C.I. AC 439 (1) HESTON. ISLEWORTH Hes 20 Borough of Heston and Isleworth. 1933 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, 1933. LOWE & SONS (PRINTERS) LTD,, 52, Hanworth Road, Hounslow. 1 1933. REPORT ON THE HEALTH OF THE BOROUGH OF HESTON & ISLEWORTH FOR THE YEAR 1933 1 Index. Ambulance Facilities 15 Ante-Natal Care 44-45 Birth Rates 6 Canal Boats 24 Cerebro-Spinal Fever 38, 40, 41, 42 Chicken Pox 38 Children Act 17 Cleansing of Verminous Persons 38 Clinics and Treatment Centres 16 Deaths, Causes of 7 Death Rates 6 Dentures for Mothers 46 Diphtheria 36,40,41,42 Diphtheria Immunization (Report by Dr. Bousfield) 36-37 Drainage and Sewerage 18 Encephalitis Lethargica 38,40,41,42 Enteric Fever 38, 40, 41, 42 Erysipelas 38, 40, 41, 42 Factory and Workshop Act, 1901 23 Food, Inspection and Supervision of 30-35 General Provision of Health Services in the Area 10-15 Home Help 48 Home Visiting 48 Hospitals 11-14 Housing 25-29 Industries, Local 9 Infant Deaths 6, 8 Infant Life Protection 17 Infectious Diseases 36-42 Influenza 38 Inspection and Supervision of Food 30-35 Laboratory Statistics 10 Legislation in Force 11 Malaria 41 Maternal Mortality 15, 46 Maternity and Child Welfare—Attendance at Centres 44 ,, ,, Centres 16,43 ,, „ Dental Treatment 46-47 ,, ,, General Arrangements 42-49 ,, „ Grants of Milk 48 ,, ,, In-patient Treatment for Dental Cases 47 Measles 38 Meat 33 Midwives 10 Milk 30-32 ,, Grants to Expectant and Nursing Mothers and to Children under three years 48 Mumps 38 Notification of Births 47 Nursing in the Home 10 Ophthalmia Neonatorum 14, 40, 41, 49 Physical Features of District 8 Pneumonia 38, 40, 41, 42 Poliomyelitis, Acute 38, 40, 41, 42 Poor Law Medical Relief 10 Population 6 Puerperal Fever 14, 38, 40, 41, 42 Puerperal Pyrexia 14,38,40,41,42 Sanitary Circumstances of the Area 18-23 Scarlet Fever 36, 40, 41, 42 Scavenging 18 Smallpox 14, 38, 41, 42 Staff 5 Tuberculosis 14, 39,40 Venereal Diseases 14 Vital Statistics 6 Voluntary Societies and Helpers 47 Water Supply 18 Whooping Cough 38 2 1 3 Public Health Department, 92, Bath Road, Hounslow. June, 1934. 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. 4 THE HEALTH COMMITTEE OF HESTON AND ISLEWORTH BOROUGH COUNCIL. as on 31st December, 1933. Alderman J. J. Clements, J.P. (Chairman). Councillor F. T. Hart (ex-officio) ,, J. J. Bonnett, O.B.E. (Vice-Chairman). ,, J. I. Kelly. ,, A. A. Bergin, J.P. (ex-officio). ,, E. W. Heath. ,, G. R. Speed. ,, D. Rhys. Councillor F. W. Buckley. ,, G. N. Shackleton. ,, J. E. Dillingham. ,, D. J. Thomas. ,, E. E. Forrest. „ A. C. Turner. Medical O fficer 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). Councillor Mrs. R. New. Alderman J. J. Clements. ,, D. Rhys. Councillor H. Collar. „ G. N. Shackleton. J. E. Dillingham. „ A. C. Turner. ,, A. L. Lang. Co-opted Members : Miss E. A. Ankritt. Mrs. E. Chedgey (Vice-Chairman). 5 STAFF. The following persons constituted the Staff of the Health Department. Medical Officer of Health— ELWIN H. T. NASH, m.r.c.s., l.r.c.p., d.p.h. Deputy Medical Officer of Health— Mrs. E. LOUISE ROBERTS, m.b., ch.b., d.p.h., Barrister-at-Law. Assistant Medical Officer of Health— VICTOR FREEMAN, m.r.c.s., l.r.c.p., d.p.h. Consultant in Puerperal Sepsis and Consultant in Obstetric Emergencies— J. W. BELL, l.r.c.p.i. and l.m., l.r.c.s.i. and 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 : Medical Officer— G. W. J. BOUSFIELD, m.d., 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) (Left December, 1933). 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. (Left December, 1932). A. B. HAULDREN, Cert, as s.i. and m.i. A. H. CORNHILL, Cert as s.i. and m.i. L. PINGUEY, Cert, as s.i. and m.i. (Commenced April, 1933). 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. and s.n., m.c.w.w. Miss B. N. TETLEY, s.r.n. Cert, c.m.b., New Health Visitor's Diploma of the Royal Sanitary Institute. Mrs. A. E. TYRRELL, Cert, c.m.b., h.v. and s.n. Miss M. G. GRIBBLE, A.R.R.C., s.r.n., Cert, c.m.b., h.v. and s.n. 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. Miss G. F. RICHARDSON, s.r.n., Cert, c.m.b., New Health Visitor's Diploma of the Roya Sanitary Institute. Mrs. G. PRISSELL, s.r.n., Cert, c.m.b., h.v. and s.n. (Commenced on permanent staff April, 1933). Miss B. P. MANNING, s.r.n., Cert, c.m.b., a.r.s.i. New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced October, 1933). 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. K. I. BISSHOPP. P. T. H. CRANDON. F. V. BELL, Cert, as s.i. H. J. ALDHOUS, Cert, as s.i. Miss D. M. DOWLING. E. E. FORREST. R. MOORE. Miss V. D. NICHOLLS. T. C. WREN. (Commenced Feb., 1933). Medical Superintendent, Mogden Joint Isolation Hospital—(Joint Isolation Hospital, Richmond with Heston and Isleworth)— ALEX. EDWARD GAMMIE, m.b., ch.b. 6 Statistics and Social Conditions of the Area. EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1933. Area (in acres) 6,851 Registrar-General's estimate of resident population (Mid-Year) 1933 84,460 Census Population, 1931 75,446 Number of inhabited houses (end of 1933) according to Rate Books 19,211 Rateable Value £613,366 (at 31st December, 1933) Sum represented by a penny rate (1932-33) £2,450 Live Births— Total. M. F. Legitimate 1340 700 640. 19) Birth rate per 1,000 of the estimated resident population 16.33 Illegitimate 40 21 Stillbirths 49 26 23 Rate per 1,000 total (live and still) births 34.2 Deaths 792 423 369 Death rate per 1,000 of the estimated resident population 9.37 Deaths from Puerperal Causes— Deaths. Rate per 1,000 total (live and still) births. Puerperal sepsis 4 2.79 Other puerperal causes 3 2.09 Total 7 4.89 Death rate of Infants under one year of age:— All infants per 1,000 live births 43.47 Legitimate infants per 1,000 legitimate live births 40.2 Illegitimate infants per 1,000 illegitimate live births 150.0 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) 6 Deaths from Diarrhoea (under two years of age) 6 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 1930-31-32-33:— 1930. 1931. 1932. 1933. £3947 : 9 : 3 £4,529 : 15 : 2½ £6,506 : 5 : 6 £7,846 : 6 : 9 VITAL STATISTICS. Population.—The Registrar-General's estimate for the population for 1933 is 84,460. The Census population in 1931 was 75,446. Deaths.—The number of deaths registered in the district was 1,707, but 1,028 of these did not belong to the district, while 113 residents died outside the district. Thus the number of deaths properly attributable to the district was 792. Adopting the basis of the population estimated by the Registrar-General, the death-rate for the district comes to 9.37 per 1,000, which is comparable with the following figures : 12.3 for England and Wales, and 12.2 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 1933 is 43.47 per 1,000 births, which is a record for this area. The rates for England and Wales and for London during the same period were 64 and 59 respectively. Births.—The total number of live births registered during the year was 1,711, excluding l'eregistrations, but 485 of these did not belong to this district, while 154 births properly belonging to this district occurred outside the district. The nett number of live births thus attributable to the district is 1,380. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 16.33 per 1,000. The birth-rate of England and Wales was 14.4 per 1,000 and for London 13.2 per 1,000. 7 Table of Causes of Deaths during 1933. Causes of Death. Civil Residents, all ages. Male. Female. All causes 423 369 1 Typhoid and paratyphoid fevers — — 2 Measles 1 — 3 Scarlet Fever 2 2 4 Whooping Cough 2 4 5 Diphtheria — 2 6 Influenza 11 13 7 Encephalitis Lethargica — 2 8 Cerebro-Spinal Fever 2 1 9 Tuberculosis of Respiratory System 40 28 10 Other Tuberculous Diseases 4 4 11 Syphilis 3 1 12 General Paralysis of the Insane, Tabes Dorsalis 3 1 13 Cancer, Malignant Disease 49 51 14 Diabetes 2 2 15 Cerebral Haemorrhage, &c. 13 22 16 Heart Disease 79 75 17 Aneurysm 2 2 18 Other Circulatory Diseases 28 20 19 Bronchitis 11 11 20 Pneumonia (all forms) 27 18 21 Other Respiratory Diseases 7 1 22 Peptic Ulcer .. .. 5 4 23 Diarrhoea, &c. (under 2 years) 3 3 24 Appendicitis 1 4 25 Cirrhosis of Liver 1 — 26 Other Diseases of Liver, &c. 1 2 27 Other Digestive Diseases 13 14 28 Acute and Chronic Nephritis 10 5 29 Puerperal Sepsis — 4 30 Other Puerperal Causes — 3 31 Congenital Debility, Premature Birth, Malformations, etc. 20 12 32 Senility 8 13 33 Suicide 5 5 34 Other Violence 30 10 35 Other Defined Diseases 40 30 36 Causes Ill-defined or Unknown — — Special causes (included in No. 35 above) Small-pox — — Poliomyelitis 2 — Polioencephalitis — 1 According to figures furnished by the Registrar-General. 8 INFANTILE MORTALITY DURING THE YEAR 1933. 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 Smallpox Chickenpox Measles . . . . . . . . . . . . . . . . . . . . Scarlet Fever . . . . . . . . . . . . 1 1 . . 2 Whooping Cough . . . . . . . . . . . . 1 . . 1 2 Diphtheria and Croup Erysipelas Tuberculous Meningitis . . . . . . . . . . . . . . . . . . . . Abdominal Tuberculosis . . . . . . . . . . . . . . . . . . . . other Tuberculous Diseases . . . . . . . . . . . . . . 1 . . 1 Meningitis (not Tuberculous) . . . . . . . . . . . . . . . . . . . . Convulsions . . . . . . . . . . . . . . 2 . . 2 Laryngitis Bronchitis . . . . . . . . . . . . . . . . . . . . Pneumonia (all forms) . . 1 . . . . 1 2 1 4 3 11 Diarrhoea . . . . . . . . . . . . . . . . . . . . Enteritis . . 1 . . 1 3 1 1 1 7 Gastritis Syphilis . . . . . . . . . . 1 . . . . . . 1 Rickets . . . . . . . . . . . . . . . . . . . . Suffocation, overlying . . . . . . . . . . 1 . . . . . . 1 Injury at Birth . . . . . . . . . . . . . . . . . . . . Atelectasis 1 . . . . . . 1 . . . . . . . . 1 Congenital Malformations 3 2 1 6 2 . . . . . . 8 Premature Birth 12 2 1 . . 15 2 2 . . . . 19 Atrophy, Debility and Marasmus . . . . 1 . . 1 . . . . . . . . 1 Other Causes 1 . . . . . . 1 . . . . 2 1 4 17 6 2 1 26 11 6 11 6 60 Nctt Births Legitimate 1340 Illegitimate 40 Nett Deaths Legitimate infants 54 Illegitimate infants 6 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 rapidly being 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. 9 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 and Candle Machinery. (23) Carbons, Stencils, Typewritter 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, (30) Pre-cast concrete works. Gramophones. (31) Motor Spirit Energiser. 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 of the Housing Act, particularly the former. 10 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 19 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 696 medical orders during 1933. Some of these cases received also out-relief and institutional treatment. COUNCIL LABORATORY, 1933. T otal. Positive. Swabs for Diphtheria sent by Medical Practitioners 297 14 Taken from Schools, Clinics and from Contacts 773 13 Sub-Cultures 9 2 Sent from Staines Joint Isolation Hospital 133 17 Total cultures examined 1212 46 Swabs examined by Clinical Research Association or at Other Laboratories (2 from Staines) 25 5 Virulency Tests - - Blood examination for Enteric Widal Tests (sent to Clinical Research Association) 5 1 Specimens of Sputum for Tubercle Bacilli sent by Medical Practitioners 114 12 Specimens of Sputum for Tubercle Bacilli taken at Clinics 8 - Hairs for Ringworm taken at Schools or Clinics 67 26 Other Specimens— Urine 220 Discharge 14 Milk 38 Faeces (sent to Clinical Research Association) 1 - Blood examinations for Anaemia 18 Swabs examined for Cerebro Spinal Fever 15 - Preparation of Materials— Tubes of Serum 1575 Throat Swab Outfits 1600 Sputum Outfits 125 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 specimen of faeces and some swabs were also examined by the Clinical Research Association. ADOPTIVE ACTS AND BYE LAWS IN FORCE. Adoptive Acts in force in the District. *Infectious Diseases (Prevention) Act, 1890. *Public Health Acts Amendment Act, 1890, Part II, III and V. *Public Health Acts Amendment Act, 1907, Parts II, *111, *IV, *V, VI and VIII. *Public Health Act, 1925, Parts *11, *111, *IV and *V were adopted in November, 1925. Maternity and Child Welfare Act, 1918. Baths and Wash-houses Acts, 1846-1899. Burial Acts, 1852-85. (Applicable to parts of the Borough only). Public Libraries Act, 1892. Private Street Works Act, 1892. Small Dwellings Acquisition Acts, 1899-1923. Local Government and 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.HA., 1875, s. 44). *Removal of Offensive Matters (P.H.A.A.A., 1890, s. 26). New Streets and Buildings (P.H.A., 1875, s. 157, and P.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.A's., 1876-1902). Employment of Children and Street Trading by Young Persons (Edu.A., 1918, s. 13). Good Rule and Government (M.C.A., 1882, s. 23). 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. In considering the hospital accommodation for the district, one is faced first with the fact that it is inadequate, and inadequate mainly from the point of view of the Hounslow Hospital, which is incapable of dealing with the ever-growing needs forced upon it by the rapid growth of the population it caters for. The time is obviously coming when voluntary effort must be recognised as incapable of dealing with hospitals in areas such as this. Rising taxation since the War has entirely altered the perspective and the possibility of private charity continuing to be the source from which the funds are drawn to support the local hospital. The scene is changing; the outlook is entirely different and will continue to get more different as the days go by. The charitable public are not by reason altogether of their innate feelings becoming less and less charitable. The portion of their income that they formerly felt they could reasonably give to mitigate the sufferings of their fellow members of society is steadily dwindling, owing to the demands of the tax-collector both imperial and local, and with the best will in the world for those who still retain the old ideals of charitable contributions, there is no longer the possibility of putting these ideals into effect. Together with this there is the pressure of taxation on the medical profession, and they are at last beginning to say that the labourer is worthy of his hire. Before the War it was the great glory of my profession that they gave their services to the sick poor and asked nothing in return. They gave in a way that no other profession or trade has ever given, and the public came to look upon this as the normal thing to expect. In some cases the public expressed its gratitude, but more often it was taken for granted. 11 12 In common fairness one asks,"Why should the medical profession be asked to render such immense serv ices as it does to the sick public with the return which is totally inadequate and which is expected of no other profession or trade ?" Why, for instance, should not a number of butchers, equal in number with the doctors on the staff, provide, with a similar proportion of remuneration from the hospital funds, all meat for the hospital, or why not a similar number of grocers, under similar circumstances, provide provisions? The public has still an extraordinary idea of what it may expect from the medical profession. It will go to a doctor and ask for attendance and for the provision of advice, physic, dressings, etc., which cost the doctors a considerable sum, with no other means of paying whatever than an overdraft on the bank of hope. A similar demand made to the butcher, the baker, or the grocer would be met with a reply which would be distinctly more forcible than polite. I ask again, "Why should the medical profession give in the way that no other profession or trade does ?" It is urged, of course, that the doctors are getting something out of it. True, they get experience, but that is the result of enthusiasm. They may get a little kudos by reason of being on the staff, but as for instance, at Wembley, where every member of the profession in the district is on the staff, that kudos means nothing, and such experience they get is all to the good of the sick public of the district. I am certain that is not the point. The medical profession as a whole is still to a large extent imbued with the monastic ideal which actuated it in the middle ages, that of relieving the sufferings of the sick poor, but it is getting tired of being exploited by all and sundry. To look at things from a business point of view, it surely is not sufficiently realised how important to the State adequate medical attention is in the early stages of disease. It is still insufficiently realised that, not only to the working man, but to 95 per cent of the population, their health is their capital. It is still insufficiently realised how a family may be handicapped under present circumstances by the presence in it of a chronically sick member. Take two families living side by side with the same income. One man marries a wife who goes sick after a confinement or some serious illness and becomes a chronic invalid, or one of the children gets rheumatic fever with subsequent heart trouble, and the doctor in both cases is, to use a colloquialism, never off the doorstep. It seems to be lost sight of so often, that whereas the neighbour who has no illness in the house can afford to give his children of his best, the others are handicapped in the race for life as compared with their neighbour, by the fact that the sick member demands that attention which means a continual series of doctors' bills, and all the additional expenses consequent on illness. Be it said that these are almost without exception gladly paid where circumstances will permit it, and the gratitude one remembers in the days when one was in practice was, and is still, a very precious thing ; but the fact remains, the children of the family with the sick member are not going to get their chance in life in the same manner as the children of their neighbour will. The time is coming, and in my opinion coming rapidly, when there will be a very wide extension of the system of insurance against not only the doctor's bill, but all that goes with sickness. It is now nearly a quarter of a century ago since I tried to do something in that direction in connection with tuberculosis. The way in which the Post Office solved a certain portion of their difficulty by means of a contribution of a half-penny a week throughout the service and the erection of their own sanatorium, stimulated the attempt to do something further. My idea was, on somewhat similar lines, to insure for a year's sanatorium treatment, and also to ensure that during that period of treatment the insurer's income, or at least 50 per cent of this amount, was continuing to the family. I took this up with the Prudential Assurance Company, and finally had a long interview with the Officers and Actuaries at Holborn, but, as might be expected, the absence of a national compulsory insurance made the whole thing impossible. There will have to be a general improvement in all the medical services, widened in my opinion to take in all the specialised services on an insurance basis, but that basis will have to be what it has never been hitherto, that is, an equitable one to the medical profession. There must be, in my opinion, for the bulk of the population by some insurance method, the elimination of the dread of the doctor's bill, and the feeling that the best possible attention is theirs by right of insurance paid. Those who have been in practice know how often a doctor is not called in by the working classes, and what one terms the " black coated worker," and to-day even by the professional classes, because of that dread of the unknown amount that they may be called on to pay, and so they put it off and put it off until they are finally compelled to call in medical aid, the patient in the meantime having a well established condition which might have been dealt with quite easily had the patient been seen earlier. There must be, in my opinion, the understanding that it is wisest to call a doctor in at the earliest departure from health. In my opinion these medical services can never be provided by the working classes on an adequate scale, including, as they must, hospital accommodation, unless they arc subsidised by the State or Municipality. Take the hospitals, for instance ; what is the position for the bulk of them at the present time ? Every device imaginable is dragged in to induce the public to part with the necessary funds to keep them open. Horse shows, Baby shows, Dog shows, Cat shows, Flag days, Comic parades, Bazaars with all sorts of child-like side shows, are brought into play to extract small sums from humble folk. 13 It was my unpleasant job, as a member of the Rotary Club, to assist at one of these efforts. I was, by reason of my membership, allotted the task of taking charge of a table on which pennies were jerked up slightly inclined planes with a series of numbered circles on them, and the players were rewarded pro-rata to the number in the circle on which the penny was ultimately pushed. Things got very slack, and I happened to have a cheap watch which was doing duty whilst my ordinary one was being repaired; its total value was only about five shillings. To hasten things up I put this on the circle with the highest chance. On several occasions I very nearly threw the whole thing up, as it positively hurt me to see people throwing money away in the effort to get that watch. Nobody won it. We made a considerable sum of money, and the majority of it was made from youngsters and poor people who really could not afford the amount they spent. To come down to concrete facts, our local hospital, according to the annual report for 1933, spent £9,096, roughly a 3¾d. rate, and out of that sum the total sum paid to the medical profession, which includes the salaries paid to two House Surgeons, amounts to the vast sum of £354 9s. 1d. I ask in common fairness to the profession I have the honour to belong to, " Is it right, is it decent ? " Patients contributed for their medical attention a sum amounting to £5,542, of which the medical profession got the balance that was left of £354 9s. Id. when £250 had been paid to the House Surgeons and extra sums for locums, and of that balance only two-thirds went to the medical profession. Say it is £75 for the sake of argument, then the whole of the emoluments which went to the medical profession for their services to the sick public in this area amount all told to £50 a year, which is less than £1 a week between the whole of the medical staff! * There is surely a serious want of perspective as to what is due to the medical profession for the services they render to the sick public. Speaking as an administrator, as one who has been Medical Superintendent of two hospitals, and under sectional control of two others, I say without hesitation, that if the burden was adequately shouldered by the Local Authority there could be made at no great cost, adequate provision of the best possible type sufficient for the needs of the district, and with what should be an adequate remuneration to the medical profession of the district for the services they render to-the public. The question may be asked, "Is it possible for the Borough Council to provide, or take over by purchase, an existing hospital ?" There is no doubt that Section 131 of the Public Health Act, 1875, gives authority for them to provide hospital accommodation for any Burgesses suffering from any type of disease, not necessarily infectious. The only exception which has been ruled against this Section is contained in one by the Ministry of Health, that Maternity Homes cannot be provided under Section 131 by reason of the fact that a lying-in woman is not sick. There is no escaping from the fact that the present accommodation is sadly below the real requirements of the district, particularly from the point of view of medical cases and children. Until the appointment of a Consulting Physician recently, I am informed that it was not possible to give the Nurses adequate training by reason of the fact that there were not the requisite number of medical cases in the hospital on which to train. (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 980 in-patients, whilst 4,156 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. The Royal Hospital (Richmond), West London Hospital (Hammersmith), and other large General Hospitals within the Metropolitan area are within comparatively easy reach by tram, bus, District Railway, or Ambulance, and although definite particulars are not available, it is certain that many people apply to these Hospitals outside the district. The Council annually subscribe £200 to the Hounslow Hospital and £50 to the Royal Hospital, Richmond. *(According to figures from the Hospital Annual Report and as supplied by the Secretary). 