??? Heston & Isleworth Urban District Council. 1931 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 1931. LOWE & SONS PRINTERS LTD. 58, Hanworth Road, Hounslow. HES 18 1931 REPORT on The Health of the HESTON & ISLEWORTH URBAN DISTRICT FOR THE YEAR 1931. 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. May, 1932. To the Chairman and Members of the Heston and Isleworth Urban District Council. Gentlemen, The Annual Report this year is designated by the Ministry as an ordinary report in contradistinction to the periodical Survey Report. 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. HESTON & ISLEWORTH URBAN DISTRICT COUNCIL J. J. Clements, Esq., j.p. (Chairman). W. J. R. Divine, Esq. (Vice-Chairman). H. J. Nias, Esq., m.b.k., j.p., ex-officio, (Chairman of the Council). F. T. Hart, Esq., ex-officio (Vice-Chairman of the OF For the Year 1931-33. Members of the Council:— Council). J. Allsop, Esq. E. W. Heath, Esq., j.p. J. J. Bonnett, Esq., A. L. Lang, Esq. o.b.e. F. W. Buckley, Esq. C. L. Lewis, Esq. H. Collar, Esq. A. E. Mace, Esq. T. W. Cox, Esq. G. N. Shackleton, Esq. R. B. Depledge, Esq. G. R. Speed, Esq. A. J. Fifxder, Esq. A. A. White, 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:— F. W. Buckley, Esq. (Chairman). J. J. Bonnett, Esq., o.b.e. J. J. Clements, Esq., j.p. W. J. R. Divine, Esq. E. W. Heath, Esq., j.p. A. L. Lang, Esq. G. R. Speed, Esq. A. A. White, Esq. Co-opted Members:— Miss E. A. Ankritt. Mrs. D. A. Starkey. 6 STAFF. The following persons constituted the Staff of the Health Department during 1931:— 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-at-Law. Fredk. M. M. Eyton-Jones, M.D., B.S. (Lond.), M.R.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— A. J. Wrigley, M.D. (Lond.), F.R.C.S. (Eng.) (Part time). Diphtheria Immunisation Clinics: Superintendent Medical Officer— G. W. J. Bousfield, M.B., B.S. (Part time). Medical Officer— W. W. King Brown, M.B., B.S., 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. J. K. Lawson, A.M.I.S.E., Cert. as S.I. and M.I. J. R. Glover, Cert. as S.I. and M.I. (Resigned April, 1931). A. E. Hollox, Cert. as S.I. and M.I. (Resigned January, 1931). A. B. Hauldren, Cert. as S.I. and M.I. (Appointed February, 1931). A. T. Harris, Cert. as S.I. and M.I. (Appointed June, 1931). 7 Disinfector and Lai oratory 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 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., 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. Also one Temporary Health Visitor. Home Help— Mrs. E. Yates. Chief Cleric— B. W. Kilby, Cert. as S.I. and M.I. Clerks— Miss R. Marshall, Cert. as S.I. P. T. H. Crandon. A. H. Cornhill, Cert. as S.I. and M.I. (Appointed as Asst. Sanitary Inspector, October, 1931). Miss G. E. Curtis. B. P. Garrod, Cert. as S.I. (Resigned January, 1931). K. I. Bisshopp. H. J. Aldhous. P. V. Bell. E. E. Forrest. Miss V. D. Nicholls. R. Moore. (Appointed January, 1,931). Medical Superintendent, Moqden Joint Isolation Hospital— (Joint Isolation Hospital, Richmond with Heston and Isleworth) John Ewing Adam, M.D., F.R.C.S., D.P.H. (Retired April, 1931). Alex. Edward Gammie, M.B., Ch.B. (Appointed May, 1931). 9 NATURAL AND SOCIAL CONDITIONS OF THE AREA. 10 EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1931. Area (in acres) 6,851 Registrar-General's estimate of resident population (MidYear) 1931 76,230 Census Population, 1931 75,446 Number of inhabited houses (end of 1931) according to Rate Books 17,810 Rateable value £562,462 Sum represented by a penny rate £2,161 Live Births— Total. M. F. Birth rate per 1,000 of the estimated resident population 17.61 Legitimate 1298 677 621 Illegitimate 45 24 21 Stillbirths 42 21 21 Rate per 1,000 total (live and still-births) births 30.32 Deaths 754 390 364 Death rate per 1,000 of the estimated resident population 10.0 Deaths from diseases and accidents of pregnancy and childbirth from sepsis 4 from other causes 3 Death rate of Infants under one year of age:— All infants per 1,000 live births 49.14 Legitimate infants per 1,000 legitimate live births 46.99 Illegitimate infants per 1,000 illegitimate live births 111.1 Deaths from Measles (all ages) None. Deaths from Whooping Cough (all ages) None. Deaths from Diarrhoea (under two years of age) 8 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 Isleworth during the years 1928-29-30-31:— 1928. £4929:15:8½ 1929. £4373:11:6 1930. £3947:9:3 1931. £4529:15:2½ VITAL STATISTICS. Population. The Registrar-General's estimate for the population for 1931 is (Birth rate) 76,230—(Death rate) 75,360. The Census population was 75,446. According to the Registrar-General's Preliminary Report on the Census of 1931, amongst the large towns showing increases in population since 1921, Heston and Isleworth is fourth on the list with an increase of 61.7 per cent. The death-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. Deaths. The number of deaths registered in the district was 1453, but 797 of these did not belong to the district, while 98 residents died outside the district. Thus the number of deaths properly attributable to the district was 754. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 10.0 per 1,000, which is comparable with the following figures: 12.3 for England and Wales, and 12.4 for London. The death-rate corrected by the Registrar-General's factor of .931 is 9.31. 12 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 1931 is 49.14 per 1,000 births, which is slightly lower than last year. The rates for England and Wales and for London during the same period were 66 and 65 respectively. Births. The total number of births registered during the year was 1441, excluding re-registrations, but 268 of these did not belong to this district, while 170 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 1343. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 17.61 per 1,000. The birth-rate of England and Wales was 15.8 per 1,000, and for London 15.0 per 1,000. Legitimacy. The following figures give the number of births:— Male. Female. Total. Legitimate 677 621 1298 Illegitimate 24 21 45 Table of Causes of Deaths during 1931. Causes of Death. Civil Residents all ages. All causes Male. Female. 390 364 1 Typhoid and paratyphoid fevers ... ... 2 Measles ... ... 3 Scarlet Fever 1 1 4 Whooping Cough ... ... 5 Diphtheria 2 2 6 Influenza 10 8 7 Encephalitis Lethargica l ... 8 Cerebro-Spinal Fever l 2 9 Tuberculosis of Respiratory System 30 17 10 Other Tuberculous Diseases 4 3 11 Syphilis 1 ... 12 General Paralysis of the Insane, Tabes Dorsalis 1 1 13 Cancer, Malignant Disease 39 58 14 Diabetes 4 6 15 Cerebral Hæmorrhage, &c. 14 17 16 Heart Disease 89 75 17 Aneurysm 2 1 18 Other Circulatory Diseases 10 23 19 Bronchitis 14 16 20 Pneumonia (all forms) 31 23 21 Other Respiratory Diseases 7 3 22 Peptic Ulcer 4 2 23 Diarrhoea, &c. (under 2 years) 6 2 24 Appendicitis 3 1 25 Cirrhosis of Liver 2 1 26 Other Diseases of Liver, etc. 1 3 27 Other Digestive Diseases 7 10 28 Acute and Chronic Nephritis 19 5 29 Puerperal Sepsis ••• 4 30 Other Puerperal Causes ••• 3 31 Congenital Debility, Premature Birth, Malformations, etc. 20 17 32 Senility 6 16 33 Suicide 7 3 34 Other Violence 20 10 35 Other Defined Diseases 34 31 36 Causes Ill-defined or Unknown ... ... Special causes (included in No. 35 above) Small-pox ... ... Poliomyelitis ... ... Polioencephalitis ... ... According to figures furnished by the Registrar-General. Infantile Mortality during the year 1931. Nett Deaths from stated Causes at various Ages under 1 Year of Age. Cause of Death. Under 1 week 1-2 weeks 2-3 weeks 3-4 weeks Total under 4 weeks. 4 weeks and under 3 mts. 3 mts. and under 6 mts. 6 mts and under 9 mts. 9 mts. and under 12 mts. Total Deaths under 1 Certified 23 5 1 3 32 16 8 6 4 66 Smallpox Chickenpox Measles Scarlet Fever Whooping Cough Diphtheria and Croup Erysipelas ... ... ... ... ... 1 ... ... ... 1 Tuberculous Meningitis ... ... ... ... ... ... ... 1 ... 1 Abdominal Tuberculosis Other Tuberculous Diseases Meningitis (not Tuberculous) Convulsions 1 ... ... ... 1 ... ... ... ... 1 Laryngitis Bronohitis ... ... ... ... ... ... ... 1 ... 1 Pneumonia (all forms) ... ... ... 1 1 ... 4 1 4 10 Diarrhœa ... ... ... ... ... ... 1 1 ... 2 Enteritis ... ... ... 1 1 4 ... ... ... 5 Gastritis Syphilis Rickets Suffocation, overlying Injury at Birth 1 ... ... ... 1 ... ... ... ... 1 Atelectasis 2 ... ... ... 2 ... ... ... ... 2 Congenital Malformations 2 1 ... ... 3 4 1 2 ... 10 Premature Birth 13 1 1 1 16 3 ... ... ... 19 Atrophy, Debility and Marasmus 1 1 ... ... 2 3 1 ... ... 6 Other Causes 3 2 ... ... 5 1 1 ... ... 7 23 5 1 3 32 16 8 6 4 66 Nett Births Legitimate 1298 Illegitimate 45 Nett Deaths Legitimate infants 6 Illegitimate infants 5 15 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. 16 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, writer ribbons, etc. (24) Biscuit making. (25) Candle making. (26) Cinema Screens. (27) Pharmaceutical facturing machinery. 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. 17 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA 18 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 the births are attended from a Nursing Home outside the district. No Midwife is employed or subsidised by this Council. Medical Relief. Poor Law Medical Relief.—The Relieving Officers issued 341 medical orders during 1931. Some of these cases received also outrelief and institutional treatment. 19 COUNCIL LABORATORY. 1931. Total. Positive. Swabs for Diphtheria sent by Medical Practitioners 347 23 Taken from Schools, Clinics and from Contacts 1039 22 Sub-cultures 18 7 Sent from Staines Joint Isolation Hospital 400 30 Total cultures examined 1804 82 Swabs examined by Clinical Research Association or at Other Laboratories (1 from Staines) 4 — Virulency Tests 5 4 Blood examination for Enteric Widal Tests 9 2 Specimens of Sputum for Tubercle Bacilli sent by Medical Practitioners 116 15 Specimens of Sputum for Tubercle Bacilli taken at Clinics 4 — Hairs for Ringworm taken at Schools or Clinics 24 7 Other Specimens— Urine 533 Discharge (1 from Staines) 10 Milk 70 Faeces 2 Blood examined for Malaria 1 Swab examined from Puerperal Pyrexia (sent to Clinical Research Association) 1 Blood examinations 14 Swabs examined for Cerebro Spinal Fever (sent to Clinical Research Association) 10 Preparation of Materials— Tubes of Serum 2200 Throat Swab Outfits 2650 Sputum Outfits 155 The bacteriological work of the Staines Joint Isolation Hospital continues to be done in the Council Laboratory. 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. The Virulency Tests are carried out for us in the Wellcome Physiological Research Laboratories. 20 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 II, III and V. *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 Child Welfare Act, 1918. Baths and Wash-houses Acts, 1846-1899. 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 the District. *Common Lodging Houses (P.H.A. 1875, s. 80). *Cleansing, etc., and Removal of Kefuse (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., 1.875, s. 164). *Fish Frying (P.H.A., 1875, s. 113). *Emission of Smoke (P.H.(S.A.)A. 1926, s. 2). School Attendance (E.E.A. 1870, s. 74, as amended by E.E.As. 1876-1902). Employment of Children and Street Trading by Young Persons (Edu.A., 1918, s. 13). Regulations made by Local Authority in force in District. Allotments (S.H. & A.A., 1908, s. 28), Allotment Regulations 1922. *These are administered wholly or partly by the Health Committee. The unstarred are administered by other Committees of the Council. 21 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, there were admitted 932 in-patients, whilst 5005 new out-patients received treatment. The demand for better accommodation for out-patients has been met during the year 1931, by the erection of a small OutPatient Department at a total cost of £1,597: 3:5. 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. An increasing number of patients are now being sent from the Staines and Uxbridge areas who were formally dealt with in their own locality. This is the result of the more up-to-date equipment and facilities for treatment which exist at the West Middlesex Hospital, as compared with the local institutions. 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, District Railway, or Ambulance, and although definite particulars are not available, it is certain that many people apply to these Hospitals outside the district. The Council annually subscribe £100 to the Hounslow Hospital and £50 to the Royal Hospital, Richmond. 22 (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. The provision of the Out-patient Department has somewhat improved the facilities for getting treatment for children in this area. (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, has been 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. (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 Middlsex 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. 23 (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. Occasionally a Medical Practitioner may arrange for a patient to go into Queen Charlotte's Maternity Hospital, Isolation Block, at Hammersmith. (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. (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, Enteric Fever, and Cerebro Spinal Meningitis. Maternity and Nursing Homes. The County Council is the Supervising Authority under the Nursing Homes Registration Act, 1927. 24 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. AMBULANCE FACILITIES. (a) For Infectious Cases. — This is provided by the Joint Hospital Committee, except for Small Pox and Ophthalmia Neonatorum cases which are removed tot other Hospitals by special arrangements. .. (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 477 accident cases were removed to hospital, and 293 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. Every Wednesday 9.45 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. V, 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. Clinics and Treatment Centres. Address. Day. Time. Provided by School Clinics (Medical Officer attending) Public Health Dept. Tuesday. 10 a.m. Heston & Isleworth Friday 10 a.m. U.D.C. 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 (facilities are also provided at 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. CHILDREN ACT (PART I), 1908. The work in connection with Infant Life Protection has continued during the year along the lines laid down on its transfer to the Local Authority in 1930. Particulars of the Law relating to this work are made known by notices in the local press from time to time, and information is also supplied at the Council's Maternity and Child Welfare Centres, and Public Health Department. All the Health Visitors are fully aware of the requirements of the Law, and they promptly investigate and report on such cases as come to their knowledge by verbal reports. No prospective foster-mother is registered until she has supplied full details of her circumstances, etc., and the Visitor has submitted a satisfactory report on the condition of the home. The Health Visitors paid 419 visits in connection with this work during the year, and many of the foster-children were brought regularly to the Maternity and Child Welfare Centres. One foster child, aged 2 years 4 months, died of Diphtheria in the early part of the year. The death took place in Mogden Isolation Hospital. 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. The interviewing of foster-mothers and other callers with regard to their difficulties and the requirements of the Law, and other matters in regard to Infant Protection, involves an amount of time which is out of all proportion to what would appear to be the total amount of work done. 28 Administration of Part I. of the Children Act, 1908, during the year 1931. I. Notification:— (i) Number of foster parents on the Register : — (a) at the beginning of the year 74 (b) at the end of the year 83 (ii.) Number of children on the Register :— (а) at the beginning of the year 63 (б) at the end of the year 62 (c) who died during the year 1 yd) on whom inquests were held during the year — II. Visiting:— Number of Visitors holding appointments under Section 2 (2) at the end of the year :— Health Visitors 5 III. Number of cases (if any) in which proceedings were taken during the year Nil. 29 SANITARY CIRCUMSTANCES. 30 SANITARY CIRCUMSTANCES. Water Supply. There were, as far as is known, at the end of the year 32 private wells frorm which the water was used for domestic purposes. In 30 other cases there axe wells, but an alternative supply from the main exists for domestic purposes. In 47 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 1931 : — (a) Foul Water Sewers 20,230 feet. (b) Surface Water Sewers 23,360 feet. Work is now proceeding on a complete West Middlesex Sewage Scheme which will 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. 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 1931 collection of house refuse has continued weekly as before, and was disposed of by means of dumping on a site in the Staines Road, Hounslow. The method of disposal is that each day's tipping is completely covered with earth. Four more low loading 31 electric collecting vehicles fitted with dustless covers have replaced the remaining old-type lorries. The eight electric vehicles with the occasional assistance of a small lorry, are now undertaking the transportation of the whole of the refuse of the district. During the year, as a result of action taken, there were supplied 146 new ashbins. Sanitary Inspection of District. See pages 32 to 39. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc. The number of premises on which nuisances were outstanding at the end of 1930 was 434. To these another 792 premises whereat nuisances were recorded in 1931 were added, giving a total of 1226 premises. Of these 739 had the nuisances remedied, leaving 487 premises at which nuisances still existed at the end of the year. During the year, nuisances at 46 houses were reported to the Health Committee, which, added to the 45 brought forward from 1930 made a total of 91. 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 53 of the houses. In one case it was decided to take no further action, leaving 37 cases to be carried forward to 1932, Comparative figures for the years 1929, 1930 and 1931, in connection with nuisances, are submitted herewith :— 1929 1930 1931 Number of complaints received 590 566 495 Premises at which nuisances were located 1261 902 792 Number of First Informal Notices 1200 905 719 Number of Reminders and Letters 124 861 472 Number of Statutory Notices 90 230 78 32 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. Far example, in one small street of houses the removal of the restriction would mean £1000 extra per annum to the owner owing to the increased rent charged when a house becomes decontrolled. Proceedings. Proceedings for non-compliance with notices served under Section 94 of the Public Health Act, 1875, were instituted in 5 instances. Summonses were withdrawn in 4 cases where work was in progress or had been completed. In the remaining one instance an Order to abate the nuisances was made, and a fine of £5 : 0 : 0, together with £2:2:0 costs was imposed. SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc.... 18931 Inspections, etc., re Nuisances, Contraventions, etc.: Number of premises, etc., inspected on complaint 681 Number of premises inspected in connection with infectious diseases 170 Total number of premises, etc., primarily inspected in connection with nuisances 1169 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1.9201923 3 Number of other visits made to premises, etc., in connection with nuisances, etc. 112101 Number of visits made to works in progress 3100 Number of interviews with owners, builders, etc. 2057 33 Action taken (including action taken under Housing Act, 1930, Section 17). Number of premises, etc., whereat nuisances were recorded during the year 792 Number of premises, etc., on which defects, etc., were remedied— (a) by owners or occupiers 737 (b) by local authority in default of owner or occupier 2 Number of cautionary or intimation notices given— (а) verbal 201 (b) written 518 Number of letters and reminders re nuisances sent 472 Number of Statutory Notices issued 78 Number of proceedings taken 5 Number of convictions obtained 1 Number of proceedings withdrawn 4 Number of cases dismissed — Number of appeals made against decision of Council — Number of appeals dismissed — Common Lodging Houses: Number registered 2 Number of inspections made 19 Number of contraventions outstanding from previous year — Number of contraventions found 3 Number of contraventions remedied 3 Number of contraventions outstanding at end of year — Canal Boats used as Dwellings: Number of inspections made 52 Number of contraventions outstanding from previous year 11 Number of contraventions found 17 Number of contraventions remedied 211 Number of contraventions outstanding at end of year 7 34 Movable Dwellings, Caravans, Tents, etc.: Number of inspections made 44 Number of contraventions outstanding from previous year 13 Number of contraventions found 2 Number of contraventions remedied 2 Number of contraventions outstanding at end of year 13 Bakehouses: Number in district (a) factories 14 (b) workshops 8 Number of underground bakehouses in district 1 Number of inspections made 250 Number of contraventions outstanding from previous year 4 Number of contraventions found 24 Number of contraventions remedied 25 Number of contraventions outstanding at end of year 3 Slaughterhouses (including