Borough of Heston and Isleworth. 1932 ANNUAL REPORT of the Medical Officer of Health and School Medical Officer for the BOROUGH OF HESTON AND ISLEWORTH for the Year ending 31st December, 1932. LOWE & SONS (PRINTERS) LTD., 52, Hanworth Road, Hounslow 1932. REPORT on THE HEALTH of the BOROUGH OF HESTON & ISLEWORTH FOR THE YEAR 1932. by ELWIN H. T. NASH, m.r.c.s., l.r.c.p., d.p.h. Medical Officer of Health. Index. Ambulance Facilities 13 Ante-Natal Care 44-46 Birth Rates 6 Canal Boats 22 Cerebro-Spinal Fever 35, 39, 40, 41 Chicken Pox 36 Children Act 15 Cleansing of Verminous Persons 36 Clinics and Treatment Centres 14 Deaths, Causes of 7 Death Rates 6 Dentures for Mothers 47 Diphtheria 31, 35, 38, 39, 40, 41 Diphtheria Immunization (Report by Dr. Bousfield) 31-35 Drainage and Sewerage 16 Encephalitis Lethargica 35 Enteric Fever 35, 39, 40, 41 Erysipelas 35, 39, 40, 41 Food, Inspection and Supervision of 28-30 General Provision of Health Services in the Area 10-13 Home Help 49 Home Visiting 49 Hospitals 11, 12 Housing 23-27 Industries, Local 9 Infant Deaths 6, 8 Infant Life Protection 15 Infectious Diseases 31-41 Influenza 36 Inspection and Supervision of Food 28-30 Laboratory Statistics 10 Legislation in Force 11 Malaria 36 Maternity and Child Welfare—Attendance at Centres 43 ,, ,, Centres 14 ,, ,, Dental Treatment 46-48 ,, ,, General Arrangements 42-50 ,, „ Grants of Milk 49, 50 „ ,, In-patient Treatment for Dental Cases 48 Measles 36 Meat 28, 29 Midwives 10 Milk 28, 30 ,, Grants to Expectant and Nursing Mothers and to Children under three years 49, 50 Mumps 36 Notification of Births 48 Nursing in the Home 10 Ophthalmia Neonatorum 39, 40, 41, 50 Physical Features of District 8 Pneumonia 36,39,40,41 Poliomyelitis, Acute 35, 39, 40 Poor Law Medical Relief 10 Population 6 Puerperal Fever 35, 39, 40, 41 Puerperal Pyrexia 35, 39, 40, 41 Sanitary Circumstances of the Area 16-22 Scarlet Fever 31, 39, 40, 41 Smallpox 35, 39, 40 Staff 5 Tuberculosis 36, 37 Venereal Diseases 14 Vital Statistics 6 Voluntary Societies and Helpers 48 Water Supply 16 Whooping Cough 36 Public Health Department, 92, Bath Road, Hounslow. June, 1933. To the Chairman and. Members of the Heston and Isleworth Borough 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. 3 THE HEALTH COMMITTEE of HESTON AND ISLEWORTH BOROUGH COUNCIL. as on 31st December, 1932. Alderman J. J. Clements, J.P. (Chairman). „ J. J. Bonnett, O.B.E. (Vice-Chairman). „ H. J. Nias, M.B.E., J.P., ex-officio. „ A. A. Bergin, J.P., ex-officio. „ G. R. Speed. Councillor F. W. Buckley. T. W. Cox. Councillor E. E. Forrest. „ H. F. Metcalfe, M.B.E., D.C.M. „ D. Rhys. „ G. N. Shackleton. „ D. J. Thomas. „ A. C. Turner. „ J. Woulfe. Medical Officer of Health: Elwin H. T. Nash, M.R.C.S., L.R.C.P., D.P.H. MATERNITY AND CHILD WELFARE COMMITTEE. Councillor F. W. Buckley (Chairman). Alderman A. A. White. Councillor E. E. Forrest. „ A. L. Lang. „ Mrs. R. New. Councillor D. Rhys. „ A. C. Turner. „ Mrs. N. Wood. „ R. Wright. Co-opted Members: Mrs. E. Chedgey. Mrs. S. Spooner (Vice-Chairman). 4 STAFF. The following persons constituted the Staff of the Health Department during 1932:— 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. (Left April, 1932). Victor Freeman, M.R.C.S., L.R.C.P., D.P.H. (Commenced August, 1932). 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). Dental Surgeons— I. Cohen, L.D.S., R.C.S. (Eng.) H. F. Metcalf, L.D.S., R.C.S. (Eng.) (Part time). 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 A. B. Hauldren, Cert. as S.I. and M.I. A. H. Cornhill, Cert. as S.I. and M.I. Disinfector and Laboratory Attendant— F. J. Cobb. Assistant Disinfector and Laboratory Attendant— J. Josephs (Part time). Health Visitors and School Nurses— Mrs. C. E. M. Ottley, Cert. C.M.B., H.V. & S.N., M.C.W.W. Miss B. N. Tetley, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the 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. (Left Oct., 1932). 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. (Left Sept., 1932). Miss G. M. Clare, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss E. I. Bartlett, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced Sept., 1932). Miss G. F. Richardson, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced Oct., 1932). Also one Temporary Health Visitor. Home Help— Mrs. E. Yates. Chief Clerk— B. W. Kilby, Cert. as S.I. and M.I. Clerks— Miss R. Marshall, Cert. as S.I. P. T. H. Crandon. Miss G. E. Curtis. (Left June, 1932). K. I. Bisshopp. H. J. Aldhous. F. V. Bell. E. E. Forrest. Miss D. M. Dowling. Miss V. D. Nicholls. R. Moore. Vacancy for one Junior Clerk. Medical Superintendent, Mogden Joint Isolation Hospital—(Joint Isolation Hospital, Richmond with Heston and Isleworth)— Alex. Edward Gammie, M.B., Ch.B. 5 Natural and Social Conditions of the Area. EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1932. Area (in acres) 6,851 Registrar-General's estimate of resident population (Mid-Year) 1932 81,100 Census Population, 1931 75,446 Number of inhabited houses (end of 1932) according to Rate Books 19,983 Rateable Value (at 31st December, 1932) £595,505 Sum represented by a penny rate (1931-32) £2,345 Live Births— Total. M. F. Legitimate 1367 698 669 Birth rate per 1,000 of the estimated resident population 17.36 Illegitimate 41 18 23 Stillbirths 35 18 17 Rate per 1,000 total (live and still-births) births 24.26 Deaths 788 383 405 Death rate per 1,000 of the estimated resident population .. 9.72 Deaths from diseases and accidents of pregnancy and childbirth from sepsis 3 from other causes 1 Death rate of Infants under one year of age:— All infants per 1,000 live births 60.34 Legitimate infants per 1,000 legitimate live births 59.99 Illegitimate infants per 1,000 illegitimate live births 73.17 Deaths from Measles (all ages) 14 Deaths from Whooping Cough (all ages) 5 Deaths from Diarrhoea (under two years of age) 9 Poor Law Relief.—I am indebted to the 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 1929-30-31-32:— 1929. £4373: 11:6 1930. £3947: 9:3 1931. £4529: 15: 2½ 1932. £6506: 5: 6 VITAL STATISTICS. Population.—The Registrar-General's estimate for the population for 1932 is 81,100. The Census population in 1931 was 75,446. Deaths.—The number of deaths registered in the district was 1586, but 907 of these did not belong to the district, while 109 residents died outside the district. Thus the number of deaths properly attributable to the district was 788. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 9.72 per 1,000, which is comparable with the following figures: 12.0 for England and Wales, and 12.3 for London. 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 1932 is 60.34 per 1,000 births, which is somewhat higher than last year. The rates for England and Wales and for London during the same period were 65 and 66 respectively. Births.—The total number of births registered during the year was 1729, excluding re-registrations, but 469 of these did not belong to this district, while 183 births properly belonging to this district occurred outside the district. The nett number of births thus attributable to the district is 1443. Adopting the population basis suggested by the Registrar-General for the calculation of the birthrate, this comes to 17.36 per 1,000. The birth-rate of England and Wales was 15.3 per 1,000, and for London 14.2 per 1,000. 6 Table of Causes of Deaths during 1932. Causes of Death. Civil Residents. all ages. Male. Female. All causes 383 405 1 Typhoid and paratyphoid fevers — — 2 Measles 5 9 3 Scarlet Fever — — 4 Whooping Cough 4 1 5 Diphtheria 1 2 6 Influenza 8 10 7 Encephalitis Lethargica — — 8 Cerebro-Spinal Fever 2 — 9 Tuberculosis of Respiratory System 21 30 10 Other Tuberculous Diseases 3 4 11 Syphilis — — 12 General Paralysis of the Insane, Tabes Dorsalis 3 — 13 Cancer, Malignant Disease 56 52 14 Diabetes 3 6 15 Cerebral Haemorrhage, &c. 9 19 16 Heart Disease 67 75 17 Aneurysm 1 — 18 Other Circulatory Diseases 31 16 19 Bronchitis 8 13 20 Pneumonia (all forms) 31 27 21 Other Respiratory Diseases 2 3 22 Peptic Ulcer 7 3 23 Diarrhoea, &c. (under 2 years) 5 4 24 Appendicitis 2 1 25 Cirrhosis of Liver 1 4 26 Other Diseases of Liver, &c. 1 1 27 Other Digestive Diseases 9 7 28 Acute and Chronic Nephritis 11 10 29 Puerperal Sepsis — 3 30 Other Puerperal Causes — 1 31 Congenital Debility, Premature Birth, Malformations, etc. 23 23 32 Senility 5 15 33 Suicide 10 5 34 Other Violence 28 13 35 Other Defined Diseases 26 48 36 Causes Ill-defined or Unknown — — Special causes (included in No. 35 above) Small-pox — — Poliomyelitis — — Polioencephalitis — 1 According to figures furnished by the Registrar-General. 7 INFANTILE MORTALITY DURING THE YEAR 1932. 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 mths 3 mths and under 6 mths 6 mths and under 9 mths 9 mths. and under 12 mths Total deaths under 1 year Certified 24 8 4 5 41 13 10 12 9 85 Smallpox Chickenpox Measles .. .. .. .. .. .. .. 1 .. 1 Scarlet Fever Whooping Cough .. .. .. .. .. 1 .. 1 1 3 Diphtheria and Croup Erysipelas Tuberculous Meningitis .. .. .. .. .. .. 1 1 .. 2 Abdominal Tuberculosis .. .. .. .. .. .. .. .. 1 1 Other Tuberculous Diseases Meningitis (not Tuberculous) .. .. .. .. .. 1 .. .. .. 1 Convulsions .. 1 .. .. 1 .. .. .. .. 1 Laryngitis Bronchitis .. .. .. .. .. 1 1 .. .. 2 Pneumonia (all forms) .. 2 .. .. 2 2 3 3 2 12 Diarrhoea .. .. .. .. .. .. 1 1 .. 2 Enteritis .. .. .. 1 1 1 2 1 .. 5 Gastritis Syphilis Rickets .. .. .. .. .. .. .. 1 .. 1 Suffocation, overlying Injury at Birth 3 .. .. .. 3 .. .. .. .. 3 Atelectasis 2 .. .. .. 2 .. .. .. .. 2 Congenital Malformations 2 2 .. 1 5 5 .. 1 1 12 Premature Birth 14 2 2 2 20 .. 1 .. .. 21 Atrophy, Debility and Marasmus 2 .. 1 1 4 .. .. .. .. 4 Other Causes 1 1 1 .. 3 2 1 2 4 12 24 8 4 5 41 13 10 12 9 85 Nett Births Legitimate 1367 Illegitimate 41 Nett Deaths Legitimate infants 82 Illegitimate infants 3 PHYSICAL FEATURES OF THE DISTRICT. The Borough 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. 8 The industries are increasing, the chief being:— (1) Beer, etc., brewing. (16) Motor Cars. (2) Boat building and repairing. (17) Fancy papers. (3) Colours and dyes. (18) Aeroplanes. (4) Flour, etc., milling. (19) Engineering works. (5) Gravel quarrying. (20) Disinfectants. (6) Market Gardening. (21) Laundries. (7) Rubber Tyres, etc. (22) Linoleum. (8) Pewterware & Candle Machinery. (23) Carbons, Stencils, Typewriter ribbons etc. (9) Pharmaceutical Chemistry. (24) Biscuit making. (10) Soaps, powders and perfumes. (25) Candle making. (11) Sweets, confectionery. (26) Cinema Screens. (12) Wines. (27) Pharmaceutical Manufacturing machinery. (13) Sawmills and Joinery. (28) Coach building and wheelwrights. (14) Fire extinguishers, etc. (29) Dyeing and cleaning. (15) Wireless apparatus and accessories. Gramophones. (30) Pre-cast concrete works. 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. 9 General Provision of Health Services in the Area. 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 17 Midwives practising in the district. This figure does not include 5 Midwives on the staff of the West Middlesex County Hospital. 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 614 medical orders during 1932. Some of these cases received also out-relief and institutional treatment. COUNCIL LABORATORY, 1932. Total. Positive. Swabs for Diphtheria sent by Medical Practitioners 335 25 Taken from Schools, Clinics and from Contacts 961 36 Sub-Cultures 25 5 Sent from Staines Joint Isolation Hospital 139 19 Total cultures examined 1460 85 Swabs examined by Clinical Research Association or at Other Laboratories (1 from Staines) 8 1 Virulency Tests (1 from Staines) 3 1 Blood examination for Enteric Widal Tests (1 from Staines) 8 — Specimens of Sputum for Tubercle Bacilli sent by Medical Practitioners 134 13 Specimens of Sputum for Tubercle Bacilli taken at Clinics 2 — Hairs for Ringworm taken at Schools or Clinics 19 7 Other Specimens— Urine 235 Discharge (2 from Staines) 18 Milk 40 Faeces (sent to Clinical Research Association) 1 — Faeces (sent to Hospital for Tropical Diseases) 1 — Blood examinations 28 Swabs examined for Cerebro Spinal Fever (sent to Clinical Research Association) (from Staines) 1 1 Preparation of Materials— Tubes of Serum 2050 Throat Swab Outfits 2350 Sputum Outfits 135 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 cf 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 Labotarories. 10 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., *III., *IV., *V., VI and VIII. *Public Health Act, 1925, Parts *II., *III., *IV., and *V. were adopted in November. 1925. Maternity and Child Welfare Act, 1918. Baths and Wash-houses 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 Refuse (P.H.A., 1875, s. 44). *Houses Let in Lodgings (P.H.A., 1875, s. 90). *Tents, Vans, Sheds, etc. (H.W.C.A., 1885, s. 9 (2). *Slaughter Houses (P.H.A., 1875, s. 169, and T.I.C.A., 1847, s. 128). *Prevention of Nuisances (P.H.A., 1875, s. 44). *Keeping of Animals (P.H.A., 1875, s. 44). *Removal of Offensive Matters (P.H.A.A.A., 1890, s. 26). New Streets and Buildings (P.H.A. 1875, s 157, & P.H.A.A.A. 1890, s. 23). Pleasure Grounds (P.H.A., 1875, s. 164). *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. 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 938 in-patients, whilst 4326 new out-patients received treatment. West Middlesex County 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 formerly 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 County Hospital, as compared with the local institutions. Owing to the increasing demand daily the Hospital accommodation is taxed to its utmost capacity, so much so that it has been found necessary to transfer minor cases to other Hospitals of the County Council. 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. 11 The Council annually subscribe £200 to the Hounslow Hospital and £50 to the Royal Hospital, Richmond. (2) Children.—The Children's Ward at the Hounslow Hospital contains 8 cots and 4 beds. A considerable number of children are also dealt with at the West Middlesex County Hospital and the London Hospitals. (3) Maternity.—There is no definite provision in the district other than the West Middlesex County Hospital for maternity cases, apart from private nursing homes charging considerable fees. The maternity block there, however, is greatly used 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 Institution in the Bell Road is now closed in so far as in-patients are concerned, but still remains open on certain sessions for out-patients. (6) Chronic Sick.—As far as I am aware, the only Hospital for these cases is the West Middlesex County Hospital. (7) Mental Deficiency.—There is no public or voluntary institution in this district. Cases are sent by the County Council and Public Assistance Authority to various Homes and Hospitals for which they are suitable. (8) Orthopaedic.—There is no special provision for orthopaedic treatment at the local Hospitals, apart from massage. Most of the patients requiring special advice or treatment attend at the Royal National Orthopaedic Hospital, London. (9) Ear, Nose and Throat.—The Hon. Ear and Throat Surgeon attends at Hounslow Hospital fortnightly, and in-patients are also dealt with for these conditions. The West Middlesex County 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 have been admitted, on the application of the Medical Practitioner attending, to the West Middlesex County Hospital. Occasionally a Medical Practitioner has arranged for a patient to go into Queen Charlotte's Maternity Hospital, Isolation Block, at Hammersmith, and negotiations are now proceeding to include this provision within the Corporation's Maternity and Child Welfare Scheme. (1) Ophthalmia Neonatorum.—An arrangements 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. The accommodation at Mogden is now insufficient for this district in view of the tremendous growth in the population, and from time to time arrangements have to be made for cases to be admitted to outside hospitals, usually those belonging to the London County Council. 12 A Joint Committee has however been meeting to consider a recommendation I made with regard to the formation of a Joint Hospital Board, made up of representatives from neighbouring districts in the South-West area of Middlesex, to consider the establishment of a central hospital or hospitals to serve that area. Meetings have been held to this end, and the Joint Committee is now reaching the end of its deliberations. Maternity and Nursing Homes.—The County Council is the Supervising Authority under the Nursing Homes Registration Act, 1927. Maternal Mortality.—These deaths are investigated by the Medical Officer of Health as far as possible, in conjunction with the medical practitioner in attendance, and the report is made on the prescribed form to the Maternal Mortality Committee of the Ministry of Health. Some difficulty is experienced in getting reports which are of any substantial value. 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 to 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 522 accident cases were removed to hospital, and 326 cases of non-infectious disease were removed to hospitals or nursing homes. 13 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 Borough Council. Diphtheria Immunisation Clinic Public Health Dept. Monday 2.0 p.m. „ Infant Welfare Centres Congregational Hall, Hounslow Tuesday 2.0 p.m. „ 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. „ Public Health Dept. Thursday 10.0 a.m. „ Maternity and Child Welfare Dental Clinic Public Health Dept. As for School Dental Clinics (see below) „ Minor Ailments Clinics (Nurse attending) Public Health Dept. Every week-day 9.0 a.m. „ Village Hall, Heston Every week-day 9.0 a.m. Isleworth Public Hall Every week-day 9.0 a.m. Ophthalmic Clinic Public Health-Dept. Thursday 2.0 p.m. „ Friday 2.0 p.m. School Clinics (Medical Officer attending) Public Health Dept. Tuesday 10. a.m. Heston & Isleworth Borough Council. Friday 10 a.m. Village Hall, Heston Thursday 10.30 a.m. Isleworth Public Hall Monday 10.30 a.m. „ School Dental Clinic Public Health Dept. Monday 9.30 a.m. and 2.0 p.m. Tuesday 9.30 a.m. and 2.0 p.m. Wednesday 9.30 a.m. and 2.0 p.m. Thursday 9.30 a.m. and 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 Sunday 7.30 a.m. to 7.30 p.m. 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 Maternity and Child Welfare Centres, and Public Health Department. All the Health Visitors are fully acquainted with the requirements of the Law, and they promptly investigate and report on such cases as come to their knowledge by verbal reports. The Health Visitors paid 558 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 child died during the year. This child (aged 3 months) was taken to the Maternity and Child Welfare Centre the day after he was received by the foster-mother, and was found to be marasmic. Four days later he was removed by the grandfather on the advice of whose doctor the child was admitted to Hounslow Hospital, where death took place after eleven days. Cause of death—Marasmus Acute Enteritis. 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. A list is kept of approved persons who wish to undertake the nursing and maintenance of a foster-child. No person is placed in this list until full details of her circumstances, etc., have been supplied, and the Health Visitor has found the condition of the home 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. Administration of Part I of the Children Act, 1908, during the year, 1932. (a) Number of persons receiving children for reward on the Register at the end of the year 54 (b) Number of children on the Register:— (i) at the end of the year 66 (ii) who died during the year 1 (iii) on whom inquests were held during the year Nil. (c) Number of Infant Protection Visitors holding appointments under Section 2 (2) at the end of the year who were:— (i) Health Visitors 7 (ii) Female, other than Health Visitors Nil. (iii) Male Nil. (d) Number of persons (in addition to or in lieu of Visitors under (c) above ) or societies authorised to visit under the proviso to Section 2 (2) Nil. (e) Proceedings taken during the year:— No. of Cases. Section of Act under which taken. Nil. — (f) Number of cases in which the local authority has given a sanction during the year:— (i) Under (a) of Section 3 Nil. (ii) Under (b) of Section 3 Nil. (iii) Under (c) of Section 3 Nil. (g) Number of orders obtained during the year:— From a Justice. From the local Authority. (i) Under (a) of Section 5 (1) Nil. Nil. (ii) Under (b) of Section 5 (1) Nil. Nil. (iii) Under (c) of Section 5 (1) Nil. Nil. 15 Sanitary Circumstances. Water Supply.—There were, as far as is known, at the end of the year, 28 private wells from which the water was used for domestic purposes. In 28 other cases there are 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 1932:— (a) Foul Water Sewers 12,910 feet. (b) Surface Water Sewers 26,200 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, approximately 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 1932 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.. 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 150 new ashbins. Sanitary Inspection of District.—See pages 17 to 20. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc.—The number of premises on which nuisances were outstanding at the end of 1931 was 487. To these another 744 premises whereat nuisances were recorded in 1932 were added, giving a total of 1231 premises. Of these 819 had the nuisances remedied, leaving 412 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 37 brought forward from 1931 made a total of 83. 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 48 of the houses. In two cases it was decided to take no further action, leaving 33 cases to be carried forward to 1933. Comparative figures for the years 1930, 1931 and 1932, in connection with nuisances, are submitted herewith:— 1930 1931 1932 Number of complaints received 566 495 493 Premises at which nuisances were located 902 792 744 Number of First Informal Notices 905 719 794 • Number of Reminders and Letters 861 472 571 Number of Statutory Notices 230 78 58 16 The housing problem, as I have said in previous reports, is one of extraordinary difficulty from many points of view. One is bound to admit that the removal of the Rent Restriction Act would in many cases, create immense hardship. For example, in one small street of houses the removal of the restriction would mean £1,000 extra per annum to the owner owing to the increased rent charged when a house becomes decontrolled. Proceedings.