AC 439(1) HESTON ISLEWORTH MDDX r-\". HfiS 21 BOROUGH of HESTON and ISLEWORTH 1934 Annual Report OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE BOROUGH of HESTON and ISLEWORTH For the Year Ended 31st December, 1934 1934 REPORT ON THE HEALTH OF THE BOROUGH OF HESTON & ISLEWORTH FOR THE YEAR 1934 BY ELWIN H. T. NASH, m.r.c.s., l.r.c.p.. d.p.h.. Medical Officer of Health Index Ambulance Facilities 15 Ante-Natal Care 55-56 Birth Rates 8, 9 Canal Boats 24 Cerebro-Spinal Fever 49, 51, 52, 53 Chicken Pox 50 Children Act 17 Cleansing of Verminous Persons 50 Clinics and Treatment Centres 15, 16 Deaths, Causes of 9 Death Rates 8 Dentures for Mothers 57 Diphtheria 36, 37-49, 51, 52, 53 Diphtheria Immunisation (Special Report) 37-49 Drainage and Sewerage 18 Encephalitis Lethargica 49, 51, 52, 53 Enteric Fever 49, 51, 52, 53 Erysipelas 49, 51, 52, 53 Factory and Workshop Act, 1901 23 Food, Inspection and Supervision of 29-31 General Provision of Health Services in the Area 12-16 Home Help 59 Home Visiting 58 Hospitals 12-16 Housing 25-28 Industries, Local 11 Infant Deaths 8, 9, 10 Infant Life Protection 17 Infectious Diseases 36-5 Influenza 50 Inspection and Supervision of Food 29-31 Laboratory Statistics 12 Legislation in Force 13 Malaria 52 Maternal Mortality15, 56 Maternity and Child Welfare—Attendance at Centres 54 „ „ Centres 16, 54 „ „ Dental Treatment 57 „ „ General Arrangements 54-60 „ „ Grants of Milk 59 Measles 50 Meat 29, 30 Midwives 12 Milk 29 ,, Grants to Expectant and Nursing Mothers and to Children under three years 59 Mumps 50 Notification of Births 58 Nursing in the Home 12 Nutrition Research—Carnegie Grant 32-35 Ophthalmia Neonatorum .,. 14, 49, 51, 52, 53, 60 Physical Features of District 10 Pneumonia 49, 51, 52 53 Poliomyelitis 49, 51, 52 53 Population 8 Puerperal Fever 14, 49, 51, 52, 53 Puerperal Pyrexia 14, 49, 51, 52, 53 Sanitary Circumstances of the Area 18-28 Scarlet Fever 36, 51, 52, 53 Scavenging 18 Smallpox 14, 49, 52, 53 Staff 7 Tuberculosis 14, 50, 51, 53 Venereal Diseases 14 Vital Statistics 8 Voluntary Societies and Helpers 58 Water Supply 18 Whooping Cough 50 3 Public Health Department, 94a, Bath Road, Hounslow. July, 1935. To the Mayor, Aldermen and Councillors of the Borough of Heston and Isleworth. Gentlemen, The Annual Report this year is one designated by the Ministry as an Ordinary Report in contradistinction to the periodical Survey Report. In view of the fire at Clipstone House some matters will unavoidably be omitted, as the first draft of the report and some of the records which had been carefully kept, were badly damaged or destroyed. The delay in getting such Report as I am able to make before the Committee, is due entirely to the difficulty in getting together the information from the wreckage that remained. No one who has not experienced a fire in their offices can appreciate in the slightest degree the devastating effect which it has on one's routine and records. I cannot speak too highly of the way the staff rose to the occasion as we were able to carry out a complete service within four days of the fire. I wish to express my appreciation to the Council for the consideration shown to me by all members during the past year. I am, Gentlemen, Your obedient servant, ELWIN H. T. NASH, Medical Officer of Health. 5 THE HEALTH COMMITTEE OF HESTON AND ISLEWORTH BOROUGH COUNCIL as on the 31st December, 1934. Councillor J. E. DILLINGHAM (Chairman). „ D.J. THOMAS (Vice-Chairman). Alderman H. G. BODY. J. J. BONNETT, O.B.E. J. J. CLEMENTS, J.P. G. R. SPEED. Councillor F. T. HART. E.W. HEATH, J.P. C.L. LEWIS, J.P. (ex-officio). J. OWNER. D. RHYS. G. N. SHACKLETON. A. C. TURNER. Medical Officer of Health: ELWIN H. T. NASH, m.r.cs., l.r.c.p., d.p.h. MATERNITY AND CHILD WELFARE COMMITTEE Councillor A. C. TURNER (Chairman). Alderman G. R. SPEED. Councillor J. E. DILLINGHAM. J. FARMER. J. I. KELLY. Councillor J. OWNER. D. RHYS. W. F. J. RICHARDSON. G. N. SHACKLETON. Co-opted Members: Miss E. A. ANKRITT. Mrs. E. CHEDGEY (Vice-Chairman). 6 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.6. (eng.). W. A. LILLEY, b.d.s., l.d.s. (manc.) (Commenced July, 1934). Chief Sanitary Inspector— R. H. BUTLER, a.m.i.s.e., Cert, as s.i. and m.i. Deputy Chief Sanitary Inspector and Housing Inspector— A. B. HAULDREN, Cert, as s.i. and m.i. District Sanitary Inspectors— G. W. ASHWORTH, Cert, as s.i. and m.i. A. H. CORNHILL, Cert, as s.i. and m.i. G. LATIMER, Cert, as s.i. and m.i. (Commenced August, 1934). K. J. SMITH, Cert, as s.i. and m.i. (Commenced October, 1934). L. PINGUEY, Cert as s.i. and m.i. (Left August, 1934). Disinfector and Laboratory Attendant—F. J. COBB. Assistant Disinf ector 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 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. Home Help—Mrs. E. YATES (Left December, 1934). Chief Clerk—b. W. KILBY, Cert. as s.i. and m.i. Clerks— Miss R. MARSHALL, Cert as s.i. C. PARRY Commenced August, 1934). P. T. H. CRANDON. Miss D. M. DOWLING. H. TOWLE (Commenced August, 1934). E. E. FORREST. K. I. BISSHOPP (Left March, 1934). Miss V. D. NICHOLLS. H. J. ALDHOUS, Cert as s.i. and m.i. R. MOORE. (Left June, 1934). T. C. WREN (Left January, 1934). F. V. BELL, Cert as s.i. and m.i. H. A. MILLER (Commenced January, 1934. H. M. B. BURGE (Commenced September, Left October, 1934). 1934). ONE TEMPORARY JUNIOR. Medical Superintendent, Mogden Joint Isolation Hospital—(Joint Isolation Hospital, Richmond with Heston and Islcworth)—ALEX. EDWARD GAMMIE, m.b., ch.b. Statistics and Social Conditions of the Area. EXTRACTS FROM VITAL STATISTICS OF THE YEAR 1934. Area (in acres, including 42 acres of water) 7,261 Registrar-General's estimate of resident population (Mid-Year) 1934 87,797 Census Population, 1931 76,254 Number of inhabited houses (end of 1934) according to Rate Books 22,179 Rateable Value (at 31st December, 1934) £696,257 Sum represented by a penny rate (1933-34) £2,646 Live Births—- Total. M. F. Legitimate 1271 642 629 Birth rate per 1,000 of the estimated Illegitimate 48 26 22 resident population 15.06 Stillbirths 44 26 18 Rate per 1,000 total (live and still) births 32.28 Deaths 863 435 428 Death rate per 1,000 of the estimated resident population (Corrected) 10.34 Deaths from Puerperal Causes— Rate per 1,003 total Deaths. (live and still) births. Puerperal sepsis 1 .73 Other puerperal causes 3 2.20 Total 4 2.93 Death rate of Infants under one year of age:— All infants per 1,000 live births 47.76 Legitimate infants per 1,000 legitimate live births 46.42 Illegitimate infants per 1,000 illegitimate live births 83.33 Deaths from Measles (all ages) 12 Deaths from Whooping Cough (all ages) 2 Deaths from Diarrhoea (under two years of age) 5 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 1931-32-33-34:— 1931. 1932. 1933. 1934. £4,529 15 2½ £6,506 5 6 £7,846 6 9 £8341 0 0 VITAL STATISTICS. Change of Boundary.—The statistics of Births and Deaths and Notifiable Diseases are composite figures combining the records for the first portion of the year prior to the date of the change with those for the altered area for the remaining portion of the year. The normal mid 1934 estimate of population is 87,797, but a working population figure modified to take into account the fact of the change of boundary for a part of the year has been used for working out certain of the Births, Deaths and Infectious Disease rates. Population.—The Registrar-General's estimate for the population for 1934 is 87,797. The Census population in 1931 was 76,254, this being the revised figure, as altered under the provisions of the Middlesex Review Order, 1933. Deaths.—The number of deaths registered in the district was 1,677, but 963 of these did not belong to the district, while 149 residents died outside the district. Thus the number of deaths properly attributable to the district was 863. Adopting the basis of the population estimated by the Registrar-General, the corrected death-rate for the district comes to 10.34 per 1,000, which is comparable with the following figures : 11.8 for England and Wales, and 11.9 for London. 8 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 1934 is 47.76 per 1,000 births. The rates for England and Wales and for London during the same period were 59 and 67 respectively. Births.—The total number of live births registered during the year was 1,759, excluding re-registrations, but 555 of these did not belong to this district, while 115 births properly belonging to this district occurred outside the district. The nett number of live births thus attributable to the district is 1319. Adopting the population basis suggested by the Registrar-General for the calculation of the birth-rate, this comes to 15.06 per 1000. The birth-rate of England and Wales was 14.8 per 1,000 and for London 13.2 per 1,000. Table of Causes of Deaths during 1934. Causes of Death. Civil Residents, all ages. All causes Male. Female. 435 428 1 Typhoid and paratyphoid fevers — — 2 Measles 8 4 3 Scarlet Fever 2 — 4 Whooping Cough 1 1 5 Diphtheria 3 1 6 Influenza 5 1 7 Encephalitis Lethargica — — 8 Cerebro-Spinal Fever — — 9 Tuberculosis of Respiratory System 31 27 10 Other Tuberculous Diseases 11 3 11 Syphilis 1 — 12 General Paralysis of the Insane, Tabes Dorsalis 2 2 13 Cancer, Malignant Disease 54 70 14 Diabetes 3 9 15 Cerebral Haemorrhage, &c. 22 18 16 Heart Disease 94 99 17 Aneurysm 3 3 18 Other Circulatory Diseases 17 18 19 Bronchitis 10 12 20 Pneumonia (all forms) 30 26 21 Other Respiratory Diseases 6 4 22 Peptic Ulcer 3 — 23 Diarrhoea, &c. (under 2 years) 2 3 24 Appendicitis 2 2 25 Cirrhosis of Liver 4 2 26 Other Diseases of Liver, &c. — — 27 Other Digestive Diseases 15 18 28 Acute and Chronic Nephritis 11 15 29 Puerperal Sepsis — 1 30 Other Puerperal Causes — 3 31 Congenital Debility, Premature Birth, Malformations, etc. 26 12 32 Senility 7 13 33 Suicide 4 5 34 Other Violence 20 13 35 Other Defined Diseases 38 41 36 Causes Ill-defined or Unknown — — Special causes (included in No. 35 above) — — Small-pox — — Poliomyelitis — — Polioencephalitis — — According to figures furnished by the Registrar-General. 9 INFANTILE MORTALITY DURING THE YEAR 1934. 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 ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... ... 1 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... Tuberculous Meningitis ... ... ... ... ... ... ... ... ... 1 Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ... Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... ... ... Convulsions ... ... ... ... ... ... ... ... 1 2 Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... ... 1 1 Pneumonia (all forms) ... ... ... ... ... 4 2 ... ... 6 Diarrhoea ... ... ... ... ... ... ... ... ... ... Enteritis ... ... ... ... ... ... 2 ... 2 4 Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... 1 ... ... 1 Injury at Birth 2 ... ... ... 2 ... ... ... ... 2 Atelectasis ... ... ... ... ... ... ... ... ... ... Congenital Malformations 1 ... ... ... 3 8 1 ... ... 12 Premature Birth 15 ... ... ... 15 4 ... ... ... 19 Atrophy, Debility and Marasmus 2 ... ... ... 4 3 2 ... ... 9 Other Causes 1 1 ... 1 3 2 ... ... ... 5 22 1 3 2 28 21 8 2 4 63 Nett Births Legitimate 1271 Illegitimate 48 Nett Deaths Legitimate infants 59 Illegitimate infants 4 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. 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. 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. 10 The chief industries are:— (1) Beer, etc., brewing. (2) Boat building and repairing. (3) Colours and dyes. (4) Letterpress Printing. (5) Gravel quarrying. (6) Market Gardening. (7) Rubber Tyres, etc. (8) Pewterware and Candle Machinery. (9) Pharmaceutical Chemistry. (10) Soaps, powders and perfumes. (11) Sweets, confectionery (12) Wines. (13) Sawmills and Joinery. (14) Fire extinguishers, etc. (15) Electrical and Wireless equipment Gramophones. (16) Motor Cars. (17) Fancy papers. (18) Aeroplanes. (19) Engineering works. (20) Disinfectants. (21) Laundries. (22) Linoleum. (23) Carbons, Stencils, Typewriter bons, etc. (24) Biscuit making. (25) Candle making. (26) Flour milling. (27) Pharmaceutical Manufacturing Machinery. (28) Coach building and wheelwrights. (29) Dyeing and cleaning. (30) Pre-cast concrete works. (31) Motor Spirit Energiser. (32) Artificial Manure. (33) Aluminium Solder. (34) Soldering Flux. (35) Scientific Instruments. 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. 11 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 23 Midwives practising in the district. This figure does not include 6 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. COUNCIL LABORATORY, 1934. Total. Positive. Swabs for Diphtheria sent by Medical Practitioners 601 41 Taken from Schools, Clinics and from Contacts 1146 31 Sub-Cultures 26 2 Sent from Staines Joint Isolation Hospital 526 97 Total cultures examined 2299 171 Swabs examined by Clinical Research Association or at Other Laboratories 23 5 Virulency Tests 6 5 Blood examination for Enteric Widal Tests (sent to Clinical Research Association) 3 — Specimens of Sputum for Tubercle Bacilli sent by Medical Practitioners 101 9 Specimens of Sputum for Tubercle Bacilli taken at Clinics — — Hairs for Ringworm taken at Schools or Clinics 205 104 Blood examination for Wassermann Tests (sent to Camberwell Research Laboratory) 2 — Other Specimens— Urine 544 Discharge 17 Milk 32 Faeces (sent to Clinical Research Association) 8 — Blood examinations for Anaemia 13 Preparation of Materials— Tubes of Serum 2250 Throat Swab Outfits 2700 Sputum Outfits 180 The bacteriological work of the Staines Joint Isolation Hospital continues to be done in the Counul Laboratory. 12 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, Parts II, III and V. *Public Health Acts Amendment Act, 1907, Parts II, *III, *IV, *V, VI and VIII. *Public Health Act, 1925, Parts *II, *III, *IV and *V were adopted in November, 1925. Maternity and Child Welfare Act, 1918. Baths and Wash-houses Acts, 1846-1925. Burial Acts, 1852-85. (Applicable to parts of the Borough only). Public Libraries Acts, 1892-1919. Private Street Works Act, 1892. Small Dwellings Acquisition Acts, 1899-1923. Local Government and Other Officers' Superannuation Act, 1922. *These are administered wholly or partly by the Health Committee. The unstarred are administered by other Committees of the Council. Bye-laws in force in the District. Most of the bye-laws in force prior to the incorporation of the former Urban District have ceased to apply to the Borough by virtue of the scheme annexed to the Charter of Incorporation. New editions of these bye-laws are in course of preparation. HOSPITALS. (1) General.—Hounslow Hospital, Staines Road.—This is the only Voluntary Hospital within the district. It is a modern and well-equipped institution, with 72 beds, including a children's ward and X-ray Department. During the year, there were admitted 1,071 in-patients, whilst 5,713 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 of the parish. The majority of persons dealt with are residents in the Boroughs of Acton, Brentford and Chiswick, Ealing, Heston and Isleworth, and Twickenham, and the Urban Districts of Sunbury and Teddington, but, as the hospital is a unit in the County Council's Hospital Service, residents from other parts of Middlesex are admitted as need arises. A very highly qualified consulting staff is being appointed and everything is being done to bring the Hospital as nearly as possible up to the standard of the large London Hospitals. The West Middlesex County Hospital is a well-equipped modern hospital, providing accommodation for 500 patients suffering from acute medical and surgical conditions, together with a maternity wing with beds and cots for 31 mothers and their infants. The hospital is provided with electro-therapeutic, X-ray, massage and ophthalmic departments. Between 600 and 700 patients suffering from chronic illnesses are accommodated in the adjoining institution (Warkworth House). 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 £300 to the Hounslow Hospital and £50 to the Royal Hospital, Richmond. (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. 13 (3) Maternity.—There is no definite provision in the district other than the West Middlesex County Hospital lor 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. (8) Orthopaedic.—Although there is no definite orthopaedic scheme available in the district, we have an 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 annually 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.—An agreement has been made with the Queen Charlotte's Hospital Authorities whereby we can obtain admission for cases of Puerperal Fever or Puerperal Pyrexia into their Isolation Block at Ravenscourt Park. Other cases arising in the district are 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 Joint Board foreshadowed in my Report for 1933 will soon be an established fact. The Board comes into existence officially on the 1st April, 1935. As a result of the Board's deliberations, the Mogden Hospital is to be made the main and ultimate Hospital, and arrangements are foreshadowed for enlarging the Hospital eventually to 280 beds. In the meantime Twickenham and Hampton Hill Hospitals are being blended in the provisional scheme. The appointment of a whole-time Medical Superintendent is also foreshadowed. Numerous conferences have taken place with the Architect, and the first part of the scheme is the enlargement of Mogden by 84 beds. The demand for further accommodation at Mogden, and particularly for observation blocks, is urgent indeed. 14 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.—Two Ambulances have been provided for accident cases and removal of non-infectious cases to hospitals or nursing homes within or outside the district. During the year 821 accident cases were removed to hospital, and 497 cases of noninfectious disease were removed to hospitals or nursing homes. CLINICS AND TREATMENT CENTRES, 1934. During the year the Isleworth Health Centre was opened at Busch House. This is a temporary scheme to deal with the increasing work in that area until such time as the permanent Health Centre can be built there, and it enabled Ante-Natal Clinics, Dental Qinics, both for mothers and children, and Eye Clinics to be held there, which has met a definite need which existed for some years. In addition, the better accommodation at Busch House enabled the Maternity and Child Welfare and School Clinics, which had previously been conducted at Isleworth Public Hall, to be run under much better conditions than ever before. Isleworth Public Hall as a Clinic, was closed down on the opening of Busch House. Further efforts have been made to find some sort of accommodation at the Cranford end of the district where growth is taking place very rapidly. In addition a re-consideration of further accommodation at Clipstone House has been made by the Committee on various occasions. (This of course has been entirely superseded by the fire. A resolution has been passed that the remains of the building be demolished and a new Health Centre erected). 15 16 CLINICS AND TREATMENT CENTRES, 1934. Clinics and Treatment Centres. Address. Day. Time. Provided by Ante-Natal Clinics Public Health Department, Every Wednesday. 9.45 am. Heston and Isleworth 92, Bath Road, Hounslow. Borough Council. Isleworth Health Centre, Busch First Tuesday of each 9.45 am. ,, House, Isleworth, month. ,, Diphtheria Immunisation Clinics Public Health Department. Monday. 10.30 a.m. and 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. 10.0 a.m. ,, Isleworth Health Centre. Monday. 2.0 p.m. ,, Wednesday. 2.0 p.m. ,, Friday. 2.0 p.m. ,, Public Health Department. Wednesday. 2.0 p.m. ,, Thursday. 10.0 a.m. ,, Maternity and Child Welfare Public Health Department. As for School Dental Dental Clinics Isleworth Health Centre. Qinics (see below). Minor Ailments Clinics Public Health Department. Every week-day. 9.0 a.m. ,, (Nurse attending) Village Hall, Heston. Every week-day. 9.0 a.m. ,, Isleworth Health Centre. Every week-day. 9.0 a.m. ,, Ophthalmic Clinics Public Health Department. Thursday. 2.0 p.m. ,, Friday. 2.0 p.m. ,, Isleworth Health Centre. Thursday. 10.0 a.m. ,, School Clinics Public Health Department. Tuesday. 10.0 a.m. ,, (Medical Officer attending) Friday. 10.0 a.m. ,, Village Hall, Heston. Thursday. 10.30 a.m. ,, Isleworth Health Centre. Monday. 10.30 a.m. ,, School Dental Clinics Public Health Department, and Monday. 9.30 a.m. and 2.0 p.m. ,, Isleworth Health Centre. T uesday. 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. ,, Tuberculosis Dispensary Saturday. 9.30 a.m. ,, Bell Road, Hounslow. Monday. 10.0 a.m. Middlesex C.C. Venereal Diseases Clinic Thursday. 2.30 p.m. ,, West London Hospital, Monday to Friday. 10.0 a.m. to noon and ,, mersmith (facilities are also 3.0 to 7.0 p.m. provided at other London Saturday. 11.0 a.m. to noon and ,, Hospitals). 5.30 to 6.30 p.m. 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. 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 51 (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 8 (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. Nil. (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 Nil. (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. In September the Housing and Town Planning Committee considered the question of allowing foster-children to be received in Council Houses, and it was decided that this should not be permitted. This decision was communicated to the foster-mothers concerned, and they are being taken off the Register as and when the foster-children are removed from their care. 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. 17 Sanitary Circumstances Water Supply.—There were, as far as is known, at the end of the year, 31 private wells from which the water was used for domestic purposes. In 43 other cases there are wells, but an alternative supply from the main exists for domestic purposes. In 22 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. 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 1934 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. During the year, as a result of action taken, there were supplied 86 new ashbins. Sanitary Inspection of the District.—See pages 18-28.—During the year, owing to the increase in the district work, an additional District Sanitary Inspector was appointed by the Council. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc.—The number of premises on which nuisances were outstanding at the end of 1933 was 420. To these another 582 premises whereat nuisances were recorded in 1934 were added, giving a total of 1,002 premises. Of these 579 had the nuisances remedied, leaving 423 premises at which nuisances still existed at the end of the year. During the year, nuisances at 20 houses were reported to the Health Committee, which, added to the 16 brought forward from 1933 made a total of 36. 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, 28 had been dealt with, leaving 8 cases to be carried forward to 1935. Comparative figures for the years 1932, 1933 and 1934, in connection with nuisances, are submitted herewith:— 1932 1933 1934 Number of complaints received 493 550 514 Premises at which nuisances were located 744 648 582 Number of First Informal Notices 794 612 559 Number of Reminders and Letters 571 589 567 Number of Statutory Notices 58 36 24 18 Proceedings.