HES 24 Borough of Heston and Isleworth 1937 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, 1937 1937 REPORT ON THE HEALTH OF THE BOROUGH OF HESTON & ISLEWORTH FOR THE YEAR 1937 BY ELWIN H. T. NASH, m.r.c.s., m.r.c.p., d.p.h., Medical Officer of Health. (PRESIDENT ELECT, SOCIETY OF MEDICAL OFFICERS OF HEALTH) 3 Index Airport, Heston 50 Ambulance Facilities 17 Ante-Natal Care 10, 51, 54 Birth Rates 13 Blindness, Prevention of 50 Canal Boats 27 Chicken Pox 42 Child Life Protection 57, 58 Cleansing of Verminous Persons 42 Clinics and Treatment Centres 18 Convalescent Treatment 59 Deaths, Causes of 14 Death Rates 13 Dentures for Mothers 58-60 Diphtheria 37, 42, 44-46 Diphtheria Immunisation 9, 38-41 Disinfestation (Bugs) 17, 24-25 Drainage and Sewerage 19, 23 Dysentery 45, 47-49 Encephalitis Lethargica 42, 44-46 Enteric Fever 42, 44-46 Erysipelas 42, 44-46 Factory and Workshop Act, 1901 26 Food, Inspection and Supervision of 11, 22, 34-36 General Provision of Health Services in the Area 16 Home Help 61 Home Visiting 61 Hospitals 16 Housing 24, 25, 28-33 Industries, Local 13 Infant Deaths 13-15, 53 Infectious Diseases 22, 37-46 Influenza 42 Inspection and Supervision of Food 11, 22, 34-36 Laboratory Statistics 16 Maternal Mortality 58, 59 Maternity and Child Welfare—Attendances at Centres 51, 52 „ „ Centres 18, 51, 52 „ „ Dental Treatment 51, 58-60 „ „ General Arrangements 51-62 „ „ Grants of Milk 62 Measles 9, 10, 42 Meat 22, 34, 35 Midwives 54-57 Milk 34 „ Grants to Expectant and Nursing Mothers and to Children under three years 62 Mumps 42 Notification of Births 52 Nursing Homes 62 Nursing in the Home 16 Nutrition Research—Carnegie Grant 10, 36 Ophthalmia Neonatorum 17,42,44,45,62 Pneumonia 42, 44-46 Population 13 Puerperal Fever 42, 44-46 Puerperal Pyrexia l7, 44-46 Sanitary Circumstances of the Area 19 Scarlet Fever 37, 44-46 Scavenging Smallpox 17, 42, 45, 46 Smoke Abatement 22, 24 Staff 7, 12 Swimming Baths and Pools 27 Tuberculosis 17, 43, 44 Venereal Diseases Vital Statistics 8, 13 Voluntary Societies and Helpers 60, 61 Water Supply 19, 22 Whooping Cough 42 Public Health Department, 94a, Bath Road, Hounslow. June, 1938. 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 I would particularly draw attention to the introductory summary on page 8. In submitting my last Annual Report, I wish to express my appreciation to the Council for the continued consideration and support 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, 1937. Councillor J. E. DILLINGHAM {Chairman). „ A. C. TURNER (Vice-Chairman). Alderman J. J. BONNETT, O.B.E. F. SALMON. Councillor Mrs. M. M. ASHDOWN. H. G. BODY. E. W. HEATH, J.P. H. G. HEARN. L. H. C. HUDD. G. RAVENHILL. „ D. RHYS, M.A., J.P. {Mayor). F. SARD. A. P. SNELLING. MATERNITY AND CHILD WELFARE COMMITTEE Councillor H. G. HEARN {Chairman). ,, A. C. TURNER {Vice-Chairman). Alderman J. J. BONNETT, O.B.E. Councillor Mrs. M. M. ASHDOWN. H. G. BODY. J. E. DILLINGHAM. E. W. HEATH, J.P. F. SARD. A. P. SNELLING. Co-opted Members : Miss E. A. ANKRITT. Mrs. F. M. STEPHENS. 6 STAFF The following persons constituted the Staff of the Health Department. Medical Officer of Health—ELWIN H. T. NASH, M.R.C.S., M.R.C.P., D.P.H. Deputy Medical Officer of Health—Mrs. EVA LOUISE ROBERTS, M.B., CH.B., D.P.H., Barrister-at-Law. Senior Assistant Medical Officer of Health—R. H. G. H. DENHAM, M.D., D.P.H. (Commenced Feb., 1937). Assistant Medical Officer of Health—JOHN TUDOR LEWIS, M.D., D.P.H. (Left July, 1937). LIONEL JAMES BACON, M.A., M.R.C.S., L.R.C.P., B.Chir., D.P.H. (Commenced August, 1937). 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. Consultant to Ante-Natal Clinic—K. BOWES, M.D., M.S., F.R.C.S. Medical Officer Diphtheria Immunisation Clinics—G. W. J. BOUSFIELD, M.D., B.S. (Part-time). Superi'isory Dental Surgeon—I. COHEN, L.D.S., R.C.S. (Eng.). Dental Surgeons—W. A. LILLEY, B.D.S., L.D.S. (Mane.). B. COOKE, L.D.S. (Mane.). L.C. MANDEVILLE, L.D.S., R.C.S. (Eng.). Miss C. C. JEFFERSON, L.D.S. (Mane.). (Commenced November, 1937). Chief Sanitary Inspector—R. H. BUTLER, A.M.I.S.E., Cert, as S.I. nd M.I. Deputy Chief Sanitary Inspector and Housing Inspector—A. B. HAULDREN, Cert, as S.I. and M.I. Assistant Housing Inspector—F. G. DAVIES, Cert, as S.l. and M.I. District Sanitary Inspectors— G. W. ASHWORTH, Cert, as S.I. and M.I. G. LATIMER, Cert, as S.I. and M.I. A. H. CORNHILL, Cert, as S.I. and M.I. K. J. SMITH, Cert, as S.I. and M.I. Disinfector and Laboratory Attendant—F. J. COBB. Assistant Disinfector and Laboratory Attendant—F. S. ALLAWAY. Mortuary Attendant—H. ELLIS. Resident Caretakers—Dockwell Hospital—Mr. and Mrs. DOWER. Superintendent Health Visitor, Inspector of Midzvives and Supervisor of Nursing Homes— Miss J. M. EVANS, S.R.N., S.C.M., New Health Visitor's Diploma of Royal Sanitary Institute; Sanitary Inspector's Diploma of Royal Sanitary Institute. (Commenced September, 1937). Health Visitors and School Nurses— Mrs. C. E. OTTLEY, S.C.M., H.V., and S.N., M.C.W.W. (Retired July, 1937). Miss B. N. TETLEY, S.R.N., S.C.M. New Health Visitor's Diploma of the Royal Sanitary Institute. Mrs. A. E. TYRRELL, S.C.M., H.V. and S.N. Miss M. G. GRIBBLE, A.R.R.C., S.R.N., S.C.M., H.V. and S.N. Miss G. M. CLARE, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss E. I. BARTLFTT, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. Mrs. G. PRISSELL, S.R.N., S.C.M., H.V. and S.N. (Left March, 1937). Miss B. P. MANNING, S.R.N., S.C.M., A.R.S.I., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss L. B. YOUNG, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. (Left August, 1937). Miss S. McCARTHY, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced January, 1937). Miss M. O'SU'LLIVAN, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced January, 1937). Miss E. LLOYD. S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced August, 1937). Miss E. C. MIDDLETON, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced September, 1937). Miss L. C. PRICE, S.R.N., S.C.M., New Health Visitor's Diploma of the Royal Sanitary Institute. (Commenced December, 1937). Municipal Midwives—(Commenced October, 1937). Mrs. M. E. BRASH. Miss E. M. CLARKE. Miss F. BUCKLEY Mrs. G. M. JUKES. Miss K. POTBURY. (Left December, 1937). Mrs. D. T. WOODLEY. Mrs. H. M. YORWARTH. Miss D. M. WESTON. Chief Clerk—B. W. K1LBY, Cert, as S.I. and M.I. Clerks— Miss R. MARSHALL, Cert, as S.I. Miss V. D. NICHOLLS. P. T. H. CRANDON. Miss V. GOODBODY. H. L. LAW. Miss S. M. BALL. (Commenced Nov., 1937). J. W. DEAN. Miss M. GARRY. M. W. LANGFORD. Miss M. A. DIXON. (Transferred from Dental B. C. MALLABAND. (Commenced Nov., 1937). Section November, 1937). N. A. ROGERS. (Left August, 1937). L.H.HAYWARD. E. E. FORREST. G. PITT. R. POWELL. 7 SUMMARY OF COMPARABLE STATISTICS, YEAR 1937. England and Wales. 125 County Boroughs and Great Towns including London. 148 Smaller Towns (Resident Populations 25,000 to 50,000 at 1931 Census). London Administrative County. Heston and Isleworth. Notes. Rates per 1,000 Population. Births : Live. 14.9 14.9 15.3 13.3 14.9 This rate is lower than last year, but is up to the rate for the rest of the country generally. There were 9 less Births than in the previous year, and with the increased population this results in a lower Birth Rate than last year, when the rate was 15.7. Deaths: All Causes. 12.4 12.5 11.9 12.3 9.46 There were 30 more Deaths than the previous year, when the rate was 9.55. The death rates throughout the country, except for London, were generally higher than in the previous year. Our rate was slightly lower. Diphtheria. 0.07 0.08 0.05 0.05 0.01 The rate for this district is substantially lower than any of the comparable rates in the groups shown, and lower than our own rate for last year. Scarlet Fever. 0.01 0.01 0.01 0.01 0.01 Although the numbers are small, the rates for Heston and Isleworth compare favourably. Whooping Cough. 0.04 0.04 0.03 0.06 0.01 Influenza. 0.45 0.39 0.42 0.38 0.38 Notifications: With regard to notifications apart from Deaths, the incidence of Scarlet Fever was higher and compares as shown. Diphtheria notifications in this district were again very much lower than throughout the country generally as shown by the comparative rates. Scarlet Fever. 2.33 2.56 2.42 2.09 2.43 Diphtheria. 1.49 1.81 1.38 1.93 0.18 Rates per 1,000 Live Births. Infantile Mortality : 58 62 55 60 39.78 The rate 39.78 is the record low rate for this district, and the lowest of the comparative rates as shown. 