Knacker's Yard): Number on register (a) registered premises 4 (&) licensed premises (including one licensed knacker's yard) 4 Number of inspections and visits made 1019 Number of contraventions outstanding from, previous year 5 Number of contraventions found 11 Number of contraventions remedied 16 Number of contraventions outstanding at end of year — Cowsheds: Number of persons registered 5 Number of premises registered 5 Number of cowsheds on register 8 Number of milch cows in district 75 Number of inspections made 67 35 Number of contraventions outstanding from previous year Number of contraventions found Number of contraventions remedied Number of contraventions outstanding at end of year Dairies and Milkshops: Number of persons registered Number of premises registered Number of inspections made Number of contraventions outstanding from previous year Number of contraventions found Number of contraventions remedied Number of contraventions outstanding at end of year Offensive Trades: Number of businesses established in district Number of inspections made Number of contraventions outstanding from previous year Number of contraventions found Number of contraventions remedied Number of contraventions outstanding at end of year Ice Cream Vendors: Number on register Number of inspections made Number of contraventions found Number of contraventions remedied Public Health (Meat) Regulations, 1924: Number of inspections made No notice of slaughtering given Improper notice of slaughtering given No precautions taken for the prevention of contamination 1 1 1 1 52 35 569 2 11 6 7 19 195 12 12 40 42 980 1 10 e 36 Written notices sent 1 Verbal notices given 13 Inspection of Food: Number of meat inspections 1058 Number of fish inspections 172 Number of provision inspections 296 Number of greengrocery and fruit inspections 258 Number of hawkers' foodstuff inspections 137 Number of other food inspections 129 Unsound Food: Number of articles seized Number of articles condemned by magistrate Number of parcels seized Number of parcels condemned by magistrate Number of carcases and offal surrendered Number of carcases surrendered (excluding offal) Number of articles surrendered 14 Number of parcels surrendered 5 Number of organs or parts surrendered during slaughtering 296 infectious Diseases, Disinfections, etc.: Number of visits made 711 Number of rooms disinfected— (а) Ordinary infectious diseases 297 (б) Tuberculosis 98 (c) Other diseases 11 Number of rooms stripped and cleansed after infectious diseases— (а) by owners or occupiers 9 (б) by local authority 3 Number of articles disinfected or destroyed 1894 37 Smoke Abatement: Number of observations made 36 Number of nuisances outstanding from previous year — Number of nuisances found 2 Number of nuisances abated 1 Number of nuisances outstanding at end of year 1 Water Supply: Number of supplies provided or reinstated 5 Number of cisterns cleansed, repaired, covered, etc 5 Number of draw taps connected direct to main 47 Number of water service pipes or taps repaired 12 Approximate percentage of houses supplied on constant system 99.95 Drainage and Sanitary Arrangements, etc., of existing Buildings: Water Closets: Number of water closets provided or reconstructed 16 Number of walls, etc., cleansed 9 Number repaired, supplied with water or otherwise improved 317 Number cleansed or unstopped 15 Approximate percentage of houses provided with water closets 99 Sinks: Number of new sinks provided 85 Number of sinks repaired or improved 34 Drains: Number examined, exposed, etc. Number unstopped, repaired, trapped, etc. Number of waste pipes provided, disconnected, repaired trapped or unstopped Number of soil pipes fixed, repaired or improved Number of ventilating shafts fixed, repaired or improved 4 135 68 2 25 38 Number of fresh air inlets provided, repaired or improved 9 Number of rain water pipes disconnected from drain 7 Number of gully traps inserted or improved 124 Number of disconnecting: traips inserted 2 Number of inspection chambers inserted 1 Number of inspection chambers repaired, improved sealed or cleansed 12 Number of drains constructed or reconstructed 18 Total length of drain pipes laid (4in.-371ft.) (6in.-6ft.) 377ft, Number of tests and re-tests applied 20 Number of other works executed 1 Approximate percentage of houses draining into Council's sewer 99 Cesspools: Number rendered impervious, emptied, cleansed, etc. 1 Removal of Household Refuse: Number of new ashbins provided 146 Dampness: Number of roofs stripped, renewed or repaired ... 321 Number of gutters and rain water pipes provided, repaired or unstopped 336 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 458 Number of damp-proof courses provided 122 Number of sites covered with impervious material Number of yards paved, repaired or drained 231 Interior Work: Number of rooms stripped and cleansed (other than in connection with infectious disease) 305 Number of floors, walls ,& ceilings repaired or renewed 1660 Number of rooms in which ventilation provided or improved 46 39 Number of rooms in which lighting provided or improved 33 Number of window frames and sashes provided, repaired or unfixed 1131 Number of stoves or grates provided or repaired 419 Number of instances in which ventilation under floors provided or improved 150 Number of other repairs 335 Sundry Nuisances, etc. : Number of instances in which domestic cleansing enforced 15 Number of food stores provided, cleansed or improved 24 Number of washing coppers provided or repaired 130 Number of rooms sprayed for the removal of vermin by the Disinfector 41 Number of instances in which overcrowding abated 57 Number of instances of improper keeping of animals abated 11 Number of offensive accumulations removed 29 Number of urinals provided, repaired, cleansed or improved 5 Number of dung pits provided, repaired or improved 1 Number of other nuisances abated 53 Report on the administration of the Factory and Workshop Act, 1901.1 in connection with FACTORIES, WORKSHOPS AND WORKPLACES. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspection madk by Sanitary Inspectors. Premises. Number of Number on Register. (2) Inspections. (3) Written Notices. (4) Prosecutions. (5) Factories (including Factory Laundries) 94 250 8 Nil. Workshops (including Workshop Laundries) 148 333 11 Workplaces (other than Outworkers' premises) 40 35 4 Outworkers 40 34 ... Total 322 652 23 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Number of Prosecution 7 Outstanding Jan. 1st. 1931. 2 Found during 1931. 3 Remedied during 1931. 4 Outstanding Dec. 31st, 1931. 5 Referred to H.M. Inspector 6 Nuisances under the Public Health Acts:-* Want of cleanliness 2 7 9 ... Nil. Nil Want of ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors ... ... ... ... Other nuisances 7 18 21 4 Sanitary accommodation— Insufficient 1 2 1 2 Unsuitable or defective 3 32 32 3 Not separate for sexes ... ... ... ... Offences under the Factory and Workshop Act:— Illegal occupation of underground bakehouse (s.101) ... ... ... ... Breach of special Sanitary requirements for bakehouses (ss. 97-100) 1 11 11 1 Other offences:— Excluding offences relating to outwork ... ... ... ... Total 14 70 74 10 Nil. 1 *Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop! 1901, and remediable under the Public Health Acts. †Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by at District Council, and the standard of sufficiency and suitability of sanitary accommodation for persons employed in factories and workshops enforced is that required by to Sanitary Accommodation Order of 4th February, 1903. 41 OUTWORK (a) Outwork in unwholesome premises, Section 108 Nil. (b) Outwork in infected premises, Sections 109-l10 21 PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS OR REGULATIONS. There are 359 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, Outworkers' Premises and Ice Cream Vendors' Premises. SCHOOLS. There are 15 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. 42 COPY OF REPORT FORWARDED TO THE MINISTRY OF HEALTH DATED 18th FEBRUARY, 1932, 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, 1931,, as to the execution of the Canal Boats Acts, 1877, and 1884, and of the Regulations made thereunder, within the Urban District of Heston and Isleworth, Middlesex. Inspectors Appointed under Canal Boats Acts, at 31si December, 1931— R. H. Butler (Chief Sanitary Inspector). G. W. Ashworth (District Sanitary Inspector). A. B. Hauldren (District Sanitary Inspector). A. T. Harris (District Sanitary Inspector). No special remuneration is paid for the position. Number op Inspections, etc.— Number of Inspections made 52 Number of Canal Boats inspected 47 Number of boats found in order 34 Number of boats with three infringements 1 Number of boats with two infringements 2 Number of boats with one infringement 10 Nature of Contraventions, etc— Cabins not in a cleanly and habitable condition 5 Paintwork of internal surfaces of cabin requiring renewing 4 No proper water vessels provided 4 Registration certificate not in order 2 No proper separation of sexes 2 Legal Proceedings— No legal proceedings have been taken during the year. Infectious Disease— No cases of infectious disease were reported as occurring among the Canal Boat population during the year. 43 HOUSING. 44 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 745 houses for letting purposes. At the same time, progress has been made with building houses for sale. The total number purchased during the year under the Small Dwellings Acquisition Act was 108, and the total amount of loans under the Small Dwellings Acquisition Act up to the end of 1931 was £2,998,245. 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. I repeat what I said last year with regard to the necessity of purchasing a house in order to find accommodation; 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 46 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. Moreover I find in a number of cases the huge amount drained from the income to pay the rent, is seriously affecting the nutrition of the family, especially the mothers and children, by reason of the lessened amount available. In addition there is still the unsolved difficulty of the old folks. There is only one solution in my opinion, which is the provision of little groups of small houses surrounding a paved close providing 45 the minimum requirements for decent living involving the least possible labour, such as is compatible with their advanced years and attenuated incomes. Most of the rents these old folks pay are under 7/-, some as low as 5/6, and their total income is only the old age pension of 10/- each. Further the coal consumption necessary to keep these old folks, who feel the cold intensely, adequately warmed, is greater than in the case of younger people. It is no use. The rents that are charged for the smallest houses being built to let are far beyond their limited possibilities. Houses grouped round a flagged court that is cleansed by every rainfall diminishes the dirt tramped in to the house, and with it the work of cleaning. Further the grouping in small numbers, about a dozen or so, is happier for the old folks, who prefer life amongst others of similar age with similar outlooks and ideas incidental to their incapacities, than to be planted here and there amongst the younger and more active members of the population, who generally speaking are impatient with the idiosyncracies of old age. During the year in connection with the inspection of existing houses under the Housing Consolidated Regulations, 1925, one of the Sanitary Inspectors was appointed Housing Inspector and has since devoted his whole time to these duties. This has ensured that the housing work has been carried out in a more systematic manner. HOUSING CONDITIONS STATISTICS. 1. GENERAL. Number of New Houses erected during the year : — (a) Total (including figures given below) 1,881 (b) With State assistance under the Housing Acts :— (1) By the Local Authority 78 (2) By other Bodies or Persons — 46 2. INSANITARY AND UNFIT DWELLING HOUSES. 1. Inspection of Dwelling-Houses during the Year. (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 612 (6) Number of inspections made for the purpose 612 (2) (a) Number of dwelling-houses (included under head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 225 (b) Number of inspections made for the purpose 225 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 49 (4) Number of dwelling-houses (exclusive of those red to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 276 2. Remedy of Defects during the Year without Service of Formal Notices : — Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers 21.8 3. Action under Statutory Powers during the Year : — A. Proceedings under Sections 17, 18 and 23 of the Housing Act, 1930' (1) Number of dwelling-houses in respect of which notices were served requiring repairs 54 (2) Number of dwelling-houses which were rendered fit after service of formal notices : — 47 (a) By owners 19 (b) By local authority in default of owners 1 B. Proceedings under Public Health Acts :— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 15 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 24 (b) By local authority in default of owners 3 C. Proceedings under Sections 1.9 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 39 (2) Number of dwelling-houses demolished in ance of Demolition Orders 9 D. Proceedings under Section 20 of the Housing Act, 1930 : (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil E. Proceedings under Section 3 of the Housing Act, 1925 : (1) Number of dwelling-houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) By owners 11 (b) By local authority in default of owners Nil 48 (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close ... Nil F. Proceedings under Sections 11, 14 and 15 of the Housing Act, 1925 :— (1) Number of dwelling-houses in respect of which Closing Orders were made Nil (2) Number of dwelling-houses in respect of which Closing Orders were determined, the dwellinghouses having been rendered fit 3 (3) Number of dwelling-houses in respect of which Demolition Orders were made Nil (4) Number of dwelling-houses demolished in ance of Demolition Orders Nil G. Other matters :— (1) Number of dwelling-houses closed voluntarily 7 (2) Number of dwelling-houses demolished voluntarily 7 3. UNHEALTHY AREAS. Areas represented by the Local Authority with a view to Clearance or Improvement Schemes under Part I of the Act of 1930 Nil 49 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 1930— *1-3, Poplar Cottages, Town Wharf, Isleworth 3 8/1/14 24/2/14 ... 22/12/14 *15, South Street, Isleworth 1 11/1/15 27/4/15 ... 23/11/15 14-34, London Road, Brentford End 11 10/6/29 23/7/29 ... 25/3/30 1-10, Syon Place. London Road. Brentford End 10 10/6/29 23/7/29 ... 25/3/30 65-75, Han worth Road. Hounslow 6 13/5/29 25/6/29 ... 28/10/30 175, Twickenham Rd, Isleworth 1 12/1/20 26/4/21 ... 28/10/30 30/11/31 177, „ „ 1 13/5/29 25 6/29 ... 28/10/30 30/11/31 1 & 3, Wellington Road North Hounslow 2 13/5/29 25/6/29 27/10/31 * Demolition deferred. 50 Table shewing dwelling-houses represented as unfit for human habitation—Continued. Premises. No. of houses represented by M.O.H. Dale of representation. Date Closing Order made. Date Closing Order determined. Date Demolition Order made. Date Demolition Order obeyed. Date Demolition Order enforced. 240 & 242, London Rd., Isleworth 2 11/11/29 17/12/29 ... 28/10/30 11, 13 & 14, Syon Cottages Syon Lane, Isleworth 3 11/11/29 17/12/29 ... 28/10/30 31/8/31 12, Syon Cottages, Syon Lane, Isleworth 1 9/3/25 28/4/25 ... 25/11/30 31/8/31 125, Vicarage Farm Road, Heston 1 11/11/29 17/12/29 ... 28/10/30 8/5/31 127 (East) Vicarage Farm Road, Heston 1 11/11/29 17/12/29 ... 28/10/30 2/2/31 127 (West) Vicarage Farm Road, Heston 1 11/11/29 17/12/29 ... 28/10/30 4/5/31 6, London Road, Brentford End 9/12/29 28/1/30 ... 28/10/30 8, London Road, „ 1 26/11/29 25/2/30 ... 27/1/31 10 & 12, London Rd., „ 2 26/11/29 17/12/29 ... 28/10/30 The Hut at the rear of Sunnyholme, Wellington Road South, Hounslow 1 7/7/30 Hut not demolished-10/1/31, undertaking given by owner that when it is empty it will not again be used for human habitation. 51 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 enforced. Dealt with in 1931:— 16-22, Barrack Rd., Hounslow 4 9/11/31 ... ... 1-12, Gordon House Square, Isleworth 12 12/10/31 ... ... 24/11/31 121-127, Heston Road, Heston 4 13/7/31 ... ... 22/12/31 2-14, High Street, Hounslow 7 9/11/31 ... ... 22/12/31 1-5, Grosvenor Place, High Street, Hounslow 5 13/7/31 ... ... 7 & 9, Jersey Road, Lampton 2 8/6/31 ... ... 11, 13 and 15, Jersey Road, Lampton 3 8/6/31 ... ... 28/7/31 4-10, The Circle, Lampton Road, Lampton 7 11/5/31 ... ... 22/9/31 91-97, New Heston Road, Heston 4 11/5/31 ... ... 28/7/31 18, The Square, Isleworth 1 9/11/31 ... ... 12/11/31 53 INSPECTION AND SUPERVISION OF FOOD. 54 INSPECTION AND SUPERVISION OF FOOD. The following is the record of inspection of food premises:— Meat 1058 Pish 172 Provisions 296 Greengroceries and Fruit 258 Hawkers' Food Stuffs 137 Number of other Food Inspections 129 Milk. This year has seen an enormous increase in the sale of sterilized milk in the district. The present position is that we, who have fought for and succeeded in large measure in raising the Milkshops to a satisfactory standard, are faced with the determined efforts of the vendors of sterilized milk to degrade the premises from which milk can be sold to a depth such we hoped never to see again. Every little general store, no matter how dirty, dusty or smelly is being approached to sell sterilized milk in bottles and so long as this bottle is intact we have little power to stop the sale or even to say how it shall be stored. The only thing is that we can insist on the registration of the milk seller. There is a vast difference between a tin of milk which can be cleaned outside before being opened and the sterilized milk bottle with its rubber stopper with a deep recess round the neck of the bottle which accumulates all the dust and dirt blown upon or settling on it, which immediately contaminates the contents when the bottle is opened and the contents decanted over the dusty dirty rim. By persistent effort we had raised up a class of vendor who was realizing the vital necessity of the clean handling of milk, and taking an intelligent interest in the production and distribution of an article as clean and safe as it could reasonably be made. Now is seen the lamentable spectacle of firms who have been classed as pioneers in the clean milk trade, forced by the exigencies of competition to enter into this retrogressive market. The occurrence recently of a real old fashioned case of scurvy, fed entirely on bottled sterilized milk, 55 makes one feel that the day is not far distant when sterilized milk will be labelled like tinned skim milk, "This milk is unfit for children under 1 year old," or some such warning. Recently when going to inspect the premises of an applicant for registration, the crate containing the milk was exhibited on the pavement of the forecourt amongst such things as mowing machines and garden rollers. The crate and the adjacent pavement bore ample evidence that the crate had afforded to the local canine population that relief which their human masters obtain behind a door at the side of the adjacent Public House, the entry to which is restricted to "Gentlemen." 636 inspections were carried out in respect of cowsheds, dairies and milkshops. Unofficial milk analyses are made by the Medical Officer of Health. Number of firms in the district licensed to sell— "Certified" milk 5 (8 shops) "Grade A" (Tuberculin Tested) 9 (12 shops) " Grade A " — " Grade A" Pasteurised 1. (1 shop) "Pasteurised" 4 (13 shops) 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, 2345¾ lbs. of diseased meat were surrendered. There are 7 slaughter-houses (4 registered and 3 licenced), in use in the district, and each slaughter-house received on an average 12.13 visits per month. There were 54 butchers' shops in the district at the end of 1931. 2. Public Abattoir.—There is no public abattoir in the district. Slaughtering may take place at any time, subject to the 56 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.— During the year a small quantity of tripe was seized and subsequently condemned by a Justice of the Peace. A warning letter was sent to the vendor. 4. Tubercular Meat.