—Proceedings were taken in two instances against the owners for re-letting houses where Demolition Orders had become operative. In one case the defendant was fined £10 and £5 5s. Od. costs and an order made for the tenant to vacate the premises within fourteen days and in the other case a fine of £5 with £2 2s. Od. costs was imposed and an order made for the tenant to vacate the premises within fourteen days. In another instance an owner appealed against a Demolition Order and an undertaking that the house be not again used for human habitation was accepted . SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc. 22057 Inspections, etc., re Nuisances Contraventions, etc.:, Number of premises, etc., inspected on complaint 634 Number of premises inspected in connection with infectious diseases 162 Total number of premises, etc., primarily inspected in connection with nuisances 1199 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920-1923 4 Number of other visits made to premises, etc., in connection with nuisances, etc. 1794 Number of visits made to works in progress 3569 Number of interviews with owners, builders, etc. 2575 Action taken (including action taken under Housing Act, 1930, Section 17). Number of premises, etc., whereat defects, etc., were recorded during the year 744 Number of premises, etc., on which defects, etc., were remedied— (a) by owners or occupiers 795 (b) by local authority in default of owner or occupier 24 Number of cautionary or intimation notices given— (a) verbal 255 (b) written 539 Number of letters and reminders re nuisances sent 571 Number of Statutory Notices issued 58 Number of proceedings taken 2 Number of convictions obtained 2 Number of proceedings withdrawn — Number of cases dismissed — Number of appeals made against decision of Council 1 Number of appeals dismissed — Common Lodging Houses: Number registered 2 Number of inspections made 22 Number of contraventions outstanding from previous year — Number of contraventions found.. — Number of contraventions remedied — Number of contraventions outstanding at end of year — Canal Boats Used as Dwellings: Number of inspections made 76 Number of contraventions outstanding from previous year 7 Number of contraventions found.. 12 Number of contraventions remedied 15 Number of contraventions outstanding at end of year 4 17 Movable Dwellings, Caravans, Tents, etc.: Number of Inspections made 132 Number of contraventions outstanding from previous year 13 Number of contraventions found 11 Number of contraventions remedied 12 Number of contraventions outstanding at end of year 12 Bakehouses: Number in district (a) factories 18 (b) workshops 7 Number of underground bakehouses in district 1 Number of inspections made 312 Number of contraventions outstanding from previous year 3 Number of contraventions found 29 Number of contraventions remedied 30 Number of contraventions outstanding at end of year 2 Slaughterhouses (including Knacker's Yard): Number on register (a) registered premises .. 4 (b) licensed premises (including one licensed knacker's yard) 4 Number of inspections and visits made 987 Number of contraventions outstanding from previous year — Number of contraventions of byelaw 9—animals not effectually stunned with a mechanically operated instrument 4 Number of other contraventions found 21 Number of contraventions remedied 23 Number of contraventions outstanding at end of year 2 Cowsheds: Number of persons registered 5 Number of premises registered 5 Number of cowsheds on register 8 Number of milch cows in district 83 Number of inspections made 61 Number of contraventions outstanding from previous year 1 Number of contraventions found 3 Number of contraventions remedied 4 Number of contraventions outstanding at end of year — Dairies and Milkshops: Number of persons registered 70 Number of premises registered 36 Number of inspections made 734 Number of contraventions outstanding from previous year 7 Number of contraventions found 14 Number of contraventions remedied 7 Number of contraventions outstanding at end of year 14 Offensive Trades: Number of businesses established in district 18 Number of inspections made 252 Number of contraventions outstanding from previous year — Number of contraventions found 6 Number of contraventions remedied 6 Number of contraventions outstanding at end of year — Ice Cream Vendors: Number on register 68 Number of inspections made 344 Number of contraventions outstanding from previous year — Number of contraventions found 5 Number of contraventions remedied 5 Number of contraventions outstanding at end of year — 18 Public Health (Meat) Regulations, 1924: Number of inspections made 885 No notice of slaughtering given 1 Improper notice of slaughtering given 17 No precautions taken for the prevention of contamination 5 Written notices sent — Verbal notices given 17 Inspection of food: Number of meat inspections 1098 Number of fish inspections 267 Number of provision inspections 583 Number of greengrocery and fruit inspections 511 Number of hawkers' foodstuff inspections 222 Number of other food inspections 103 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 7 Number of carcases surrendered (excluding offal) — Number of articles surrendered — Number of parcels surrendered 12 Number of organs or parts surrendered during slaughtering 299 Infectious Diseases, Disinfections, etc.: Number of visits made 833 Number of rooms disinfected— (a) Ordinary infectious diseases 300 (b) Tuberculosis 121 (c) Other diseases 24 Number of rooms stripped and cleansed after infectious diseases— (a) by owners or occupiers 19 (b) by local authority 6 Number of articles disinfected or destroyed 1641 Smoke Abatement: Number of observations made 164 Number of nuisances outstanding from previous year 1 Number of nuisances found 13 Number of nuisances abated 14 Number of nuisances outstanding at end of year — Water Supply: Number of supplies provided or reinstated 9 Number of cisterns cleansed, repaired, covered, etc. 1 Number of draw taps connected direct to main 47 Number of water service pipes or taps repaired 11 Number of samples taken for analysis from local wells 3 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 46 Number of walls, etc., cleansed 9 Number repaired, supplied with water or otherwise improved 321 Number cleansed or unstopped 6 Approximate percentage of houses provided with water closets 99 19 Sinks: Number of new sinks provided 81 Number of sinks repaired or improved 18 Drains: Number examined, exposed, etc. 3 Number unstopped, repaired, trapped, etc. 109 Number of waste pipes provided, disconnected, repaired trapped or unstopped 57 Number of ventilating shafts fixed, repaired or improved 19 Number of fresh air inlets provided, repaired or improved 10 Number of gully traps inserted or improved 144 Number of inspection chambers inserted 7 Number of disconnecting chambers improved, sealed or cleansed 1 Number of inspection chambers repaired, improved, sealed or cleansed 11 Number of drains constructed or reconstructed 3 Total length of drain pipes laid (4in.-382ft.) (6in.-lft.) 383ft. Number of tests and re-tests applied 37 Number of other works executed 2 Approximate percentage of houses draining into Council's sewer 99 Cesspools: Number rendered impervious, emptied, cleansed, etc. 5 Removal of Household Refuse: Number of new ashbins provided 150 Number of ashbins repaired 6 Dampness: Number of roofs stripped, renewed or repaired 286 Number of gutters and rain water pipes provided, repaired or unstopped 272 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 418 Number of damp-proof courses provided 132 Number of yards paved, repaired or drained 191 Interior Work: Number of rooms stripped and cleansed (other than in connection with infectious disease) 210 Number of floors, walls and ceilings repaired or renewed 1562 Number of rooms in which ventilation provided or improved 29 Number of rooms in which lighting provided or improved 51 Number of window frames and sashes provided, repaired or unfixed 1151 Number of stoves or grates provided or repaired 389 Number of instances in which ventilation under floors provided or improved 121 Number of other repairs 427 Sundry Nuisances, etc.: Number of instances in which domestic cleansing enforced 10 Number of foodstores provided, cleansed or improved 27 Number of washing coppers provided or repaired 139 Number of rooms sprayed for the removal of vermin by the Disinfector 47 Number of instances in which overcrowding abated 87 Number of instances of improper keeping of animals abated 12 Number of offensive accumulations removed 33 Number of urinals provided, repaired, cleansed or improved 45 Number of dung pits provided, repaired or improved 3 Number of other nuisances abated 46 20 Report on the Administration of the Factory and Workshop Act, 1901, IN CONNECTION WITH FACTORIES, WORKSHOPS AND WORKPLACES. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspection made by Sanitary Inspectors. Premises. (1) Number of Number on Register. (2) Inspections (3) Written Notices. (4) Prosecutions (5) Factories (including Factory Laundries) 138 370 11 Nil. Workshops (including Workshop Laundries) 156 469 4 Workplaces (other than Outworkers' premises) 48 87 5 Outworkers 35 111 .. Total 377 1037 20 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. 1 Number of Defects. Outstanding Jan. 1st. 1932. 2 Found during 1932. 3 Remedied during 1932. 4 Outstanding Dec. 31st. 1932. 5 Referred to H.M. Inspector. 6 Number of Prosecutions. 7 Nuisances under the Public Health Acts.—* Want of cleanliness 2 9 8 3 Nil. Nil. Want of ventilation .. .. .. .. Overcrowding .. .. .. .. Want of drainage of floors .. .. .. .. Other nuisances 7 27 32 2 Sanitary accommodation—† Insufficient 1 2 2 1 Unsuitable or defective 3 20 21 2 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 17 16 2 Other offences:— Excluding offences relating to outwork. .. .. .. .. Total 14 75 79 10 Nil. Nil. *Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act, 1901, and remediable under the Public Health Acts. †Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by the Corporation, and the standard of suffciency and suitability of sanitary accommodation for persons employed in factories and workshops enforced is that required by the Sanitary Accommodation Order of 4th February, 1903. 21 OUTWORK. (a) Outwork in unwholesome premises, Section 108 Nil. (b) Outwork in infected premises, Sections 109-110 Nil. PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS. OR REGULATIONS. There are 394 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. Three new schools, Chatsworth Junior, Heston Senior, and Marlborough Senior, were opened during the year, and there are now 18 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. COPY OF REPORT FORWARDED TO THE MINISTRY OF HEALTH DATED 9th FEBRUARY, 1933, 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 Re-port for the year ended. 31st December, 1932, as to the execution of the Canal Boats Acts, 1877, and 1884, and of the Regulations made thereunder, within the Borough of Heston and Isleworlh, Middlesex. Inspectors Appointed under Canal Boats Acts, at 31st December, 1932:— R. H. Butler {Chief Sanitary Inspector). G. W. Ashworth (District Sanitary Inspector). A. B. Hauldren (District Sanitary Inspector). A. H. Cornhill (District Sanitary Inspector). No special remuneration is paid for the position. Number of Inspections, etc.:— Number of Inspections made 76 Number of Canal Boats inspected 76 Number of boats found in order 65 Number of boats with two infringements 1 Number of boats with one infringement 10 Nature of Contraventions, etc.:— Cabins overcrowded 2 Paintwork of internal surfaces of cabin requiring renewing 2 No proper water vessels provided 1 Registration certificate not in order 6 Lettering, marking and numbering obliterated 1 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. 22 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 903 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 44, and the total amount of loans under the Small Dwellings Acquisition Act up to the end of 1932 was £3,023,149. 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. Last year I drew attention to the tragedy of Housing, conditions and rent and its effect on Nutrition. Again, and in more emphatic manner, I urge the importance of the problem and its solution. If it be true that as Queen Mary said "Calais" would be found written on her heart after death, so for many a Medical Officer of Health "Housing" will be found deeply graven. The reiterated appeals of those decent folk living under conditions that make life intolerable, that mean for the children a perpetual atmosphere of "D'ont," and for the harassed mother in the one room no freedom even to talk after the children are asleep, and for the parents that absence of privacy which makes things unbearable, coupled with the knowledge that it is not in one's power to help, fill one's days with a sense of helplessness which is a constant fret. In addition there is the knowledge that there are tenants earning up to £500 a year and the humilating knowledge that we have aimed too high and left stranded so many of those who, from the health point of view, and particularly that of the rising generation, are most in want of housing accommodation suitable to their needs. One is haunted by the pallid faces of some of the children and mothers living a life, " crimped, cabined and confined," and nutritionally below the needs of health. True there is that constant residuum of unhelpables that I believe the Socialists admit at 12% comprised largely of the subnormalsthe dull and backwards at school, who leave to join the army of sluts that transform the model house into a monument of inefficiency. These can only be classed as unhelpable. It isn't drink in most cases, it is want of " Grey Matter." But beyond these are many of those mothers whose strivings and whose patience compel one's whole hearced admiration and sympathy. We see so often that sick heart, made sick by hope deferred by the Housing Officer's tale of the waiting numbers, now in this area about 1,350. True a few of these are trying to get a Council House by deliberately getting into financial arrears by overhousing, hoping that their financial embarrassment will be their foremost claim to consideration for a Council House. Often the rents of the new houses have been beyond the purses of these humble folk, in many cases almost half their income going to pay for the roof over their heads, what time their bellies are bereft of the four or five shillings difference in the rent that their newer house entails. Nor is this the whole tale. For the families that are rehoused from one or two rooms, their rehousing means that the house has to be furnished. This means from l/6d. up to 5/- a week on the hire purchase system, and still less money available for nutritional needs. Housing Estates built by private enterprise still keep going up, and the houses find purchasers through building societies. But what of the future of these houses? One large estate, as nice an estate one could wish to see, started off with single owner occupiers with small initial payments and heavy rates of repayment. It is abundantly evident, that for an ever increasing number of the occupiers, the payments are beyond their capacity to maintain, even if in work. Now in house after house either the upper half is let as a separate flat or there are one or two lodgers. In one case three separate families were occupying one of these small modern houses with three bedrooms, and there was still the small bedroom used, only as a lumber room. Referring to this area, a large itinerant fishmonger who had combed the estate thoroughly, remarked to me that he thought there were only thirty-three customers worth catering for ! What is and has been wrong throughout the County ? Mainly the fact that the persons who know most of the real needs and facts, viz., the Medical Officers of Health, have been left out of the deliberations on housing and rehousing. 23 The nett result is what? In some cases, as I have said, houses occupied by individuals earning as much as £500 a year! But in case after case, the poorest, those whose housing needs are dictated by what should be the dominant need, viz., health, are still waiting, still appealing, for the decencies and amenities that they see doled out to those who can afford other accommodation. Applications have even been sent in asking for power to erect garages for the motors that the lucky occupants can afford ! So far as I know, with all the plethora of effort, mainly because they don't know the need, not one of the architectural wiseacres has solved the problem of the perambulator. Even the B.B.C. tried and published plans where a definite effort had been made, but it was no solution. Fortunately the present type of perambulator is not so destructive to walls and doorposts as was the older one with its larger wheels and projecting hubs and handles with metal shod ends. Unfortunately for a number of the poorest tenants these are still in use, purchased second and third hand. Those of us who know these homes realize as no Architect or Surveyor seems to, the damaged doorposts, and in those humble homes where the perambulator is used as the baby's cot in the living room, the dado of dirt round the room at perambulator level, resulting from the expression of the emotions of joy or rage of the occupant of the perambulator by means of its "puggy" hands on the wall. Some Authorities provide a really good standard shed which will house the perambulator and all the garden tools, etc., at a weekly rental of sixpence. Still there is room for ingenuity, especially in the non-parlour type. Could not the perambulator te housed in a special cupboard or recess with a separate door like the old fashioned coal hole, the recess being placed against the party wall and the roof of it acting as the "dresser" inside the living room? This would mean that the "pram house" would be dry and the pram aired, but it would never get inside the house. Surely there is some solution ? During the year in connection with the inspection of existing houses under the Housing Consolidated Regulations, 1925 and 1932, the housing work has continued along the lines adopted in 1931 and material progress has been made in dealing with the listed houses that could be dealt with by the service of notices. At the end of the year the Housing Inspector resigned his appointment and the vacancy was filled by the appointment of one of the District Sanitary Inspectors who had the necessary experience, and this has ensured a continuance of the work without a break. HOUSING CONDITIONS STATISTICS. 1. GENERAL. Number of New Houses erected during the year:— (a) Total (including figures given below) 997 (b) With State assistance under the Housing Acts:— (1) By the Local Authority 158 (2) By other Bodies or Persons — 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) 532 (b) Number of inspections made for the purpose 532 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 and 1932 215 (b) Number of inspections made for the purpose 215 (3) Number of dwelling-houses found to be in'a state so dangerous or injurious to health as to be unfit for human habitation 30 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 255 24 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 229 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 37 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 17 (b) By local authority in default of owners 24 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 5 (b) By local authority in default of owners 1 C. Proceedings under Sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling-houses in respect of which Demolition Orders were made 19 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 24 (3) Number of dwelling-houses rendered fit in consequence of undertaking given by owner 5 (4) Number of dwelling-houses in respect of which Demolition Orders were suspended and undertaking from owners accepted, not to relet after present tenants had vacated 2 (5) Number of prosecutions taken for letting, attempting to let, occupying or permitting to occupy houses ordered to be closed 2 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 became operative requiring repairs Nil. (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners Nil. (b) By local authority in default of owners Nil. (3) Number of dwelling-houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil F. Proceedings under Section 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling-houses in respect of which Closing Orders became operative . . Nil. (2) Number of dwelling-houses in respect of which Closing Orders were determined, the dwelling-houses having been rendered fit Nil. (3) Number of dwelling-houses in respect of which Demolition Orders became operative Nil. (4) Number of dwelling-houses demolished in pursuance of Demolition Orders 21 25 6. Other matters:— (1) Number of dwelling-houses demolished voluntarily .. 14 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. Table shewing dwelling-houses represented as unfit for human habitation prior to the passing of the Housing Act, 1930. Premises. No. of houses represented as unfit. 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 1931:— 1-3, Poplar Cottages, Town Whar 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 10/10/32 1-10, Syon Place, London Road Brentford End 10 10/6/29 23/7/29 .. 25/3/30 10/10/32 65-75, Hanworth Road, Hounslow 6 13/5/29 25/6/29 .. 28/10/30 18/5/32 †240 & 242, London Rd., Isleworth 2 11/11/29 17/12/29 .. 28/10/30 .. 6, London Road, Brentford End 1 9/12/29 28/1/30 .. 28/10/30 10/10/32 8, London Road ,, 1 26/11/29 25/2/30 .. 27/1/31 10/10/32 10 & 12, London Road ,, 2 26/11/29 17/12/29 .. 28/10/30 10/10/32 * Demolition deferred pending the widening of the street by the County Council. †11/1/32—Undertaking accepted that houses would not again be used for human habitation. 26 Table shewing dwelling-houses represented as unfit for human habitation since the passing of the Housing Act, 1930. Premises. No. of houses represented as unfit. Date of representation. Date houses rendered fit in accordance with undertaking. Date houses ceased to be used for human habitation in accordance with undertaking. Date Demolition Order made Date Demolition Order obeyed Date Demolition Order enforced. Br't forw'd from 1931:— 16-22, Barrack Rd., Hounslow 4 9/11/31 .. .. 26/1/32 .. 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 6/6/32 .. .. 7 & 9, Jersey Road, Lampton 2 8/6/31 .. .. 26/4/32 .. 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 6/6/32 91-97, New Heston Rd., Heston 4 11/5/31 .. .. 28/7/31 12/9/32 18, The Square, Isleworth 1 9/11/31 .. .. 12/11/31 .. Dealt with in 1932:— *Cottage in the Garden, Field Lane, Brentford End 1 8/2/32 .. 17/11/32 22/3/32 .. 2, Gloucester Road, Hounslow . . 1 8/2/32 .. .. 22/3/32 .. Grays Cottage, 91, Jersey Road, Heston 1 8/2/32 .. .. 22/3/32 .. 1, 2, & 3, The Circle, Lampton Road, Lampton 3 7/3/32 .. .. 26/4/32 6/5/32 1-6, Formans Cottages, North Hyde Lane, Heston 6 7/3/32 .. .. 28/6/32 .. No. 2, Cottage, Wyke Green Farm Syon Lane, Isleworth 1 11/4/32 .. .. 28/6/32 .. 144-158b, Heston Road, Heston. 11 13/6/32 .. .. .. 2a, Church Street, Isleworth 1 11/7/32 .. .. .. 59 & 61, High Street, Hounslow. 2 12/9/32 .. .. .. 160a, High Street, Hounslow 1 12/9/32 .. .. .. 19, London Road, Brentford End 1 12/12/32 .. .. .. 21, London Road, Brentford End 1 12/12/32 .. .. * Following Owner's appeal against Demolition Order. 27 Inspection and Supervision of Food. I he following is the record of inspection of food premises:— Meat 1098 Fish 267 Provisions 583 Greengroceries and Fruit 511 Hawkers' Food Stuffs 222 Number of other Food Inspections 103 Milk.