8 Introduction. In writing one's "Swan Song" one may ask "What has one accomplished, what has one achieved which has been, not only of value to the community one serves, but has been materially useful to the wider field of the world in general?" On looking back one can only view with satisfaction the researches and work one has been able to carry out with regard to Diphtheria. The first five years' research was an endeavour to ascertain accurate figures as to what immunisation really effected, that is, what the proportions were who benefited by the injection. With the T.A.M. preparation which we used we were able to establish facts which have made for progress. Subsequent investigation of other products has given an accurate comparison with the results we achieved with T.A.M. and none of these can show results in any way better, and in some ways not as good by reason of the facts which go to produce the results ultimately obtained. The balance, in my mind, is in favour of the preparation which gives the least possible re-action, despite the fact that it means an extra injection. The key to the success of this work I believe very largely hinges on the way in which the syringes are kept, the needles being sent away with that frequency which ensures that they are in absolutely perfect condition. In that case the pain is negligible. In the film which I have made, which has gone far afield, the faces of the children exhibit no trace of pain whatever, except in one case where the slightest tremor showed the child had felt something when the needle went into its arm for the injection. I felt it was imperative that something like this should be done so that the parents who were hesitating could actually see the results of the inoculation. There is not unnaturally fear on the part of the average mother at a needle being thrust into her child's arm, but despite all propaganda to the contrary, the spartan attitude which our mothers take up with regard to ensuring that as far as it is humanly possible, their children shall not have Diphtheria, is a stimulating sight. Looking back over the 40 years one has been practising the art of medicine and carrying one's memory back to the pre-anti-toxin days, practising through the days when anti-toxin made things more bearable in Isolation Hospital work in the Diphtheria Wards to the present time when one is able to say that with a population of 100,000 one had only 1 death from Diphtheria and only 18 cases notified, of which only 7 turned out to be real Diphtheria, one feels one has done something substantial for the children of the district for which one is responsible. As recorded later in this report, in 1929 we had 23 deaths from Diphtheria with a population some 40,000 less than it is at present. The most important accomplishment was the 5 years' investigation into the safety and efficiency of active immunisation against Diphtheria. In this research one was able to prove that with the normal number of injections with T.A.M., 11.8% of the children were not efficiently immunised and to show that in some cases it required as many as 6 injections before safety was reached. The results of this research together with others which have been continuously carried out have made some material contribution to the science of immunisation. In 1929, one was ploughing a lone furrow on the question of immunisation in this area, but it is now being carried out by all the surrounding Authorities. More recently our researches into the value of A.P.T. of various makes have accurately established the value of this preparation as compared with the earlier ones, such as T.A.M., one of which was put on the market with an efficiency which was tragic in its insecurity. My film has travelled through the length and breadth of this country, has been purchased by three of the Australian States and New Zealand and has, I have found, been a very material contribution to parental conversion. Whilst recognition in a wide field has been given to my pioneer efforts in other fields, the contributions that I have made to Diphtheria Immunisation give me more satisfaction than any other Public Health subject I have dealt with. One of the most satisfactory things one has been able to accomplish has been the provision of a service for the prevention of measles by co-operation with the Scout Movement. Since 1932 I have during each outbreak been able to obtain adult blood from Rover Scouts who have had Measles. One has found that the percentages of efficiency that have been published elsewhere are definitely lower than in one's own experience. It must be borne in mind that the average parent will not allow its small child to be bled to provide sufficient convalescent serum for the protection of someone else's child, and it really boils down to the fact that the only source of Convalescent Serum is to be found in the Isolation Hospitals, and in very few of them. The results one has obtained with adult serum are almost too good to be true, and fortune, certainly in the last outbreak, must have favoured us abnormally in that I obtained what has never been obtained before, namely a complete 100% efficiency, where I desired a complete immunity. The following is an extract from the report of Dr. Rankin, the Medical Superintendent of the South Middlesex, and Richmond Joint Hospital. "During the past year the method of sero-prophylaxis has been applied with marked success on two occasions when wards of the hospital were exposed to Measles. We are deeply indebted to Dr. Nash, Medical Officer of Health of Heston and Isleworth, for supplying batches of measles serum. On each occasion all susceptible contacts were completely protected and no quarantine was imposed upon the wards." 9 Only those who have had to suffer as one has personally in one's own family, the ravages of Measles, and when I say ravages I mean it in the fullest and most awful sense of the word, can appreciate what it means now-a-days to be able to say with a fair degree of certainty that their child can be rendered safe by an injection of Measles Serum. The work I have done here has been so successful that I have recently been aked to devise a scheme for the development of the Rover Scout Blood Donor Service for Measles protection, starting in the County of Middlesex, but to extend ultimately to the whole country. I cannot be too grateful for the co-operation of Mr. Finlayson, the Assistant Commissioner for this area, who supported me through thick and thin. Neither can I express too highly my gratitude to the Rovers who supplied the blood with such splendid results, and more particularly to three of them, Mr. L. Coles, Mr. J. Bennett and Mr. P. King, who have been volunteers on every occasion. The establishment of a complete orthodontic scheme with some 2,000 cases treated is a landmark in the progress of municipal dentistry and so far as I can ascertain our Orthodontic Clinic is the first Municipal Orthodontic Clinic in the English speaking world, neither can I find the history of any in those who do not speak our tongue. Mr. Cohen, the Supervisory Dental Surgeon, has, with his dental skill and thoroughness, made his invaluable contribution to the success of the scheme. The success of this work has been one of the principle joys of one's work. The gratitude of the mothers, speaking generally, is wonderful, and the difficulties of bringing the scheme to fruition fade into significance beside the results achieved. Again I want to emphasise that the beneficent effects of this work are not so much in the realms of the physical improvement as in the obliteration of the psychological affliction which spoils the patient's whole life, particularly in the case of a woman. Another piece of work which one views with substantial satisfaction is the Cookery Research, and the publication of the results in a Cookery Book made available by a grant totalling £850 from the Carnegie Trust, supplemented by £150 from my own Council. The year's research was extraordinarily interesting and the resulting Cookery Book which took so much of one's time has gone far afield—to the Yukon, to Australia—and the Federal Government of America gave it a three page review in their journal which goes to every Medical Officer of Health in the United States. Herein one has been able to make a real contribution to the science of nutrition for the humble worker of limited means. With regard to the provision for the safety of our mothers, one has been able to provide a service of the highest possible standard, largely through the sympathetic understanding, from the Public Health point of view, of our first Ante-Natal Officer, Mr. A. J. Wrigley, now on the Senior Staff at St. Thomas's, who really grasped the Public Health point of view. He left us to be succeeded by his colleague—Mr. Bowes. The closest liason with St. Thomas's, in cases of difficulty which wanted further investigation, has been invaluable. One has been able to do very great service by retaining beds in the Eastman Dental Clinic whereby our mothers can be taken in for a couple of nights and have their wholesale extractions carried out in perfect comfort whilst the Council put a Home Help in the house. This service has been immensely appreciated by a number of mothers. It will be remembered that in my Annual Report for 1934 I recorded a case of a patient at the Ante-Natal Qinic for whom I broadcast as she was found to have very early cancer, which was subsequently operated on by the Ante-Natal Specialist at St. Thomas's. I have seen this woman recently and she is in excellent health and working hard. It is very gratifying to feel that one broke new ground which was possibly responsible for saving her life, and she still remains, so far as 1 can ascertain, the only person who was broadcast for to save her life instead