—There was none seized, but 957 lbs. were surrendered during the year. The slaughter-houses on the whole are kept, so far as their construction will allow, in a fairly satisfactory condition. The butchers still continue to buy largely in the London wholesale meat markets. The Public Health (Meat) Regulations, 1924, continue to cause a considerable amount of work, although there has been a decrease of the amount slaughtered. The slaughtering is often continued well into the evening to suit the personal convenience of the butchers. Most of the butchers have accepted the restrictions imposed by the Regulations in the right spirit, but in 11 instances no notice or insufficient notice of slaughtering was given, a number of which could be avoided with a little forethought. There has been built up gradually a feeling of confidence in the decisions given and this is shown by the fact that the whole of the unsound and diseased meat dealt with during slaughtering was surrendered. When new butchers' shops are opened every effort is made to obtain fixed windows, but with the absence of positive power to demand fixed windows, there is a tendency on the part of some of 57 the butchers to adopt a standstill attitude with regard to this most desirable method of preventing contamination of the meat exposed for sale. The provision of fixed glazed windows to many of the shops in the district has proved beneficial both from the point of view of preventing contamination and maintaining longer the saleable qualities of the meat. Having regard to this improvement in certain instances, the reason for the absence of a positive policy on the matter in the Regulations is rather obscure and I venture to suggest in fairness to those butchers who have provided fixed windows on request, that provisions should be made, in the near future, for enforcing compulsorily, that all meat shall only be exposed and sold behind fixed glazed windows without any qualifications. There are in all 54 butchers' shops in the district. Up to the present, 36 have been provided with fixed windows, of which number 4 were new shops in 1931, 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. INSPECTION OF OTHER FOODS. Section 72 of the Public Health Act, 1925, provides, in some measure, for the prevention of contamination of food stuffs (other than meat) when stored or kept on enclosed premises; but there appear to be no provisions made for dealing with the contamination of foodstuffs deposited for sale, in an open manner, on forecourts to shops and on stalls and barrows standing or moving about the roadways of a district. I wish again to draw attention to the want of perspective in the way in which meat is dealt with, and such things as figs, dates, sweets and biscuits, which are eaten raw, are exposed in open shop fronts, barrows, and on street vendors' trays, on which horse dung and other filth has blown, whereas meat is cooked before being eaten. The time has come when legislation should be provided to insist that all such foods should be kept inside, and if possible under cover. 58 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 1931. Article Taken Adulterated Milk 208 4 Butter 1 — Gin 2 — Meat 14 — Minced Beef 20 — Sausages 9 — Whisky 2 — 256 4 Two of the unsatisfactory samples of milk were formal samples in which deficiencies in fat were reported. The vendors of these samples received letters of caution. Milk. I have received the following report from the County Medical Officer with regard to the action taken to safeguard the milk supply of the district:— "Work carried out by the County Council under the Milk and Dairies (Consolidation) Act, 1915, and the Tuberculosis Order, 1925. Routine examination of milch cattle was carried out during the year by Mr. Sydney Villar, F.R.C.V.S., the County Council's whole-time veterinary inspector under the Milk and Dairies Order, 1926. 368 inspections of cows in your district were carried out by Mr. Villar during 1931. As a result of these inspections four cows were found suffering from tuberculosis as defined by the Tuberculosis Order, and these were slaughtered under the Order. In addition two cows were reported by their owner as suspected to be suffering from tuberculosis; the diagnosis was duly confirmed and the cows slaughtered. 59 Twenty samples of milk were taken in course of delivery to retailers in Heston and Isleworth. These were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. One sample was found to contain living tubercle bacilli and was traced to a farm in Berkshire. As a result of communicating with the County Medical Officer of Berks it was ascertained that one cow on the farm in question had been found to be wasting and had been sent to the knacker's." Unsound Butter Scrapings and Confectionery. Information was received from a Metropolitan Borough with regard to the release of 4 cwts. of butter trimmings, for delivery to a firm of sweet confectionery manufacturers in this district, and which were unfit for human consumption. An inspection at the factory revealed that a small quantity of this butter had been used in the manufacture of some sweets during the temporary absence of the Manager. 3 cwts. 3 qrs. 15½ lbs. of butter scrapings were subsequently seized and condemned by a Magistrate and 11 cwts. 2 qrs. 16 lbs. of sweet confectionery in which the butter scrapings were used, were also surrendered and destroyed. UNSOUND FOOD, 1931. Tons. cwts. qrs. lbs. Fish 3 21 Corned Beef 6 Meat 1 0 3 21¾ Rabbits 20 Butter scrapings 3 3 15½ Sweet Confectionery 11 2 16 Total 1 17 2 16¼ 61 INFECTIOUS DISEASES. 62 INFECTIOUS DISEASE. Scarlet Fever and Diphtheria. There were 6 "return" cases of Scarlet Fever and none 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 Schick tested and 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 204 Not of civil cases removed to Hospitals 171 Percentage of cases removed to Hospitals 83.82 The incident rate of Scarlet Fever in the civil population (75,360) was 2.7 per 1,000. Two deaths took place from this cause during the year, i.e., a case mortality rate of 0.98 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 62 No. of civil cases removed to Hospitals 58 Percentage of cases removed to Hospitals 93.5 63 The incident rate per 1,000 of the civil population was 0.8 Seven cases occurred in institutions during the year. Four deaths took place from this disease, i.e., a case mortality rate of 6.45 per cent. The deaths occurred in the following age groups:— Under 1 year 1 5—10 years 1 2—3 years 1 20—35 years 1 And in the following months:— February 1 April 1 March 1 May 1 For the last four years the deaths from Diphtheria have been as follows:— Year. Year Year. Year. 1928 7 1929 23 1930 19 1931 4 The full details of the Immunization work for 1931 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. Report of work of the Diphtheria Immunisation Clinics for 1931. During the above year the work of active immunisation of the child population against Diphtheria has proceeded very satisfactorily. A decline in the numbers of children dealt with in 1931 as compared with 1930 is inevitable. Experience has shown that when this work is first instituted in any area there is a great rush of the better class of parents to secure these advantages for their children. After this initial mass of work has been dealt with, the rate of applications for immunisation settles down to normal steady proportions, and this is the condition of affairs now prevailing in Heston and Isleworth. It is satisfactory to record that the continued demand for the treatment of children is much steadier in this area than in any other locality in which I have been engaged 64 on this work. There is no finer form of propaganda for Diphtheria Immunisation than an epidemic of the disease, and our work has not had the benefit of the stimulating effect of any epidemic of the disease. In view of this our figures for both application for treatment and actual attendances are generally highly satisfactory. It must be admitted that the response from the Isleworth area is vastly inferior to that obtained from Hounslow and Heston. There will be many vain regrets for wasted opportunities in Isleworth when the next epidemic of Diphtheria comes to that district, for come it must, in due course. The sessions at present held have obtained throughout 1931. They are as follows:— At Bath Road. Monday and Wednesday afternoons, 2—4 p.m. At Isleworth Public Hall. Saturday mornings, 10 a.m.—12 noon. As regards the routine, the same careful and thorough treatment of each case is maintained as in the past. All children are Schick-tested initially, receive immunising injections if they are susceptible, and are re-tested subsequently to demonstrate satisfactory immunity before a certificate is given. Any person not rendered immune as a result of the ordinary course of injections receives further doses until it is shown that the object in view has been achieved. All cases found to be apparently naturally immune at the first Schick Test are advised to come for a further test in 3 months to confirm the previous finding before the certificate of immunity is issued. It is proposed during the year 1932 to continue this work with a degree of thoroughness not obtaining anywhere else to our knowledge. The suggestion is to re-test all children 2 years after they have been rendered immune, with the idea of ensuring that the protection still holds good. When it is realised that in the past two years there has been no single case of clinical Diphtheria among any of our children who has received a certificate of immunity, it must be admitted that we are defending a valuable position. These results are so wonderfully satisfactory that the district of Heston 65 and Isleworth seems likely to provide an object lesson to the rest of Great Britain. Sooner or later we must expect an occasional failure to prevent Diphtheria, for nothing on earth is quite perfect. Nevertheless Dr. Nash and I believe that by very thorough and careful work, the number of such failures will be extremely small. The results obtained would only have been possible with the cooperation of a District Council and Medical Officer of Health who encouraged the policy of carrying out Diphtheria Immunization in the most complete manner with the best possible materials. The absolute freedom from Diphtheria of our immunised children during the past two years has already created considerable interest both in high official quarters and throughout the country. The figures relating to the actual work of the clinics are appended. Diphtheria Immunisation, 1931. Applications for treatment received 733 Number Schick-tested during 1931 956 Number giving positive result to test 829 „ „ negative „ „ 175 *1004 *These give a bigger number than 956 because some from previous years Schick-test were dealt with. Not read owing to various causes 2 Total number of attendances at Clinics during 1931 6019 Children Schick-tested, found positive originally, immunised, and re-Schick-tested 1392 Number of these found to have become Schick-negative at the second test 1152 Number still showing varying degrees of positive re-action to the second Schick-test 157 Not read for various reasons 83 66 Secondary Inoculation courses of T.A.M. Number given 1 further injection of 1c.c. 7 Number given 2 further injections of 1 c.c. 130 Number given 3 further injections of 1 c.c. 14 Total 151 Number of certificates given during 1931 1367 G.Bousfield, M.D., Lond. Diphtheria Antitoxin. Boxes containing a Sterile Antitoxin syringe and the necessary dressings, etc., are kept at the Hounslow Police Station so as to be available in case of emergency. During 1931, 28 vials of Antitoxin of 8,000 units each were supplied to medical practitioners. Smallpox. No cases were notified during the year 1931.. Enteric Fever. There were 3 cases notified during the year, all were Paratyphoid B. One of the cases, notified from the West Middlesex Hospital was admitted from outside this district. Erysipelas. Thirty-nine cases of this disease were notified, of whom 26 were of cases in the West Middlesex Hospital. Nineteen were non-residents in this district. Ophthalmia Neonatorum. See page 99. Puerperal Fever. Five cases of this disease were notified. One notification referred to a patient from this district, who was confined in a 67 London Hospital. One patient from another district was admitted to a local Hospital and notified to me. The other three, who were removed to the West Middlesex Hospital, were residents in this district. Puerperal Pyrexia. Fourteen cases were notified; 11 of these were notified from the West Middlesex Hospital, including 9 who were not usually resident in this district. Encephalitis Lethargica. There were no cases notified this year. Cerebro-Spinal Fever. Five cases of this disease were notified. Four were notified from the West Middlesex Hospital, but two of these were not from this district. Acute Poliomyelitis. No cases were notified. Pneumonia. There were 148 cases notified.—108 notifications were from the West Middlesex Hospital. Eighty were non-resident in this district. Malaria. There was one case notified during the year, in the person of the wife of a soldier who had previously resided abroad for some years. 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:— 68  1927 1928 1929 1930 1931 Measles 35 688 83 799 9 German Measles 7 9 344 38 5 Chicken Pox 243 265 423 392 233 Mumps 352 138 106 381 132 Whooping Cough 157 171 177 144 242 Upon receipt of information of the existence of a case, inquiry is made by a School Nurse to obtain all necessary facts. Influenza. There were 18 deaths from Influenza during the year, the mortality being 0.24 per 1,000 of the population. 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. 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. 69 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 83. Thirty-six cases were notified from Institutions:— Sanatoria 17, Poor Law Institutions 12, General Hospitals 5, and Tuberculosis Dispensary 2. There were 47 deaths from Tuberculosis of the Respiratory System. Four of these were not notified. Of the new cases notified, 59 received institutional treatment during the year, and 17 died. Other Forms of Tuberculosis. The number of new cases notified during theyear was 31. Twenty-five of them were notified as receiving institutional treatment. There were 7 deaths. Two of the cases which died were unnotified. Deaths from Tuberculosis. Six deaths occurred in non-notified cases; In two of these the medical practitioners certifying the deaths thought the patients had already been notified before coming into their hands. One death occurred elsewhere, and was transferred to this district, and 3 cases were apparently not diagnosed until just before or after death. For Table showing new cases notified and deaths in 1931 see next page. 70 TUBERCULOSIS 1931. Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 ... ... ... ... ... ... 1 ... 1 1 ... 3 3 ... ... 2 ... 5 1 1 2 3 ... ... ... 1 10 1 1 4 1 ... ... ... ... 15 6 4 1 3 1 3 1 1 20 10 7 1 2 6 1 ... ... 25 14 13 4 2 10 6 ... 1 35 9 6 1 ... 5 7 ... ... 45 4 ... ... ... 4 ... ... ... 55 1 1 1 ... 2 ... ... ... 65 and upwards 3 ... ... ... 2 ... ... ... Totals 50 33 17 14 30 17 4 3 Four of the deaths from Pulmonary Tuberculosis were not notified and two deaths from Non-Pulmonary Tuberculosis were not notified. 71 DIPHTHERIA, 1931 (including Bacterial cases, 50 in number). Month. WARD. Elem. School Children. Other School Children. Other Cases. Total. Heston. Houn. Cent. Houn. Heath. Houn. Sth. Houn. West. Isleworth N. Isleworth S. Spring Grove. January 15 2 1 — 2 — 9 — 1 4 — 11 February 10 — 1 3 1 1 4 — — 3 — 7 March 7 — 1 — — — 6 — — — 1 6 April 12 — — — 1 2 7 — 2 3 — 9 May 9 — — — 1 1 6 — 1 2 — 7 June 4 — — 3 — 1 — — — 4 — — July 15 1 — 4 — 2 4 3 1 8 2 5 August 11 3 2 2 — — 1 3 — 3 — 8 September 7 — — — — 3 4 — — 2 — 5 October 4 — — 2 — — 1 1 — 1 — 3 November 10 1 — 1 — — 8 — — 4 — 6 December 8 — 2 — — — 4 2 — 3 — 5 Totals 112 7 7 15 5 10 54 9 5 37 3 72 72 Notifiable Diseases during 1931. DISEASE. TOTAL CASES NOTIFIED. TOTAL ALL AGES CASES ADMITTED TO HOSPITAL. under 1 year. 1-2 years 2-3 years 3-4 years 4-5 years 5-10 years 10-15 years 15-20 years 20-35 years 35-45 years 45-65 years 65 years and over. MOGDEN. OTHER HOSPITALS Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever ... ... 1 ... ... ... ... 1 1 ... ... ... 3 1 1 Scarlet Fever ... 3 10 10 17 102 32 13 11 5 1 ... 204 165 6 Diphtheria ... 1 3 3 4 18 14 8 9 1 1 ... 62 49 9 Erysipelas 2 2 ... ... 2 2 4 ... 8 4 10 5 39 ... 31 Puerperal Fever ... ... ... ... ... ... ... ... 3 2 ... ... 5 ... 5 Puerperal Pyrexia ... ... ... ... ... ... ... 1 9 4 ... ... 14 ... 14 Ophthalmia Neonatorum 6 ... ... ... ... ... ... ... ... ... ... ... 6 ... 3 Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebro Spinal Fever 1 ... ... ... ... ... 2 ... 2 ... ... ... 5 ... 5 Pneumonia 16 20 8 6 2 16 6 8 32 16 13 5 148 ... 120 Dysentery ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... Encephalitis Lethargica. ... ... ... ... ... ... ... ... ... ... ... ... ... ...... ... 73 Infectious Diseases, 1931. Cases Notified. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever Erysipelas. Cerebro-spinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Malaria. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Dysentery. Puerperal Pyrexia. Small-pox. January 15 5 ... 1 3 2 ... ... 28 ... 6 4 ... ... 1 ... February 7 3 ... ... 4 2 ... ... 10 ... 6 2 ... ... 1 ... March 30 2 ... ... 2 ... ... ... 17 ... 12 1 ... ... 1 ... April 18 7 ... ... 6 ... ... ... 18 ... 10 3 ... ... 1 ... May 21 5 1 ... 1 1 ... ... 11 ... 9 2 1 ... 2 ... June 22 4 ... 2 4 ... ... ... 5 ... 6 5 ... ... 2 ... July 21 11 ... 1 4 ... ... ... 5 1 8 1 2 ... 5 ... August 10 9 1 ... 3 ... ... ... ... ... 4 4 ... ... ... ... September 13 3 ... 1 3 ... ... ... 9 ... 4 2 ... ... ... ... October 24 4 ... ... 3 ... ... ... 10 ... 5 2 2 ... ... ... November 16 4 ... ... 4 ... ... ... 14 ... 8 4 ... ... 1 ... December 7 5 1 ... 2 ... ... ... 23 ... 5 1 1 ... ... ... Totals 204 62 3 5 39 5 ... ... 148 1 83 31 6 ... 14 ... Deaths from Notifiable Infectious Diseases, 1931. Age Groups. Under 1 year. 1 year. 2 years. 3 years. 4 years. 5 years. 10 years. 15 years. 20 years. 35 years. 45 years. 65 years and over Total All Ages. Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... 1 ... ... ... ... 1 ... 2 Diphtheria 1 ... 1 ... ... 1 ... ... 1 ... ... ... 4 Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... 4 ... ... ... 4 Pneumonia 10 3 4 3 ... 2 ... 2 5 4 12 9 54 Cerebro Spinal Fever ... ... ... ... ... ... 1 ... 2 ... ... ... 3 Erysipelas 1 ... ... ... ... ... ... ... 1 ... ... 1 3 Total 12 3 5 3 ... 4 1 2 13 4 13 10 70 For Tuberculosis Deaths—see other Table. 74 The table hereunder gives the number of cases of infectious diseases that were notified from the several Institutions in the district during 1931:— ENTERIC FEVER. SCARLET FEVER, DIPHTHERIA. PNEUMONIA (all forms). ERYSIPELA8. PUERPERAL FEVER. PUERPERAL PYREXIA CEREBRO 8PINAL FEVER. OPHTHALMIA NEONATORUM. PULMONARY TUBERCULOSIS. OTHER TUBERCULOSIS. MALARIA. TOTAL. West Middlesex Hospital 1 9 7 108 26 ... 11 4 1 12 9 ... 188 Hounslow Hospital ... 3 ... 4 1 1 ... ... ... ... 2 ... 11 Hounslow Barracks ... 3 ... ... ... ... ... ... ... ... ... 1 4 Mogden Isolation Hospital ... ... 2 ... ... ... ... ... ... ... ... ... 2 Collingwood College ••• ... ... ... ... ... ... ... ... ... ... ... ... St. Mary's School ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 1 15 9 112 27 1 11 4 1 12 11 I 205 In addition to the above civil cases, two military cases of Scarlet Fever and one of Malaria occurred in the Hounslow Barracks. lb 77 MATERNITY AND CHILD WELFARE. 78 MATERNITY AND CHILD WELFARE. 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, cod liver oil emulsion, 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. As reported last year the increase in the work is making things extraordinarily difficult. The incessant influx of population and economic circumstances are bringing more and more new mothers anxious to obtain advice. When it is realised that more than 1,300 houses have been erected yearly during the last 7 years, it gives some index of the growth of the district which, at the last Census (1931) was, out of the whole County, fourth in the percentage of increase of population over the previous census. The condition at Isleworth is now extremely bad. The condition of the waiting-room on the afternoons when the sessions are being held is not a question of seeing, it is a question of smelling. The gross overcrowding at many sessions was relieved to a certain extent by the extra session, but the growth of the district in that area has rendered that again of little avail to cope with the difficulty and discomfort. It speaks volumes for the value of the work and appreciation of it, that mothers will put up with the conditions existing. 