—I want again to draw attention to the enormous sale of sterilized milk that is taking place. It is true, the vast bulk of this is sold in special bottles and the public are aware it is a different kind of milk to the cream line pasteurised milk that they are accustomed to, but it is a product bereft of certain important properties, the importance of which seems to be increasing. Surely the time has come when it should be compulsory to designate sterilized milk according to its name so as to inform the public exactly what they are buying. A new danger has now arisen in the selling of loose sterilized milk, the public being under the impression and in fact are being told, that they are buying "new" milk. With all these designations the public is getting bewildered and the sooner their number is reduced, in my opinion, the better, but at the same time I feel that it is definitely unfair to the public that they should be supplied with sterilized milk when they are not aware of what they are buying. The position, as far as a Public Authority is concerned, is fraught with difficulty. The milk vendor who is selling sterilized milk loose may have sample after sample taken and his bacterial return and his fat content will appear satisfactory according to the present standards, and yet, he is selling what after all is an article not of the nature and substance demanded. The difficulty is, there is no legal definition of milk. One milk vendor of sterilized milk being asked what he sold simply replied to every question "milk." Except for the larger post-war prices, Wilfred Buckley's definition of milk as a "4d. opalescent fluid" seems as near the truth as anything else. Well may the public ask, what is milk ? 795 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 (6 shops.) "Grade A" (Tuberculin Tested) 9 (12 shops) "Grade A" — "Grade A" Pasteurised 1 (1 shop) "Pasteurised" 4 (12 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, 2518¾ 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 11.75 visits per month. There were 56 butchers' shops in the district at the end of 1932. 2. Public Abattoir.—There is no public abattoir in the district. Slaughtering may take place at any time, subject to the requisite notice being given. From time to time suggestions have been brought forward as to the possibility of establishing an abattoir. I have on every occasion advised against it, on the grounds that I do not think that at the present time the expense is justified, owing to the fact that by far the greater part of the meat coming into the district is bought at Smithfield and inspected there. There does not seem to be with the growth of the district any great demand for further facilities for slaughtering at present. 28 3. Action under Section 117, Public Health Act, 1875:—No unsound meat was seized during the year. 4. Tubercular Meat.—There was none seized, but 1666½ lbs. were surendered 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 mainly in the London wholesale meat markets. The Public Health (Meat) Regulations, 1924, continue to cause a considerable amount of work, and the amount slaughtered has become to a large extent stabilised. The slaughtering is often continued well into the evening to suit the personal convenience of the butchers. Most of the butchers continue to accept the restrictions imposed by the Regulations in the right spirit, but in 15 instances no notice or insufficient notice of slaughtering was given, a number of which could be avoided with a little forethought. There has been established 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 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 beneicial 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. Out of a total of 56 butchers' shops in the district, 38 are provided with fixed windows, of which number 2 were new shops in 1932, one other shop 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. The reason for limiting the scope of application of this section to rooms which are not or wil not be controlled by the Factory and Workshop Act, 1901, and any amending Acts is difficult to understand. As powers were already provided under the food clauses of the Public Health Act, for dealing with any foodstuffs which are diseased or unsound or unwholesome or unfit for the food of man and are exposed, deposited or in course of preparation for sale in any such rooms controlled by the Act, to restrict the powers of preventing contamination, which may ultimately result in unfitness, seems to be somewhat opposed to the guiding principles underlying the duties of public health officers, that it is better to prevent than cure. I wish to draw attention to the want of perspective in the way in which meat is dealt with, and such things as figs, dates, sweets and biscuits, which are eaten raw, are exposed in open shop fronts, barrows, and on street vendors' trays, on which horse dung and other filth has blown, whereas meat is cooked before being eaten. The time has come when legislation should be provided to insist that all such foods should be kept inside, and if possible under cover. Sale of Food and Drugs Act.—I am indebted to Dr. J. Tate, County Medical Officer, for the following report prepared by the Chief Officer of the Public Control Department, as to the samples purchased in this area during 1932. 29 Article. Taken. Adulterated. Milk 231 2 Cream 1 – Minced Beef 2 – Perchloride of Iron Gargle 1 – Sausages 9 – Syrup of Iodide of Iron 1 – 245 2 The two unsatisfactory samples of milk were informal samples taken in course of delivery by a provincial farmer. Subsequent samples were found to be geniune. 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 during the year 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 the County Council's whole time veterinary inspector. During 1932, 435 inspections of cows were carried out in Heston and Isleworth, but none of these cows was found to be suffering from tuberculosis. One cow was reported by its owner as suspected to be suffering from tuberculosis, this diagnosis was confirmed and the cow slaughtered. During the year 1932 twenty-five samples of milk were taken from a retailer in the district. The samples were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. Three samples were found to contain living tubercle bacilli. Two of these samples were traced to farms in Berkshire and one to a farm in Hampshire. The County Medical Officer of Berkshire has informed me that two cows with suspicious udders were found on one of the farms concerned and samples of their milk taken for examination, but the results of this examination have not yet been received. I have not yet obtained information from Hampshire regarding the result of the examination of the herd concerned. UNSOUND FOOD, 1932. Tons cwts. qrs. lbs. Fish 2 17¾ Corned Beef 12 Meat 1 2 1 26¾ Rabbits 3 8 Total 1 4 0 8½ 30 Infectious Diseases. 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. No cases of Diphtheria were notified from North Hyde School during the year. Some use is made of the Dick reaction in connection with query cases of Scarlet Fever at Mogden Hospital. Scarlet Fever serum is used in nearly all cases at the hospital. The Staff of Mogden Hospital is Schick tested and immunised. 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 207 No. of civil cases removed to Hospitals 173 Percentage of cases removed to Hospitals 83.57 The incident rate of Scarlet Fever in the civil population (81,100) was 2.55 per 1,000. There were no deaths from this cause during the year. Diphtheria.—The following table shows the number of notifications received and the percentage of cases of Diphtheria removed to Hospital:— No. of civil cases notified 58 No. of civil cases removed to Hospitals 57 Percentage of cases removed to Hospitals 98.27 I he incident rate per 1,000 of the civil population was 0.72. Seven cases occurred in institutions during the year. Three deaths took place from this disease, i.e., a case mortality rate of 5.17 per cent. The deaths occurred in the following age groups:— Under 1 year 1 5—10 years 1 10—15 years 1 And in the following months:— January 1 April 1 August 1 For the last four years the deaths from Diphtheria have been as follows:— Year Year Year Year 1929 23 1930 19 1931 4 1932 3 The full details of the Immunization work for 1932 are set out in the following 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 1932. The number of fresh cases tested during the year was 413. Of these 89 were naturally immune and 324 were susceptible. Of the 538 Certificates given, 92 were naturally immune and 446 were immunised in all stages. The total number of attendances at the various clinics during the year was 3015. Up to the end of 1932 the number of certificates of immunity issued had amounted to 3,257, Of these 659 were given to naturally immune subjects and 2,598 to subjects who were originally susceptible and who were immunised at the clinics. The technical procedure employed during the last year has been the same as heretofore with the exception that a slightly larger final injection of immunising material has been given in the hope that a larger proportion of children will be immunised by the initial course of three injections. At present the number of cases is insufficient to prove anything, but so far, the results do not appear to show that the method has any advantages. The procedure will however be continued for a while. The results of re-testing immunised cases during this year is shown below:— Number rendered immune after 3 injections 356 Number rendered immune only after a secondary course of injections 81 31 The above figures emphasize the necessity for conscientious re-testing of subjects after the immunising injections. 13 children were Re Primary Schicked after 2 years and still found negative. 10 children were Re-Re-Schicked after 2 years and were found negative. 1 child was Re-Re-Schicked after 2 years and found positive and had 3 extra doses of T.A.M. We are fortunate in that we have had no single case of clinical diphtheria among cases immunised by us and certified to be naturally immune during the three years that this work has been in progress. This is a magnificent record and one which we may not hope to maintain indefinitely. A few mild cases of diphtheria must inevitably occur among large numbers of immunised persons over a long period of time. Nevertheless, by thorough and careful work it is hoped to keep the number of such apparent failures at a very low level. The failures which occur are due to variable levels of immunity too technical to be discussed in this report. The simplest parallel is that sometimes a person can resist a cold owing to an immunity to colds—while at another time that same person catches a bad cold due to a temporary lowering of that immunity. So it is with diphtheria and we are acquainted with the factors concerned. When there has been any question of an immunised or certified child having an attack of diphtheria the most complete investigations have been made and in no case has a diagnosis of clinical diphtheria been justified. Singularly few reactions have been reported by parents as a result of the immunising injections of Burroughs Wellcome's T.A.M. In the case of one brother and sister we considered it advisable to discontinue the injections on account of excessive reaction. This reaction was a peculiarity of the blood and bodies of the two children. This is proved by the fact that many other children inoculated with the same material experienced no ill effect whatsoever. Reactions in children are most rare and the case of the above brother and sister is unique in my experience. In the case of one adult also it was thought better to discontinue the course of treatment on account of reaction. Viewing the results as a whole, both as regards last year and the whole time the work has been in progress we have every cause to be completely satisfied with the results obtained. In order to attract a still larger proportion of the population more rapidly, one or two things would appear to be necessary, an epidemic of diphtheria, or the re-instigation of further active propaganda. In view of the absence of epidemic diphtheria in the district there is every reason to be satisfied with the steady flow of children to the Diphtheria Prevention Clinics. The standard of attendances and the number of fresh cases coming for treatment continues to be superior to that obtaining in other areas with which I am acquainted. In this class of work the progress is inevitably dependent on two factors. When the facilities are first provided there is a great demand for treatment by all those parents who wish to do the best possible for their children. When this initial rush has been dealt with the continuance of the work depends on the final appearance of procrastinating parents and the conversion of those who are opposed to any form of inoculation. Possibly the best stimulus of all is an epidemic of diphtheria. There is no more effective urge than that of fear. , As is always found in this work the number of clinics gradually has to be lessened, while diphtheria incidence is low, and the Saturday morning clinic at Isleworth had to be closed on 16th July, 1932 as a result of poor support. The Isleworth area has always been tardy of response to the facilities as compared with Heston and Hounslow. It was also found inadvisable to continue the Wednesday afternoon clinic and this was discontinued on 29th June, 1932. The Monday afternoon session has been found adequate to deal with the fresh cases, inoculations and re-testing at present required. It is however, desirable that children whose inoculation was completed 2 years ago should be re-tested to ascertain that the immunity is still present, and it will probably be necessary to institute a Saturday morning clinic once more in the near future to deal with this work which is of considerable magnitude, but nevertheless essential. 32 An analysis of figures and facts emerging from the total work performed in this area up to the present time is appended. (January, 1939 to 31st December, 1932). SCHICK TEST RESULTS. Age. Negative. Positive. % Negative. Total. 1 2 190 1.04 192 2 6 169 3.42 175 3 9 178 4.81 187 4 20 207 8.81 227 5 46 436 9.54 482 6 47 392 10.7 439 7 64 347 15.5 411 8 83 328 20.1 411 9 113 311 26.6 424 10 101 268 27.3 369 11 61 140 30.3 201 12 49 92 34.7 141 13 & over 58 107 35.1 165 Total 659 3165 Av.% 17.2 3824 Results of Schick tests up to and including 5 years of age. Total cases1263 Positive 1180 Negative 83 % immune 7 From 6 years to 10 inclusive. Total cases 2054 Positive 1646 Negative 408 % immune 19.8 From 11 to adult life. Total cases 507 Positive 339 Negative 168 % immune 33.1 Confirmation of Natural Schick Negatives. Of 570 natural Schick neg. cases confirmatory tests were done at a later date on 141. Of these 137 were again negative and 4 were positive. This shows a degree of reversion from Schick — ve to Schick + of 2.8%. Actual Number of Children who Attended Clinic. 5 years and under 1263 6 years to 10 inclusive 2054 11 to adult life 507 3824 Total cases actively immunised 2598 „ „ naturally immune 659 Total certificates issued to date 3257 33 An analysis of 2292 Schick positive cases who received 3 one c.c. injections of T.A.M. as the original immunising course and were retested from 4 to 7 months later. Age. Neg. after 3 T.A.M. Neg. only after additional injections. Positive after 3 T.A.M. and not yet completed. % not immunised by 3 injections. 1 108 3 2 4.4 2 107 4 1 4.4 3 115 6 1 5.7 4 131 10 3 9.0 5 232 40 2 15.3 6 241 38 4 14.8 7 223 31 2 12.9 8 234 36 4 14.6 9 222 27 4 12.2 10 188 20 2 10.4 11 91 9 2 10.7 12 62 12 2 18.4 13 & over 65 5 3 10.9 Total 2019 241 32 11.9% N.B.—Injections 1 and 2 of 1 c.c. of T.A.M. were given at weekly intervals. The third injection of 1 c.c. was given 14 days after the seconds. An analysis of 355 cases who were originally Schick positive and received an immunising course of 2 one c.c. injections of T.A.M. at weekly intervals and a third injection of 1.5 c.c.s of T.A.M. 14 days after the second injection. They were re-tested at various times over four months from the last immunising injection. Age. Neg. after 3 injections. Neg. only after additional injections. Positive after 3 T.A.M. and not yet completed. % not immunised by 3 injections. 1 23 0 1 4.1 2 24 5 1 20.0 3 20 4 3 25.8 4 27 1 1 6.9 5 56 7 4 16.4 6 46 7 2 16.3 7 33 5 1 15.3 8 14 2 0 12.5 9 23 0 0 0.0 10 20 3 1 16.6 11 15 1 2 16.6 12 2 0 1 33.3 13 & over 0 0 0 Total 303 35 17 14.6 The present short series of 355 cases does not appear to show any advantage at all in using a 3rd injection of 1.5 c.c. instead of 1 c.c. but this can probably only be determined after a much longer experience. 34 Cases tested 2 years (approx.) after having bean rendered Schick negative as a result of a course of 3 immunising injections of 1 c.c. Positive. Negative. 1 year 0 0 2 years 0 0 3 years 1 2 4 years 0 1 5 years 0 1 6 years 1 1 7 years 1 2 8 years 0 1 9 years 0 2 10 years 1 1 11 years 1 1 12 years 0 0 13 & over 0 0 5 12 = 29% reversion to Schick positive state. Statistically this short series of cases is of no value—but the work is proceeding. The results however do suggest the strong advisability of re-testing immunised children 2 years or less after they have been rendered Schick negative. While many who have reverted to the Schick positive state will doubtless possess a potential immunity—it is advisable to apply a further immunising stimulus to all those found positive after 2 years. 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 1932, 15 vials of Antitoxin of 8,000 units each were supplied to medical practitioners. Smallpox.—No cases were notified during the year 1932. Enteric Fever.—There were 4 cases notified during the year, one was Para-typhoid B. Three of the cases, notified from the West Middlesex Hospital, were admitted from outside this district. Erysipelas.—Thirty-seven cases of this disease were notified, of whom 25 were of cases in the West Middlesex Hospital. Eighteen were non-residents in this district. Ophthalmia Neonatorum.—See page 50 Puerperal Fever.—Nine cases of this disease were notified. Three of these patients were non-residents of this district, and were notified to me as a result of having been admitted to the West Middlesex Hospital, for treatment. The remaining six cases were residents. One was confined in the West Middlesex Hospital, four were removed there for treatment, and one case was not removed to Hospital. The number of deaths from Puerperal Fever was three. One of these was a transferred death into the district. In the other two cases, one death occurred at home and the other in West Middlesex Hospital. Puerperal Pyrexia.—Fifty-eight cases, were notified; 50 of these were notified from the West Middlesex Hospital, including 41 who were not usually resident in this district. Encephalitis Lethargica.—There were no cases notified this year. Cerebro-Spinal Fever.—Eight cases of this disease were notified. Six were notified from the West Middlesex Hospital, but five of these were not from this district. Acute Poliomyelitis.—One case of this disease was notified, the patient being a resident of this district. 35 Pneumonia.—There were 199 cases notified—119 notifications were from the West Middlesex Hospital. Ninety were non-resident in this district. Malaria.—No cases were notified. 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:— 1927 1928 1929 1930 1931 1932 Measles 35 688 83 799 9 952 German Measles 7 9 344 38 5 25 Chicken Pox 243 265 423 392 233 194 Mumps 352 138 106 381 132 122 Whooping Cough 157 171 177 144 242 260 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 0.22 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 repeat what I said last year, that in my opinion an open-air recovery school is a real need in this district. It is impossible for those who have not been in close personal contact with open-air recovery schools to appreciate what an open-air recovery school really means. There is so much uninformed opinion with regard to what such a school means and does. The present vogue amongst school Authorities for semi-open-air schools is being used very largely as a counterblast to the idea of an open-air recovery school. True the additional flow of air has a definite beneficial effect, even if small. In some of these schools and classrooms the idea of so much light and air into the classrooms means an intense glare for the pupils working in them, whereas in the open-air recovery school no attempt is made at working on white surfaces except in adequate shade. Moreover, the semi-open-air classrooms, as designed, depend for their efficiency on the hygienic co-operation of the teachers therein, and I am afraid that until hygiene is taught in the training colleges as a subject to be lived in school, by Medical Officers who really understand the day to day living of hygiene; instead of it being simply regarded as an academic subject in which an examination has to be passed, and for which, nowadays, honours can be obtained, we are not going to get that appreciation of the value of hygiene which is going to make it impossible, for instance, to see every window closed in a semi-open-air school, except on the north, with a temperature of 73 outside, and also to see members of the female staff with their overcoats and fur collars on teaching in a classroom, what time they expect the children whom they are teaching to be clad in their ordinary indoor garments. 36 Those who talk about the value of the semi-open-air school miss altogether what an open-air revovery school means with its periods of rest in the open-air, its adequate feeding, and the routine based on the needs of the subnormal child. In the semi-open-air school all that happens is that the child works the ordinary curriculum, but gets a little more fresh air during these lesson periods, which in my opinion, is certainly not worth the contraptions which are put in the school to effect it. The unfortunate part is, so few Medical Officers, and still fewer Architects, have had anything to do with a proper open-air recovery school, and in my experience there is more hot air and nonsense talked about the semi-open-air school and its relationship to open-air schools than any other hygienic measure for the betterment of the health of the child. Pulmonary Tuberculosis.—The number of new cases notified during the year was 88. Sixty-five cases were notified from Institutions:—Sanatoria, 23, Poor Law Institutions 22, General Hospitals 17, and Tuberculosis Dispensary 3. There were 51 deaths from Tuberculosis of the Respiratory System. Six of these were not notified. Of the new cases notified, 70 received institutional treatment during the year, and 20 died. Other Forms of Tuberculosis.—The number of new cases notified during the year was 17. Sixteen of them were notified as receiving institutional treatment. There were 7 deaths. Four of the cases which died were unnotified. Deaths from Tuberculosis.—Ten 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 the others were apparently not diagnosed until just before or after death. The following Table gives further particulars of new cases notified and deaths in 1932. TUBERCULOSIS, 1932. Age Periods. New Cases. Deaths. Pulmonary. N on-Pulmonary Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 .. .. .. 