—No Court proceedings were instituted by the Corporation during the year. Five appeals were made by owners against the Corporation's decision to make Demolition Orders and the appeals were upheld and undertakings were accepted that the premises should not again be used for human habitation until the Corporation are satisfied that the premises have been rendered fit and cancel such undertakings. SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc. 22,343 Inspections, etc., re Nuisances Contraventions, etc.: Number of premises, etc., inspected on complaint 680 Number of premises inspected in connection with infectious diseases 399 Total number of premises, etc., primarily inspected in connection with nuisances 1,263 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Act, 1920-1923 Number of other visits made to premises, etc., in connection with nuisances, etc. 2,237 Number of visits made to works in progress 1,310 Number of interviews with owners, builders, etc. 1,423 Action taken (including action taken under Housing Act, 1930, Section 17): Number of premises, etc., whereat defects, etc., were recorded during the year 582 Number of premises, etc., on which defects, etc., were remedied— (a) by owners or occupiers 578 (b) by local authority in default of owner or occupier 1 Number of cautionary or intimation notices given— (a) verbal 188 (b) written 371 Number of letters and reminders re nuisances sent 567 Number of Statutory Notices issued 24 Number of proceedings taken — Number of convictions obtained — Number of proceedings withdrawn — Number of cases dismissed — Number of appeals made against decision of Corporation 5 Number of appeals dismissed Common Lodging Houses: Number registered 2 Number of inspections made 23 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 95 Number of contraventions outstanding from previous year 5 Number of contraventions found 16 Number of contraventions remedied Number of contraventions outstanding at end of year 14 Moveable Dwellings, Caravans, Tents, etc.: Number of inspections made 33 Number of contraventions outstanding from previous year 12 Number of contraventions found — Number of contraventions remedied 4 Number of contraventions outstanding at end of year 8 19 Bakehouses: Number in district (a) factories 21 (b) workshops 10 Number of underground bakehouses in district 1 Number of inspections made 235 Number of contraventions outstanding from previous year 3 Number of contraventions found 30 Number of contraventions remedied 30 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) 5 Number of inspections and visits made 868 Number of contraventions outstanding from previous year — Number of contraventions found 4 Number of contraventions remedied 4 Number of contraventions outstanding at end of year — Cowsheds : Number of persons registered 8 Number of premises registered 8 Number of cowsheds on register 12 Number of milch cows in district 106 Number of inspections made 44 Number of contraventions outstanding from previous year 1 Number of contraventions found 3 Number of contraventions remedied 4 Number of contraventions outstanding at end of year — Dairies and Milkshops : Number of persons registered 91 Number of premises registered 38 Number of inspections made 625 Number of contraventions outstanding from previous year 5 Number of contraventions found 4 Number of contraventions remedied 6 Number of contraventions outstanding at end of year 3 Offensive Trades : Number of businesses established in district 18 Number of inspections made 154 Number of contraventions outstanding from previous year 1 Number of contraventions found 5 Number of contraventions remedied 6 Number of contraventions outstanding at end of year — Ice Cream Vendors : Number on register 74 Number of inspections made 327 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 — Public Health (Meat) Regulations, 1924 : Number of inspections made 806 No notice of slaughtering given 1 Improper notice of slaughtering given 6 Urinals, water closets, etc., communicating directly with shops, etc. 1 . No precautions taken for the prevention of contamination 1 Washable head coverings and/or overalls not used 2 Written notices sent 3 Verbal notices given 6 Inspection of food : Number of meat inspections 1,113 Number of fish inspections 249 20 Number of provision inspections 326 Number of greengrocery and fruit inspections 351 Number of hawkers' foodstuff inspections 94 Number of food preparation places inspected 404 Number of other food inspections 25 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 19 Number of carcases surrendered (excluding offal) — Number of articles surrendered 5 Number of parcels surrendered 11 Number of organs or parts surrendered during slaughtering 382 Infectious Diseases, Disinfections, etc. : Number of visits made 1,202 Number of rooms disinfected— (a) Ordinary infectious diseases 568 (b) Tuberculosis 94 (c) Other diseases 22 Number of rooms stripped and cleansed after infectious diseases— (a) by owners or occupiers 17 (b) by local authority — Number of articles disinfected or destroyed ' 1,376 Sinoke Abatement : Number of observations made 118 Number of nuisances outstanding from previous year — Number of nuisances found 19 Miscellaneous Inspections : Number of piggeries inspected 15 Number of stable premises inspected 75 Water Supply : Number of supplies provided or reinstated 19 Number of cisterns cleansed, repaired, covered, etc. 5 Number of draw taps connected direct to main 22 Number of water service pipes or taps repaired 10 Number of samples taken for analysis from local wells 3 Number of samples found polluted or impure — Number of instances where mains water supply substituted for well water — Approximate percentage of houses supplied on constant system 99.95 Drainage and Sanitary Arrangements, etc., of existing Buildings— Water Closets : Number of water closets constructed or reconstructed 23 Number of water closets cleansed or unstopped 39 Number of privies abolished 3 Number of walls, etc., cleansed 6 Number of new flushing apparatuses provided 10 Number repaired, supplied with water or otherwise improved 183 Approximate percentage of houses provided with water closets 99 Earth or Chemical Closets : Number provided or reconstructed — Sinks : Number of new sinks provided 48 Number of sinks repaired or improved 25 21 Drains : Number examined, exposed, etc. 9 Number unstopped, repaired, trapped, etc. 121 Number of waste pipes provided, disconnected, repaired, trapped or unstopped 37 Number of soil pipes fixed, repaired or improved 8 Number of ventilating shafts fixed, repaired or improved 9 Number of fresh air inlets provided, repaired or improved 23 Number of rain water pipes disconnected from drain 2 Number of gully traps inserted or improved 108 Number of disconnecting traps inserted 2 Number of inspection chambers inserted 15 Number of disconnecting chambers improved, sealed or cleansed 8 Number of inspection chambers repaired, improved, sealed or cleansed 35 Number of drains constructed or reconstructed 17 Total length of drain pipes laid (4in.-845ft.) (6in. 231ft.) 1,076ft. Number of tests and re-tests applied 105 Number of other works executed 5 Approximate percentage of houses draining into Council's sewer 99 Cesspools : Number rendered impervious, emptied, cleansed, etc. 1 Number abolished and drains connected to sewer 1 Number rendered impervious, emptied and cleansed 1 Removal of Household Refuse : Number of new ashbins provided 86 Dampness : Number of roofs stripped, renewed or repaired 165 Number of gutters and rain water pipes provided, repaired or unstopped 152 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 691 Number of damp-proof courses provided 83 Number of sites covered with impervious material 2 Number of yards paved, repaired or drained 139 Number of forecourts paved, repaired or drained 15 Interior Work : Number of rooms stripped and cleansed (other than in connection with infectious disease) 172 Number of floors, walls and ceilings repaired or renewed 1,024 Number of rooms in which ventilation provided or improved 41 Number of rooms in which lighting provided or improved 17 Number of staircases replaced, repaired or improved 41 Number of instances in which lighting to staircases provided or improved 72 -Number of handrails and balustrades to staircases, etc., provided or repaired 44 Number of window frames and sashes provided, repaired or unfixed 717 Number of doors and/or other woodwork renewed, repaired or improved 50 Number of stoves or grates provided or repaired 242 Number of washing coppers provided or repaired 81 Number of instances in which ventilation under floors provided or improved 35 Number of foodstores provided, cleansed or improved 15 Number of other repairs 114 Sundry Nuisances, etc. : Number of instances in which domestic cleansing enforced 10 Number of rooms sprayed for the removal of vermin by the Disinfector 122 Number of instances in which overcrowding abated 14 Number of instances of improper keeping of animals abated 10 Number of offensive accumulations removed 26 Number of stables provided, repaired, cleansed, or improved 2 Number of urinals provided, repaired, cleansed or improved 6 Number of dung pits provided, repaired or improved 4 Number of other nuisances abated 37 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) 142 349 9 Nil. Workshops (including Workshop Laundries) ... 155 404 5 Workplaces (other than Outworkers' premises) 58 47 1 Outworkers 34 85 Total 389 885 15 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Outstanding Ian. 1st, 1934. Found during 1934. Remedied during 1934. Outstanding Dec. 31st. 1934. Referred to H.M. Inspector. Number of Prosecutions. 1 2 3 4 5 6 7 Nuisances under the Public Health Acts—* Want of cleanliness 2 10 11 1 Want of ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors ... ... ... ... Other nuisances 6 33 35 4 Sanitary accommodation—† Insufficient 1 2 1 2 Nil. Nil. Unsuitable or defective ... 9 20 27 2 Not separate for sexes ... 3 3 ... Offences under the Factory and Workshop Act— Illegal occupation of underground bakehouse (s. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses (ss. 97-100) ... 1 13 13 1 Other offences:— Excluding offences relating to outwork ... ... ... ... Total 19 81 90 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. 23 PREMISES AND OCCUPATIONS CONTROLLED BY BYE-LAWS OR REGULATIONS. There are 496 known places in this district which call for periodical inspection as follows :— Houses let in Lodgings, Common Lodging Houses, Bakehouses, Slaughterhouses, Cowsheds, Piggeries, Stables, Dairies and Milkshops, Offensive Trades, Laundries (nonfactory), Workshops, Workplaces, Outworkers' Premises and Ice Cream Vendors' Premises. SCHOOLS. There are now 20 public elementary schools and one Central School. Some are modern up-to-date buildings, and others of the transitional period and not up to modern standards; some are considerably older and unsatisfactory from a hygienic point of view. These are being brought up-to-date so far as their structure allows. CANAL BOATS. COPY OF REPORT FORWARDED TO THE MINISTRY OF HEALTH DATED 11th FEBRUARY, 1935. Canal Boats Acts, 1877 to 1884. In accordance with Section 3 of the Canal Boats Act, 1884, I beg to present herewith the Annual Report for the year ended 31st December, 1934, 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, 1934 R. H. Butler (Chief Sanitary Inspector). G. W. Ashworth (District Sanitary Inspector). A. H. Cornhill (District Sanitary Inspector). G. Latimer (District Sanitary Inspector). K. J. Smith (District Sanitary Inspector). No special remuneration is paid for the position. Number of Inspections, etc.:— Number of Inspections made 95 Number of Canal Boats inspected 83 Number of boats found in order 70 Number of boats with one infringement 10 Number of boats with two infringements 3 Nature of Contraventions, etc.:— Cabins not weatherproof 6 Periodical painting of interiors not carried out 3 Cabins overcrowded 3 Registration Certificates not in order 3 Defective stoves 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. 24 Housing. The housing situation is steadily improving, and the Council have in view the erection of another large estate. As before, I have pursued throughout the year the policy I commenced last year of dealing with the representation and demolition of unfit houses as single individual units, and not under any clearance or improvement area. Re-consideration was given by the Public Health Committee to an area in Isleworth, but after the Committee had viewed the site it was felt that it was impossible to deal with it under either scheme. During the year an appeal against a decision was made at the County Court. The Judge visited the premises and agreed that the Council's action was the correct one. At the very end of the hearing, however, counsel for the Owner raised the point that the hearing by the Council's Public Health Committee was not really a judicial hearing. The County Court Judge reserved his judgment on this point which eventually was given against the Council by reason of the fact that the hearing was not a judicial one. Proceedings were commenced again and on the second occasion the Owner made no demur to the Closing Order. Bugs.—During the year 15 houses of families who were moving into Council Houses were dealt with by the sanitary staff by means of Cimex. HOUSING CONDITIONS STATISTICS. 1. GENERAL. Number of New Houses erected during the year 1266. 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) 761 (b) Number of inspections made for the purpose 869 (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 188 (b) Number of inspections made for the purpose 296 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 78 (4) Number of dwelling-houses (exclusive to those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 87 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 ... ... ... 74 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 17 25 (2) Number of dwelling-houses which were rendered fit after service of formal notices:— (a) By owners 13 (b) By local authority in default of owners 1 B. Proceedings under Public Health Acts:— (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 5 (2) Number of dwelling-houses in which defects were remedied after service of formal notices:— (a) By owners 9 (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 85 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders 28 (3) Number of dwelling-houses rendered fit in consequence of undertaking given by owner — (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 ... ... ... 14 3. UNHEALTHY AREAS. Area represented by the Local Authority with a view to Clearance or Improvement Schemes under Part I of the Act of 1930 Nil. Dwelling-houses represented as unfit for human habitation prior to the passing of the Housing Act, 1930. There is only one house outstanding under this heading—No. 15, South Street, Isleworth, which was represented as unfit for human habitation in January, 1915, and a Closing Order made in April of the same year. A Demolition Order was made on the 23rd November, 1915, but demolition has been deferred pending the widening of the street by the County Council to whom the property belongs. 26 Table shewing dwelling-houses represented as unfit for human habitation since the passing of the Housing Act, 1930. Premises. No. of houses represented as unfit. Dates of representations. Dates houses rendered fit in accordance with undertakings. Dates undertakings accepted that houses would not be re-let for human habitation. Dates Demolition Orders made. Dates Demolition Orders obeyed. Dates Demolition Orders enforced. Brought forward from 1933 :— 1-6, Forman's Cottages, North Hyde Lane, Heston 6 7/3/32 ... ... 28/6/32 10/4/34 144-l58b, Heston Road, Heston 11 13/6/32 ... ... ... ... 19, London Road, Brentford End 1 12/12/32 ... ... 31/1/33 ... 21, London Road, Brentford End 1 12/12/32 ... ... 31/10/33 ... 31, 33 and 35, Vine Place, Houns- low 3 7/3/33 ... ... 25/4/33 6/4/34 34-44, Gloucester Road, Hounslow 6 9/5/33 ... ... 27/2/34 ... 12-18, Tivoli Road, Hounslow 4 9/5/33 ... ... 27/2/34 ... 36-40, London Road, Brentford End 3 9/5/33 ... ... 27/6/33 31/1/34 6 and 8, Fairfield Road, Hounslow 2 5/9/33 ... ... 28/11/33 9/10/34 1-14, Crosby Terrace, Station Road, Hounslow 14 5/9/33 ... ... 28/12/33 ... 5-12, Clarence Terrace, Hounslow 8 10/10/33 ... ... 28/11/33 5/9/34 7-27, Vine Place, Hounslow 11 14/11/33 ... ... 27/2/34 ... 27 Continuation of Table showing dwelling-houses represented as unfit for human habitation since the passing of the Housing Act, 1930. Premises. No. of houses represented as unfit. Dates of representations. Dates houses rendered fit in accordance with undertakings. Dates undertakings accepted that houses would not be re-let for human habitation. Dates Demolition Orders made. Dates Demolition Orders obeyed. Dates Demolition Orders enforced. Dealt with in 1934 :— 149 and 151, Hanworth Road, Hounslow 2 6/2/34 ... ... 27/3/34 ... ... 1 and 2, Worthing Cottages, North Hyde Lane, Heston 2 6/2/34 ... ... 27/3/34 29/5/34 ... 11, 13, 15 and 17, Church Street, Isleworth 4 6/3/34 ... ... 31/7/34 ... ... 78, South Street, Isleworth 1 6/3/34 ... ... 24/4/34 ... ... 1 and 3, Church Street, Isleworth 2 5/6/34 ... ... ... ... ... 5, 7 and 9, Church St., Isleworth 3 5/6/34 ... ... 31/7/34 ... ... 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, The Parade, Lampton Rd., Lampton 10 5/6/34 ... ... 31/7/34 ... ... 1 and 3, North Street, Isleworth 2 5/6/34 ... 25/10/34 31/7/34 ... ... 5 and 7, North Street, Isleworth 2 5/6/34 ... ... 25/9/34 ... ... 11, North Street, Isleworth 1 5/6/34 ... ... 27/11/34 ... ... 1 and 2, The Square, Isleworth 2 5/6/34 ... 25/10/34 31/7/34 ... ... 6, The Square, Isleworth 1 5/6/34 ... ... 28/12/34 ... ... 7, The Square, Isleworth 1 5/6/34 ... ... 27/11/34 ... ... 1, Swan Street, Isleworth 1 5/6/34 ... 25/10/34 31/7/34 ... ... 1 and 2, Hall Farm Cottages, Vicarage Farm Road, Heston 2 5/6/34 ... ... 31/7/34 5/11/34 ... 64, High Street, Hounslow 1 10/7/34 ... ... 25/9/34 ... ... 66, 68 and 70, High St., Hounslow 3 10/7/34 ... ... ... ... ... 185, 187, 189 and 191, Lampton Road, Hounslow 4 10/7/34 ... ... 25/9/34 ... ... 42,44, 46,48 and 50, London Road, Brentford End 5 10/7/34 ... ... 25/9/34 ... ... 244 and 246, London Road, Isleworth 2 10/7/34 ... ... 25/9/34 ... ... Basement Flats, 79 and 81, Lampton Road, Hounslow 2 4/9/34 ... ... ... ... ... 3, 5, 7 and 9, Tivoli Rd., Hounslow 4 4/9/34 ... ... 30/10/34 ... ... 179, Lampton Road, Hounslow 1 9/10/34 ... ... 28/12/34 ... ... 83, 85, 87, 89, 91, 93, 95, 97, 99 and 101, London Rd., Brenford End 10 9/10/34 ... ... 28/12/34 ... ... 131, 133 and 135, New Heston Road, Heston 3 9/10/34 ... ... 28/12/34 ... ... Gray's Cottage, Cranford Lane, Heston 1 13/11/34 ... ... ... ... ... 6 and 8, Hartland Road, Isleworth 13, Holloway Street Hounslow 2 4/12/34 ... ... ... ... ... 1 4/12/34 ... ... ... ... ... 16, South Street, Isleworth 1 4/12/34 ... ... ... ... ... 18 and 20, South Street, Isleworth 2 4/12/34 ... ... ... ... ... 28 Inspection and Supervision of Food. The following is the record of inspection of food premises :— Meat 1,113 Fish 249 Provisions 326 Greengroceries and Fruit 351 Hawkers' Food Stuffs 94 Food Preparation Places Inspected 404 Number of other Food Inspections 25 Fried Fish Shops.—Applications periodically are made for the establishment of fried fish premises, but the Council still hold to the policy of spacing them out and controlling the supply in the district, thus ensuring two things : — 1. Control of the offensive trade, and 2. The quality of the goods supplied. 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. 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 1934, seventeen samples of milk were taken from retailers in the district. These samples were submitted to the Lister Institute for animal inoculation tests, but in none of these cases was the presence of tubercle bacilli demonstrated. Five cows were reported by owners as showing 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 others showed clinical symptons of tuberculosis. All were slaughtered under the Tuberculosis Order, 1925, of the Ministry of Agriculture. Routine examination of milch cattle was carried out during the year by Mr. R. Wooff, M.R.C.V.S., the County Council's whole time veterinary inspector, and 616 inspections of cows were made. None of these cows was found to be suffering from tuberculosis." 669 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 9 (7 shops). "Grade A" (Tuberculin Tested) milk 11 (11 shops). " Grade A " milk — " Grade A " Pasteurised milk 2 (2 shops). " Pasteurised " milk 9 (14 shops). (two of these are licensed producers of " Pasteurised " milk). 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 now 8 slaughter-houses (4 registered and 4 licensed), in use in the district, and each slaughter-house received on an average 9 visits per month. There were 67 butchers' shops in the district at the end of 1934. 29 2. Public Abattoir.—There is no public abattoir in the district. Slaughtering may take place at any time, subject to the requisite notice being given. From time to time suggestions have been brought forward as to the possibility of establishing an abattoir. I have on every occasion advised against it, on the grounds that I do not think that at the present time the expense is justified, owing to the fact that by far the greater part of the meat coming into the district is bought at Smithfield and inspected there. There does not seem to be with the growth of the district any great demand for further facilities for slaughtering at present. 3. Action under Section 117, Public Health Act, 1875 :—No unsound meat was seized during the year. 4. Diseased Meat.—There was none seized, but a total of 3,294 lbs. were surrendered during the year, including 2,360 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 7 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 67 butchers' shops in the district, 46 are provided with fixed windows, of which number 6 were new shops in 1934; 3 other shops are provided with one fixed window and one window made to open; 2 have one fixed window and two windows made to open, and the remainder have windows made to open. INSPECTION OF OTHER FOODS. Efforts are being made to get the large Stores to cover such food products as are sold on the counter. The public are very curious in their outlook in these things and in one of the largest Stores in the district when discussing the matter with the Manager, and in particular relation to biscuits which were exposed in open compartments on the counter, he said that there were only two kinds of biscuits which his public would buy in packets, one of which was a cream cracker, but I am advised he is experimenting with celophane as a wrapper, and in other directions. I am hoping that in the near future some method will be evolved specially to cover all foodstuffs for sale. 