79 The difficulty at Hounslow is in another direction. The premises are adequate, but the volume of work is such that it is practically impossible to get through it, and quite impossible to attempt any teaching or demonstration work whilst a session is in progress. The re-organisation of the Ante-Natal Clinic under Dr. Wrigley has been of enormous benefit. The care and manner with which he deals with the patients has increased the work enormously. Not only are the midwives bringing their cases up in greater numbers, but what is the most satisfactory thing to my mind is that the doctors in the district are now bringing their cases up for consultation. A further session has had to be put on to cope with the increasing numbers. The increase in the dental work in both mothers and children » is well shown in the report of the Dental Surgeon, attached. I want again to emphasise the fact that the only way in which we are getting the children between 2 and 5 back to the Clinic in any number, is entirely due to the provision of dental treatment. Experience elsewhere has shown that mere invitations to bring the children up for a medical examination in the manner of a school inspection, is almost entirely futile. Personally, I see nothing short of nursery schools which will bring these children under critical medical inspection, in what is now shown to be the most vulnerable time of their life. It is only the power of compulsion which will bring about adequate medical supervision of these children. In our own area, the keeping open of the minor ailments treatment Clinics during the holidays has shown how directly the compulsion, which is derived from the school in session, is the critical factor in securing attendances for the necessary treatment. Directly the schools close the attendances become comparatively few. Unless some other legal machinery can be devised to bring these children under medical supervision, I am afraid the days will be 80 far off before we can cope with the beginning of many of the diseases which affect the children during their school life. One has to face this fact, particularly at the present time, that amongst the poorer members of the community, particularly with the enormous rents they have to pay at the present time, there is a very direct tendency to avoid expenditure of any kind which can be regarded by the parent as not absolutely necessary. Apart from the West Middlesex Mutual Benefit Society in which the children are insured, and therefore there is no other expenditure, the only manner in which free treatment can be obtained is through the Public Assistance Authority. Hospital treatment is now no longer gratuitous. It must be borne in mind that expenditure of even small sums, which many people look upon as trivial, assumes a very different aspect in importance if the amount is regarded in terms of loaves of bread that sum will purchase. One has to face the fact that a number of these children are the offspring of parents who are living very definitely below the nutritional line, and the result is that there is recurring illness, which in all probability would not arise were the nutrition of the family adequate. As I pointed out elsewhere, these children are continually short of protein, carbo-hydrate surfeited, bulky and flabby, and lack the ordinary resistances that the well fed child possesses. This age group of 2 to 5 is under these conditions, assuming a larger and larger importance in the nation's health, and it is welcome news that the Consultative Committee of the Board of Education is seeking some solution to the problem of safeguarding these children, a problem which, in these times of national financial stress, is going to be handicapped at every turn, but the importance of the matter to the nation and its uprising generations, cannot be gainsaid. 81 The application which has been made for new premises as a Health Centre at Isleworth, has been tossed about between one department and another with little sympathy for any expenditure, and if I may say so, an inadequate appreciation of the difficulties under which the work is being done, of the tremendous growth of the district which is still going on, and of the fact that of the total cost of the building, only a portion will be chargeable to this work. Admitted at once, that the suggested building is not such as one would put up if building afresh, but it is necessary to spend a large amount on this building or else pull it down, to do which would be criminal. The necessary expenditure with regard to the structure of what is from a point of view of its site and structure, an extraordinarily good building for the purposes for which we require it, should be deducted from the gross amount which was originally put up as the cost of the scheme. No one desires under the present circumstances more than I do, to curtail expenditure in every direction, but I believe that good work in the Infant Welfare Clinics is a business proposition from the point of view of the nation. The foundations of a healthly childhood, are the only ones on which can be reared the sturdy structure of a healthy adult life. At the Isleworth end we have reached this position, that not infrequently mothers put their heads inside the waiting room and go away again, appalled at the crowd, the heat, and the smell. It must be borne in mind also that amongst the Isleworth population, the majority of which consists of poor families, the work there is of greater importance in a way than in any other part of the district. 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. 1926 11,567 1929 17,667 1.927 14,020 1930 19,222 1928 16,625 1931 27,318 82 It will be seen that the attendances have more than doubled in the last six years. The average attendances per session during the year 1931. were as follows:— At Douglas Road Centre 90.0 At Isleworth Centre 54.8 At Heston Centre 57.5 Approximately 69 per cent. of the children born in the district attend at one of the Infant Welfare Centres before they are a year old, an increase of 9 per cent. over last year's figure. The number of individual mothers and children attending the Clinics is shewn hereunder:— Douglas Road, Hounslow— 1927 1928 1929 1930 1931 Mothers 688 605 733 868 1087 Children 880 802 914 946 1232 Isleworth: Public Hall— Mothers 305 356 367 458 578 Children 414 460 452 522 757 Heston— Mothers — 157 212 305 392 Children — 013 253 355 478 The comments I made last year on preputial adhesions still hold, with only one difference, that whereas in these cases last year every one of them had been seen by a woman medical officer who was unmarried, this year, in one case only at one Clinic, where the child had been seen before coming into this district, apparently the medical officer was a married woman. 83 Sales at Clinics. Quantity. Receipts. £ s. d. Cow and Gate 11749 lbs. 885 7 3 Half-Cream Cow and Gate 1687 lbs. 130 10 8 Ostermilk 664 lbs. 52 7 7 Hemolac 117 lbs. 7 10 9 Lacidac 59 packet 6 14 8 Virol 963¾ lbs. 79 12 1 Malt 13 lbs. 9 9 Oil and Malt 751 lbs. 27 6 0 Lactagol 1254 tins. 71 2 2 Cod Liver Oil Emulsion 4698 bottles 1.52 19 4 Bemax 634 packets 13 4 2 Total £1,427 4 5 Ante-Natal Clinic. This Clinic is held at 92, Bath Road, Hounslow. Owing to the increasing attendances it was necessary in May, 1931, to put on another additional session, which is held on the second 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, who relinquished the Ante-Natal Clinic work at the end of December, 1930, still acts as Consultant for obstetric emergencies when required by a Medical Practitioner in a difficult case, and for Puerperal Fever oases where a second opinion is desired. Mr. A. J. Wrigley, M.D., F.R.C.S., was appointed to take over the Ante-Natal Clinic work at the beginning of the year (1931). The following are the figures with regard to the attendances at the Clinic:— 84 Year. 1930 Year. 1931 Attendances by expectant mothers during the year 30 0 583 Average attendance of expectant mothers per session 16.6 18 Total number of expectant mothers who attended the Clinic during the year 187 342 The number of mothers who attended the Ante-Natal Clinic worked out as a percentage of the total notified births during the year 1931, was 26.8. Dr. Wrigley's report is as follows:— "This Clinic is held at 92, Bath Road, Hounslow. Owing to the increase in numbers it was necessary in May, 1931, to put in an additional session which is held on the second Wednesday in each month. A comparison of the work done in the department in 1.930 and 1931 is of interest. 1930 1931 Sessions 18 32 Total Number of Attendances 300 583 New Patients 187 313 It is to be hoped that the increase in the number of new patients is a result of appreciation of the work done in the clinic. The majority of the cases are referred by the midwife in charge, and a few of these nurses lately have made a point of attending themselves whenever possible with their patients. One or two midwives have begun to arrange for all the patients upon whom they wish advice to attend upon a certain Wednesday in the month. The midwives are encouraged to attend with their patients as the plan ensures an investigation into any point on which the former may have doubts, gives instruction to the midwife, and also brings her into personal contact with the medical officer. 85 A brief resume of the investigation of each new case is as follows:— Enquiry is made into the past history of the patient and all illnesses, fevers, or accidents are noted. Questions are asked about the health during the pregnancy, especially in relation to constipation, shortness of breath, sickness, evidence of kidney disease, etc. By this time the ice is broken and information can be obtained about the social and domestic circumstances of the patient with a view to possible help in necessitous cases, the advisability of having the baby at home, etc., etc. This last investigation has perhaps done as much good and been as much help to the mother as any other. The patient is then examined first in regard to her general condition. This includes an estimate of her build and physique, examination of the heart, lungs, teeth, and breasts. Any doubts held on the advisability of breast-feeding are explained at once. A visit to the patient's dentist or in cases of poverty to the dental clinic, is urged in the event of decayed teeth. The pelvic measuremens are taken with a view to ensuring as far as possible that there is no contraction of the birth canal. If the patient is seen in the latter months of pregnancy the position and size of the baby is noted and the prospective mother is reassured on this point. Any case presenting any abnormality is advised to attend the clinic regularly. During the year the routine examination has revealed a number of early cases of toxaemia of pregnancy. The majority of these cases have responded to light diet and rest in bed at home. A few cases have required more energetic treatment and have been referred either to their own doctor, to the West Middlesex Hospital, and in one instance to St. Thomas's Hospital. Aid has been sought from the same sources in the cases of pelvic contraction. In many instances the position of the baby has been corrected by the external version of a breech presentation. In two mothers this was not possible and arrangements were made for them to have the version 86 performed under anaesthesia at St. Thomas's Hospital. Several cases of twins were observed and the mothers were able to make appropriate preparations. Perhaps one of the greatest assets the clinic possesses is that both mothers and midwives can feel that there is a special authority, actually on the spot in Hounslow, to which they can go for advice and reassurance or to which they can appeal. A thorough examination of an ante-natal case takes some considerable time, and the numbers on occasion have been such that cases had to be seen far too hurriedly. Steps have been taken to remedy the fault, especially with a view to emphasising the consultative nature of the clinic. The very large attendances were partly the result of the fact that a few of the midwives in the district had obtained an incorrect conception of the functions of the ante-natal department, and evidently expected that they would be responsible no longer for any ante-natal observation of their cases." A. J. Wrigley. MATERNAL MORTALITY Ante-Natal Services. Arising out of Circular 1167, and Memo 156/M.C.W. of the Ministry of Health, I made the following report to the Maternity and Child Welfare Committee:— 9 th February, 1931. "It would seem from Memorandum 156/M. & C.W. that the Committee are reporting what has more or less been common knowledge for some time, that a considerable proportion of the deaths resulting from child-birth, are preventable. I would like here to emphasize a point of view which is so often overlooked when dealing with these matters, and that is that to think merely in terms of death, is to get an inaccurate picture of the problem, as a very large number of women are condemned 87 to suffer from various forms of ill-health which arise from causes similar to but not so great as those which produce the death of the patient. This invalidity produces far reaching results in the home. The mother in often transformed from a cheery, happy individual to a querulous, cantankerous invalid, and this attitude of mind often has a seriously adverse effect upon such children as there may be, quite apart from: the husband. It will be seen from the report that the Committee emphasizes the fact that Institutions such as the East End Maternity Hospital are dealing with enormous numbers of mothers with extremely satisfactory results, and when it is realised that these East End Hospitals are catering for a class of population where circumstances of living are—speaking generally—more adverse than they are in most districts, it only emphasizes still more the necessity for seeing that more is done to ensure safety at child-birth, in districts where conditions of living are really more satisfactory, but which would seem to be more dangerous to the prospective mother. With regard to our own activities. We provide an extremely able Specialist at the Ante-Natal Clinic where the midwives are encouraged to bring up their cases. Unfortunately in the past the midwives did not avail themselves of this service to any large extent. The circumstances under which the Ante-Natal work is now being carried out are already having such widespread results with regard to the attendances, that I am bound to ask that an extra session be provided at once, with the probability of having to ask for a second in a very short time. I would stress the importance of the provision of the really skilled service as there is no false security given to the mother as the result of an opinion based on inadequate knowledge. As far as the educational side of the work is concerned this is carried out by the Health Visitors in the homes of the people when they visit. 88 The Obstetric Specialist dictates his letters of information to the doctors or midwives concerned with the patients who attend unaccompanied, at the end of the Clinic, so that the information is in the hands of the person who is to attend the confinement, at the earliest possible date. It is suggested that the Centre might be at the disposal of the medical men of the district, in order to examine their patients ante-natally. I think it would be found that very, very, few medical practitioners would be likely to avail themselves of this offer, in fact I should be very surprised if a single practitioner responded to the invitation. That the offer should be made in order to see what the response would be, I think would be wise, on the understanding that these cases are not seen by the general practitioner on the day on which the Consultant attends. The Committee have appointed a Consulting Obstetrician to deal with emergencies which may arise at the confinement or after, and in oases of Puerperal Fever; Dr. Bell still retaining this portion of the work. With regard to the midwives, there seems to be an adequate supply except in the Isleworth area, which has apparently for some time been short handed. The Memorandum suggests the possibility of Municipal midwives. My own feeling is most emphatically against the use of Municipal midwives, and the reason is that if a certain number of Municipal midwives are appointed, it is impossible to avoid arousing the hostility of all the other practising midwives against the Clinics, both Ante-Natal and Infant Welfare, because the practising midwives feel that any patient going to the Municipal Clinic gets in touch with the Municipal midwife and that she is sure to lose a proportion of her patients as the result of their attendance. Experience has shown in the past that this is so. Therefore if the supply of Midwives is short in any particular area, I am convinced that, speaking in the interests of the patients of the district, it is wiser for the Local Authority to 89 sidise a midwife if necessary, so as to be sure she can earn a decent living. The difficulty with regard to handy women is not great in this area except in Isleworth, and we have had considerable difficulty in the past with regard to febrile complications after labour in the case of handy women. Personally, I should be only too glad to see these people swept away, but the fact- remains at present a large number of the poorer people cannot afford the services of both a midwife and a doctor, and if they have engaged a doctor they have to save in other directions. I believe the abolition of the handywoman would be a considerable measure of safety. The only question being how this should be brought about, the difficulty is entirely financial. With regard to Hospital beds I feel that as time progresses there will be a greater and greater demand for delivery to take place in Maternity Hospitals under circumstances such as cannot be provided in the homes of the people. We put forward a proposition some years ago with regard to Redlees as a Maternity Home. It was turned down by the Ministry on the grounds that we could not make adequate provision for the nurses. Experience has shown since that time that it is unwise to establish a Maternity Hospital of less than 30 beds, and the larger the Hospital the better. It is true that accommodation is being provided at the West Midlesex Hospital, and there is talk of extension, but the fact remains that any connection with Poor Law and Relieving Officers is going to be one of the stumbling blocks for some time after these Institutions disappear into the limbo of the past. I think the present moment is one rather for watchfulness as to what the needs of the district are going to be rather than an immediate decision with regard to a Maternity Hospital. Things are in a state of flux and we might find ourselves with an empty Hospital for which a use may be wanted, and I think a premature decision at the moment would be unwise. 90 With regard to the proposition for ancillary services; home helps under the present circumstances do not seem so much in demand as they were before the population got used to living under closer conditions as the result of the War. There seems to be much more, what. I may call neighbourly assistance, offered than there was before, and a greater disposition on the part of the patients to utilize the services of a neighbour that they know, rather than somebody that they do not, but we do find that where the home help has been in the house and they realize how much her services contributed to the mental comfort of the patient, and the happiness of the home, they are freely asked for should a second confinement occur. With regard to sterilized Maternity outfits, I consider the Committee might well take this matter over. At present all that has been done is that the Mothers' Committee at the Douglas Road Centre are providing for small numbers. They were made at working parties held by the mothers, and are kept at Miss Scott's disposal for such as want them. There is no doubt that in the future there will be a much greater use made of sterilized outfits and that confinements will be carried out more on the lines of the Operating Theatre than of the ordinary bed-side. The number of cases of infection that have occurred by haemolytic streptococci found in the throats of the nurse or doctor will I think ensure that masks are worn in the same way as they are in an Operating Theatre. With regard to education, the Health Visiters are carrying on a day to day education in the homes of the women, but I think the periodic public lectures by people of more than local repute would be of very definite value, and I would suggest as an experiment that two lectures be given say in March or April at the Council House, when it would be possible to see by the attendance and the questions asked what the value of such methods of propaganda would be likely to be. My own expectation is that we should get a crowded audience and the results would be extremely valuable. 91 Summary of recommendations:— (1). The immediate provision of a further Ante-Natal Clinic Session per month. Attendances are now averaging 25; the number which is recommended in order to do adequate justice to the cases is 1.2. Even supposing that the insured mothers are not admitted this will only reduce the numbers by possibly one-fifth, and there are still far too many. With regard to the insured mothers, the Memorandum specifically states that although the insured mothers are entitled to Ante-Natal supervision by their general practitioner, the function of the clinic is "the examination and routine supervision of such women as ask for it." With regard to the possibility of local practitioners availing themeselves of the premises, equipment and nursing staff for their examination of their own patients, I suggest that the practitioners be circularised to see if they would make any use of the services provided. (2). With regard to the provision of a midwifery service in the district, generally speaking except in Isleworth, there is an adequate supply of midwives, and at present I have no recommendation to make. (3). With regard to sterilized maternity outfits I recommend that these be provided by the Committee for the use of the mothers in the district, at a charge to be settled by the Committee. (4). Lastly I strongly recommend that public lectures be given at the Council House, and I suggest two in the coming winter by recognised authorities, on the importance of care of the pregnant mother. The fees for the authorities such as I recommend would be in the neighbourhood of £5:5:0. Amounts to cover the cost of the above recommendations have been included in the estimates." 