1 .. .. 1 2 1 .. .. 1 .. .. .. .. .. 5 2 1 3 2 2 .. 1 .. 10 2 .. 2 1 .. .. .. .. 15 6 11 2 1 2 2 .. .. 20 8 8 .. 1 2 8 .. .. 25 14 13 .. 1 5 8 .. .. 35 8 6 .. 2 4 9 1 1 45 3 2 .. .. 4 2 .. .. 55 1 2 .. .. 2 1 .. .. 65 and upwards .. 1 .. .. .. .. .. 1 Totals 44 44 8 9 21 30 3 4 Six of the deaths from Pulmonary Tuberculosis were not notified and four deaths from Non-Pulmonary Tuberculosis were not notified. 37 DIPHTHERIA, 1932 (including Bacterial cases, 28 in number). Month. WARD. Elem. School Chldren Other School Chldren Other Cases Total Hstn. Houn. Cent. Houn. Hth. Houn. Sth. Houn. West lslewth N. lslewth S. Spng. Grve. Jan. 7 – – 1 – – 6 – – 1 – 6 Feb. 7 – – – – – 4 2 1 3 – 4 Mar. 3 – – – – – 2 1 – – — 3 April 11 – – 1 – 1 2 6 1 6 – 5 May – – – – – – – – – – – June 3 – – – – – 3 – – – – 3 July 7 – – 3 – – 4 – – 3 – 4 August 7 – 1 3 3 – – – – 4 – 3 Sept. 9 – – 1 7 – – 1 – 6 1 2 Oct. 18 2 2 7 1 – 1 4 1 8 1 9 Nov. 11 – 4 1 1 – 5 – – 4 – 7 Dec. 3 – – – 1 – 1 1 – 2 – 1 Totals 86 2 7 17 13 1 28 15 3 37 2 47 38 39 Notifiable Diseases during 1932. 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 .. .. .. .. .. 2 .. .. .. 4 2 1 Scarlet Fever .. 4 5 10 20 95 37 8 23 4 1 .. 207 155 18 Diphtheria 1 2 6 9 2 19 9 4 6 .. .. .. 58 50 7 Erysipelas 2 1 2 1 .. 1 1 .. 4 6 13 6 37 .. 30 Puerperal Fever .. .. .. .. .. .. .. .. 9 .. .. .. 9 .. 8 Puerperal Pyrexia .. .. .. .. .. .. .. 5 43 9 1 .. 58 .. 54 Ophthalmia Neonatorum 7 .. .. .. .. .. .. .. .. .. .. .. 7 .. 2 Poliomyelitis .. .. .. .. .. .. .. 1 .. .. .. .. 1 .. 1 Cerebro Spinal Fever .. .. 1 .. .. 2 1 2 2 .. .. .. 8 2 6 Pneumonia 19 20 14 10 9 24 5 10 31 23 26 8 199 .. 125 Dysentry .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Malaria .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Encephalitis Lethargica .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. For Tuberculosis Notifications—see other Table. INFECTIOUS DISEASES, 1932. CASES NOTIFIED. Scarlet Fever. Diphtheria. Enteric Fever Puerperal Fever. Erysipelas. Cerebro-spinal Fever. Poliomyelitis. Pneumonia. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Puerperal Pyrexia. January 12 1 2 2 5 .. .. 32 11 1 .. 6 February 13 4 .. .. 2 2 .. 12 7 1 1 2 March 13 1 .. .. 4 .. .. 30 5 2 .. 7 April 17 8 .. .. 4 2 .. 32 10 3 .. 7 May 14 .. 1 2 2 2 .. 14 7 .. 2 3 June 8 2 .. 3 5 2 .. 13 7 4 .. 6 July 22 5 .. .. 2 .. .. 9 3 1 .. 2 August 8 5 1 .. 2 .. .. 2 8 2 1 September 18 6 .. 2 2 .. .. 11 6 .. 1 7 October 19 14 .. .. 3 .. 1 8 8 3 1 3 November 22 9 .. .. 3 .. .. 14 7 .. 1 6 December 41 3 .. .. 3 .. .. 22 9 .. .. 9 Totals 207 58 4 9 37 8 1 199 88 17 7 58 In addition to above there was 1 Military case of S.F. and 2 of Cerebro Spinal Fever. There were no cases notified during the year of the following diseases:—Encephalitis Lethargica, Malaria, Dysentry, or Small Pox. DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES, 1932. Age Groups. Under 1 year. 1 yr. 2 yrs. 3 yrs. 4 yrs. 5 yrs. 10 yrs. 15 yrs. 20 yrs. 35 yrs. 45 yrs. 65 yrs. and over. Total all Ages. Small Pox .. .. .. .. .. .. .. .. .. .. .. .. .. Scarlet Fever .. .. .. .. .. .. .. .. .. .. .. .. .. Diphtheria 1 .. .. .. .. 1 1 .. .. .. .. .. 3 Enteric Fever .. .. .. .. .. .. .. .. .. .. .. .. .. Puerperal Fever .. .. .. .. .. .. .. .. 3 .. .. .. 3 Pneumonia 12 7 1 .. 3 .. .. .. 6 5 8 16 58 Polio- Encephalitis .. .. .. .. .. .. .. 1 .. .. .. .. 1 Cerebro-Spinal Fever 1 .. .. .. .. .. .. .. 1 .. .. .. 2 Eyrsipelas .. .. 1 .. .. .. .. .. .. 1 .. .. 2 Total 14 7 2 .. 3 1 1 1 10 6 8 16 69 For Tuberculosis Deaths—see other Table. 40 The table hereunder gives the number of cases of infectious diseases that were notified fron the several Institutions in the district during 1932:— Enteric Fever. Scarlet Fever. Diphtheria Pneumonia (all forms) Erysipelas. Puerperal Fever. Puerperal Pyrexia. Cerebro Spinal Fever Ophthalmia Neonatorum Pulmonary Tuberculosis. Other Tuberculosis. Total. West Middlesex Hospital 3 23 9 119 25 4 50 6 1 17 5 262 Hounslow Hospital .. 1 1 1 3 .. .. .. .. .. 2 8 Hounslow Barracks .. 1 .. .. .. .. .. 1 .. .. .. 2 Mogden Isolation Hospital .. .. .. .. .. .. .. .. .. .. .. .. Collingwood College .. .. .. .. .. .. .. .. .. .. .. .. St. Mary's School .. 2 .. .. .. .. .. .. .. .. .. 2 Totals 3 27 10 120 28 4 50 7 1 17 7 274 In addition to the above civil cases, one military case of Scarlet Fever and two of Cerebro-Spinal Fever occurred in the Hounslow Barracks. 41 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. One Clinic weekly at Clipstone House, on Thursday 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. The number of new houses erected in the Borough during the year was 997, and when it is realised that more than 1,300 houses have been erected yearly during the previous 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. On the 27th October, 1932, it was necessary to start a fresh Clinic at Clipstone House to deal with the new influx which was taking place at the west end of the town. This, although one was told that it was impossible to run a morning Clinic8—that the mothers would not come and that it would be a failure—proved to fill such a need that the attendances soon ran up to over one hundred, and now another session is in prospect. As I said last year, there can be no better testimonial for the work than the attendances at the Isleworth Clinic, considering the circumstances under which the work has been done. The Committee are trying to push on with a scheme for a temporary building that will relieve the congestion, but on every hand the cry is " Economy, Economy." In the meantime we are doing the best under the circumstances. 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 healthy 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. 42 As I said last year, the dental work is bringing more and more toddlers under review than anything else. Honestly, we have not time to deal with many toddlers. There are many things I want, and want badly, for the mothers and children at the Clinics. I want to see the toddlers more often, I want definite instruction, I want organized cookery demonstrations. As I happen to be personally a practical cook, I find that I have to give the cookery lessons to the individual mother when I find she is up against a difficulty with the toddler's food, but it ought not to be my job. There is one thing that keeps one's nose on the grindstone despite all the discomforts and disappointments in connection with the work, and that is, the gratitude of some of the parents for what one is able to do for the welfare of their little ones. For instance, at a dance given in aid of a Boys' Club, I was stopped by one of the Officials in connection with the Boys' movement, and asked if I were Dr. Nash. I said "yes." He said, "May I speak to you afterwards? " and after one of the dances when I was free I approached the individual in question, who greeted me with the astounding remark—" May I shake you by the hand, Sir." I asked "Why?" to which he replied, "I think we have the finest little girl in Hounslow. My name is so-and-so, and you will remember what an awful trouble she was to bring up. I feel I should like to thank you and shake you by the hand for all you have done." It is such things which lighten the drudgery, which are a counterblast to the fretful mother with an only child who worries over every little thing, and who at the end of it has little gratitude and only criticism if she does not get all she wants. As I said, it is such things which make one keep on, feeling that at least one has done something for some parent which they appreciate. The work in the Clinics is made harassing by recurrent appeals from the mothers to me as Health Officer, to know if I can do something towards helping them get a Council House. They tell me the circumstances, and I, who am the duly appointed Health Officer of the district, can only say that it is no concern of mine, that I have nothing to do with it. It is true that when the Borough was formed in November there was a definite effort on the part of a section of the Council to place the housing under the aegis of the Public Health Committee on the grounds that there was only one reason why these people are being re-housed, and why the Local Authority is spending money on housing to the extent that it is, and that is "Health." By the narrowest of margins the status quo ante survived, and all I can say in response to the harrowing tale, is that I have nothing to do with it. I want to emphasize again what I said last year with regard to the nutritional needs of some these people; largely it is the effect of ignorance. As I said last year, their main difficulty is a carbo hydrate surfeit, and an insufficiency of first class protein. First class protein was never so cheap as it is at the present time, but it is the ignorance of how to buy it and how to use it, which dominates the situation. One of the greatest difficulties in feeding some of these folk is the prejudice that exists. The number that will not eat fat is enormous. One has only to talk to any cookery teacher in the cookery centre to find how this prejudice, mainly due to ignorance, dominates the diets of the poorer people. The attenda nces of children at all the Centres during the last six years have been as follows:— Year. No. of attendances. Year. No. of attendances. 1927 14,020 1930 19,222 1928 16,625 1931 27,318 1929 17,667 1932 31,656 It will be seen that the attendances have more than doubled in the last six years. The average attendances per session during the year 1932 were as follows:— At Douglas Road Centre 93.1 At Clipstone House, Bath Road, Centre (10 Sessions only) 57.0 At Isleworth Centre 66.9 At Heston Centre 67.3 Approximately 71 per cent. of the children born in the district attend at one of the Infant Welfare Centres before before they are a year old, an increase of 2 per cent. over last year's figure. 43 The number of individual mothers and children attending the Clinics is shewn hereunder:— Douglas Road Hounslow— 1928 1929 1930 1931 1932 Mothers 605 733 868 1087 1085 Children 802 914 946 1232 1741 "Clipstone House," Bath Road, Hounslow— Mothers – – – – 132 Children – – – – 153 Isleworth Public Hall— Mothers 356 367 458 578 690 Children 460 452 522 757 763 Heston— Mothers 157 212 305 392 451 Children 213 253 355 478 534 Sales at Clinics. Quantity. Receipts. £ s. d. Cow and Gate 12370 lbs. 885 12 3 Half-Cream Cow and Gate 1141 lbs. 84 9 9 Ostermilk 471 lbs. 36 17 9 Hemolac 1100 lbs. 87 6 6 Lacidac 959 packets 86 18 6 Virol 909£ lbs. 74 10 0 Sugar of milk 92 lbs. 5 3 9 Oil and Malt 422 lbs. 15 14 3 Lactagol 1268 tins. 72 11 4 Cod Liver Oil Emulsion 5168 bottles 165 4 8 Bemax 535 packets 11 2 6 Adexolin 5 phials 10 0 Total £1526 1 3 Ante-Natal Clinic.—The Clinic is held at 92, Bath Road, Hounslow every Wednesday morning. The following are the figures of the attendances at the Clinic:— 1931 1932 Attendances by Expectant Mothers during the year 583 696 Number of Sessions 32 52 Average attendance per Session 18 13.4 No. of Mothers attending Ante-Natal Clinic shown as a percentage of total notified biths 26.8 29.03 New Patients 313 388 Total number of expectant Mothers who attended the Clinic during the year 342 396 There were 10 Post-Natal Cases. 2 Patients had Lax Abdominal Muscles. Of these, one was advised to take exercises and have a proper abdominal corset made, the advice being acted upon. The other patient was advised to have an abdominal belt, and her husband being unemployed, this was obtained through the Public Assistance Officer. 1 Patient had Piles and was referred to her own Doctor. 4 Patients had Back Ache and were advised to take more rest. 3 Patients had slight discharges and were referred to their own Doctors. Dr. Wrigley's report is as follows— : In 1932 a new departure was made and the Ante-Natal Clinic is now held on every Wednesday morning throughout the year. This change has been most helpful, and has virtually abolished the exceptionally large attendances on certain days which resulted in hurried unsatisfactory work. The weekly Clinic was undoubtedly appreciated also by patients and midwives. 44 Miss Scott's departure was deplored by all. Her place has been taken by Mrs. Prissell who already has shown her great interest in this branch of public health, and as a result of her enthusiasm a considerable amount of the purely clerical work has been loaded on to the shoulders of two voluntary workers. The attendance figures for 1932 show a further rise. The further increase in the number of new patients is made more surprising when it is recalled that these amounted to 187 in 1930. The figures of the number of patients attending any clinic may be used only to a certain extent as a guide of the necessity or popularity of such a department of public health work. There is a tendency these days, especially among the general public and their administrative bodies, to gauge the success and utility of such clinics entirely by the numbers of attendances. In other words the clinic is a shop and the greater the turnover the more successful the business. This rule will not apply to medicine, at any rate to any branch thereof that necessitates a careful examination of the patient. Thus it is not advisable that the increase in the number of patients should continue indefinitely. Should it occur some machinery will be necessary whereby normal, uncomplicated cases are filtered, and only those whose pregnancy departs from the normal should be referred for the so-called "specialist " supervision. The routine of work done is identical with that outlined in last year's report. In order to abolish unnecessary duplication of work no patient now attends who has booked for her confinement any doctor in private practice or who is to be confined in any Hospital. It was found, for instance that patients who had arranged for their confinement in the West Middlesex Hospital were attending the Ante-Natal Clinics of that institution and also the clinics at Bath Road. Similarily, any patient who states that she is being attended in her pregnancy and confinement by a doctor in private practice is not examined. A note is sent at once to the doctor in question stating that the patient presented herself at the clinic, and would only be seen if the doctor wished this to occur and sent with the patient a note to that effect. It is gratifying to be able to state that slow but steady increase in the use of the clinic is being made by doctors practising in the neighbourhood. No treatment is dispensed by the Clinic. The investigation of the patient only is performed. Furthermore it is only in exceptional cases that the patient is referred direct from the Clinic to any institution, such as a voluntary hospital. The routine adopted and followed is that patients who complain of such symptoms as obstinate constipation, dyspepsia, heartburn, insomnia, coughs, colds, etc., or in whom any abnormality is detected are referred to their own doctor, or a doctor of their choice. A letter is sent and states that at the visit of the patient to the Clinic such-and-such an abnormality was found and that the patient has been referred to her doctor for advice and treatment. Should the doctor in question require specialist advice on this or another point he is at liberty to seek it wherever he will, and occasionally consults the Ante-Natal Clinic Officer to request his aid. By this means it should be, and in practice is, possible for the clinic and private practitioners each to fulfil their own function and to work in harmony. As one who does similar work in other parts of Greater London the writer cannot omit to make a few remarks on the "education" of the majority of patients who attend the Ante-Natal Clinic. Elsewhere a woman, whose mouth contains a number of decayed stumps and roots of teeth has more often than not to be dragged to the dentist, despite a full and patient explanation of the necessity for advising the step. In Hounslow this is the exception. Patients frequently ask at their first visit if they ought to see their dentist, or should their financial state be poor, whether they may be allowed to attend the Dental Clinic. Only occasionally is it that the medical officer's advice upon dental treatment signored. This year the clinic has served the public in another capacity. A few young mothers whose new home is in Hounslow, had arranged to be confined in their parent's house, generally in a distant part of the country. The Clinic has been able to provide these people with ante-natal supervision before they are handed over to the local midwife. 45 The attendances, presentations, etc., for the year 1932 are as indicated below:— Attendances. Attended by. Primip. 180 = 306 attendances. Doctors 24 Multi. 208 = 390 ,, Midwives Nursing Homes 150 18 On Books 388 = 696 ,, West Middlesex Hospital Other Hospitals 43 7 Presentations. Defects. L.O.A. Multi. 41 Dental Caries 73 L.O.A. Prim. 50 Varicose Veins 7 R.O.A. Multi. 19 Poor Nipples 12 R.O.A. Prim. 17 Worms 2 R.O.P. Multi. 2 Pyorrhoea 1 R.O.P. Prim. 7 Epilepsy 2 L.O.P. Multi. – Pyelitis 2 L.O.P. Prim. 1 Cystitis 1 Breach Multi. 2 Obstinate Constipation 1 Breach Prim. 4 Albumin 3 Not diagnosed M. 44 Sugar 4 Not diagnosed P. 27 Twin Pregnancies 2 X-Rayed 4 Sputum 1 Vaginal Swabs 4 External Version 8 Not Pregnant 14 Referred to Hospital 11 Referred to Own Doctor 8 Moved from District 24 Eclampsia (premature twins, lived 2 days) 1 Deaths of Mothers (each attended Clinic once—death from natural causes) 2 Premature Births 2 Full-time Babies died within first month 4 MATERNAL MORTALITY. I am glad to report that negotiations are proceeding to a satisfactory conclusion for the admission of cases of Puerperal Fever to the Isolation Block at Queen Charlotte's Hospital at Ravenscourt Park. DENTAL CLINIC. The following is the Dental Surgeon's Report for the year :— MATERNITY & CHILD WELFARE DENTAL SCHEME—1932. General Comments. Supply of Cases.—As indicated last year, the then newly appointed Ante-Natal Surgeon, sent us many cases, this year he has beaten his own record, the proof is the number of appointments sent, together with the net attendances. Appointments show an increase of 322 from 828 in 1931 to 1,150 in 1932. Net attendances from 711 in 1931 were 925 in 1932, an increase of 214. The percentages of the Actually Treated have climbed from 65.6 per cent. to 68.7 per cent., an increase of 3.1 per cent. Evaluation of the above figures.—They do not altogether give a full value of the work they have entailed, because in dealing with the youngest of the young and the " all sorts " conditions of the Mothers, greater difficulty is experienced in disposing of these cases, the Clinic can congratulate itself in spite of increased work, it has increased its percentage of Actually Treated, another proof of the Mothers' anxiety to save the child from dental caries, pain and deformities, which have been too often the Mothers' lot. New factors and problems solved in 1932.—The danger of creating a series of open wounds in half of the mouth, and leaving active contaminating matter in the other half, was too great to contemplate, and the only safe treatment was to have the anaesthetic of a more general nature than is used in Clinics, and all the bad teeth extracted at one operation. Clinics have skilled and experienced staffs for this work, but no facilities for operative work of this class. Hence arrangements are made for these cases to be treated in the Dental Wards of Charing Cross Hospital—this Authority paying an arranged fee to the Royal Dental Hospital for the services provided. 46 When the extractions are completed, this Clinic resumes responsibility for the treatment and supply of dentures. All the above operations could be done by the Clinic staff, if a Dental Clinic bed was allocated for the purpose in our local hospital. Comparative figures:— Year. Mothers. Children Total. Appointments were 1930 165 224 389 1931 412 416 828 1932 652 498 1,150 Attendances were 1930 129 204 333 1931 338 373 711 1932 491 434 925 Mothers Permanent teeth. Children Deciduous teeth Total. Fillings 93 215 308 Extractions— Gas 270 362 632 655 Local Anaesthetic 2 21 23 Dentures supplied to mothers. Year. Uppers. Lowers. 1931 18 18 1932 37 5 The number of individual mothers supplied with dentures during 1932 was 34. Details of work 1932-1931. 1932 1931 Treated 925 467 Fillings 308 116 Referred for Gas 132 92 Extractions—Local anaesthetic 23 13 do. General anaesthetic 632 566 Administrations of General anaesthetics 217 218 Advice 46 36 Treatment postponed 32 14 Refused to submit, wait, etc. 10 4 Dressings 15 8 Impressions taken 121 63 Charting and Estimating 79 73 Silver Nitrate Treatment 44 61 Dentures eased 21 9 Scaling and polishing 16 — I. COHEN, L.D.S., R.C.S., Eng., Dental Surgeon. Scale of Charges for Provision of Dentures. £ s. d. £ s. d. 1 Tooth 11 0 8 Teeth l 10 3 2 Teeth 13 9 9 „ l 13 0 3 „ 16 6 10 „ l 13 0 4 „ 19 3 11 „ l 13 0 5 „ 1 2 0 12 „ l 13 0 6 „ 1 4 0 13 „ l 13 0 7 „ 1 7 6 14 „ l 13 0 The steady rise in the dental work for the mothers and children is most satisfactory as will be seen. The bulk of the appointments have been kept, and the work in three years has practically trebled. With regard to dental cases requiring extractions under a general anaesthetic for extensive operation, I reported to my Committee as follows, and the agreement was entered into with the Royal Dental Hospital:— 47 " 9th May, 1932. Special Dental Cases requiring In-patient Treatment. The Committee will remember that I reported some time ago with regard to the difficulty of safely dealing with a certain class of mother, where there was a very bad condition of the mouth, at our Clinic, and I was authorised to get in touch with various hospitals to ascertain whether they could undertake this work for us. Various hospitals were approached but could not or would not entertain the matter. The Royal Dental Hospital finally undertook to deal with them, subject to the necessary formal arrangements being made. The question of cost was one which they have had to go into, and I have just heard from the Royal Dental Hospital that on account of their somewhat heavy costs and the very small income received from the patients, they feel that a reasonable charge to us for this work would be at the rate of 25/- per day per patient. In the great majority of cases one day in hospital would be sufficient; in rare cases it might run to two or in some rarer cases three days. The extra days necessary being an index of the need for this treatment. I recommend that the offer of the Royal Dental Hospital be accepted, as I feel that in the long run it will be of material benefit to the mothers concerned, and relatively to the permanent, benefit which will be secured—the cost is low. I suggest that in any assessment for payment by the mothers this contingency be regarded as one coming within the scope of the treatment necessary, and should not be a charge on the parent, owing to the urgency from the public health point of view." Notification of Births. Number of live births notified during the year 1,329 Number of still births notified 35 Notified by midwives 904 Notified by parents or doctors 460 No special measures exist for dealing with unmarried mothers or illegitimate children of such, but cases not wholly destitute have derived benefit through the Council's scheme for grants of food and milk. VOLUNTARY SOCIETIES AND HELPERS. This year has brought tragedy, for it is no less to our Maternity and Child Welfare work, in that Dr. Sydney Owen has relinquished his work as Physician-in-charge of Out-Patients to take over the children's beds in the West London Hospital. When I say tragedy, I mean it with no depreciation to his very able successor, but there is no other word which adequately describes the loss to the mothers attending our Clinics. I am in touch with so many of the leading pediatricians in London, many of them I know well, but there is no one I have come across who takes such meticulous care over the investigation of a case sent to him at the Out-Patient Department, and whose reports are so carefully and fully ccnsidered. I wish now to take this public opportunity of rendering to Dr. S. Owen on my behalf, and behalf of the mothers of this district, our most grateful and heartfelt thanks for all that he has done for the it tie ones under my charge. If he had done nothing else, his name will ever be remembered with heartfelt gratitude by those of us who have seen his work that he has done for the difficult cases that have arisen in our Clinics. It is here that we have to say farewell, and appreciate the fact that the time has come when the burden of out-patient work is due to be laid down for others to take over. There is only one glimmer of satisfaction, which is that when it comes to the point of a child being admitted into the West London Hospital, it will then come under the charge of a man who has done so much for me on behalf of the little ones, for years past. 