14 (2) Children.—The Children's Ward at the Hounslow Hospital contains 14 cots. 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 Dispensary in Bell Road is the only institution in the district, and caters only 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. A very small proportion of the cases are sent by the County Council to various Homes and Hospitals. It is to be hoped that the opening of Shenley Mental Hospital will do something to facilitate the hopeless position which exists at the present time with regard to obtaining places for the great majority of the cases who really need them. (8) Orthopaedic.—Although there is no definite orthopaedic scheme available in the district, we have an unofficial arrangement with the Royal National Orthopaedic Hospital whereby all our cases are seen on special reference from this department. The difficulty, however, commences when it is necessary to obtain the massage and electrical treatment which is sometimes advised for these cases. So far, the number of cases does not warrant the appointment of a member of the staff to carry out this work. The Local Authority contributes the sum of £15 to the Royal National Orthopaedic Hospital as some recognition of the services rendered. (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 Puerperal Pyrexia.—During the year an arrangement was concluded with Queen Charlotte's Hospital Authorities for the admission of any cases of Puerperal Fever or Puerperal Pyrexia into their Isolation Block at Ravenscourt Park. Some few cases have been admitted to the West Middlesex Hospital. (11) Ophthalmia Neonatorum.—An arrangement exists whereby cases of Ophthalmia Neonatorum can be admitted to the St. Margaret's Hospital of the London County Council. (12) Small Pox.—We are now one of the constituent Authorities included in the Middlesex County Council scheme for dealing with Small Pox which arises in the County. The cases are admitted to the hospitals of the London County Council. Dockwell Hospital, the old Small Pox Hospital, which is situated at the western end of the district, has been kept with a caretaker in residence and ready at any time to deal with any infectious disease emergency which might arise. (13) Fevers.—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. The result of the deliberations of the constituent Authorities has resulted in a Joint Board being recommended, which will come into operation next year, whereby the three Hospitals in the district of south-west Middlesex, namely, Mogden, Twickenham and Hampton, will be pooled. The demand for further accommodation at Modgen, and particularly for observation blocks, is urgent indeed. 15 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 487 accident cases were removed to hospital, and 401 cases of non-infectious disease were removed to hospitals or nursing homes. An additional new ambulance was obtained in October, 1933. 16 CLINICS AND TREATMENT CENTRES, 1933. 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. Wednesday 2.0 p.m. „ 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. Village Hall, Heston Isleworth Public Hall Every week-day 9.0 a.m. „ Every week-day 9.0 a.m. 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. School Dental Clinic Village Hall, Heston Isleworth Public Hall Public Health Dept. Thursday 10.30 a.m. Monday 10.30 a.m. „ 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. 17 ADMINISTRATION OF PART I. OF THE CHILDREN ACT, 1908, AS AMENDED BY PART V. OF THE CHILDREN AND YOUNG PERSONS ACT, 1932. (a) Number of persons on the Register who were receiving children for reward at the end of the year 55 (b) Number of children on the Register:— (i) at the end of the year 68 (ii) who died during the year Nil. (iii) on whom inquests were held during the year Nil. (c) Number of Infant Protection Visitors 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) of the Act of 1908 .. .. Nil. (e) Proceedings taken during the year:— No. of Cases. Act and Section under which proceedings were taken. 1 Children and Young Persons Act, 1932, s. 67. (f) Number of cases in which the local authority has given a sanction during the year:— (i) Under (a) of Section 3 of the Act of 1908 Nil. (ii) Under (b) of Section 3 of the Act of 1908 Nil. (iii) Under (c) of Section 3 of the Act of 1908 Nil. (g) Number of orders obtained during the year under Section 67 of the Act of 1932:— (i) From a court of summary jurisdiction 1 (ii) From a single justice Nil. 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 783 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. The foster-mothers, with one exception, have discharged their duties satisfactorily. In the one case the home conditions had continued to be dirty and generally unsuitable, and the fostermother was told to return the child to the legal parent. This she refused to do. As conditions did not improve it was necessary to obtain an order under section 67 of the Act of 1932, from a court of summary jurisdiction, directing the removal of the child. The child was subsequently placed with a reliable foster-mother in the area. 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. 18 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 32 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 1933:— (a) Foul Water Sewers 11,700 feet. (b) Surface Water Sewers 10,200 feet. Work is still proceeding on a complete West Middlesex Sewage Scheme which will pick up the sewage of this district. 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 1933 collection of house refuse has continued weekly as before, and was disposed of by "controlled tipping" on a site in the Staines Road, Hounslow. Eight electric vehicles and two petrol driven lorries undertook the transportation of the whole of the refuse of the district. The amount of refuse tipped during the year was 22,303 tons. During the year, as a result of action taken, there were supplied 94 new ashbins. Sanitary Inspection of District.—See pages 19-22.—The number of sanitary inspectors was depleted to the extent of one inspector during the first three months of the year, arising out of a change in the personnel. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc.—The number of premises on which nuisances were outstanding at the end of 1932 was 412. To these another 648 premises whereat nuisances were recorded in 1933 were added, giving a total of 1,060 premises. Of these 640 had the nuisances remedied, leaving 420 premises at which nuisances still existed at the end of the year. During the year, nuisances at 28 houses were reported to the Health Committee, which, added to the 33 brought forward from 1932 made a total of 61. 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 45 of the houses, leaving 16 cases to be carried forward to 1934. Comparative figures for the years 1931, 1932 and 1933, in connection with nuisances, are submitted herewith:— 1931 1932 1933 Number of complaints received 495 493 550 Premises at which nuisances were located 792 744 648 Number of First Informal Notices 719 794 612 Number of Reminders and Letters 472 571 589 Number of Statutory Notices 78 58 36 19 Proceedings.—Action was taken by way of Court Proceedings in the following instances during the year :— 6 cases were against tenants of unfit premises for non-compliance with notices to quit and orders were made for the tenants to vacate the premises within 28 days. 1 case for non-compliance with notice to abate certain nuisances—order made to abate nuisances within 28 days and costs imposed. 2 cases for non-compliance with notices to provide suitable and sufficient sanitary accommodation, etc.—costs and daily penalties were imposed and orders made for works to be completed in one case within 14 days and in the other within 21 days. 1 case for preventing polluted well water being used for drinking purposes—costs were imposed and an order made against owner to cease to use well water for this purpose within 7 days. SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc. 21,015 Inspections, etc., re Nuisances Contraventions, etc.: Number of premises, etc., inspected on complaint 829 Number of premises inspected in connection with infectious diseases 310 Total number of premises, etc., primarily inspected in connection with nuisances 1,412 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920-1923 2 Number of other visits made to premises, etc., in connection with nuisances, etc. 1,551 Number of visits made to works in progress 1,238 Number of interviews with owners, builders, etc. 1,267 Action taken (including action taken under Housing Act, 1930, Section17): Number of premises, etc., whereat defects, etc., were recorded during the year 648 Number of premises, etc., on which defects, etc., were remedied— (a) by owners or occupiers 629 (b) by local authority in default of owner or occupier 11 Number of cautionary or intimation notices given— (a) verbal 177 (b) written 435 Number of letters and reminders re nuisances sent 589 Number of Statutory Notices issued 36 Number of proceedings taken 10 Number of convictions obtained 10 Number of proceedings withdrawn — Number of cases dismissed — Number of appeals made against decision of Council — Number of appeals dismissed — Common Lodging Houses: Number registered 2 Number of inspections made 15 Number of contraventions outstanding from previous year — Number of contraventions found — Number of contraventions remedied — Number of contraventions outstanding at end of year — Canal Boats Used as Dwellings: Number of inspections made 47 Number of contraventions outstanding from previous year 4 Number of contraventions found 6 Number of contraventions remedied 5 Number of contraventions outstanding at end of year 5 20 Moveable Dwellings, Caravans, Tents, etc.: Number of Inspections made 253 Number of contraventions outstanding from previous year 12 N umber of contraventions found 4 Number of contraventions remedied 4 Number of contraventions outstanding at end of year 12 Bakehouses: Number in district (a) factories 20 (b) workshops 6 Number of underground bakehouses in district 1 Number of inspections made 163 Number of contraventions outstanding from previous year 2 Number of contraventions found 15 Number of contraventions remedied 14 Number of contraventions outstanding at end of year 3 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 1,048 Number of contraventions outstanding from previous year 2 Number of contraventions of byelaw 9—animals not effectually stunned with a mechanically operated instrument 2 Number of other contraventions found 5 Number of contraventions remedied 7 Number of contraventions outstanding at end of year — Cowsheds: Number of persons registered 5 Number of premises registered 5 Number of cowsheds on register 8 Number of milch cows in district 60 Number of inspections made 36 Number of contraventions outstanding from previous year — Number of contraventions found 2 Number of contraventions remedied 1 Number of contraventions outstanding at end of year 1 Dairies and Milkshops: Number of persons registered 77 Number of premises registered 36 Number of inspections made 446 Number of contraventions outstanding from previous year 14 Number of contraventions found 9 Number of contraventions remedied 18 Number of contraventions outstanding at end of year 5 Offensive Trades: Number of businesses established in district 18 Number of inspections made 118 Number of contraventions outstanding from previous year — Number of contraventions found 3 Number of contraventions remedied 2 Number of contraventions outstanding at end of year 1 Ice Cream Vendors: Number on register 71 Number of inspections made 242 Number of contraventions outstanding from previous year — Number of contraventions found 1 Number of contraventions remedied 1 Number of contraventions outstanding at end of year — 21 Public Health (Meat) Regulations, 1924: Number of inspections made 906 No notice of slaughtering given 6 Improper notice of slaughtering given 10 No precautions taken for the prevention of contamination — Written notices sent 2 Verbal notices given 14 Inspection of food: Number of meat inspections 1,117 Number of fish inspections 191 Number of provision inspections 300 Number of greengrocery and fruit inspections 324 Number of hawkers' foodstuff inspections 128 Number of food preparation places inspected 257 Number of other food inspections 13 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 9 Number of carcases surrendered (excluding offal) — Number of articles surrendered 5 Number of parcels surrendered 10 Number of organs or parts surrendered during slaughtering 337 Infectious Diseases, Disinfections, etc.: Number of visits made 1,035 Number of rooms disinfected— (а) Ordinary infectious diseases 435 (b) Tuberculosis 134 (c) Other diseases 7 Number of rooms stripped and cleansed after infectious diseases— (a) by owners or occupiers 13 (b) by local authority 2 Number of articles disinfected or destroyed 1,624 Smoke Abatement: Number of observations made 22 Number of nuisances outstanding from previous year — Number of nuisances found 5 Number of nuisances abated 5 Number of nuisances outstanding at end of year — Water Supply: Number of supplies provided or reinstated 6 Number of cisterns cleansed, repaired, covered, etc. 3 Number of draw taps connected direct to main 32 Number of water service pipes or taps repaired 8 Number of samples taken for analysis from local wells 8 Number of samples found polluted or impure 3 Number of instances where mains water supply substituted for well water 2 Approximate percentage of houses supplied on constant system 99.95 Drainage and Sanitary Arrangements, etc., of existing BuildingsWater Closets: Number of water closets provided or reconstructed 9 Number of privies abolished 2 Number of walls, etc., cleansed 8 Number repaired, supplied with water or otherwise improved 227 Number cleansed or unstopped 18 Approximate percentage of houses provided with water closets 99 Earth or Chemical Closets : Number provided or reconstructed 1 Sinks : Number of new sinks provided 48 Number of sinks repaired or improved 22 Drains : Number examined, exposed, etc. 3 Number unstopped, repaired, trapped, etc. 95 Number of waste pipes provided, disconnected, repaired, trapped or unstopped 55 Number of soil pipes fixed, repaired or improved 2 Number of ventilating shafts fixed, repaired or improved 18 Number of fresh air inlets provided, repaired or improved 15 Number of gully traps inserted or improved 72 Number of disconnecting traps inserted 1 Number of inspection chambers inserted 9 Number of disconnecting chambers improved, sealed or cleansed 3 Number of inspection chambers repaired, improved, sealed or cleansed 7 Number of drains constructed or reconstructed 4 Total length of drain pipes laid (4in.-422ft.) (6in.-22ft.) 444ft. Number of tests and re-tests applied 18 Number of other works executed 33 Approximate percentage of houses draining into Council's sewer 99 Cesspools : Number rendered impervious, emptied, cleansed, etc 3 Removal of Household Refuse : Number of new ashbins provided 94 Number of ashbins repaired 1 Dampness : Number of roofs stripped, renewed or repaired 212 Number of gutters and rain water pipes provided, repaired or unstopped 195 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 405 Number of damp-proof courses provided 116 Number of yards paved, repaired or drained 135 Interior Work : Number of rooms stripped and cleansed (other than in connection with infectious disease) 168 Number of floors, walls and ceilings repaired or renewed 1,174 Number of rooms in which ventilation provided or improved 52 Number of rooms in which lighting provided or improved 25 Number of staircases replaced, repaired or improved 33 Number of instances in which lighting to staircases provided or improved 21 Number of handrails and balustrades to staircases, etc., provided or repaired 24 Number of window frames and sashes provided, repaired or unfixed 752 Number of stoves or grates provided or repaired 292 Number of instances in which ventilation under floors provided or improved 80 Number of other repairs 186 Sundry Nuisances, etc. : Number of instances in which domestic cleansing enforced 13 Number of foodstores provided, cleansed or improved 6 Number of washing coppers provided or repaired 91 Number of rooms sprayed for the removal of vermin by the Disinfector 112 Number of instances in which overcrowding abated 37 Number of instances of improper keeping of animals abated 14 Number of offensive accumulations removed 38 Number of urinals provided, repaired, cleansed or improved 7 Number of dung pits provided, repaired or improved 2 Number of other nuisances abated 48 22 Report on the Administration of the Factory and Workshop Act, 1901, IN CONNECTION WITH FACTORIES, WORKSHOPS AND WORKPLACES. INSPECTION OF FACTORIES, WORKSHOPS AND WORKPLACES. Including Inspection made by Sanitary Inspectors. Premises. Number of Number on Register. Inspections Written Notices. Prosecutions (1) (2) (3) (4) (5) Factories (including Factory Laundries) 135 242 2 Nil. Workshops (including Workshop Laundries) 159 289 7 Workplaces (other than Outworkers' premises) 50 65 5 Outworkers 35 55 Total 379 651 14 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES.' Particulars. Number of Defects. Outstanding Jan. 1st. 1933. Found during 1933. Remedied during 1933. Outstanding Dec. 31st. 1933. Referred to H.M. Inspector. Number of Prosecutions. 1 2 3 4 5 6 7 Nuisances under the Public Health Acts.— Want of cleanliness 3 4 5 2 Want of ventilation .. 1 1 .. Overcrowding .. .. .. .. Want of drainage of floors .. .. .. .. Other nuisances 2 16 12 6 Sanitary accommodation— Insufficient 1 .. .. 1 Nil. Nil. Unsuitable or defective 2 33 26 9 Not separate for sexes •• •• •• •• Offences under the Factory and Workshop Act— Illegal occupation of underground bake house (s.101) •• •• •• •• Breach of special sanitary requirements for bakehouses (ss. 97-100) 2 11 12 1 Other offences:— Excluding offences relating to outwork •• •• •• •• Total 10 65 56 19 Nil. Nil. *Including those specified in Sections 2, 3, 7 and 8, of the Factory and Workshop Act, 1901, and remediable under the Public Health Acts. †Section 22 of the Public Health Acts Amendment Act, 1890, has been adopted by the Corporation, and the standard of sufficiency and suitability of sanitary accommodation for persons employed in factories and workshops enforced is that required by the Sanitary Accommodation Order of 4th February, 1903. 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 435 known places in this district which call for periodical inspection as follows :— Houses let in Lodgings, Common Lodging Houses, Bakehouses, Slaughterhouses, Cowsheds, Piggeries, Dairies and Milkshops, Offensive Trades, Laundries (non-factory), Workshops, Workplaces, Outworkers' Premises and Ice Cream Vendors' Premises. 23 SCHOOLS. There are now 18 public elementary schools and one central school. Some are modern upto-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 upto-date so far as their structure allows. CANAL BOATS. During the year difficulty arose with regard to the interpretation of what was necessary to ensure the adequate ventilation of canal boats with internal combustion engines. The Regulations which were drawn up in 1878 were drawn up when all canal boats were horse drawn. Subsequently some steam boats were on the canals, but they did not produce the conditions which arise when internal combustion engines with their dangerous risks, are used, and the conditions which were suitable when these Regulations were drawn up are not only unsuitable, but have with them a definite element of danger when there is the possibility of the escape of exhaust gases into the living quarters. As the engine has been placed for'ard of the living quarters at the stern of the boat, and is not sealed off, there is no let or hindrance in the majority of instances from any gases escaping from the engine room into the living quarters. Regulation 3(H) of the Canal Boat Regulations states that " The boat, if intended to be ordinarily used for the conveyance of any foul or offensive cargo shall contain between the space to be occupied by such cargo and the interior of any cabin intended to be used as a dwelling, two bulk-heads of substantial construction which shall be separated by a space not less in any part than four inches, and open throughout to the external air and furnished with a pump for the removal of any liquid from such space, and the one adjoining the space to be occupied by the cargo shall be water-tight." It is obvious that this Regulation was made as strict as this in order to deal with what is only described as a " foul or offensive cargo," whereas the escape of exhaust gases from an internal combustion engine must be classed as potentially dangerous, quite apart from any question of them being objectionable. Whilst admitting that the more or less open air life during the greater part of the day tends to lessen any risk, the conditions during the day and night in the case of fly boats, and in other boats in cold weather when the cabin doors are closed, are such that there is a definite passibility, in thecase, of exhaust gases entering the cabin, of serious consequences to the occupants almost as great as those in respect of which repeated warnings appeared in the press in connection with private garages and exhaust gases. Regulation 3(C), to the effect that " Every cabin, if intended to be used as a dwelling shall be provided with sufficient means for the removal of foul and the admission of fresh air, exclusive of the door or doors and of any opening therein," seems, as far as motor vessels are concerned, a dead letter, and would, in my opinion, appear to be a definite laxity. In passing these boats in the condition in which we see them in the Brentford Dock, there has been, in my opinion, a definite violation of the Regulations higher up the canal where these boats are registered. There is also room for improvement in the ventilation usually found in the case of non-motor canal boats, having regard to the present knowledge of ventilation and the appliances available for effecting a definite improvement. It is invariably the practice to rely solely on the rear door opening, or hatch in the case of fore cabins and very small openings in the bulkheads ventilating into the cargo space, which, when the boat is loaded are occluded by the cargo, which again is battened down under tarpaulins. Another point to be considered is that during inclement weather or at night the door opening or hatch is not available as a means of ventilation. COPY OF REPORT FORWARDED TO THE MINISTRY OF HEALTH DATED 25th JANUARY, 1934, WITH REGARD TO CANAL BOATS. Canal Boats Acts, 1877 to 1884. In accordance with Section 3 of the Canal Boats Act, 1884, I beg to present herewith the Annual Report for the year ended 31s/ December, 1933, as to the execution of the Canal Boats Acts, 1877, and 1884, and of the Regulations made thereunder, within the Borough of Heston and Isleworth, Middlesex. Inspectors Appointed under Canal Boats Acts, at 31st December, 1933 :— R. H. Butler [Chief Sanitary Inspector). G. IV. Ashworth (District Sanitary Inspector). A. H. Cornhill (District Sanitary Inspector). L. Pinguey (District Sanitary Inspector). No special remuneration is paid for the position. 