92 Dental Clinic. The following is the Dental Surgeon's Report for the year:— MATERNITY & CHILD WELFARE DENTAL CLINIC. General Comments on 1931 work. The effects of change-over. In previous years the Ante-Natal Specialist sent us "some" cases. A change over in this office leaves one in serious doubt, if this new officer could possibly have missed one case requiring dental treatment or decision. At all events, one can write, he is an Officer who is keenly alive to the devastating danger to pregnant and nursing mothers and children, of what an untreated sewerage farm of Oral sepsis can do. In no case was a patient sent to us who ought not to have been sent. In this year, as in last year, many were "years" after the time they should have come or been sent for dental aid. Advice Cases. The word "Advice" is true in its literal meaning, but has a further signification, no doubt observed by many, yet not written. The mothers are getting "tooth minded." There is a greater anxiety to know:— (a) Why the deciduous teeth are discoloured? (b) Why they are not coming straight and/or level? (c) If they are stopping the eruption of the permanent teeth? (d) Any other point, a mother's fears conjure. Refused to submit. It is my considered opinion and experience, that in all cases the mother is the culprit. The home control has been wanting and these cases are usually those of better off families, and alas, "only child" cases. The child, in this Clinic, when sympathetically handled, leaves nothing to be desired in its attitude and bearing to our dental work. I am satisfied, if the mothers would only leave these children in the hands of my present Staff this item should never appear 93 again in an M. & C.W. Report. The conduct of the children on "Gas" sessions when the parent is not admitted to the room, bears out this statement. Anyone with experience will talk to the child and incidentally lead round to what troubles it, and the child in its own little way will give its own story correctly. Yet the mothers are not content and give a different version and argue with the child. In all cases so far the mother is wrong and the child right; obviously so on inspection. Treatment postponed. This is due largely to the physical condition of the patient at the moment, and the advisability of letting Nature run its course before man steps in. Objectors. Having none to record may be a sign, let us pray it is, of the "dawn of an intelligent parental era." Silver Nitrate Treatment. Has again proved a consolation and sheet anchor in our treatment of making the deciduous teeth last their oral age. Comparative figures:— Year. Mothers. Children. Total. Appointments were 1929 141 187 328 1930 165 224 389 1931 412 416 828 Attendances were 1929 129 176 305 1930 129 204 833 1.931 338 373 711 Mothers Permanent Teeth. Children Deciduous Teeth. Total. Fillings 30 86 116 Extractions- Gas 248 318 566 579 Local Anaesthetic 6 7 13 94 General Anaesthetics were given to 107 Mothers and 111 Children, total 218. Local Anaesthetic was given to 6 Mothers and 7 Children, total 13. Dentures. Year. Uppers. Lowers. 1930 6 3 1931 18 18 The number of individual mothers supplied with dentures during 1981 was 20. In one other case, a denture previously supplied was repaired. Details of work 1931-1930. 1931 1930 Treated 467 210 Fillings 116 59 Referred for Gas 92 67 Extractions—Local Anaesthetic 13 4 do. General Anaesthetic 566 387 Adminstrations 218 11.8 Advice 36 18 Treatment postponed 14 3 Refused to submit 4 3 Dressings 8 11 Impressions taken 63 6 Charting and Estimating 73 31 Objectors — 1 Silver Nitrate Treatment 61 25 Dentures Eased 9 — Scale of Charges for Provision of Dentures. £ s. d. £ s. d. 1 Tooth 11 0 8 Teeth 1 10 3 2 Teeth 13 9 9 „ 1 13 0 3 „ 16 6 10 „ 1 13 0 4 „ 19 3 11 „ 1 13 0 5 „ 1 2 0 12 „ 1 13 0 6 „ 1 4 0 13 „ 1 13 0 7 ,, 1 7 6 14 „ 1 13 0 95 Notification of Births. Number of live births notified during the year 1242 Number of still births notified 30 Notified by midwives 725 Notified by parents or doctors 547 No special measures exist for dealing with unmarried1 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. I feel I must pay a special tribute and record my very grateful thanks to Dr. Sydney Owen, the Physician in charge of the Children's Department of the West London Hospital. His assistance in cases of difficulty and the careful painstaking and illuminating reports which he has furnished on these cases, are such as I have never come across in my experience elsewhere. I only wish it were possible to retain Dr. Owen's services as a Consultant to our scheme, at some fee which would in some little way recompense him for the infinite pains he takes with cases that are sent from our district. Apart from this, in cases requiring admission, wherever it can be done, I can always rely on Dr. Owen doing his best in the circumstances. 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 (who was a co-opted member of the Committee), Mrs. Goff, Mrs. Hogg, Mrs. Griffin, Mrs. Griffiths, Mrs. Killick, Mrs. Cox, Mrs. Knight, Mrs. Davies, Mrs. Bergin, 96 Mrs. Bartholomew, Miss Goff, Miss Dobinson, Miss Madge Dobinson Mrs. Harrison, Mrs. Sandford, Mrs. Everette, Mrs. Buckingham, Mrs. Newton, Mrs. Sutton, and Miss Flyn at the Hounslow Centre; Mrs. Chedgey, Mrs. Watson, Mrs. Jones, Mrs. Newman, Mrs. Curd, and Miss Wooton at Isleworth; Mrs. Rose, Mrs. Pitkin, Mrs. Griffiths, and Mrs. Ardley at Heston. Thanks are also due to the undermentioned for gifts of prams, toys, high-chairs, clothing, etc., which are given to the other mothers. Mrs. Rushton, Mrs. Goff, Mrs. Hackett, Mrs. Sargeant, Mrs. Gould, Mrs. Newman, Mrs. Diack, Mrs. Wilkinson, Mrs. Dolphin, Mrs. Knight, Mrs. Wren, Mre. Jassoy, Mrs. Holloway, Mrs. Davis, Mrs. Munro, Mrs. Dolton, Mrs. Bruce, Mrs. Howse, Mrs. Groves, Mrs. Bugg, Mrs. Franklin, Mrs. Hughes, Mrs. Buckingham, Mrs. Baker, Mrs. Martyn, Mrs. Vincent, Mrs. Short, and Miss Goff at the Hounslow Centre; Mrs. Major, Mrs. Sharpe, rMs. Crabbe, Mrs. Ismay, Mrs. Harris, Mrs. Lambert, Mrs. Elais, Mrs. Grant, Mrs. Shore and Mrs. Gallagher at Isleworth; and Mrs. Wilby at Heston. At the Isleworth Christmas Party, Mrs. Kenyon again organised a concert, and also gave a dancing display. Mrs. Brown did valuable work in connection with the arrangements for the tea. Thanks are also due to Miss Costello for her musical items. Home Visiting. The visits by the Health Visitors in connection with the Maternity and Child Welfare Work are shown in the following table:— 97  1927 1928 1929 1930 1931 1st visits to babies under 1 year 1020 1125 1304 1395 1472 Routine Re-visits to babies and Children up to 5 years 4474 4204 4311 3982 4190 Inquiries made, elicited— Feeding—Natural 747 806 887 980 1105 Artificial 41 47 44 77 64 Both 16 40 32 56 51 Sleeping with parents 200 247 277 260 247 Using Comforter 148 154 168 195 217 Mother working during pregnancy 36 51 48 53 44 Year 1931. Other Visits— Ante-natal First visits 78 Subsequent visits 15 Infants' Deaths and Stillbirths, Visits paid 77 Ophthalmia Nenonatorum and Discharging Eyes 135 Infantile Diarrhoea 2 Puerperal Fever and Puerperal Pyrexia 9 Measles and German Measles 2 Children under 5 years. Whooping Cough 69 Mumps 5 Chicken Pox 18 Pneumonia 44 Bronchitis 8 Milk and Food Cases 42 Home Help 28 Social Conditions 45 Summary of Nurses' Visits:— Total to expectant mothers 93 „ children under 1 year of age 4591 „ children between the ages of 1 and 5 years 2381 Visits re Public Health matters, infectious diseases, tuberculosis, etc. 508 Total 7573 98 Health Visitors' attendances at the Maternity and Child Welfare Centres, Ante-Natal Clinics, etc., 584. Health Visitors' attendances at Diphtheria Immunisation Clinics, 260. Home Help for Mothers. The Home Help paid 127 visits during the year, and her work was found of considerable value. She also assists at the Centres, and makes dressings, 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, 77 children have been cleansed. 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 257. It is noticeable that with the present financial stringency which arose out of the national crisis, there is beginning to be a very definite upward trend in the number of applicants for assistance, which increase, if it continues, will no doubt present its problem with regard to expenditure in due course. 99 OPHTHALM1A NEONATORUM year 1931. Cases. V1s1on Un1mpa1red. V1s1on 1mpa1red. Total Bl1ndness. Deaths Not1f1ed. Treated. At Home. 1n Hosp1tal. 6 3 3 5 1 ... ... An agreement ex1sts w1th the London County Counc1l for the adm1ss1on of cases of Ophthalm1a Neonatorum to St. Margaret's Hosp1tal when necessary. HESTON and 1SLEWORTH URBAN D1STR1CT EDUCAT1ON COMM1TTEE twenty-fourth ANNUAL REPORT OF THE SCHOOL MED1CAL OFF1CER FOR THE Year Ended 31st December. 1931 CONTENTS PAGE Blind ch1ldren 28, 41 Crippl1ng defects 12, 24, 43 Deaf ch1ldren 11, 24, 28, 38,41 Dental defects and treatment 11, 24, 39, 48, 50-59 Dental Surgeon's Report 50-59 Defective v1s1on 11, 18, 19-24, 38,46 Ear disease and hearing 11, 24, 38, 45 Employment of children 34 Ep1lept1cs 28,39,41 Exclusions 10, 35 Eye defects 11, 18, 19-24, 38, 45,46 Eye Clinic (R0eport by Dr. Roberts) 19-24 F1nd1ngs of med1cal 1nspect1on 10, 11, 12, 38-40 Following up 14 Infant and Ch1ld Welfare Work, Co-ord1nat1on w1th Infectious disease 12, 13, 14 Malnutr1tion 12,38 Medical 1nspect1ons 9, 37 Medical treatment 15, 45, 46, 47 Mentally defectives 28,41 M1nor ailments 15, 16, 45 Nurses' work in schools 14,35.49 Open Air Schools 24,25 Orthodontic work 52 Orthopaedic cases 24 Parents, Co-operation of 27 Prosecutions 36 Provision of Meals 26 Ringworm 18, 38,45 School Attendance Officers, Co-operation of 27 School Clinics 15,16 School hygiene 9 School Nurses' work 14, 35, 49 Schools in the Area 6 Sk1n diseases 11, 18, 38, 45 Spectacles 18, 19,46 Staff 5 Statistical tables 37-49,58,59 Teachers, Co-operation of 27 ,, Med1cal Examination of 35 Tonsils and Adenoids 10, 17, 47 Tuberculosis 11, 18, 39, 42 Uncleanliness 10, 35. 49 Voluntary Bodies, Co-operation of 28 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, 1931. 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, 1931-32 A. A. BERGIN, Esq., J.p., c.c. {Chairman). Members of the Council-.— J. ALLSOP, Esq. A. L. LANG, Esq. F. W. BUCKLEY, Esq. C. L. LEWIS, Esq. J. J. CLEMENTS, Esq., j.p. A. E. MACE, Esq. T. W. COX, Esq., m.c. H. J. Nias, Esq., m.b.f.., j.p (.Ex-Offcio). W. J. R. DIVINE, Esq. W. QUENBY, Esq. A. J. FIELDER, Esq. G. N. SHACKLETON, Esq. F. T. HART, Esq. {Ex-Offcio). G. R .SPEED, Esq. E. W. HEATH, Esq., j.p. A. A. WHITE, Esq. J. A. KING, 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 i> School Medical Officer : — ELWIN H. T. NASH, m.r.c.s., lr.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. One Temporary Health Visitor (whole-time). Clerical Staff— B. W. Kilby (Chief Clerk). Miss R. Marshall. P. T. H. Crandon. Comprising the whole A. H. cornhill. Miss G. E. Curtis. Clerical Staff of the Pui> b p garrod lic health department, (left January, 1931) \ K. I. blsshopp. f part of whose duties are F BeijLDH°US' concerned with the School E. E. Forrest. Medical Service. Miss V. D. Nicholls. R. Moore. (commenced January, 1931) I Dental Clinic Assistant and Clerk—MlSS I. M. TOMES. Dental Mechanic (part-time)—T. CHENEY. 6 ELEMENTARY SCHOOLS IN THE AREA. School Department. *Accommodation. Average Number on * Registers. Alexandra Boys' 440 460 ” Girls' 400 439 Berkeley Junior 400 471 Brentford End Infants' 100 100 Bulstrode Senior Boys' 400 449 ” ” Girls' 400 397 Grove Road Boys' 326 317 ” Girls' 326 324 ” Infants' 368 312 Heston Mixed and Infants' 712 6 77 Hounslow Heath Boys' 350 322 ” Girls' 350 301 ” Infants' 340 291 Hounslow R.C. Mixed and Infants' 304 250 Hounslow Town Boys' 454 412 ” Girls' and Infants' 624 633 Isleworth Blue Boys' 210 167 ” Girls' and Infants' 2084 224 Isleworth Town Senior Mixed 400 539 ” Junior Mixed 588 567 St. Mary's R.C. Boys' 150 139 ” Girls' and Infants' 240 202 Spring Grove Central 342 335 ” Junior 290 334 Woodlands St. John's Infants' 125 67 Worple Road Junior Mixed 260 278 ” Infants' 265 249 Total 9448 9256 Numbers as at December, 1930 8444 8271 * These numbers are for December, 1931. It will be seen that since a year ago the number of children attending elementary schools in this district has increased by about 1,000, and the effect of this continuing increase is being steadily felt in the demands made on the various branches of the School Medical Service. 7 INTRODUCTION. There are no special matters to call attention to other than the extraordinary growth of the district, which is producing administrative problems which have to be constantly reassessed in the light of the new centres of the population and new school requirements. The Orthodontic work which was reported on for the first time last year, has gone on steadily throughout the year. The response fell after the first rush, but it is now constant and steady, the only difference being that there is a larger proportion of the cases coming forward at the present time whose means are inadequate to pay the full cost. Looked at in the light of experience there must be, I am c6nvinced, a decentralization, if this work is to spread throughout the country. That is, that the Orthodontic Specialist must visit the Clinic in the same way as is done by Orthopaedic Specialists under the Orthopaedic schemes, and there must be raised a class of Orthodontic Specialist who will be able to deal with his own radiograms. This at present is the only stumbling block to the accomplishment of the scheme as I see it. The increase in this work has raised the whole tone of the Dental work. The public are realising that behind this work, which has hitherto in the popular mind been merely associated with "filling holes or pulling teeth," is the scientific attempt to deal with the mouth, taking the long view and not merely dealing with the present situation. It has put the whole work on a higher plane in the public's estimation. One of the most interesting things to note is how the mothers with bad deformities themselves—some of them are still exhibiting serious inferiority complexes as a result of their deformity—are anxious above everything else that their children shall have everything that can possibly be done for them to ensure that the defect which has overshadowed the whole of their life shall be remedied. My own feeling is that this work must and will become an integral part of the day to day work of the School Dental Clinic in the future. It is only when one sees the mass of these cases and the woeful condition of some of these mouths from the point of view of deformity, that one realises how much has been neglected in the past. 8 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 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 yield a far smaller percentage of cases requiring treatment. It is of course 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. All effort, therefore, to conserve and improve the health of the pre-school child must be encouraged, for it is probably true to say that early care and preventive treatment could have cleared away many of the defects we are now called upon to deal with in the school child. (1b). 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. 9 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. At Spring Grove Central School 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. Similar arrangements exist at the new Bulstrode School, where there is also a Cookery Centre. 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 arranged for every school in the district, and, except in one school, a re-inspection was also carried out. The exception is the Bulstrode Senior School, which opened in September and had its first medical inspection in December. 10 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 2869, which is slightly less than the number inspected last year, and 400 more than were inspected in 1929. The school population, however, has been increased during the past year by nearly 1,000 children, so that many more sessions must of necessity be devoted to school medical inspection during 1932. 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. (0). Uncleanliness. The number of cases discovered at routine medical inspections was 110, and special medical inspections at the Clinics revealed a further 543 cases. Three hundred and three children were excluded from school during the year on account of nits or vermin. (b). Tonsils and Adenoids. A total of 205 children were found to be suffering from enlarged tonsils, and of these 133 were referred for operation and 72 for observation. Forty-six children had Adenoids only, 26 being referred for treatment and 20 for observation. In a further 211 cases both conditions were present, 154 children being referred for operation and 57 for observation. t! (c). Tuberculosis. One child examined during routine medical inspection was marked for observation as a case of suspected pulmonary tuberculosis, and one as a case of tuberculosis of the skin. Special inspections reveled 3 cases of suspected pulmonary tuberculosis, and one case of tubercular hip. (d). Skin disease. A total of 409 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, accounting for more than half of this year's total. Table II. shows that there were 139 cases of " Other skin diseases." These include such conditions as eczema, alopecia, seborrhoea, etc. («). External Eye Disease. Twenty cases of minor disease of the eye, including 8 cases of blepharitis and 3 of conjunctivitis, were discovered at routine medical inspections. In addition, 129 cases, including 28 of blepharitis and 41 of conjunctivitis, were discovered at the Special Clinics. (/). Defective Vision and Squint. Routine medical inspections revealed 207 cases of defective vision, 167 being referred for treatment. Sixteen cases of squint were also discovered, 14 being referred for treatment. At the Special Clinics, 111 cases of defective vision and 16 of squint were referred for treatment. {g). Ear Disease and Hearing. Amongst children examined at the routine medical inspections, 68 cases of defective hearing were found, 44 of these being referred for treatment. Nine cases of ear disease were also discovered, 6 being referred for treatment. Special examinations at the Climes account for 45 cases of defective hearing; and 131 cases of ear disease. (h). Dental Defects. Three hundred and seventy-five cases of dental caries were discovered at routine medical inspection, and a further 95 cases were found by examination at the Special Clinics. 12 At the routine dental inspections in the schools, a total of 5,152 children were found requiring treatment. Table IV on page 48 gives further statistics in this connection. See also Statistical Table on pages 58 and 59. (i). Deformities. One hundred and eighty-eight cases of deformity of varying 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 Hat feet. Malnutrition. Officially, according to our returns, there are two cases of malnutrition that have been discovered during Routine Medical Inspection. It is idle to suppose that this is in any way a true picture of mal or subnormal nutrition in our district. Malnutrition still continues to be a bone of contention. All the systems of height and weight are, to my mind, of little value as they do not touch the real root of the problem. 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 111 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 1931, and the three previous years. 1931 1930 1929 1928 Small-pox — 2 — — Scarlet Fever 106 77 118 51 Diphtheria 26 88 239 54 Measles 9 799 83 688 German Measles 5 38 344 9 Mumps 132 381 106 138 Chicken-pox 233 392 423 265 Whooping Cough 242 144 177 171 753 1921 1490 1376 One thing the Department was extremely grateful for was that the incidence of Infectious Disease was very low during the year 1931, as will be seen from the above figures. 13 Th1s table shows the 1nc1dence of 1nfect1ous d1sease 1n each school dur1ng 1931 : — SCHOOL. SCARLET FEVER D1PHTHER1A MEASLES GERMAN MEASLES MUMPS CH1CKEN POX WHOOP1NG COUGH Alexandra Boys 8 ... 2 ... 3 14 43 ,, Girls 6 ... 1 1 1 14 24 Berkeley Junior 7 ... 1 ... ... 19 15 Bulstrode Senior Boys 2 ... ... ... ... 1 ... ,, ,, Girls ... ... ... ... ... 1 ... Brentford End Infants ... ... ... ... 1 3 ... Grove Road Boys 2 1 ... ... ... ... ... ,, ,, Girls 6 2 ... ... 1 1 ... ,, ,, Infants 3 ... ... ... 16 14 23 Heston Mixed and Infants 2 ... ... ... 32 11 20 Hounslow Heath Boys 5 4 ... ... 1 ... ... ,, ,, Girls 7 5 ... ... ... 3 1 ,, ,, Infants ... 11 ... ... ... 2 15 3 Hounslow R.C. Mixed & Infants 4 ... ... ... 5 6 6 Hounslow Town Boys 3 ... ... ... 2 5 1 ,, ,, Girls and Infants 19 1 ... ... 10 15 29 1sleworth Blue Boys ... ... 1 ... ... 5 ... ,, ,, G1rls & Infants ... ... 1 ... 1 25 ... 1sleworth Town Senior Mixed 1 ... ... ... 5 5 3 ,, ,, Jun1or Mixed 4 2 ... ... 9 57 24 St. Mary's Boys 1 1 ... ... 1 ... ... ,, Girls & Infants 1 2 ... ... 2 5 5 ... Spring Grove Central ... 1 ... ... ... 2 ,, ,, Junior 2 2 1 ... 5 3 19 Woodlands St. John's infants 1 ... ... ... 35 ... 1 1 Worple Road Junior Mixed 2 ... ... 1 1 3 „ ,, Infants 9 4 ... 2 ... 7 22 Total 106 26 9 5 132 233 242 14 The School Nurses continue to visit all cases of non-notihable infectious disease, and, as has been pointed out in previous years, this work takes up a considerable 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. The successful campaign in regard to immunisation against Diphtheria has been continued during the year, 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. Nurses paid 1205 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 them 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 relating to their activities during the year under review. DUTIES. 1. Attend Routine Medical Inspections at schools with the Medical Officer, and assist in weighing and measuring children, etc. 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. 15 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 1931. Attendances. Routine Medical Inspections 165 Re-inspections 29 Eye Clinics 98 Minor Ailments Inspection Clinics (with Medical Officer) 178 ,, ,, Treatment Clinics 894 Dental Inspections 41 ,, Clinics 494 Cleanliness Surveys 46 Cleanliness Clinics 35 Other Attendances (Special Clinics, Med. Exam. of Teachers, School Sports, etc.) 26 Visits. Re Infectious Disease 1254 Re Clinic Absentees 221 Following up 1205 Other Visits 30 8.