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. 48 Special mention must be made of the undermentioned for services rendered at the Welfare Clinics, and also for gifts of prams, toys, clothing, etc., which are given to the other mothers. Mrs. Griffen, Mrs. Killick, Mrs. Goff, Miss Goff, Mrs. Davies, Mrs. Sheen, Mrs. Buckingham, Mrs. Gilchrist, Mrs. Dolphin, Mrs. Thompson, Mrs. Bugg, Mrs. Wren, Mrs. Franklin, Mrs. Porter, Mrs. Rich, Mrs. Harrison, Mrs. Hillman, Mrs. Wright, Mrs. Ellis, and Mrs. Addison at the Hounslow (Douglas Road) Centre ; Mrs. Sutton, Miss Huguier, and Mrs. Hunt at the Hounslow (Clipstone House) Centre; Mrs. Agar, Mrs. Watson, Mrs. Chedgey, Mrs. Jones, Mrs. Newman, and Miss Wotton at the Isleworth Centre ; Mrs. Rose, Mrs. Ardley, Mrs. Griffiths, and Mrs. McDonald at the Heston Centre. At the Isleworth Christmas Party Mrs. Brown did valuable work in connection with the arrangements for the tea. Home Visiting.—The visits by the Health Visitors in connection with the Maternity and Child Welfare Work are shown in the following table:— 1928 1929 1930 1931 1932 1st visits to babies under 1 year 1125 1304 1395 1472 1520 Routine Re-visits to babies and Children up to 5 years 4204 4311 3982 4190 3210 Inquiries made, elicited— Feeding—Natural 806 887 980 1105 1135 Artificial 47 44 77 64 95 Both 40 32 56 51 44 Sleeping with parents 247 277 260 247 154 Using comforter 154 168 195 217 175 Mother working during pregnancy 51 48 53 44 29 Year 1932. Other visits. Post-natal 5 Ante-natal—First visits 67 Subsequent visits 8 Infants' Deaths and Stillbirths, Visits paid 98 Ophthalmia Nenonatorum and Discharging Eyes 183 Infantile Diarrhoea 2 Puerperal Fever and Puerperal Pyrexia 22 Measles and German Measles 53 Whooping Cough 22 Chicken Pox 8 Pneumonia 64 Bronchitis 26 Children under 5 years. Milk and Food Cases 50 Home help 12 Infant Protection Visits 558 Social conditions 27 Summary of Nurses' Visits. Total to expectant mothers 75 „ children under 1 year of age 4053 ,, children between the ages of 1 and 5 years 2007 Visits re Public Health matters, infectious diseases, tuberculosis, etc. 228 Total 6363 Health Visitors' attendances at the Maternity and Child Welfare Centres, Ante-Natal Clinics, etc., 627. Health Visitors' attendances at Diphtheria Immunisation Clinics, 191. Home Help for Mothers.—The Home Help paid 26 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 87 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. 49 Where the amount is over 7/6 per head, no grant is made. The number of grants made during the year was 831, against 257 for the previous year. It is noticeable that with the present financial stringency which arose out of the national crisis, there has been 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. OPHTHALMIA NEONATORUM Year 1932. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Deaths. Notified. Treated. At Home. In Hospital. 7 4 3 6 – – 1 An agreement exists with the London County Council for the admission of cases of Ophthalmia Neonatorum to St. Margaret's Hospital when necessary. Borough of Heston and Isleworth Education Committee. TWENTY-FIFTH ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR ENDED 31ST DECEMBER 1932. contents. Blind children 31, 35 Crippling defects 30, 37 Deaf children 31, 35 Deformities 9, 34 Dental defects and treatment 9, 24-30, 39 Dental Surgeon's Report 24-30 Defective vision 8, 13, 31, 33, 38 Discharging ears, Treatment of (Special Report by Dr. Roberts) 21-24 Ear disease and hearing 9, 21, 33, 38 Employment of children 31 Epileptics 31, 35 Exclusions 8, 13 Eye defects 8, 13, 33, 38 Findings of medical inspection 8, 9, 33, 34 Following up 11 Infant and Child Welfare Work, Co-ordination with 7 Infectious disease 9, 10 Malnutrition 9, 33 Medical inspections 7, 33, 34 Medical treatment 11-30 Mentally defectives 31,35 Minor ailments 11, 38 Nurses' work in schools 11 Open Air Schools 30 Orthodontic work 27, 28 Orthopædic cases 30 Parents, Co-operation of 30 Prosecutions 13 Provision of Meals 30 Ringworm 13 School Attendance Officers, Co-operation of 30 School Clinics 11, 12 School hygiene 7 School Nurses' work 11 Schools in the Area 6 Skin diseases 8, 13, 33, 38 Spectacles 13, 38 Staff 5 Statistical tables 33-39 Teachers, Co-operation of 30 ,, Medical Examination of 32 Tonsils and Adenoids 8, 12, 33, 39, Tuberculosis 8, 12, 34, 36 Uncleanliness 8, 13, 39 Vision Testing (Special Report by Dr. Roberts) 13-21 Voluntary Bodies, Co-operation of 31 To the Chairman and Members of the Borough of Heston and Isleworth Education Committee. Ladies and Gentlemen. I beg to present the Annual Report of the School Medical Service for the year ended 31st December, 1932. 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. (Note.— During the year 1932 the receipt of the Charter of Incorporation necessitated the re-election of the Council, with a resulting change in the constitution of the Committees). Chairman, April to November, 1932, A. A. BERGIN, ESQ., J.P. Members of the Committee, 31st December, 1932. Alderman G. R. SPEED {Chairman). Alderman A. A. BERGIN, J.P. (ex-officio). Alderman J. J. CLEMENTS, J.P. „ H. J. NIAS, M.B.E., J.P. (ex-officio). „ A. A. WHITE. Councillor H. BAKER. „ J. FARMER. „ A. J. FIELDER. „ F. T. HART. „ E. W. HEATH, J.P. „ A. L. LANG. „ C. L. LEWIS. Councillor A. E. MACE „ R. H. MANNING. „ D. RHYS. „ G. N. SHACKLETON. „ D. J. THOMAS. „ R. WRIGHT. Co-opted Members— Miss E. a. ankritt. w. t. kenwood, Esq. b.a. d. Mcdonald, Esq. Mrs. S. SPOONER. O. WARDMAN, Esq., Ph.D School Medical Officer— ELWIN H. T. NASH m.r.c.s., l.r.c.p., d.p.h. 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. (Left April 1932). victor Freeman, M.R.C.S., L.R.C.P., D.P.H. (Commenced August 1932). Dental Surgeons—I. COHEN, L.D.S. R.C.S., Eng. H. F. Metcalf, L.D.S., R.C.S., Eng. (Part time). Orthodontic Consultant—H. R. Evans, 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 jof 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. (Left Oct., 1932). 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. (Left, Sept. 1932). Miss G. M. Clare, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss E. I. Bartlett, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced, Sept. 1932). Miss G. F. Richardson, S.R.N., Cert. C.M.B., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced, Oct. 1932). One Temporary Health Visitor (whole-time). Clerical Staff— B. W. kllby, (Chief Clerk). Miss R. Marshall. P. T. H. Crandon. A. H. cornhill (Transferred to post of Sanitary Inspector, Feb. 1932). Miss G. E. Curtis. (Left June 1932). K. I. Bisshopp. H. J. Aldhous. F. V. Bell. E. E. Forrest. Miss D. M. Dowling. Miss V. D. Nicholls. R. Moore. Vacancy for one Junior Clerk. Comprising the whole Clerical Staff of the Public Health Department, part of whose duties are concerned with the School Medical Service. Dental Clinic Clerk Attendant—mlss I. m. tomes. Junior Dental Clinic Clerk Attendant—mlss m. B. mabbs. (Commenced, Sept. 1932). Dental Mechanic (part-time)—t. cheney. 5 ELEMENTARY SCHOOLS IN THE AREA. School. Department. *Accommodation. Average Number on * Registers. Alexandra Boys' 440 407 „ Girls' 400 449 Berkeley Junior 400 437 Brentford End Infants' 100 100 Bulstrode Senior Boys' 440 462 „ „ Girls' 440 437 Chats worth Junior 400 333 Grove Road Boys' 326 322 „ Girls' 326 341 „ Infants 368 279 Heston Senior Mixed 440 298 ,, Junior Mixed 593 564 Hounslow Heath Boys' 446 449 „ Girls' 350 375 „ Infants' 340 421 Hounslow R.C. Mixed and Infants' 304 292 Hounslow Town Boys' 364 404 „ Girls' and Infants 564 463 Isleworth Blue Boys' 210 193 „. Girls' and Infants 284 229 Isleworth Town Junior Mixed 400 466 „ Infants' 444 343 Marlborough Senior Mixed 560 502 St. Mary's R.C. Boys' 150 157 „ Girls' and Infants 240 197 Spring Grove Central 342 350 „ Junior 290 266 Woodlands St. John's Infants' 125 73 Worple Road Junior Mixed 260 272 „ Infants' 265 239 Total 10611 10120 Numbers as at December, 1930 ... ... ... 8444 8271 Numbers as at December, 1931 ... ... ... 9448 9256 * These numbers are for December, 1932. It will be seen that since December, 1930, the number of children attending elementary schools in this district has increased by nearly 2,000, and the effect of this continuing increase is being steadily felt in the demands made on the various branches of the School Medical Service. 6 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. Freeman, who succeeded 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 four Centres with a total of nine 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. (b). The Care of Debilitated Children under School Age. As mentioned above, children up to the age of five years have access to the Welfare Centres, and no debilitated child need go without advice and the treatment for which we have facilities. Cases of Measles, Whooping Cough, etc., if requiring to be nursed, are usually dealt with by the local Nursing Associations. There is no provision of hospital accommodation for Measles or Whooping Cough cases other than occasionally in the Public Assistance Hospital. 3 THE SCHOOL MEDICAL SERVICE IN RELATION TO PUBLIC ELEMENTARY SCHOOLS. School Hygiene. The School buildings and sanitary arrangements are periodically inspected, and a complete survey of the schools is made from time to time. Every school in the district is visited at least twice a year by a Medical Officer. Dinner Hour Arrangements. 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 Bulstrode, Heston, and Marlborough Senior Schools, where there are Cookery Centres. In a number of schools certain children bring food of various kinds for their mid-day 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 has been carried out in all the schools except the Marlborough Senior School. This school was opened in November, and as the medical staff had no time available up to the end of the year, it was impossible to put this school in the programme of school medical inspections. The majority of the children had been transferred from the old Isleworth Town Senior School, and therefore those who came within the Code Age Groups were examined during the inspection at that school in June and July. 7 A re-inspection has followed each routine inspection after a period of approximately three months. The age groups selected for inspection are those laid down by the Board of Education, viz.:— 1. All new entrants (5 year old children). 2. Second Age Group (8 year old children). 3. Third Age Group (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 4,057, an increase of well over 1,000 on last year's figure. As anticipated in my Report for 1931, many more sessions have had to be devoted to School Medical Inspection during 1932, and towards the end of the year it was necessary to engage extra medical assistance for this purpose. 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 FINDINCS OF MEDICAL INSPECTIONS. (a). Uncleanliness. The number of cases discovered at routine medical inspections was 116, and special medical inspections at the Clinics revealed a further 639 cases. Three hundred and seventy-five children were excluded from school during the year on account of nits or vermin. (b). Tonsils and Adenoids. Three hundred and sixty-six children were found to be suffering from enlarged tonsils, and of these 169 were referred for operation and 197 for observation. Thirty-three children had Adenoids only, 15 being referred for treatment and 18 for observation. In a further 280 cases both conditions were present, 185 children being referred for operation and 95 for observation. (c). Tuberculosis. One child examined during routine medical inspection was marked for observation as a case of suspected pulmonary tuberculosis. Special inspections revealed one definite case of pulmonary tuberculosis and 4 suspected cases. One suspected case of tubercular hip was also found. (d). Skin disease. A total of 399 cases of various skin diseases were reported during the year, and, with the exception of three cases, all were referred for treatment. As usual, impetigo was the commonest disease, accounting for nearly half of this year's total. Table II. shows that there were 192 cases of "Other skin disease." These include such conditions as eczema, alopecia^ seborrhoea, etc. (e). External Eye Disease. Thirteen cases of minor disease of the eye, including 8 cases of blepharitis and 2 of conjunctivitis, were discovered at routine medical inspections. In addition, 201 cases, including 26 of blepharitis and 73 of conjunctivitis, were discovered at the Special Clinics. (/). Defective Vision and Squint. Routine medical inspections revealed 250 cases of defective vision, 181 being referred for treatment. Seven cases of squint were also discovered, 5 being referred for treatment. At the Special Clinics, 110 cases of defective vision and 4 of squint were referred for treatment. 8 (g). Ear Disease and Hearing. Amongst children examined at the routine medical inspections, 59 cases of defective hearing were found, 29 of these being referred for treatment. Twenty-two cases of ear disease were also discovered, 16 being referred for treatment. Special examinations at the Clinics account for 25 cases of defective hearing; and 196 cases of ear disease. (h). Dental Defects. Nine hundred and ninety-two cases of dental caries were discovered at routine medical inspection, and a further 119 cases were found by examination at the Special Clinics. At the routine dental inspections in the schools, a total of 6,254 children were found requiring treatment. Table IV on page 39 gives further statistics in this connection. See also Statistical Table on page 26. (i). Deformities. One hundred and thirty-five 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 flat feet. Malnutrition. Officially, according to our Returns, there are 10 cases of malnutrition which have been discovered during Routine Medical Inspection. That this is a true picture of the departure from normal nutrition which exists amongst our school children as a whole is far from the real fact. These are only the grosser cases. At the present time there is, in my opinion, a far too optimistic view of the nutrition amongst the children and even some adults. That there is gross malnutrition to any extent it is certainly not true to say, but that there is sub-normal nutrition of varying amounts I am convinced is the true picture. The unfortunate fact, as I have expressed before, is that the metric systems of assessment lose sight of one of the main features in the picture of sub-normal nutrition, that is, the protein starved, carbo-hydrate surfeited child who is bulky and flabby and whose height-weight index does not disclose that particular fact. Those of us who, for a quarter of a century, have had to deal with school children and who in the early days learnt the syndrome which sub-normal nutrition produces, have a knowledge which the medical officer of later date has never had the chance of acquiring. The picture has been modified in various ways, but to those of us who have learnt the syndrome it remains even after modifying. I want again to point out how accurate that can be. I have used these figures before, but they are worth repeating. At a tea given to the children at one of the Isleworth Schools some time ago I picked out 13 children who to my mind were obviously suffering from malnutrition. In 12 of the 13 cases either the father was dead, or had been out of work for six months or more. Surely, one out of 13 is not a big margin of error. I am convinced that this sub-normal nutrition is due to two causes:— (1) High Rent. As I pointed out last year in my Report as Medical Officer of Health, some of the families pay as much as 46 per cent, of their income in rent. (2) Mismanagement of the family income due to two causes. (а) The inability to buy properly. (b) The inability to prepare the food which has been bought. There is, as I have seen as a result of some of the budgets which have been kept for me by some of the mothers, a very definite protein shortage in dietary in a number of these humble people. I am convinced that one of the great needs at the present time is education in the homes of these people as to how to prepare, within the means at their disposal, meals which will provide not only a balanced diet, adequate in calories, but adequate in vitamin content. 6 INFECTIOUS DISEASE. The rules as to exclusion of infected children and contacts as laid down by the Ministry of Health and Board of Education in the joint Memorandum of 1927, have been carefully followed. The following table shows the infectious disease which occurred among children attending public elementary schools during 1932, and the three previous years. 9  1932 1931 1930 1929 Small-pox – – 2 – Scarlet Fever 105 106 77 118 Diphtheria 30 26 88 239 Measles 952 9 799 83 German Measles 25 5 38 344 Mumps 122 132 381 106 Chicken-pox 194 233 392 423 Whooping Cough 260 242 144 177 1688 753 1921 1490 This table shows the incidence of infectious disease in each school during 1932: — SCHOOL. SCARLET FEVER. DIPHTHERIA. MEASLES. GERMAN MEASLES. MUMPS. CHICKEN POX. WHOOPING COUGH. Alexandra Boys 7 1 65 ... 15 70 19 ,, Girls 9 4 52 ... ... 23 16 Berkeley Junior 4 ... 89 1 2 3 10 Brentford End Infants ... 2 25 5 ... 1 13 Bulstrode Senior Boys 3 ... 3 ... 1 ... ... ,, ,, Girls 6 1 1 ... ... 1 ... Chatsworth Junior 9 3 47 2 3 9 17 Grove Road Boys 2 1 ... ... 1 1 1 ,, Girls 7 2 4 ... 1 1 1 ,, ,, Infants 5 ... 123 ... 2 8 27 * Heston Senior * ,, Junior 11 ... 63 3 8 2 21 Hounslow Heath Boys ... ... 16 ... 3 2 2 ,, ,, Girls 3 2 11 ... 2 1 3 ,, ,, Infants 4 2 145 2 17 2 65 Hounslow R.C. Mixed & Infants 1 2 47 ... ... 1 2 Hounslow Town Boys 2 1 5 1 4 1 2 ,, ,, Girls and Infants 7 1 81 ... 5 5 25 Isleworth Blue Boys 2 ... 5 ... ... 1 ... ,, ,, Girls and Infants 1 ... 22 5 1 5 ... † Isleworth Town Junior † ,, ,, Infants 13 2 62 4 7 5 4 Marlborough Senior ... ... ... ... ... ... 1 St. Mary's Boys ... ... 1 ... ... 9 ... ,, Girl and Infants 1 2 2 ... ... 1 ... Spring Grove Central ... ... 1 ... ... 2 ... ,, ,, Junior 3 1 51 1 49 6 4 Woodlands St. John's Infants 1 ... 4 ... 1 ... 24 Worple Road Junior Mixed 2 3 2 1 ... 3 ... ,, ,, Infants 2 ... 25 ... ... 31 3 T otals 105 30 952 25 122 194 260 * These figures also include cases that occurred in the old Heston Mixed and Infants' Schools. t These figures include cases that occurred in the old Isleworth Town Senior and Junior Schools. The School Nurses continue to visit all cases of non-notifiable infectious disease, and, as has been pointed out in previous years, this work takes up a 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 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. 10 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 810 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. 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 re-inspection of dirty children (Cleanliness Clinics). 11. Visit children's homes for enquiries in cases of non-notifiable infectious disease. 12. Visit homes of children who fail to attend Clinics or attend irregularly. Summary of School Nurses' work during 1932. Attendances. Routine Medical Inspections 218 Re-inspections 30 Eye Clinics 113 Minor Ailments Inspection Clinics (with Medical Officer) 175 ,, ,, Treatment Clinics 987 Dental Inspections 16 ,, Clinics 553 Cleanliness Surveys 71 Cleanliness Clinics 52 Other Attendances (Special Clinics, Med. Exam, of Teachers, School Sports, etc.) 29 Visits. Re Infectious Disease 2593 Re Clinic Absentees 202 Following up 810 Other Visits 26 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 continue to be much in evidence. 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. 11 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 attending Minor Ailments Clinics. Total attendances for treatment 1930 2,036 8,349 1931 2,413 10,803 1932 2,761 11,057 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 the year it was necessary to commence the two medical sessions per week at Hounslow, half an hour earlier, but the large attendances frequently cause very late Clinics. However, that is all the extra time the Medcal Officer in charge of this Clinic can spare, and really a further half-day session per week is indicated. The following figures show the increase in the number of special examinations at School Clinics by Medical Officers:— Year. Total number of Special examinations and re-examinations by Medical Officer. 1930. 2,532 1931. 3,534 1932. 3,802 (b). Tonsils and Adenoids. As prevously stated, 369 children were referred for treatment on account of enlarged tonsils and adenoids. Of this number, 125 were operated on under the arrangements made by the Authority with the Hounslow and Richmond Hospitals in 1921, 53 received operative treatment by private arrangements of the parents, and 2 cases received non-operative treatment. The actual number treated during 1932 is therefore 180 out of 369 referred for treatment, or 48 per cent. 