24 Number of Inspections, etc. :— Number of Inspections made 47 Number of Canal Boats inspected 34 Number of boats found in order 28 Number of boats with one infringement 6 Nature of Contraventions, etc. :— Cabins not provided with sufficient ventilation 5 Cabins not in a cleanly and habitable condition 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. REM ARKS :—Difficulties were experienced during the year in connection with this work owing to the pressure of other work and the temporary reduction of staff due to the resignation of one inspector. Housing. There is a steady improvement in the housing situation by reason of the still further supply of Council Houses. I have pursued throughout the year the policy with which I commenced of dealing with the representation and demolition of unfit houses as single individual units, and not under any clearance or improvement area. There is in this district, in my opinion, under the present Regulations, no area which can be scheduled as a clearance area, and in the case of any small area which might be dealt with as an improvement area, it is better, quicker and more efficacious to deal with them individually. There is no fuss and no public enquiry. In only one case has there been any resistance to the order. In that instance I dealt with fourteen houses in a row as individuals. The owners, who were builders, resisted the representation, but when the schedule of necessary repairs was placed before them they admitted that they could not be repaired at a reasonable cost. A number are dealt with by reason of the fact that the cost of repairs is unreasonable. The question of dealing with unfit houses on the basis of an unreasonable cost, means, of course, that a very careful estimate has to be made of what the actual cost of carrying out the schedule of repairs will be. No action is taken until this has been done, so that one is in a position to cite exactly what it will cost, at current prices, to put the house into a habitable state of repair. In one case, the owner, from a sentimental point of view, was prepared to spend what was an unreasonable amount, in fact a most unreasonable amount, and did so, making an excellent job of what was really an unbusinesslike proposition. During the year 1933, 233 houses of the non-parlour type, but none of the parlour type were erected on the Martindale Estate, and 10 bungalows for elderly couples were erected in the proximity of the Hounslow Heath Senior School. With re-housing is cropping up the problem of the bug. I made the following report with regard to dealing with the problem :— I suggested that the portion of the stables approximating at Redlees Mansion adjoining the entrance to the Recreation Ground should be partitioned off, and an entrance made from the main road so as to convert it into a gas-tight chamber which would contain two full-sized pantechnicons, so that the furniture and all the clothing could be packed therein and disinfested before the entrance into the new Council House. Alongside should be constructed bathing premises for both sexes wherein the householders can be cleansed, and at the same time provided with a temporary change of clothes what time their belongings are disinfested. It must be realised, however, that even with this the scheme would not be a hundred per cent effective in keeping the premises free from infestation. Rules should be made forbidding the purchase of secondhand furniture or pictures once the tenant has taken possession of the house, unless these have been through the disintestation process. At the same time I suggested that it would be worth while arranging with all the secondhand furniture dealers that either free, or for a small sum, a van load of furniture could be put through the disinfestation chamber before it is exposed for sale on the understanding :— (a) That it shall be kept entirely separate in clean premises from any other secondhand furniture, and (b) That we would affix to each article of furniture a label stating that it had been disinfested. This matter was considered, and an estimate obtained from Mr. H. W. Seymour, of Chiswell House, 133-139, Finsbury Pavement, London, E.C.2. 25 At the present minute an alternative proposition is being considered, namely, that the old smallpox hospital premises be utilised so that the disinfestation can take place on the premises, which are completely isolated, and the hospital premises, which are in good order, can be used for housing the actual tenants, and if need be, the neighbours on either side, while the premises are disinfested. I have been using, pending the installation of a Cyanide apparatus, one of the other advertised preparations on the premises before the furniture has been removed. In view of one's own experience and that of other districts, I have no hesitation in saying that if the work is to be a hundred per cent efficient there is nothing I know of except Cyanide that will do the job, but to do the job efficiently before the tenants enter the house, and to allow them opportunities of importing bugs into clean premises is to render the whole thing futile. There may be a certain amount of difficulty with certain tenants, but it seems to me that can be easily got over by making it one of the conditions of tenancy, that if necessary, they must comply with any instructions given which may facilitate the disinfestation of any premises, either those they occupy or those adjoining. It must be borne in mind, in dealing with bugs, that their manifestations are not always the limit of their visible presence. An excellent example occurred at a local institution. It was found, after a maid had left, who had been many years in the Institution, that her bed bore manifest evidence of bugs. I was asked what to do. I advised the only thing in my opinion was fumigation with Cyanide. This was carried out by Mr. Seymour, and when the fumigation was over it was found that the bugs were not only present in the next room along the corridor, but in the one beyond that as well, and on the other side had invaded the linen cupboard. One's advice for dealing drastically with the matter was abundantly justified. The recommendations that I made some years ago that adequate and proper provision should be made in labour saving houses with just sufficient accommodation to meet the needs of older persons, have at last come into being. The accompanying plans show the two types of houses which have been built to meet those needs. 26 HOUSING CONDITIONS STATISTICS. 1. GENERAL. Number of New Houses erected during the year :— (a) Total (including figures given below) 1,056 (b) With State assistance under the Housing Acts:— (1) By the Local Authority 196 (2) By other Bodies or Persons 860 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) 544 (b) Number of inspections made for the purpose 565 (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 1ll (b) Number of inspections made for the purpose 132 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 54 (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 113 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 127 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 8 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 14 (b) By local authority in default of owners 11 B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 13 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 12 (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 36 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 35 (3) Number of dwelling-houses rendered fit in consequence of undertaking given by owner 1 (4) Number of dwelling-houses in respect of which undertaking from owners accepted, not to re-let houses for human habitation 5 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. G. Other matters :— (1) Number of dwelling-houses demolished voluntarily 8 27 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 Wharf, Isleworth 3 8/1/14 24/2/14 22/12/14 13/2/33 *15, South Street, Isleworth 1 11/1/15 27/4/15 23/11/15 * Demolition deferred pending the widening of the street by the County Council. 28 Table shewing dwelling-houses represented as unfit for human habitation since the passing of the Housing Act, 1939. Premises. No. of houses represented as unfit Dates of representations. Dates houses rendered fit in accordance with undertakings. Dates undertaking accepted that houses would not be re-let for human habitation. Dates Demolition Orders made Dates Demolition Orders obeyed Dates Demolition Orders enforced. Br't forw'd from 1932:— 16-22, Barrack Rd., Hounslow 4 9/11/31 .. .. 26/1/32 28/11/33 1-12, Gordon House Square, Isleworth 121-127, Heston Road, Heston 12 4 12/10/31 13/7/31 .. .. 24/11/31 22/12/31 9/5/33 30/5/33 2-14, High Street, Hounslow 7 9/11/31 .. .. 22/12/31 28/5/33 7 & 9, Jersey Road, Lampton 2 8/6/31 .. .. 26/4/32 30/1/33 11, 13 and 15, Jersey Road, Lampton 3 8/6/31 .. .. 28/7/31 27/2/33 18, The Square, Isleworth 1 9/11/31 4/7/33 .. 12/11/31 •• 2, Gloucester Road, Hounslow 1 8/2/32 .. 4/4/33 22/3/32 .. Grays Cottage, 91, Jersey Road, Heston 1 8/2/32 .. . . 22/3/32 13/11/33 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 .. 5/9/33 31/1/33 59 & 61, High Street, Hounslow 2 12/9/32 .. 9/5/33 •• •• 160a, High Street, Hounslow 1 12/9/32 .. 4/7/33 28/3/33 •• 19, London Road, Brentford End. 1 12/12/32 .. .. 31/1/33 .. 21, London Road, Brentford End 1 12/12/32 .. .. 31/10/33 .. Dealt with in 1933:— .. .. .. 4 and 6, New Heston Road, Heston 2 7/2/33 .. .. 28/3/33 2/9/33 31, 33 and 35, Vine Place, Hounslow 3 7/3/33 .. .. 25/4/33 .. 77, New Heston Road, Heston 1 4/4/33 premises demolished 25/10/33 .. 34-44, Gloucester Road, Hounslow 6 9/5/33 .. .. .. .. 12-18, Tivoli Road, Hounslow 4 9/5/33 .. .. . . .. 36-40, London Road, Brentforc End 3 9/5/33 .. .. 27/6/33 .. 6 and 8, Fairfield Road, Houns low 2 5/9/33 ' ' .. .. 28/11/33 .. 1-14, Crosby Terrace, Statior Road, Hounslow 14 5/9/33 .. .. 28/12/33 .. 5-12, Clarence Terrace, Houns low 8 10/10/33 .. .. 28/11/33 .. 7-27, Vine Place, Hounslow 11 14/11/33 .. .. .. .. 29 Inspection and Supervision of Food. The following is the record of inspection of food premises :— Meat Fish Provisions Greengroceries and Fruit Hawkers' Food Stuffs Food Preparation Places Inspected Number of other Food Inspections 1,117 191 300 324 128 257 13 Fried Fish Shops.—A new trouble has arisen in connection with the Fish Frying trade where control is obtained in the District by reason of the trade being scheduled as a nuisance. This is being evaded by means of mobile fish restaurants of two classes, one of which can be controlled and the other cannot, under the present ruling. In the first class, the frying is actually done on the mobile restaurant. These are elaborately fitted up but are capable of being a very considerable nuisance by reason that they take their offensive smell wherever they go. The second class gets over the ruling in the areas where fish frying is scheduled as an offensive trade by frying outside the area, and then bringing the fried fisli in specially jacketed containers into the district where the trade of fish frying is scheduled as a nuisance. Be it said at once, that the class of fish which is carried in is not nearly as satisfactory as that which is purchased direct from the shop. In this District, control has been exercised so that the number of fried fish shops is definitely limited. A plan of campaign has been agreed upon by the Public Health Committee with the double object of controlling the nuisance and to ensure that for those that want fried fish they can get a good article by reason of the fact that the businesses established are sufficiently far apart to make it really worth while to do the thing properly. There is obviously some further legislation wanted. The opinion has been expressed that the re-heating of fried fish is carrying on the business of fish frying, but the maintenance of heat by means of the jacketed containers does not seem to contravene the Byelaws which control the fish frying business. If there are sufficient of the public who like this sodden stuff it may become a matter of considerable competition with those who, under the control of the Council, are supplying the public with a really satisfactory article. Milk.—I want again to emphasise the extent of sale of sterilised milk. The amount that the public purchases has forced into the market well-known purveyors who have done their best to keep out of it. The point which seems to be of paramount importance in the sale of sterilised milk is the homogenisation. Cream-line pasteurised milk can never be re-assembled so as to give a proper mixture of the cream with the milk from which it has separated out. There is no doubt, to my mind, that homogenised milk makes a far better cup of tea and coffee, and there is also the fact that the housewife claims that homogenised makes far better milk puddings than the ordinary pasteurised milk, and it is to this fact I think must be attributed the enormous sale of sterilised milk. It seems a thousand pities that homogenised milk cannot be kept free from the periodic spoiling by the oily or turnipy flavour which seems to afflict it. I have taken it up with the milk companies, and they do not seem to be able completely to eliminate this drawback. If this can be definitely eliminated, in my opinion the days of the cream-line pasteurised milk are doomed, as compared with homogenised pasteurised milk for household purposes, as everything is in favour of the homogenised product. In addition to a note of the number of samples of milk taken under the Food and Drugs Act for analysis, 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 :— " During the year 1933, eight samples of milk were taken from a retailer in the district. These samples were submitted to the Lister Institute for animal inoculation tests for the presence of tubercle bacilli. One sample was found to contain living tubercle bacilli. This sample was traced to a farm in Berkshire. Information was received from the County Medica.1 Officer of Berkshire that three individual samples and one bulk sample were taken from the herd at this farm, and that the results of the biological test are not yet available. During 1933 two cows were reported by owners as shewing symptoms suspicious of tuberculosis and were examined by one of the County Council's veterinary surgeons, one proved positive to the tuberculin test and the other shewed clinical symptoms of tuberculosis. Both were slaughtered under the Tuberculosis Order, 1925, of the Ministry of Agriculture." 30 During the year an application was received for a milk vendor tobe registered in this district. During the period which his application was under discussion he was purveying milk in the district and sundry infringements of the Acts covering a milk vendor's business were perpetrated. His record was such that the Council decided to refuse his application. He had been convicted in at least two different names in four different Courts for a series of offences which were as follows :— (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Selling milk from which 12% original fat had been abstracted. 12% fat abstracted. Selling skimmed milk to which colouring matter had been added on 9/1/22. Selling milk to which colouring matter had been added on 18/1/22. Ditto on 20/1/22. Ditto on 24/1/22. Ditto on 6/2/22. Selling skimmed milk to which colouring matter had been added. Selling separated milk to which colouring matter had been added. Ditto (aiding and abetting). Selling skimmed milk to which colouring matter had been added. Ditto. Ditto. Selling milk from a vehicle which had not his name and address inscribed thereon. Selling milk from a hand cart which had not his name and address inscribed thereon. Aiding and abetting three other defendants in the use of his (X) dairy without the other defendants being registered in respect of the premises. Fined £3 3s. and £1 Is. costs. Fined £3 3s. and 10s. 6d. costs. Fined £7 and £1 Is. costs. Fined £1 and £1 Is. costs. Ditto. Ditto. Ditto. Fined £7 and £1 ls. costs. Fined £4 and £2 costs. Fined £4. Fined £7 and £1 ls. costs. Ditto. Ditto. Fined £2 and £1 ls. costs. Fined 10s. and 21s. costs. Fined £10 and £10 10s. costs. His application was made in the name of " X.X. " It was proved that although he applied for registration in this name, it was not his own name, and there was no registration under the Registration of Business Names Act, 1916. He had stated on the application form that it was his full christian name and surname. The practice of the individual in question is to buy surplus supplies of bulk milk largely at the Railway Stations, where it is delivered, and to sell it at about 2d. a quart under the customary local price. It was proved that rounds were rapidly worked up in this way and then sold, and it was also known that in one case the money paid had been refunded as a result of action by the purchaser, on the ground that sale was fraudulent by reason of a breach of warranty. The following report of the cross examination is illuminating. Question : What is the milk you are selling now ? Answer : It is pasteurised, but I sell it as ordinary milk. Question : What is the difference between pasteurised and sterilized milk ? Answer : I do not know. Question : Does the public know it is " Pasteurised milk " ? Answer : No, I sell it as " ordinary milk." Question : You sell it as " fresh milk " ? Answer : No, I sell it as " milk." The analysis of samples of the milk by means of the three recognised tests showed Soluble Albumin—0.053% Milk Sugar—3.96% (Polarimeter). 4.01% (Gravimetrically). Paraphenylene-diamine Test—No coloration. 31 The report was as follows :—• " The results for milk sugar agree with each other. The absence of colour with paraphenylene-diamine shews that the milk has been heated above 80°C. The result for soluble albumin is very low, pointing to its almost complete removal. On these findings, I am of opinion that the milk has been sterilized." For the information of those who have not had to deal with this subject before, the importance of these tests is that the soluble albumin determined by Sebelein's method shows a 0.4% to 0.5% of soluble albumin in fresh milk, while sterilised milk contains not more than 0.1%. In the estimation of milk sugar by the Polarimeter and gravimetrically, if the former is much less than the latter the milk is probably sterilised. In the paraphenylene-diamine test, fresh milk gives an immediate blue coloration, while sterilised milk gives no coloration within 10 minutes. Pasteurised milk occupies a position midway between fresh milk and sterilised milk in all these tests, and a mixture of fresh milk and sterilised milk will behave like pasteurised milk. I am indebted both to Dr. Monier Williams and Dr. Hamill for considerable help and information in dealing with this matter. The plea which was raised was as follows A man must not sell milk unless he is registered. Why therefore can a Local Authority refuse registration because of previous history of the applicant in some other district ? But if that contention is right, he can go from the area of one Local Authority to that of another without let or hindrance, that is if a purveyor commits an offence and is struck off the register in the area of one authority, he can apply to another authority who must register him. That surely cannot be the intention of the Section which gives power to refuse registration. If the purveyor cannot be refused registration on the grounds that his previous history shows he is likely to endanger the public health, the section appears to me to be practically useless. Further, a person is bound to apply for registration, and if he does so, I submit that he should apply in his own name irrespective of any trade name he uses, otherwise there is no positive identification. He can say his name is XY, when his real name is GH. The vendor in question in the course of his evidence said he was registered in the name of XY, when there was no such person as XY. He admitted that any person receiving a letter on his trade note-paper would have thought that they were dealing with a person named XY and not G.H. The defence objected that there was no official from the Board of Trade to prove the search for the name in the Register of Business Names, and also objected to evidence of conviction from another Court, which was not proved by an official of that Court. The defence also objected to any record of the previous convictions being submitted as evidence. Although the irregularities were admitted, the Bench held that they were " of the opinion that the reason for removal from the register was insufficient " and the appeal was granted with costs against the Council. In the meantime, a very large round has been worked up, the public buying what they think is something of the nature, not demanded, but expected. 482 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 (7 shops). " Grade A " (Tuberculin Tested) milk 8 (11 shops). " Grade A " milk — " Grade A" Pasteurised milk 1 (1 shop). " Pasteurised " milk 5 (14 shops). 32 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. There are 7 slaughter-houses (4 registered and 3 licenced), in use in the district, and eich slaughter-house received on an average 12.48 visits per month. There were 61- batchers' shops in the district at the end of 1933. 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 or further facilities for slaughtering at present. t 3. Action under Section 117, Public Health Act, 1875 :—No unsound meat was seized during the year. 4. Diseased Meat.—There was none seized, but a total of 2,891 lbs. were surrendered during the year, including 1,527 lbs. of tubercular meat. 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 16 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 beneficial both from the point of view of preventing contamination and maintaining longer the saleable qualities of the meat. Having regard to this improvement in certain instances, the reason for the absence of a positive policy on the matter in the Regulations is rather obscure and I venture to suggest in fairness to those butchers who have provided fixed windows on request, that provisions should be made, in the near future, for enforcing compulsorily, that all meat shall only be exposed and sold behind fixed glazed windows without any qualifications. Out of a total of 64 butchers' shops in the district, 45 are provided with fixed windows, of which number 6 were new shops in 1933 ; 3 other shops are provided with one fixed window and one window made to open, one of which was a new shop in 1933 ; 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 will 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. 33 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. We are an extraordinary people in the way we strain at the gnat and swallow the camel. Some people do not seem to care in the least what happens to their food. Whilst many are pressing for the wrapping of bread, others do not seem to mind whether it is tumbled into the manure at the roadside by the lad that delivers it, or what happens. Last summer, during the hot weather, day after day I watched bread being delivered by a girl on a bicycle in a sleeveless dress, with an old fashioned baker's basket slung over her back, cycling along the road on days which made one feel hot even to stand still, let alone cycle. At least two of the loaves out of the contents of the basket must have been in fairly intimate contact with her armpits. Of course, there is no accounting for taste, but if people like their bread delivered in such condition it is a curious taste. Whilst the advertising columns of the papers shriek with the illustrated horrors of " body odour," some people do not seem to mind whether they get it with their breakfast bread or not. On another occasion, on getting nearer to the office I saw another baker's roundsman with a hand-barrow, retrieving from among the horse dung and other dust in the gutter, a loaf which had gone adrift in moving. It was put back with no compunction to be delivered in the ordinary way apparently. On other occasions, a lorry from a large wholesale bread firm stopped regularly at a certain corner, and was surrounded by men with hand carts in which they apparently delivered the bread. The bread in the lorry was put straight on to the floor of the lorry and built up inside, and in transferring the loaves to the smaller delivery hand carts, the procedure was much the same as for bricks. The men frequently jumped straight from the road 011 to the tail board of the lorry along which the bread was pushed, and deposited in the course of its removal. A compulsory wrapping of bread immediately after it has been made is surely one of the requirements which needs expediting. Although not exactly food, cigarettes are things one puts into one's mouth, and the condition of one of the factories I was privileged to inspect recently gives one furiously to think how enormous sums may be spent on producing a product of very high quality, and yet the whole thing from the point of view of purity rendered absolutely nugatory by one weak link in the chain, the strengthening of which to perfection would have cost nothing compared with the money which is lavished in otherwise unimportant directions. Whilst inspecting the factory in question, whose reputation is world-wide, one found tobacco lying on the mixing floors, beautiful maple floors apparently spotless, but tramping about amongst the tobacco and all over the floor were the girls employed on that particular work, wearing the shoes which looked like those they would have walked to the factory in. I asked the representative of the firm who was taking us round, whether those shoes were the same shoes they wore in the street, or did they supply them with special shoes to work in amongst the tobacco which found its way into their customers' mouths. My question apparently touched them on the raw. They were rather peeved that the question should be asked, but I elicited the fact that they were the ordinary shoes in which they tramped the dung-littered streets on their way to and from work. Dry horse dung looks very much like some tobacco, but why pay for it, quite apart from the sanitary and aesthetic side of the question. The firm in question maintained some 300 clerks simply to deal with their gift coupon scheme. Part of that colossal sum would surely have been better spent on providing the employees with some form of footwear which would not make an undesirable present to their customers, in addition to the gifts for their coupons. 