—MEDICAL TREATMENT. (a). Minor Ailments. The Minor Ailments Clinics have again proved to be a very active feature of the School Medical Service, and here, as in other branches of our work, the results of an increasing school population are much in evidence. 16 The Clinics are open at 9 a.m. every week-day throughout the year 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 a.m. Heston—Thursdays, at 10.30 a.m. Isleworth—Mondays, at 10.30 a.m. Cases are referred to the Clinics from school medical inspections, or are sent in by Head Teachers, School Attendance Officers, and Health Visitors. The majority of the cases, however, are sent in by Head Teachers, who doubtless realise the value of prompt treatment in maintaining a good school attendance. Since the middle of 1929 the Minor Ailments Clinics have been kept open during school holidays (except such general holidays as Christmas Day, Bank Holidays, etc.), but there is always a considerable drop in the attendance when schools are closed, which points to the fact that, but for the vigilance of Teachers and Attendance Officers during term time, many of the cases of minor ailments would go untreated and neglected. The following comparative figures are interesting: — Year. No. of individual children Total attendances attending Minor Ailments Clinics. for treatment 1930 2036 8,349 1931 2413 10,803 In addition to providing daily treatment for minor ailments, these Clinics also serve as centres for the more detailed examination of special cases than the pressure at routine medical inspections at schools will permit. Here again the calls upon the Medical Officer's time, particularly at the Hounslow Clinic, have been so great that at the beginning of 1932 it has been necessary to commence the two medical sessions per week at Hounslow, half an hour earlier. That is all the extra time the Medical Officer in charge of this Clinic can spare, and really a further half-day session per week is indicated. The total number of special examinations and re-examinations made by Medical Officers at these clinics during 1931 was 3,534, compared with 2,532 in 1930. 17 (b). Tonsils and Adenoids. As previously stated, 313 children were referred for treatment on account of enlarged tonsils and adenoids. Of this number, 78 were operated on at the Hounslow Hospital under the arrangements made by the Authority in 1921, 74 received operative treatment by private arrangements of the parents, and three cases received non-operative treatment. The actual number treated during 1931 is therefore 155 out of 313 referred for treatment, making nearly 50 per cent., compared with 42 per cent. in 1930, 40 per cent. in 1929, and 25 per cent. 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 after the operation. The Authority pays the Hospital one guinea for each operation. Towards the end of the year under review the Committee went into the question of the scales of repayment by parents, and it was decided that no alteration be made in the existing scales but that, in assessing the amounts to be refunded by parents, the amount of rent paid be deducted from the weekly income of the family. The scale of repayment is as follows: — Weekly family income per 'head, after deducting rent. Contribution Under 8/- nil. From 8/- to 10/- 5/- From 10/- to 12/- 10/- Above 12/- 21/- In my Report for 1930 mention was made of the difficulties experienced in dealing with children of members of the Hospital Savings Association. Parents felt that they were entitled to free treatment, but the Association would not undertake to pay the full cost of tonsils and adenoid operations, nor would the local Hospital accept the Association's vouchers in this connection. 18 Wise parents accepted the position, paid to the Authority the contribution they were assessed to pay, and then obtained what refund they could from the Association ; the other parents did nothing. All difficulties, however, will be removed in future as the Authority has now agreed to accept the Hospital Savings Association vouchers in lieu of any contribution from the parents, and the Association in return has decided to pay an agreed sum per case to the Education Committee for this treatment of their members' children. (t). 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 45) shows that 369 cases of skin disease, and 984 miscellaneous cases of bruises, sores, chilblains, etc., were treated under the Authority's scheme during the year. Ringworm of the Scalp.—Ten cases were successfully treated by X-ray under our arrangements with Dr. Arthur (of Ealing) during 1931. The Authority pays Dr. Arthur's fee of £1 : 1:0 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 112 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. (f). Vision. Five hundred and thirty-one cases were submitted to refraction, compared with 443 in 1930, and 413 in 1929, and 297 in 1928. Spectacles were prescribed in 480 cases and obtained before the end of the year in 472 cases. Seventeen other cases were treated by private arrangement of the parents; and spectacles were obtained in 15 cases. I am indebted to Dr. Roberts, who is in charge of the Refraction Clinic, for the following report: — 19 VISION AND THE REFRACTION CLINIC. The work of the Refraction Clinic continues to increase and more children were seen in 1931 than in any preceding year; 1,785 appointments were given and 1,666 actual attendances made, giving a percentage attendance of over 93 for the whole year. Letters were received in 17 cases of those absent, giving valid reasons for absence, such as illness. In 1930, 1,578 appointments were made and the attendances numbered 1,471, giving an almost identical percentage attendance of just over 93. This is extremely satisfactory, and shows that the parents not only appreciate the work which is being done, but what is more important still, realise the necessity of conserving their children's vision. It is a complete vindication of the time spent in explanation and demonstration to parents. Every parent is told in simple language what is the matter with the child's eyes, and how the glasses help to remedy the defect with any necessary instruction as to the child's habits and the avoidance of eye strain. I am convinced that this is a necessary corollary to the prescription of spectacles, as the intelligent co-operation of parents is absolutely vital to the successful treatment of visual defects. Alas, not every parent co-operates as well as one could wish, but the response is very encouraging, and where Clinic and parent work together the result is always satisfactory. The number of refractions done was 531, an increase of 88 over last year. Spectacles were prescribed in 480 cases, and obtained in 98 per cent. of the cases by the end of the year, the figures for 1930 being 405 spectacles prescribed, which were obtained in 97 per cent. of the cases. Two clinics have been held weekly during the school terms, but owing to the cases left over from 1930, 8 extra clinics were held early in the year. This year has ended with a waiting list of over 100, and it will be necessary again to have extra clinics to reduce the numbers of those waiting. The increasing numbers will doubtless lead to the establishment of a third weekly clinic in the near future. The outstanding feature of interest concerning vision during the year was the publication in the autumn of the Board of Education " Report of the Committee of Inquiry into Problems connected with Defective Vision in School Children," a Report which should prove of great usefulness to all who are dealing with the vision of children, and which should stimulate enquiries into the problems it indicates. 20 In Part IV., under the heading "General Conclusions," the Committee makes two points: — 1. That a more searching test is necessary than the one at present employed in the schools for the detection of visual defects. 2. That children should be brought earlier under the test than is done at present, when only children who have attained the age of eight are tested as a routine measure. The routine test for defective vision referred to in the Report is Snellen's long distance test, which is the one in general use in the School Inspections and Clinics. With regard to point 2, I am pleased to be able to state that in this district children of five to six years of age (i.e. entrants) have had their vision tested in school as a routine measure since 1924. I was impressed by the possibility of a defect in vision being overlooked for the first three school years—or even longer if a child misses the first inspection—when an earlier test would have avoided this. In practice, testing the vision of children of five presents no real difficulty—it only requires patience. Many children already know their letters when first seen—actually most of them do not pronounce the letters as such, but make the appropriate sounds which is how they are taught the alphabet in the Infant class. These, however, are quite simple to follow. It is much easier, but not imperative, to have someone to point to the letters, as a young child finds it difficult to keep its place when reading. In most Infant Schools the Head Teacher will do this, and she is a great help, as her presence tends to allay any nervousness on the part of the children. Most children, however, respond well. Young children are usually pleased to show what they can do. The actual testing is done by the Nurse who accompanies the Medical Officer, and for the Infants we always use Dr. Nash's modification of the Snellen test type consisting of the five vowels in " lower case" type, which are the letters and type that the Entrant is most familiar with—whereas other cards are printed in capitals. Any children who cannot read, or where the testing is doubtful, are referred to the subsequent Re-inspection. In three or four months' time most of them can be tested. An exceptional case which still does not know the letters is referred to the Routine Medical Inspection next year—so that at the worst, a child's vision is tested at six years of age. 21 The results obtained are not infallible, but in my experience they are as accurate as those of older children. Vision testing by reading Snellen cards is at best only a rough and ready method of detecting visual defects, which is the first point made in the Report, where it is suggested that a more searching test is necessary. Testing vision by test cards can only give evidence of manifest errors of vision. Under our present system if a child reads 6/6 or 6/9 and has no symptoms of eye strain such as headaches, sore eyes, etc., he is passed as needing no treatment, yet he may be hypermetropic or slightly myopic. Only a refraction with the use of atropine to paralyse the accommodation will show the true picture The Committee of Inquiry states in the Report that on financial and administrative grounds it cannot at present advise that every child should have his eyes examined by refraction as a routine measure, but it has recommended a modification of tne usual procedure to enable early myopic cases to be detected and followed up by fuller examination. It is suggested that before each child is passed as requiring no treatment the examiner should place a + 1 sphere before the reading eye. Under this condition, in the words of the Report, if the child is hypermetropic he will still read 6/6, possibly even more easily than before; if he is emmetropic (normal) or slightly myopic the visual acuity will become less than it was before, and in the latter case may diminish to 6/36 . For practical purposes hypermetropic cases, i.e those whose vision remains the same or is improved by the addition of + I sphere may be neglected as relatively unimportant. The problem then is to distinguish between normal vision and early myopia in those whose vision is decreased by the addition of + i sphere to the reading eye. After reading the Report I immediately put into practice the suggestion of the second testing with a + i sphere, and from the beginning of November to the end of the term all children in the schools have been so tested. I had no idea of the numbers whose vision would be adversely affected by this procedure and desired to see what the probable addition to the work would be if possible myopic cases were followed up by refraction. I give the results below— The schools examined were those which still remained to be examined this year, i.e. on the ordinary school programme and not selected in any way. They comprised— 22 Hounslow Heath Junior Girls. ,, ,, ,,Boys. Hounslow Roman Catholic Mixed and Infants. Berkeley Junior Mixed and Infants. Bulstrode Senior Girls. Boys. The usual procedure was followed of testing with Snellen's Test Type at 20 feet, and all the testing was done by the same nurse, who has been doing the work for years, and is very accurate. Also from time to time I retested children and our results al.vays agreed, so that I have no hesitation in accepting her figures. The number of children examined whose vision was marked as requiring no treatment was 405. The ages varied from 5—13. The accompanying tables show the results obtained. TABLES showing alteration in Vision due to placing + 1 Sphere before the Reading Eye of 405 Children whose Vision was 6/6 or 6/9, and who showed no signs of eye strain. Unit of alteration—one Snellen line. BOYS. Number Tested Number of Boys showing:— INCREASE. NO CHANGE. DECREASE. (.Snellen lines). 0 2 1 2 3 4 s 224 33 3 7 93 55 4 Number Tested Number of Girls showing-:— INCREASE. NO CHANGE. DECREASE. (Snellen lines). 1I (6/6p 6,6p increased to 6,6 6/6) 4 1 2 3 4 5 181 26 39 77 31 3 NOTE.—For the purpose of calculating the difference in vision in the above table, all partly read lines are counted as the line above, e.g. 6/6p is recorded as 6/9, and in cases where the vision is different in each eye the worse vision has been taken. GIRLS. 23 55 Children included in the above table showed a difference of vision between the two eyes. Of these, 5 girls showed a difference in natural vision, viz. : — (1) 6/6 6/12 c + 1 sphere added 6 12 6/18 (2) 6/6 6/9 ,, ,, ,, 6/9 6/12 (3) 6/9 6/6 „ ,, ,, 6/9 6/9 (4) 6/96/6 ,, ,, ,, 6/24 6/24 (5) 6/6 6/9 „ „ „ 6/18 6/24 The vision of the remaining 50 children showed a difference between the eyes only when + 1 sphere was added, viz. : — Boys: 20 had a difference of 1 Snellen line. 6,, ,, ,|2 ,, lines. 2 ,, ,. 3 ,, lines. Girls: 18,,,, ,,1 ,, line. 4 ,, ,, ,, 2 ,, lines. These figures show that out of 405 children there were only 7 whose vision remained the same or was improved after the addition of + 1 sphere to the reading eye. According to the Report, therefore, these children are hypermetropic, whilst the remaining 398 have normal vision or are slightly myopic, and we have then to distinguish between the normal who need nothing further and the slight myopes who do need to be followed up and refracted if possible. I cannot feel, however, that emmetropes and slight myopes account for all those children whose vision was adversely affected by the +1 sphere. If one were dealing only with simple hypermetropia, normal vision and simple myopia this would undoubtedly be the case, but there are also the small astigmatic errors to be considered. I feel certain that cases of simple hypermetropic astigmatism of less than one diopter would have their visual acuity considerably decreased by the addition of a + 1 sphere. Yet many of such cases would have good vision with no subjective symptoms, and would therefore come into the category of those who were to be tested again with the + 1 sphere. If this is so, and at present I can produce no figures in proof of it, one would have to distinguish between normal vision, slight simple hypermetropic astigmatism and slight myopia. It is difficult to see how this can be done except by refraction, which would be impossible if my figures are correct, on account of the large numbers. 24 It may be, however, that a working standard could be taken which would catch the early myopes, e.g. all children whose vision is decreased by 4 or 5 Snellen lines to be refracted. The Committee of Inquiry may have information which would indicate what is the importance of the varying diminution of vision after the addition of a + 1 sphere. I have submitted my figures to the Board of Education and am awaiting their guidance before endeavouring to follow up cases by refraction. Meanwhile, childern are continuing to be tested with a + 1 sphere in the schools, so that further figures will shortly be available. E. L. ROBERTS, Assistant School Medical Officer. (g). Ear Disease and Hearing. One hundred and fifty-six 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. The Dental Surgeon's Report on the work of the Dental Clinic is given on pages 50 to 59. (i). Crippling Defects and Orthopaedics. Although handicapped by the absence of an official scheme for the treatment of crippling defects, we have nevertheless been able to secure expert advice for such cases as have required it. This is entirely due to the kindness of the Royal National Orthopaedic Hospital, where 56 cases from this area have been seen as out-patients during the year. In addition 5 children have received in-patient treatment at the Hospital, and 5 at the country branch at Brockley Hill, Stanmore, 4 of whom were in Hospital at the end of the year. It is proposed to draw up a definite scheme for the treatment of orthopaedic defects in the near future. 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. 25 Open Air Schools. Each passing year makes the demand for an Open Air School more and more insistent. During the latter part of 1931 the number of sub-normal children was greater than I have ever seen before; so much so that a part of Thursday morning has been established for children to attend for blood examination. On visiting the schools, I have at times watched the children coming out of school, and have been worried by the pallid faces of these sub-normal children. I am more than ever convinced that an Open Air School with all that it connotes, is becoming an urgent Public Health matter in this area, and unless a suitable site is secured before the district is built over, the opportunity will be lost for good and all. Never since I entered the School Medical Service have I been so concerned about the well-being of some of these little folk it is my duty to supervise from the health point of view. Surely it is wise to take the long view. For practically all of the children in our public elementary schools their Health is their Capital, and for those whose health is not up to normal standard, their best and in many cases their only means of earning an adequate livelihood, is by means of their educational attainments rather than by their physical attributes. For most of these sub-normal children, that education which is to be their sheet anchor is largely lost owing to broken attendance at the ordinary school. What is the usual history? Firstly, the child finds that the pace is too swift for its debilitated powers, which produces more worry and further debility, and then a breakdown of some kind. Then ensues a period of perplexity. How is the child to get the necessary recuperative rest ? In most cases the family has no surplus for Convalescent Homes and such things. In addition, the extra strain of keeping the child interested, if not amused, throughout the day is another irritant to the already fretted nerves of an anxious and overworked mother. In the end, after a more or less prolonged absence, the child returns to school, only to find that the educational wave has inexorably passed on, and the child finds itself floundering in the troubled waters of subjects that it imperfectly understands, and vainly trying to rear an educational superstructure on the shifting sands of imperfect knowledge. This produces more trouble. Teachers are but human, and it increases the burden of their work to have to give special lessons to these educational laggards who are constantly in difficulties. 26 Here let me pay a special tribute to the patience displayed by the teachers in attempting to help these children, but with all the goodwill it can't be done. The child again succumbs to the added nervous strain piled on its physical disability—talking in its sleep of the daily difficulties that cannot be overcome, worrying the harassed mother who hears the nocturnal voicings of the ever present anxieties. And so the ebb and flow of disabilities and anxieties go on. The child falls further and further behind in physical and educational progress, only to swell the sum of human flotsam and jetsam on leaving school, drifting hither and thither on the sea of chronic unemployment, a constant source of expense to the nation—mainly through the Public Assistance Authority. If by means of an Open Air School these children can ultimately take their place in the world with established health on which is built an educational edifice sufficient to ensure a competence, then surely an Open Air School is a business proposition. It must be remembered that an Open Air School is quite a different proposition from our most modern schools which are " built on open air lines," that is, in fine weather they can be thrown open on one side and thus form a series of open air classrooms. But the " Open Air School" is more, much more, than this. It is a system with the following very important factors superadded to the open air classroom: — 1. Efficient meals. 2. Sufficient compulsory rest. 3. Lessons taken in the open air. 4. Modified curriculum to suit the sub-normal child. 5. More efficient medical supervision. 1 0 PHYSICAL TRAINING. 