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 1934. Article Taken. Adulterated. Milk 193 7 Brandy 1 — Cocoa 1 — Cream 1 — Gin 9 5 Hake 3 2 Honey 2 — Lemon Sole 3 1 Meat 1 — Meat, cooked 3 30 Meat Pies 1 — Minced Beef 7 — Rum 3 1 Sausages 8 2 Whisky 15 7 251 25 Number of Prosecutions 5 Number of Convictions 5 The seven adulterated samples of milk were taken in course of delivery from a Berkshire farmer. All the samples contained added water, and the farmer was prosecuted and ordered to pay £15 15s. Od. "as costs." Two fishmongers were prosecuted for selling respectively haddock for hake and witch for lemon sole. UNSOUND FOOD, 1934. Tons. cwts. qrs. lbs. Bacon 4 Corned Beef 6 Fish 2 21 Meat 1 12 1 9 Poultry 1 1 11 Rabbits 2 14 Total 1 15 0 9 31 CARNEGIE TRUSTEES NUTRITION RESEARCH. From April onwards this work has been carried out in premises specially provided by my Council. The Carnegie Trustees voted £500 for this research which was to be made in two directions. (1) The utilisation of the cheaper cuts of meat, and (2) The provision of first class protein. The Council voted the sum of £120 to provide premises, apparatus and necessary clerical assistance, so that the £500 voted by the Trustees should all be available for the research work. A special hut was erected in the grounds of Clipstone House, adjoining the central building, provided with a sink and the necessary cupboard accommodation, and an ordinary coal range, two types of gas cookers and an electric cooker, all of a type similar to those which are being installed in the houses on the Council's estates. All the apparatus, with the exception of a large fish kettle, deep fat frying pans, and baskets, were purchased from Woolworth's, the idea being that as none of the apparatus cost more than sixpence, everything that was used for the research was available for the poorer members of the community. The deep fish frying pan and basket was eventually discovered to be manufactured by a firm in East London. These were deep enough to hold 51/2lbs. of fat, had a safety lip of half an inch all round, with an opening for a pourer, and together with the basket were obtained for l/9d. A cover which exactly fitted was obtained at Woolworth's for twopence. These were most satisfactory and perfectly safe in contrast to the type which has recently been put on the market, which are not deep enough for fat frying, and are, in my opinion, really dangerous. The object of the research, apart from the scientific provision of adequate food, was the provision of meals which should be palatable, and if possible, pleasing in appearance, and for that reason many of the experimental dishes were altered many times until the desired aim was attained. Careful records were kept of each experiment, and cards of different colours used according to the fuel used. As will be seen, on the face of it, the cards give the fullest details:— Name of Prepared Food, Materials, Measure, Weight, Cost, Calories, Vitamin, Weight lost in Cooking, Time Taken, Fuel Consumption, and Final Cost. On the reverse, in addition to the method of preparation, the report of four tasters is shown. This I felt was important as it is not everyone who realises that we who are educated to more delicate flavours are not the best critics of the taste of food supplied to the humbler members of the community. No. Fuel Main Ingredients Name of Prepared Food No. of Persons Materials Measure Weight Cost Calories Vitamin TOTALS PRO. CHO. FAT. Weight loss in Cooking, Actual Per Cent TOTAL CALORIES TIME TAKEN Hours Minutes FUEL CONSUMPTION Initials Preparation Amount Cooking Cost REMARKS COST Food Fuel Total Cost 32 It must be borne in mind that there is often a craving, especially among the humbler members of the community, for more pronounced flavours, as for example, vinegar, sauces and pickles. The use of sauce is so great a habit, that very often the only taste that a prepared dish had was the sauce with which it was covered. Some time since, in one family I discovered that a girl of twelve years was having a whole bottle of a well known sauce all to herself each week. For this reason, in addition to the meals being sampled by me personally and my chief research worker, an unemployed man and the wife of a different unemployed man sampled the meals, and we each expressed our opinions as to what, if anything could be done to improve the flavour or the appearance of the dish. The criticisms obtained in many instances were distinctly useful. I was extremely fortunate with the staff I obtained, particularly my chief research worker. Miss Hook, to whom the bulk of the credit for the ultimate results must go. One tried in every way to utilise articles which could be obtained at small cost. For example, on each side of bacon cut in the grocer's shop, in order to produce the tidy looking rashers which are exposed for sale in little piles, there is from 3/4lb. to 1/4lbs. of scrap waste. This waste is exactly the same bacon as the next cut, which is sold at l/4d. or more per lb. This waste can in many places be bought for twopence a pound, and the highest price I have paid for it is fourpence. I found in many cases it was being sent to candle or soap makers. True, if this becomes a saleable product the price will go up a certain extent, but it will still be cheaper than the rasher prices. The addition of a small quantity of this bacon is one of the chief methods of producing the good flavour in many meat dishes, and in certain fish dishes. Again, one found that in one of the big stores some 251bs. of biscuit dust was a burden. Not broken biscuits which are sold at fourpence to fivepence a pound, but dust from the bottom of the tins. This, of course, has a high food value due to the butter and sugar in addition to the protein obtained from the flour. By mixing this dust with a two-penny raspberry jelly, a delightful pudding was produced, appetising to look at, and of high nutritive value. It is, of course, to be realised that in using the cheaper cuts of meats, particularly clod, shin of beef and sticking piece, that there is a high fibrous tissue content, and that the most satisfactory way of cooking is by stewing very slowly. One found that this method of cooking was one that many mothers would not be bothered to use, and also that they were not prepared to eat the food prepared in this manner. Their principle method of cooking, particularly in the poorest homes, was to fry everything and frying in the most greasy and unwholesome manner possible. In one house in which I happened to call just when dinner was being prepared, where the condition of the premises was such that it was to be demolished as being unfit for human habitation, the dinner being prepared consisted entirely of a very large frying pan filled with chops and sausages, and still more sausages were on the table—possibly the most expensive and wasteful form of meal that can be prepared for people in those circumstances. Method of Preparation Utensils REPORT ON COOKED FOOD BY SAMPLERS A. B. C. D. COMMENTS SUGGESTIONS 33 I sent my chief research worker into some of the humbler homes with a Health Visitor— (a) To find out what they had in the house in the way of food, and the method of its preparation. (b) What reserve they had apart from day to day catering. (c) What utensils they had to cook with. One was rather surprised to find that in a large number of houses, even among the very poor, they had a large iron saucepan twelve inches in diameter, and about the same depth. This, it was found, was utilised more for washing clothes than for cooking food. But its possibilities from a cookery point of view were, of course, very large. In November I had a fortnight's demonstrations in Isleworth, taking Isleworth as that part of the district representing the most concentrated area of the poorer members of the community. In view of a certain amount of hostility that had been evinced, it was necessary to ensure that there was no failure, and publicity was an expensive part of the campaign. It was a matter of regret that in one section I particularly wanted to reach, practically every poster I put up was pulled down. Outside the Hall on the main 'bus route through Isleworth, a large hanging streamer was suspended inviting people to attend to see " How to Stretch the Food Shilling." The Isleworth Public Hall was utilised for the demonstrations, and not only had it to be specially adapted for the audience, but adapted so that the audience could see everything that went on in the way of preparing the food, and for this reason I had special tables made for the platform. These were specially floodlighted by an electric installation. This took a considerable number of experiments before one got the floodlighting exactly on the hands of the demonstrator in the most efficient way. The method of the exhibition was that food was partly prepared in our experimental kitchen. I determined that the usual procedure adopted by the Gas Companies and the Milk Publicity Council, and others who hold food demonstrations, of offering small portions of the food prepared, on a fork, was useless for my purpose, and it was arranged that every member of the audience was supplied with a cardboard picnic plate with a substantial portion and the necessary cutlery for its consumption. At each demonstration six dishes, including puddings, were prepared and demonstrated. The bulk of the food was, as I have stated, prepared in the experimental kitchen, taken down in bulk by motor cars to the Hall, and was there finished off by two assistants. In the case of some dishes, however, they had actually to be prepared whilst the demonstration was taking place. In addition to this, each dish was demonstrated and prepared by Miss Hook from first to last on the platform. I cannot speak too highly of Miss Hook's methods which, if I may say so were as perfect as anything I have seen in this direction. She had her audience held from first to last, and her explanations were so lucid that they kept the audience interested from beginning to end. At the end of the demonstrations by Miss Hook, the meals demonstrated were passed to the audience. This, of course, raised a number of difficult problems :— (a) How to get the food over hot to the audience. (b) How to ensure that no mess be made. I arranged the Hall so that the seats were in rows of four, with a passage way of adequate width between. I obtained twenty girls from one of the schools, ten of whom took the food out, each having a corridor. The other ten were provided with baskets and went to collect the cutlery and debris at the completion of each course. With this arrangement no girl had more than two people on each side of her corridor to deal with. Therefore, there was no stretching and no spilling. The arrangement was that the food that was prepared for the audience was served over a table at the back of the platform, the girls all proceeding the same way and taking out their tray with their plates without confusion. The scheme worked so well that throughout the fortnight's demonstration there was not a single upset or mess on the floor. In order to ensure that the audience should hear everything, loud-speakers were installed, but these were discontinued as Miss Hook found she could make herself heard in all parts of the Hall without them. It was, of course, necessary to have some assistance for washing up dishes, and these were housed in a room adjoining the Hall. In view of the actual cookery that was taking place, safety was ensured by providing two large extinguishers on either side of the platform, and a fireman was also in constant attendance. I opened the proceedings each session with a short general talk on nutrition and cookery. I was extremely fortunate in that for the fortnight's demonstration Miss Hook was assisted on the platform by the head of one of the best known Domestic Training Colleges in the country, who came without fee to assist Miss Hook in friendship's name. I cannot be too grateful for assistance which she gave throughout the fortnight. 34 In addition, the assistant who had been working with Miss Hook in our researches for some time, herself a duly trained cookery expert, provided a trio on the platform, which was the main contribution to what was from first to last, an extremely successful demonstration. The proceedings were opened on the first occasion by His Worship the Mayor, who evinced his personal appreciation by demanding a second helping of one of the dishes which we christened " Cod Hot Pot," and which was generally highly appreciated. One felt as time went on, that one would have been doing a really national work if one had been able to go up and down the country disseminating the information which one had gained, which would not only have resulted, I am convinced, in better nutrition, but a better appreciation of how to feed a family. The fact that one is a practical cook as a result of years of experience, was found of inestimable value in criticising the various dishes from the point of view of improving either their preparation or their flavour. I cannot be too grateful to the Council for allowing me to undertake this research, and for the help which they gave to further it, and I am convinced that if the information can be disseminated to those who really need it, something will have been done to materially improve their conditions of living. Not only was there a good attendance from people in our own district, but deputations were sent over from various districts around London, and on one occasion the Committee of the Carnegie Trustees themselves came to see the result of the work which they had been fostering. 35 Infectious Diseases. Scarlet Fever and Diphtheria.—There were 14 "return" cases of Scarlet Fever and none of Diphtheria during the year. The usual period allowed when speaking of a " Return Case " is 28 days after the return home of a case from Hospital, or 28 days after the release of a case from isolation at home. No cases of Diphtheria were notified from North Hyde School during the year. Some use is made of the Dick reaction in connection with query cases of Scarlet Fever at Mogden Hospital. Scarlet Fever serum is used in nearly all cases at the hospital. The Staff of Mogden Hospital is Schick tested and immunised. Scarlet Fever.—The following table shows the number of cases which have been notified, and the number and percentage of cases which have been removed to Hospital:— No. of civil cases notified 386 No. of civil cases removed to Hospitals 333 Percentage of cases removed to Hospitals 86.27 The incident rate of Scarlet Fever in the civil population (87,555) was 4.41 per 1,000. There were two 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 99 No. of civil cases removed to Hospitals 98 Percentage of cases removed to Hospitals 99.0 The incident rate per 1,000 of the civil population was 1.13. Twenty-seven cases occurred in institutions during the year. Four deaths occurred from this disease, i.e., a case mortality rate of 4.04 per cent. The deaths occurred in the following age groups :— 1—2 years 1 3—4 years 2 10—15 years 1 And in the following months :— March 2 October 1 November 1 For the last five years the deaths from Diphtheria have been as follows :—• Year Year Year Year Year 1930 19 1931 4 1932 3 1933 2 1934 4 The full details of the Immunisation work for 1934 are set out in the following report. 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. The total attendances during the year amounted to 5,750. The cases concluded and issued with certificates of apparent immunity during the year amounted to 646. Of these 582 persons had been successfully immunised. 64 were found to be naturally immune. 36 REPORT ON A FIVE YEARS' INVESTIGATION INTO THE SAFETY AND EFFICIENCY OF ACTIVE IMMUNISATION AGAINST DIPHTHERIA This investigation formed part of a campaign to protect the child population of the Borough of Heston and Isleworth, following a severe outbreak of Diphtheria with a high mortality in 1929. The main underlying idea was to demonstrate, as clearly as possible, that immunisation with a suitable substance is a safe, almost painless, and practically completely efficient method of safeguarding the child population against Diphtheria. It was also considered essential to create public confidence by publishing the facts and figures resulting from the investigation, and to show that immunisation, when carried out efficiently, by competent physicians, is virtually 100% free from any risks of untoward happenings. The antigen selected for this work was Messrs. Burroughs Wellcome's Toxoid-antitoxin Mixture (T.A.M.). Despite pressure from various sources to use later preparations, and the one shot variety in particular, no deviation from the original preparation was made, except in the case of 12 children who showed more reaction to T.A.M. than is usually the case. These subjects were given Toxoid-antitoxin Floccules (T.A.F.), for their final immunising injections. It was felt that parents attending the Diphtheria Prevention Clinic came with the purpose that their children should not have Diphtheria at all if it could be avoided. Their idea was not merely that the child should be treated to the extent of ensurng that if an attack occurred, it should be a milder one than if immunising injections had not been given. They are not asking for the employment of methods which may leave as many as one child in five unprotected. At the present time the general practitioner, as well as the public health officer, is being pressed on all sides by representatives of firms that manufacture ' single injection ' immunising preparations, in an endeavour to procure their wide utilisation. It must be borne in mind that many of the new preparations are liable to produce severe reactions in a proportion of the children, and if employed at all generally, the method should be reserved for the smallest children, unless a Moloney test is first performed. Even so, the data as regards the percentage of persons immunised by 'one-shot' methods, and the durability of that immunity, are insufficient for this type of immunisation to be generally recommended. Working on the lines that we have been doing with T.A.M., we consider that we have produced results which compare very favourably indeed with those obtained with any other antigen in existence. It is possibly true that as long as Antitoxin is used, there is a very slight risk of sensitising a very small percentage of cases, but so far, in the five years' work, we have had no untoward symptoms arising from this cause. It does appear that when children have been immunised with T.A.M., that there may be some degree of serum sensitisation, but this does not seem to be of any serious extent. The closest contact has been kept with Dr. Gammie, the Medical Superintendent of the Joint Isolation Hospital. Since his appointment four years ago, Dr. Gammie, to whom we are deeply grateful, has kept careful notes of the condition of immunised children from this district entering the hospital. It should be realised that in alluding to the children having serum injections, this does not only refer to the Diphtheria patients, but to all kinds of injections for Scarlet Fever, Cerebrospinal Fever, etc., containing horse serum. His report is as follows :— " The following are the completed figures with regard to the susceptibility to serum rashes of children immunised with T.A.M. During just over four years commencing April 1931, 1101 patients had injections of antitoxin of various kinds containing horse serum, in Mogden Hospital. Four of these were children undergoing immunisation at the time. Two had rashes and two did not, but as they might only have been desensitized by the T.A.M., I propose to omit them from the total. There are thus 1,097 cases to investigate, and of these 293 had serum rashes. None of them had serious symptoms, either in the immunised or the non-immunised group, but I have divided the rashes into severe and not severe. By a severe rash I mean either a rash of very unusal intensity and extent, or one accompanied by a sharp rise of temperature, considerable localized oedema of any part of the body, or well marked joint pains. 1,015 non-immunised patients received serum treatment, and 239 (21.7%) of these developed rashes, of which 24 (10%) were severe. 82 immunised children had serum, and rashes occurred in 54 (65.8%), of which 13 (24%) were severe. I think it only fair to point out that the proportion of cases receiving scarlatinal antitoxin was somewhat higher amongst the immunised than amongst the non-immunised children, and this form of antitoxin seems to be more liable to produce reactions than the diphtheria antitoxin; but I think the figures show clearly that T.A.M. does sensitize a child to future injections of horse serum. It is equally clear, however, that one need only expect discomfort, as in no case has actual danger arisen." 37 Undoubtedly it would be desirable to employ a totally serum-free prophylactic if a satisfactory preparation were available. In the present state of these preparations, however, such does not seem possible. All the strong toxoid preparations are liable to produce reactions after the immunising dose unless controlled by Moloney tests, and these tests are not feasible in clinics held only once weekly. It therefore appears to be desirable to use a prophylactic which causes little or no disturbance at the time of immunisation, and to run the almost negligible risk of slight sensitation in event of a child requiring horse serum subsequently for any reason. If the serum sensitivity were of a dangerous degree this view could not conscientiously be expressed. One appreciates the fact that a general practitioner may desire to dispense with the Schick test, as in the absence of mass psychology, which is a feature of the clinic, there is more likely to be resistance and tears when children are treated separately in the consulting room. Tears with us are not common, by reason of the mass psychology, and a film which was taken by one of us is going over the country, and even to Australia, showing that the procedure of immunisation is not a painful one. The difficulty of the general practitioner is that if he neglects the Schick test, he remains unwarned of pseudo-reactors, who definitely are more likely to show reaction to immunising materials of all descriptions. Obviously also, he has no idea whether he is immunising without need. On the other hand, if he dispenses with the posterior Schick test, he must warn parents that the routine with T.A.M. may leave a proportion of the children incompletely immunised. Some children may require extra injections. It must be remembered that 'A NON-IMMUNE CHILD, BELIEVED TO BE IMMUNE, IS IN GREATER DANGER THAN IF IT HAD NEVER BEEN TAKEN BY ITS PARENTS TO BE PROTECTED, BECAUSE THERE IS LIABLE TO BE DELAY IN CALLING FOR MEDICAL ASSISTANCE.' Hence the vital importance of making certain that immunity has been established, or of warning the parents of the true position. {Note. No quotation from the last paragraph is to be published or copied unless it contains the whole of that paragraph and the preceeding one.) In this work, it was hoped to determine exactly what could be accomplished by the use of one single preparation as regards the initial production of immunity in as large a number of children as could be thoroughly investigated. Further it was desired to find a partial answer to the oftdebated question, " How long does artificially-produced active immunity last?" As far as the co-operation of parents could be obtained, it was determined that every child who had become Schick-negative as a result of T.A.M. injections should receive a further Schick test about three years later. If the immunity of any subjects had waned, the purpose-was to restore it by further injections. Despite the pronouncement of the League of Nations and the Army Authorities that a preliminary Schick test is unnecessary, it was decided to apply the test in eveiy case when possible, for the following reasons :— (1) To ascertain with accuracy the number of naturally immune cases compared with those requiring to be immunised. (2) To ensure that no child should be given immunising injections unless they were necessary. (3) To obtain statistical evidence of value. It is clear that no figures purporting to relate to the efficiency of immunisation are of any value unless it can be shown that all the cases under discussion were originally susceptible to Diphtheria, i.e., Schick-positive. Our opinion is that the giving of injections to children who do not need them is both unscientific and unsound. In our experience the initial sorting of the children into immune and susceptible classes has been more instrumental in creating public confidence than has any other part of the procedure. The parent who finds that one of her children is naturally immune and needs no further injections, compared with the other child who does, is glad indeed, and there appears to be no doubt that the Schick test is widely appreciated. It may be easier to overcome prejudiced or nervous parents by stating that when the test is omitted, the number of injections or attendances is reduced by one. Such procedure has not been necessary in this work. Such success as we have attained has been by means of scientific work combined with utter frankness, and by periodic publicity of various kinds. It must be realised that while Dudley's work was done in a relatively closed community of a circumscribed character, the investigation described here was carried out in a Borough with a constantly growing population, the growth being the fourth largest in the country in the last intercensal period. Much of that growth has been due to a population influx, planted in our midst by neighbours, who are particularly resistant to all public health overtures. Before giving figures and stating conclusions, the bare facts may be given. Out of 3526 children either naturally Schick-negative or rendered so as a result of adequate injections. THERE HAS BEEN NO DEATH FROM DIPHTHERIA. THERE HAVE BEEN 38 ONLY TWO MILD CASES IN IMMUNISED CASES BELIEVED TO BE IMMUNE, AND ONE MILD CASE IN A NATURALLY SCHICK-NEGATIVE CHILD WHO HAD REMOVED FROM THE DISTRICT AT THE TIME OF THE ATTACK.' The Diphtheria incidence among children passed through our hands amounts only to:— 0.06% of all cases tested who received certificates stating that they were believed to be immune to Diphtheria. The investigation about to be described was conducted as follows:— Every new case attending the clinic was Schick-tested irrespective of age. A careful record was kept of the size and intensity of all the positive or pseudo reactions. The Schick-positive cases received three injections of T.A.M. by one of two methods. Method 1. 