34 Sale of Food and Drugs Act.—I am indebted to Dr. J. Tate, County Medical Officer, for the following report, as to the samples purchased in this area during 1933. Article. Taken. Adulterated. Milk 188 1 Milk, Sterilized 4 — Hake 8 5 Meat 2 — Minced Beef 1 — Sausages 3 — 206 6 One sample of milk contained a small percentage of added water, and the vendor was cautioned. Two fishmongers were prosecuted for selling respectively haddock and coalfish as hake. UNSOUND FOOD, 1933. Tons. cwts. qrs. lbs. Bacon 11 Corned Beef 12 Fish 3 0 Meat 1 5 3 7 Poultry 3 16 Rabbits 1 51 Total 1 7 3 23} 35 Infectious Diseases. Scarlet Fever and Diphtheria.—There were 10 " return " cases of Scarlet Fever and one 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 391 No. of civil cases removed to Hospitals 344 Percentage of cases removed to Hospitals 87.97 The incident rate of Scarlet Fever in the civil population (84,460) was 4.62 per 1,000. There were four 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 50 No. of civil cases removed to Hospitals 49 Percentage of cases removed to Hospitals 98.0 The incident rate per 1,000 of the civil population was 0.59. Twelve cases occurred in institutions during the year. Two deaths occurred from this disease, i.e., a case mortality rate of 4.0 per cent. The deaths occurred in the following age groups:— 2—3 years 1 5—10 years 1 And in the following months:— February 1 August 1 For the last five years the deaths from Diphtheria have been as follows:— Year. 1929 23 Year. 1930 19 Year. 1931 4 Year. 1932 3 Year. 1933 2 The full details of the Immunisation work for 1933 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 scientifically accurate as it is possible to make it. Report of work of the Diphtheria Immunisation Clinics for 1933. The number of new cases presenting themselves for Schick-testing and Immunisation during the year was 420. The total attendances during the year amounted to 2,558. It would at first appear that less cases have been dealt with at the clinic sessions than in the year 1932, where the respective numbers were 413 new cases and 3,015 attendances. In this connection it must however be borne in mind that there had been also a Wednesday afternoon clinic at Hounslow up to June 29th, 1932, and a Saturday morning clinic at Isleworth until July 16th, 1932, on which dates both the above clinics were closed down.. The Monday afternoon clinic in 1933 actually dealt with about 85% of the total of attendances received by the equivalent of approximately two clinics weekly in the year 1932. Of the 420 new cases (Primary Schick Tests) in 1933:— 367 gave Positive readings, 41 gave confirmed Negative readings, 12 did not attend for reading. The cases concluded and issued with certificates of apparent immunity during the year amounted to 384. Of these 343 persons had been successfully immunised. 41 were found to be naturally immune. 36 A determined attempt is being made to follow up the immunised cases from two to three years after the completion of the original immunising course. As far as circumstances permit, such persons are sent for in rotation, and re-Schick-tested, with a view to finding out how many cases show a tendency to revert to the susceptible state. With only one clinic a week it has been impassible to deal with as many of these subjects as would have been desirable, but it is hoped to make more ample provision for this type of work in 1934. The number of subjects actually tested after from 2 to 3 years from the date of original immunisation was 153, this number actually including 58 persons who had been originally naturally immune. The results were :— Natural Immunes. (58 subjects). Still Schick-negative, 57. Schick-positive, 1. Immunised Subjects. (95 children). Still Schick-negative, 83. Again Schick-positive, 12. It will thus be seen that among the naturally immune group the percentage of reversion to susceptibility amounted only to 1.7%. In the immunised group the percentage of reversion appeared to be 12.6. In this connection, it must however be borne in mind that the reversion to some degree of apparent susceptibility does not necessarily mean that such subjects would be likely to contract Diphtheria. The essential factor in immunisation appears to be the training of the body to produce antitoxin when required. The original production of the Schick-negative state in an initially susceptible person provides some guarantee that the body has received a good training in antitoxin production. Even though a subject may subsequently show a positive reaction, the first trace of diphtheria infection is often enough to restore the activity of the antitoxin production mechanism, so that the person again becomes protected very rapidly by these means, and Diphtheria does not develop. Of the 12 originally immunised persons who had reverted to some degree of Schick-positive reaction, 5 received further immunising injections, and were subsequently shown to have been rendered Schick-negative again. A further 6 received extra injections but have not yet been re-tested. One case had no further injection. Up to the date of this report no child immunised at the clinics has contracted diphtheria. There have been eight cases in which there was a suspicion of Diphtheria in subjects believed to be immune. Full investigations showed that the diagnosis was faulty in 6 cases, which were subsequently shown to be suffering from other conditions. The two remaining cases were found to be carriers of Diphtheria bacilli only, and they presented no clinical symptoms of the disease, and took no harm from the presence of the organism. On the 22nd December a child who had removed to Romford was notified as suffering from a very mild attack of Diphtheria. This child had not been immunised at the clinic, as it appeared to be naturally immune. In this connection it must be plainly stated that in course of time we shall undoubtedly meet with a few mild cases of Diphtheria, both among immunised and naturally immune subjects. Such cases are due to no fault in the methods adopted. They occur as a result of the ever changing factor of the human body. Some persons are easy to immunise and retain the protection almost indefinitely. Conversely others are initially difficult to immunise, and tend to lose the protection rapidly. Only by careful and thorough work can we hope to maintain the number of apparent failures at a minimum. This we are attempting to do, as previously mentioned, by following up the old cases, and by dealing with the new ones with the utmost thoroughness. It is indeed satisfactory that during the whole time this work has been in progress at Heston and Isleworth that one is only obliged to record one apparent case of Diphtheria in a child considered naturally immune, no cases among our immunised subjects, and of course, no deaths in either class. A very careful and exhaustive analysis of all the figures obtained up to the end of 1932 was given in the annual report for that year. The figures which we have to add are not sufficient materially to affect those statistics, which are based on a considerable number of cases. It is proposed to re-analyse all our figures when the number of additional cases appears to make this worth while. The figures for 1933 added to those for previous years show that a total of 3,641 certificates have been issued up to the end of 1933. Of these 700 were given to naturally immune persons. 2,941 were given to immunised subjects. The methods previously utilised at the clinics have again been found satisfactory, and the larger third dose of 1.5 c.c. of T.A.M. has been found to be of definite advantage. By the date of the next report, sufficient figures will be available which should leave no doubt as to the value and desirability of this procedure. G. BOUSFIELD, M.D. (Lond.). 37 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 1933, 20 vials of Antitoxin of 8,000 units each were supplied to medical practitioners. Smallpox.—No cases were notified during the year 1933. Enteric Fever.—There were 5 cases notified during the year. Three of the cases, notified from the West Middlesex Hospital, were admitted from outside this district. Erysipelas.—Fifty-four cases of this disease were notified, of whom 36 were of cases in the West Middlesex Hospital. Thirty-one were non-residents in this district. Ophthalmia Neonatorum.—See page 49. Puerperal Fever.—Twelve cases of this disease were notified. Nine 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 three cases were residents. One was confined in the West Middlesex Hospital, and one in Queen Charlotte's Hospital. One case was removed to Hospital for treatment. The number of deaths from Puerperal Sepsis was four. None of these deaths took place at home. Puerperal Pyrexia.—Forty-nine cases were notified ; 47 of these were notified from the West Middlesex Hospital, including 33 who were not usually resident in this district. Encephalitis Lethargica.—Two cases were notified this year. Cerebro-Spinal Fever.—Six cases of this disease were notified. Four were notified from the West Middlesex Hospital, but one of these was not from this district. Acute Poliomyelitis.—Five cases of this disease were notified; three of these were notified from West Middlesex Hospital, and two were non-residents of this district. Pneumonia.—There were 234 cases notified—171 notifications were from the West Middlesex Hospital. One hundred and twenty-four were non-resident in this district. 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 six years :— 1928 1929 1930 1931 1932 1933 Measles 688 83 799 9 952 108 German Measles 9 344 38 5 25 13 Chicken Pox 265 423 392 233 194 362 Mumps 138 106 381 132 122 940 Whooping Cough 171 177 144 242 260 287 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 24 deaths from Influenza during the year, the mortality being 0.28 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. See also page 25-26. 38 TUBERCULOSIS. I repeat what I said last year, that in my opinion an open-air recovery school is a real ne:d in this district. It is impossible for those who have not been in close personal contact with opmi-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. Pulmonary Tuberculosis.—The number of new cases notified during the year was 113. Sixty-two cases were notified from Institutions :—Sanatoria 33, Poor Law Institutions 22 and General Hospitals 7. There were 68 deaths from Tuberculosis of the Respiratory System. Of the new cases notified, 72 received institutional treatment during the year, and 26 died. Other Forms of Tuberculosis.—The number of new cases notified during the year was 27. Eight of them were notified as receiving institutional treatment. There were 8 deaths. One of the cases which died was unnotified. Deaths from Tuberculosis.—-Ten deaths occurred in non-notified cases. In three of these the medical practitioners certifying the deaths thought the patients had already been notified before coming into their hands. Two deaths occurred elsewhere, and were 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 1933. TUBERCULOSIS, 1933. Age Periods. New Cases. Deaths. Pulmonary. Non-Pulmonary Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 .. .. 1 1 1 .. .. .. 1 .. .. 2 3 .. .. 1 2 5 1 1 4 1 .. .. .. .. 10 4 .. 1 1 1 .. .. 1 15 3 6 3 1 2 5 .. .. 20 7 9 2 .. 5 5 1 .. 25 24 15 3 2 9 6 1 .. 35 8 8 .. .. 5 5 1 .. 45 12 4 .. 1 12 5 .. .. 55 4 2 .. .. 3 1 .. .. 65 and upwards 2 3 .. 1 2 1 .. 1 Totals 65 48 16 11 40 28 4 4 Nine of the deaths from Pulmonary Tuberculosis were not notified and one death from Non-Pulmonary Tuberculosis was not notified. 39 INFECTIOUS DISEASES, 1933. CASES NOTIFIED. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Cerebrospinal Fever. Encephalitis Lethargica. Poliomyelitis. Polio- Encephalitis. Pneumonia. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Puerperal Pyrexia. January 27 3 .. .. 1 .. .. .. .. 48 5 .. .. 8 February 31 2 .. 1 2 1 1 1 .. 33 5 .. 1 5 March 54 2 .. .. 3 .. .. 1 .. 17 16 5 1 3 April 13 5 .. .. 6 .. .. .. 1 17 9 .. 1 6 May 34 6 .. .. 5 2 .. .. .. 16 14 5 1 4 June 16 4 .. .. 4 2 .. .. .. 18 8 2 .. 4 July 36 7 2 2 6 .. .. .. .. 13 15 3 2 6 August 24 8 .. 4 3 .. .. 2 .. 10 10 2 1 .. September 20 3 .. .. 7 .. .. .. .. 5 7 2 1 2 October 49 3 1 .. 5 .. 1 .. .. 19 11 2 .. 2 November 31 4 1 2 6 .. .. 1 .. 16 8 3 3 4 December 56 3 1 3 6 1 .. .. .. 22 5 3 .. 5 Totals 391 50 5 12 54 6 2 5 1 234 113 27 11 49 In addition to above there was 1 Military case of S.F. There were no cases notified during the year of the following diseases:—Malaria, Dysentry, or Small Pox. DIPHTHERIA, 1933 (including Bacterial cases, 12 in number). Month. WARD. Elem. School Chldren Other School Chldren Other Cases Total Hstn. Houn. Cent. Houn. Hth. Houn. Sth. Houn. West Islewth N. Islewth S. Spng. Grve. Jan. 5 — 2 1 — 2 — — — 2 — 3 Feb. . • 2 — 1 — — 1 — — — 2 — — Mar. 2 — — — — — 2 — — — 1 1 April 7 — 1 — 3 — 3 — — 1 — 6 May 6 — — — 2 — 3 1 — 2 1 3 June .. 5 — — — — — 2 1 2 1 — 4 July .. 9 — 1 1 2 3 2 — — 4 1 4 August . 10 — — — — 2 6 2 — 2 — 8 Sept. 4 — — 1 — — 1 2 — 1 — 3 Oct. 3 — — — — — 3 — — 1 — 2 Nov. 5 1 — — — — 4 — — 3 — 2 Dec. 4 1 — 1 — — 2 — — — — 4 Totals .. 62 2 5 4 7 8 28 6 2 19 3 40 40 Notifiable Diseases during 1933. 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 3 •• •• •• 5 1 4 Scarlet Fever 2 10 16 24 37 173 60 16 44* 6 4 •• 392* 261* 84 Diphtheria 1 3 2 4 3 17 4 3 10 1 2 •• 50 36 13 Erysipelas •• •• 1 •• •• •• 2 4 9 7 23 •• 54 2 38 Puerperal Fever •• •• •• •• •• •• •• •• 9 3 •• •• 12 •• 12 Puerperal Pyrexia •• •• •• •• •• •• •• 4 35 9 1 •• 49 •• 49 Ophthalmia Neonatorum 11 •• •• •• •• •• •• •• •• •• •• •• 11 •• 5 Poliomyelitis •• •• •• •• 1 1 1 •• 2 •• •• •• 5 •• 5 Cerebro Spinal Fever •• •• •• 1 •• •• 1 1 3 •• •• •• 6 1 5 Pneumonia 10 10 12 6 5 27 7 10 50 30 46 21 234 •• 184 Dysentry •• •• •• •• •• •• •• • • •• •• •• •• •• •• •• Malaria •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• Encephalitis Lethargica •• 1 •• •• •• •• •• •• •• 1 •• •• 2 •• 2 Polio Encephalitis •• 1 •• •• •• •• •• •• •• •• •• •• 1 •• •• For Tuberculosis Notifications—see other Table ♦Includes one military case of Scarlet Fever. 41 DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES, 1933. 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 2 .. .. .. 1 .. .. .. •• 1 .. .. 4 Diphtheria .. .. .. .. .. 1 .. .. .. •• .. .. 2 Enteric Fever .. .. .. .. .. •• .. .. .. .. .. .. .. Puerperal Fever •• .. .. .. .. •• .. .. 2 1 .. .. 3 Puerperal Pyrexia .. .. .. .. .. .. .. .. 1 .. .. .. 1 Pneumonia 10 .. .. .. .. .. .. 1 4 2 14 14 45 Poliomyelitis .. •• .. .. .. .. .. 1 1 .. .. .. 2 Polio- Encephalitis .. 1 .. .. .. .. .. .. .. .. .. .. 1 Encephalitis Lethargica .. .. .. .. .. .. .. .. .. .. 1 1 2 Cerebro-Spinal Fever .. .. .. 1 .. .. 1 1 .. .. .. .. 3 Erysipelas .. .. .. .. .. .. •• .. .. .. .. 1 1 Total 12 1 1 1 1 1 1 3 8 4 15 16 64 For Tuberculosis Deaths—see other Table. The table hereunder gives the number of cases of infectious diseases that were notified from the several Institutions in the district during 1933:— Enteric Fever. Scarlet Fever. Diphtheria. Pneumonia (all forms) Erysipelas. Puerperal Fever. Puerperal Pyrexia. Cerebro Spinal Fever. Ophthalmia Neonatorum. Pulmonary Tuberculosis Other Tuberculosis. Poliomyelitis. Total. West Middlesex Hospital 3 57 12 171 36 10 47 4 3 21 4 3 371 Hounslow Hospital 1 2 – 9 2 – 1 1 – – 4 1 21 Hounslow Barracks – 1 – – – – – – – – – – 1 Mogden Isolation Hospital – – – – – – – – – – – – – Collingwood College – – – – – – – – – – – – – St. Mary's School – – – – – – – – – – – – – Totals 4 60 12 180 38 10 48 5 3 21 8 4 393 In addition to the above civil cases, one military case of Scarlet Fever occurred in the Hounslow Barracks. 42 INFANTILE MORTALITY RATE. RATE FOR ENGLAND AND WALES SHOWN RATE FOR HESTON AND ISLEWORTH SHOWN RATE PER THOUSAND BIRTHS. YEAR. Maternity & Child Welfare. Before reporting on the Maternity and Child Welfare scheme I think it is well to draw attention to the Infantile Mortality Kate since 1914, which shows what really is the result of infant welfare work in this district. We have during the latter years been amongst the districts of the country with the best record in this respect. In the year 1933 we have beaten all previous records. When one looks back, as I have said before, on an ideal of 60 per 1,000, which was held up years ago as an ideal to aim at, but which would never be attained, one feels that as Medical Officer of Health one has not lived in vain, nor that one's administrative efforts to do well for the infants under one's care have been anything but a success. The scheme is as follows:— Three sessions weekly at the Congregational Hall, Douglas Road, Hounslow, on Tuesday, Wednesday, and Thursday afternoons. Three sessions weekly at the Public Hall, Isleworth, on Monday, Wednesday and Friday afternoons. Two sessions weekly at Heston Village Hall, one on Tuesday afternoons, and one on Friday mornings. One session 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 to keep pace with generally, and especially by reason of the limitations of Isleworth Public Hall and Clipstone House. 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 1,056, and when it is realised that about 1,000 houses have been erected every year during the previous 8 years, it gives some index of the abnormal and continuing 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. I still get repeated appeals from various mothers to help them to obtain a Council House. I am glad to place on record the way in which the Housing Officer is co-operating in order to ensure that the best results are obtained in the housing and re-housing of the people of the district, and it is all to the good that there is greater co-operation between the Housing Committee and the Health Committee. As was forecast last year, the growth of the Clinic at Clipstone House is necessitating a second weekly session. This will be rapidly filled. There is already difficulty in dealing with the western end of the town and the prospect of the addition of Cranford to this Area, two miles away from the Clinic, is going to make things still more difficult. The temporary building scheme for improving the conditions at Isleworth Clinic has been dropped in view of the maturing of a scheme for a really good permanent Clinic at Isleworth; and the use of Busch House, which has been purchased by the Council is under consideration, as a temporary expedient until the permanent building can be erected. As I reported last year, the efficient Dental Scheme is bringing more and more toddlers under review than anything else. The plea that I put in last year for Cookery Demonstrations bids fair to become established. The Carnegie Trustees have granted me £'500 towards Nutritional Research from the point of view of cookery, and one of the grounds for the application that I made was the knowledge we should get as a result of research which we could communicate to the people in the Clinics and in their homes. As I said on previous occasions, I am a practical cook and time after time after time when I go into the humbler homes, by reason of that knowledge, it grieves me sorely to see the messy meals, or apology for meals, which are served not only in a wasteful manner but in a manner ignorant of all nutritional needs and so often served in a manner which takes away from the meal any idea of comfort or pleasure in its consumption. My Council have also offered to help in anything that will benefit the people for whom they are responsible. They have agreed to assist the Carnegie Grant by erecting a special research kitchen and supplying the necessary apparatus, fuel, gas, etc., up to an amount of £120, thereby leaving the £500 grant from the Carnegie Trustees to be devoted in full to the actual Research Work. 43 The attendances of children at all the Centres during the last six years have been as follows:— Year. No of attendances. Year. No. of attendances. 1928 16,625 1931 27,318 1929 17,667 1932 31,656 1930 19,222 1933 35,110 It will be seen that the attendances have more than doubled in the last six years. The average attendances per session during the year 1933 were as follows:— At Douglas Road Centre 79.0 At Clipstone House, Bath Road, Centre 69.8 At Isleworth Centre 70.0 At Heston Centre 68.6 Approximately 74.2 per cent of the notified live births attend at one of the Infant Welfare Centres before they are a year old, an increase of 3 per cent over last year's figure. Clipstone House has a delightful garden, one section of which is well wooded adjoining the Clinic, and in the very hot weather the Infant Welfare Clinic was held in the trees in the open, as the Waiting Room and Consultation Room was so insufferably hot by reason of the fact that both of them faced full south with the sun pouring on them. These alfresco Clinics were a great success. The accompanying photograph was taken on one of those afternoons in question. The number of individual mothers and children attending the Clinics is shown hereunder:— Douglas Road, Hounslow— 1929 1930 1931 1932 1933 Mothers 733 868 1087 1085 860 Children 914 946 1232 1741 1078 Clipstone House, Bath Road, Hounslow— Mothers — — — 132 467 Children — — — 153 557 Isleworth Public Hall— Mothers 367 458 578 690 685 Children 452 522 757 763 824 Heston— Mothers 212 305 392 451 435 Children 253 355 478 534 550 Sales at Clinics. Quantity. Receipts. £ s. d. Cow and Gate 9895 lbs. 679 7 7 Half-Cream Cow and Gate 1069 lbs. 73 8 6 Ostermilk 820 lbs. 60 5 4 Hemolac 31 lbs. 2 5 6 Lacidac 309 packets. 32 3 9 Virol 598£ lbs. 45 9 2 Sugar of milk 282 lbs. 17 5 0 Oil and Malt 389 lbs. 13 10 9 Lactagol 947 tins. 52 14 8 Cod Liver Oil Emulsion 7273 bottles. 222 14 8 Bemax 351 packets. 7 6 3 Adexolin 90 phials. 8 0 10 Total £1214 12 0 Ante-Natal Clinic.