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. The Committee, however, allow Cod Liver Oil and Malt to be sold at cost price at the School Clinics for children recommended by the School Medical Officers. 27 The arrangement foreshadowed in my Report for 1930, whereby children might obtain milk regularly at school for a nominal payment, has been put into practice. The scheme is organised on a self-supporting basis, and its adoption by the teachers is entirely voluntary. At the end of the year 19 Head Teachers had adopted the scheme, and well over 2,000 children were having their daily bottle of milk. 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 1931 a parent or other relative attended in 2,160 instances, representing 75.3 per cent. 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. 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. 28 16.—CO-OPERATION OF VOLUNTARY BODIES. The Public Assistance Committee has very kindly given assist ance in one or two cases during the year, and the Invalid Children's Aid Association has, we know, dealt with some of our school children. The Middlesex Edward VII. Memorial Fund from time to time provides a seaside holiday or convalescence for a few necessitous children. The National Society for the Prevention of Cruelty to Children has continued to render valuable assistance in cases of parental neglect, 27 cases having been referred to the Society during the year. 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. 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. All mentally abnormal children, other than those who have been notified to the Local Mental Deficiency Authority, are reexamined frequently, and in any case not less than once in twelve months. At the end of 1931 there were 22 children being maintained by the Education Committee at institutions outside the district. Three were in Schools for the Blind, and three were in Schools for the Partially Blind. Six were in a school for the Deaf. Three were in schools for the Mentally Defective. Two were in schools for Epileptics. Two were in a Residential School for Cripples. Two were in Residential Open-Air Schools. One child was in the Royal National Orthopædie Hospital. 29 The Autumn of 1931 saw the culmination of a fight for justice in the matter of the adoption of a child who was subsequently certified as mentally defective. The matter is so important that it is necessary, I think, to set the facts out in some detail. The child—a girl now 12 years old—was adopted at the age of 4 years 11 months by a childless couple of the very best working class type. The first time I saw the child after she entered school I told them she was mentally abnormal, and that something should be done with regard to returning the child to its parents, or to the National Children Adoption Association, through whose machinery the child had been adopted. I got into touch with one of the members of the Adoption Association, and finally was given an interview by the solicitor to the Association. The attitude adopted by him may be gathered from the following letter. " The Contract entered into by the adopting parents can in no sense be taken to be conditional upon the opinion of the Association's Medical Adviser proving correct. Obviously, such a course would be most impracticable as you, in your position as Medical Officer of Health, will be the first to appreciate. " The fact of the child being now found to be abnormal does not affect the adopting parents' Agreement, and after one month has expired from the date of the adopting parents taking possession of the child, the adopting parents surely have no right, and indeed cannot expect the Association to again assume responsibility for any child adopted through their good offices. The adopting parents must deal with the child as they would were it their own." The point I raised with the Association was that they had not provided the adopting parents with what they had asked for, viz. a normal child. After considerable correspondence on the matter I wrote to Lady Astor, who at that time was deeply interested in the Act. The following is an' extract from the letter. "I want to draw your attention to a difficulty—.and that a serious one—in the Adoption Act. Whilst wholeheartedly supporting the principles involved, there is just one point that has been overlooked, and the consequences are so serious that I feel something ought to be done, and the best way I can illustrate the position is by giving details of the case I have under my care at the present time. 30 "The National Children Adoption Association provided two people in my district—working class parents of the very best type—with a child about 4½ years of age. The first time I saw this child when she reached school age, I pointed out that the child was, in my opinion, one that would have to be certified as mentally defective. I put this point up to the Society, and had an interview with their legal Adviser. They not unnaturally raised every possible obstacle to the rescinding of the agreement. I put it to them that they did not perform their part of the contract, in that in the words of the Food and Drugs Act they had not supplied these parents with goods of the nature and substance demanded. The parents had come to them anxious to adopt a normal child, and although the physical history appeared all right, I gather that no attempt was made—or ever is made—to assess the mental capabilities of the children that are handed over. The position now is extraordinarily painful. These parents, who have looked after the child in an excellent manner, were not unnaturally greatly distressed, when it was my unfortunate duty last week to certify the child under the Education Acts as feeble minded. It does seem too great a burden to put on adopting parents. I admit the difficulties of cancelling the contract. I admit the difficulties to the child who may be taken from what is an excellent home, back either to an unsuitable one or even to the care of the Guardians, but I do feel very strongly that there should be some amending clause in the Act, amending it in such a way that if the child is subsequently found on examination to be certifiable as feeble minded, that the contract should be terminated, if the adopting parents so desire. That would leave it open in the case where the child has been taken very young, and the adopting parents may have become so attached as to be prepared to make the sacrifice of looking after such a case, but I think they should be in a position to cancel the contract on the grounds that the child supplied to them was not such as it was deemed to be when the contract was signed. " These parents, who as I have said, are of the very best type, who would make, and are anxious to make a good home for a normal child, are not unnaturally distressed at the possibility of being permanently responsible for a child who will probably be a drag on them for the rest of their days, and a disappointment in that she will not be one on whom they can lavish the enormous fund of affection which would be there for a normal child." 31 Lady Astor very kindly put me in touch with Mr. J. F. W. Galbraith, K.C., M.P., who was responsible for the Act of 1926. This unfortunately produced nothing to solve the difficulty. The Society seemed to want to make the adoption appear legal. As this adoption had been made before the Act of 1926 it was covered by the decision of Humphrys v. Polak (1901) 2 K.B. 385, which states that " the mother of a bastard child cannot by contract transfer her right of custody to another person, and a contract transferring her rights to another person is invalid." In correspondence with Mr. Galbraith my view on the matter was set forth in the following letter: — " With regard to the case under consideration, in view of the ruling of Humphrys v. Polak (1901) 2 K.B. 385, I propose to throw the child back on the National Society on the grounds that their contract is invalid, but I was raising the point, as one which seems to me should be dealt with under the Adopting Act. " All adoptions are undertaken—I think we may agree without exception—on the basis that the child is normal at the time of its adoption, but in the case of a mentally defective, the very definition strikes the root of the matter; the condition being defined as one being present at or soon after birth. As these manifestations do not show themselves— except in the grosser cases—until some time later, it seems to me that the dice are loaded against the adopting parents. Though these cases are rare, the issues are tragic. It is agreed that the adopting parents take a normal child for better or worse, that is they take all risks with regard to matters which arise after adoption, but in these cases there is already present a definite defect, although not obvious at the time of adoption. This in some cases is ascertainable by an expert; in others it is not ascertainable until a later date, but has existed and was present at the time the adoption took place. Therefore it seems to me that there should be a loop-hole, in view of the fact that the adoption has taken place under circumstances which had the adopting parents been aware of, would have been an absolute bar as far as the adopting parents are concerned. It seems to me that this could be got over by some amending clause, as stated before, that should the child be subsequently certified as mentally defective by the School Medical Officer or other certifying Officer, that in itself should be sufficient to cancel the adoption. 32 " If the child becomes insane that is a different matter, and is included in the phrase ' for better or worse,' in that there is a condition which has arisen after the adoption, but if mental deficiency existed at the time, although not obvious, this should render—in my opinion—any contract whether through the Courts or otherwise—null and void." Things dragged on until after an interview with Miss Musson, she took the matter up again with the Society. At this time the officers of the Society had changed, and a very different atmosphere prevailed; the Secretary seemed willing and anxious to do what was right, and eventually the Society itself suggested drafting a Bill to cover the point which I had raised. It was also also ascertained that the child had been born in Thavies Inn, which is a Venereal Hospital for pregnant women. This fact had not been communicated to the adopting parents, or if it had, the nature of the Hospital had not been made clear to them. Later in 1931 things got serious, and the state of affairs is best shown in my letter to the Clerk to the Public Assistance Authority:—• " You will probably be hearing from the Secretary of the National Adoption Association with regard to the abovementioned child. " This case is an absolute tragedy. The adopting parents are the best type of Yorkshire folk, and took this child from the National Adoption Association. The first time I saw the child I told them that in my opinion it was a mental defective. Subsequent events proved the correctness of my diagnosis, and she has been duly certified—with an intelligence quotient of 55. " The adopting parents were at first loath to part with the child, but latterly she has developed undesirable habits, is robbing them, and threatening the adopting mother, who is giving way under the strain and worry of the present position. " I have been fighting the Association on this matter for nearly six years, and this morning I have had an interview with the Secretary, who has agreed that it is impossible to expect the adopting parents to keep the child. " An additional factor of serious importance is that the child was born in Thavies Inn, which as you know is the City of London Hospital for pregnant women suffering from venereal disease. This fact was concealed from the adopting parents. 33 "The adoption as you know is illegal, and the only method of dealing with the case seems to be through your Authority. I have suggested to the Secretary this morning that he should write to you so that whatever is done can be done on an amicable basis, as the adopting parents of course have the right to put the child outside the gate, in which case of course she would be brought to your Institution, but I think it will be far better if the thing can be done in decency and in order. " I enclose herewith a copy of my letter to the legal Adviser to the Society, from which you will see the line I took up then. The old Society officers fought against the child being taken back, but the present regime have recognised that in justice to the adopting parents the only thing to do is to relieve them of a burden which cannot be fastened on them by the law." Eventually in the Autumn the child was got away to a Home, under the Middlesex County Council, and the adopting parents freed from what had been latterly an intolerable burden. The tragedy of it all is this. The adopted child, owing to its mental defect, was not in a position to realise the advantages of its adoption. The adopting parents have now passed the age when they want to undertake another adoption, and some normal child has been deprived of a home in good circumstances, with people whose childless life had left them with an aching hunger for someone on whom to bestow their affection ; their patience in the early years of this tragedy was pathetic. I wish to pay a special tribute to the assistance rendered by Miss Musson, the Secretary of the Society for the Unmarried Mother and her child, and also to the present Secretary of the National Children Adoption Association, who, recognising the justice of the fight I was making, entirely reversed the attitude I met with at the beginning. It does seem to me imperative that there should be an amending Bill, so as to safeguard adopting parents. As I pointed out in the correspondence, they postulate when they adopt a child that they are being given a normal child, and that they have a right to expect that it is normal, and should the child turn out to be abnormal it is surely their right that the adoption should be cancelled 34 It is absurd to say that an adopting parent should have the same responsibilities in perpetuity as the parents who bred a child of their own bodies. If they have some defect or taint, which appears in their children, that is their responsibility entirely, but it does appear to me absolutely wrong that such a responsibility should be considered to be equally imposed on an adopting parent. This final act of justice—I cannot call it anything else—to these adopting parents has meant six years fighting and a file of 64 documents. If it helps to get an amending Act on the Statute Book at an early date, it will be time and trouble wellindeed very well, spent. 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. Ninety-five children were examined and 94 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 Department. 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. 35 22.—CIAL ENQUIRIES. See Dr. Roberts' report on pages 19 to 24 with regard to vision testing. 23.—MISCELLANEOUS. Forty-seven teachers were medically examined and 2 were reexamined during the year in connection with their appointments on the teaching staff of the Authority. Ninety 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. Twenty-one examinations were made during 1931. Six children were referred for treatment on account of dental caries, and one for squint. TREATMENT OF UNCLEANLINESS. 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 has been possible to increase the number of examinations to 6774, compared with 4211 in 1930 and 782 in 1929. Number of visits to schools by Nurses 41 Total number of children examined 6774 ,, ,, ,, „ given warning notices 350 ,, ,, ,, „ excluded as verminous 6 1. (Few) 287 Found to have nits— 2. (Bad) 39 V 3. (Very Bad) 24 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 (1) 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. 36 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. Seventy-seven children were cleansed by Mrs. Yates during 1931. During 1931 it was found necessary to take legal proceedings in 8 cases, with the following results: 6 cases were fined 5/- each 2 cases were fined 10/- each 37 TABLE 1.—RETURN OF MEDICAL INSPECTIONS A.—Routine Medical Inspections. Number of Code Group Inspections- Entrants 976 Intermediates 1133 Leavers 442 Total 2551 Number of other Routine Inspections 318 B.—Other Inspections. Number of Special Inspections 2135 Number of Re-Inspections 4663 Total 6798 38 TABLE II. A. RETURN OF DEFECTS found by Medical Inspection In the Year ended 31st December, 1931. 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 2 7 2 I Uncleanliness (See Table IV., Group V.) ... ... ... ... Skin— Ringworm— Scalp ... ... 10 ... Body ... ... 11 ... Scabies ... ... 14 ... Impetigo 1 ... 234 ... Other Diseases (non- tuberculous) 5 ... 133 1 Eye— Blepharitis 6 2 28 ... Conjunctivitis 3 ... 41 ... Keratitis ... ... ... ... Corneal Opacities ... ... ... ... Defective Vision (excluding squint) 167 40 111 4 Squint 14 2 16 ... Other Conditions 6 3 57 3 Ear– Defective Hearing 44 24 43 2 Otitis Media 2 1 57 1 Other Ear Diseases 4 2 69 4 Nose and Throat— Enlarged Tonsils only 57 58 76 14 Adenoids only 16 17 10 3 Enlarged Tonsils and Adenoids 92 43 62 14 Other Conditions 5 6 114 10 Enlarged Cervical Glands (non-tuberculous) 6 23 52 6 Defective Speech ... 1 ... ... 39 TABLE II.—Continued. Defects or Diseases Routine Inspections. Special Inspection#. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. 1 2 3 4 5 Teeth—Dental Diseases (see also Table IV., Group IV.) 374 1 93 2 Heart and Circulation— Heart Disease— Organic 1 1 4 7 Functional 10 60 13 27 Anaemia 4 9 7 1 Lungs— Bronchitis 1 5 33 3 Other Non-Tuberculous Diseases ... 2 38 6 Tuberculosis— Pulmonary— Definite ... ... ... ... Suspected ... 1 2 1 Non-PuImonary— Glands ... ... ... ... Spine ... ... ... ... Hip ... ... ... 1 Other Bones and Joints ... ... ... ... Skin ... 1 ... ... Other Forms Nervous System— Epilepsy ... ... 2 2 Chorea ... ... 7 2 Other Conditions ... 9 15 7 Deformities— Rickets ... ... ... 1 Spinal Curvature 2 51 6 4 Other Forms 25 75 17 7 Other Defects and Diseases 16 17 996 93 40 B.—Number of individual children found at Routine Medical Inspection to require treatment. (Excluding Uncleanliness and Dental Diseases). Group. Number of Children. Percentage of children found to require treatment. Inspected. Found to require treatment. Code Groups— Entrants 976 160 16.39 Intermediates 1133 208 18.35 Leavers 442 84 19.00 Total (Code Groups) 2551 452 17.71 Other Routine Inspections 318 40 12.57 41 TABLE III.—RETURN of all Exceptional Children in the area. Boys Girls Total Children suffering from the following types of Multiple Defect, i.e., any combination of Total Blindness, Total Deafness, Mental Defect, Epilepsy, Active Tuberculosis, Crippling (as defined in penultimate category of the Table), or Heart Disease 3 4 7* Blind (including partially blind). (i.) Suitable for training in a School for the totally blind. At Certified Schools for the Blind ... 3 3 At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 1 1 (ii.) Suitable for training in a School for the partially blind. At Certified Schools for the Blind or Partially Blind ... 3 3 At Public Elementary Schools 1 2 3 At other Institutions ... ... ... At no School or Institution 2 3 5 Deaf (including deaf and dumb and partially deaf). (i.) Suitable for training in a School for the totally deaf or deaf and dumb. At Certified Schools for the Deaf 3 3 6 At Public Elementary Schools ... 1 1 At other Institutions ... ... ... At no School or Institution ... ... ... (ii.) Suitable for training in a School for the partially deaf. At Certified Schools for the Deaf or Partially Deaf ... ... ... At Public Elementary Schools 2 ... 2 At other Institutions ... ... ... At no School or Institution ... ... ... Mentally Defective. Feebleminded. At Certified Schools for Mentally Defective Children 3 ... 3 At Public Elementary Schools 13 3 16 At other Institutions ... 1 1 At no School or Institution 3 3 6 Notified to the Local Mental Deficiency Authority during the year. Idiots 2 1 3 Imbeciles 5 2 7 Others ... 1 1 Epileptics. Suffering from severe epilepsy. At Certified Schools for Epileptics 1 1 2 At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 1 2 3 Suffering from epilepsy which is not severe. At Public Elementary Schools 2 5 7 At no School or Institution ... ... ... * Particulars of these cases are given at the end of the I able, on page 44. 42 TABLE III.—Co/itinued. Boys Girls Total Physically Defective. Active pulmonary tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 2 ... 2 Quiescent or arrested pulmonary tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Tuberculosis of the peripheral glands. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 1 1 Abdominal tuberculosis. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Tuberculosis of bones and joints (not including deformties due to old tuberculosis). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 1 2 3 At Public Elementary Schools ... ... ... At other Institutions 1 ... 1 At no School or Institution 1 1 2 Tuberculosis of other organs (skin, etc.). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... 43 TABLE III.—Continued. Boys. Girls. Total. Physically Defective (continued). Delicate Children, i.e., all children (except those included in other groups) whose general health renders it desirable that they should be specially selected for admission to an Open Air School. At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... ... ... At Certified Residential Open Air Schools 2 1 3 At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 76 61 137 At other Institutions 1 ... 