of being broadcast for to go and watch some relation die. With regard to Flat Rate Payments. I have no hesitation in saying that the success which has attended our scheme for the provision of spectacles and also for the percentage of cases dentally treated, is due to the introduction of the flat rate method of payment. When I took office I found parents being charged large sums for spectacles with frames unnecessarily expensive, which daunted, by reason of its magnitude, the parent who had been told that her child wanted glasses. The substitution of a fiat rate payment, originally 4/-, raised to 4/6d. for a rather better class of frame, and also a flat rate of charge for repairs, has done an enormous amount to increase the number of children provided with glasses by reason of the fact that the total liability was known. There is no terror of the unknown bill. 10 The success of this flat rate payment system, together with the administrative arrangements has resulted in one being able to record last year that every single child in this area who required glasses obtained them. In 1934 we got the only multiple store in existence at the time, to cover in their sweet counter and fifty lineal feet were put under glass. The glass covered top was carried right to the back of the goods displayed so that no droppings of dust, with the accompanying bacteria, fall on the goods. In the majority of exhibits of this nature in Stores and shops (and I spend a lot of time prying into these things), the top glass slab does not extend far enough back to really keep the goods displayed clean. In a very large number the top shelf is limited to about 6" or 9" instead of the 20" in the case under discussion. The Manager reported that from the point of view of display the arrangements were "very satisfactory" but the actual result was that the sales dropped by 26% right through the sweet department although wrapped bar chocolates which were displayed on the top of the glass case showed an increase in the sales of 75%. With regard to biscuits, at my request they tried to decrease the sale of loose biscuits, and increase the number of packeted varieties. At that time they had only mild success with two varieties, namely cream crackers and ginger nuts. Six of the best sellers were selected and packeted, and put in front, the bulk of the display being immediately behind on the counter. The sales dropped 50% and 40% as compared with the same displays of loose biscuits. It must be borne in mind that these multiple stores have a totally different problem to deal with from the point of view of cleanliness, to the ordinary shop. Whereas the ordinary shop has nothing but potential customers coming in for some specific article, the multiple stores are thronged with numbers of people, and particularly children, who have no definite idea of making any purchase at all. The older people come in to have a look round and see if there is anything they may want, and the children very often out of curiosity. Various kinds of coverings were used at my suggestion. Cellophane windows, afterwards complete cellophane, but the results were little better than the completely opaque coverings. Six varieties were prepared in both coverings. The ordinary packing sold as before, but the cellophane was a complete failure. However, in the interests of hygienic trading the experiments were persisted in and now the packeted varieties have been increased to 30, although these are responsible for only 15% of the volume of trade of the whole department. The packeted biscuit section occupies the premier counter position. The only other way we found we could cover in biscuits was to have them displayed in the original 7 lb. tin with a plate glass cover which just fitted the tin. The firm are anxious to win the public over to the sale of the packeted biscuit as not only is the packet ideal from a health point of view, but it is also of great interest to the vendor as this method of sale involves no waste whatsoever. One of the other big multiple stores in the district has put in an extremely well constructed and efficient glass covered and fronted stall for the sale of biscuits, many of which are chocolate covered. It would be thought that this effort to keep the food clean and wholesome would be appreciated by the purchasers. Not a bit! The District Surveyor of the firm in question rang me up one day to inform me of their difficulty. The matter was so important that I went down to the Store and had a long conference with him. The position was illuminating and made one wonder what the intelligence of our British public really is. I was shown the cash receipts of all the stores of the firm in the neighbourhood of this district and as far round as the north of London, where they had not, so far, attempted to cover in the biscuits in this manner. Whereas during the previous year the receipts had increased steadily in all the surrounding stores to a very material extent, in the store in our district where they had got the best arrangement for keeping the display clean and wholesome, not only had the receipts not increased but they had materially decreased. Such is the encouragement to a firm who has spent a considerable amount of money in trying to conform with the desires of the Health Department and at the same time make its display more attractive. I make a point of going round the various towns to see how these things are dealt with. I went over during the Christmas Holiday to a neighbouring town where biscuits are quite uncovered, and stood, as I usually do, and watched for a considerable period, the way the public re-acted. Here, during the Bank Holiday period, the biscuits were all open to dust and dirt blowing about, but what made me furious was the way in which people, particularly old people, coughed with hearty liberality all over the biscuits, or sneezed with colds that were rife at that period of the year, and yet any effort to try and keep the biscuits clean and wholesome is very nearly defeated by the public. The second firm referred to rang me up because they felt that the loss they were incurring was such that they must revert to their previous open method of selling biscuits, open but unhygienic. I finally induced them to give the glass case a further three months' trial. It is a lamentable thing to see the splendid efforts of the people providing food for the British people defeated by the utter lack of intelligence of those whom they are trying to help. 11 One speaks strongly on the matter, but having worked so hard to obtain a really satisfactory protection for food, and having got it, it is disappointing in the extreme to see all one's, efforts ignored. It is so curious because in the same premises as those referred to above, and I say it without fear of contradiction, is the finest food counter I have ever seen. The display of food under the glass covered counters together with the refrigerator make up a unit which is as near perfection as it can be. Its perfection is such that it has introduced an entirely new class of customer into the store by the enticing character of the food already cut and displayed in an attractive fashion. Such is the tale of one's pioneering efforts and the results one has been able to accomplish thereby, which one leaves behind with satisfaction as a result of 17 years' work for an Authority who latterly have given me every encouragement that any Medical Officer of Health could have to ensure that the Ratepayers of the District do get a Public Health Service which means to them the improvement in their health if it has been lost, and the retention of it if it is good. 1 he importance of this is only apparent when one realises that for the vast majority of our ratepayers, as it is also for the citizens of the country as a whole, their health is their capital and with the loss of health come those miseries and disasters which ruin the happiness of so many families. So I take farewell of a staff which has been hardworking, loyal and very efficient. The younger members have re-acted very well to my office motto " There is only room at the top, any fool can be at the bottom." They have worked hard in their evenings and taken their certificates which mean promotion, either with us or elsewhere. At times the rapidity with which the staff changed by outside promotions was embarrassing, and made the work of those remaining unduly burdensome. To Dr. Roberts, my special thanks. She has always upheld in my absence the high standard we have set and has done splendid work in the regions of defective vision, work that is without equal in its efficiency so far as I know. Members of the Council and Committees are perhaps not fully aware of the excellent results which have been obtained by Dr. Roberts in this field. She is accustomed to getting on with the work for its own sake and like many a flower " it blushes unseen " except to those who know its real value. As an anaesthetist she is very far above the average. This again is not work which is seen by the public, but I know its value. To Mr. Butler again I want to express my gratitude to the full. The years when his deafness confined him to the office made things difficult. The possession of one of the new hearing aids has enabled him to resume to the full his duties as Chief Sanitary Inspector. His absolute integrity, straight as a gun barrel, has been so long as I have known him, an asset of incalculable value to the Council. Then to Mr. Kilby, my Chief Qerk. I am not usually stumped for words, but I find it difficult indeed to express my gratitude for the most efficient and loyal service that any chief could ask and receive for years on end. One other person to whom I must pay special tribute is Dr. Bousfield, whose meticulously careful work in the immunisation section has enabled us to make a substantial contribution to the science of diphtheria immunisation. The meticulous care with which the work has been done has left us with a record which cannot be surpassed anywhere. In relinquishing my post as Medical Officer, I knew that there are many many mothers of the children of the Clinics and Schools who cherish memories of the fat doctor who ministered to their little ones, the while they sat on his knee, ate his biscuits, kissed him when they went, and trusted him and were fond of him. The growth of administration work that took me from the children was a sad parting indeed. And so farewell. 