—The Clinic is held at 92, Bath Road, Hounslow every Wednesday morning. There has, in years gone by, been a section of the general practitioners who disclaim loudly against the Public Health Departments and the various Clinics, and the Ante-Natal Clinic in particular. It is as well that the general practitioners should realise that much of the present state of affairs is due to the general practitioners themselves. To quote a case which appeared at the Clinic, the child had a sterno mastoid haematoma as a result of certain amount of difficulty with the after-coming head of a breech presentation. The mother volunteered the following statement with regard to the child. When she was about five months pregnant she went to the Doctor who had succeeded to the practice of her original practitioner. He booked the confinement but made no attempt to arrange for any ante-natal supervision whatever. Being dissatisfied with this, she appeared at the Ante-Natal Clinic where she was seen, but referred to her own Doctor. As she had been dissatisfied with the first Doctor, she refused to go back to him, but consulted a second practitioner. He also booked the confinement but again made no attempt to arrange for any Ante-Natal supervision, to the mother's intense annoyance. She went elsewhere. The reason for her annoyance was that the original practitioner who had left the district and who had attended her when her first child was born, arranged that if everything went 44 all right he would like to see her at the seventh month to make sure that everything was going well and did so, also arranging that if everything was not perfectly all right, she was to let him know. The mother, like all mothers now-a-days, reads the daily press, and felt that neither of the two Doctors who she consulted were to be trusted in view of the lack of interest that was exhibited in her condition as compared to the original Doctor, who, she felt was doing what was right. In circumstances such as these, is it to be wondered at that the general public, who through the daily press are becoming more and more informed, in fact in some respects I think over informed of what some people call the perils of parenthood, should seek advice from sources other than the general practitioners, and if so is there anyone to blame but the general practitioners themselves ? The following are the figures of attendances at the Clinic 1931 1932 1933 Attendances by Expectant Mothers during the year 583 696 738 Number of Sessions 32 52 52 Average Attendance per Session 18 13.4 14.2 No. of Mothers attending Ante-Natal Clinic shown as a percentage of total notified births 26.8 29.03 28.0 New Patients 313 388 336 Total number of expectant Mothers who attended the Clinic during the year 342 396 373 There were in addition 26 Post-Natal Cases, as against 10 in 1932. Dr. Wrigley's report is as follows:— The attendance figures show another rise. Last year stress was laid upon the fact that whereas this increase undoubtedly can be taken as an index of the public appreciation of the work, it could only continue up to a certain point, beyond which work would be hurried and inefficient to the great detriment of those patients who attend. Saturation point has been reached, but, at the time of writing, relief is in sight. Arrangements have been made to provide a centre at Isleworth for the convenience of patients resident in that part of the Borough. Enormous benefit will accrue, not only in the direction of convenience and of lessening the congestion at Clipstone House, but also, and this is more important, prospective mothers at or near term will not have to undertake a long journey at this critical time. The routine of the work remains unaltered. All patients who state that they have already engaged a doctor to attend them in their pregnancy and confinement are referred back at once to their medical attendant. A note is sent at the same time informing the doctor that the patient would only be examined again at the clinic if she brought with her a written request to that effect. It is most gratifying to be able to report that in 1933 for the first time there has been an increase in the number of those patients who are referred back to the clinic by their private doctor for the purpose of supervision in the pregnancy. In addition, the clinic has been used in 1933 to a greatly increased extent by practitioners in Hounslow, and apparently regularly in two instances, for purposes of consultation. Perhaps it is in this capacity that it fulfils its real function. The use of the clinic by the private practitioner in Hounslow is an entirely new feature and was apparent for the first time in the year under consideration. It appears also that full use is made of the clinic by every midwife in Hounslow. Some accompany their patients on their visits with unfailing regularity. They are able to examine the patient with the obstetrician. When this is done it results in inestimable benefit to the patient and the midwife. The patient appreciates that her attendant is fully acquainted with the exact state of affairs ; and, as one midwife put it, " for the first time since I finished my training I am beginning to regain the feeling that I know a little about my work and am reasonably up to date." Midwives use the clinic for another purpose that is certainly not mentioned in the definition of ante-natal work. They never appear without a series of questions upon the difficulties and doubts that arise in the course of their daily practice, and frequently an inquisition is held upon some troublesome case that they have attended in the last few days. Such co-operation with the doctors and midwives in practice in the Borough adds greatly to the value to the community of the ante-natal clinic. During 1933 as a direct result of the energy of the Nurse in charge of the ante-natal clinic, a system is now in operation whereby the non-attendance of the patient is at once noticed. Whereas the majority of the women attend regularly, sometimes perhaps too often, a small minority fail, either as a result of sickness, ignorance, or laziness. These cases are visited personally and the circumstances are inquired into there and then. Co-operation with the Dental Department continues unhindered and many mothers must, as a result, emerge from pregnancy in a greatly improved state of health, as compared to their condition before treatment. In conclusion, it is to be hoped that 1934 will be able to show such a good record. A. J. WRIGLEY, M.D., F.R.C.S. 45 MATERNAL MORTALITY. We have now concluded a scheme with Queen Charlotte's Hospital whereby any case of Puerperal Fever arising in the district can be admitted at once, in order to obtain the highest specialist treatment which is available therein. At last I am able to report that I have completed the chain of activities which are to ensure that as far as possible at the present time, every mother in the district is ensured of the safest possible confinement by the wise provision of the Local Borough Council. There is now available for every pregnant woman in the area:— (a) An Ante-Natal Specialist, (b) An Obstetric Specialist in case of difficulty at the confinement, (c) A Specialist in case of Puerperal Fever, and (d) Beds provided at Queen Charlotte's Hospital, as I stated above, in case further treatment is required. In addition to this, from the dental side there is provision of everything that can ensure that the mother's mouth is cleaned before her confinement. Cases are recommended by the Ante-Natal Specialist for dental treatment, and where this necessitates the removal of large numbers of teeth there is the provision subsequently of dentures. These dentures are paid for on the following scale, which was based on that of the National Insurance Act:— £ s. d. £ s. d. 1 Tooth 11 0 8 Teeth 1 10 3 2 Teeth 13 9 9 Teeth 1 13 0 3 Teeth 16 6 10 Teeth 1 13 0 4 Teeth 19 3 11 Teeth 1 13 0 5 Teeth l 2 0 12 Teeth 1 13 0 6 Teeth l 4 9 13 Teeth 1 13 0 7 Teeth l 7 6 14 Teeth 1 13 0 But where the financial circumstances of the mother make this impossible, the amount which shall be paid, if any, is assessed by a special sub-committee. Payment is allowed by instalments. Where the extractions are numerous, in order that the mother shall get the least possible upset an arrangement is made through the Royal Dental Hospital to admit the patients to their beds in Charing Cross Hospital for one or two nights, as may be necessary, for which we pay at the rate of 25s. per night. Thus, I think without fear of contradiction, we can say that in this area we have one of the most complete schemes, if not the most complete, in the country for ensuring the safety of our parturient women. Although there is no Municipal Maternity Home included amongst the foregoing arrangements made by the Borough Council, the erection of a first-class Maternity Block which is going to be increased, in the West Middlesex County Hospital, provides a service which otherwise would become the duty of the Borough Council. DENTAL CLINIC. The following is from the Dental Surgeon's Report for the year:— MATERNITY & CHILD WELFARE DENTAL SCHEME, 1933. General Comments. Supply of Cases.—There was a slight increase in the number of patients dealt with, and appointments show an increase from 1,150 in 1932 to 1,524 in 1933. Net attendances increased from 925 in 1932 to 1,116 in 1933. 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. Comparative figures :— Year. Mothers. Children. Total. Appointments were 1931 412 416 828 1932 652 498 1150 1933 717 807 1524 Attendances were 1931 338 373 711 1932 491 434 925 1933 548 568 1116 Mothers. Permanent teeth. Children. Deciduous teeth. Total. Fillings 30 249 279 Extractions— Gas 344 465 809 [842 Local Anaesthetic 10 23 33 Dentures supplied to mothers. Year. Uppers. Lowers. 1932 37 5 1933 42 34 The number of individual mothers supplied with dentures during 1933 was 40. 46 Special Dental Cases Requiring In-Patient Treatment. The arrangements with the Royal Dental Hospital for dealing with special cases requiring multiple extractions was fully set out in last year's Report. Our thanks are again due to the Royal Dental Hospital Authorities for their valuable help in this branch of the work. During the year 1933, 12 cases received In-Patient Treatment through the Hospital under this scheme. With regard to nursing mothers, the scheme failed to come to fruition, due to the fact that the Hospital Authorities would not take in the child with the nursing mother unless it was regarded as a separate patient occupying a separate bed. It was impossible to move them from this attitude, thus the scheme came to nothing. The whole essence of the idea was that the child should be kept on the breast. Notification of Births. Number of live births notified during the year .. .. .. .. .. 1,287 Number of still births notified .. .. .. .. .. .. .. 42 Notified by midwives .. .. .. .. .. .. .. .. 897 Notified by parents or doctors .. .. .. .. .. .. .. 432 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. We miss the co-operation which we have had for years from Dr. Sydney Owen, but I should like to place on record the way in which his successor, Dr. Copeman, has filled the place from the point of view of the medical cases, and also want to place on record my thanks to Mr. C. Jennings Marshall, M.S., F.R.C.S., both at Charing Cross Hospital and at the Victoria Hospital for Children, for the splendid work, and to the many others who help me in the various hospitals to bring health and happiness to the little ones for whom I am responsible. The Isleworth Nursing Association and the Osterley, North Hounslow and Heston Nursing Association are the only Voluntary Societies in direct contact with the Council's Maternity and Child Welfare Scheme. Special mention must be made of the 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. Northcote, Mrs. Goff, Mrs. Buchenham, Mrs. Clear, Mrs. Merritt, Mrs. Hartley and Mrs. Edwards at the Hounslow (Douglas Road) Centre ; Mrs. Hugier and Mrs. Kilby at the Ante-Natal Clinic ; Mrs. Killick, Mrs. Short, Mrs. MacDonald, Miss G. Quarterman, Mrs. Hunt and Mrs. Clarke at the Hounslow (Clipstone House) Centre ; Mrs. Chedgey, Mrs. Watson, Mrs. Newman, Mrs. Jones, Mrs. Major, Mrs. Gibbs, Mrs. Lambert, Mrs. Sands and Mrs. Wright at the Isleworth Centre ; Mrs. Ardley, Mrs. Griffiths, Mrs. McDonald, Mrs. Rose, Mrs. Dowling, Mrs. Wolton and Mrs. Fletcher at the Heston Centre. At Clipstone House it has been the custom for the mother in better circumstances to provide the layette and useful baby clothing for the expectant mother who has found it a difficult matter owing to unemployment of the husband, etc. VOLUNTARY SOCIETIES AND HELPERS. 47 Details of work 1933-1932. 1933 1932 No. of patients 370 335 Fillings 279 308 Referred for Gas 170 132 Extractions—Local anaesthetic 33 23 do. General anaesthetic 809 632 Administrations of General anaesthetics 256 217 Advice 83 46 Treatment postponed 31 32 Refused to submit, wait, etc. 11 10 Dressings 16 15 Impressions taken 90 121 Charting and Estimating 129 79 Silver Nitrate Treatment 63 44 Dentures eased 15 21 Scaling and polishing 12 16 I. COHEN, L.D.S., R.C.S. (Eng.), Dental Surgeon. Home Visiting.—The visits by the Health Visitors in connection with the Maternity and Child Welfare Work are shown in the following table:— 1929 1930 1931 1932 1933 1st visits to babies under 1 year 1304 1395 1472 1520 1346 Routine Re-visits to babies and children up to 5 years 4311 3982 4190 3210 4720 Inquiries made, elicited— Feeding—Natural 887 980 1105 1135 1093 Artificial 44 77 64 95 77 Both 32 56 51 44 36 Sleeping with parents 277 260 247 154 126 Using comforter 168 195 217 175 170 Mother working during pregnancy 48 53 44 29 48 Year 1933. Other visits. Post-natal 16 Measles and German Ante-natal—First visits 123 Measles 10 Subsequent visits 38 Whooping Cough 64 Children Infants' Deaths and Stillbirths, Visits paid 81 Mumps under Chicken Pox 22 5 years. Ophthalmia Neonatorum and Discharging Eyes 123 Pneumonia 15 Bronchitis 27 Infantile Diarrhoea .. 3 Milk and food cases 53 Puerperal Fever and Puerperal Pyrexia .. .. 15 Home help 32 Infant Protection Visits 783 Social conditions 131 Summary of Nurses' Visits. Total to expectant mothers 161 „ children under 1 year of age 3919 „ children between the ages of 1 and 5 years 3527 Visits re Public Health matters, infectious diseases, tuberculosis, etc. 418 Total 8025 Health Visitors' attendances at the Maternity and Child Welfare Centres, Ante-Natal Clinics, etc., 689. Health Visitors' attendances at Diphtheria Immunisation Clinics, 89. Home Help for Mothers.—The Home Help paid 52 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 Is. 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 101 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— 4s. per head Free. 4s. to 5s. per head Parent pays one-third cost. 5s. to 7s. 6d. per head Parent pays two-thirds cost. Where the amount is over 7s. 6d. per head, no grant is made. The number of grants made during the year was 1,052, against 831 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. 48 New Milk Scale.—Towards the end of the year, as a fairly large proportion of applicants had to be treated as special cases, to assist them sufficiently it became apparent that the scale needed reconsideration. The Committee favour a more generous scale which will probably come into operation next year. OPHTHALMIA NEONATORUM, Year 1933. Cases. Vision Unimpaired. Vision. Impaired. Total Blindness. Removed from District and Deaths. Notified. Treated. At Home. In Hospital. 11 7 4 9 — — 2 An agreement exists with the London County Council for the admission of cases of Ophthalmia Neonatorum to St. Margaret's Hospital when necessary. 49 Borough of Heston and Isleworth Education Committee TWENTY-SIXTH ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR ENDED 31st DECEMBER, 1933. CONTENTS. Arrangements for Treatment 11, 34 Blind children 25, 31 Co-ordination 7 Deaf children 25, 31 Deformities 30 Dental defects and treatment 9, 15, 35 Dental Surgeon's Report 16-19 Ear disease and hearing 9, 15, 29 Emergency Dental Cases 19 Epileptic children 25, 32 Eye defects 9, 12, 13-15, 29, 34 Findings of medical inspection 7, 29, 30 Following up 10 Health Education 28 Heart Disease and Rheumatism 9, 23, 30, 32 Infectious disease 23, 24 Malnutrition 11, 29 Medical inspections 7, 29 Medical treatment 11, 34 Mentally defectives 25, 31, 33 Minor ailments 9, 11 Nose and Throat defects 9, 15, 29, 35 Nurses' work in schools 10 Occupation Centre, see under Miscellaneous on page 28 Open Air Education 24 Orthodontic work (Report of the Orthodontic Consultant) 20-22 Orthopaedic and Postural defects 9, 23, 35 Parents, Co-operation of 25 Parents' Payments 27, 28 Physical Training 25 Prosecutions 11 Provision of Meals 25 Ringworm 12, 29 Scholarship children, see under Miscellaneous on page 28 School Attendance Officers, Co-operation of 25 School Clinics, see under Minor Ailments on page 11 School hygiene 7 School Nurses' work 10 Schools in the Area 6 Skin diseases 9, 11, 29 Special Enquiries 28 Spectacles 13, 34 Staff 5 Statistical tables 29-35 Teachers, Co-operation of 25 „ Medical Examination of, see under Miscellaneous on page 28 Tonsils and Adenoids 9, 15, 29, 35 Tuberculosis 9, 23, 30, 32 Uncleanliness 11, 35 Visual defects and External Eye disease 9, 12, 13-15, 29, 34 Voluntary Bodies, Co-operation of 25 To the Chairman and Members of the Borough of Heston and lsleworth Education Committee. Ladies and Gentlemen, I beg to present the Annual Report of the School Medical Service for the year ended 31st December, 1933. I wish again to express my thanks to the members of the Committee for the kindness and support they have shown me. I am, Ladies and Gentlemen, Your obedient servant, ELWIN H. T. NASH Members of Education Committee Alderman G. R. SPEED (Chairman). Alderman A. A. BERGIN, J.P. (ex-officio). Alderman H. G. BODY. „ H. J. NIAS, M.B.E., J.P. (Vice-Chairman). „ A. A. WHITE. Councillor H. BAKER. J. FARMER. A. J. FIELDER. „ F. T. HART (ex-officio). E. W. HEATH, J.P. A. L. LANG. C. L. LEWIS. Councillor J. MACKIE. R. H. MANNING. D. RHYS. G. N. SHACKLETON. D. J. THOMAS. R. WRIGHT. Co-opted Members— Miss E. A. ANKRITT. Mrs. E. E. BERGIN. J. B. MADDEN, Esq. F. E. KINSEY, Esq. D. McDONALD, Esq. School Medical Officer— ELWIN H. T. NASH, m.r.c.s., l.r.c.p., d.p.h. STAFF School Medical Officer— ELWIN H. T. NASH, m.r.c.s., l.r.c.p., d.p.h. Deputy School Medical Officer— Mrs. EVA LOUISE ROBERTS, m.b., ch.b., d.p.h., Barrister-at-Law. Assistant School Medical Officer— VICTOR FREEMAN, m.r.c.s., l.r.c.p., d.p.h. Dental Surgeons—I. COHEN, l.d.s., r.c.s., eng. H. F. METCALF, l.d.s., r.c.s., eng. (Part time). (Left 31st December, 1933). Orthodontic Consultant—H. R. EVANS, l.d.s., r.c.s., eng. Orthodontic Demonstrator, Children's Department, Royal Dental Hospital. Radiographer—D. ARTHUR, m.d., d.p.h. Health Visitors and School Nurses— Mrs. C. E. M. OTTLEY, Cert., c.m.b., h.v. and s.n., m.c.w.w. Miss B. N. TETLEY, s.r.n., Cert., c.m.b., New Health Visitor's Diploma of the Royal Sanitary Institute. Mrs. A. E. TYRRELL, Cert., c.m.b., h.v. and s.n. Miss M. G. GRIBBLE, A.R.R.C., s.r.n., Cert, c.m.b., h.v. and s.n. 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. Miss G. F. RICHARDSON, s.r.n., Cert, c.m.b., New Health Visitor's Diploma of the Royal Sanitary Institute. Mrs. G. PRISSELL, s.r.n., Cert, c.m.b., h.v. and s.n. Miss B. P. MANNING, s.r.n., Cert, c.m.b., a.r.s.i., New Health Visitor's Diploma of the Royal Sanitary Institute. Clerical Staff— B. W. KILBY (Chief Clerk). Miss R. MARSHALL. P. T. H. CRANDON. K. I. BISSHOPP. H. J. ALDHOUS. F. V. BELL. E. E. FORREST. Miss D. M. DOWLING. Miss V. D. NICHOLLS. R. MOORE. T. C. WREN. (Commenced Feb., 1933). 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—Miss I. M. TOMES. Junior Dental Clinic Clerk Attendants—Miss M. R. MABBS. Miss C. J. JOTHAM. Dental Mechanic (part-time)—T. CHENEY. (Commenced, April, 1933). 5 ELEMENTARY SCHOOLS IN THE AREA. School. Department. * Accommodation. Average. Number on *Registers. Alexandra Boys' 428 407 „ Girls' 388 435 Berkeley Junior 400 405 Brentford End Infants' 91 100 Bulstrode Senior Boys' 480 570 „ „ Girls' 480 547 Chatsworth Infants' 400 363 Grove Road Boys' 326 315 „ Girls' 326 341 „ Infants' 368 27S Heston Senior Mixed 400 362 „ Junior Mixed 390 373 „ Infants' Infants' 203 222 Hounslow Heath Boys' 494 580 „ Girls' 398 490 „ Infants' 340 473 Hounslow R.C. Mixed and Infants 30 296 Hounslow Town Junior Boys' 334 306 „ Junior Girls' and I 488 428 Isleworth Blue Boys' 177 192 „ Girls' and Infants 284 210 Isleworth Town Junior Mixed 460 543 „ Infants' 428 406 Marlborough Senior Mixed 600 696 St. Mary's R.C. Boys' 180 147 „ Girls' and Infants' 226 202 Spring Grove Central 392 331 „ Junior 240 251 Woodlands St. John's Infants' 75 59 Worple Road Junior Mixed 260 242 „ Infants' 250 226 Total 10636 10793 Numbers as at December, 1931 9448 9256 Numbers as at December, 1932 10611 10120 *These numbers are far December, 1933. Since December, 1930, the number of children attendingelementary schools in this district has increased by 2,500, 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 and Dr. Freeman are engaged in school medical work as well as the other health services. This applies also to the nursing and clerical staff, so that co-ordination of all the services is complete. The popularity and success of our Maternity and Child Welfare 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 ten sessions weekly. Children may attend these Centres until they reach school age, and upon the recommendation of the Medical Officers, may, before they reach school age, attend the School Clinics for treatment of visual and dental defects and minor ailments. X-ray treatment for Ringworm can also be arranged. 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. All effort 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. More and more children are being brought to the Dental Clinic by their parents from the Maternity and Child Welfare Centres demanding attention to their teeth, but it is almost without exception the same story. The parents bring the child up because the child is in pain; not because the teeth have decayed, and it is amazing how many of the parents when questioned, admit that it was not so much the child's dental trouble that brought them up but their own loss of rest at night consequent on it. 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. During the year under review however there were no special efforts made for critical reporting on the matters under the headings detailed in the memorandum Form 6M. (Schedule) from the Board of Education, issued as a guidance for the Reports of School Medical Officers on the year's work. It may be stated however that there are no official arrangements for drying children's clothes or boots other than spreading them in the recognised cloakrooms. 4.—MEDICAL INSPECTION. 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. Every school in the Borough has been visited twice by a Medical Officer during the year— once for a routine medical inspection, and subsequently for the re-examination of children who had been found to need treatment or observation. The total number of routine medical inspections carried out during the year was 3,586. The number inspected in 1932 was 4,057, but in spite of the decrease in 1933 it has been necessary to engage extra medical assistance regularly throughout the year. The pressure in all other sections of School Medical Work, particularly in the School Clinics, has continued unabated, and the Authority's Medical Officers have been quite unable to cope with the requirements, even by cutting down the lunch interval sometimes to a matter of minutes, and prolonged afternoon sessions. 7 Disturbances of School Arrangements. No one supposes that the ordinary school curriculum is not disorganised to some extent bv the needs of medical inspection especially where all the available accommodation is required lor educational purposes. The Head Teachers of the district, however, are to be congratulated upon the arrangements they make under such difficult conditions, and I Should like to place on record once again my appreciation of the fact that the inspecting Medical Officer is always made as comfortable as circumstances permit. 5.—FINDINGS OF MEDICAL INSPECTIONS. (a). Malnutrition. Malnutrition in the full sense of the word again shows the small figures I have drawn attention to on previous occasions, but sub-normal nutrition is still as manifest as ever. Some slight index of this may be found in the number of children who have been passed as suitable for Milk Meals at school, but even this does not give a full picture of all the cases of subnormal nutrition. It is interesting to see how throughout the Country the number of Medical Officers who are now beginning to call attention to sub-normal nutrition is steadily growing. In order to find a possible way out, I have been for some time trying to obtain a grant in order to carry out some Research Work by way of translating the Nutritional Committee's findings into practical politics as far as the poorer members of the community are concerned. Much of this sub-normal nutrition is not due to deficiency of wages or relief, but is due to ignorance or crass stupidity. During the year the Carnegie Trustees have voted me a grant of £500 for research in this direction which I hope may make available some figures and facts which will help the class of individuals one is referring to. At the same time one realises only too well the amazing difficulty one is up against in attempting to take this section of the population out of their dietetic ruts, many of which are habits of generations. 