1 c.cm. was given, followed by 1 c.cm. in 7 days time. A third injection of lc.cm. was given a fortnight after the second. Method 2. This modification, which was employed on a separate series of cases, was identical except that the third injection consisted of 1.5 c.cm. of T.A.M. instead of lc.cm. Three to four months later all subjects were sent for in order that they might be re Schicktested. Any found to be still positive received further injections and, after an interval, further Schick tests, the procedure being continued in each case until a Schick-negative state was attained. Cases have been called up again after an average interval of 3.6 years from the date of their original immunisation, in order that they might receive a further test, and if necessary, further immunising injections. Naturally Schick-negative cases have also been re-investigated from 3 to 6 months after their original Schick test, and also a number were examined at the end of three years. By such means the exclusion of Diphtheria from this community of thoroughly treated persons was attempted. It may be noted at this point that reactions of an undesirable nature in children treated with T.A.M. (given by deep intra-muscular injection into the upper arm) are rare and trivial. In only two cases during the whole of this work has it been necessary to abandon the attempt to produce active immunity on account of excessive reaction, and curiously enough these two cases were brother and sister. Both appeared to have an extraordinary idiosyncracy to the immunising material, which has not been met with by us in other children. Turning to the actual results of the investigation, the figures are given below of the reactions obtained in 5203 primary Schick tests, divided into their various age groups. 39 TOTAL PRIMARY SCHICK TESTS PERFORMED DURING THE FIVE YEARS 5203 Percentage positive 84.82. Percentage naturally negative 15.18. Age Cases Tested Negative Positive Percentage Immune 1 341 3 338 0.88 2 338 6 332 1.7 3 243 12 231 4.9 4 373 27 346 7.2 5 763 63 700 8.2 6 607 57 550 9.4 7 551 83 468 10.3 8 493 96 397 19.4 9 493 129 364 26.1 10 405 108 297 26.6 11 227 70 157 30.8 12 163 58 105 35.5 13 206 78 128 37.8 Total all ages 5203 790 4413 15.18 It will be noticed that the largest jump in natural immunity occurs between the years of 7 and 8, and these figures certainly suggest that children over 7 years of age should be Schicktested before a course of immunisation is undertaken Up to the age of 7 years the primary Schick test may possibly be dispensed with in routine work, if the figures obtained subsequently are not to be employed eventually for statistical purposes. Results of Schick Tests up to and including 5 years of age. Total cases 2058. Positive 1947. Negative 111. From 6 to 10 years inclusive. Percentage immune 5.37. Total cases 2549. Positive 2076. Negative 473. From 11 to Adult Life. Percentage immune 18.5. Total cases 5%. Positive 390. Negative 206. Percentage immune 34.5. Actual Numbers of Subjects of Various Ages who have Attended Clinic. 5 years and under 2058 6 to 10 years inclusive 2549 11 years to adult life 596 5203 Total Certificates Issued to Date, 4287. (1) Actively immunised 3523 (2) Naturally immune 764 40 As has been stated previously, children found to be primarily Schick-negative have received a confirmatory Schick Test later when possible. Of the 790 naturally immune subjects in the above series, it was found possible to re-test 341 at a period of from 3 to 6 months later. The results were as follows :— Still Schick-negative 336 Reversion to some degree of Positive reaction 5 Percentage of reversion 1.46 The next analysis made was in relation to the percentage of children of all ages who were successfully immunised by three injections of 1 c.cm. of T.A.M. The second injection was given 7 days after the first, and the third injection made 14 days after the second. The results of the second Schick tests made from 3 to 4 months after the last injection are given below, tabulated in age groups. Investigation covering 2323 cases Re-Schicked from 3 to 4 months after immunisation by Method 1. Age Negative after 3 Injections Negative only after Further Injections Total Cases Percentage not Immunised 1 108 5 113 4.4 2 107 6 113 5.3 3 118 8 126 6.3 4 140 15 155 9.6 5 235 42 277 15.1 6 241 43 284 15.1 7 227 34 261 13.0 8 238 40 278 14.3 9 223 31 254 12.2 10 188 22 210 10.4 11 92 11 103 10.6 12 62 14 76 18.4 13 and over 65 8 73 10.9 Total all ages 2044 279 2323 11.8 From the above it will be seen that 11.8% of the subjects were not effectively immunised by these means. Naturally the matter was not allowed to rest there, and the 279 who were not immunised by the three injections were given a further series of as many injections as proved necessary. They were all ultimately shown to have become Schick-negative. It must be remarked that there is really no guide as to the number of extra injections that will be required by resistant cases other than perhaps the intensity of the second Schick Test reaction as compared with that obtained in the primary test. This is one argument in favour of keeping some sort of accurate record of the nature and extent of the original positive test. More will be said on the subject of the procedure adopted in those cases where additional injections are required later in this paper. On the whole, the results obtained from the above series of cases left us dissatisfied, and it was resolved to determine whether a larger final dose of T.A.M. would produce a higher rate of immunity among the children at the end of three or four months. The procedure adopted in Method 2 was to give all Schick-positive subjects two injections of lc.cm. of T.A.M. at weekly intervals, followed 14 days later by a final injection of 1.5 c.cm. 41 1203 cases have been investigated and the results of re-testing at the end of three or four months were as follows:— Age Negative after 3 Injections Negative only after further Injections Total Cases Percentage not Immunised 1 105 0 105 0.0 2 121 5 126 3.9 3 106 6 112 5.3 4 106 2 108 1.8 5 232 13 245 5.3 6 149 16 165 9.7 7 107 12 119 10.1 8 66 1 67 1.5 9 55 2 57 3.5 10 45 3 48 6.2 11 29 1 30 3.3 12 11 0 11 0.0 13 10 0 10 0.0 Total all ages 1142 61 1203 5.0 It will be observed that failure to immunise by this procedure amounted only to 5%, a marked improvement on the results of the former routine, which produced 11.8% of cases requiring further injections. This 5% of children of course received further injections and were all ultimately shown to have become Schick-negative. At this point it may be profitable to discuss further the question of the extra injections required by obstinate cases. Initially, when three injections of 1 c.cm. were employed, the failures were treated by means of a further complete course of 3 injections of 1 c.cm. When it became obvious that the response to the new method of immunisation was considerably better than that obtained by the old method, a modification in the manner of treating failures was adopted. Subjects showing a positive Re-Schick Test received 1 c.cm. immediately, followed by a second injection of 1.5 c.cm. of T.A.M. 14 days later. This method has been found to be satisfactory in nearly every case, and has been adopted as a routine. Only a relatively small number of cases are found which fail to respond to this modified second series, and who require further injections. It must, however, be admitted that occasional cases are met with which require 9 or even more injections before the Schick-negative state can be established. One wonders what would be the fate of these subjects were they treated by the 'one-shot' method, uncontrolled by any Schick or Moloney test ! The next point of outstanding importance appeared to be to determine the durability of the immunity produced as a result of 3 injections of 1 c.cm. of T.A.M. It has not yet been possible to investigate this point in the case of the newer method in which the larger third dose was employed, for the work is too recent for 3 year tests to be performed. The table appended shows the extent of reversion to some degree of Schick-positive reaction in a group of children tested at an average of 3.6 years after they had proved to be Schick-negative as a result of three injections of 1 c.cm. of T.A.M. 42 ANALYSIS OF THE SCHICK STATE OF 362 CHILDREN IMMUNISED (AT AN AVERAGE OF) 3.6 YEARS PREVIOUSLY. Age Remaining Schick Negative Reverted to some degree of Schick positive Percentage of reversion Total cases 1 24 2 7.6 26 2 21 0 0.0 21 3 23 2 8.0 25 4 27 1 3.5 28 5 40 5 11.1 45 6 47 5 9.6 52 7 49 4 7.5 53 8 53 3 5.3 56 9 32 2 5.8 34 10 10 1 9.0 11 11 5 0 0.0 5 12 6 0 0.0 6 Total all ages 337 25 6.9 362 Attention was next directed to a study of the permanency of the Schick-negative state in naturally immune subjects. Only 60 cases have been collected for this purpose at an average of 3 years from the time at which they had been found originally to be naturally Schick-negative. The results obtained were as follows:— 43 NATURALLY IMMUNE CHILDREN TESTED AT AN AVERAGE OF 3 YEARS AFTER THE PRIMARY NEGATIVE SCHICK TEST. Age Number tested Still Schick negative Reverted to Schick Positive Percentage of reversion 1 0 0 0 0.0 2 1 1 0 0.0 3 2 2 0 0.0 4 3 3 0 0.0 5 5 5 0 0.0 6 4 4 0 0.0 7 12 9 3 25.0 8 16 16 0 0.0 9 8 8 0 0.0 10 7 7 0 0.0 11 1 1 0 0.0 12 1 1 0 0.0 Total all ages 60 57 3 5.0 In both the foregoing tables the ages given are those of the children when they presented themselves originally for treatment. The actual ages at the time of re-test were of course from three to four years greater than those shown in the tables. It is now interesting to compare the variation in the Schick-negative state in the two groups, the artificially and the naturally immune. Immunised by three injections of 1 c.cm. of T.A.M. 6.9% reversion Naturally immune subjects 5.0% reversion Difference 1.9% The fact that the immunised subjects show only 1.9% more tendency to reversion than the naturally immune subjects is both interesting and gratifying. This is additionally pleasing because there has been little obvious epidemic diphtheria in the district to stimulate immunity in the artificially immunised subjects, and it has been generally thought in the past that the natural Schick-negative state was a much more permanent phenomenon in the absence of fresh stimuli than was the artificially produced negative state. It is realised abundantly that with these small numbers, the statistical " probable error " is higher than it would be in dealing with larger numbers. In view of the advantage gained by Method 2 employing 1.0 c.cm., 1.0 c.cm. and 1.5 c.cm. as the dosage, it is proposed to try the effect of increasing the second dose to 1.5 c.cm. as well as the third. The results of this work will be published in due course, and it is hoped further to reduce the figure of 5% not completely immunised by the routine of method 2. The various figures given in the tables are appended here in graphic form, as it is felt that their real significance may be more readily appreciated thus. 44 45 A study of these graphs reveals at least one point of interest. However one looks at them, the fact emerges that the ideal time at which to undertake active immunisation is under the age of 5 years. Taking the Schick-Test table dealing with primary tests it will be noted that nearly all children are susceptible to up to this age. The tables dealing with the results of immunisation courses show that the response to active immunisation is, on the whole, definitely more reliable before the age of 5 years than at a later time in childhood. The result of Schick tests made 3.6 years after immunisation shows that this early-bestowed immunity is relatively well maintained. The greatest consideration of all however lies in the fact that Diphtheria is particularly liable to be fatal to young children. On this ground alone immunity should be conferred as earl)'' as possible in life. It is therefore particularly gratifying to find that the experimental work indicates that it is also expedient from a technical point of view to commence active immunisation at a very early age. It will now be of interest to consider the extent to which these measures have been successful in preventing Diphtheria among those children whose parents have sought the protection of the clinics, and to compare the incidence of the disease with that which has occurred among the children of the incredulous or lazy section of the population. During the five year period, 17 cases which have attended the Immunisation Clinic previously have been notified as suffering from Diphtheria. These notifications have been made either as the result of a positive swab being obtained from the patient or because of the opinion of a doctor on the clinical appearances alone. A careful examination of such cases has been made as far as was possible, and the history of each is given under an appropriate heading. It is unfortunate that in the Hospital to which the majority of these patients has been sent, the notes previous to 1931 are not of great value, but the records of these cases are included. Class 1. Cases proved not to have any evidence of Diphtheria at all. Case 8.F. Aet. 10. Notified 10.11.31. Withdrawn as a case of Vincent's Angina. The Medical Superintendent's report on this case is :—' Admitted 9.11.31. Said to be the first day of illness. Had a thick whitish patch of membrane on either tonsil, with moderate enlargement of cervical glands. Received 20,000 units of antitoxin. No K.L.B. were found in the swabs of throat and nose taken 9.11.31 and on 10.11.31. A direct smear proved the case to be one of Vincent's Angina. Discharged 20.11.31.' Duration of stay in hospital 11 days. Case 12. F. Aet. 6. This child was Schick tested first on 30.9.31. Result, strongly positive. Received two doses of 1 c.c. T.A.M. 7.10.31, 14.10.31, and one dose of 1.5 c.c. T.A.M. 28.10.31. A re-Schick test done 16.3.32 was negative. Was notified as suffering from Diphtheria 8.3.33. Was admitted to hospital 8.3.33 with a history of headache and sore throat since 3.3.33. The throat was very inflamed and the tonsils enlarged. There was no membrane. Cultures from the nose and throat were negative 8.3.33 and 10.3.33. A Schick test was done on admission, and this proved to be negative. No serum was given. Discharged 13.3.33. Duration of stay in hospital 5 days. Case 13. F. Aet. 7. Notified 16.3.33 as a case of Diphtheria. Had been Schick tested 24.2.30 and found positive. Was given three injections of T.A.M. (1 c.c.) 26.3.30, 2.4.30, and 16.4.30. A re-Schick test on 27.9.30 was negative. The Medical Superintendent's notes are:— ' Admitted 16.3.33, with a history of sore throat for three days. The tonsils were almost covered with a patchy membranous-looking exudate. There was very little glandular enlargement. The smell was strongly suggestive of Diphtheria. 4000 units of antitoxin were given, and a Schick test was done. The throat was clear in two days, and cultures taken 16.3.33 and 18.3.33 were negative. The Schick test was also negative, and she was discharged on 20.3.33. Duration of stay in hospital only 4 days. Class 2. Cases suspected to have been Diphtheria in which the provisional or subsequent diagnosis is very doubtful. Case 2. M. Aet. 8. The child was Schick tested on 23.4.30, the result being doubtful. Was notified 29.4.30 as suffering from Diphtheria, from the Princess Louise Hospital, Kensington, where the child was under treatment for Rheumatism, a swab having been taken from its nose. The case was supposed to be a nasal carrier, but as the swab proved to be negative, there appears to be no ground even for this diagnosis. The child was discharged from hospital 12.5.30, and a Schick test performed 28.8.30 was found to be faintly positive. This child was subsequently immunised and found to be Schick-negative after two injections of T.A.M. 46 It is extremely difficult to understand how the above case ever came to be certified as Diphtheria at all. Case 3. M. Act. 10. Schick tested 3.5.30 and found to be positive. Received first immunising dose of 1 c.c. of T.A.M. 10.5.30. Was notified as a case of Diphtheria 26.5.30. Treated at home and discharged as well 4.6.30. A cure effected in nine days hardly appears to confirm a diagnosis of clinical Diphtheria. Case 9. M. Aet. 5. Schick test 21.6.30 was markedly positive. Received three injections of 1 c.c. of T.A.M., 28.6.30, 5.7.30, and 19.7.30. A re-Schick test 11.2.31 proved still to be positive and two extra doses of 1 c.c. of T.A.M. were given 18.2.31 and 4.3.31. The child did not attend for a subsequent Schick test. The Medical Superintendent's report was:—'Admitted 11.11.31 with a history of nasal discharge since 9.11.31. This was swabbed at home, and reported by the Health Office to be doubtful. (The organism was subsequently found to be virulent.) The child was said to have been immune to Diphtheria, but had been resistant to immunisation. The throat was slightly injected on admission, and there was a watery nasal discharge, with sores on both nostrils and upper lip. Throat and nose cultures taken 11.11.31, 15.11.31 and 20.11.31 were all negative. The Schick test was negative. The child was allowed up on 16.11.31 and discharged 21.11.31.' It will be observed that his stay in hospital amounted only to 10 days, and that no K.L.B. could be demonstrated after three successive attempts by the hospital authorities. The grounds for calling this a case of clinical Diphtheria appear to be scanty indeed. Case 15.M. Aet. 7. Schick tested 29.6.32. Result positive. Received 1 c.c. of T.A.M. 11.7.32. Was admitted to hospital with Scarlet Fever 18.7.32. Found on examination to have K.L.B. in nasal swab. Throat was injected, but there was no membrane, nor was there nasal discharge. 2000 units of antitoxin were given. All other swabs were negative to K.L.B., and he was discharged 25.8.32. Further immunising doses of 1 c.c. of T.A.M. were given 7.11.32 and 14.11.32, and 1.5 c.c. on 28.11.32. Re-Schick 1.5.33 was negative. There appears to be no ground whatever to regard this as in any way more than a transitory nasal carrier, possibly of non-virulent K.L.B., for this patient was known to have been Schick-positive within a fortnight of the discovery of the organisms. If he had been carrying virulent bacilli, he would presumably have contracted clinical Diphtheria, which he did not. Class 3. Cases apparently suffering from real clinical Diphtheria at such a time as immunity could not have been expected to have developed. Case 1. M. Aet. 8. The patient had had only two of the necessary three immunising injections of lc.c. of T.A.M. on 17.3.30 and 24.3.30. Was notified as suffering from Diphtheria 22.4.30. Was discharged from hospital 19.5.30. Received a further inoculation 23.6.30 and when Schick tested 17.1.31 was found to be very positive. Two further injections were given 24.1.31 and 7.2.31 and the patient was re-tested 9.5.31, and was found to have become Schick negative. Case 4. F. Aet 6. Was Schick tested 19.5.30 and found to be positive. Received first immunising dose of T.A.M., 26.5.20. Was removed to hospital suffering from Diphtheria 29.5.30 and died 2.6.30. Case 5. M. Aet. 10. Patient was Schick-tested 31.5.30 and found positive. Received two immunising injections of 1 c.c. of T.A.M. 4.6.30 and 11.6.30. This patient was admitted to the West Middlesex County Hospital 1.7.30, having been taken ill 24.6.30, and was notified by the hospital authorities on 2.7.30. Case 6. F. Aet. 6. Tested 7.5.30 and found Schick-positive. Three injections of T.A.M. (1 c.c.) were given 14.5.30, 21.5.30 and 4.6.30. Was notified from bacteriological examination on 8.7.30 as suffering from Diphtheria. Patient was swabbed as a result of a discharge from the nose of some weeks' duration. The culture of K.L.B. was found to be virulent. Case 7. M. Aet. 2. Tested 26.4.30 and found to be positive to the Schick Test. Two injections of T.A.M. (1 c.c.) were given 3.5.30 and 10.5.30. Was notified as suffering from Diphtheria 11.7.30. Discharged from hospital 13.8.30 The third injection of T.A.M. was given 27.8.30, and a re-Schick test 17.10.31 proved to be negative. Case 10. M. Aet. 2. This patient gave a positive primary Schick test 21.3.32, and received two injections of T.A.M. (1 c.c) 21.3.32 and 28.3.32. Notified as suffering from Diphtheria 5.4.32, and remained in hospital until 2.5.32 Subsequently re-Schicked 1.5.33 and found to< be still positive. Given 1 c.c. of T.A.M. 8.5.33 and 1.5 c.c. on 22.5.33. Did not subsequently reappear for Schick testing. Medical Superintendent of Hospital reported :— Admitted 4.4.32 with a history of one day's sore throat. He had a fair-sized membranous patch on the left tonsil, and several small patches on the right, with some glandular enlargement. He received 8000 units of antitoxin, and a Schick test was done. The throat culture was negative, but the culture from the nose showed K.L.B. On 6.4.32, as the throat was not clearing well, 8000 units were again given. A culture taken from the throat at this date proved positive. On 9.4.32 the throat was quite clear, and the Schick test proved negative. He was kept in bed until 23.4.32. Further cultures 22.4.32, 26.4.32 and 30.4.32 were all negative. He was discharged 2.5.32.' 47 Case 14. F. Act. 9. Schick test 23.11.31 gave a strong positive reading. Two injections of 1 c.c. of T.A.M. were given 30.11.31 and 7.12.31, but the child did not put in any further appearance Notified as suffering from Diphtheria 21.7.33. She was removed to one of the L.C.C. hospitals. The report of the Medical Superintendent was :—' Admitted 21.7.33 (2nd day of disease.) Small deposit on right tonsil. No discharges. 8000 units of antitoxin given. 22.7.33, throat clean. Throat and nose swabs taken. 5.8.33 throat swab,Virulent K.L.B. Nose swab, no K.L.B. No complications. Discharged 28.8.33.' Case 17. Shortly after the closure of the five years, a medical man appeared at the Public Health Department, just as it was closing on Saturday, reporting that a child who had three injections of T.A.M., had a suspicious throat. The last injection had only been given a week previously. On hearing a description of the case, I advised immediate removal. The Medical Superintendent reported that the condition of the throat was such that in the case of an ordinary child he would have given her at least 80,000 units intravenously. The child herself, however, was not ill, and received only 8000 units, with a completely satisfactoiy result. Class 4. Cases of Diphtheria among persons who might have been expected to be immune. Case 11. M. Aet. 9. Schick test performed 22.2.30 gave a strong positive result. Three doses of 1 c.c. of T.A.M. given 1.3.30, 14.4.30 and 28.4.30. Patient was subsequently shown to have become Schick-negative. Patient removed to hospital 28.11.32. Medical Superintendent's report:—' A throat swab outside was returned positive. The throat was inflamed and a few points of exudate were seen on the tonsils. He was Schick-tested and found to be negative 2.12.32, upon which he was allowed to get up. Several successive throat cultures were positive. He developed Scarlet Fever while in hospital, and was discharged 15.1.33 ' Tn this case it is worthy of note that the patient was only kept in bed on account of the socalled Diphtheria for a period of 5 days, a truly remarkable instance of the protection of autogenous antitoxin against Diphtheria toxaemia. Also an admirable example of the slightness of the disease when it occurs in a conscientiously immunised person. Case 16. F. Aet. 5. Schick tested 7.3.31. Slightly positive. Received three injections of T.A.M., 14.3.31, 21.3.31 and 11.4.31 Re-Schick test 19.9.31 was negative. Child was notified as suffering from Diphtheria 17.10.34. There were small paper-thin patches of yellow membrane on enlarged tonsils, with a curly edge starting to peel off. The case was bacteriologically positive. 