12 Statistics and Social Conditions of the Area EXTRACT FROM VITAL STATISTICS OF THE YEAR, 1937. Area (in acres, including 42 acres of water) 7,261 Registrar-General's estimate of resident population (Mid-Year) 1937 99,420 Census Population, 1931 76,254 Number of inhabited houses (end of 1937) according to Rate Books 26,681 Rateable Value (at 31st December, 1937) £858,603 Sum represented by a penny rate (1937-38) £3,443 Live Births— Total. M. F. Legitimate . 1435 753 682 Illegitimate 48 28 20 Stillbirths 35 12 23 Deaths 895 426 469 Birth rate per 1,000 of the estimated resident population 14.9 Rate per 1,000 total (live and still) births 23.05 Death rate per 1,000 of the estimated resident population (Corrected) 9.46 Rate per 1,000 total Deaths, (live and still) births. Deaths from Puerperal Causes— Puerperal sepsis 2 1.31 Other puerperal causes 3 1.97 Total 5 3.29 Death rate of Infants under one year of age:— All infants per 1,000 live births 39.78 Legitimate infants per 1,000 legitimate live births 37.63 Illegitimate infants per 1,000 illegitimate live births 104.16 Deaths from: Cancer (all ages), 126; Measles (all ages), 1; Whooping Cough (all ages), 1; Diarrhoea (under 2 years of age), 9. SOCIAL CONDITIONS. The greater part of the district is largely a dormitory for workers in London. The chief industries are:— (1) Beer, etc., brewing. (18) Aeroplanes. (2) Boat building and repairing. (19) Engineering. (3) Colours and dyes. (20) Disinfectants. (4) Letterpress Printing. (21) Laundries. Gravel quarrying. (22) Linoleum. (6) Market Gardening. (23) Carbons, Stencils, Typewriter ribbons, etc. (7) Rubber Tyres, etc. (8) Pewterware and Candle Machinery. (24) Biscuit making. (9) Pharmaceutical Chemistry. (25) Candle making. (10) Soaps, powders and perfumes. (26) Coach building and wheelwrights. (11) Sweets, confectionery. (27) Dyeing and cleaning. (12) Wines. (28) Pre-cast concrete works. (13) Sawmills and Joinery. (29) Celluloid works. (14) Fire extinguishers, etc. (30s) Artificial Manure. (15) Razors and razor blades. (31) Aluminium Solder. (16) Motor Cars. (32) Soldering Flux. (17) Fancy papers. (33) Scientific Instruments. The district still continues to develop and there is now little open land available for building purposes, the great majority of houses that are going up being of the working class type, valued round about £600 to £800. Great use has been made of the Small Dwellings Acquisition Act, and of the Housing Act, particularly the former. VITAL STATISTICS. Population.—The Registrar-General's estimate for the population to the middle of 1937 is 99,420. 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 1,981, but 1,231 of these did not belong to the district, while 145 residents died outside the district. Thus the number of deaths properly attributable to the district was 895 an increase of 30 on the figures for the previous year. 13 Adopting the basis of the population estimated by the Registrar-General, the corrected death-rate for the district comes to 9.46 per 1,000, which is comparable with the following figures:— Comparison of death rates and infantile mortality rates and stillbirth rates per 1,000 population. England and Wales 125 County Borough and Great Towns including London 148 Smaller Towns London Administrative County Heston and Isleworth Births.—The total number of live births registered during the year was 2,671, excluding re-registrations, but 1,356 of these did not belong to this district, while 168 births properly belonging to this district occurred outside the district. The nett number of live births thus attributable to the district is 1,483, a decrease of 9 compared with last year's figure. Adopting the population basis supplied by the Registrar-General for the calculation of the birth-rate, this comes to 14.9 per 1,000. The birth-rate of England and Wales was 14.9 per 1,000 and for London 13.3 per 1,000. Death Infant Death rates. rate. Stillbirths. 12.4 58 0.60 12.5 62 0.67 11.9 55 0.64 12.3 60 0.54 9.46 39.78 0.35 According to figures furnished by the Registrar-General. 14 Table of Causes of Deaths during 1937. Causes of Death. Civil Residents. all ages. All causes Male. 426 Female. 469 1 Typhoid and paratyphoid fevers — — 2 Measles — 1 3 Scarlet Fever 1 — 4 Whooping Cough — 1 5 Diphtheria — 1 6 Influenza 16 22 7 Encephalitis Lethargica — 1 8 Cerebro-Spinal Fever — 1 9 Tuberculosis of Respiratory System 21 25 10 Other Tuberculous Diseases 4 3 11 Syphilis 1 1 12 General Paralysis of the Insane, Tabes Dorsalis 2 — 13 Cancer, Malignant Disease 58 68 14 Diabetes 8 5 15 Cerebral Haemorrhage, &c. 15 22 16 Heart Diseases 100 143 17 Aneurysm 1 1 18 Other Circulatory Diseases 29 26 19 Bronchitis 18 9 20 Pneumonia (all forms) 25 16 21 Other Respiratory Diseases 9 4 22 Peptic Ulcer 8 3 23 Diarrhoea, &c. (under 2 years) 7 2 24 Appendicitis 2 3 25 Cirrhosis of Liver 3 1 26 Other Diseases of Liver, &c. — — 27 Other Digestive Diseases 9 11 28 Acute and Chronic Nephritis 7 4 29 Puerperal Sepsis — 2 30 Other Puerperal Causes — 3 31 Congenital Debility, Premature Birth, Malformations, etc. 19 11 32 Senility 7 19 33 Suicide 4 4 34 Other Violence 20 13 35 Other Defined Diseases 31 41 36 Causes Ill-defined or Unknown Special causes (included in No. 35 above) 1 2 Small-pox — — Poliomyelitis — — Polioencephalitis - 1 INFANTILE MORTALITY DURING THE YEAR, 1937. 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 ... ... ... ... ... ... ... ... ... ... Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... Erysipelas ... ... ... ... ... ... ... ... ... ... Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... ... 1 ... 1 Meningitis (not Tuberculous) ... ... ... ... ... ... ... 1 1 2 Convulsions ... ... ... ... ... ... ... ... Laryngitis ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... 1 ... 1 Pneumonia (all forms) ... ... 1 ... 1 3 4 ... 3 11 Diarrhoea ... ... ... ... ... 2 ... ... ... 2 Enteritis ... ... ... ... ... 2 2 ... 2 6 Gastritis ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... Suffocation, overlying ... ... ... ... ... ... ... ... Injury at Birth 1 1 ... ... 2 ... ... ... ... 2 Atelectasis 4 ... ... ... 4 ... ... ... ... 4 Congenital Malformations 2 ... 1 ... 3 1 ... ... ... 4 Premature Birth 13 ... 1 ... 14 2 ... ... ... 16 Atrophy, Debility and Marasmus 1 ... ... ... 1 ... ... ... ... 1 Other Causes 2 2 1 ... 5 1 2 ... 1 9 23 3 4 ... 30 11 8 3 7 59 Infantile Mortality. As we have no information transmitted to us with regard to some of the births which occur outside the district, and are subsequently transferred in, it is not possible with absolute accuracy to work out the comparative rates of infant mortality for each ward in the Borough, but as far as this is possible with the figures available, and they may be taken as a fairly reliable indication, the numbers of infant deaths and the rates per thousand of the births occuring within the various wards are appended. Heston. Hounslow Central. Hounslow Heath. Hounslow South. Hounslow West. Isleworth North. Isleworth South. Soring Grove No. of Deaths. 12 4 12 5 3 * 6 9 8 Rates per 1,000 Births. 48.97 37.38 37.26 20.92 24.79 40.0 60.40 53.3 The rate for the District as a whole was 39.78. 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 1937 is 39.78 per 1,000 births, which is the record figure for this district. Last year's figure was 48.25, and our previous record figure was 40.77 in 1935. Some comparative rates are shown on page 14. 