1 have been criticised severely, and I am still being criticised, because I have said repeatedly, and still persist in saying, that the teaching of cookery in the schools is largely responsible for the present condition of unsatisfactory nutrition. Let me say at once, this is not the fault of the schools but the system they have to work to. It must be remembered in mitigation of their trouble that they are primarily educational and therefore have to work to a syllabus; there is some elasticity, but unfortunately not enough. The difficulty is that the cost of the dietetic base line used in teaching is too high. Anybody who has had to deal with catering in any way, or run a household, knows how damnably difficult it is, if wages are reduced, to cut the cost, say 10s. a week, and how very much easier it is if wages go up, to amplify, and for that reason, if the base line and expenditure is high to start with it makes it very much more difficult than if the base line is lower, as this can be added to when there is any increase in wages. As long ago as before the War I raised this point of the base line. As I put it then " Many of the children who are being taught to cook in terms of three pounds a week will never handle more than twenty-five shillings a week as long as they live." I have been accused of wanting to depress the living conditions of the poorer classes. There is nothing further from the truth than this accusation. The facts being as they are, and seeing what I do, it seems to me imperative, so long as economic conditions remain as they are, to do whatever lies in one's power to enable those with very restricted incomes to make the best use of their incomes, because in my experience so much of their inability to use the income they do receive is the result of dietetic ignorance. (b). Uncleanliness. The number of cases discovered at routine medical inspections was 107, and special medical inspections at the Clinics revealed a further 801 cases. Five hundred and twenty-six children were excluded from school during the year on account of nits or vermin. 8 (c). Minor Ailments and Diseases of the Skin. A total of 357 cases of various skin diseases were reported during the year, and, with the exception of 16 cases, all were referred for treatment. As usual, impetigo was the commonest disease. Table II. shows that there were 150 cases of " Other skin disease; " these include such conditions as eczema, alopecia, seborrhoea, etc. (d). Visual Dcfects and External Eye Disease. Routine medical inspections revealed 200 cases of defective vision, 166 being referred for treatment. Eighteen cases of squint were also discovered, 17 being referred for treatment. At the Special Clinics, 116 cases of defective vision and 15 of squint were referred for treatment. Sixteen cases of minor disease of the eye, 11 of which were blepharitis, were discovered at routine medical inspections. In addition, 183 cases, including 18 of blepharitis and 48 of conjunctivitis, were discovered at the Special Clinics. (e). Nose and Throat Defects. Three hundred and twenty-five children were found to be suffering from chronic tonsillitis, and of these 146 were referred for operation. Seventeen children had Adenoids only, 11 being referred for treatment and 6 for observation. In a further 218 cases both conditions were present, 111 children being referred for operation and 107 for observation. (/). Ear Disease and Defective Hearing. Amongst children examined at the routine medical inspections, 54 cases of defective hearing were found, 26 of these being referred for treatment. Twenty-five cases of ear disease were also discovered, 24 being referred for treatment. Special examinations at the Clinics account for 22 cases of defective hearing; and 156 cases of ear disease. (g). Dental Defects. One thousand one hundred and ninety-one cases of dental caries were discovered at routine medical inspection, and a further 141 cases were found by examination at the Special Clinics. At the routine dental inspections in the schools, a total of 2,429 children were found requiring treatment. Table IV on page 35 gives further statistics in this connection. See alsc Statistical Table on page 18. (h). Orthopaedic and Postural Defects. One hundred and thirty-three 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 ot slight spinal curvature and flat feet. (i). Heart Disease and Rheumatism. Twenty-one cases of heart trouble were found during the year to need treatment, whilst 92 cases were marked for observation. (j). Tuberculosis. Routine medical inspection failed to reveal any case or suspected case of Tuberculosis this year, but one case of Tuberculosis of the glands was discovered during special inspections. 9 (k). Other Defects and Diseases. Twenty-five defects, found during routine medical inspection, which could not be classified under any other heading in Table II were referred for treatment. These show a wide range of troubles, and include such conditions as Hernia; Enuresis; Minor Injuries; and two cases of Obesity. The number of "other defects and diseases" found as a result of special inspections was 1,302. Of these, 1,270 were referred for treatment. They were almost entirely minor injuries. 6.—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 659 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 1933. Attendances. Routine Medical Inspections ... ... ... ... ... ... ... ... 204 Re-inspections ... ... ... ... ... ... ... ... ... ... 37 Eye Clinics 117 Minor Ailments Inspection Clinics (with Medical Officer) 172 „ „ Treatment Clinics 957 Dental Clinics ... ... ... ... ... ... ... ... ... ... 558 Cleanliness Surveys 65 Cleanliness Qinics 57 Other Attendances (Special Clinics, Med. Exam, of Teachers, School Sports, etc.) 37 10 Visits. Re Infectious Disease 2504 Re Clinic Absentees 155 Following up 659 Other Visits 195 7.—ARRANGEMENTS FOR TREATMENT. (a). Malnutrition. During the year the Committee formulated and adopted a scheme for the provision of milk at school for undernourished children. Further reference to this will be found under " Provision of Meals," page 25. This scheme has not been running long enough to show any reliable results. Next year however, we shall be in a position to judge the effect. Cod Liver Oil and Malt is sold at cost price at the School Clinics for children recommended by the School Medical Officer. (b). 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 9,855, compared with 8,724 in 1932, 6,774 in 1931, 4,211 in 1930, and 782 in 1929. Number of visits to schools by Nurses 69 Total number of children examined 9855 „ „ „ „ given warning notices 636 „ „ „ „ excluded as verminous 40 1. (Few) 506 Found to have nits— 2. (Bad) 108 3. (Very Bad) 22 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. One hundred and one children were cleansed by Mrs. Yates during 1933 During 1933 it was found necessary to take legal proceedings in 7 cases, with the following results:— Five cases Fined 5/- each. Once case Fined 10/- One case ined 10/- and ordered to pay costs. (c). Minor Ailments and Diseases of the Skin. 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. 11 The Clinics are open at 9 a.m. every week-day throughout the year for the treatment of minor ailments at the following centres:— Hounslow—Clipstone House, 92, Bath Road. Heston—The Village Hall. Isleworth—The Public Hall. A Medical Officer attends the Clinics on the following days:— Hounslow—Tuesdays and Fridays, at 10 a.m. Heston—Thursdays, at 10.30 a.m. Isleworth—Mondays, at 10.30 a.m. Cases are referred to the Clinics from school medical inspections, or are sent in by Head Teachers, School Attendance Officers, and Health Visitors. The majority of the cases, however, are sent in by Head Teachers, who doubtless realise the value of prompt treatment in maintaining a good school attendance. 1,049 cases of minor injuries, bruises, sores, chilblains, etc., and 293 cases of skin disease, were treated during the year at the School Clinics. 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 1933 2,914 10,225 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 Medical Officer in charge of this Clinic can spare, and really a further half-day session per week is indicated. Ringworm of the Scalp. Fifteen cases were treated by X-ray under our arrangements with Dr. Arthur (of Ealing) during 1933. 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 (d). Visual Defects and External Eye Disease. Five hundred and eighty-one cases were submitted to refraction, compared with 537 in 1932, 531 in 1931, 443 in 1930, 413 in 1929, 297 in 1928. Spectacles were prescribed in 569 cases and obtained before the end of the year in 559 cases. 12 The following figures show the increase Clinics by Medical Officers:— in the number of special examinations at School Year. Total number of Special examinations and Re-examinations by Medical Officer. 1930. 2,532 1931. 3,534 1932. 3,802 1933. 3,957 Eleven other cases were treated by private arrangement of the parents, and spectacles were obtained in all cases. A total of 148 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. In the early part of the year the Hospital Saving Association offered an arrangement whereby the Association would be responsible for a portion of the cost of spectacles prescribed for members' children. Anything that would be an aid in obtaining the treatment prescribed for any of our school children is always welcomed, and since May we have been able to accept Hospital Saving Association vouchers in connection with the supply of spectacles, and for the change of lenses when such is due to a variation in a child's vision. The repair of spectacles is excluded from the scheme. The value of the voucher varies, as shown below:— Type and cost of spectacles. Value of voucher. Heavy Nickel ... 4/6 2/3 Rolled Gold 8/- 3/9 Rolled Gold and Shellite 9/6 3/9 Cost of lenses. One lens 1/10 11d. Two lenses 3/3 1/8 I am indebted to Dr. Roberts, who is in charge of the Refraction Clinic, for the following report:— VISION AND THE REFRACTION CLINIC. For many years there has been a steady annual increase in the work done at the Refraction Clinic and the figures for 1933 show that this increase is still maintained. It has been necessary to supplement the usual two Clinics weekly by a third whenever the waiting list has been unduly long. Two thousand, two hundred and eleven appointments were made and the attendances numbered 2,090, giving a percentage attendance of 95 for the whole year. This is not only a higher number of appointments than in any previous year but is also a record attendance figure. This attendance gives cause for real satisfaction as it shows that the constant and patient work of educating parents in the importance of conserving children's vision is bearing a rich harvest. The attendance figures for the past four years have been consistently good and give a percentage for four years of 93.75. 1930—1,578 appointments with 93% attendance. 1931-1,785 „ „ 93% 1932—1,944 „ „ 94% 1933-2,211 „ „ 95% Refractions. Five hundred and eighty-one children were submitted to refraction compared with 537 in 1932. Spectacles were prescribed in 569 cases and 559 of these received spectacles by the end of the year. It will be noticed that the attendance figure of 2,211 is large compared with the number of refractions, viz:—581. Normally, each child for whom spectacles are prescribed attends three times, once for the preliminary examination and to receive the atropine, once for refraction and lastly to be examined wearing the spectacles prescribed. The remaining appointments are due to the following-up of children by re-examination. The parent of every child receiving spectacles is notified in a year's time that the child should be re-examined in order to see if the spectacles are still suitable. A consent form for this re-examination is enclosed and many parents avail themselves of this opportunity. In a number of cases refraction is unnecessary. Special cases such as progressive myopes are seen at shorter intervals such as 6 or 3 months, and children receiving special instructions for squint or allied conditions may be seen at monthly intervals. This re-examination of children adds considerably to the work of the Clinic but is absolutely necessary if permanent benefit to vision is to be obtained. It is to be regreted that lack of time prevents the further following-up of those children whose parents ignore the re-examination notice. 13 Use of a + 1 Sphere before the Reading Eye in the Routine Vision Testing of Children in School. Last year I gave a detailed report of this procedure during the year 1932, having reported in 1931 on results obtained by two months' use of this test in that year. It will be remembered that the Committee of Inquiry into Problems connected with defective Vision in School Children issued a Report in 1931 in which the above procedure was advocated as a means of picking out early myopes who would otherwise be overlooked by the ordinary Snellen Long Distance Test. Roth my reports were concerned solely with those children who, without spectacles, read either 6/6 or 6/9 with the Snellen Long Distance Test, and who had no signs of eye strain. The results obtained showed that a large number of children had their vision adversely affected by placing a +1 sphere before the reading eye (90% in 1932), but refraction alone would have showed whether such children were emmetropic or suffering from slight hypermetropic astigmatism or slight myopia. Refraction of such a large number of children is impossible in routine work and therefore this new procedure offered no help in the detection of early myopes. Under 1% of the 1932 children (25 in number) had their vision reduced by 5 or 6 Snellen lines and 20 of these were refracted, showing slight myopia and slight hypermetropia combined in many cases with an astigmatism of 0.25 diopter. In three cases only were spectacles prescribed, two of these showed signs of eye strain, and the third had a deterioration of vision, not apparent when the child was tested eight months previously. It was decided therefore to follow up the remaining 17 cases and to continue using the +1 sphere in the routine vision testing during 1933 and to mark for observation any cases whose vision was diminished by 5 or more Snellen lines. Results of following up 17 Children whose Vision at the Routine Medical Inspection in 1932 was diminished by 5 or more Snellen Lines when reading through a + 1 Sphere. Five children had left before another Inspection or Re-inspection took place at their school. Eleven children have been re-examined and in all cases their vision remained satisfactory and there were no symptons of strain. One boy was absent from school and has not been seen. The three children for whom spectacles were prescribed were placed on the Refraction Clinic Register and will be called again to the Clinic in twelve months. In 1933 there were only two children whose vision was diminished by 5 Snellen Lines when a +1 sphere was placed before the reading eye Both were girls aged respectively 12 and 13. The latter, aged 13, is at the Central School where children are examined annually and is one of the seventeen children who were followed up from 1932. Both girls have been re-examined and their vision remained satisfactory. In the light of the results obtained since November, 1931, by the use of a +1 sphere before the reading eye in the routine testing of vision of school children, it would appear that this procedure fails to detect early myopia. It entails a considerable addition to the work, and since its results are inconclusive it has been decided to discontinue its use. Refraction of all children seen at the Routine Medical Inspection is the only sure way of detecting early myopes, but such a large increase of work is impossible with the present staff of the School Medical Service, neither is universal refraction desirable on account of the unnecessary interruption of school work to numbers of children who would be found to need no spectacles. It is also a debatable point as to whether small errors, even though myopic, should be corrected in children with good vision and no symptons of strain. I feel strongly that spectacles should not be prescribed in such cases although it would be advisable to follow up such children. The Snellen Long Distance Test combined with an enquiry into any symptoms of eye strain is a useful and sufficiently reliable means of weeding out children who need further examination by refraction. Under the present system, however, children are only tested at three or four year intervals, during which time defects may manifest themselves and often escape detection by parent or teacher. I am of opinion that the most useful reform in the routine vision testing of school children would be to increase the frequency of these tests. 14 Children should be tested at least annually. This would entail an increase in work, but one which should be possible as it could be carried out by competent nurses, without the intervention of Medical Officers. At present, in this Borough with its largely increased and increasing population, we cannot embark on additional work of this kind, but I look forward to the time when we may be able to put it into practice. E. L. ROBERTS, Deputy School Medical Officer. (e). Nose and Throat Defects. Four hundred and five children were referred for treatment on account of Nose and throat defects. Of this number, 130 were operated on under the arrangements made by the Authority with the Hounslow and Richmond Hospitals in 1921, 37 received operative treatment by private arrangements of the parents, and 26 cases received other forms of treatment. Our methods of arranging operative treatment for tonsils and adenoids 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 whch 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 operation. 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 Hospital Saving 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. (f). Ear Disease and Defective Hearing. One hundred and ninety-nine cases of ear disease or defective hearing were dealt with at the school clinics, and 7 were treated by private arrangement of the parents. Dr. Roberts reports that the use of B.I.P. Paste in the treatment of Otorrhoea has been continued during 1933 and that this year's results have confirmed the good opinion of it expressed in her Special Report in 1932. It has become the routine treatment in the two School Clinics under her charge and is extensively used in the third under the Assistant School Medical Officer, Dr. Freeman. In a very few cases B.I.P.P. has not appeared suitable as in these the paste has formed a dark compound which has irritated the tissues. Such cases have been put on Rectified Spirit with Boric insufflation and have done well, healing in a shorter time than cases previously treated with Rectified Spirit and insufflation only, so that it would appear that some benefit is obtained by the initial use of B.I.P.P. even in cases where its continued use is not advisable. (g). Dental Defects. The work in the Dental Section has been one of progress on the one hand.and retrogression on the other, or rather lack of progress due to the fact that our Dental Department is like a plant which is choked by weeds, owing to the lack of accommodation which makes expansion of the work impossible. The Isleworth Clinic so long visualised but so long delayed by various matters is responsible for holding up the work urgently required to cope with the increase in the school population. At long last there seems a probability of something evolving in the new area in the way of Clinic premises, even of a temporary character to deal with the ever increasing demand at Isleworth for adequate facilities for that end of the district. 15 The progress of the Orthodontic Work under Mr. Evans' guiding care is all that can he desired. Mr. Evans has absorbed the Public Health spirit and from the amount he gets through, his work might almost be classed among the sweated industries, as his morning sessions average some 65 cases. This may seem appalling at first sight, but when it is realised how rapidly these cases can be visualised and the treatment dictated to the stenographer at the chair side, it will be realised that this is not as formidable as it appears, but it is too much. Let me here draw attention to the way in which the amount of work is got through. In the same way it takes an amazing number of accessory units to keep the firing line going in an army, so in organising work such as this it must be realised that value for money is obtained best if the spear head of the attack on dental disease (that is the Dental Surgeon) is saved every kind of work except that of making the expert decisions for which he is appointed. I find that in the various Clinics I have seen the Dental Surgeon's time is so often taken up with doing work which could be just as well, if not better, done by a Junior Clerk at a salary of say, £80 per year, whilst the highest paid professional officer could be left available for the work which he alone can do. I am convinced by what I have seen that one of the crying needs of the Dental work throughout the country is the provision for the Dental Surgeons of adequate clerical assistance so that he can get on with the work which he is really appointed for. As year after year goes by so we receive complaints from a certain small section of the parents with regard to the time they have to wait in the Dental Waiting Room. It does not seem to matter what appointments one makes, certain parents seem to have no morals whatever with regard to the keeping of their appointments. They will turn up an hour before their appointment time, full of hope that they will be able to elbow their way in front of someone else if they come early enough, and the fact that this is not allowed produces recriminations and scenes and ructions of various kinds in the Waiting Room before other parents. These same parents, if they paid a fee for the privilege of having their children's teeth attended to privately, would not mind waiting for an appointment in the Private Waiting Room of a Dentist they are paying. And the higher the fee they paid the more content they would be to wait without a grumble. But there is a certain small section who because an Officer draws his income out of the Rates feel that it is their peculiar prerogative to show, as they conceive it, their superiority as his master by kicking up a fuss if the Dentist's findings do not coincide with their ideas of the treatment needed and seem to take a malignant delight in metaphorically wiping their boots on an officer whom, as they generally put it in their letters of complaint " we pay for out of the Rates." Everything has been done to try and bring some kind of order, whilst at the same lime reducing as far as practicable the waiting time of the parents, realising that their time is like ours, valuable. The Dental Surgeon reports as follows :— During the year the pressure of the increasing demands of the Dental Scheme has continued. A third Dental Clinic Clerk Attendant was appointed in April to relieve senior officers of as much simple routine work as possible. There was some difficulty in getting the second whole time Dental Surgeon's post established, and in order to keep the work going at all efficiently a number of sessions had to be put in by temporary officers. 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. Inspections. . These have had to be cut down owing to insufficient staff in the first place, and it was also impossible to utilise fully the services of two Dentists working in one room. In view of this it was useless to inspect and bank up large numbers awaiting treatment when the condition of the children would differ considerably from the inspection finding when they eventually got appointments for treatment. 