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 when this is received the child's name and address is sent to the appropriate Hospital. The hospitals make the appointment for treatment, and the Authority pays one guinea for each case operated on. The scale of parents' repayments is as follows: — Weekly family income per head, after deducting rent. Parents' contribution towards cost of o-peration. Under 8/- nil. From 8/- to 10/- 5/- From 10/- to 12/- 10/- Above 12/- 21/- This scale of repayments does not apply to parents who are members of the rlospital Savings Association. In these cases the Association's Voucher is accepted in lieu of a contribution, and the Association in return pays an agreed sum per case to the Education Committee for this treatment of their members' children. (c). Tuberculosis. Any suspicious case is immediately referred to the County Tuberculosis Officer, with whose Dispensary in Bell Road we are in constant touch. 12 (d). Skin Disease. Table IV. (page 38) shows that 373 cases of skin disease and 1193 miscellaneous cases of bruises, sores, chilblains, etc. were treated under the Authority's scheme during the year. 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 8724, compared with 6774 in 1931, 4211 in 1930, and 782 in 1929. Number of visits to schools by Nurses 63 Total number of children examined 8724 ,, ,, ,, ,, given warning notices 405 ,, ,, ,, ,, excluded as verminous 25 1. (Few) 328 Found to have nits— 2. (Bad) 67 3. (Very Bad) 10 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. 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. Eighty-seven children were cleansed by Mrs. Yates during 1932. During 1932 it was found necessary to take legal proceedings in 6 cases, with the following results: One case Adjourned sine die. One case Adjourned for one month (*) One case Cautioned. One case Ordered to pay costs. Two cases Fined 5/- each. * This case was re-heard early in January, 1933, when the parents were ordered to pay Costs. Ringworm of the Scalp.—Five case were successfully treated by X-ray under our arrangements with Dr. Arthur (of Ealing) during 1932. 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 176 external eye defects were treated at the School Clinics during the year. These were chiefly conjunctivitis, blepharitis, with some phlyctenular ulcers and suppurating conditions of the lids. (/). Vision. Five hundred and thirty-seven cases were submitted to refraction, compared with 531 in 1931, 443 in 1930, 413 in 1929, 297 in 1928. Spectacles were prescribed in 500 cases and obtained before the end of the year in 490 cases. Twelve other cases were treated by private arrangement of the parents, and spectacles were obtained in 4 cases. I am indebted to Dr. Roberts, who is in charge of the Refraction Clinic, for the following report— Report on the use of a -J- 1 Sphere before the Reading Eye in the Routine Vision Testing of Children in School. In 1931 the Board of Education published a Report of the Committee of Inquiry into Problems connected with Defective Vision in School Children. In Part IV., under the heading " General Conclusions," the Committee states that it considers that early myopes are likely to be overlooked under the present system of vision testing in the Schools by the use of the Snellen long distance test, where, if a child reads 6/6 or 6/9 and is without subjective symptoms, he is passed as normal. A modification of this procedure is advocated, viz., the placing of a + 1 sphere before the reading eye, which the' Committee considers should render 13 it possible to pick out those children needing fuller examination since "under this condition, if the child is hypermetropic he will read 6/6 possibly even more easily than before; if he is emmetropic or slightly myopic the visual acuity will become less than it was before, and in the latter case may diminish to 6/36." This suggestion was put into practice at once in this District, but, as only two months of the year remained, the figures were small and conclusions could not be drawn; a report of them is given in the School Medical Officer's Report for 1931. This year the use of the + 1 sphere has been continued and the results for the whole year collected and tabulated. The testing was done with Snellen's Test Type at 20 feet, natural vision being tested first and then the vision with a + 1 sphere placed before the reading eye. The vision testing was done, except in the case of 341 children, by the same nurse who has been doing the work for years. All Infants have their vision tested ; those who were able to read at the Routine Inspection are included in the Tables below—whilst those who could not then read were noted to be re-tested at the following Re-inspection, but the figures are not included in the Tables, as in some cases the Re-inspections have not yet taken place. ROUTINE MEDICAL INSPECTIONS FOR THE YEAR 1932. Tables shewing alteration in vision due to -placing a + 1 sphere before the reading eye of 3,064 children whose vision was 6/6 or 6/9 without spectacles and who shewed no signs of eye strain, and ivere therefore marked as requiring no treatment. UNIT OF ALTERATION—ONE SNELLEN LINE. TABLE 1. (Totals). TOTAL BOYS AND GIRLS. Number tested. Total number shewing:— Increase. No change. Decrease (Snellen Lines). 0 294 9.60% 1 2 3 4 5 6 3064 560 688 1083 414 24 1 18.28% 22.45% 35.35% 13.51% 0.78% 0-03% TABLE II. BOYS. N umber tested. Number of Boys shewing:— Increase. No change. Decrease (Snellen Lines). 0 165 10.22% 1 2 3 4 5 6 1614 261 352 565 257 13 1 16.17% 21.81% 35-01% 15-92% 0.81% 0.06% TABLE III. GIRLS. Number tested. Number of Girls shewing : — Increase. No change. Decrease (Snellen Lines). 0 129 8.90% 1 2 3 4 5 6 1450 299 336 518 157 11 0 20.62% 23.17% 35.72% 10.83% 0.76% Note.— For the purpose of calculating the difference in vision in the Tables, all partly read lines are counted as the line above, e.g. 6/6p is recorded as 6/9, and in cases where there is a difference of vision between the*eyes the worse vision has been taken. 14 Anisometropia. 349 children (11.3% of total) included in the above tables shewed a difference of vision between the two eyes, of which 227 were boys and 122 girls. Of these, 61 boys shewed a difference of natural vision of one Snellen line and 6 had a difference of two lines. With + 1 sphere added 17 of the 61 boys had a difference of one Snellen line between the eyes and 3 boys had a difference of two lines, the remaining 41 boys having similar vision in each eye. The addition of + 1 sphere to the 6 boys shewing a difference of natural vision of 2 lines caused 4 to have similar vision between the eyes and 2 to differ by one line. 33 girls had a difference of natural vision of one Snellen line, and 2 had a difference of two lines. With + 1 sphere 8 of the 33 girls had a difference of one line, one had two lines difference, whilst 24 had similar vision in each eye. The two girls with a difference of two lines natural vision had a difference of one line only with the addition of + 1 sphere. The remaining 160 boys and 87 girls shewed a difference in vision between the eyes only after + 1 sphere was added. Boys. 141 had a difference of 1 Snellen line. 16 ,, ,, „ 2 „ lines. 3 ,, ,, „ 3 „ lines Girls. 72 ,, ,, ,,1 ,, line. 11 ,, ,, ,,2 ,, lines. 4 ,, ,, „ 3 „ „ Summarised this gives Natural Anisometropia 3.3% Anisometropia with + 1 sphere 8.0% Total 11.3% It will be seen that the tables show no instance of a child's vision being improved by the addition of the + 1 sphere. Actually one boy and one girl had a slight increase of vision in one eye, with a decrease in the other. As the decrease was the greater they have been classified under that heading. The absence of improvement of vision does not necessarily give a true picture since the School Test cards do not usually have a 6/5 line, therefore, any child seeing 6/6 who might be improved by the addition of + 1 sphere would merely be reported as " No change." The two columns "Increase" and "No change" however should indicate Hypermetropia, and therefore it would appear that 9.6% of the children tested were Hypermetropic, who, since they had good vision and no subjective symptoms, do not require further consideration. The remaining 90.4% were all adversely affected by the addition of the + 1 sphere and therefore according to the Report of the Committee of Inquiry should be either Emmetropic (normal vision) or Myopic. I feel, however, that small degrees of Hypermetropic Astigmatism of less than 1 diopter would probably account also for a diminution of vision with an added + 1 sphere. Since this report is based on loutine work and is not a Special Inquiry it has been impossible to do refractions to prove or disprove this, but some of the special refractions given later show that this does occur. The point however is not of practical importance, since mild degrees of hypermetropic astigmatism with no symptoms and good vision would need no treatment until symptoms arose. The essential problem however is to distinguish the early myopes, and without refraction it is impossible to do this with certainty. In passing, however, it may be noted that the emmetropes present a minor problem, as in the gowing child the tendency is for the eyes to become more myopic, consequently emmetropia may be only the mid-stage in the passage from infantile hypermetropia to the myopia of the older child. Therefore, in order to safeguard the vision of growing children, it should be necessary to follow-up, at least by more frequent testing, those children who are emmetropic as well as those who are slightly myopic. Obviously, however, those children who are already slightly myopic are the more important. 90.4% of the children tested must therefore be considered as either emmetropic, slightly myopic or possibly with a low degree of hypermetropic astigmatism. The number is too large to make refraction of all the children possible in the routine work. Had this been done it would have meant an addition of 2,770 refractions, which is five times as many as those done in the ordinary course of treatment. I suggested, however, last year that a working standard might be taken which would catch the early myopes, and it is obvious that it is the larger degrees of diminution which are the most likely to be myopes. In view of this year's figures it would seem practicable to refract all children whose vision with + 1 sphere is diminished by five or more Snellen lines. This represents 0.81% of the total children or 25 in actual figures. 15 13.51% or 414 children had their vision diminished by 4 Snellen lines—a figure too large to refract. It will be noticed in Table I. that the figures rise in each column from "No change" onwards, reaching the maximum in those decreased by 3 Snellen lines, then falling again, with a very sharp drop between the decrease of 4 and 5 Snellen lines. Much the same rise and fall is shewn in Tables II. and III., where the returns are classified according to sex. An endeavour was made to refract the 25 children whose vision was decreased by 5 and 6 Snellen lines. They were dealt with as special cases and seen out of school hours on a Saturday morning, Homatropine being used as the mydriatic instead of the usual Atropine in use at the Eye Clinic. Twenty in all presented themselves for refraction, two were absent, two had left school, and one refused examination. It is difficult to classify these results, and therefore the refractions are given in full corrected to infinity. Boys. R.A. (13.12.23). Before mydriatic RV 6/9 LV 6/6p + 0.25 + 0.25 = 6/6 c + 1 sphere RV 6/36 LV 6/36 + 0.25 + 0.25 = 6/6 Boy now complaining of eyes aching—spectacles ordered. L.D. (2.11.20). Before mydriatic RV 6/6 LV 6/6 + 1.5 + 1.25 c + 1 sphere RV 6/24 (1) LV 6/18 + 1.0 + 1.0 B.C. (6.2.20). Before mydriatic RV 6/5 LV 6/5 + 0.5 + 0.5 c + 1 sphere RV 6/36 LV 6/36 + 0.5 + 0.5 J.R. (6.10.23). Before mydriatic RV 6/5p LV 6/5p + 0.75 + 0.75 c + 1 sphere RV 6/24p LV 6/24p + 1.0 + 0.75 F.E. (17.7.19). Before mydriatic RV 6/6p LV 6/6p + 0.75 + 0.75 c + 1 sphere RV 6/36 LV 6/36 + 0.75 + 0.75 C.H. (4.9.19). Before mydriatic RV 6/6p LV 6/6j + 1.25 + 1.0 c + 1 sphere. RV 6/36 LV 6/36 + 1.0 + 1.0 P.G. (26.1.24). Before mydriatic RV 6/6 LV 6/6 + 1.25 + 1.5 c + 1 sphere RV 6/24p LV 6/24p + 1.25 *+ 1.5 16 B.W. (13. 8.24). Before mydriatic RV 6/5p LV 6/5p + 0.25 0 c + 1 sphere RV 6/24 LV 6/18p + 0.25 + 0.25 P.D. (9.7.23). Before mydriatic RV 6/6p LV 6/6p 0 "0 c + 1 sphere RV 6/12 LV 6/12 + 0.75 + 0.75 J.G. (12.4.20). Before mydriatic RV 6/9 LV 6/36 + 0.25 + 0.25 = 6/5 c + 1 sphere RV 6/36 LV 6/0 — 0.5 — 0.5 1 sph = 6/6 Spectacles ordered. N.W. (31.10.19). Before mydriatic RV 6/5 LV 6/5 — 0.5 — 0.5 c + 1 sphere RV 6/18p LV 6/18p — 0.25 — 0.5 S.P. (24.3.20). Before mydriatic RV 6/6p LV 6/6p — 0.5 — 0.5 c + 1 sphere RV 6/36 LV 6/36 — 0.25 — 0.25 Girls. J.B. (17.5.23). Before mydriatic RV 6/6p LV 6/6p + 0.75 + 1.0 c + 1 sphere RV 6/36 LV 6/36 + 1.0 + 1.25 B.G. (14.2.24). Before mydriatic RV 6/6 LV 6/6p + 1.0 + 0.75 c + 1 sphere RV 6/18 LV 6/36 + 1.0 + 0.75 A.G. (27.12.26). Before mydriatic RV 6/6p LV 6/6p + 0.75 + 0.5 c + 1 sphere RV 6/24p LV 6/36p + 0.5 + 0.25 E.N. (12.2.20). Before mydriatic RV 6/9p LV 6/9p + 0.5 + 0.75 1 = 6/6 c + 1 sphere RV 6/36 LV 6/36 + 0.5 + 0.5 = 6/6 Now complaining of eyes—spectacles ordered. 17 V.F. (9.11.19). Before mydriatic RV 6/6p LV 6/6p + 0.5 + 0.5 c + 1 sphere RV 6/36 LV 6/36 — 0.5 — 0.25 M.T. (29.5.18). Before mydriatic RV 6/6p LV 6/6p + 0.25 — 0.25 c + 1 sphere RV 6/36 LV 6/36 0 — 0.25 B.W. (21.5.23). Before mydriatic RV 6/6 LV 6/6 — 0.25 0 c + 1 sphere RV 6/24p LV 6/24p — 0.25 0 W.H. (15.2.20). Before mydriatic RV 6/6 LV 6/6 — 0.25 - 0.5 c + 1 sphere RV 6/36 LV 6/36 — 0.25 -0.5 It will be noticed that not all these children exhibited a difference of 5 Snellen lines with + 1 sphere when tested at the Clinic immediately before the Homatropine was installed. In most cases the discrepancies are slight and can be accounted for by the varying conditions pertaining in the schools—particularly as to lighting of the test card—also several months had elapsed between the testing at school and the subsequent refraction. One case only suggests an error in the first testing, viz., the boy P.D., who read 6/12 through + 1 sphere. In three cases only was it considered necessary to prescribe spectacles—two because there were now symptoms of strain and their sight was improved by correcting their small errors, and one (J.G.) because the vision in his left eye was found to have deteriorated to 6/36 since he was tested in school, which in his case had been 8 months previously. His vision then was RV 6/6, LV 6/9. The other 17 were marked for observation and will have their vision tested whenever the Medical Officer visits their school instead of waiting years for their next routine examination. Spectacles were not ordered as I do not consider it either necessary or justifiable to saddle children with spectacles for the correction of small errors which are causing neither bad vision nor strain. Twenty cases is too small a number from which to draw conclusions, they can only serve as a guide as to what may be expected in similar circumstances. All the errors are small, and in most there is astigmatism of 0.25 diopter in either one or both eyes. It would appear also that slight hypermetropic astigmatism as well as slight myopia causes a large decrease in vision where a + 1 sphere is used. It is quite possible that similar results would be obtained if children in the lower Snellen Decrease groups were also refracted ; one cannot tell without refracting them. A further rough age analysis has been made of the figures, classified according to type of school and sub-divided according to sex. 18 ACE ANALYSIS—Classified according to the type of school. TABLE IV. TOTAL NUMBER OF BOYS AND GIRLS EXAMINED—3,064. Type of School. Number showing: — Total numbers examined. Increase No Change. Decrease (Snellen Lines). 1 2 3 4 5 6 Infants (Ages 5 & 6) 0 147 136 148 361 38 1 0 831 17.69% 16.37% 17.81% 43.44% 4.57% 0.12% Junior (Ages 8 & 9) 0 82 220 346 478 206 10 0 1342 6.11% 16.39% 25.78% 35.62% 15.35% 0.75% Senior (Ages 12 & 13) 0 44 132 142 197 115 12 1 643 6.84% 20.53% 22.08% 30.64% 7.88% 1.87% 0.16% Central (Ages 11-15) 0 21 72 52 47 55 1 0 248 8.47% 29.03% 20.97% 18.95% 22.17% 0.40% TABLE VI. GIRLS (No. examined 1,450). Type of School. Number showing : — Total numbers examined. Increase No Change. Decrease (Snellen Lines). 1 2 3 4 5 6 Infants (Ages 5 & 6) 0 61 77 75 187 14 1 0 415 14.69% 18.55% 18.07% 45.06% 3.37% 0.24% Junior (Ages 8 & 9) 0 44 124 171 216 72 4 0 631 6.97% 19.65% 27.1% 34.23% 11.41% 0.63% Senior (Ages 12 & 13) 0 19 60 61 90 46 5 0 281 6.76% 21.35% 21.71% 32.03% 16.37% 1.78% Central (Ages 11-15) 0 5 38 29 25 25 1 0 123 4.06% 30.89% 23.58% 20.32% 20.32% 0.81% TABLE V. BOYS (No. examined 1,614). Type of School. Number showing : — Total numbers examined. Increase No Change. Decrease (Snellen Lines). 1 2 3 4 5 6 Infants (Ages 5 & 6) 0 86 59 73 174 24 0 0 416 20.67% 14.18% 17.55% 41.83% 5.77% Junior (Ages 8 & 9) 0 38 96 175 262 134 6 0 711 5.34% 13.50% 24.61% 36.85% 18.85% 0.84% Senior (Ages 12 & 13) 0 25 72 81 107 69 7 1 362 6.91% 19.89% 22.38% 29.56% 19.06% 1.93% 0.28% Central (Ages 11-15) 0 16 34 23 22 30 0 0 125 12.80% 27.20% 18.40% 17.60% 24.00% 19 One would postulate that there should be a larger proportion of hypermetropic children amongst infants, and that therefore they would yield the highest percentage of " No Change " cases. The Tables show that this is so, the percentage figure being twice that of other age groups. Conversely, at the other end of the scale the infants provide the lowest percentage of children decreased by 5 Snellen lines. Theoretically one would expect that infants would provide a smaller percentage of all cases of decrease in vision with a + 1 sphere than would other age groups, and this is so in decreases of 1, 2, 4, 5 and 6 Snellen lines—but in a decrease of 3 Snellen lines the infants have a much larger figure than other age groups. I do not know if there is any significance in this. In Table I. (Total Children) it will be seen that a decrease of 3 Snellen lines represents over one-third of all children tested, and this figure is repeated when analysed according to sex. It seems probable that this decrease of 3 lines represents the most normal reaction to reading with a + 1 sphere, and infants, therefore, show a higher percentage of normality than do other age groups. Indeed a decrease of 2 and 3 Snellen lines accounts for 57% of all the children, and it seems reasonable to take these degrees of diminution of vision as normal. Theorising from figures, however, particularly a small number such as 3,064, is usually unprofitable and often dangerous. Summary. 1. The advisability of a more thorough scheme of visual examination of school children. This is stressed by the Committee of Inquiry of the Board of Education, who, as a result of their investigations point out the danger of early myopic conditions being overlooked. This must be the practical experience of all those who do refractions in the School Clinics. From time to time children appear at the Refraction Clinic with a visual acuity of 6/24 or less—children who have never left the district, and who have been examined and found normal at their previous routine examinations. Refractions show from 1-2 diopters of myopia. How are such children to be found and treated earlier ? 2. The use of the + 1 sphere in the routine vision testing in the schools appears to offer a useful method of detecting children who require further investigation—but its value is at present minimised by lack of knowledge as to what is the real meaning of the results obtained. The number of children whose vision is adversely affected by a + 1 sphere was 90% of those children who would be passed as normal under the ordinary procedure. This makes refraction impossible unless it were made the subject of a special inquiry. 3. Under 1% had their vision reduced by 5 Snellen lines or more, and therefore represent the greatest deviation from the normal reaction of visual acuity when a + 1 sphere is used, and should be in the greatest need of further investigation. The smallness of the figure makes this a practicable proposition, and it would seem desirable to refract and follow up all such children. 4. The refraction results of the twenty cases show slight hypermetropia and slight myopia combined in many cases with an astigmatism of 0.25 diopter. The question then arises : Should slight myopic errors be corrected by the prescription of lenses in cases of good vision and with no subjective symptoms? On the assumption that the myopia will progress and that the wearing of correcting lenses will prevent or check this advance, the answer should be in the affirmative—but wc have no precise knowledge of this, only the known general tendency of myopia to increase in the growing child. The individual factor, also, cannot be overlooked, and it may well be that small degrees of myopia fit in satisfactorily with the general "make-up" of some children, and are in fact normal for such children. I am strongly of opinion that small errors of any kind should not be corrected unless there is evidence of a lessened visual acuity or signs of strain. But such children should be followed up and their vision tested frequently in case symptoms should arise at a later date. 5. Greater frequency in testing the vision of school children would seem more advantageous than increasing the numbers of refractions by endeavouring to refract children who may be slightly myopic though without symptoms. So long as children are discovered and treated within a short time of the appearance of symptoms, there cannot be any real injury effected. At present, however, the long intervals between the routine inspections make it possible for children to be left for years with a disability untreated. This is particularly so during the four year interval between Intermediates and Leavers—and at the very period when visual defects are likely to manifest themselves owing to the increased work at school. True, there are the School Clinics to which a child can always be referred if the defect is noted, and many do obtain treatment in this way. But many also are missed by parent or teacher—this year 250 cases of visual defect were discovered at the routine inspection against 112 found during special inspection at the School Clinics. 