISH. Model No. 408. Female. Age 14 years. Diagnosis : — No room for | 3. | 3 suspicion that it is impacted. X-rays desirable to clear up this point. Unable to get any history of (a) Extraction of, or (b) Eruption of 5 | 5. After reading X-rays will the R.D.H. Surgeon indicate the treatment, and if | 3 is impacted, state if this is a case better treated as a R.D.H. in-patient at Charing ross Hospital. Report of the Royal Dental Hospital Orthodontic Specialist Radiographs of this case show that the left upper canine is badly impacted and is pressing hard up against the lateral on one side and the first premolar on the other, and that the root is bent. I think this tooth should be removed as soon as possible. In view of the advanced caries of the lower six year old molars I would recommend the extraction of these two teeth and the upper second molar at the same time, and that no further treatment is required. I shall be pleased to do this case as an In-Patient at Charing Cross on Wednesday 16th. The patient should go in on Tuesday 1 cth and stay until Thursday or Friday. (Signed) F. ST. J. STEADMAN. 6 7 Model No. 478. Model No. 459. Model No. 406. 68 Model No. 317. Model No. 307. Right side. Left side. 69 Model No. 317. Female. Age 10 2/i2ths. Diagnosis:— Class i. Neutroclusion. Small jaws. Crowded. No room for | 3 Linguoversion 2 | Linguoversion 2 |. Crowded out labially. 3 |. Report of the Royal Dental Hospital 0rthodontic Specialist:— There is a slight tendency to distal occlusion of the lower jaw which I think may be ignored as it does not complicate the case and shows no tendency to progress. Face and jaws are both small and teeth rather disproportionately large. I think treatment should be by reducing the number of teeth rather than attempting to expand the jaws. I suggest the immediate extraction of 4 | 4. 1 1 The extraction of 1 | will relieve crowding in lower jaw completely and at the same time release the 2 [ (at present in lingual occlusion to 1 |) to come forward. I think the pressure of the tongue should push forward the 2 | into line without further interference. Extraction of | 4 will enable | 3 to come into place Extraction of 4 j will similarly allow | 3 to erupt, it should at the same time give the necessary room to allow 2 | to come forward. All this may be expected to occur without any mechanical interference, but I should watch the case rather closely after the extractions and if any tendency for the 5 | 5 to come forward manifested itself, I should insert a vulcanite splint plate to hold them back. If this has to be done it might be advisable to incorporate in the same plate a device to push forward the 2 | (I prefer a screw sunk in the vulcanite). I should at the same time design the plate to prevent | 2 from moving laterally into the space required for | 3 though I think this unlikely. Should the 2 [ delay unduly in coming forward, a splint plate mipht possibly be required to prevent 3 | 1 from encroaching on the space required. (Signed) A. N. AINSWORTH. Me lei No. 307. Female. Age 9 6/12ths. Diagnosis:— Class 1. Labioversion 21 j 1. Inferior Retrusion. Finger, sucker. Report of the Royal Dental Hospital Orthodontic Specialist:— Mouth breathing habit continues. (Operation for Tonsils and Adenoids at 4 years.) At present I suggest "oval screen " to be worn at night; " lip exercisor," and instruction in proper breathing. X-ray shows 3 3 in favourable alignment, so that at a later date the case could be treated by extraction of 4 | 4 and retraction of 321 1123. (Signed) S. A. RIDDETT. 70 Model No. 539. Male. Age 11 n/12ths. Diagnosis: — Class i. No room for | 3. Lower fronts imbricated. Report of the Royal Dental Hospital Orthodontic Specialist:- We have had X-rays taken of the upper canine region left and right. Both areas present considerable difficulty. On the right there is not enough room without extraction or expansion of the arch, and much too much room will be gained if the first premolar is extracted. On the left the canine tooth is apparently lying at an obtuse angle to the lateral, and even if the first premolar be removed, I have considerable doubt as to whether the canine will travel sufficiently far to take up its correct alignment in the arch. On the whole I would advise no treatment at the moment, but would be glad to see the boy in about 6 months' time. (Signed) A. C. PACKHAM. Model No. 598. Male. 7 8/12ths. Diagnosis:— Linguoversion of right upper two. Report of the Royal Dental Hospital Orthodontic Specialist — In my opinion the crowded condition of this mouth can be best treated at the moment by the extraction of the two lower temporary canines. The right lower lateral incisor will probably be moved into the arch by the tongue. Later on the extraction of the four first premolars will be necessary. X-rays show that all second premolars are present. Ultimate treatment usually depends on the amount of growth that takes place, and for this reason I should like to see this case again in 12 months' time. It is just possible that I shall advise the extraction of the lower incisor later on, but at present it is impossible to decide which will be the best course to take. It is extremely important to remember that a too early extraction of permanent teeth is contra-indicated as it interferes with the normal bone growth. (Signed) H. R. EVANS. 71 Model No. 539. Model No. 596.