8000 units of antitoxin were given, and the child was not at all ill. This is again another striking example of the slightness of an attack in a carefully immunised subject. It is worthy of note that, in this experiment, we have advised parents to have the child's Schick reaction checked at the clinic in a year or two after immunisation, with a view to finding any possible backsliders, and re-immunising them. The last case was in a child whose parents had not availed themselves of this advice, and in the previous case over two years had elapsed. All the notifications have been investigated and described, as it is desired to make it clear that there is nothing to hide. In addition to the above two cases who have been immunised, a case was notified from another Borough just before Christmas, 1934. This child had been Schick tested and found to be naturally immune 21/2 years before. She had not come up for a re-test, having left the district, and was admitted to hospital with what was described by the Medical Officer of Health of the district, as a " very mild attack of clinical Diphtheria" The only cases that really concern the actual experiment are the last three, vis., Class 4, and the nature of these has been so harmless that they are encouraging rather than depressing. Anything approaching a death in an immunised and Schick-negative child is quite unknown in our experience. It must, of course be admitted that the immunity afforded by the present Schick level, though adequate as a protection against the 'mitis ' strains of K.L.B., may sometimes be expected to break down when submitted to mass attack by the more virulent ' intermediate and gravis ' strains. Nevertheless, even when these grave infections are encountered, it appears to be the case that actual life is not in danger, and that grave sequelae are extremely rare in persons who have ever been immunised by any scientifically efficient process. CONCLUSIONS. (1) It appears that by thorough and careful work, Diphtheria can be practically stamped out by active immunisation, and that fatal Diphtheria can be rendered non-existant, even in an open community. (2) A very definite advantage has been shown to result from the administration of a larger third dose of T.A.M. (Method 2), as only 5% of subjects have been found to be incompletely immunised as a result of this procedure. 48 (3) That immunity bestowed by three injections of 1 c.cm. of T.A.M. is maintained at the end of an average of 3.6 years in 93.1% of children, and that at the end of three years 19 out of 20 children found to be naturally Schick-negative originally can be expected to have retained that natural immunity, i.e., the Schick-negative state. (4) The ideal time to immunise children from every point of view appears to be under the age of 5 years. (5) That T.A.M. is an antigen which can be relied upon to produce very few objectionable reactions indeed. (6) That children over the age of 7 years ought to be Schick-tested prior to immunisation treatment, but that if circumstances demand it, the test might be omitted in those of 7 years of age or under, Pseudo reactions in this age group being rare. (7) That if all Schick-testing is to be abolished, a general practitioner will be wise in the light of present knowledge, to adopt our method 2 in preference to modern and incompletely tried 'one shot' (alum toxoid) preparations, or even in preference to our method 1. (8) That practitioners adopting this method (2) without any Schick-testing, have a duty to their patients. It behoves them to explain clearly that one child in 20 may not have complete protection. (9) That no methods ought to be generally employed which produce excessive or unnecessary reactions, and which have not been submitted to a really adequate clinical test as to their merits over a sufficiently long period of time. (10) It appears that immunising mixtures containing a small amount of serum are liable to produce a certain amount of sensitisation, but that experience shows that this is not of any serious extent. ELWIN H. T. NASH. GUY BOUSFIELD. 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 1934, 49 vials of Antitoxin of 8000 units each were supplied to medical practitioners. Smallpox.—No cases were notified during the year 1934. Enteric Fever.—There were 2 cases notified during the year. One was notified from the West Middlesex Hospital, and was a resident in this district. Erysipelas.—Eighty-two cases of this disease were notified, of whom 61 were of cases in the West Middlesex Hospital. Forty-seven were non-residents in this district. Ophthalmia Neonatorum.—See page 60. Puerperal Fever.—Twenty-three cases were notified. Twenty of these cases were notified from the West Middlesex Hospital, of whom 16 were not usually resident in this district. One case was confined in Queen Charlotte's Hospital, and two others in Nursing Homes, one of these being removed to Queen Charlotte's Hospital for treatment. Only one death occurred from Puerperal Sepsis. Puerperal Pyrexia.—Forty-one cases were notified; 37 of these were notified from the West Middlesex Hospital, including 29 who were not usually resident in this district Encephalitis Lethargica.—One case was notified during the year. Cerebro-Spinal Fever.—Three cases of this disease were notified. One was notified from the West Middlesex Hospital, but this case was not usually resident in this district. Two Military cases were also notified. Acute Poliomyelitis.—Two cases of this disease were notified. Pneumonia.—There were 205 cases notified—149 notifications were from the West Middlesex Hospital. One hundred and seven 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:— 49  1929 1930 1931 1932 1933 1934 Measles 83 799 9 952 108 901 German Measles 344 38 5 25 13 66 Chicken Pox 423 392 233 194 362 417 Mumps 106 381 132 122 940 153 Whooping Cough 177 144 242 260 287 144 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 8 deaths from Influenza during the year, the mortality being 0.09 per 1000 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. TUBERCULOSIS. I repeat what I said last year, that in my opinion an open-air recovery school is a real need in this district. It is impossible for those who have not been in close personal contact with open-air recovery schools to appreciate what an open-air recovery school really means. There is so much uninformed opinion with regard to what such a school means and does. Pulmonary Tuberculosis.—The number of new cases notified during the year was 77; Of the new cases, 55 were receiving institutional treatment at the time of notification, and 15 died. There were 58 deaths from Tuberculosis of the Respiratory System. Ten cases were transferred into the area, after notification in other districts. Other Forms of Tuberculosis.—The number of new cases notified during the year was 21. Fifteen of them were notified as receiving institutional treatment. There were 14 deaths. Three of the cases which died were unnotified. Deaths from Tuberculosis.—Thirteen deaths occurred in non-notified cases. In one of these the medical practitioner certifying the death thought the patient had already been notified before coming into his hands. Seven deaths occurred elsewhere, and were transferred to this district, and the others were apparently not diagnosed of new cases notified and deaths in 1934. The following Table gives further particulars of new cases notified and deaths in 1934. TUBERCULOSIS, 1934. Age Periods. New Cases. Deaths Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. M. F. M. F. M. F. M. F. 0 ... ... 1 ... ... ... 1 ... 1 1 ... 3 1 ... ... 3 1 5 ... 1 ... 3 ... ... ... ... 10 ... 2 1 2 1 1 ... ... 15 5 4 ... 1 2 3 1 ... 20 9 3 2 1 7 7 ... ... 25 8 8 2 2 6 6 3 1 35 10 6 2 ... 5 4 2 1 45 10 4 ... ... 5 4 ... ... 55 3 2 ... ... 3 1 ... ... 65 and upwards ... 1 ... ... 2 1 ... ... Totals 46 31 11 10 31 27 11 3 Ten of the deaths from Pulmonary Tuberculosis were not notified and three deaths from Non- Pulmonary Tuberculosis were not notified. 50 INFECTIOUS DISEASES, 1934. CASES NOTIFIED. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Cerebro-Spinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorium. Puerperal Pyrexia. January 46 3 ... 3 11 ... ... ... 23 4 5 1 1 February 42 3 ... 1 13 ... ... 1 38 3 2 ... 1 March 47 9 ... 4 12 2 ... ... 28 1 1 ... 8 April 42 7 1 1 15 ... ... ... 22 12 2 2 1 May 29 18 ... 2 3 1 ... ... 34 13 2 ... 2 June 30 10 ... ... 8 ... ... ... 19 5 1 5 7 July 33 10 ... 1 3 ... ... ... 12 7 ... 1 4 August 16 7 ... 3 4 ... 1 ... 1 10 1 ... 3 September 31 6 ... ... 2 ... ... ... 7 11 5 2 2 October 23 19 1 5 4 ... ... 1 5 5 2 1 1 November 25 5 ... 2 4 ... ... ... 9 10 1 3 5 December 22 2 ... 1 3 ... ... ... 7 9 1 ... 6 Totals 386 99 2 23 82 3 1 2 205 90 23 15 41 In addition to the above there were 2 Military cases of Scarlet Fever, 1 of Diphtheria and 2 of Cerebro-Spinal Fever. DIPHTHERIA, 1934 (including Bacterial cases, 33 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. 3 ... ... ... ... ... 2 1 ... ... 1 2 Feb. 7 ... ... ... 1 ... 4 1 1 2 ... 5 Mar. 11 ... ... ... ... 3 5 3 ... 1 ... 10 Apr. 10 1 ... 3 ... 2 4 ... ... 1 ... 9 May 19 2 4 4 ... ... 9 ... ... 12 1 6 June 13 ... ... 6 ... ... 4 3 ... 6 ... 7 July 13 ... ... 4 2 ... 4 3 ... 10 ... 3 Aug. 8 ... ... 1 ... 2 5 ... ... 1 ... 7 Sept. 7 ... ... 4 ... ... 3 ... ... 4 1 2 Oct. 31 ... ... 2 18 ... 8 3 ... 20 ... 11 Nov. 7 1 ... ... ... ... 6 ... ... 3 ... 4 Dec. 3 ... ... ... ... ... 1 2 ... ... 1 2 . Totals 132 4 4 24 21 7 55 16 1 60 4 68 51 Notifiable Diseases during 1934. 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 ... ... ... ... ... ... ... ... ... 2 ... ... 2 1 1 Scarlet Fever 1 3 15 21 24 177 71 18 38 13 5 ... 386 260 73 Diphtheria 1 2 4 7 6 56 10 4 8 1 ... ... 99 56 42 Erysipelas 5 ... ... ... 1 1 3 2 18 12 24 16 82 ... 68 Puerperal Fever ... ... ... ... ... ... ... 2 17 4 ... ... 23 ... 22 Puerperal Pyrexia ... ... ... ... ... ... ... 7 32 2 ... ... 41 ... 37 Ophthalmia Neonatorum 15 ... ... ... ... ... ... ... ... ... ... ... 15 ... 13 Poliomyelitis ... ... ... 1 ... ... 1 ... ... ... ... ... 2 1 1 Cerebro Spinal Fever ... ... ... ... 1 ... 1 ... ... 1 ... ... 3 ... 3 Pneumonia 9 11 11 6 4 29 14 4 37 20 47 13 205 ... 165 Dysentry ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... Polio Encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... For Tuberculosis Notifications—see other Table. 52 DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES, 1934. 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 ... ... 1 ... ... 1 ... ... ... ... ... ... 2 Diphtheria ... 1 ... 2 ... ... 1 ... ... ... ... ... 4 Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... 1 ... ... ... 1 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia 9 3 3 ... ... 1 ... ... 1 6 20 13 56 Poliomyelitis ... ... ... ... ... ... 1 ... ... ... ... ... 1 Polio- Encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... ... ... Cerebro-Spinal Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... ... 3 3 Total 9 4 4 2 ... 2 2 ... 2 6 20 16 67 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 1934:— 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 1 15 23 149 61 20 37 1 13 12 8 ... 340 Hounslow Hospital ... 1 2 7 2 ... ... 1 ... 2 1 1 17 Hounslow Barracks ... 1 1 1 ... ... ... ... ... ... ... ... 3 Mogden Isolation Hospital ... ... ... ... ... ... ... ... ... ... ... ... ... Collingwood College ... ... ... ... ... ... ... ... ... ... ... ... ... St. Mary's School ... ... ... ... ... ... ... ... ... ... ... ... ... Totals 1 17 26 157 63 20 37 2 13 14 9 1 360 In addition to the above civil cases, two military cases of Scarlet Fever, one of Diphtheria and two of Cerebro-Spinal Fever occurred in the Hounslow Barracks. 53 Maternity and Child Welfare. In July, Busch House was opened as a temporary clinic until such time as a new up-to-date one is built. This gives us a large waiting room for the Maternity and Child Welfare Clinic, and a Consulting Room for the School Qinic and Ante-Natal Clinic, together with cubicles for the ante-natal mothers, and accommodation for minor ailment dressings and a dark room for the Eye Clinic, on the ground floor. On the first floor there is a fully equipped Dental Operating Room with a Gas Recovery Room adjoining, a Dental Waiting Room, and Offices for the dental clerks. On the top floor there is a rest room for the female staff, and also a room for the Medical Officer and Dental Surgeon. In addition there is a kitchen used partly for demonstration purposes and partly for a means for any of the staff providing themselves with a mid-day meal. The formal opening took place on 27th June, 1934. It is hoped that the advent of the clinic into the Brentford End area will result in overcoming the apathy which existed among sections of the population which have come into the area from Brentford and Chiswick. Efforts have been made to obtain some sort of accommodation for the Cranford end of the area, which is now growing very rapidly, but so far without success. The Village Hall which at one time we hoped might be utilised has been seized by the Education Authorities to provide school accommodation owing to the rapid growth at that end of the district. The attendances of children at all the Centres during the last six years have been as follows:— Year. No. of attendances. Year. No. of attendances 1929 17,667 1932 31,656 1930 19,222 1933 35,110 1931 27,318 1934 33,102 The average attendances per session during the year 1934 were as follows:— At Douglas Road Centre 78.8 At Clipstone House, Bath Road, Centre 68.0 At Isleworth Centre 54.9 At Heston Centre 58.9 Approximately 64.4 per cent. of the notified live births attended at one of the Infant Welfare Centres before they were a year old. The number of individual mothers and children attending the Clinics is shown hereunder:— 1930 1931 1932 1933 1934 Douglas Road, Hounslow— Mothers 868 1087 1085 860 820 Children 946 1232 1741 1078 953 Clipstone House, Bath Road, Hounslow— Mothers — — 132 467 513 Children — — 153 557 569 fsleworth Public Hall and Busch House— Mothers 458 578 690 685 562 Children 522 757 763 824 726 Heston- Mothers 305 392 451 435 330 Children 355 478 534 550 387 54 Sales at Clinics. Quantity. Receipts. Cow and Gate 8599 lbs. 584 9 5 Half-Cream Cow and Gate 1355 lbs. 95 10 5 Ostermilk 464 lbs. 35 15 9 Hemolac 16 lbs. 1 4 0 Lacidac 148 packets 14 8 2 Virol 418¼ lbs. 32 2 11 Sugar of milk 235 lbs. 13 12 6 Oil and Mall 415 lbs. 13 10 9 Lactagol 1214 tins 63 16 10 Cod Liver Oil Emulsion 7554 bottles 213 10 8 Bemax 372 packets 7 11 8 Adexolin 109 phials 6 11 3 Total £1082 4 4 Ante-Natal Clinic. Dr. Wrigley's report which had been presented was destroyed in the fire. I have nothing but praise for the way in which Dr. Wrigley's work has been done. The clinic continues to grow and now every midwife in the district is bringing or sending cases to the Ante-Natal Clinic. The following figures of attendances at the Clinic:— 1932 1933 1934 Attendances by Expectant Mothers during the year 696 738 831 Average Attendance per Session 13.4 14.2 14.0 Number of Sessions 52 52 59 No. of Mothers attending Ante-Natal Clinic shown as a percentage of total notified live and still births 29.03 28.0 31.8 New patients 388 336 384 Total number of expectant Mothers who attended the Clinic during the year 396 373 419 there were in addition 31 post-Natal Cases, as against 26 in 1933. For the first time, as far as I am able to ascertain, broadcasting was used, not to inform the relations of a patient that they were to go to such and such a hospital to see a patient who was seriously ill, but to find the whereabouts of a patient in order to save her life. The facts were that a married woman came to the Ante-Natal Clinic early in pregnancy and was found to have a very early carcinoma of the cervix. The Ante-Natal Specialist did not inform her of the real condition, but took steps to arrange for her immediate admission to hospital with a view to operation. As soon as these arrangements were concluded, that is, within two days, steps were taken to get in touch with the patient, but it was found that the house was empty. Subsequent evidence showed that following a long spell of unemployment, they had got info arrears with their rent and an Ejectment Order had been put into force, and they had been put out of the house, and where they had gone, nobody that we could find in the immediate vicinity had any idea. In view of the seriousness of the woman's condition and the imperative need for the saving of time, knowing the rapidity with which this condition progresses during pregnancy, I asked the B.B.C. whether they would broadcast at the six o'clock news that night. I had, of course, to tell them as much of the circumstances as would show them the urgency of the matter. They agreed to do it, but warned me that I should be inundated with reporters from the various newspapers. At the six o'clock news the S.O.S. went over. The address, by some mistake, was wrongly given. I immediately telephoned to the B.B.C. and in an amazingly short time, the announcer corrected the mistaike that had been made in the original broadcast. The forecast of the Authorities at the B.B.C. with regard to reporters, was fully confirmed. Most of the London newspapers rang up and were not satisfied in some cases with either one or 55 two calls. They all received the same reply, that as a medical man the matter was confidential, and I could give them no further information about the patient. This apparently only stimulated the curiosity of some still further. It was left for one paper, however, to find out by some means or other where the patient lived, and they telephoned me late at night to say they had found the patient, who was living with her mother in X Street, and she would be at my office at nine o'clock in the morning. The broadcast had asked that the woman in question should call at the Public Health office in this area, or any other area where she happened to live, first thing in the morning I got to the office the following morning before it was due to open, so as to ensure that no information was given to any reporter or enquirer. I waited and waited, time slipped by, and it was not until nearly ten o'clock that the patient came in, having read at breakfast time in one of the papers, an account of the broadcast. Bearing the fragments of the paper in her hand, she wanted to know what it was all about, and I had, of course, to inform her of the gravity of her condition, and I am glad to say that within forty-eight hours—she insisted on making preparations before going into hospital—she was in hospital, and dealt with. I saw her some time after she came out, having had radium applied, and been operated on, and she was looking in excellent condition. I have seen her on various occasions since, and she says she feels first rate. I had considerable qualms at first about invoking the assistance of the B.B.C., and I was criticised by some of my colleagues for so doing, but knowing all the circumstances as I did, and the disappearance of the patient, I felt it was the only means I had of ensuring the early treatment of the patient's condition, and looking back on it afterwards I had no regrets, but the reverse. This is, as I said, I believe the first time on record that the B.B.C. has been invoked to save the life of a patient who had a chance, and to them I expressed, and again express my gratitude for the help they gave in this case. MATERNAL MORTALITY. 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, 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. Where this necessitates the removal of large numbers of teeth, there is the provision subsequently of dentures. Towards the end of the year the Committee reconsidered the scale of payments to be made by the mothers for these dentures, and the following new scale was put into operation:— Income per head after deducting rent. Charge to patient Less than 8/- Nil Under 9/- 1/8th Between 9/- and 10/- ¼th Between 10/- and 11/- 3/8ths Between 11/- and 12/- ½ Above 12/- Full cost The Committee also decided that in cases where the person responsible for payment for the supply of dentures—usually the husband—becomes unemployed, on production of proof of unemployment, the payments due during the period of unemployment are to be cancelled and written off. Where the extractions are numerous, in order that the mother shall get the least possible upset, an arrangement is made through the Royal Free Hospital (Eastman Dental Clinic), to admit the patients to their beds for one or two nights, as may be necessary, for which we pay at the rate of 15s. 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. 56 Although there is no Municipal Maternity Home included in 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, 1934. General Comments. Supply of Cases.—There was a slight increase in the number of patients dealt with, and appointments show an increase from 1524 in 1933 to 2061 in 1934. Net attendances increased from 1116 in 1933 to 1576 in 1934. 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 1932 652 498 1150 1933 717 807 1524 1934 Total ... 2061 Attendances were 1932 491 434 925 1933 548 568 1116 1934 Total ... 1576 Mothers. Permanent teeth. Children. Deciduous teeth. Total. Fillings 98 238 336 Extractions— Gas 445 567 1012 1062 Local Anaesthetic 31 19 50 Dentures supplied to mothers. Year. Uppers. Lowers. 1933 42 34 1934 42 39 The number of individual mothers supplied with dentures during 1934 was 45. Details of other work, years 1933 and 1934. 1933 1934 Administrations of General Anaesthetics 256 307 Advice 83 76 Dressings 16 59 Impressions taken 90 86 Charting and Estimating 129 179 Silver Nitrate Treatment 63 183 Scaling and Polishing 12 38 I. COHEN, L.D.S., R.C.S. (Eng.), Dental Surgeon. 57 Notification of Births. Number of live births notified during the year 1275 Number of still births notified 41 Notified by midwives 914 Notified by parents or doctors 402 No special measures exist for dealing with unmarried mothers or illegitimate children of such, but cases not wholly destitute have derived benefit through the Council's scheme for grants of food and milk. VOLUNTARY SOCIETIES AND HELPERS. The Isleworth Nursing Association and the Osterley, North Hounslow and Heston Nursing Association are the only Voluntary Societies in direct contact with the Council's Maternity and Child Welfare Scheme. Special mention must be made of the 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. Goff, Miss Goff, Mrs. Jacklin, Mrs. A. Jacklin, Mrs. Sturton, Mrs. Northcote, Mrs. Jones, Mrs. Shirley, Mrs. Bartholomew, Mrs. Addison, Mrs. Buckingham and Mrs. Keen, at the Hounslow (Douglas Road) Centre; Mrs. Day, Mrs. Chadwick, Mrs. Biggers, Mrs. McDonald, Miss Beal, Mrs. Hunt and Mrs. Zimmerman at the Hounslow (Clipstone House) Centre; Mrs. Brierly, Mrs. Colbrook, Mrs. Griffiths, Mrs. Rose, Mrs. Ardley, Mrs. Andrews, Mrs. Watson, Mrs. Whitehead and Mrs. Clarke at the Heston Centre; Mrs. Chedgey, Mrs. Newman, Mrs. Jones, Mrs. Griffin, Miss Beale and Mrs. Ebbutt, at the Isleworth 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 the unemployment of the husband, etc. Home Visiting.—The visits by the Health Visitors in connection with the Maternity and Child Welfare Work are shown in the following table:— 1930 1931 1932 1933 1934 1st visits to babies under 1 year 1395 1472 1520 1346 1320 Routine Re-visits to babies and children up to 5 years 3982 4190 3210 4720 4024 Inquiries made elicited— Feeding—Natural 980 1105 1135 1093 1042 Artificial 77 64 95 77 93 Both 56 51 44 36 40 Sleeping with parents 260 247 154 126 116 Using comforter 195 217 175 170 167 Mother working during pregnancy 53 44 29 48 45 Year 1934. Other Visits. Post-natal 5 Ante-natal—First visits 139 Subsequent visits 56 Infants' Deaths and Stillbirths, Visits paid 81 Ophthalmia Neonatorum and discharging Eyes 78 Puerperal Fever and Puerperal Pyrexia 16 Measles and German Measles 105 Whooping Cough 30 Children Mumps 4 under Chicken Pox 47 5 years. Pneumonia 14 Bronchitis 23 Milk and food cases 46 Home help 49 Infant Protection Visits 533 Social conditions 50 58 Summary of Nurses' Visits. Total to expectant mothers 195 Total children under 1 year of age 3566 Total children between the ages of 1 and 5 years 2820 Visits re Public Health matters, infectious diseases, tuberculosis, etc. 1349 Total 7930 Health Visitors' attendances at the Maternity and Child Welfare Centres, Ante-Natal Clinics, etc., 722. Health Visitors' attendances at Diphtheria Immunisation Clinics, 192. Home Help for Mothers.