20 Annual testing of vision of all children would be a step in the direction of discovering early myopia which requires treatment—it would mean a considerable increase of work, but certainly much less than the general refraction of school children. Meanwhile, the use of + 1 sphere in the routine vision testing is a practicable addition to the work. In the light of further knowledge it may prove of great utility, and for the present the following up of children showing a decrease of 5 Snellen lines seems a useful procedure. (g). Ear Disease and Hearing. Two hundred and twenty cases of deafness or ear disease were dealt with at the School Clinics, and 10 were treated by private arrangement of the parents. I am indebted to Dr. Roberts for the following report on the treatment of discharging ears: — REPORT ON THE USE OF B.I.P.P. IN THE TREATMENT OF DISCHARGING EARS IN A SCHOOL CLINIC. Treatment of discharging ears in school children at the Clinics has long been one of the least successful of the many conditions treated here, and it is generally acknowledged that this condition is very difficult to treat successfully. In this district there is no Ear Clinic, and discharging ears have to be treated at the Minor Ailment and Daily Treatment Clinics, and supervised by the Medical Officer of the Clinic, and they are not usually seen by an Aural Specialist. Consequently treatment is restricted, and consists mainly of cleansing the ear, which after a varying time heals, often breaking down again subsequently. Hydrogen Peroxide is most frequently used and Rectified Spirit with Boracic insufflation in suitable cases. Other agents such as Neo-Protosil and Antivirin have been tried, but did not seem to procure better results than Hydrogen Peroxide, and this has become the routine treatment. Ionisation has been obtained in a few cases with good results, but it is not available at the School Clinic, and it is difficult for children to be sent up to a London Hospital, as, •even when such treatment can be arranged, parents cannot often afford either the time or the money, and in some cases do not want to take the trouble. A few cases have been treated at the West Middlesex Hospital by arrangement with the Medical Superintendent, but the School Clinic has to treat the bulk of the cases. Such cases are chiefly those of middle ear suppuration or discharge after mastoid operation, often of long duration before seen or cases which have had previous trouble and broken down again. No acute cases are treated—a few are seen and referred at once for hospital or private medical treatment. Some have only the External Auditory Canal or Meatus affected such as with boils or eczema—these are in the minority and clear up quickly. In all cases where enlarged and unhealthy Tonsils or Adenoids are present an endeavour is made to have these removed. Advice is also given as to the general health of the child, though often this appears to be good. In April, 1932, B.I.P.P. was first tried. This was used with great success by Mr. Rutherford Morrison of Newcastle during the war for the treatment of septic wounds. It is a paste comprised of:— I had personal experience of its use for 2 years at the Military Hospital, Endell Street. The procedure was then to open up and thoroughly clean the wound under anaesthetic removing all dead tissue. B.I.P.P. was then rubbed well in to all parts and the wound stitched up. Results were extremely good, the whole process of healing being accelerated and, a most important point, dressings were reduced to a minimum, the wound being left untouched for one week after operation unless there was a rise of temperature, in contra-distinction to the daily or twice daily dressings of other treatments. An adaptation of this procedure is made when used in the ear. The ear is first thoroughly cleansed with Hydrogen Peroxide, dried with wool, and then the paste applied on a swab. Naturally this is not done under anaesthetic, and the restricted area of the outer and middle ear make it difficult to apply the paste to all parts—which difficulty is increased where the surface is pocketed and the opening of the canal small. Therefore the method is not as successful as when applied to open wounds. In cases where it is very difficult to apply, the paste can be diluted with more Liq. Paraffin and dropped into the ear, but it does not appear to act so well, as the tissues are inclined to become sodden. It is not necessary to plug the meatus with wool, and the child is not seen again for 3 or 7 days—usually 3 days after the first application. The ear is not touched in the interval. Fresh applications are made as considered necessary with a 3 or 4 day interval—often longer. E. L. ROBERTS Assistant School Medical Officer. Bismuth Sub Nitrate Iodoform Liq. Paraffin ... 1 part. 2 parts. 1 part. 21 The first case on which B.I.P.P. was used was an old Tubercular double Mastoid of 6 years' standing. This case is given at length below. It was seen almost daily for some time so as to watch the reaction to B.I.P.P. The result exceeded all expectations, as in one application the discharge almost ceased and all smell vanished. As the condition improved and fewer treatments were necessary (twice weekly and finally once weekly) the child was at last able to forget her ear, with very good results on her psychological and also her physical condition until unfortunately later she showed signs of abdominal Tuberculosis. Twenty-one cases in all (19 Otitis Media and 2 of post Mastoidectomy discharge) were treated with B.I.P.P. last year—14 treated with B.I.P.P. only and 7 long standing cases which had had other treatment. These are detailed below. Of the 14 treated with B.I.P.P. only—12 cleared up entirely, and up to date (March, 1933) there has apparently been no recurrence, i.e., children have not been sent again to the Clinic. Four children had one application. Six children had two applications. One child had three applications. One child had five applications. Of the remaining two, one had 9 applications and had not completely cleared up when he left school, although there was only an occasional small amount of discharge. The other had one application, and 7 days later there was no discharge—the child was then absent from the Clinic and turned up again early in 1933 with slight discharge, having had Influenza in the interval. Although the 12 healed results are satisfactory, one cannot say that they would not have cleared up in the same amount of time with other treatment, but it is absolutely certain that they would not have done so with so few treatments. Hydrogen Peroxide requires at least daily treatment at the Clinic, and usually has to be used once or twice daily at home. It would be very rare for a case to clear up within a week, and most of them drag on for very much longer, making a large number of treatments. Of the seven old standing cases, two were discharged as healed, three remained with the ear moist and occasionally slight discharge and two went to hospital for other complaints with the ear still discharging. The number of applications, however, was much greater than those in which B.I.P.P. only had been used. See details below. In all the cases treated, only one child complained of the ear running during the interval after treatment. In cases where discharge persists it is of a mucoid character, and does not overflow into the meatus, and there is no unpleasant smell, therefore the children and their associates can forget that the ear trouble exists. This is an enormous gain—the sight and smell of a child with aural discharge is definitely offensive, and Hydrogen Peroxide only removes the smell for a short time, and it recurs with fresh discharge which soaks up the wool plugs. Consequently such children tend to be shunned, and even their parents complain bitterly about the smell. The psychological effect on a sensitive child must be definitely bad, and the incessant treatments necessary to keep an ear clean are wearisome to all concerned. B.I.P.P. does away with all this—children are seen once or twice weekly at the Clinic and treatment given when necessary. There is no treatment at home, no smell and in most cases no appearance of discharge. Summary. 1. B.I.P.P. has not proved a perfect cure for discharging ears, but it does at once ameliorate the condition and effects a cure at least as quickly as other agents used at the Clinic. 2. It reduces the number of treatments enormously, which is of great value in saving the Nurses' time at the Treatment Clinics, and since the child attends Clinics less often there is less disturbance of School Attendance. 3. It does away with treatment at home which is an advantage, as home treatment is often neglected or inadequately performed. 4. It removes all offensive smell at once and permanently. 5. In most cases there is no visible evidence of discharge from the beginning of treatment, and therefore no outward sign of aural trouble. Old Standing Cases Treated with B.I.P.P. after other Treatment. G.M. (17.7.21). 1926 Profuse discharge right and left—sent to a London Hospital. 1927 Double Mastoidectomy, considered Tubercular—later sent to Convalescent Home. 1928 Both ears continue to discharge. 1929 having Out-Patient treatment (Ultra Violet and Ionisation) at nearby hospitallater returned to Ear, Nose and Throat Hospital in London for further operation. 22 1930 Both ears discharging intermittently—left ear, deep sinus in bone behind Pinna. Attended Clinic daily for cleansing treatment according to instruction of surgeon in London, whom she saw periodically. Began school again. Had considerable pain left ear from time to time, and was absent from school periodically. Child very run down. 1931 In-patient local hospital for 9 weeks. On leaving hospital both ears discharging. Treated daily at Clinic as above. June-November, Convalescent treatment at seaside. 1932 Left Sinus continues to discharge, right ear intermittent discharge—again treated at Clinic for cleansing and seeing Surgeon in London periodically. Returned to school half-days, but later was re-excluded on account of pain and poor general condition. In April her mother was unable to continue to attend the hospital in London on account of the cost of fares, and the child then came directly under the care of the Clinic, and treatment with B.I.P.P. was started. Her condition at this time was—left ear, deep sinus with profuse evil smelling discharge—considerable pains at intervals. Right ear—intermittent slight discharge. General condition of child very poor. Treatment previously had been cleansing three times daily with Hydrogen Peroxide—this was usually done each morning at the Clinic with the mother carrying out the other cleansings. On 19.4.32 the left sinus was well cleansed and B.I.P.P. applied as thoroughly as possible and lightly plugged with wool with no treatment at home. 20.4.32. No discharge, no pain and no smell. 21.4.32. Slight discharge—more B.I.P.P. applied. 22.4.32. No discharge. 23.4.32. No discharge and more B.I.P.P. added. 25.4.32. No discharge. 26.4.32. No discharge, moist-—B.I.P.P. 27.4.32. No discharge. 28.4.32. No discharge—B.I.P.P. 3.5.32. Pain left ear, no discharge, fomented. Foments continued for 6 days and no fresh B.I.P.P. added—very slight discharge. 10.5.32. Sinus dry, no pain—appears to be healing from bottom. 31.5.32. Returned to school in afternoon. Was seen several times weekly and B.I.P.P. applied when necessary—also to right ear when discharge recommenced. By the end of June was being seen twice weekly and B.I.P.P. applied when necessary—sinus from time to time showed slight discharge but looked healthier, and was very slowly filling in. General condition very much improved. From 24.8.32. Able to attend school all day and Clinic twice weekly— occasional discharge from left sinus and from right ear. B.I.P.P. used when necessary. In October, 1932, this child showed signs of Abdominal Tuberculosis, and her general condition became worse. In December she was sent away to the Royal Sea Bathing Home, Margate. In spite of this illness the left sinus continued to remain satisfactory—only occasional and slight discharge—treated weekly with B.I.P.P. during last 6 weeks, and although the sinus was still deep it was smaller than at the commencement of treatment with B.I.P.P. E.C. (21.12.19). Attended Clinic February, 1928, with discharge after Left Mastoidectomy. Has continued under treatment more or less daily until B.I.P.P. was started in November, 1932. On occasions during that time the condition has cleared, but without regular supervision discharge has always recurred. Different kinds of treatment had been tried, but the condition did not clear permanently. General condition has remained good throughout. Since B.I.P.P. was started, the girl has been seen only once a week, with no treatment at home. Actually it was only necessary to give two applications of B.I.P.P. to the end of the year—-with the ear remaining clean and sweet, although the condition has not permanently cleared. J.W. (24.6.23). Old standing case of Left Otorrhœa—general condition very poor. Had 12 applications of B.I.P.P. without appreciable change in the ear condition, the only gain being that the child was treated once in 3 days instead of three times a day. Went into hospital for general condition in October. 23 B.C. (16.9.20). Right Otorrhœa treated one month with Hydrogen Peroxide three times a day. Then B.I.P.P. commenced—12 applications at approximately weekly intervals—healed. (Treated twice in January, 1933, and finally discharged January 31st.) S.J. (29.5.21). Double Otorrhoea, July 1931. Treated daily at Clinic and with Hydrogen Peroxide drops at home. Did not clear. August, 1932, B.I.P.P. begun. 17 applications until end of year at 3 or 7 days interval according to condition. At the end of the year there was no discharge from either ear, but the mucosa remained moist and the case could not be discharged as healed. H.I. (14.4.20). Right Otorrhoea—treated 4 months more or less daily at Clinic with Hydrogen Peroxide and then Antivirin. Discharge remained considerable. B.I.P.P. begun and after on application discharge lessened. 13 applications made at 3 or 7 day intervals. At end of year there was occasional slight discharge only. F.S. (26.9.17). Left Otorrhoea—treated daily at Clinic with Hydrogen Peroxide for 4 weeks—still profuse discharge. Then B I.P.P. applied and again in 3 days, when discharge ceased. One more application (making 3 in all)—condition cleared and case discharged. Cases Treated with B.I.P.P. only. D.B. Profuse right purulent discharge—previous trouble. 2 applications with 3 days interval—healed. L.B. Left mucous discharge—previous trouble—1 application—healed. J.T. Right muco purulent discharge 14 days duration—5 applications, 4 with interval of 3 days—1 with 6 days interval—healed. Followed up for 4 weeks—remained clear. R.F. Left muco purulent discharge—2 applications 4 days interval—healed. G.F. Left muco purulent discharge—old recurring trouble—2 applications, 6 days interval — healed. F.H. Slight discharge with earache—1 application—healed. E.H. Slight discharge—2 applications, 7 days interval—healed. J.M. Discharge following earache—2 applications, 7 days interval—healed. O.D. Double Otorrhoea—previous trouble—one application—healed. F.S. Left purulent discharge—previous trouble—2 applications—2 days interval—healed. L.A. Left profuse mucous discharge—previous trouble—3 applications, interval of 3 and then 9 days—healed. R.P. Right muco purulent discharge following earache—1 application—healed. L.L. Right thick discharge—previous trouble—9 applications—3 with 3 days interval—6 with 7 day. Was not completely cleared when boy left school. L.D. Left profuse discharge—previous trouble—one application—cleared. (Child was absent from re-inspection and turned up again 14 days later (in 1933) with slight discharge and has not yet cleared but during this time she has had influenza). E. L. Roberts, Assistant School Medical Officer. (h). Dental Defects. The Dental Surgeon's Report on the work of the Dental Clinic is given below. ANNUAL REPORT OF THE SCHOOL DENTAL SURGEON. During the year the pressure of the increasing demands of the Dental Scheme has continued, and has become very heavy. With a view to reducing the large number awaiting treatment, extra Dental Assistance was allowed, and during the first three months of the year a part-time Dental Surgeon assisted for a number of sessions. As this was found to be totally insufficient, the part-time Dental Surgeon, Mr. H. F. Metcalf, was appointed half-time as from April 1st, 1932, with a resulting increase in the amount of work carried out under the School Dental Scheme. Later in the year, a Junior Dental Clinic Clerk Attendant was also appointed, which helped to some extent, but at the end of the year there was a very large number of cases still awaiting appointments for treatment. 24 It must be realized that with the abnormal increase in the school population, it is no longer possible to meet the demands of a complete Dental Scheme with the present Dental Staff, and the matter of making the half-time Dental Surgeon's post a whole time one is a very real necessity if the work is to be carried out at all satisfactorily, the only alternative being to relax the annual Dental Inspection of each school child, and to inspect and treat such children as conditions allow. 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. Inspection. The number of children inspected—7,519, is somewhat higher than last year's figure. Of these 6,254, or 83.2 per cent., were found to require treatment. The Routine Inspections have completely surveyed the children in the schools, apart from absentees, objectors, and the children in the Marlborough School, which was opened late in the year. Since the appointment of the half-time Dental Surgeon, all inspections have been done by this officer, and the Dental Nurse has again proved her usefulness in every detail within her capacity in the Clinic work, particularly in exlaining how to adjust expansion and other screws in Orthodontic cases, taking impressions, etc. The endeavour to catch absentees from Dental Inspections by informing the parents that their children had missed the annual Dental Inspection, and offering them the opportunity to come to the Clinic if they wished, was continued, but only 41 availed themselves of this opportunity out of the total absentee number of 494. With regard to the Board's Table IV., Group IV. (Dental Defects, page 39) it should be noted that the number of "Specials," 1,788, represents 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 1,788 are made up as follows:— (1) Referred for Gas, or Gas and Ethyl Chloride 1104 (2) Advice given 362 (3) Treatment postponed 316 (4) Inspection after Gas—required further treatment 6 1788 Conservative Treatment. 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—3,858, which works out at 105 fillings per 100 children treated ; the figure for the whole country averages 70 fillings per 100 children treated (Health of the School Child, 1931). Good results continue to be obtained from the Silver Nitrate treatment referred to last year. A saving financially has been secured by buying Zinc Oxide and Eugenol in small quantities instead of proprietary articles. This allowed a more extensive use of this mixture for lining deep cavities, a treatment which continues to give us all we desire; freedom from pain, and saving of pulps. Two hundred and seven such treatments were applied in 1932. Extractions. The number of teeth extracted was 6,117 (946 Permanent; 5,171 Temporary), which again compares favourably with the average for the country as given in the same report above referred to. The average figure is 207 per 100 children treated ; our figure was 167 extractions per 100 children treated, again indicating the desire to save rather than extract a tooth which can be made useful. A plea is here entered to all those colleagues upon whom the duty of reporting lies, to make their statistics on the lines here attempted, or alternatively, to suggest a better standard by which the activities of various Clinics can be better compared. The form of the Board's Table IV. showing dental defects has again been amplified (see next page) in order to show items of information which may help towards the proper comparison of the dental statistics of different authorities. A better appreciation of their import is conveyed to the reader if opposite certain figures percentages and notes are given throughout the whole table, where possible and applicable. 25 DENTAL INSPECTION AND TREATMENT—YEAR 1932. Average number of Elementary School children on registers at middle of year, June—9,805. Age. No. Total. No. Requiring Treatment. Per Cent. Requiring Treatment Remarks. 1. No. of children 5 803 614 76.5 Percentage inspected at Routine Inspection worked out on School population as at middle of year— 76.6 per cent. (a) who were 6 955 789 82.6 spected at 7 912 785 86.1 ine Dental 8 977 852 87.2 spections. 9 978 844 86.3 10 954 808 84.7 11 724 585 80.8 12 716 576 80.4 13 374 303 81.0 14 115 91 79.1 15 11 7 63.6 7519 6254 83.2 No. of Special Inspections 1788 Remarks. (b) No. of Children found to require treatment at Routine Dental Inspections 6254 (b) This equals 83.2 per cent. of the children inspected at Routine Inspections. (c) No. of Children actually treated 3655 (c) 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 58.44. 2. Half days devoted to Inspection ... 51 663' 2. Average number inspected per session— 147. Included in the 450 ordinary treatment sessions which were entirely devoted to Orthodontic Treatment. These sessional figures are for 1 Wholetime Dental Surgeon and 1 Part-time Dental Surgeon (see below). Treatment—Ordinary 450 do. Gas 135 Administration—Clerical 19 Dental Committee Meetings 8 3. Attendances made by children for treatment 6361 3. The gross attendances made by children at the Dental Clinic were 8,293, but children were not always physically treated, for various reasons, every time they attended. 4. Fillings—Permanent Teeth 3347 3858 4. The ratio of fillings in permanent teeth to extractions of permanent teeth was 353 fillings to 100 extractions. Temporary Teeth 511 5. Extractions— Perm. Temp. At Treatment Sessions 1 643 6117 At Gas Sessions 945 4528 Total 6. Administrations of general anaesthetics for extractions 1756 6. The percentage of attendances for "Gas" 1,756 of total attendances 6,361 was 27.6. 7. Other Operations 2671 Special work undertaken—An Orthodontic Scheme. Other work—Maternity and Child Welfare Dental Scheme for children up to 5 years of age, and nursing and expectant mothers. Attendances: 925; Extractions 655; Fillings 308. Administrations of General Anaesthetics: 217 ; Other operations: 75. Staff responsible for the above work:— 1 Dental Surgeon Whole-time. 1 ,, ,, Half-time from 1.4.32. plus 19 extra sessions. 1 Approved Dental Nurse. 1 Clerk Attendant. 1 Junior Clerk Attendant from Sept., 1932. Plus some clerical assistance from the Office of the School Medical Officer. Extra Staff for Gas Sessions only. 1 Anaesthetist (Asst. School Medical Officer). 