16 For this reason Inspections have only been carried on sufficiently to keep the Surgeons occupied to their full capacity, or rather their full capacity as conditioned by the limited accommodation. With regard to the Board's Table IV., Group IV. (Dental Defects, page 35), it should be noted that the number of "Specials," 1,646, 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 1,646 are made up as follows :— (1) Referred for Gas, or Gas and Ethyl Chloride 1043 (2) Advice given 441 (3) Treatment postponed 160 (4) Inspection after Gas—required further treatment 2 1646 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—5,227, which works out at 158 fillings per 100 children treated, whilst the number of permanent teeth filled— 4,657, works out at 141 permanent teeth filled per 100 children treated; the figure for the whole country averages 62 fillings per 100 children treated (Health of the School Child, 1932). Extractions. The number of teeth extracted was 5,094 (1,082 Permanent; 4,012 Temporary). With regard to the extraction of permanent teeth, the figure given in the Health of the School Child, 1932, is 31 permanent teeth extracted per 100 children treated. Our figure was 32 extractions of permanent teeth per 100 children treated. 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. 17 DENTAL INSPECTION AND TREATMENT—YEAR 1933. Average number of Elementary School children on registers at middle of year, June—10,557. Age. No. Remarks. 1. No. of children 5 296 (a) who were inspected at Routine Dental Inspections 6 319 7 259 8 204 9 262 10 262 11 357 12 343 13 351 14 67 15 25 2745 No. of Special Inspections 1646 (b) No. of Children found to require treatment at Routine Dental Inspections 2429 (b) This equals 88.5 per cent, of the children inspected at Routine Inspections. (c) No. of Children actually treated 3296 (c) In arriving at this figure each child is only counted once even though it attended several times during the year for treatment. 2. Half days devoted to Inspection 19 2. Average number inspected per session— 144. Treatment—Ordinary 586 Included in the 586 ordinary treatment sessions are 38 sessions which were entirely devoted to Orthodontic Treatment. do. Gas 122 Administration—Clerical 10 Dental Committee Meetings 6 743 These sessional figures are for 1 whole time dental surgeon and additional sessions by part-time Surgeon (see below). 3. Attendances made by children for treatment 8246 3. The gross attendances made by children at the Dental Clinic were 10,043, but children were not always physically treated, for various reasons, every time they attended. 4. Fillings— 4. The ratio of fillings in permanent teeth to extractions of permanent teeth was 430 fillings to 100 extractions. Permanent Teeth 4657 5227 Temporary Teeth 570 5. Extractions— Perm. Temp. 5094 At Treatment Sessioins 1 686 At Gas Sessions 1081 3326 Total 6. Administrations of general 6. The percentage of attendances for " Gas " 1,583 of total attendances 8,246 was 19.19. thetics 1583 7. Other Operations 2543 Staff responsible for the above work:— 1 Dental Surgeon Whole-time. 1 „ „ Half time. 1 Approved Dental Nurse. 1 Clerk Attendant. 2 Junior Clerk Attendants. (The second additional Junior Clerk Attendant took up duty from the 3rd April, 1933). Plus some clerical assistance from the Office of the School Medical Officer. Extra Staff for Gas Sessions only. 1 Anaesthetist (Deputy School Medical Officer). 1 Trained Nurse (Recovery Room). For orthodontic Sessions. Orthodontic Consultant—1 session per month. Dental Mechanic—Once a week. The 1,583 "administrations of general anaesthetics for extractions "represents the number of times gas was given, and not the number of sessions devoted to extractions under gas, which was 122. 18 Dentures for School Children. In four 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—2,543—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 249 Dressings 181 Scaling and Polishing Teeth 36 Treatment of Gums 30 do. by Drugs 1 Separating Teeth 7 Destroying the Pulp 10 Orthodontic Cases (Advice) 337 Impressions taken—Upper 412—Lower 392 804 Orthodontic—Appliances fitted 117 do. do. adjustments 317 do. Appliances repaired and progressive alterations 23 do. Cases reviewed 424 Dentures for School Children 4 Bites and Tries in 3 2543 Attendances made by Children for Treatment. The figure 8,246 shown in the Board's Table is not the gross figure of school children's attendances at the Dental Clinic, which was 10,043, all of which were nominally " attendances for treatment,"but, although making such attendances, only 8,246 were treated physically, the remainder being referred for gas, inspected, treatment postponed, etc., which latter classes of attendances were counted as special inspections. It will be seen that the number of attendances made by children for treatment was very much larger than in 1932. Emergency Cases. This branch of the dental service has now been running for four 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 1933, 695 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 1s. 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 1933 were as follows :— From School Children treated (ordinary 1s. fee) £135 10 0 From School Children (Orthodontic fees) £134 15 6 From Maternity and Child Welfare cases treated—1s. fees £16 16 0 I. COHEN, l.d.s., r.c.s., Eng. School Dental Surgeon. 19 ANNUAL REPORT OF ORTHODONTIC CONSULTANT. In submitting this report on the work carried out by the Orthodonic Section of the Dental Clinic during the year 1933, I feel that a favourable opportunity is presented to me to draw attention not only to the specific activities of the Section but also to put before you a larger and more comprehensive view of Orthodontic activity at Dental Clinics. I should like to indicate my views as to the future possibilities and worthwhileness of the Orthodontic Clinic generally— possibilities in which I have the profoundest faith and optimism; a worthwhileness which I am convinced merits the closest attention on the part of Public Health Authorities. It must be a matter of considerable pride as well as of importance to realise that the Orthodontic Section of the Heston and Isleworth Public Health Department represents the only such scheme now in operation which can claim the official recognition of the Board of Education. At its inception in 1930 and throughout the ensuing three years the Section was of necessity conducted in co-operation with the Royal Dental Hospital because with such a highly specialised branch of dental surgery it was essential for the patients receiving treatment to visit the Hospital and undergo a specialist's examination. The specialists could then submit a report on each case to the Clinic's Dental Surgeon who had entire charge of the subsequent treatment. The Royal Dental Hospital. At this point I should like to say how great is the appreciation due to the Royal Dental Hospital and the members of its staff who gave their opinions on the cases submitted. Without their assistance it would have been impossible to establish the Orthodontic Scheme on a satisfactory basis. I should like, moreover, especially to emphasise the indebtedness of the Clinic to the Hospital's Medical Registrar, Mr. E. Faulkner Ackery; only by reason of his personal interest and activities was it possible to interpolate the additional work emanating from the Clinic into the normal Hospital routine without causing grave inconvenience and delay to an institution already working at high pressure. In August, 1932, I was appointed Orthodontic Consultant to the Clinic. I am, therefore, now in a position to report on the progress of the Scheme, firstly, by reason of my early association with the organisation of the necessary arrangements carried out at the Hospital, and secondly, by reason of the very much closer contact I have established in the course of my duties since taking office with you eighteen months ago. It is my desire to examine the subject of Orthodontics in school clinics from the angle of Public Authorities, to consider the point of view of the recipients of the treatment, and to acknowledge the efforts of those who have contributed so much hard work in bringing the Scheme to fruition. Early Misgivings. I must admit that when I was first approached with a view to co-operation in the formation of a complete Orthodontic Scheme, I was inclined to the view that here was an attempt to attain the impossible. It seemed to me then that it would be impracticable to devote such time as Orthodontic specialisation would demand without interfering seriously with the ordinary routine dental work of the Clinic. The pessimism implicit in the foregoing misgivings may perhaps be excused when it is remembered that had first and foremost determined in my own mind to leave no stone unturned in order to carry the Scheme to a successful conclusion, should I eventually undertake the suggested programme. I did not intend to accept the responsibility of fostering so important a Scheme by merely dabbling on the fringe of the subject. Furthermore, it was apparent to me at the outset that in order to attain the success I wished for the treatment of malocclusion would have to be truly comprehensive and not merely selective as had been—and still is—the case at other Clinics. My goal was to be the assurance of adequate treatment for all applicants with but a single session per week. And this, I feared, would prove harder of attainment in practice than in theory. Doubts Unfounded. I am, therefore, happy to be able to inform you that as a consequence of my experience during the past year I realise that my initial outlook was altogether unjustified. I have in fact, been frankly astounded to find that such a large number of cases can be treated, and treated adequately, by devoting only one session each week to Orthodontics. It must be obvious that a very great deal of time and labour has been saved by the discontinuance of the earlier practice of sending every patient to the Royal Dental Hospital. Also, be it noted, the cessation of this previously inevitable course has resulted in relieving the parents of additional costs, and avoiding much loss of time to both child and parent. The Clinic is now able to deal with every case demanding Orthodontic treatment which comes to its notice; no patient need be refused. The fact that a large measure of success has been attained in every case serves to confound another argument sometimes put forward against the practice of Orthodontics at school clinics, I refer to the alleged inability on the part of the normal Clinic staff to carry out the essential instructions of the Consultant. The treatment of orthodontic cases is a speciality; yet I am glad to be able to place on record the fact that my instructions have invariably been followed to the letter, hereby contributing in no small measure to the steady continuance of success which has been a feature of last year's work. 20 Staff Efficiency. In Mr. I. Cohen, the School Medical Service has a dental surgeon who has proved invaluable in the furtherance of orthodontic treatment. His understanding of the subject, both practical and theoretical, is of a high order. I should like to offer Mr. Cohen my personal thanks for the very efficient manner in which he has attended to my instructions and supervised the work. He has offered me every facility for progressive and intensive Orthodontic treatment of the many patients coming through his hands. This, in conjunction with his willingness at all times, proves him indeed a valuable servant of the Borough. From the other members of the Clinic Staff, both professional and clerical, I am glad to be able to report not only a service of technical efficiency, but also a sympathetic appreciation of the problems encountered in the administration of Orthodontics at a School Clinic. Throughout the year I have observed the most friendly co-operation to exist between all members of the Staff. The National Viewpoint. I regard the particular activities of the Orthodontic Section of the Clinic during the past year as very valuable material when judged from the broader viewpoint of Clinic Orthodontic work as such. From the problems encountered and overcome by the Section there has, in my opinion, become available a wealth of practical experience which should prove of more worth in aiding the evolution of a possible National Orthodontic Scheme than any amount of erudite theories, however academically corect the latter might be. Proof has been obtained, for example, that the work of the Section has served as invaluable propaganda amongst the parents of the children attending the Borough schools It is, of course, an a priori necessity to obtain the consent of the parents before the child may be treated, and, simple as this sounds, there is no need for me to remind you that it is a procedure fraught with considerable difficulty. The idea, so firmly fixed in the minds of many parents, that cases of malocclusion or irregularities should be left alone for Nature to cure, is one of the hardest hindrances which have to be overcome. Since the Clinic has effected so many successful (and to the lay mind " spectacular ") cures, the barriers of indifference and prejudice are slowly breaking down. Indeed it has been brought to my notice on more than one occasion that the parents of successful cases have eventually given their ungrudging approval and appreciation of services rendered. Time will show whether this; greatly to be desired orientation of outlook on the part of the parents may be the prelude to a larger and more National conversion to the acceptance of the Orthodontic Scheme for this country. If feasible, and I sincerely believe it is, the inauguration of Orthodontic Clinics throughout the land will, in my opinion, bestow a direct and far-reaching benefit on the people of England. The results in this pioneer Borough are most encouraging and at the close of 1933 I look forward with confidence to the eventual extension of the Scheme on National lines. Objections Encountered. At this stage I think it is only fair to draw attention to the two main objections which are put forward by the opponents of the Orthodontic Clinic. These objections are :— 1. The treatment will involve loss of time for ordinary dental practice. 2. The treatment takes too much thought of appearance, i.e., the aesthetic principle predominates. Now I think that you will admit that objection No. 1, whilst being perhaps inevitably encountered in the theoretical and preliminary stages of the institution of an Orthodontic Clinic, will not have much validity in the light of practical experience such as has been afforded by last year's proceedings of this Clinic. I have already pointed out that the efficient way in which the Clinic have been able to handle a large number of cases throughout 1933 (and this with but one session per week), has occasioned me much pleasurable surprise. I have in fact found that the normal function of the Dental Clinic is in no way interfered with by the Introduction of an Orthodontic Scheme. The Aesthetic Problem. Objection No. 2, viz : that the protagonists of Orthodontics incline to attach too much importance to the improvement of appearance, involves rather deeper problems. In brief, I maintain that the Orthodontic view is that health rather than appearance should always be the aim, but that nevertheless appearance is a factor in life demanding considerable attention. My primary object in the treatment of all cases has been to render the individual a clean and healthy mouth, to equip the child with a normal and hygenic denture which will carry it through life without attracting innumerable allied complaints. The psychological effect of a more normal as opposed to a more abnormal denture is perhaps, more profound than one may at first imagine. But it should be obvious to anyone that the abnormal denture provides a very large loophole for the development of inferiority complexes in the unlucky patient. These complexes will be strengthened by the undeniable fact that on leaving school the child will discover that dental malformations are a very real handicap to a career. Employers nowadays pay quite an amount of attention to dental condition, and rightly so. 21 Malocclusion or irregularities predispose the individual to dental disease. This is a hard and undeniable fact, without any psychological complement; subsequent general ill-health assuredly comes the way of the unfortunate possessor of irregular dentures. Crowded teeth spell decay— that should be plain to all. Surely it must, therefore, be obvious that objection No. 2 cannot be put forward in any good faith. Public Health demands a healthy mouth for every child and this is the Orthodontist's primary concern. Aesthetic results are not denied importance—they are given secondary consideration. Treatment and Benefits. I have during the past year endeavoured wherever possible to employ the least amount of apparatus consistent with the Orthodontic treatment determined, and then only the simplest types of appliances. A prime consideration here is the matter of expense, but there is also the fact that my aim is always to prevent rather than cure. For this reason I consider it most desirable to treat the cases by judicious extraction at the right time, trusting in the powers of Nature to complete the preventitive process. This, I am convinced, tends to promote a healthy condition generally. All the appliances so far employed are of the removable variety, fixed apparatus is discouraged not only on account of its relatively higher cost but also because of the much greater time required for its adaption. If malocclusion can be treated by early attention, more serious after-developments are definitely less probable. Again, if deciduous teeth are unsaveable, the employment of splint plates subsequent to extraction goes a long way to prevent the travelling of other teeth and so avoids overcrowding at a later stage. Amongst the numerous ills attendant upon dental malformation is that of mouth-breathing, with all its undesirable consequences. In fact with certain forms of malocclusion mouth-breathing is a concommitant complaint. The ills by which the mouth-breather is imperilled are many and serious, and the great importance of early corrective Orthodontic treatment cannot be more clearly emphasised than in such cases. Remove the malocclusion and make normal lip-approximation possible and you remove the chief incentive to mouth-breathing. Normalise the denture first; then the breathing can be regularised by instruction. Future Developments. In looking forward to the coming year's work, there would appear to be every reason to suppose that the satisfactory results obtained by the Orthodontic Section to date will continue. I have already drawn attention to the useful propaganda effect that the Scheme has achieved, and the progressive enlargement of a sympathetic understanding outlook on the part of the parents will do much to ease the way for earlier and more complete treatment of suspect and developing cases. This will mean more patients to deal with and more treatments to carry out, but I have every confidence that those concerned will be ready and willing to handle as many cases as may come their way. The necessity for the installation of an X-ray apparatus at the Clinic has become more urgent, and I consider that the Council should give the matter their earnest attention. I know that the question of expense is no light one, but I would point out that such apparatus has several applications in other branches of the Clinic's activities, in which, indeed, it may in truth be as much needed as it is in the Orthodontic Section. In conclusion it seems to me that the experience gained from the working of this pioneer Orthodontic Clinic is of an entirely promising nature and warrants the assumption that the practice of Orthodontics in school Clinics throughout the country is wholly desirable and emminently practicable. My personal convictions carry me further, and I am convinced that a National Scheme is an absolute necessity to conserve the health of the Nation. If such a Scheme receives the recognition and approval of the Board of Education and is eventually adopted, the Nation as a whole will then be indebted to you in a very large degree. You have already incurred the gratitude of the Dental Profession both for your original conception of the pioneer scheme at this Clinic, and for making it possible for the preliminary plans to be put into practical operation. I look forward to the time when the Orthodontic Section of the Heston and Isleworth Dental Clinic will be acknowledged by similar clinics throughout the land not only as the leading spirit in such work but also as the continued model of success for all centres. ORTHODONTIC CASES. I now append details of the treatment of some typical forms of malocclusion which have been encountered at the Clinic. It should be borne in mind in looking at these illustration that in each case the age given is that at the commencement of treatment. H. R. EVANS, l.d.s., r.c.s., eng., Orthodontic Consultant. Orthodontic Demonstrator, Children's Department, Royal Dental Hospital. 22 Before Treatment. After Treatment. Before Treatment. After Treatment. CASE No. 1. Male. Age 8 7/\2ths. TYPE OF MALOCCLUSION. TREATMENT. The left upper incisor (above the tooth marked with a cross) in lingual occlusion. Left upper incisor advanced over lower incisors by means of vulcanite plate into which was inserted a screw. The parent was instructed to turn the screw a half turn every other day. This is a type of case frequently met with. The lower incisor marked with a cross was loose when the patient was first seen and the tooth was becoming denuded of bone. This is indicated in the photographs by the difference in the level of the gum margin before and after treatment. ■ - Before Treatment. After Treatment. Before Treatment. After T reatment. CASE No. 2. Female. Age 8 11/12ths. TYPE OF MALOCCLUSION. Supernumerary in upper incisor region. Labioversion of left upper incisor. Torsion of upper left second incisor. TREATMENT. Radiographs showed that there was only a single supernumerary tooth present. This was removed and the two displaced upper incisors brought into correct alignment by means of a vulcanite plate carrying stainless steel finger springs. Treatment took roughly 7 months. Before Treatment. After Treatment. Before Treatment. After T reatment. CASE No. 3. Female. Age 8 11/12ths. TYPE OF MALOCCLUSION. TREATMENT. Class 1. Protrusion of upper incisors. Upper incisors retracted by means of vulcanite plate carrying labial wire. Adjustments were made to the appliance roughly once a fortnight over a period of four months. The patient is now wearing the plate as a retainer. Before Treatment. After Treatment. Before Treatment. After Treatment. CASE No. 4. Female. Age 7. TYPE OF MALOCCLUSION TREATMENT. Class II Division 1. Inferior Retrusion with Secondary Proclination of the upper incisors and Close Bite. When this child was first seen in April, 1932, an operation for Tonsils and Adenoids was advised in order to give the patient a clear nasal passage and thus assist in curing the mouth breathing. The upper arch was then expanded by means of a Badcock plate to which was attached a labial retraction wire. This plate also served as a biting plate to raise the bite. The effect of expanding the arch has been to allow the mandible to come forward of its own accord and the teeth are now in normal occlusion. The patient is at present wearing a retention plate. There is every reason to assume that the mandible will remain in the forward position. The child's profile is, incidentally, greatly improved. Before Treatment. After Treatment. Before Treatment. After T reatment. CASE No. 5. Female. Aqe 9 1/12t/t. TYPE OF MALOCCLUSION. Class II. Division I. Inferior Retrusion with Secondary Proclination of upper incisors. Open Rite and Retroclination of lower incisors due to thumb sucking. This patient is a sister of Case 4. TREATMENT. The parent was instructed how to stop the thumb sucking. The lower incisors were then advanced by means of a vulcanite plate into which screws were inserted, the parent being instructed to turn the screws a half turn every other day. The subsequent treatment was to expand the upper arch and retract the upper incisors by means of a Badcock plate carrying a labial wire. As in the case of the sister the mandible came forward when sufficient room had been made by expansion to allow it to do so. The right upper first permanent molar was unsaveable and was extracted before the eruption of the second molar, thus allowing the latter to travel forward and erupt in the position of the former. Before Treatment. After Treatment. CASE No. 6. Male. Aqe 10. TYPE OF MALOCCLUSION. TREATMENT. Class III. Upper incisors in lingual occlusion. The treatment was carried out by means of the appliance shown in the photograph, i.e., a vulcanite plate into which were inserted metal screws. The parent was instructed to turn the screws a half turn every other day. The central incisors were first of all advanced over the lowers and this was followed by the advancement of the lateral incisors. Before Treatment. After Treatment. Before Treatment. After Treatment. CASE No. 7. Female. Age 9 7/\2ths. TYPE OF MALOCCLUSION. Class III. Upper incisors and canines in lingual occlusion. This is a similar type of case to Case No. 6, but much more difficult to treat by means of removable appliances. TREATMENT The treatment was commenced by fitting an inclined plane to the lower incisors. This appliance forced the upper incisors forward. When these teeth had been advanced to a certain degree a similar plate to the one used in Case No. 6 was inserted to complete the treatment. I consider that it is an achievement to have obtained a successful result in this case at a School Orthodontic Clinic. N.B.