—In November a new scheme for the provision of Home Helps was instituted. A panel of Home Helps, had been formed, and as far as possible each is called upon to attend a case in turn. The proximity of the Home Help's address to that of the applicant is sometimes a deciding factor. Persons entitled to the assistance of a Home Help are those whose income is less than 8/per head per week after the rent has been deducted, but in very exceptional circumstances, at the discretion of the Medical Officer of Health, this may be extended up to 10/- per head. No charge is made to the applicant for the services of the Home Help. Usually the Home Help attends at a case for two weeks after the birth of the infant, but in some cases, i.e. where the husband is unemployed, etc., a Home Help is sent in for half days only. This enables the husband who can help in the home, to sign on at the Employment Exchange and also look for employment. The number of cases at which the Home Helps have been called upon to attend during the year, was 30. The rate of payment of the Home Help is £2 per week. 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 number of grants made during the year was 1181, against 1052 for the previous year. I mentioned in my Annual Report for last year that the Committee were in favour of a more equitable Income Scale to assess the proportion of the cost to be borne by the applicants. Comparison with other authorities indicated that our Income Scale was somewhat low, and we had found it necessary frequently to treat cases as "Specials" and assess them outside the scale. The Committee considered the matter fully in January and decided to adopt the undermentioned scale for a trial period of six months from the 1st April. NEW INCOME SCALE. Number in Family. Income per head after deducting rent Proportion of cost to be paid by applicant Free up to l/3rd. 2/3rds. 2 7/- 7/1d. to 8 /- 8/1 to 10/- 3 6/6d. 6/7d. to 8/- 8/1d. to 9/- 4 6/6d. 6/7d. to 8/- 8/1d. to 9/- 5 6/- 6/1d. to 7/6d. 7/7d. to 8/6d. 6 5/6d. 5/7d. to 7/- 7/ld. to 7/6d. 7 5/- 5/1d. to 6/6d. 6/7d. to 7/- 8 4/6d. 4/7d. to 6/- 6/1d. to 6/6d. 9 4/- 4/1d. to 5/6d. 5/7d. to 6/- 59 The matter was reviewed in October, when it was found that the introduction of the new scale had resulted in an increase of 31% in the Council's share of the cost of the milk supplied. The new scale is being continued. OPHTHALMIA NEONATORUM, Year 1934. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Removed from District and Deaths. Notified. Treated. At Home. In Hospital. 15 2 13 5 — — 10 An agreement exists with the London County Council for the admission of Ophthalmia Neonatorum to St. Margaret's Hospital when necessary. 60 BOROUGH of HESTON and ISLEWORTH EDUCATION COMMITTEE TWENTY-SEVENTH Annual Report OF THE SCHOOL MEDICAL OFFICER FOR THE YEAR ENDED 31st DECEMBER, 1934 CONTENTS. Arrangements for Treatment 11 Blind children 25, 30 Co-ordination 7 Deaf children 25, 30 Deformities 29 Dental defects and treatment 10, 15-21, 34 Dental Surgeon's Report 15-18 Ear disease and hearing 10, 15, 28, 33 Emergency Dental Cases 18 Epileptic children 25, 29, 30 Eye defects 9, 14, 28, 33 Findings of medical inspection 8, 28 Following up 10 Health Education 27 Heart Disease and Rheumatism 10, 21, 29, 31 Infectious disease 21, 22 Malnutrition 8, 11, 28 Medical inspections 7, 28, 29 Medical treatment 11, 33, 34 Mentally defectives 25, 30, 32 Milk, Supply of 24, 25 Minor ailments 9, 12, 33 Nose and Throat defects 9, 15, 28, 34 Nurses' work in schools 11, 34 Occupation Centre, see under Miscellaneous on page 27 Open Air Education 23 Orthodontic work (Report of the Orthodontic Consultant) 18-21 Orthopaedic and Postural defects 10, 21, 34 Parents, Co-operation of 25 Parents' Payments 27 Physical Training 23 Playground Classes 23 Prosecutions 12 Provision of Meals 23 Ringworm 13, 33 School Attendance Officers, Co-operation of 25 School Clinics, see under Minor Ailments on page 12 School hygiene 7 School journeys 23 School Nurses' work 11, 34 Schools in the Area 6 Secondary Schools 27 Skin diseases 9, 12, 28, 33 Special Enquiries 27 Spectacles 14, 33 Staff 5 Statistical tables 28-34 Teachers, Co-operation of 25 „ Medical Examination of, see under Miscellaneous on page 27 Tonsils and Adenoids 9, 15, 27, 28, 34 Tuberculosis 10, 21, 29, 31 Uncleanliness 9, 12, 34 Visual defects and External Eye disease 9, 14, 28, 33 Voluntary Bodies, Co-operation of 25 To the Chairman and Members of the Borough of Heston and Isleworth Education Committee. Ladies and Gentleman, I beg to present the Annual Report of the School Medical Service for the year ended 31st December, 1934. 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). „ H. J. NIAS, M.B.E., J.P. (Vice-Chairman). Alderman A. A. BERGIN, J.P. (ex-officio). Alderman H. G. BODY. Councillor H. BAKER. Councillor C. L. LEWIS, J.P. A. J. BALDWIN. „ J. OWNER. J. E. DILLINGHAM. „ W. F. J. RICHARDSON. J. FARMER. „ D. RHYS. A. J. FIELDER. „ G. N. SHACKLETON. E. W. HEATH, J.P. „ D. J. THOMAS. J. I. KELLY. „ R. WRIGHT, M.C. Co-opted Members— MIss E. A. ANKRITT. E. R. HAMILTON, Esq., m.a., b.sc. Mrs. E. E. BERGIN. Dr. O. WARDMAN. J. V. BACKES, Esq., a.r.c.s., a.i.c., d.i.c. 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. W. A. LILLEY, b.d.s., l.d.s. (commenced 2nd July, 1934). 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). P. T. H. CRANDON. Miss R. MARSHALL. H. TOWLE. F. V. BELL. H. M. B. BURGE. C. PARRY. E. E. FORREST. Miss D. M. DOWLING. Miss V. D. NICHOLLS. R. MOORE. O. E. GIBSON. Comprising the whole Clerical Staff of the Public Health Department, part of whose duties are concerned with the School Medical Service. Dental Clinic Clerk Attendants—Miss M. B. MABBS. Miss C. J. JOTHAM. Miss E. J. BEMNER. Miss A. M. FRAMPTON. Dental Mechanic (part-time)—T. CHENEY. 5 ELEMENTARY SCHOOLS IN THE AREA. School. Department. *Accommodation. Number on *Registers. Alexandra Junior 428 401 „ Infants' 468 440 Berkeley Junior Mixed and Infants' 450 445 Brentford End Infants' 91 94 Bulstrode Senior Boys' 480 456 „ Girls' 480 466 Chatsworth Infants' 400 377 Cranford Junior Mixed and Infants' 120 135 Grove Road Junior Mixed 652 534 „ Infants' 368 254 Heston Senior Mixed 400 359 „ Junior Mixed 430 423 „ Infants' Infants' 249 254 Hounslow Heath Senior Mixed 480 487 Junior Boys' 494 472 Junior Girls' 446 431 „ „ Infants' Infants' 440 463 Hounslow R.C. Mixed and Infants' 330 308 Hounslow Town Junior Boys' 286 307 „ Junior Girls' and Infants' 488 421 Isleworth Blue Boys' 177 139 „ Girls' and Infants' 284 198 Isleworth Town Junior Mixed 540 557 „ Infants' 428 432 Marlborough Senior Mixed 640 636 St. Mary's R.C. Boys' 180 131 „ Girls' and Infants' 226 199 Spring Grove Central 392 374 „ Junior Mixed and Infants' 240 266 Woodlands St. John's Infants' 75 43 Worple Road Junior Mixed 260 258 „ Infants' 250 216 Total 11672 10976 Numbers as at December, 1932 10611 10120 Numbers as at December, 1933 10636 10793 *These numbers are for December, 1934. Since December, 1930, the number of children attending elementary schools in this district has increased by 2,700, 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 service of the health of pre-school children is, at presnt, entirely on a voluntary basis. They come to the Infant Welfare Centres as a result of the good work done there, but even there it falls very far short of what is in the interests of the children. Personally, I see no hope for adequately dealing with the two to five years age group which provides us with many untreated defects, except through Nursery Schools, where with compulsory attendance goes compulsory medical inspection. 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 have been 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 4,224, which is the largest number ever inspected in one year by this Authority. It has been necessary to engage extra medical assistance regularly throughout the year, and the pressure in all other sections of School Medical Work, particularly in the School Clinics, has continued unabated. 7 Disturbances of School Arrangements. No one supposes that the ordinary school curriculum is not disorganised to some extent by the needs of medical inspection especially where all the available accommodation is required for educational purposes. The Head Teachers of the district, however, are to be congratulated upon the arrangements they make under such difficult conditions, and I should like to place on record once again my appreciation of the fact that the inspecting Medical Officer is always made as comfortable as circumstances permit. 5.—FINDINGS OF MEDICAL INSPECTIONS. (a). Malnutrition. Our figures are probably as near the truth as any other figures sent in to the Board of Education, but are really not a reliable index of what is malnutrition. As I have said before, again and again, mathematical formulae as evidence of the amount of nutrition are in most cases not worth the paper they are written on, in that many of the cases of carbo-hydrate surfeit, particularly those who are large and bulky, slip through the wide mesh of the mathematical net. Again in these mathematical formulas no account is taken of the genetic conditions, as exampled from a report of a racing centre where the children of the jockeys of small build were largely put down as suffering from malnutrition, a report about on a par with one which came from the Midlands some time ago where, owing to the exuberance of one of the Medical Officers, the percentage of children reported to be suffering from demonstrable Tuberculosis astounded the whole country. The trouble is that the early training of the medical student, as far as malnutrition is concerned, is entirely wrong. His experience is largely spent in the normal from the merely nutritional point of view, and the hinterland between normal and disease with its graduations from one to the other is to him an uncharted sea. I withdraw nothing I have said in the past with regard to malnutrition and its existence, and this is summed up in the following letter which appeared in the Lancet on the 16th March, 1935, over my signature, which, although strictly not arising in the year under discussion, sets forth my opinions. To the Editor of The Lancet. What is Malnutrition ? Sir,—Your leading article of Feb. 16th with this title is timely indeed. It is such a relief to find that mathematical indices and formulae have no place therein. There has been so much uninformed writing in the past which has only obscured the issue, and those who have followed these mathematical standards have missed many of the most marked cases of malnutrition. Much of malnutrition, as you so rightly point out, is not due to shortage of food but to wrong feeding. How often one has seen the active wiry youngster, particularly about 10 years of age, put down as malnourished because, measured by the standard laid down by one writer, its ribs were obvious. Active, glossy, elastic skinned, glossy haired, with mucous membranes of good colour, true, with every bit of fat run off in its activities, but in perfect health, this child is as far removed from malnutrition as the poles asunder. On the other hand, the big bloated, carbohydrate, surfeited child with its ribs invisible, but dull, lack-lustre skin and hair, and pallid mucous membranes, often with a lack of appetite which deludes the ignorant into the idea that the child cannot want food, is suffering from severe malnutrition. Malnutrition is a syndrome which those who know rarely mistake. It is true that in the pre-war days there was an added item which helped in the case of girls—viz., the character of the hair. This, owing to the habit of bobbing, and the greater care necessitated thereby, has definitely diminished the character of this contribution to the syndrome. In dealing with children in school there are two opinions which often do not coincide : that of the medical officer and that of the teacher. Just after the war, when attached to the headquarter staff of the L.C.C., I got a far-seeing head teacher in a boys' school in a poor area to help me in an investigation. I got him to go right through the school and put down all the boys he thought were suffering from malnutrition. Afterwards I went right through the school and put down those I considered were suffering from malnutrition. We had a central block where we agreed. The head teacher had a block at one end that he thought were malnourished, and I did not. I had a block at the other end that I considered malnourished, and he did not. The ones he considered malnourished and I did not, appeared to be cases where the head teacher, knowing the family circumstances, thought that they ought to be. There is another mistake that is frequently made in some of these cases in mistaking pallor for anaemia. There is a certain type of child whose face is habitually pale, but its mucous membranes are good. There is another that gets a temporary pallor when confronted with an 8 examining medical officer. Conversely there is the child who gets a temporary flush in the presence of the examining medical officer, and is as a result as highly placed as the former pallid child is lowly placed by the inexpert. It is well not to make assessment in appearance without seeing the children in a group later, when their appearance may entirely belie the original estimate. How well I remember the fury of one of our ablest school medical officers in the country, as the result of a notice with regard to his daughter, who had won a scholarship at a famous secondary school, where she had been examined by a junior medical officer, to the effect that she was suffering from anaemia—she being one of the pallor cases referred to. Eight years ago I called attention to the importance of the clinical syndrome as compared with mathematical methods. It is good indeed to see that at last there is to be an investigation based on clinical experience. There is also occasionally a class of case which it is true does not conform to type in that viewed above the collar the primary impression is one of malnutrition, which is negatived by the condition of the child when stripped. Again there is a class of case which needs further investigation, in that all the circumstances are favourable and yet without any previous history of gross illness there is some imbalance, possibly endocrine, which is manifesting itself as malnutrition. Sherman is abundantly right in insisting on the failure to convert money into the proper diet. This has been evident for long to those of us who know the homes internally. Thanks to the Carnegie Trustees I am being enabled, as a result of a grant of £500, supplemented by my Borough Council, to carry out investigations to assist in the acquisition of more knowledge as to how money can be transformed into nutrition. In conclusion, let me quote from an old record of eight years ago. At a tea given in one of our schools, I picked out 13 children sitting at table, who, in my opinion, were suffering from malnutrition. In 12 of the cases either the father was dead or had been out of work for six months, and in the 13th case I had no time to go into the question of dietetic error. Surely a syndrome accurate to this extent is an obvious clinical entity, as obvious as myxoedema, but it must be admitted, as elusive in lesser cases as early myxoedema. How often one has seen in the past, families living side by side on the same wage and under practically identical conditions, in which the following contrast occurs. In the one case the man has married a woman who has been in domestic service in a professional man's family where she obtained years of experience in utilising everything in the way of food that was left over, and in practising economy, an economy unknown to many of those with much smaller incomes, but whose children are nutritionally satisfactory. Whereas in contrast to this is the housewife next door whose feckless habits in the matter of food are evidenced by the malnutrition of her children.—I am, Sir, yours faithfully, Elwin H. T. Nash, M.O.H. and S.M.O., Borough of Heston and Isleworth. (b). Uncleanliness. The number of cases discovered at routine medical inspections was 99, and special medical inspections at the Clinics revealed a further 595 cases. Three hundred and ninety-six children were excluded from school during the year on account of nits or vermin. (c). Minor Ailments and Diseases of the Skin. A total of 449 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 where 214 cases of " Other skin disease; " these include such conditions as eczema, alopecia, seborrhcea, etc. (d). Visual Defects and External Eye Disease. Routine medical inspections revealed 237 cases of defective vision, 206 being referred for treatment. Twenty cases of squint were also discovered, 17 being referred for treatment. At the Special Clinics, 133 cases of defective vision and 17 of squint were referred for treatment. Twenty-one cases of minor disease of the eye were discovered at routine medical inspections, and 205 cases were discovered at the Special Clinics. (e). Nose and Throat Defects. Two hundred and forty-six children were found to be suffering from chronic tonsillitis, and of these 114 were referred for operation. Twenty-five children had Adenoids only, 15 being referred for treatment and 10 for observation. 9 In a further 288 cases both conditions were present, 155 children being referred for operation and 133 for observation. (f). Ear Disease and Defective Hearing. Amongst children examined at the routine medical inspections, 45 cases of defective hearing were found, 22 of these being referred for treatment. Seventeen cases of ear disease were also discovered, 12 being referred for treatment. Special examinations at the Clinics account for 31 cases of defective hearing, and 174 cases of ear disease. (g). Dental Defects. One thousand eight hundred and sixteen cases of dental caries were discovered at routine medical inspection, and a further 184 cases were found by examination at the Special Clinics. At the routine dental inspections in the schools, a total of 5,438 children were found requiring treatment. Table IV., Group V. on page 34 gives further statistics in this connection. See also Statistical Table on pages 16 and 17. (h). Orthopaedic and Postural Defects. One hundred and twelve cases of deformity of varying degrees were discovered by inspections at the schools and at the Special Clinics. The greater number of these were cases of slight spinal curvature and flat feet. (i). Heart Disease and Rheumatism. Eighteen cases of heart trouble were found during the year to need treatment, whilst 124 cases were marked for observation. (j). Tuberculosis. No case of Tuberculosis was found during routine medical inspections, but three cases of Tuberculosis of the glands were discovered by special inspection. (k). Other Defects and Diseases. Thirty-seven defects were found during routine medical inspection, which could not be classified under any other heading in Table II. Eleven of these 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 by special inspection was 1,100. Of these, 1,041 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 776 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. 10 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 Qinics with Medical Officer. 6. Attend Minor Ailments Treatment Qinics 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 1934. Attendances. Routine Medical Inspections 235 Re-inspections 33 Eye Clinics 118 Minor Ailments Inspection Clinics (with Medical Officer) 210 „ „ Treatment Clinics 929 Dental Clinics 764 Cleanliness Surveys 62 Cleanliness Qinics 57 Other Attendances (Special Clinics, Med. Exam. of Teachers, School Sports, etc.) 106 Visits. Re Infectious Disease 2332 Following up 776 Other Visits 55 7.—ARRANGEMENTS FOR TREATMENT. In July the Isleworth School Clinic, which for many years had been carried on in most inadequate accommodation at the Public Hall, was transferred to Busch House, Busch Corner, where a temporary scheme has been put into operation to deal with the work more satisfactorily in the larger premises there at our disposal, pending the erection of a permanent Health Centre to serve that developing district. With the added accommodation, it has been possible also to provide a complete Dental Clinic and to hold Eye Clinics there. This has resulted in an appreciable saving to the people of Isleworth in not having to travel the considerable distance to the Hounslow Centre as was previously the case. It is hoped that this will result in better use being made of the Dental Clinic particularly by the Isleworth population, as time goes on. The working conditions, even with the temporary scheme, are already much better. (a). Malnutrition. Milk can now be supplied twice daily at school, free or at part cost, to children who have been recommended for this on medical grounds. Further reference to this will be found on page 24. 11 Cod Liver Oil and Malt is sold at cost price at the School Clinics for children recommended by the School Medical Officer. In necessitous cases it can be supplied free. (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 10,175, compared with 9,855 in 1933. Number of visits to schools by Nurses 67 Total number of children examined 10175 „ given warning notices 575 „ „ „ „ excluded as verminous 45 1. (Few) 438 Found to have nits— 2. (Bad) 78 3. (Very Bad) 14 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 man employed by the Education Committee, 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 who had done the work of cleansing heads since 1923 gave up this work in October last. Mr. Arnell, a Hairdresser, who received special instruction at a London County Council Cleansing Station, then took over the work. The Committee supplies the Sacker's Comb and Shampoo. Mr. Amell receives the 1/- fee per case in payment for his services. Eighty-nine children were cleansed under the Authority's arrangements during 1934. During 1934 it was found necessary to take legal proceedings in 13 cases, with the following results:— One case Dismissed by Bench. Two cases Dismissed with Warning. One case Adjourned Sine Die. Three cases Fined 4/- each. Four cases Fined 5/- each. One case Fined 7/6d. One case Fined 10/- (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. 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—Busch House, Busch Corner. 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. 12 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. 835 cases of minor injuries, bruises, sores, chilblains, etc., and 288 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 1934 2,695 7,925 In addition to providing daily treatment for minor ailments, these Clinics also serve as centres for the more detailed examination of special cases than is possible at routine medical inspections at schools. The number of cases attending these Clinics has been so great that in the early part of the year we had to allocate a further half-day session each week at the Hounslow Clinic for special examinations by the medical officer. The following figures show the increase in the number of special examinations at School Clinics by Medical Officers:— Year. Total number of Special examinations and Re-examinations by Medical Officer. 1930 2,532 1931 3,534 1932 3,802 1933 3,957 1934 4,646 Ringworm of the Scalp. This year there has been a large increase in the number of cases—47 in all having occurred, the majority of which came from the Isleworth area. Every endeavour has been made to check the spread of the infection, and whole schools have been examined in the hope of detecting hitherto unnoticed cases which might be a focus of infection. During the year thirty-seven cases were treated by X-ray under the Authority's scheme, one had X-ray treatment elsewhere, whilst twelve refused X-ray and had other treatment privately. Unfortunately in a number of cases X-ray treatment did not prove the speedy means to a cure which it had done in the past, with the result that a number of cases remained infected for many months, and although excluded from school, remained a source of danger to other children, and in all probability accounted for some of the new cases which occurred. In the Spring a mercury vapour lamp with Wood's glass filter was obtained as an aid to diagnosis in the large number of children who needed to be examined. Previously we had relied on a clinical examination with removal of suspected hairs for microscopic examination. Microscopic examination is absolutely certain provided that an infected hair has been removed, but it is easy to miss a few infected hairs in a thick crop of hair. With the Wood's glass filter this is impossible, as each infected hair is clearly picked out and can then be removed for microscopic examination. This is the routine now adopted in each suspected case, first examination under the Wood's glass filter, and secondly, any infected hairs found are removed and examined under the microscope to confirm the diagnosis. No children are re-admitted to school until they have had two negative examinations at an interval of one week. After re-admission they are kept under observation and re-examined under the Wood's glass filter until the Medical Officer is satisfied that there is no return of the infection. 