1 At no School or Institution 3 1 4 Crippled Children (other than those with active tuberculous disease) who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life. At Certified Hospital Schools 2 ... 2 At Certified Residential Cripple Schools 1 1 2 At Certified Day Cripple Schools ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 15(2) 16 31 (2)* At other Institutions 2 (2) 1 3(2)* At no School or Institution ... 2(2) 2(2)* Children with heart disease, i.e., children whose defect is so severe as to necessitate the provision of educational facilities other than those of the public elementary school. At Certified Hospital Schools ... ... ... At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 1 4 5 At other Institutions ... ... ... At no School or Institution ... ... ... * The figures in brackets indicate the number of children who should be receiving Special School education. 44 Children Suffering from Multiple Defects. Boys. Particulars. Case No. I Old Rt. Hemiplegia. Walks with marked limp. Some Atrophy Rt. upper limb. Dull and backward. At Public Elementary School. ” ” 2 Severe Epilepsy. Mentally retarded. At no school. ” ” 3 Certified Mental Defective. Paralysis lower limbs. Cannot walk without support. At no school. Girls. Case No. I Certified Mental Defective. Congenital Morbus Cordis. At no school. ” ” 2 Blind. Mentally retarded. Too re tarded for ordinary Blind School. At Court Grange Special School South Devon. ” ” 3 Petit Mal. Some paralysis Rt. side Uses left hand for everything. At Public Elementary School. ” ” 4 Blind. Dull and backward. At no school. 45 TABLE IV. Return of Defects treated during the year ended 31st December, 1931. TREATMENT TABLE. Group 1.—Minor Ailments (excluding Uncleanliness, for which see Group V.). Disease or Defect Number of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise. Total. 1 2 3 4 Skin— Ringworm, Scalp 10 ... 10 Ringworm, Body 11 1 12 Scabies 11 ... 11 Impetigo 231 1 232 Other Skin Diseases 106 11 117 Minor Eye Defects— (External and other, but excluding cases falling in Group II.) 112 7 119 Minor Ear Defects 156 5 161 Miscellaneous— (e.g., minor injuries, bruises, sores, chilblains, etc.) 984 13 997 Total 1621 38 1659 46 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) 531 14 3 548 Other Defect or Disease of the eye (excluding those recorded in Group I.) ... ... 2 2 Total 531 14 5 550 Total number of children for whom spectacles were prescribed— (а) Under the Authority's Scheme 480 (b) Otherwise 15 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme 472 (b) Otherwise 15 TABLE IV.—Continued. Croup III.—Treatment of Defects of Nose and Throat. Number of Defects. Received Operative Treatment. Received other forms of Treatment. Total number treated. Under the Authority's Scheme, in Clinic or Hospital. By Private Practitioner or Hospital, apart from the Authority's Scheme. Total. (1) (2) (3) (4) (5) 78 74 152 3 155 47 48 TABLE IV.—Continued. Group IV.—DENTAL DEFECTS. (I). Number of children who were : (a) Inspected. Aged : Routine age groups 5 765 Total 6804 6 814 7 909 8 903 9 923 10 951 11 760 12 336 13 302 14 141 Specials 1486 Grand total 8290 (b) Found to require treatment 5152 (c) Actually treated 2555 (2) Half-days devoted to Inspection 42 Total 478 Treatment—Ordinary 313 Gas 91 Administration—Clerical 24 Dental Committee—Meetings 8 (3). Attendances made by children for treatment 5035 (4). Fillings Permanent teeth 2695 Total 3085 Temporary teeth 390 (5). Extractions— Permanent teeth—At Treatment Sessions 2 Total 4444 ,, Gas Sessions 429 Temporary teeth—At Treatment Sessions 486 ,, Gas Sessions 3527 (6). Administrations of general Anaesthetics for extractions 1206 (7). Other operations Permanent teeth Total 3006 Temporary teeth 49 TABLE IV.—Continued. Croup V UNCLEANLINESS AND VERMINOUS CONDITIONS. (i.) Average number of visits per school made during the year by the School Nurses 1.6 (ii.) Total number of examinations of children in the schools by the School Nurses 6774 (iii) Number of individual children found unclean 356 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 77 (v.) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 (b) Under the School Attendance Bye-laws 8 50 MEDICAL TREATMENT—DENTAL DEFECTS. Report of the School Dental Surgeon. During the year the pressure of the increasing demands of the Dental Scheme has been acutely experienced, and various means adopted to deal with the large number of children seeking treatment. A well trained staff working as a team is an essential for rapid and efficient Dental Clinic work. The output of work suffered to some extent by the difficulty experienced in getting a satisfactory Dental Clerk Attendant in the early months of the year, but a very efficient Dental Attendant was finally appointed in September, 1931, which appointment has enabled me to increase output latterly. This experience of the difficulty in securing satisfactory assistance has led me to the conclusion that the time has come when junior Dental Clinic Clerk-Attendants should be appointed to be trained up to the work, to avoid disturbing the continuity of the Clinic work as far as possible. I put the preliminary qualifications for such female " apprentices " as:—minimum age 16, useful knowledge of shorthandtypewriting, personality (for dealing with mothers and children in connection with the trials of dental treatment), good teeth, legible writing and accuracy at simple arithmetic. The number of cases awaiting treatment at the end of the year was rather large, and the consideration of the appointment of an additional half-time Dental Surgeon cannot be much longer delayed if the demands of the work are to be met. The work divides itself into sections:— 1. Inspection. 2. Conservative Treatment. 3. Treatment by Extractions, with and without general anaesthetics. 4. Orthodontic Treatment. 5. Other operations. The number of children inspected—6,804, is somewhat higher than last year's figure. Of these 5,152 were found to require treatment, or 75.72 per cent. In the Annual Report of Sir George Newman for 1930—" The Health of the School Child," the findings throughout the country show that 69.5 per cent. of the children inspected required treatment. 51 The Routine Inspections have completely surveyed the children in the schools, apart from absentees and objectors, and some of the children in the Bulstrode School, which was only opened late in the year. The findings at these Inspections are shown in the Tables in this report. Following the formal recognition of the Dental Nurse by the Board of Education in March, 1931, she has been used to a large extent to relieve me of much of the routine inspecting, charting and recording work, and of the 6,804 children seen at routine inspections 3,605 were inspected by me and 3,199 by the Dental Nurse, the latter working at a speed and with such accuracy as to call for special praise. An endeavour is now being made also to catch absentees from Dental Inspections by notifying the parents that their children have missed the annual Dental Inspection, and offering them an opportunity to come to the Clinic if they so wish. Sixty-one cases availed themselves of this offer, and these children were also inspected by the Dental Nurse on coming to the Clinic. With regard to the Board's Table IV., Group IV. (Dental Defects, page 48) it should be noted that the figure " specials," 1,486, represent special " Inspections " of various kinds at the Clinic and not individual children. Some of these specials will also have had a Routine Dental Inspection and be included in these figures. They also may have had to be referred more than once as specials, and will thus have been recorded on each occasion as a special inspection. The 1,486 are made up as follows:— Number Total Referred for Gas, or Gas and Ethyl Chloride 768 Advice found necessary; Routine Clinic Work 135 Advice (Orthodontic) to parents re cases found at Inspections and during Clinic Visits ... 345 Treatment postponed 173 Absentees at School Inspections; inspected at Clinic 61 Inspection after Gas—required further treatment 4 1,486 It may be said that the chief aim of the treatment here is towards conserving the teeth, keeping extractions down to a minimum. This is indicated by the fillings figure—3,085, which works out at nearly 85 fillings per 100 children treated ; the figure for the whole country averages 68 fillings per 100 children treated, ("Health of the School Child—1930"). 52 Our ratio of fillings to extractions (permanent teeth) was 625 fillings to 100 extractions. Conservative Treatment.—A considerable amount of use has been made of Silver Nitrate treatment. This of course does not consist of filling a tooth (which has to be explained to parents), but treating a decaying temporary tooth in such a way as to relieve pain, make the tooth able to function, arrest the progress of caries, and save the tooth till the last moment possible; a highly important matter in relation to the orthodontia of the mouth. Generally speaking this treatment has been very successful in the type of case to which it has been applied. Two hundred and sixty-five such treatments were applied in 1931. Extractions.—The number of teeth extracted was 4,444 (431 permanent—4,013 temporary), which again compares favourably with the average for the country as given in the same report above referred to. The average figure is 211 extractions per 100 children treated; our figure was 174 extractions per 100 children treated, again indicating the desire to save, rather than extract a tooth which can be made useful. The form of the Board's Table IV. showing dental defects has been amplified (pages 58 and 59) in order to show items of information which may help towards the proper comparison of the dental statistics of different authorities. It would seem helpful if such a form, amplified along these lines, could be generally adopted. A better appreciation of their import might be conveyed to the reader if opposite certain figures percentages could be shown throughout the whole table, where possible and applicable. The 1,206 "administrations of general anassthetics for extractions" represents the number of times gas was given, and not the number of sessions devoted to extractions under gas, which was 91. In some districts very few extractions appear to be done under a general anaesthetic. The number of children in respect of whom these administrations were made was 1,094, as some of them had to come in more than once for gas, where extractions could not 'be completed at one sitting or was not considered advisable. ORTHODONTIC SCHEME. The Orthodontic Scheme, fully described in last year's Report, continues to function very successfully. A further 110 cases came under treatment during the year 1931, making the total that have come under treatment since its inception in May, 1930—253, a total of 18 months under review. 53 Of these 34 have completed treatment, 157 are under treatment and the remainder have been closed for various reasons, such as " left district," but the majority of the closed cases had practically completed treatment. The need for Orthodontic treatment is very definitely established, but it must be admitted that considerations of time and cost will be factors which may have a detrimental influence against its widespread and general extension. The estimated number of children with minor orthodontic defects—who attend the Clinic here—is as high as 15 per cent. During the year 345 children were seen either at Inspections or Clinics with " substantial misplacements," the parents were given the full particulars to enable them to take advantage of the Orthodontic scheme for their children if they so desired, and 110 accepted treatment. The following table gives some indication of the work involved during the past year. Dental Clinic—Orthodontic Work, Year 1931. Orthodontic Advice 345 Impressions taken—Upper 557 Lower 537 Fitted Appliances 165 Adjustments of ditto 657 Repairs of ditto 8 Cases periodically seen 380 Number of sessions 42 Dental Mechanic—times in attendance 42 Visits (in honorary capacity) by Royal Dental Hospital Consultant—Mr. Evans 2 The defects found since the scheme commenced are set out below, it being understood that the numbers do not represent individual patients, as one patient may have several defects. 54 Orthodontic—Defects Found. Year 1930 (7 months only). Year 1931 (A full year) Narrow Arches (Contracted Jaws) 24 l6 Labioversions (Labioplacements) 20 14 Linguoversions (Linguoplacements) 20 23 General Crowding and Imbrications 32 57 Interlocked (Crossed) Bites 2 1 Habits—Lip Suckers 3 2 Thumbs do. 2 0 Tongue do. 1 0 Finger do. 2 1 Nasal Obstruction — 1 Open Bite 2 3 Close Bite (Overlappings) 12 12 Perversions 4 2 Torsoversion (Medio-Disto-Placements) 14 27 Supraversion (Supraplacements) 2 1 Infraversions (Infraplacements) — 4 Inferior Retrusions 21 10 Superior Protrusions 1 2 Impacted Teeth 2 — Mouth Breathers — 2 Biting on the Gums — 12 Parent desiring Consultant's opinion . — 9 Buried Supernumerary Tooth — 1 Proclinations of Upper Fronts — 3 Erupting outside the Arch — 2 Erupting in the Palate ... — 1 Supernumerary Teeth — 2 Wide Diastema — 4 The object of the orthodontic scheme was to enable treatment to be obtained at the minimum expenditure of time and money on the part of the parents. To this end it was hoped that the single visit to the Royal Dental Hospital, for the Consultant's opinion and advice as to the lines of treatment, would suffice in nearly all cases. Quite an appreciable number, however, present conditions which necessitate a review by the Consultant say 3, 6 or 12 months later, as the condition develops, and in some cases the condition has not developed sufficiently at the second visit. This was got over to some extent by sending fresh models showing the latest development, and by leaving the Dental Surgeon here to decide whether a case had progressed sufficiently 55 to be reviewed by the Consultant, before sending one up on what might prove a fruitless visit. The most recent and successful procedure, however, was to collect these cases at suitable intervals, and Mr. H. R. Evans acted as Visiting Orthodontist from the Royal Dental Hospital and saw the cases at the School Dental Clinic. This proved extremely advantageous, and it is to be hoped that it may be possible in the near future to make permanent arrangements on these lines. For the year 1931 the following details of plates, etc., made for patients may be interesting. One plate may of course have several jobs to do in correcting different abnormalities in the one patient's mouth. Plates (all descriptions) 79 Progression, alterations to appliances 46 Replacing plates (entirely new) 23 Repairs 12 Oral Screens 6 Lip Exercisors 6 The special orthodontic fees received for patients during 1931 amounted to £151 : 16: 0. The net cost of the scheme with the experience we have had of its working for about one year and seven months, would appear to be in the neighbourhood of £150 a year, after income has been allowed for. This figure included a proportion of staff costs, Royal Dental Hospital fees, payments to Mechanic for models, attendances at Clinic and appliances made, and a number of miscellaneous expenses; indeed all expenditure that would not have been incurred had not the scheme come into being. The probability is that this figure may increase to about a net £200 a year. In four cases where the extraction of permanent teeth was unavoidable, and children were leaving school, dentures were provided. These are charged for on the same scale as dentures supplied to mothers. Forty-two sessions were entirely devoted to this work, the Dental Mechanic then being in attendance. Monday morning is the established Orthodontic session. 56 Other Operations.—The figure shown in the table—3006— is made up as follows, and is of course considerably augmented by the orthodontic scheme, as this work in statistical form cannot be shown elsewhere in the Board's table:— Number Grand Total. Silver Nitrate Treatment 265 Dressings 261 Scaling and Polishing Teeth 64 Treatment of Gums 59 do. by Drugs 5 do. by Knife 3 Devitalizing the Pulp 18 Separating Teeth 23 Repairs to Appliances 8 Dentures fitted (Children) 4 Impressions taken—upper and lowers 1094 Appliances fitted 165 do. adjusted 657 do. use supervised 380 3006 Attendances Made by Children for Treatment.—The figure 5035 shown in the Board's table is not the gross figure of school children's attendances at the Dental Clinic, which was 6681, all of which were nominally " attendances for treatment," but, although making such attendances, only 5035 were treated physically, the remainder being referred for gas, given advice, inspected, treatment postponed, etc., which latter classes of attendances were counted as special inspections. Emergency Cases.—This branch of the dental service has now been running for over two years, and is being increasingly appreciated. In order to save children from suffering pain, a scheme was devised whereby any urgent dental case could be referred by any Head Teacher to the Clinic, on any afternoon when the schools were open, at 2 p.m., which was later changed to 1.45 p.m. On coming into the Clinic these cases are dealt with in addition to the normal appointments, and take precedence over them. This is a humane provision and, during the year 1931, 757 cases were so referred by the Head Teachers. 57 It will be realized that this on occasions means a more or less unexpected and substantial addition to an afternoon's work, but with the intelligent co-operation of the Head Teachers, who have been asked strictly to limit the issue of these tickets to really urgent cases, it has been found to fill a real need in avoiding perhaps several days' delay in getting treatment. Several unfortunate cases of teeth being fractured as a result of a child's fall in the playground, have also been dealt with, but these present their own special problem, and arrangements are being made for these to be dealt with by the Royal Dental Hospital in view of the necessity for a Radiogram, to arrive at the amount of unseen damage. The second Dental Chair which was purchased during the year has proved invaluable since the Dental Nurse's official recognition, as she has been able to undertake much minor dental work, working side by side with and under the supervision 'of the Dental Surgeon. The Dental Clinic fee of I /- payable by each patient has again operated throughout the year. It covers one year's ordinary treatment at the Dental Clinic, and includes a general anesthetic when this is necessary. Orthodontic fees are additional to this. The fees taken at the Clinic during 1931 were as follows:— From School Children treated (ordinary 1/- fee) £111 13 0 From School Children (orthodontic fees) 151 16 0 From Maternity and Child Welfare cases treated 1 /- fees 8 14 0 I. COHEN, L.D.S., R.C.S. ENG., School Dental Surgeon. DENTAL INSPECTION AND TREATMENT—YEAR 1931. Average number of Elementary School children on registers at middle of year (June)—8829. Age. No. Total. No. Requiring Treatment. Percentage Requiring Treatment. Remarks. 1. No. of 5 765 520 67.9 Percentage inspected at Routine Inspections worked out on school population as at middle of year = 77 per cent. (a) children 6 814 659 80.9 who were 7 909 6 79 74.6 inspected 8 903 666 73.7 at Routine 9 923 714 77.3 Dental 10 951 744 78.2 spections. 11 760 606 79.7 12 336 263 78.2 13 302 221 73.1 14 109 80 15 30 16 2 6804 5152 75.7 No. of Special Inspections 1486 (b) No. of children found to require treatment at Routine Dental Inspections 5152 Remarks. This equals 75.7 per cent. of the children inspected at Routine Inspections. (c) No. of children actually treated 2555 In arriving at this figure each child is only counted once even though it attended several times during the year for treatment. The percentage of children treated of those found to require treatment at Routine Inspections is 49.6. 58 2. Half days devoted to Inspection 42 Average number inspected per session=162. Included in the 313 ordinary treatment sessions are 42 sessions which were entirely devoted to Orthodontic Treatment. These sessional figures are for one Dentist only. Treatment—ordinary 313 do. gas 91 Administration—Clerical 24 Dental Committee Meetings 8 478 3. Attendances made by children for treatment 5035 The gross attendances made by children at the Dental Clinic were 6681, but children were not always physically treated, for various reasons, each time they attended. 4. Fillings—Permanent Teeth 2695 The ratio of fillings in permanent teeth to extractions of permanent teeth was 625 fillings to 100 extractions. Temporary Teeth 390 3085 5. Etractions— Perm. Temp. At Treatment sessions 2 486 At Gas sessions 429 3527 431 4013 4444 6. Administrations of general anaesthetics* for extractions (* Nitrous Oxide, and Nitrous Oxide with Ethyl Chloride.) 1206 The percentage of attendances for " Gas " (1206) of total attendances (5035) was = 23.9. 7- Other operations Special work undertaken.—An Orthodontic Scheme. 3006 See details on page 56. Other work.—Maternity and Child Welfare Dental Scheme for children up to 5 years of age, and nursing and expectant mothers. Staff responsible for the above work.— 1 Dental Surgeon. Extra Staff for Gas sessions only. 1 Dental Nurse, formally approved by Board of Education, for minor dental work, 17/3/31. 1 Anaesthetist (Assistant School Medical Officer). 1 Trained Nurse (Recovery room). 1 Clerk-Attendant. For Orthodontic Sessions:— Plus clerical assistance from Office of School Medical Officer. Once a week the Dental Mechanic is also in attendance. 59