—The ages recorded in these cases is the age of the patient at the commencement of the treatment. (h). Orthopaedic and Postural Defects. Although handicapped by the absence of a Clinic for the supervision of crippling dcfccts, we have, nevertheless, been able to secure expert advice for such cases as have been found to require it. This is due entirely to the co-operation of the Royal National Orthopaedic Hospital, at whose Out-patient Department 28 school children from this area attended during the year. Three children were admitted to the Hospital for in-patient treatment for the following respective conditions; Infantile Paralysis; Genu Varum and Lordosis; and Torticollis. The Education Authority paid the usual maintenance charges. One child, for whom exercises were recommended on account of severe Scoliosis, was able to have regular supervision at the Brentford and Chiswick Orthopaedic Clinic by arrangement with that Education Authority. Four other children are known to have obtained in-patient treatment by private arrangement at the Royal National Orthopaedic Hospital for the following conditions:—T.B. Spine; Kypho-Scoliosis; Flat Feet; and Arthritis of Right Hip. Eight children received non-residentional treatment of various forms, e.g., Exercises; Manipulation and Special Boots. (i). Heart Disease and Rheumatism. We have no arrangements for the medical treatment of cases of heart disease and rheumatism, but all cases which we discover are referred to Hospitals for expert opinion and advice. These cases, however, are kept under observation at the school clinics, where they attend regularly. Many cases attend school half-days for a period, or have otherwise modified curricula. (j). Tuberculosis. The treatment of tuberculosis is in the hands of the Middlesex County Council. Any suspicious case is immediately referred to the County Tuberculosis Officer, with whose Dispensary in Bell Road we are in constant touch. 8.—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 1933, and the three previous years. 1933 1932 1931 1930 Small-pox — — — 2 Scarlet Fever 186 105 106 77 Diphtheria 17 30 26 88 Measles 108 952 9 799 German Measles 13 25 5 38 Mumps 940 122 132 381 Chicken-pox 362 194 233 392 Whooping Cough 287 260 242 144 1913 1688 753 1921 23 This table shows the incidence of infections disease in each school during 1933 :— SCHOOL SCARLET FEVER DIPHTHERIA MEASLES GERMAN MEASLES MUMPS CHICKEN POX WHOOPING COUGH Alexandra Boys 24 ... 37 l 44 6 24 ,, Girls 12 3 30 l 32 2 27 Berkeley Junior 6 ... ... ... 20 48 19 Brentford End Infants 4 ... ... ... 27 8 39 Bulstrode Senior Boys 3 1 ... ... 4 1 ... ,, ,, Girls 4 ... ... ... 5 ... ... Chatsworth Infants 10 1 ... l 110 19 18 Grove Road Boys 5 ... ... ... 28 19 1 ,, „ Girls 9 1 ... ... 32 11 1 ,, „ Infants 10 ... ... ... 134 88 41 Heston Senior ... ... ... ... 7 3 1 ,, Junior 4 ... ... l 75 18 7 ,, Infants 1 ... ... ... 1 2 22 Hounslow Heath Boys 3 ... ... ... 53 7 2 ,, ,, Girls 9 ... 2 l 42 7 1 ,, ,, Infants 16 1 35 6 151 17 22 Hounslow R.C. Mixed & Infants 7 ... ... ... 4 1 12 Hounslow Town Boys 5 ... ... ... 15 4 3 ,, ,, Girls & Infants 1 1 1 ... 57 2 7 Isleworth Blue Boys 1 1 ... 1 3 1 1 ,, ,, Girls & Infants 2 ... ... ... 3 6 9 Isleworth Town Junior 4 3 ... ... 14 14 1 ,, ,, Infants 10 3 1 1 45 40 18 Marlborough Senior 6 ... ... ... 8 4 ... St. Mary's Boys 2 ... ... ... 5 1 1 ,, Girls & Infants 11 ... ... ... 5 ... 8 Spring Grove Central 4 ... ... ... 6 2 ... „ ,, Junior 2 ... ... ... 3 11 19 Woodlands St. John's Infants 3 ... ... ... 4 20 1 Worple Road Junior Mixed 3 ... 2 ... 1 ... 1 „ ,, Infants 5 2 ... ... 2 ... 20 186 17 108 13 940 362 287 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. 9.—OPEN-AIR EDUCATION. (a). Playground Classes. Playground classes are arranged in most of the schools in the Borough during fine weather, and all schools are supplied with the necessary furniture. (b). Open-Air Classrooms. There are no open-air classrooms in any of the public elementary schools of the Borough. (c). School Journeys and Camps. A camp was established during the summer at Ham Island, near Windsor, and parlies of 20 girls were sent there in successive weeks from the Bulstrode Girls' Senior School. There will probably be developments under this heading in the future. 24 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. 11.—PROVISION OF MEALS. Table II of the Statistics at the end of this Report shows that 157 cases of Malnutrition were found by Special Inspection. These cases were amongst the children who had been sent up by the Head Teacher as suggested cases for Milk Meals. Of the 157 cases, 31 were granted free Milk, 56 were assessed to pay part cost, and 45 refused Milk Meals. In 25 cases the parents' circumstances were above the scale, and they were therefore assessed to pay the full cost. Up to the end of the year 8,591 Milk Meals were supplied under the Committee's scheme; 5,304 were free Meals, and 3,287 at part cost. Apart from the provision of Milk free and at part cost, there is a self-supporting Milk Scheme which has been running for over 2 years. This scheme has been adopted by 26 Head Teachers in the P>orough, and an average of 7,900 bottles of Milk are supplied weekly. The cost is one penny per bottle containing one-third of a pint. The provision of Meals proper is under consideration and a scheme will probably be put into operation early in the coming year. 12.—CO-OPERATION OF PARENTS, TEACHERS, SCHOOL ATTENDANCE OFFICERS AND VOLUNTARY BODIES. 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 1933 a parent or other relative attended in 2,792 instances, representing 77.8 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. 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. 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. 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. 13.—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. 25 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. The question of dealing adequately, not only with mentally defective children, but with the psychologically abnormal child, is one of the most unsatisfactory things one has to deal with. Repeatedly examining these children when nothing can be done for them by reason of the policy enunciated from head-quarters is practically hopeless. There are no vacancies and the nett result is an accumulation of notes which have not benefited the child one whit. At least, in this district, we do try and keep a watch on them and examine every one at least annually, but what happens in some districts passes my comprehension, as we get children coming from other districts who have never been examined at all and who on entering this district have been found to be as much as seven years retarded, some of them well on in years as far as school age is concerned. I make an invariable practice of writing to the school authorities of every child who comes in and in the vast majority of cases I get the information, and there is no evidence from some of these that the child has ever been mentally assessed. How they escape is past my comprehension. One knows that sympathetic teachers are apt to magnify the abilities of some of these children much out of kind-heartedness or a knowledge of the parents. Some of them are possibly kept away from Medical Inspection, but I am still at a loss to know how it is we get the number of cases of this kind that we do, unless it is like the Local Authority who when questioned because their Reports showed no Mentally Defectives, replied that so long as there was no possibility of accommodation there was no possible use in " ascertaining." The psychological cases which one deals with by therapeutic interviews keep dropping in, and it is really one of the happy things to see how much can be done for these cases by an understanding of their psychology. As I have said before, how one longs to change some of their parents for them. To know that these poor little characters are doomed to spend their early life in the environment of their unstable parents is little short of tragic. As an example of the sort of case which comes under no other heading, the following is an instance. A boy aged 12, in more or less comfortable circumstances, was sent down because he wept when he went to school. This used to occur daily and commenced a year-and-a-half before he was first seen by me. Up to then he had been more or less an ordinary child except somewhat nervous. He got nervous attacks which caused diarrhoea, four or five evacuations taking place repeatedly. There was a marked habit spasm of the neck and shoulder. The psychological background was most unsatisfactory. Seven years previously his little sister was killed by a motor-cycle in his presence. That produced a very severe upset at the time. A year-and-a-half previous to the examination, a favourite uncle died which seems to have been the beginning of the present trouble. There was no physical basis for his trouble whatever. At the time of examination he was lachrymose, weeping at the slightest thing and it had been found impossible to get him back to school at the beginning of the term a few days previously. He was found to be worried by Mathematics and French and also the fact that he had no pals at school. Apparently the same trouble had arisen at the commencement of every term in his new school. After an interview I took him down in my car to the school and handed him over to the Head Master, having arranged that he should get extra tuition in Mathematics and French. There was no more trouble that term. I arranged however that he was to report to me every Saturday morning simply so that he could feel that there was somebody to whom he could turn out his mental rag-bag in case of difficulty. Everything appeared to be going all right although it was obvious that the Saturday morning visit was the sheet anchor which kept him steady. At the beginning of the next term however he could not face up to school and was brought down later in the day and by a parent. Again one was able to smooth things out and he went off to school by himself without any trouble and reported satisfactorily on the following Saturday. He came down regularly until I felt that stability had been reached. His Head Master reports satisfactory progress and he is fitting into school life in a way he did not before. There was another psychological difficulty due to a relationship which had undoubtedly some slight bearing on the trouble, but that one was able to straighten out. Certainly the outlook for the boy is very materially better than when one saw him first. This is merely an instance, but the trouble one has with so many of the parents of these difficult children drives one to distraction. As I said before, one wishes to goodness one could change them. If some of these boys were placed with a placid cowlike mother, who at the same time has a will of her own which compels obedience, it would be the salvation of some of these products of the unstable and neurotic mother. 26 At the end of 1933 there were 27 children being maintained by the Education Commiltee 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 21 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 21 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. Seven 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 seven children should be in a special school or class for such cases. Eight children were in a school for the Deaf. Four were in schools for the Mentally Defective. Five were in schools for Epileptics. One was in a Residential School for Cripples. Three were at Residential Open-Air Schools. 14.—FULL-TIME COURSES OF HIGHER EDUCATION FOR BLIND, DEAF, DEFECTIVE AND EPILEPTIC STUDENTS. Nothing has been done under this heading by the Authority during the year. 15.—NURSERY SCHOOLS. There are no nursery schools in the area. 16.—SECONDARY SCHOOLS AND OTHER INSTITUTIONS OF HIGHER EDUCATION. These schools come under the Middlesex County Council. 17.—PARENTS' PAYMENTS. (a). Tonsils and Adenoids. Parents contributions towards the cost of operations, which are assessed in accordance with the undermentioned scale are paid by the parents direct to the Education Department. Weekly family income per Parents' contribution towards head, after deducting rent. cost of operation. 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 Hospital Saving 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. (b). Defective Vision. Parents pay for spectacles at the Health Department, where all Eye Clinics are held. No trouble is experienced in this connection, as spectacles are not supplied until paid for. (Note that during 1933 spectacles were supplied to 98% of the cases for whom they were prescribed). Repairs also are dealt with in the same manner. Parents unable to afford the cost of spectacles can make application for special consideration, when in most cases the spectacles are supplied free of cost. (c). Dental Treatment. The flat rate of Is. per child is paid on attendance at the Clinic, and includes all ordinary treatment for the following 12 months. Orthodontic fees are paid into the Health Department. The majority of parents pay by instalments, which necessitates the issue of Payment Cards, and a full system of book-keeping in the office. 27 (d). Ringworm. A flat rate of 2s. 6d. per case is charged for each case treated by X-Rays. This fee is paid at the School Clinic after treatment. (e). Cleansing of Heads. The fee of Is. per case is paid by the parents direct to Mrs. Yates, who does the cleansing. Mrs. Yates pays these fees into the Borough Treasurer's Office. 18.—HEALTH EDUCATION. The only talk given to school children by a member of the Authority's staff was by one of the Health Visitors to a class of 50 girls who were about to leave the Bulstrode Senior Girls' School. The topic was " Washing the Baby." The class had previously had lessons at school with a doll for a model, but on the occasion of the demonstration by the Health Visitor a baby was available through the kindness of a mother who attends one of the Maternity and Child Welfare Centres. A similar talk was given by another Health Visitor last year. Pressure of work in all our sections prevents an extension of this sort of instruction but its usefulness and interest to girl " Leavers " is fully realised. 19.—SPECIAL ENQUIRIES. See Dr. Roberts' report on pages 13 to 15 with regard to vision testing. 20.—MISCELLANEOUS. Thirty-one 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 the children attending the Hounslow Occupation Centre. Twenty children were examined during 1933. Eight of these were found to need treatment on account of dental caries, and two for enlarged Tonsils and Adenoids. Two cases have received treatment at the School Dental Clinic. 28 STATISTICAL TABLES. TABLE 1.—RETURN OF MEDICAL INSPECTIONS, 1933. A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants 1127 Second Age Group 1203 Third Age Group 939 Total 3269 Number of other Routine Inspections 317 B.—Other Inspections. Number of Special Inspections 2983 Number of Re-Inspections 5014 Total 7997 TABLE II.A. RETURN OF DEFECTS found by Medical Inspection in the Year ended 31st December, 1933. 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 2 16 157* 1 Skin— Ringworm— Scalp ... ... 20 ... . . Body ... ... 37 ... Scabies 1 ... 5 ... Impetigo ... ... 144 ... Other Diseases (non-tuberculous) 14 16 120 ... Eye— Blepharitis 7 4 17 1 Conjunctivitis ... • • • 47 1 Keratitis ... ... 1 ... Corneal Opacities ... ... ... ... Defective Vision (excluding Squint) 166 34 116 ... Squint 17 1 15 ... Other Conditions 2 3 117 ... Ear— Defective Hearing 26 28 22 ... Otitis Media 9 1 89 1 Other Ear Diseases 15 ... 64 2 Nose and Throat— Chronic Tonsillitis only 57 165 89 14 Adenoids only 6 6 5 ... Chronic Tonsillitis and Adenoids 74 101 37 6 Other Conditions 8 51 129 ... Enlarged Cervical Glands (non-tuberculous) 24 155 51 2 Defective Speech ... 1 1 1 *This figure is the result of the special examination of a large number of children who were referred by Head Teachers for Milk Meals. 29 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 1 3 9 4 Functional 8 74 3 11 Anaemia 12 18 21 ... Lungs— Bronchitis 1 ... 16 1 Other Non-Tuberculous Diseases 5 33 45 6 Tuberculosis— Pulmonary— Definite ... ... ... ... Suspected ... ... ... ... Non-Pulmonary— Glands ... ... 1 ... Bones and Joints ... ... ... ... Skin ... ... ... ... Other Forms ... ... ... ... Nervous System— Epilepsey 1 ... 1 1 Chorea ... ... 12 1 Other Conditions 1 7 17 7 Deformities— Rickets ... 1 ... ... Spinal Curvature 3 36 8 1 Other Forms 17 38 26 3 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 25 35 1270 32 B.—Number of individual children found at Routine Mcdical 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 1127 147 13.05 Second Age Group 1203 151 12.47 Third Age Group 939 112 11.93 Total (Code Groups) 3269 410 12.52 Other Routine Inspections 317 22 6.94 30 TABLE III.—RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Children suffering from Multiple Defects, i.e., any combination of Total Blindness, Total Deafness, Mental Defect, Epilepsy, Active Tuberculosis, Crippling, or Heart Disease 2* *See details at foot of page 32. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 5 — — — 5 PARTIALLY BLIND CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. . 1 — 7 — 1 9 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At Other Institutions. At no School or Institution. . 8 — — — 8 PARTIALLY DEAF CHILDREN. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — — 1 1 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 4 19 2 5 30 31 TABLE III.—continued. EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 5 1 — 1 7 PHYSICALLY DEFECTIVE CHILDREN. A. Tuberculous Children. I.—CHILDREN SUFFERING FROM PULMONARY TUBERCULOSIS. At Certified Special Schools. At Public Elementary Schools At Other Institutions. At no School or Institution. Total. 4 1 — — 5 II.—CHILDREN SUFFERING FROM NON-PULMONARY TUBERCULOSIS. At Certified Special Schools. At Public Elementary Schools At Other Institutions. At no School or Institution. Total. 6 — - 6 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 7 160 1 11 179 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 2 33 — 6 41 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution Total. — 2 — 1 3 Children suffering from Multiple Defects: — Certified M.D. 1 Severe Epilepsy. Boys—2 Certified M.D. 1 Paralysis Lower Limbs . 32 At no School or Institution At no School or Institutiot STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1933, BY THE LOCAL EDUCATION AUTHORITY TO THE LOCAL MENTAL DEFICIENCY AUTHORITY. Total Number of Children notified 4 Analysis of the above Total. Diagnosis. Boys. Girls. 1. (i) Children incapable of receiving benefit or further benefit from instruction in a Special School; (a) Idiots 1 — (b) Imbeciles 1 1 (c) Others — — (ii) Children unable to be instructed in a Special School without detriment to the interests of other children: (c) Moral defectives — — (b) Others — — 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 1 — 3. Feeble minded children notified under Article 3, i.e., "special circumstances" cases - — 4. Children who in addition to being mentally defective were blind or deaf — — Grand Total 3 1 33 TABLE IV—RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER. 1933. TREATMENT TABLEGROUP I.—MINOR AILMENTS (excluding Uncleanliness, for which see Group VI.) Disease or Defect. No. of Defects treated, or under treatment during the year. Under the Authority's Scheme. Otherwise Total. (1) (2) (3) (4) Skin— Ringworm-Scalp. (The number in brackets were treated by X-Rays.) 15 (15) 5 (1) 20 (16) Ringworm-Body 35 2 37 Scabies 5 1 6 Impetigo 154 2 156 Other skin disease 99 13 112 Minor Eye Defects 148 11 159 (External and other, but excluding cases falling in Group II). Minor Ear Defects 199 7 206 Miscellaneous 1049 21 1070 {e-g-, minor injuries, bruises, sores, chilblains, etc). Total 1704 62 1766 GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I.). Defect or Disease. No. of Defects Dealt with. No. of children for whom spectacles were Under the Authority's Scheme By Private Practitioner or at Hospital, apart from the Authority's Scheme. Otherwise Total Prescribed (1) Obtained (2) (i) Under the Authority's Scheme. (ii) Otherwise (i) Under the Authority's Scheme (ii) Otherwise (1) (2) (3) (4) (5) Errors of Refraction (including squint). 581 4 6 591 Other Defect or Disease of the Eyes (excluding those recorded in Group I). — 1 — 1 569 11 559 11 Total 581 5 6 592 34 TABLE IV.—continued. GROUP III.—TREATMENT OF DEFECTS OF NOSE AND THROAT. NUMBER OF DEFECTS Received Operative Treatment. Received other forms of Treatment. Total Number Treated. Under the Authority's Scheme, in Clinic or Hospital By Private Practitioner or Hospital, apart from the Authority's Scheme. Total (1) (2) (3) (4) (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) 1 1 128 5 — 31 1 6 1 159 1 26 193 (i) Tonsils only, (ii) Adenoids only, (iii) Tonsils and adenoids, (iv) Other defects of the nose and throat. GROUP IV.—ORTHOPAEDIC AND POSTURAL DEFECTS. Under the Authority's Scheme. 0) Otherwise. (2) Total number treated. Residential treatment with education. Residential treatment without education. Non-residential treatment at an orthopaedic clinic Residential treatment with education. Residential treatment without education. Non-residential treatment at an Orthopaedic clinic (i) (ii) (iii) (i) (ii) (iii) Number of children treated 3 - 1 4 — 8 16 GROUP V.—DENTAL DEFECTS. (1) Number of Children who were:— (i) Inspected by the Dentist: Age. No. 5 296 6 319 7 259 8 204 9 262 Routine Age Groups 10 262 Total 2745 111 357 12 343 13 351 114 67 15 25 Specials 1646 Grand Total 4391 (ii) Found to require treatment 2429 (iii) Actually treated 32% (2) Half days devoted to:— Inspection 19 Treatment (Ordinary) 586 (Gas) 122 Administration (Clerical) 10 Dental Committee Meetings 6 743 (3) Attendances made by children for treatment 8246 (4) Fillings:— Permanent teeth 4657 Temporary teeth 570 5227 (5) Extractions:— Permanent teeth 1082 Temporary teeth 4012 5094 (6) Administrations of general anaesthetics for extractions 1583 (7) Other operations:— Permanent teeth — Temporary teeth — 2543 GROUP VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. (i) Average number of visits per school made during the year by the School Nurses 2.3 (ii) Total number of examinations of children in the Schools by School Nurses ... 9855 (iii) Number of individual children found unclean 676 (iv) Number of children cleansed under arrangements made by the Local Education Authority 101 (v) Number of cases in which legal proceedings were taken (a) Under the Education Act, 1921 — (b) Under School Attendance Ryelaws 7 35