13 (d). Visual Defects and External Eye Disease. Five hundred and fifty-two cases were submitted to refraction. Spectacles were prescribed in 517 cases and obtained before the end of the year in 498 cases. Five other cases were treated by private arrangement of the parents. Spectacles were prescribed and obtained in one of these cases. A total of 154 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. I am indebted to Dr. Roberts, who is in charge of the Refraction Clinic, for the following report:— VISION AND THE REFRACTION CLINIC. This year there has been a slight increase in the number of appointments made, but one has to record the lowest percentage attendance for the last five years. Two thousand, two hundred and fifty-five appointments were made and the attendances numbered 2,083, giving a percentage attendance of 92.37 for the whole year. In 1933 the percentage attendance was 95. As in previous years, the two weekly sessions were supplemented by a third when the waiting list required it. In July the Busch House Health Centre at Isleworth was opened and this has enabled the third Refraction Clinic to be held there for the benefit of people living at that end of the district. The arrangement now is that two Refraction Clinics are held weekly at Clipstone House, Hounslow, and one at Busch House, Isleworth. It has always been felt that the necessity of calling Isleworth children to Hounslow acted as a deterrent to some of the Isleworth parents accepting treatment for their children on account of the distance from their homes. It was hoped that the Isleworth Clinic would remove any such difficulty, but up-to-date the response has not been as good as had been expected. Only 326 appointments have been made since July 7th—this represents the total of those accepting treatment —as there has been no waiting list—children having been seen within a few days of the consent form being received. The attendances also were not very satisfactory—they numbered 298, giving a percentage attendance of 91.41. At Hounslow, the appointments for the year were 1929 and the attendances 1,785, giving a percentage attendance of 92.53. These figures of course, include a number of Isleworth cases who were seen at Hounslow prior to July. The comparable figures are from the beginning of July to the end of the year. At Hounslow 40 sessions were held—at Isleworth 20. Eight hundred and seventy-three appointments were given at Hounslow and 815 attended, giving a percentage attendance of 93.36, whilst at Isleworth, there were 326 appointments and 298 attendances, giving a percentage attendance of 91.41. These figures show that an average attendance at the Hounslow Clinic was 20.37, whilst at Isleworth, during the same period, the average was only 14.9. At Hounslow there is always a waiting list and the interval between the consent form being received and the appointment has frequently been six to eight weeks, and we have only kept the waiting list within bounds by holding up the re-examination notices and sending them several months late. At Isleworth, as has been mentioned, there has been no waiting, and the re-examination notices are up-to-date. Refractions. Five hundred and fifty-two children were submitted to refraction under the Authority's Scheme; Spectacles were prescribed in 517 cases and of these 498 received them by the end of the year. These figures are slightly lower than in 1933 (581 refractions, 569 spectacles prescribed, 559 obtained)—doubtless the decrease is due to the larger number of absentees. E. L. ROBERTS, Deputy School Medical Officer. 14 (e). Nose and Throat Defects. Three hundred and ninety-seven children were referred for treatment on account of nose and throat defects. Of this number, 94 were operated on under the arrangements made by the Authority with the Hounslow and Richmond Hospitals in 1921, 34 received operative treatment by private arrangements of the parents, and 13 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 which they are asked to state details of their income and outgoings, number in family, etc. As soon as this form is completed and returned, it is forwarded to the Education Secretary who fixes the amount the parents shall be asked to contribute towards the cost of the operation. The parents are then asked to give their written consent to the operation, and when this is received the child's name and address is sent to the appropriate Hospital. The hospitals make the appointment for treatment, and the Authority pays one guinea for each case operated on. The scale of parents' repayments is as follows:— Weekly family income per head, after deducting rent. Parents' contribution towards cost of 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 eighty-nine cases of ear disease or defective hearing were dealt with at the school clinics, and 19 were treated by private arrangement of the parents. B.I.P. Paste is still used extensively in the three school clinics and the results are extremely satisfactory. (g). Dental Defects. Progress in the Dental Section has not been as rapid as could be desired. This is chiefly due to lack of staff and premises, which matters are now receiving attention with a view to their considerable expansion. The Isleworth Clinic so long visualised was established in temporary premises at Busch House, Busch Corner, Isleworth, at the beginning of September, 1934, and as time goes on, should prove of considerable advantage to the Isleworth population, as the distance they have to travel for dental treatment has been so greatly reduced. Pending the appointment of the second whole time Dental Surgeon, Mr. Lilley, the work was carried on in the first part of the year by using temporary Dental Surgeons on a sessional basis. Mr. Lilley, the Junior Dental Officer, commenced duty in July, 1934, and over the whole year the work done by the various Dental Surgeons amounted, in terms of sessions, to rather less than two whole time Dental Surgeons, which is definitely insufficient to cope adequately with the work. Two Junior Dental Clinic Clerk Attendants were appointed and took up duty in April. The following is extracted from the Dental Surgeon's report:— Inspections. Although it was not found possible to inspect every child in the schools, the number of routine dental inspections was 5,949, against 2,745, the figure for the previous year. With regard to the Board's Table IV., Group V. (Dental Defects, page 34), it should be noted that the number of "Specials," 1,917, 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. 15 The 1,917 are made up of the following types of cases:— (1) Referred for Gas, or Gas and Ethyl Chloride Hounslow. 1,700 Isleworth. 217 (2) Advice given (3) Treatment postponed (4) Inspection after Gas—required further treatment Total 1,1917 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—5,901, which works out at 154 fillings per 100 children treated, whilst the number of permanent teeth filled— 5,072, works out at 133 permanent teeth filled per 100 children treated. Extractions. The number of teeth extracted was 5,191 (959 Permanent; 4,232 Temporary). This works out at 25 permanent teeth extracted per 100 children treated. Statistics. 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 below) in order to show items of information which may help towards the propter 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. DENTAL INSPECTION AND TREATMENT—YEAR 1934. Average number of Elementary School children on registers at middle of year, June—10,995. Age. No. Remarks. 1. No. of children 5 523 (a) who were inspected at Routine Dental Inspections 6 586 7 724 8 774 9 749 10 768 11 639 12 467 13 587 14 131 15 3 5949 No. of Special Inspections 1917 (b) No. of Children found to require treatment at Routine Dental Inspections 5438 (b) This equals 91.4 per cent, of the children inspected at Routine Inspections. (c) No. of Children actually treated 3811 (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 37 2. Average number inspected per session— 160. Treatment—Ordinary 732 Included in the 732 ordinary treatment sessions are 51 sessions which were entirely devoted to Orthodontic Treatment. do. Gas 97 Administration—Clerical 18 Dental Committee Meetings 4 888 These sessional figures are for approximately 2 whole time dental surgeons, (see below). 16  No. Remarks. 3. Attendances made by children for treatment 10530 3. The Gross attendances made by children at the Dental Clinic were 12,584, 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 528 fillings to 100 extractions. Permanent Teeth 5072 Temporary Teeth 829 5901 5. Extractions— Perm. Temp. At Treatment Sessions 35 1000 At Gas Sessions 924 3232 Total 5191 6. Administrations of general anæsthetics 1386 6. The percentage of attendances for "Gas" 1,386 of total attendances for treatment 10,530 was 13.16. 7. Other Operations 4457 The 1,386 "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 97. Staff responsible for the above work:— 1 Senior Dental Surgeon whole time (whole year). Equivalent, in terms of sessions to nearly two whole time Dental Surgeons for whole year. 1 Junior „ „ „ „ (from July). Temporary Dental Surgeons on Sessional basis. 1 Approved Dental Nurse. 2 Clerk Attendants. 2 Junior Clerk Attendants. (These two junior Clerk Attendants took up duty from the 16th April, 1934). Plus some clerical assistance from the Office of the School Medical Officer. Extra Staff for Gas Sessions only. 2 Anaesthetists (Deputy School Medical Officer and Assistant School Medical Officer). 1 Trained Nurse (Recovery Room). For Orthodontic Sessions. Orthodontic Consultant—1 session per month. Dental Mechanic—Once a week. Dentures for School Children. In four cases dentures were supplied for school children where the state of the mouth left by the necessary extractions was such that it was imperative to supply dentures to replace the teeth removed. 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—4,457—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 443 Dressings 421 Scaling and Polishing Teeth 76 Treatment of Gums 34 „ by Drugs 2 Separating Teeth 10 Destroying the Pulp 1 Orthodontic Cases (Advice) 485 Impressions taken 1,289 17 Orthodontic Appliances fitted 189 Orthodontically treated 1,503 Bites and Tries in and attendances for Dentures for school children 4 4,457 Attendances made by Children for Treatment. The figure 10,530 shown in the Board's Table is not the gross figure of school children's attendances at the Dental Clinic, which was 12,584, all of which were nominally " attendances for treatment," but, although making such attendances, only 10,530 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 showed an appreciable increase over the figures for 1933. Emergency Cases. This branch of the dental service has now been running for five 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 1934, 912 cases were so referred by Head Teachers. These facilities prove a boon both for teachers and children, and teachers are now using the greatest care in only sending us cases of children in pain. Here and there a parent gets an emergency ticket for a child not in pain, and in these cases, the teacher is always informed and left to deal with the parent concerned. 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 1934 were as follows:— From School Children treated (ordinary 1s. fee) £154 13 0 From School Children (Orthodontic fees) £154 9 9 From Maternity and Child Welfare cases treated—1s. fees £20 0 0 I. COHEN, l.d.s., r.c.s., eng., School Dental Surgeon. ANNUAL REPORT OF ORTHODONTIC CONSULTANT. The Orthodontic Section of the Heston and Isleworth Public Health Department has now completed its fourth year of work, and is still the sole such organisation in the country existing under recognition of the Board of Education. In submitting my report for 1934 I am glad to be able to inform you that the large measure of success achieved in previous years has not only been maintained but has been considerably enlarged upon in the course of the past twelve months. Before drawing your attention to some of the more interesting points which arise from a review of last year's work, I should like to say how glad I am to note that the Board of Education is still evincing a great deal of official interest in the progress of this pioneer scheme. I feel certain that the gratifying results which have again been a marked feature of the work of the Section during 1934 must have considerable weight in tending to convince the Board of the service which could be rendered to the Nation by an eventual adoption of a National Orthodontic Scheme. I shall return to this later. 18 Increase in Cases Handled. During the year 1934 the Orthodontic Section has handled no fewer than 196 new cases—an increase of 110 over the new cases recorded for the previous year. This very considerable addition to the number of new patients passing through the hands of the Section deserves consideration from two distinct points of view. The fact that such an increase has occured without causing any disturbance in the Clinic's normal routine dental practice offers a strong argument in support of the contention that the restriction of orthodontics to one session per week will not prevent the treatment of a large number of cases, and will not give rise to confusion in allied sections of the Clinic. At one time and in some quarters it was alleged that a single session each week could not hope to cope with a large number of cases and still give full attention to each patient, especially in view of the fact that orthodontics is so highly specialised a subject. The limitation of time imposed by a single session per week would, it was thought, permit of only a percentage of the cases being treated; additional sessions, on the other hand, would seriously jeopardize the regular dental work. The past year has proved beyond a shadow of doubt that such fears are ill-founded. The second point of view which emerges from a realisation of this growth in the number of cases receiving attention is the fact that it indicates a strengthening of the co-operation which must exist between the parents and the Clinic. During 1934 the outlook of the parents has undergone a decided change for the better—parents have become more " orthodontic minded." Without their co-operation, it is of course, impossible to make any headway in the successful application of an orthodontic scheme at a school clinic. Any indication, therefore, of an increased sense of understanding on the part of parents should be a matter of considerable satisfaction. Parents are now prepared, if necessary, to make some sacrifices in order to ensure that their children may be permitted to receive full orthodontic treatment. The year under review was, moreover, notable for many instances of the receipt of precise enquiries from parents as to the exact benefits likely to accrue from the treatment of malocclusion, and this, be it noted, was in reference to children who had not at that time received any attention whatsoever at the Clinic. I think you will agree with me, therefore, that this enlargement of interest and fuller sense of responsibility on the part of the parents is in every way a most satisfactory feature of the year's work. The Weekly Session. At this pioneer clinic we still have the satisfaction of being able to proclaim that no case is ever refused treatment. The operation of the orthodontic scheme is truly comprehensive—all who come are served—and there is never any question here of selecting only a certain number of the prospective patients in order to suit the working arrangements of the staff. The fact that the steadily increasing number of cases is being handled without difficulty is, in itself, a tribute to the efficiency of the organisation and the intelligent co-operation of the entire staff, to whom my thanks are again due for their work throughout 1934. No ordinary dental work is, of course, attended to on the session day, so that the whole time at my disposal can be devoted strictly to the examination of orthodontic cases. The clinic's dental surgeons have, during the course of their normal routine inspections, noted in advance all instances of malocclusion and have made the necessary arrangements for the patients to attend the sessions. The history of each case is provided by the dental nurse, together with any personal observations of the dental surgeon who has introduced the patient. In this way I am able to diagnose, and prescribe treatment for, a large number of cases with a minimum expenditure of time per case. Orthodontic Appliances. Throughout 1934 there has been need for a larger number of the simple types of appliances which it is my practice to specify. This increase, however, has been on a pro rata scale, and is of course, due to the rise in the number of patients treated. Actually, the fact has emerged that a greater number of treatments does not call for a disproportionate increase in either time devoted to or financial expenditure on the production of the requisite amount of apparatus. I would go further, indeed, and observe that experience gained during the year has even enabled me to reduce the ratio of appliances used to patients treated. It is my aim to use always as little apparatus as possible in the treatment of malocclusion. It may be worth pointing out at this stage that the work engendered by the Orthodontic Section does not call for the employment of a full time mechanic; indeed, the introduction of such 19 a post would, in my opinion, be definitely bad economy. For the production of all the appliances which are required in connection with the increased number of treatments, the present arrangements at the Clinic are quite adequate. I have at no time suffered any inconvenience or delay in this direction. In regard to the taking of X-ray photographs where such are necessary, I consider that the present arrangements at the West London Hospital are quite satisfactory. Facial Appearance. I think you are fully aware of my answer to the so-called "æsthetic objection" to the practice of orthodontics, viz:—that the prime concern of orthodontia is the provision of a perfectly functioning mouth, and that only after this has been achieved can there be permitted to arise the question of facial appearance per se. The true orthodontist must be first and foremost a preventer of disease, and secondly (for psychological and aesthetic reasons) a curer of facial deformities; he must never be a mere beauty specialist. The fact that both aesthetic and psychological considerations have nevertheless a definite bearing on the problem is, however, particularly well borne out by a case which was brought to my notice last year. A boy of 16 years of age had left school having, through influence, secured a clerical situation. He duly commenced his work which, it so happened, consisted of interviewing the firm's clients throughout the day. After the lapse of a week, however, the employers intervened as it had become only too apparent that the unfortunate youth could not hope to succeed at the particular duty which had been allocated to him—his deformity not only made him painfully selfconscious but his appearance was obviously repugnant to those with whom he came in contact. The lad was, therefore, tactfully yet firmly informed that unless he took immediate steps to improve his facial appearance he could not be permitted to continue in his situation. It should be noted, incidentally, that this intervention of commerce came as a result of experience and not from a priori dictates. Now it appears that this boy had in fact come before the Orthodontic Clinic some three years previously, and after some delay in obtaining the parents consent, he had been sent to the Royal Dental Hospital for examination. Before the treatment prescribed there could be commenced the boy gained a scholarship, and so graduated to a secondary school, thus passing out of the jurisdiction of the Clinic. During the time he attended the higher grade school no orthodontic treatment was sought because it would have interfered with his school hours and also because his parents failed to appreciate the gravity of his condition. The models and skiagram which appear on the next page show the boy's condition before he gained his scholarship, and at the end of his first week of employment. I believe this to be by no means an isolated example of the tragedy liable to a tend an untreated orthodontic condition, and its import lies in the fact that it illustrates the " commercial " danger of malocclusions. It must not be overlooked that although this boy obtained his situation through influence a week's work nevertheless proved his unfitness for the post, and his prospects in commerce were thus blighted almost at the start. Children suffering from malocclusions who are obliged when seeking situations to make personal application to employers will in nine cases out of ten be foredoomed to utter failure. Facial deformities due to malocclusion are likely to prove not only an actual barrier to commercial success, but the very realisation of their presence must perforce result in a profound psychological repression on the unfortunate individuals in question. The attitude of the employer I do not criticise—dental hygiene is to-day most rightly taken well into consideration by many employers of labour. I would add that I have since taken this boy on as a patient at the Royal Dental Hospital, and treatment is now being carried out. But—and here is a point I wish to stress—the final result can hardly be as successful as if a proper and complete treatment had been undertaken whilst he was still attending your Borough school. I regard this case as a vivid illustration of the imperative need for parents to realise their responsibility for ensuring that their children shall receive early attention in order that a satisfactory cure shall result from treatment completed before the school leaving age is reached. The National Outlook. The continued success of the weekly session scheme, and the experience gained during the past year of the readiness with which the Section can undertake treatment of a steadily increasing number of cases, clearly indicates to me the entire fitness of the scheme for extension on National lines as an integral part of ordinary school dental work. 20 1. Model showing lateral view of patient's mouth on 26th April, 1930, shortly before he obtained a scholarship. 2. Model showing lateral view ot patient's mouth when brought by his mother to see the School Medical Officer on 24th November, 1934, after leaving school. 3. Model of upper and lower bite on 24th April, 1930. 4. Model of upper and lower bite on 24th November, 1934. 