15 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. The Corporation has increased their subscription to the funds of each Association, to 30 guineas. The Nursing Service has now been extended to Cranford to provide for the rapidly growing population at the western end of the district. LABORATORY WORK, 1937. The routine Laboratory work has been carried out in the Laboratory at the temporary premises occupied by the Department. Certain speciments are sent to outside Laboratories. Total. ive. Swabs for Diphtheria sent by Medical Practitioners 234 6 Taken from Schools, Clinics and from Contacts 446 13 Sub-Cultures 13 — Sent from Staines Joint Isolation Hospital 278 66 Total Cultures examined 971 85 Specimens sent to Clinical Research Association. Swabs 32 5 Virulency Tests (13 from Staines Joint Isolation Hospital) 18 10 Blood, for Enteric Widal Tests 2 1 Blood, for Dysentery 1 — Cerebro-Spinal Fluid (from Staines Joint Isolation Hospital) 1 — Swabs for organisms other than Diphtheria Bacilli (24 sent from Staines Joint Isolation Hospital) 34 - Specimens sent to Camberwell Research Laboratory. Blood, for Wassermann Tests 3 Other Specimens—Council Laboratory. Sputum for Tubercle Bacilli sent by Medical Practitioners 105 5 Sputum for Tubercle Bacilli taken at Clinics 1 — Hairs for Ringworm taken at Schools or Clinics 20 7 16 Urine—2,746: Discharge—4: Milk—2: Blood for Anaemia—6 Preparation of Materials:— Tubes of Serum—900: Throat Swab Outfits—1,300: Sputum Outfits—150. The bacteriological work of the Staines Joint Isolation Hospital is dealt with through the Council Laboratory. HOSPITALS. The following are the Hospitals serving the general needs of the district:— General.—Hounslow Hospital, Staines Road. Royal Hospital, Richmond. West London Hospital, Hammersmith. West Middlesex County Hospital, Isleworth. The Corporation annually subscribe £300 to the Hounslow Hospital, and £50 to the Richmond Hospital. Maternity.—West Middlesex County Hospital, but a few cases are dealt with in the Hounslow Hospital and some at the large London Hospitals. Venereal Disease.—West London Hospital, or at almost any London Hospital. Tuberculosis.—County Council Dispensary, Bell Road, Hounslow (Out-Patients only). Orthopaedic.—This treatment is still carried out through the Royal National Orthopaedic Hospital to whom a grant of £15 per annum is made by the Council in return for services rendered. Puerperal Pyrexia.—An agreement also exists between this Corporation and Queen Charlotte's Isolation Hospital Authorities, whereby cases of Puerperal Pyrexia can be sent to their Isolation Block at Ravenscourt Park. A number of cases from this and other surrounding districts are also dealt with at the West Middlesex Hospital. Ophthalmia Neonatorum.—Cases requiring hospital treatment are sent by arrangement to St. Margaret's Hospital of the London County Council. Smallpox.—This district is included in the Middlesex County Council's scheme for dealing with Smallpox which arises in the County. The cases are admitted to the hospitals of the London County Council. Fevers.—South Middlesex Fever Hospital, Isleworth, controlled by the South Middlesex and Richmond Joint Hospital Board. Dockwell Hospital.—This old Smallpox Hospital situated at the western end of the district has been kept with a caretaker in residence, and ready at any time to deal with emergencies which might arise. It is at present being utilised in connection with the housing of families whilst their houses and belongings are disinfested, and the accommodation has been improved during the year for this purpose. AMBULANCE FACILITIES. (a) For Infectious Cases.—This is provided by the Joint Hospital Committee, except for Smallpox, Ophthalmia Neonatorum and Puerperal Pyrexia cases which are removed to other Hospitals by special arrangements. (b) For Non-Infectious and Accident Cases.—The ambulance service in the Borough is efficient, there being two ambulances at the Central Fire Station. A new ambulance has been purchased to replace the oldest one which had been in use since the service was inaugurated by the Corporation. 17 18 CLINICS AND TREATMENT CENTRES, 1937. Clinics and Treatment Centres. Address. Day. Time. Provided by Ante-Natal Clinics Isleworth Health Centre, Busch Corner, Isleworth. Every Monday, Tuesday and Wednesday. 9.30 a.m. Heston and Isleworth Borough Council. Diphtheria Immunisation Clinics Congregational Hall, Douglas Road, Hounslow. Isleworth Health Centre, Monday. 10.30 a.m. and 2.0 p.m. „ Friday, 10.30 a.m. „ Infant Welfare Centres Congregational Hall, Hounslow. Monday, Tuesday and Wednesday. 2.0 p.m. „ Thursday. 10.0 a.m. and 2.0 p.m. „ Friday. 2.0 p.m. „ Village Hall, Heston. Monday and Tuesday. 2.0 p.m. „ Friday. 10.0 a.m. „ Isleworth Health Centre. Monday, Wednesday and Friday. 2.0 p.m. „ Maternity and Child Welfare Dental Clinics 35, Bath Road, Hounslow. Isleworth Health Centre. As for School Dental Clinics (see below). „ Minor Ailments Clinics (Nurse attending) 94a, Bath Road, Hounslow. Every week-day. 9.0 a.m. „ Village Hall, Heston. Every week-day. 9.0 a.m. „ Isleworth Health Centre. Every week-day. 9.0 a.m. „ Junior School, Cranford. Every week-day. 9.0 a.m. „ Ophthalmic Clinics 94a, Bath Road, Hounslow. Wednesday. 2.0 p.m. „ Thursday. 2.0 p.m. „ Isleworth Health Centre. Thursday. 2.0 p.m. „ School Clinics (Medical Officer attending) 94a, Bath Road, Hounslow. Tuesday. 10.0 a.m. and 2.0 p.m. „ Friday 10.0 a.m. „ Village Hall, Heston. Thursday. 10.0 a.m. „ Isleworth Health Centre. Monday & Thursday. 10.0 a.m. „ School Dental Clinics 35, Bath Road, and Monday, Tuesday, | 9.30 a.m. and 2.0 p.m. „ Isleworth Health Centre. Wednesday, Thursday and Friday. Saturday. 9.30 a.m. „ Tuberculosis Dispensary Bell Road, Hounslow. Monday. 10.0 a.m. Middlesex C.C. Thursday. 2.0 p.m. It Venereal Diseases Clinic West London Hospital, Hammersmith. Monday to Saturday. 7.30 a.m. to 7.30 p.m. ft Sundays. 10.0 a.m. to 12 noon. it Facilities are also provided at other London Hospitals. 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 Med;cal Practitioners. The only Day Nursery in the district was closed in 1920. The Monday Session at Heston M. & C.W. Centre is temporary, to deal with Cranford mothers until a Cranford Centre is opened. Sanitary Circumstances Water Supply.—There were, as far as Is known, at the end of the year, 30 private wells from which water was used for domestic purposes. In 53 other cases there are wells, but an alternative supply from the main exists for domestic purposes and business purposes. In 28 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. During the year the following extensions have been made to the sewers:—Foul water— 2,091 lineal yards; Surface water—3,431 lineal yards. Work in connection with the West Middlesex Sewage Scheme, which will take all the sewage of this district, is completed and in operation, with the exception of the Cranford area. The connection of the sewers in the Cranford area to the new system of trunk sewers was in progress at the end of the year. Closet Accommodation.—Accommodation on the water carriage system is almost general throughout the district, approximately 99.9 per cent, of the houses having water closets. Scavenging.—This is carried out by the Local Authority, and is under the control of the Borough Surveyor. During 1937 collection of house refuse continued weekly as before, and was disposed of by "controlled tipping" on a site in the Staines Road, Hounslow. Eight electric vehicles and four 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 was supplied 109 new asbins. Sanitary Inspection of the District.—See pages 19-33. The district work has continued to grow during the year with the further increase of the population and a large amount of additional work has fallen to the lot of the Sanitary Inspectors through the overcrowding provisions of the Housing Act, 1936. I am pleased to report, however, that the extra demands made on the staff, have, so far, been met, but with some difficulty. Nuisances, Contraventions of Bye-Laws, Defective Drainage, etc.—The number of premises on which nuisances were outstanding at the end of the year 1936 was 463. To these, another 595 premises whereat nuisances were recorded in 1937 were added, giving a total of 1,058 premises. Of these 561 had the nuisances remedied, leaving 497 premises at which nuisances still existed at the end of the year. During the year, nuisances at 59 houses were reported to the Health Committee, which, added to the 51 brought forward from 1936 made a total of 110. 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, 74 had been dealt with, leaving 36 cases to be carried forward to 1938. Comparative figures for the years 1935, 1936 and 1937, in connection with nuisances, are submitted herewith:— 1935 1936 1937 Number of complaints received 474 738 698 Premises at which nuisances were located 618 603 595 Number of First Informal Notices 648 616 646 Number of Reminders and Letters 667 865 1105 Number of Statutory Notices 57 46 56 19 Proceedings.