1 Trained Nurse (Recovery Room). For Orthodontic Sessions. Dental Mechanic—Once a week. 26 The 1,756 "administrations of general anæsthetics for extractions" represents the number of time gas was given, and not the number of sessions devoted to extractions under gas, which was 135. In some districts very few extractions appear to be done under a general anaesthetic. Parents are slowly, yet, I think, surely becoming more enlightened with regard to dental matters, but we still get cases of complete ignorance, sometimes accompanied by a curious attempt to cover it by a display of knowledge. Two instances will suffice:— (1) The class of parents who seem to think that unless they see anything wrong, nothing can be wrong dentally. They are difficult to convince, their chief idea being the Dental Surgeon is "out to get trade," and their attitude, if they give way after an explanation by the Dental Surgeon, seems to be—here is the child—Kismet—and they hand the child over to us with an air of resignation, but hoping for the best. (2) A parent was informed that the child required treatment. In reply a letter was received stating that it did not as nothing was "wrong." The parent was invited to bring the child to the Clinic and the Dental Surgeon's report would be demonstrated. She came with the child. Six or eight teeth were found "wrong," some hopelessly carious and unsaveable. On questioning the mother she replied to the effect that her daughter about sixteen years old always "inspected" her children's mouths and declared nothing was " wrong." She, the mother, did not look, not feeling qualified to give an opinion! Orthodontic Scheme. The new cases coming under treatment during the year numbered 146. The Orthodontic scheme has continued during the year much on the lines previouslydescribed, but there has been one important change. Experience had demonstrated that if it was possible to have a visiting Orthodontic Specialist at the Clinic, this would be advantageous, and time and expense would also be saved to the parents, the visits to the Royal Dental Hospital being dispensed with, except for very exceptional cases. Mr. H. R. Evans was appointed to this post. He commenced in August, 1932, and visits the Clinic monthly, seeing all new cases and reviewing the old ones. Up to the end of the year the Specialist had visited five times, seeing 68 new cases and also reviewing 64 old cases, making a total of 132 patients seen, or an average of over 26 per visit. This arrangement is a great advantage, in that it is not necessary to be within easy reach of a Dental Hospital in order to administer an Orthodontic scheme successfully, which had seemed to be necessary up to the time of this appointment. I must, however, here tender my warmest thanks and great appreciation for the vital work done by the Royal Dental Hospital in fostering this scheme from its inception, in conjunction with the Dental Clinic here. Their co-operation has been invaluable, and without it the scheme could never have come to fruition. The changes in procedure which come about as time advances are those which experience indicates to be improvements; this method being the only rational one to follow, so that whilst our demands upon the Royal Dental Hospital are not now so heavy, our appreciation of their help is none the less. From time to time Orthodontic cases and other cases—accidents to children's teeth involving broken teeth, etc., are sent there for X-Ray, all of which are dealt with speedily and satisfactorily. It would seem that as time goes on in order to make the Clinic's scheme even more self-contained, it will be necessary to install a suitable X-Ray apparatus in the Clinic when this becomes a practicable possibility, both from the financial point of view and from the point of view of members of the staff being sufficiently trained to operate it, and the ability of present and future Dental Surgeons on the staff to interpret correctly the X-Ray photograps. In connection with this I would suggest that the Dental Surgeons be permitted at suitable times, to attend a short course of lectures on Orthodontic and practical X-Ray work. The Junior Dental Surgeon, who has carried out most of the inspections, confirms my opinion that the number of children with Orthodontic defects is much higher than one would suppose, and at a rough estimate he puts the percentage at well over 33% of the children inspected, who need some form of Orthodontic treatment. The main work of Orthodontic treatment is confined to one session a week—Monday mornings, when the Dental Mechanic visits. The Specialist visits on one Monday morning per month. With regard to the various classes of Orthodontic cases, it would seem, reading through reports of other School Dental Clinics, where Orthodontic work is done, only selected cases are treated, but here there is no selection, any case being eligible for treatment who can pay the fee of 37/-, and where the parents cannot afford this they may apply for treatment at reduced cost or even free, and the special Sub-Committee dealing with these cases deals with them very sympathetically. The following is the scale:— 27 The total income is found, the rent is deducted, and the remaining amount is divided by the number of persons in the family, and on the scale the charges are:— Income less than 8/- per head Free Between 8/- and 10/- per head 9/- Between 10/- and 12/- per head 18/- Above 12/- per head full amount £1 17 0 Cases of special difficulty are specially considered. Simple treatment by extraction only, is of course carried out in suitable cases. There seem to be varying dental opinions with regard to the most suitable teeth to extract to secure best results, but the writer does not incline to any one school, all have their place and use in skilled hands. Mechanic's Fees. The Mechanic attends once a week at the Clinic during the Orthodontic session, and is paid a fee of 7s. 6d. for each attendance. He brings the various models and appliances previously ordered, and takes notes of the Dental Surgeon's instructions, and also makes any necessary minor adjustments of appliances required, at these sessions. This is a very useful provision. The Dental Surgeon assesses the fee to be paid to the Dental Mechanic for each appliance made, the Mechanic supplying all the materials himself The amount paid to the Dental Mechanic during the year was £6131 15s. 11d., made up as follows:— For models £21 18 9 For appliances, dentures, etc. ... £87 14 8 For attendances at Clinic £16 2 6 Total £131 15 11 Fewer models will be needed in future in view of the attendance of the Orthodontic Specialist at the Clinic, whereas formerly, a dental model had to be taken in each case to be sent up to the Royal Dental Hospital when the Specialist there was considering the case. The following gives the numbers and classification of Orthodontic appliances supplied:— Coil springs 9 Inclined planes 2 Splints 11 Retention 4 Labial wire and coil spring 1 Expansion 14 Expansion and retraction 7 Retraction 30 Expansion and screws 2 Screws 26 Expansion and inclined plane 1 Bite plates 3 Retraction and inclined plane 4 Lip Exercisor 1 Repairs 10 Progressive alterations 5 Gold bands 4 Dentures for school children 2 Total 136 Dental Clinic Orthodontic Work—Year 1932. The following Table gives some indication of the work involved during the past year:— Impressions taken Upper 449 Lower 444 Total 893 Orthodontic appliances fitted 129 Orthodontic adjustments 430 Orthodontic cases—advice 451 Orthodontic cases—reviewed 342 28 Dentures for School Children. In two cases where the extraction of permanent teeth was unavoidable and there was no other course, dentures were provided for school children. These are charged for on the same scale as for dentures supplied to mothers under the Maternity and Child Welfare Dental Scheme. Other Operations. The figure shown in the Table—2671—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:— Silver Nitrate Treatment 207 Dressings 108 Scaling and Polishing Teeth 63 Treatment of Gums 22 do. by Drugs 5 Separating Teeth 1 Destroying the Pulp 8 Orthodontic Cases (Advice) 451 Impressions taken Upper 449 893 Lower 444 Orthodontic—Appliances fitted 129 do. do. adjustments 430 do. Appliances repaired and progressive alterations 10 do. Cases reviewed 342 Dentures for School Children 2 2671 Attendances made by Children tor Treatment. The figure 6,361 shown in the Board's Table is not the gross figure of school children's attendances at the Dental Clinic, which was 8,293, all of which were nominally " attendances for treatment," but, although making such attendances, only 6,361 were treated physically, the remainder being referred for gas, 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 three years and is much 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 at 1.45 p.m. on any day when the schools were open. On coming into the Clinic these cases are dealt with in addition to the normal appointments, and take precedence over them. During the year 1932, 713 cases were so referred by Head Teachers. In connection with these emergency tickets it has happened not infrequently when the children have appeared at the Clinic that the cases were not such as could be described as urgent, but the Head Teachers' attention having been drawn to the necessity of limiting the issue of these tickets to really urgent cases, the number has diminished somewhat. Clinic Fees. The Dental Clinic fee of 1/-, 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 anaesthetic when this is necessary. Orthodontic fees are additional to this. The fees taken at the Clinic during 1932 were as follows:— From School Children treated (ordinary 1/- fee) £158 12 0 From School Children (Orthodontic fees) £185 9 9 From Maternity and Child Welfare cases treated—1/- fees £12 13 0 Clinic Accommodation. With the appointment of the half-time Dental Surgeon and the general increase in the work, the present accommodation has been taxed to its utmost during the past year, and to cope properly with the work there is no question that further Clinic and Waiting Room accommodation is required at the Central Clinic or elsewhere. 29 I wish here to express my sincere thanks and appreciation to the members of the Committee, the School Medical Officer, the Dental Clinic Staff and all members of the Public Health Department Staff whose work brings them in touch with dental matters, for their kindness and ready help and co-operation during a somewhat difficult year. I. Cohen, L.D.S., R.C.S., Eng., School Dental Surgeon. (i.) Crippling Defects and Orthopaedics. An intimation was received from the Board of Education in June to the effect that progress with an Orthopaedic Scheme was not considered to be justified. The proposal, mentioned in last year's Report, to draw up a definite scheme for the treatment of Orthopaedic defects has not therefore materialised, but 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 co-operation of the Royal National Orthopaedic Hospital, where 19 school children from this area have been seen as out-patients during the year. In addition, 3 school children received in-patient treatment, 2 at the Royal National Orthopaedic Hospital, and one at the County branch, Brockley Hill, Stanmore. 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 playground during the summer. 10.—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 provision of meals for school children has not been undertaken during the year, although the matter is before the Committee at the time of writing this Report. The self-supporting Milk Scheme whereby children obtain milk regularly at school for a nominal payment has continued throughout 1932, and by the end of the year 25 Head Teachers had adopted the scheme, the milk being supplied in bottles containing one-third of a pint, at a cost of 1d. per bottle, to the extent of nearly half a million bottles per annum. Cod Liver Oil and Malt is sold at cost price at the School Clinics for children recommended by the School Medical Officers. 1 2 SCHOOL BATHS. No school in this district is provided with baths. 1 3 CO-OPERATION OF PARENTS. Every effort is made to secure the co-operation of parents in the work of the doctors, dentists and nurses. Parents are invited to attend all routine medical inspections and during 1932 a parent or other relative attended in 3,110 instances, representing 76.7 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. 1 4 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. They also undertake the verification of returns of income made by parents when applying for various forms of assistance. 30 16.—CO-OPERATION OF VOLUNTARY BODIES. The Public Assistance Committee has very kindly given assistance 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, several 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. All mentally abnormal children, other than those who have been notified to the Local Mental Deficiency Authority, are re-examined frequently and in any case not less than once in twelve months. At the end of 1932 there were 22 children being maintained by the Education Committee at institutions outside the district. Two were in a school for Mentally Retarded Blind Children, three were in Schools for the Blind, and one was in a School for the Partially Blind. In addition to these 6 children who are in Special Schools for the Blind, we have 18 children attending elementary schools in the area who suffer from a high degree of myopia. Fifteen of these have been supplied with special desks. Each of the 18 children has special consideration at school, and the Head Teachers and Class Teachers are supplied with instructions as to the best position for the child in the class-room ; the type of work that can be allowed, etc. The teachers are asked to pass the leaflet of instructions on as the child is promoted. Six of the children have vision so defective that in accordance with the Board of Education's definition in Table III., they must be classified as partially blind. These six children should be in a special school or class for such cases. Seven children were in a school for the Deaf. Two were in schools for the Mentally Defective. Three were in schools for Epileptics. One was in a Residential School for Cripples. One was in the Royal National Orthopaedic Hospital. One was at a Residential Open-Air School. One was at the Children's Heart Home, Lancing. 18.—NURSERY SCHOOLS. There are no nursery schools in the area. 19.–SECONDARY SCHOOLS. 20.—CONTINUATION SCHOOLS. These schools come under the Middlesex County Council- 21–EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. The conditions of the employment of children and young persons in this area are regulated by Bye-Laws. Certain employments are prohibited, and in others the hours of employment are regulated. Children between the ages of 13 and 14 employed in the sale or delivery of milk or newspapers, or in domestic work away from home, must hold a certificate from the School Medical Officer to the effect that such employment will not be prejudicial to their health or physical development, and will not render them unfit to obtain proper benefit from their education. Forty-five such children were examined and the necessary certificate of fitness for work was granted in each case. 31 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. 22. SPECIAL ENQUIRIES. See Dr. Roberts' report on pages 13 to 21 with regard to vision testing, and her report on pages 21 to 24 on the treatment of ear defects. 23.–MISCELLANEOUS. Forty-five teachers were medically examined during the year in connection with their appointments on the teaching staff of the Authority. Eighty-eight candidates for scholarships at the Spring Grove Central School were also examined. Under an arrangement with the Middlesex County Council and the Central Association for Mental Welfare we have undertaken the annual medical inspection of children attending the Hounslow Occupation Centre. Eleven children were examined during 1932, and 2 of these were found to need treatment on account of dental caries. Both received treatment at the School Dental Clinic. 32 Statistical Tables. TABLE 1.–RETURN OF MEDICAL INSPECTIONS, 1932. A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants 1288 Second Age Group 1410 Third Age Group 1052 Total 3750 Number of other Routine Inspections 307 B.—Other Inspections. Number of Special Inspections 2052 Number of Re-Inspections 4803 Total 6855 TABLE II. A. RETURN OF DEFECTS found by Medical Inspection In the Year ended 31st December, 1932. Defect or Disease. 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 4 6 ... ... Skin— Ringworm— Scalp 1 ... 4 ... Body ... ... 8 ... Scabies ... ... 7 ... Impetigo 3 ... 184 ... Other Diseases (non-tuberculous) 11 3 178 ... Eye— Blepharitis 3 5 26 ... Conjunctivitis 2 ... 73 ... Keratitis ... ... ... ... Corneal Opacities ... ... ... ... Defective Vision (excluding Squint) 181 69 110 2 Squint 1 2 4 ... Other Conditions 2 1 99 3 Ear- Defective Hearing 29 30 24 1 Otitis Media 9 6 67 ... Other Ear Diseases 7 ... 129 ... Nose and Throat— Enlarged Tonsils only 80 182 89 15 Adenoids only 7 17 8 1 Enlarged Tonsils and Adenoids 152 91 33 4 Other Conditions 1 14 106 4 Enlarged Cervical Glands (non-tuberculous) 17 50 32 2 Defective Speech 1 2 1 33 TABLE II.—Continued. Defect or Disease. 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 Heart and Circulation— Heart Disease— Organic 3 3 9 8 Functional 1 124 4 6 Anaemia 1 3 8 ••• Lungs— Bronchitis 4 10 18 4 Other Non-Tuberculous Diseases 1 21 43 7 Tuberculosis— Pulmonary— Definite ... ... 1 ... Suspected ... 1 4 ... Non-Pulmonary— Glands ... ... ... ... Spine ... ... ... ... Hip ... ... ... 1 Other Bones and Joints ... ... ... ... Skin ... ... ... ... Other Forms ... ... ... ... Nervous System— Epilepsey ... ... 1 ... Chorea ... ... 4 3 Other Conditions 2 2 10 8 Deformities— Rickets ... ... ... ... Spinal Curvature 5 46 8 1 Other Forms 9 55 11 ... Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 7 36 1235 81 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 1288 153 11.87 Second Age Group 1410 187 13.26 Third Age Group 1052 122 11.59 Total (Code Groups) 3750 462 12.32 Other Routine Inspections 307 25 8.14 34 TABLE III.—RETURN of all Exceptional Children In the area. Boys Girls Total Children suffering from the following types of Multiple Defect, i.e., and combination of Total Blindness, Total Deafness, Mental Defect, Epilepsy, Active Tuberculosis, Crippling (as defined in penultimate category of the Table), or Heart Disease 2 2 4* Blind (including partially blind). (i) Suitable for training in a School for the totally blind. At Certified Schools for the Blind 1 2 3 At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... (it) Suitable for training in a School for the partially blind. At Certified Schools for the Blind or Partially Blind 1 1 At Public Elementary Schools 4 2 6 At other Institutions ... At no School or Institution ... ... 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 4 7 At Public Elementary Schools ... ... ... 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 1 ... 1 At other Institutions ... ... ... At no School or Institution ... ... ... Mentally Defective Feebleminded. At Certified Schools for Mentally Defective Children 2 ... 2 At Public Elementary Schools 17 2 19 At other Institutions ... ... ... At no School or Institution 2 3 5 Notified to the Local Mental Deficiency Authority during the year. Idiots 1 ... 1 Imbeciles 3 ... 3 Others ... 1 1 Epileptics. Suffering from severe epilepsy. At Certified Schools for Epileptics 1 2 3 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 1 4 5 At no School or Institution ... ... ... *Particulars of these cases are given at the end of the Table, on page 37 35 TABLE III.—Continued. Boys Girls Total Active pulmonary tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 2 1 3 At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... 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 ... ... ... Physically Defective. 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 ... 1 1 At no School or Institution ... ... ... 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 deforrnties due to old tuberculosis). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board ... 2 2 At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 2 1 3 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 ... ... ... 36 TABLE III.—Continued. Boys Girls Total 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 1 1 2 At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 90 66 156 At other Institutions 5 • •• 5 At no School or Institution 3 3 6 Physically Defective (continued). 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 1 ... 1 At Certified Residential Cripple Schools 1 ... 1 At Certified Day Cripple Schools ... ... ... At Certified Residential Open Air Schools ... ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 17 (3) 10 27 (3)* At other Institutions ... ... ... At no School or Institution ... 2 (») 3 (») 5 (4)* Children with heart disease, i.e., children whose defect is so severe as to necessitate the provision of education facilities other than those of the public elementary school. At Certified Hospital Schools ... 1 1 At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... ... ... At Certified Resid'ental Open Air Schools ... ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementarv Schools ... 2 2 At other Institutions ... ... • • • At no School or Institution ... ... ... * The figures in brackets indicate the number of children who should be receiving Special School Education. Children Suffering from Multiple Defects. Boys (2) Case No. 1 Severe Epilepsy Certified Mental Defective At no School or Institution Case No. 2 ...Paralysis lower limbs Certified Mental Defective Ditto. Girls (2) Case No. 1 Totally Blind Mentally retarded Too retarded for ordinary Blind School. At Court Grange Special School, South Devon Case No. 2 Ditto. Ditto 37 Group 1.—Minor Ailments (excluding Uncleanliness, for which see Croup 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 5 ... 5 Ringworm, Body 7 1 8 Scabies 6 1 7 Impetigo 222 4 226 Other Skin Disease 133 23 156 Minor Eye Defects— (External and other, but excluding cases falling In Group II.) 176 17 193 Minor Ear Defects 222 10 232 Miscellaneous— {e.g., minor injuries, bruises, sores, chilblains, etc.) 1193 30 1223 Total 1964 86 2050 TABLE IV. Return of Defects treated during the year ended 31st Deoember, 1932. TREATMENT TABLE. 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) 537 12 549 Other Defect or Disease of the eyes (excluding those recorded in Group I.) ... ... 4 4 Total 537 12 4 553 Total number of children for whom spectacles were prescribed— (a) Under the Authority's Scheme 500 (£) Otherwise 4 Total number of children who obtained or received spectacles— (a) Under the Authority's Scheme 490 (b) Otherwise 4 38 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. (2) (3) (4) (5) 125 53 178 2 180 Crou IV DENTAL DEFECTS. (1) Number of children who were: (a) Inspected Aged: Routine age Groups 5 6 7 8 9 10 11 12 13 14 15 803 955 912 977 978 954 724 716 374 115 11 Total 7519 Specials 1788 Grand total 9307 (b) Found to require treatment 6254 (c) Actually treated 3655 (2) *Half-days devoted to Inspection Treatment—Ordinary Gas Administration—Clerical Dental Committee Meetings 51 450 135 19 8 Total 663 (3). Attendances made by children for treatment 6361 (4). Fillings. Permanent teeth Temporary teeth 3347 511 Total 3858 (5). Extractions— Permanent teeth Temporary teeth 946 5171 Total 6117 (6). Administrations of general Anaesthetics for extractions 1756 (7). Other operations Permanent teeth Temporary teeth Total 2671 *An additional Dental Surgeon was appointed half-time on 1st April, 1932, thus, the sessions represent: One full-time Dental Surgeon's work for the whole year, and one half-time Dental Surgeon's work for nine months, plus 19 sessions prior to his appointement Croup V.–UNCLEANLINESS AND VERMINOUS CONDITIONS. (i.) Average number of visits per school made during the year by the School Nurses 2.1 (ii.) Total number of examinations of children in the schools by the School Nurses 8724 (iii.) Number of individual children found unclean 430 (iv.) Number of children cleansed under arrangements made by the Local Education Authority 87 (v.) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 — (b). Under the School Attendance Bye-laws 6 39