5. Skiagram taken on 26th May, 1930, just before boy obtained a scholarship, showing supernumeraries and overcrowding. To the average parent Figures 1 and 3 denote no very serious deformity pending. The seriousness of the position is, however, indicated in the skiagram taken at the time. I am convinced that the time is now ripe for the commencement on practical lines of an orthodontic scheme which will embrace the whole of the country, and which, moreover, can be offered at no extra charge beyond the regular school dental fees. I consider it a highly significant fact that throughout 1934 there was evidence of a considerable amount of interest on the part of Public Health Officials, and others, in the conduct of the orthodontic scheme at your clinic. Numerous requests were received from school dental officers, council officials and various lay individuals who are concerned with public health matters, for permission (which was invariably granted) to visit the Heston and Isleworth Clinic for the purpose of making a personal investigation of the routine adopted. When the fact of these enquiries is combined with the fact that a number of other clinics are actually endeavouring to formulate similar orthodontic schemes, it becomes apparent that there is a growing realisation of the importance and value of school orthodontic clinics. It seems to me to be obvious that we have here clear indications not only of the immediate need for a National Scheme, but also of the fact that (since there is abundant evidence of the will to establish such schemes) the time has definitely arrived for a start to be made under the guidance and authority of the Board of Education. In conclusion, I should like to express the hope that when I submit my next annual report I shall be in the happy position of knowing that your Orthodontic Section is no longer the sole such clinic under recognition of the Board of Education. I hope I shall be able to refer to it as the leading Clinic in a series of similar institutions established throughout the country. H. R. EVANS, l.d.s., r.c.s., eng., Orthodontic Consultant. Orthodontic Demonstrator, Children's Department, Royal Dental Hospital. (h). Orthopaedic and Postural Defects. Although handicapped by the absence of a Clinic for the supervision of crippling defects, 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 Orthopædic Hospital, at whose Out-patient Department 32 school children from this area attended during the year. Two children were admitted to the Hospital for in-patient treatment. One was a case of severe bowing of leg following a street accident. The other case was one of Anterior Poliomyelitis and was admitted to the Orthopaedic Hospital after 10 months in-patient treatment at the Hounslow Hospital. Two other children are known to have obtained in-patient treatment by private arrangement at the Royal National Orthopaedic Hospital for the following conditions:—Kypho-Scoliosis, and Right Talipes. Twenty-three children received non-residential 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 1934, and the four previous years. 21  1934 1933 1932 1931 1930 Small-pox — — — — 2 Scarlet Fever 210 186 105 106 77 Diphtheria 44 17 30 26 88 Measles 901 108 952 9 799 German Measles 66 13 25 5 38 Mumps 153 940 122 132 381 Chicken-pox 417 362 194 233 392 Whooping Cough 144 287 260 242 144 1935 1913 1688 753 1921 This table shows the incidence of infectious disease in each school during 1934:— SCHOOL. SCARLET FEVER DIPHTHERIA. MEASLES GERMAN MEASLES MUMPS CHICKEN POX WHOOPING COUGH Alexandra Junior 50 5 29 5 3 13 1 „ Infants Berkeley Junior Mixed & Infants 1 - 48 1 1 1 15 Brentford End Infants 4 3 7 - 8 21 8 Bulstrode Senior Boys 2 - - - - - 2 „ „ Girls 11 - 1 - - 3 - Chatsworth Infants 11 6 131 - 1 4 - Cranford Junior Mixed & Infants 4 - 17 3 - - - Grove Road Junior Mixed 19 - 78 3 - 11 33 „ „ Infants Heston Senior Mixed 4 1 - - - 1 - „ Junior Mixed 2 - 5 - - 2 - „ Infants 3 2 98 1 1 3 2 Hounslow Heath Senior Mixed 3 - 3 — — 2 — „ „ Junior Boys 13 3 6 3 1 29 2 „ „ Junior Girls 4 — 10 8 2 30 — „ „ Infants 18 10 89 33 1 168 35 Hounslow R.C. Mixed & Infants 4 — 11 2 3 4 4 Hounslow Town Junior Boys 3 — 8 — — 3 — „ „ Junior Girls & Infants 4 — 57 2 17 2 5 Isleworth Blue Boys - — - — 1 3 — „ „ Girls & Infants - 4 8 — — 4 — Isleworth Town Junior Mixed 15 1 4 — 11 13 2 „ „ Infants 15 3 78 2 24 54 18 Marlborough senior Mixed 5 — — — 10 7 — St. Mary's Boys 1 1 9 — 7 1 — „ Girls & Infants 2 2 22 — 16 5 — Spring Grove Central 3 1 2 — 1 2 1 „ „ Junior Mixed & Infants 4 — 48 2 1 20 3 Woodlands St. John's Infants 2 2 30 — 22 2 10 Worple Road Junior Mixed 1 — 12 — 3 2 — „ „ Infants 2 — 90 1 19 7 3 210 44 901 66 153 417 144 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. 22 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. A number of playground classes are held during the summer months and an encouragement to the holding of these classes has been that a number of classrooms in Schools have been provided with additional doors opening directly on to the playground and all obsolete furniture in Infants' Schools has been replaced by tables and chairs so that the children can easily take their chairs out into the playground. • (b). Open-Air Classrooms in Elementary Schools. The Schools planned during the last year and where building has already commenced or about to commence have open air classrooms, i.e., the whole of one side is formed of French windows in two cases and in the third case two sides can be completely thrown open with a two feet wall below. (c). School Journeys and Camps. During the last year one School took two parties of girls for a week each in school term to Ham Island near Windsor, and one school took a party of boys to a Camp at Lyme Regis during the holidays. 10.—PHYSICAL TRAINING. Every teacher taking the subject was supplied with a copy of the new Board of Education Syllabus of Physical Training. The Committee organised three courses for:— (a) Infants' teachers. (b) Women teachers in Junior and Senior Schools. (c) Men teachers. which practically all the teachers taking the subject attended. The Senior Schools have been supplied with a full complement of gymnastic apparatus except in one case where there is no teacher suitably qualified to do this advanced work. More playing fields have been brought into use during the year in particular Smallberry Green of 8 acres and the Marlborough School field after levelling and sowing of grass. There has also commenced the laying out of two large grass plots, one each for Alexandra Infants' and Alexandra Junior Schools. At Grove Road School the area of tarpaving has been materially increased in order to enable Physical Training lessons to be carried on in good conditions. During the coming year this is being done also at Heston Senior and Berkeley Junior Schools. The number of Schools holding Schools athletic sports is increasing and having every encouragement. The facilities for swimming have been increased and the attendances at the Baths have increased from 14,000 in 1933 to 23,000 in 1934. Proposals have been sent to the Board of Education to build a gymnasium at the Spring Grove Central School to be used also for Evening Institute work. At this School the Committee have appointed a woman teacher of Physical Training from Chelsea Physical Training College and intend this summer to appoint a similarly qualified man teacher from the Carnegie Physical Training College. 11.—PROVISION OF MEALS. The scheme for the provision of dinners for school children commenced in May. The dinners are served at 5 centres (four cafes and one school caretaker's home). The centres and the meals have been inspected periodically by the medical staff to ensure that thev are up to the necessary standard. The following menus have been supplied to the caterers for their guidance:— 23 Dinners—Summer. First Week. Second Week. Sunday. Corned Beef or Roast Beef. Salad. Potatoes. Jam Tarts and Custard. Cold Boiled Ham. Salad. Potatoes. Baked Swiss Apple Pudding. Monday. Shepherds Pie and Haricots. Rice Pudding. Mixed Vegetable Soup. Baked Ginger Pudding. Tuesday. Lentil and Tomato Roast. Potatoes and Brown Gravy. Custard and Stewed Gooseberries. Roast Beef and Yorkshire Pudding. Potatoes and Greens. Raw Fruit. Wednesday. Roast Leg of Mutton. Potatoes. Flageolets. Raw Fruit Salad. Egg and Cheese Salad. Bread and Butter. Boiled Apple Pudding. Thursday. Dutch Roll. Greens and Potatoes. Boiled Rasin Pudding. Stewed Steak and Savoury Balls. Thick Brown Gravy and Carrots. Baked Bread Pudding. Friday. Salmon Salad. Potatoes. Eve's Pudding. Baked Fish. Potatoes and Beans and Parsley Sauce. Ground Rice Pudding and Stewed Plums. Saturday. Steak and Kidney Pie. Potatoes and Greens. Fruit Mould. Baked Sausages and Onions. Tomatoes and Potatoes. Lemon Pudding. Dinners—Winter. First Week. Second Week. Sunday. Roast Beef. Yorkshire Pudding. Greens, Potatoes. Raw Fruit. Roast Mutton. Greens and Potatoes. Stewed Gooseberries and Custard. Monday. Shepherds Pie and Haricots. Rice Pudding. Mixed Vegetable Soup. Baked Ginger Pudding and Treacle Sauce. Tuesday. Irish Stew. Peas. Eve's Pudding. Dutch Roll. Greens and Potatoes. Boiled Apple Pudding. Wednesday. Vienna Steaks. Mashed Turnips and Potatoes. Ground Rice Pudding. Roast Beef and Suet Pudding. Potatoes and Greens. Apples or Figs. Thursday. Toad in the Hole. Greens and Potatoes. Stewed Plums and Custard. Stewed Steak and Savoury Balls. ThickBrown Gravy and Carrots. Baked Bread Pudding. Friday. Lentil Soup. Boiled Rasin Pudding. Baked Fish, Parsley Sauce. Potatoes and Butter Beans. Jam Roly Poly. Saturday. Steak and Kidney Pudding. Potatoes and Parsnips. Raw Fruit. Baked Sausages and Onions. Tomatoes and Potatoes. Rice Pudding. These meals can be supplied at 7d. a day to any elementary school child. During December 195 necessitous children received dinners free, and one other case was assessed to pay one fourth of the cost. SPECIAL REPORT ON MILK CASES. Since the initiation in 1933 of special arrangements for the supply of milk to school children on medical grounds, the number recommended has been 289. Of these, the records of 242 have been considered, the remainder having had milk for less than 4 months, an insufficient period on which to form an estimate of progress. Of these 242 children, 146 had been getting 2 bottles of milk a day for a longer period than 4 months (the majority over a year), 50 were getting a third of a pint only per day, and the remaining A6 had not had milk for various reasons. An attempt was made to assess the improvement, or otherwise, in the physical condition of all these children since the date of the examination when they were first recommended for milk on medical grounds. All factors were, as far as possible, taken into account in this estimation; thus, the change in appearance, as judged by the elasticity of the skin, the subcutaneous fat, colour of mucous membranes, the hair, etc., the increase in weight—and whether the general health was reported to have improved. No laboratory estimations were done, with the exception of 2 or 3 cases in which a blood-count was performed. On this basis the findings were as follows:— 24 Recommended for Milk on Medical Grounds. 1. Children in receipt of 2/3rds of a pint per day. Total 146. Improved—96: Doubtful or no improvement—50. 2. Children in receipt of l/3rd of a pint per day. Total 50. Improved—25: Doubtful or no improvement—25. 3. No extra milk at school. Total 46. Improved—20: Not improved—26. As the administration of milk, or the absence of it, was not under controlled conditions, precise value cannot be attached to the above figures. The much higher percentage improvement of those on two bottles a day is, however, very suggestive. Milk-meals via the schools occasion certain difficulties and problems which will have to be overcome. Firstly, there is the question of school holidays. At a period when increased exercise and open air stimulate the appetite, the daily milk intake is decreased, unless the parents themselves supply the deficiency. Their ability to do this is usually in inverse ratio to the need. During illness or convalescence, or when there are frequent absences from school on account of illness, the supply of milk is again apt to be most unsatisfactory when it is most required. Fortunately the supply of milk during school holidays is now being considered, and milk will be given experimentally during the next Easter holidays. A certain number of children recommended but not receiving milk were stated to suffer digestive disturbances, and the parents objected on this ground. In other instances, it was said that the child's appetite at the usual meal-time was spoiled by the milk. A few parents could not be persuaded that milk had much food value, and a few refused or could not be bothered to fill in the assessment form. V. FREEMAN. In addition to the above mentioned cases, 66 per cent. of the school children in the Borough are having Milk daily under the self-supporting scheme. Before the Milk Marketing Board's scheme came into operation last October, only about 14 per cent. of the children were having milk. 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 1934 a parent or other relative attended in 3,012 instances, representing 71.3 per cent. Parents are urged also to attend the Treatment Clinics and it is gratifying to find that an increasing number of parents do attend and show their desire to obtain, and assist in the treatment of their children. 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. Psychological cases, as I mentioned last year, keep dropping in and present their problems for elucidation. One of the most interesting was a small boy, a very bright lad whose father was connected with the scholastic profession. The family had recently come into the district to live alongside a school. The house had been taken in this situation by reason of the fact that the boy could not hold his water day or night. He wetted his bed at night, he wetted himself during the day. Shortly after their arrival in the new house the character of the school was altered to that of a Junior Mixed School, and the boy, therefore, had to be transferred to a school a mile-and-ahalf away. The father was seriously upset by this and wanted a medical certificate that the boy might remain at the original school in spite of his age. The father alleged that it was quite impossible for the boy to travel even the 'bus journey and stated that whenever he took him out in a motor-car he had constantly to stop for him to empty his bladder, in fact, from the father's description, it would appear that the unfortunate bladder was almost canine in character. I refused to grant a certificate and took the boy in hand, first making arrangements with the teacher at the school where he was transferred, to allow him, at first, to leave the room if necessary. Once a week the boy came up to me for a therapeutic interview. Not only did the father write to the Education Secretary saying that he entirely disagreed with me, but that he had taken the boy to a local doctor who was prepared to support him in his request that the boy be allowed to attend the school close to his home. In spite of the father's protests, and the medical certificate, the boy attended the school to which he had been transferred, and as a result of psychotherapeutic measures for three months, I was satisfied that his condition as far as enuresis was concerned, both nocturnal and diurnal, was completely cured. In this case, the boy's real trouble was the domination of the parent. At the end of 1934 there were 34 children being maintained by the Education Committee at institutions outside the district. One was in a school for Mentally Retarded Blind Children, four were in Schools for the Blind, and two were in a School for the Partially Sighted. In addition to these 7 children who are in Special Schools, we have 28 children attending elementary schools in the area who suffer from a high degree of myopia. Thirteen of these have been supplied with special desks. Each of the 28 children has special consideration at school, and the Heal 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. Four 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 sighted. These four children should be in a special school or class for such cases. Nine 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, and one was at the Royal National Orthopaedic Hospital's County Branch, Stanmore. Six were at Residential Open-Air Schools. One was at a Residential School for children with Heart Disease. In March the Committee came to an arrangement with Dr. J. D. M. Cardell, whose qualifications are in accordance with Circulars 1353 of the Ministry of Health and 1431 of the Board of Education, to act as Consulting Ophthalmic Surgeon and Certifying Officer in cases of blindness. No child of school age, however, was certified blind during the year. 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. 26 16.—SECONDARY SCHOOLS AND OTHER INSTITUTIONS OF HIGHER EDUCATION. Up to the present time these schools have been under the Middlesex County Council, bul on and from the 1st April, 1935, we shall take over the Dental inspection and treatment and Ophthalmic treatment of children in the Secondary Schools of the Borough. 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 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. (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 1934 spectacles were supplied to over 96% 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 1s. 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. (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 1s. per case is paid by the parents direct to Mr. Arnell who does the cleaning. Mr. Arnell retains all fees collected in payment for the work done. 18.—HEALTH EDUCATION. No special action has been taken under this heading during the year. 19.—SPECIAL ENQUIRIES. No special enquiries have been carried out during the year. 20.—MISCELLANEOUS. Eleven teachers were medically examined during the year in connection with their appointments on the teaching staff of the Authority. 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-four children were examined during 1934. Twelve of these were found to need treatment on account of dental caries, and one for enlarged Tonsils and Adenoids. Five cases have received treatment at the School Dental Clinic. 27 STATISTICAL TABLES. TABLE 1.—RETURN OF MEDICAL INSPECTIONS, 1934. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups— Entrants 1361 Second Age Group 1450 Third Age Group 1112 Total 3923 Number of other Routine Inspections 301 B.—Other Inspections. Number of Special Inspections 2057 Number of Re-Inspections 4543 Total 6600 TABLE II. A. RETURN OF DEFECTS found by Medical Inspection in the Year ended 31st December, 1934. Defect or Disease. Routine Inspections. Special Inspections. No. of Defects. No. of Defects. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. Requiring treatment. Requiring to be kept under observation, but not requiring treatment. 1 2 3 4 5 Malnutrition 4 ... 173* ... Skin— Ringworm— Scalp ... ... 47 ... Body ... ... 24 ... Scabies ... ... 21 ... Impetigo 1 ... 142 ... Other Diseases (non-tuberculous) 35 15 163 1 Eye— Blepharitis 7 7 39 ... Conjunctivitis 2 ... 67 ... Keratitis ... ... 1 ... Corneal Opacities ... ... 1 ... Defective Vision (excluding Squint) 206 31 129 4 Squint 17 3 17 1 Other Conditions 4 1 97 2 Ear— Defective Hearing 22 23 28 3 Otitis Media 3 4 76 1 Other Ear Diseases 9 1 95 2 Nose and Throat— Chronic Tonsillitis only 34 110 80 22 Adenoids only 4 8 11 2 Chronic Tonsillitis and Adenoids 91 124 64 9 Other Conditions 9 79 104 2 Enlarged Cervical Glands (non-tuberculous) 6 120 81 6 Defective Speech ... 1 3 2 *167 of these cases were recommended for Milk Meals. 28 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 5 12 15 Functional 3 83 2 21 Anaemia 5 30 32 4 Lungs— Bronchitis 5 14 37 4 Other Non-Tuberculous Diseases 7 55 29 4 Tuberculosis— Pulmonary— Definite ... • • • ... ... Suspected ... ... ... ... Non-Pulmonary— Glands ... ... 3 ... Bones and Joints ... ... ... ... Skin ... ... ... ... Other Forms ... ... ... ... Nervous System— Epilepsey ... ... 3 ... Chorea ... ... 16 1 Other Conditions 1 8 14 4 Deformities— Rickets ... 1 ... ... Spinal Curvature 8 13 13 2 Other Forms 6 39 20 10 Other Defects and Diseases (excluding Uncleanliness and Dental Diseases) 11 26 1041 59 Total 501 801 2685 181 B.—Number of individual children found at Routine Medical Inspection to require treatment. (Excluding Uncleanliness and Dental Diseases). Group. Number of Children. Inspected. Found to require treatment. Prescribed Groups— Entrants 1361 126 Second Age Group 1450 161 Third Age Group 1112 148 Total (Prescribed Groups) 3923 435 Other Routine Inspections 301 20 Grand Total 4224 455 29 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 31. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 5 — — — 5 PARTIALLY SIGHTED CHILDREN. At Certified Schools for the Blind. At Certified Schools for the Partially Sighted. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 1 1 4 — — 6 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 9 - - - 9 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. — — — — — — 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 17 4 5 30 30 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. 1 — — 1 2 II.—CHILDREN SUFFERING FROM NON-PULMONARY TUBERCULOSIS. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 2 2 1 1 6 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 7 199 — 8 214 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 2 33 1 2 38 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 1 1 — 2 4 Children Suffering from Multiple Defects:— Boys—2 1 Certified M.D. Severe Epilepsy. At no School or Institution. *1 Certified M.D. Suspected Epilepsy. At Public Elementary School *Two Special Schools have rejected this case. 31 STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1934, 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 - — (b) Imbeciles 1 3 (c) Others — — (ii) Children unable to be instructed in a Special School without detriment to the interests of other children: (a) Moral defectives — — (b) Others — — 2. Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 — — 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 1 3 32 TABLE IV.—RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1934. TREATMENT TABLE. GROUP 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. (1) X-Ray Treatment 37 1 38 (2) Other — 12 12 Ringworm-Body 20 4 24 Scabies 16 4 20 Impetigo 140 5 145 Other skin disease 112 23 135 Minor Eye Defects 154 14 168 (External and other, but excluding cases falling in Group II). Minor Ear Defects 189 19 208 Miscellaneous 835 82 917 (e.g., minor injuries, bruises, sores, chilblains, etc). Total 1503 164 1667 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 Otherwise Total Prescribed Obtained (1) (2) (i) (ii) (i) (ii) Under the Authority's Scheme Otherwise Under the Authority's Scheme Otherwise (1) (2) (3) (4) Errors of Refraction (including squint) 552 1 553 517 1 498 1 Other defect or disease of the Eyes (excluding those recorded in Group I). - 4 4 - - - - Total 552 5 557 33 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 Total (1) (2) (3) (4) (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) - — 94 — 10 - 24 — 10 - 118 — 13 141 (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. (1) Otherwise. (2) Total number treated. Residential treatment with education. (i) Residential treatment without education. (ii) Non-residential treatment at an orthopaedic clinic. (iii) Residential treatment with education. (i) Residential treatment without education. (ii) Non-residential treatment at an Orthopaedic clinic. (iii) Number of children treated 2 — 16 2 — 7 27 GROUP V.—DENTAL DEFECTS. (1) Number of Children who were:— (2) Half days devoted to:— (i) Inspected by the Dentist: Inspection 37 Aged: Treatment (Ordinary) 732 Total Routine Age Groups 5 523 Total 5949 „ (Gas) 97 888 6 586 Administration (Clerical) 18 7 724 Dental Committee Meetings 4 8 774 (3) Attendances made by children for treatment 10,530 9 747 10 768 11 639 (4) Fillings:— 12 467 Permanent teeth 5072 Total 13 587 Temporary teeth 829 5901 14 131 (5) Extractions:— 15 3 Specials 1917 Permanent teeth 959 Total Temporary teeth 4232 5191 Grand Total 7866 (6) Administrations of general anaesthetics for extractions 1386 (ii) Found to require treatment 5438 (7) Other operations:— Permanent teeth — Total (iii) Actually treated 3811 Temporary teeth — 4457 GROUP VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. (i) Average number of visits per school made during the year by the School Nurses 2.09 (ii) Total number of examinations of children in the Schools by School Nurses 10,175 (iii) Number of individual children found unclean 575 (iv) Number of children cleansed under arrangements made by the Local Education Authority 89 (v) Number of cases in which legal proceedings were taken (a) Under the Education Act, 1921 — (b) Under School Attendance Byelaws 13 34 G. W. BARBER & CO. (T.U) 77, Hanworth Road. Hounslow.