—During the year Court proceedings were instituted by the Corporation with respect to the following cases:— Occupation of two caravans in a Yard. Occupiers each fined 10/- and 10/- per day for continuing offence. Appeals were made in the County Court by an owner against the Corporation's decision to make Demolition Orders in respect of two houses owned by him. The Demolition Orders were squashed and undertakings not to re-let accepted. An appeal was made by an owner against a notice issued requiring him to cleanse a house from vermin. The appeal was dismissed as the Court held that it had not been validly lodged. An owner appealed against the requirements of a notice served under section 9 of the Housing Act, 1936, and the Judge found that the appellant had remedied certain minor matters, but had not remedied the major matters. An order was made varying the notice served by the Council, so as to require the outstanding matters to be remedied. SANITARY WORK, ETC. Inspections—General: Total number of inspections and re-inspections, etc. 30,596 Inspections, etc., re Nuisances, Contraventions, etc.: Number of premises, etc., inspected on complaint 839 Number of premises inspected in connection with infectious diseases 191 Total number of premises, etc., primarily inspected in connection with nuisances 1,124 Number of premises inspected under Increase of Rent and Mortgage Interest (Restrictions) Acts, 1920-1933 1 Number of other visits made to premises, etc., in connection with nuisances, etc. 3,274 Number of visits made to works in progress 4,419 Number of interviews with owners, builders, etc. 3,014 Action taken (including action taken under Housing Act, 1930, Section 17): Number of premises, etc., whereat defects, etc., were recorded during the year 595 Number of premises, etc., on which defects, etc., were remedied— (a) by owners or occupiers 560 (b) by local authority in default of owner or occupier 1 Number of cautionary or intimation notices given— (a) verbal 148 (b) written 498 Number of letters and reminders re nuisances sent 1,105 Number of Statutory Notices issued 56 Number of proceedings taken 2 Number of convictions obtained 2 Number of proceedings withdrawn — Number of cases dismissed — Number of appeals made against decision of Corporation 4 Number of appeals upheld 3 Number of appeals dismissed 1 Common Lodging Houses: Number registered 2 Number of inspections made 7 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 51 Number of contraventions outstanding from previous year 18 Number of contraventions found 4 Number of contraventions remedied 7 Number of contraventions outstanding at end of year 15 20 Movable Dwellings, Caravans, Tents, etc.: Number of inspections made 297 Number of contraventions outstanding from previous year - Number of contraventions found 37 Number of contraventions remedied 37 Number of contraventions outstanding at end of year - Bakehouses: Number in district (a) factories 23 (b) workshops 9 Number of underground bakehouses in district 1 Number of inspections made 152 Number of contraventions outstanding from previous year 3 Number of contraventions found 18 Number of contraventions remedied 21 Number of contraventions outstanding at end of year - 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 1 634 Number of contraventions outstanding from previous year - Number of contraventions found 13 Number of contraventions remedied 9 Number of contraventions outstanding at end of year 4 Cowsheds: Number of persons registered 2 Number of premises registered 2 Number of cowsheds on register 4 Number of milch cows in district 54 Number of inspections made 35 Number of contraventions outstanding from previous year — Number of contraventions found — Number of contraventions remedied — Number of contraventions outstanding at end of year — Dairies and Milkshops: Number of persons registered 116 Number of premises registered 37 Number of inspections made 480 Number of contraventions outstanding from previous year 8 Number of contraventions found 6 Number of contraventions remedied 11 Number of contraventions outstanding at end of year 3 Offensive Trades: Number of businesses in district 20 Number of inspections made 79 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 — Ice Cream Vendors: Number on register 123 Number of inspections made 345 Number of contraventions outstanding from previous year — Number of contraventions found — Number of contraventions remedied — Number of contraventions outstanding at end of year — 21 Public Health (Meat) Regulations, 1924 : Number of inspections made 491 No notice of slaughtering given 1 No notice or improper notice of diseased condition given 1 Improper use of slaughterhouse 1 Insufficient ventilation to shops 1 Insufficient periodical cleansing of shops and utensils, etc. 2 No precautions taken for prevention of contamination 9 No proper refuse and/or rubbish receptacles provided 6 Insufficient sanitary accommodation and/or washing facilities 10 Written notices sent 25 Verbal notices given 6 Inspection of Food : Number of meat inspections 1,101 Number of fish inspections 150 Number of provision inspections 60 Number of greengrocery and fruit inspections 182 Number of Hawkers' foodstuff inspections 44 Number of food preparation places inspected 306 Number of other food inspections 84 Unsound Food: Number of Carcases seized 1 Number of Carcases condemned by magistrate 1 Number of parcels seized — Number of parcels condemned by magistrate — Number of carcases and offal surrendered 15 Number of carcases surrendered (excluding offal) — Number of articles surrendered 75 Number of parcels surrendered 44 Number of organs or parts surrendered during slaughtering 425 Infectious Diseases, Disinfections, etc.: Number of visits made 675 Number of rooms disinfected— (a) Ordinary infectious diseases 322 (b) Tuberculosis 76 (c) Other diseases 16 Smoke Abatement: Number of observations made ... ... ... ... ... ... 339 Number of nuisances proven ... ... ... ... ... ... 17 Shops Act, 1934 : Number of contraventions outstanding from previous year 4 Number of premises whereat sanitary accommodation found to be insufficient 9 Number of premises whereat washing facilities found to be insufficient 2 Number of premises where additional sanitary accommodation provided 3 Number of premises where additional washing facilities provided 3 Number of Certificates of Exemption granted 3 Number of contraventions outstanding at end of year 6 Miscellaneous Inspections: Number of piggeries inspected 123 Number of stable premises inspected 139 Urinals inspected 10 Water Supply: Number of supplies provided or reinstated 10 Number of cisterns cleansed, repaired, covered, etc. 7 Number of draw taps connected direct to main 28 Number of water service pipes or taps repaired 16 Number of samples taken for analysis from public supply 1 Number of samples found polluted or impure — Approximate percentage of houses supplied on constant syste 99.91 22 Drainage and Sanitary Arrangements, etc., of existing Buildings— Water Closets: Number of water closets constructed or reconstructed 22 Number of water closets cleansed or unstopped 14 Number of walls, etc., cleansed 12 Number of new flushing apparatuses provided 30 Number of new water closet pans or pedestals provided 91 Number repaired, supplied with water or otherwise improved 168 Approximate percentage of houses provided with water closets 99.9 Earth or Chemical Closets: Number provided or reconstructed 5 Number provided with deodorants or repaired 1 Sinks: Number of new sinks provided 57 Number of sinks repaired or improved 30 Drains: Number examined, exposed, etc. 90 Number unstopped, repaired, trapped, etc. 126 Number of waste pipes provided, disconnected, repaired, trapped or unstopped 59 Number of soil pipes fixed, repaired or improved 4 Number of ventilating shafts fixed, repaired or improved 38 Number of fresh air inlets provided, repaired or improved 34 Number of rain water pipes disconnected from drain 1 Number of gully traps inserted or improved 161 Number of disconnecting traps inserted or improved 4 Number of disconnecting and inspection chambers inserted 46 Number of disconnecting and inspection chambers repaired, improved, sealed or cleansed 37 Number of drains constructed or reconstructed 54 Total length of drain pipes laid (4 in.-2,702 ft.) (6 in.-143 ft.) 2845 ft. Number of tests and re-tests applied 426 Number of other works executed 11 Approximate percentage of houses draining into Council's sewer 99.64 Cesspools: Number rendered impervious, emptied, cleansed, etc. 1 Removal of Household Refuse: Number of new ashbins provided 109 Number of ashbins repaired 1 Dampness: Number of roofs stripped, renewed or repaired 260 Number of gutters and rain water pipes provided, repaired or unstopped 232 Number of instances in which external brickwork, sills, etc., repaired, renewed or rendered impervious 731 Number of damp-proof courses provided 112 Number of sites covered with impervious material 2 Number of yards paved, repaired or drained 121 Number of forecourts paved, repaired or drained 11 Interior Work: Number of rooms stripped and cleansed 373 Number of floors, walls and ceilings repaired or renewed 1,172 Number of rooms in which ventilation provided or improved 73 Number of rooms in which lighting provided or improved 36 Number of staircases replaced, repaired or improved 40 Number of instances in which lighting to staircases provided or improved 61 Number of handrails and balustrades to staircases, etc., provided or repaired 37 Number of window frames and sashes provided, repaired or unfixed 1,104 Number of doors and/or other woodwork renewed, repaired or improved 127 Number of stoves or grates provided or repaired 318 Number of washing coppers provided or repaired 67 Number of instances in which ventilation under floors provided or improved 73 Number of foodstores provided, cleansed or improved 88 Number of other repairs 62 23 Sundry Nuisances or Contraventions, etc.: Number of instances in which domestic cleansing enforced 12 Number of rooms sprayed for the removal of vermin by the Disinfector 166 Number of houses disinfected prior to demolition 6 Number of instances in which overcrowding abated 5 Number of instances of improper keeping of animals abated 12 Number of offensive accumulations removed 55 Number of pigstyes provided, repaired, cleansed or improved 1 Number of stables provided, repaired, cleansed, or improved 3 Number of urinals provided, repaired, cleansed or improved 6 Number of dung pits provided, repaired or improved 3 Number of instances of articles given in exchange for rags, old clothes or similar articles 1 Number of other nuisances or contraventions abated 166 SMOKE ABATEMENT. During the year 339 observations were made, resuiting in 17 nuisances being proven in connection with 10 premises. The policy adopted has been on the lines of offering advice in the elimination of the nuisance rather than by legal action to obtain abatement, and this has been attended with a fair measure of success. It was necessary during the year to serve seven statutory notices with respect to tne emission of black smoke for more than two minutes during a period of half an hour, as prescribed in the Byelaw for the Regulation of the Emission of Smoke. Some trouble was experienced through the emission of grit and gritty particles from chimneys in connection with three factories in the district which gave rise to a number of complaints from persons residing in the vicinity of the chimneys. In one case it was due to the change over from hand firing to mechanical stoking, in another case the cause was the experimenting with different fuels during the initial stage of a new boiler plant, and in the third case due to the use of low grade fuel. The department was still co-operating at the close of the year with the occupiers of the factories in finding a solution to this difficult problem. The increased inclination to instal mechanical apparatus tends to eliminate the human element in stoking and ensures more positive methods of feeding the fires, but this to some extent is counter-balanced by the use of lower grade fuels which are prone to cause grit nuisance if proper care is not taken. ERADICATION OF BED BUGS. (a) Number of Council houses— (i) found to be infested 37 (ii) disinfested 37 (b) Number of other houses— (i) found to be infested 66 (ii) disinfested 43 Of the 23 verminous premises outstanding at the end of the year, 17 were premises in connection with which demolition orders were operative. There has been no change in the methods employed for freeing houses from bed bugs. In the cases of very bad infestation of Council houses, fumigation is with Hydrogen Cyanide and in cases of moderate infestation spray insecticides are used. All disinfestations with Cyanide are carried out by a Contractor and treatment with spray insecticides is carried out by the local authority. Verminous furniture is disinfested with Hydrogen Cyanide and bedding, etc., is treated in a steam disinfector by arrangement with the Middlesex County Council at their local institution, prior to the tenants' removal into Council houses. Tenants of Council houses are advised generally by the Corporation's Housing Officials with regard to the methods to be adopted to prevent infestation or re-infestation, but no specific campaign is in operation at present. In the majority of cases, houses, other than Corporation houses, are sprayed by the local authority at the request of owners or occupiers with an insecticide solution of low volatile properties—three sprayings over a period of twenty-one days is the average treatment. If the bugs are not eliminated at the end of that period, the local authority may carry out further sprayings or the tenant may be supplied with a small hand spray and fluid, and instructed in their use. In a limited number of cases, resort has been made to fumigation in addition to spraying. Only in a small number of cases have owners, through the agency of their builders, carried out the necessary disinfesting work. 24 The privately owned houses, found to be infested, are kept under observation for varying periods and the occupiers advised by the Sanitary Inspectors as to the necessary action they should take to deal with the infestation and to prevent re-infestation. During the year a number of experiments have been carried out to find an apparatus which would disinfest clothing satisfactorily with heavy naphtha. The Council provided £50 for the erection of the experimental apparatus and the experimental work was done under the direction of Mr. McKenny Hughes of the Natural History Museum, Secretary of the Bug Committee of the Medical Research Council and necessitated the installation of an electrical heater in order to provide the necessary temperature. This occasioned a certain amount of difficulty and had ultimately to be enlarged as the temperature required could not be reached with the original installation. Arrangements were made whereby at a certain period during the disinfestation re-inforcement could be made through specially made holes at the back of the apparatus. The disinfestation of furniture is still carried out by cyanide in the grounds of Dockwell Hospital, where everything of this kind is now centred. The families are accommodated at Dockwell while their houses are being disinfested. 25 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 on Register. Number of Inspections. Written Notices. Prosecutions. (1) (2) (3) (4) (5) Factories (including Factory Laundries) 184 201 13 Nil. Workshops (including Workshop Laundries) 160 93 4 Workplaces (other than Outworkers' premises) 77 56 5 Outworkers 65 20 Total 486 370 22 Nil. DEFECTS FOUND IN FACTORIES, WORKSHOPS AND WORKPLACES. Particulars. Number of Defects. Outstanding Jan. 1st, 1937. Found during 1937. Remedied during 1937. Outstanding Dec. 31st. 1937. Referred to H.M. Inspector. Number of Prosecutions. 1 2 3 4 5 6 7 Nuisances under the Public Health Acts—* Want of cleanliness 1 10 11 ... Want of ventilation ... ... ... ... Overcrowding ... ... ... ... Want of drainage of floors 1 1 2 ... Other nuisances 3 28 27 4 Sanitary accommodation—† Insufficient 3 3 4 2 Nil. Nil. Unsuitable or defective 5 11 14 2 Not separate for sexes ... ... ... ... Offences under the Factory and Workshop Act— Illegal occupation of underground bakehouse (s. 101) ... ... ... ... Breach of special sanitary requirements for bakehouses (ss. 97-100) 1 8 9 ... Other offences : — Excluding offences relating to outwork ... ... ... ... Total 14 61 67 8 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 26 PREMISES AND OCCUPATIONS CONTROLLED BY BYELAWS OR REGULATIONS. There are 580 known places in this dictrict 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. During the year two new schools were opened. Cranford Junior School was opened in April and replaced the Temporary School which had been established in the Memorial Hall. Chatsworth Junior School was opened in August. Both of these new schools have accommodation for 400 children. The number of children on the registers at the end of the year was 11,792, accommodated in thirty-four departments, including one Central School. The influx of population continues to put severe strain on the accommodation and in eleven departments this has to be supplemented by the use of huts, etc. SWIMMING BATHS AND POOLS. The principal municipal swimming baths at present are situated at Hounslow and are provided with an up-to-date filtration and chlorination plant, and are in every way satisfactory, another and out-of-date swimming bath is provided at Isleworth. The older swimming bath at Isleworth will be closed down, when the new and larger swimming baths with appurtenances on modern lines, now being erected at Isleworth and Heston, are completed. The one privately owned Swimming Pool situated in the district is provided with a satisfactory chlorinating, cleansing and aeration plant, which is kept in continuous operation for the whole 24 hours during the summer season. CANAL BOATS. COPY OF REPORT FORWARDED TO THE MINISTRY OF HEALTH DATED 11th MARCH, 1938. Public Health Act, 1936. In accordance with Section 249 of the Public Health Act, 1936, I beg to present herewith the Annual Report for the year ended 31st December, 1937, as to the steps taken to carry into effect the provisions of the said Act, and the Canal Boat Regulations, 1878, within the Borough of Heston and Isleworth, Middlesex. Inspectors Appointed :— The whole of the inspectorial staff is appointed as Canal Boats Inspectors by virtue of their appointments as Sanitary Inspectors. Only two of these are actively engaged in the work. Number of Inspections, etc.:— Number of Inspections made 51 Number of Canal Boats inspected 42 Number of Boats found in order 39 Number of Boats with one infringement 2 Number of Boats with two infringements 1 Nature of Contraventions, etc. :— Boats conspicously lettered and/or numbered 2 Certificates not produced 1 Water vessel not capable of holding 3 gallons of water 1 Legal Proceedings :— No legal proceedings have been taken during the year. Infectious Disease. No case of infectious disease was reported as occurring among the Canal Boat population during the year. 27 Housing The housing situation is steadily improving and the Council have completed during the period under review two new estates, totalling 346 houses at the Great West Road and Worple Road No. 2 Estates. Latterly the Council have co-operated with the County Council in dealing with property on a large scale at Isleworth. A large road widening scheme has been planned to take the through traffic and improvements all round that area are contemplated. HOUSING STATISTICS. 1. GENERAL. Number of New Houses erected during the year:— Number of Dwellings (a) By private enterprise—Houses and flats 1096 (b) By the local authority 308 1404 2. INSANITARY AND UNFIT DWELLING HOUSES. 1. Inspection of Dweling-Houses during the Year. (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 830 (b) Number of inspections made for the purpose 848 (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 119 (b) Number of inspections made for the purpose 133 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 119 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 121 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 ... ... ... 286 3. Action under Statutory Powers during the Year :— A. Proceedings under Sections 9, 10 and 16 of the Housing Act, 1936 :— (1) Number of dwelling-houses in respect of which notices were served requiring repairs 17 (2) Number of dwelling-houses which were rendered fit after service of formal notices :— (a) By owners 34 (b) By local authority in default of owners 2 B. Proceedings under Public Health Acts (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 28 (2) Number of dwelling-houses in which defects were remedied after service of formal notices :— (a) By owners 18 (b) By local Authority in default of owners 3 28 C. Proceedings under Sections 11 and 13 of the Housing Act, 1936 :— (1) Number of dwelling-houses in respect of which Demolition Orders were made 75 (2) Number of dwelling-houses demolished in purusance of Demolition Orders 71 (3) Number of dwelling-houses rendered fit in consequence of undertaking given by owner 8 (4) Number of dwelling-houses in respect of which undertaking from owners accepted, not to re-let houses for human habitation 14 D. Proceedings under Section 12 of the Housing Act, 1936 :— (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 1 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit E. Housing Act, 1935.—Overcrowding :— (1) (a) Number of dwellings overcrowded at the end of the year 346 (b) Number of families dwelling therein 346 (c) Number of persons dwelling therein 2209 (2) Number of new cases of overcrowding reported during the year 37 (3) (a) Number of cases of overcrowding relieved during the year 44 (b) Number of persons concerned in such cases 272 (4) Particulars of any cases in which dwelling-houses have again become overcrowded after the Local Authority have taken steps for the abatement of overcrowding — F. Other matters :— (1) Number of dwelling-houses demolished voluntarily 26 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. 29 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 undertakings to render fit accepted. 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 1936 :— 1-14, Crosby Terrace, Station Road, Hounslow 14 5/9/33 ... ... ... 28/12/33 2/3/37 ... 179 and 181, Hanworth Road, Hounslow 2 6/2/34 ... ... ... 27/3/34 20/1/37 ... 78, South Street, Isleworth 1 6/3/34 ... ... ... 24/4/34 ... ... 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, The Parade, Lampton Rd., Lampton 10 5/6/34 ... ... ... 31/7/34 28/6/37 ... 5 and 7, North Street, Isleworth 2 5/6/34 ... ... ... 25/9/34 ... ... 6, The Square, Isleworth 1 5/6/34 ... ... ... 28/12/34 ... ... 64, High Street, Hounslow 1 10/7/34 ... ... ... 25/9/34 ... ... 42, 44, 46 and 48, London Road, Brentford End 4 10/7/34 ... ... ... 25/9/34 ... ... 244 and 246, London Road, Isleworth 2 10/7/34 ... ... ... 25/9/34 15/1/37 ... 83, 85, 87, 89, 91, 93, 95, 97, 99 and 101, London Road, Brentford End 10 9/10/34 ... ... ... 28/12/34 ... ... Gray's Cottage, Cranford Lane, Heston 1 13/11/34 ... ... ... 29/1/35 10/11/37 ... 6 and 8, Hartland Road, Isleworth 2 4/12/34 9/7/35 29/7/37 ... ... ... 2 and 4, Fairfields Road, Hounslow 2 8/1/35 ... ... ... 30/4/35 29/6/37 ... 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10, Toynes Cottages, Toynes Alley, London Road, Isleworth 10 5/3/35 ... ... ... 25/6/35 6/9/37 ... 2, 3, 4 and 5, Field's Cottages, Toynes Alley, Isleworth 4 9/4/35 ... ... ... 25/6/35 6/7/37 ... 1, 2, 3 and 4, Quinion's Cottages Fern Lane, Heston 4 9/7/35 ... ... ... 24/9/35 22/10/37 ... 1, 2, 3, 4, 5 and 6, Williams Place, Ivy Lane, Hounslow 6 9/7/35 ... ... ... 24/9/35 7/12/37 ... 142, Linkfield Road, Isleworth 1 9/7/35 ... ... ... 24/9/35 ... ... 111, 113 and 115, St. John's Road, Isleworth 3 8/10/35 ... ... ... 26/11/35 24/6/37 ... 1, 2, 3, 4, 5 and 6, Syon Cottages, Syon Lane, Isleworth 6 8/10/35. ... ... ... 26/11/35 22/9/37 ... 68, Upper Sutton Lane, Heston 1 8/10/35 ... ... ... 26/11/35 30/4/37 ... 139, 141, 143 and 145, Heston Road, Heston 4 12/11/35 ... ... ... 30/12/35 27/4/37 ... 54, 56 and 58, South Street, Isleworth 3 12/11/35 ... ... ... 30/12/35 1/9/37 ... 60, 62 and 70, South Street, Isleworth 3 12/11/35 ... ... ... 30/12/35 ... ... 30 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 undertakings to render fit accepted. 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. 157 and 159, Twickenham Road, Isleworth 2 12/11/35 ... ... ... 30/12/35 ... ... 72, South Street, Isleworth 1 10/12/35 ... ... ... ... ... ... 76, South Street, Isleworth 1 10/12/35 ... ... ... 28/1/36 ... ... 80, South Street, Isleworth 1 10/12/35 ... ... ... 25/2/36 ... ... 82, South Street, Isleworth 1 10/12/35 ... ... ... 28/1/36 ... ... 74, 76 and 78, Linkfield Road, Isleworth 3 7/1/36 25/2/36 10/11/37 ... ... ... ... 12, 14, 16, 18, 20, 22 and 24, North Street, Isleworth 7 7/1/36 ... ... ... 27/4/37 ... ... 11, The Square, Isleworth 1 7/1/36 29/6/37 ... ... ... ... ... Wharf Cottage, Hayes Road, North Hyde, Heston 1 4/2/36 ... ... ... 1/9/36 26/2/37 ... 19 and 21. Grove Road, Hounslow 2 7/4/36 28/7/36 2/3/37 ... ... ... ... 108, 110, 112, 114 and 116, Sutton Road, Heston 5 7/4/36 ... ... ... 26/5/36 13/8/37 ... 12, The Square, Isleworth 1 5/5/36 ... ... ... 29/12/36 ... ... 13, The Square, Isleworth 1 5/5/36 ... ... ... 23/2/37 30/10/37 ... 109, Wellington Road North, Hounslow 1 5/5/36 ... ... ... 30/6/36 ... ... 53, Whitton Road, Hounslow 1 5/5/36 ... ... ... 29/9/36 3/11/37 ... 21 and 23, Heath Road, Hounslow 2 9/6/36 ... ... ... 28/7/36 22/10/37 ... 17 and 19, Heath Road, Hounslow 2 8/9/36 ... ... ... 29/12/36 22/10/37 ... 15 and 17, North Street, Isleworth 2 8/9/36 ... ... ... 25/5/37 ... ... 1, Tivoli Road, Hounslow 1 8/9/36 ... ... ... 27/10/36 27/4/37 ... 2, 4, 6, 8, 10 and 12, Linkfield Road, Isleworth 6 6/10/36 23/2/37 ... ... ... ... ... 69 and 71, Staines Road, Hounslow 2 6/10/36 ... ... ... 24/11/36 ... ... "Somerset Lodge," North Street, Isleworth 1 6/10/36 ... ... ... ... ... ... Bungalow adjoining "Lyndhurst," Green Lane, Hounslow 1 10/11/36 ... ... ... 29/12/36 ... ... 691, London Road, Hounslow 1 8/12/36 ... ... 23/2/37 ... ... ... 22 and 23, The Square, Isleworth 2 8/12/36 ... ... 30/3/37 ... ... ... 51, Whitton Road, Hounslow 1 8/12/36 ... ... ... 26/1/37 3/11/37 ... Dealt with during 1937 :— ... ... ... ... ... ... 89, 91, 93, 95, 97 and 99, High Street, Hounslow 6 5/1/37 ... ... ... 23/2/37 ... ... 31 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 undertakings to render fit accepted. 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. 9, South Street, Isleworth 1 5/1/37 ... ... ... 23/2/37 ... ... 65, Staines Road, Hounslow 1 5/1/37 ... ... 30/3/37 ... ... ... 67, Staines Road, Hounslow 1 5/1/37 ... ... 28/9/37 ... ... ... Wooden Sectional Hut, Blackberry Farm, Cranford Lane, Heston 1 2/2/37 ... ... ... 30/3/37 28/6/37 ... 10, Hartland Road, Isleworth 1 2/2/37 27/4/37 ... ... ... ... ... 12, 14 and 16, Hartland Road, Isleworth 3 2/2/37 27/4/37 ... ... ... ... ... 123, 125, 127, 129, 131, 133 and 135, Bath Road, Hounslow 7 9/3/37 ... ... 28/9/37 ... ... ... 137, Bath Road, Hounslow ... 1 9/3/37 25/5/37 ... ... ... ... ... 21, Wellington Road North, Hounslow 1 9/3/37 23/9/37 ... ... ... ... ... 186, 188, 190, 192 and 194, Linkfield Road, Isleworth 5 9/3/37 ... ... ... 27/4/37 ... ... 46, Station Road, Hounslow 1 9/3/37 ... ... ... 27/4/37 ... ... 4, 6, 8, 10, 12, 14 and 16, Gloucester Road, Hounslow 7 6/4/37 ... ... ... 29/6/37 ... ... 18, 20, 22, 24, 26, 28, 30 and 32, Gloucester Road, Hounslow 8 6/4/37 ... ... ... 25/5/37 ... ... 61, 63 and 65, South Street, Isleworth 3 6/4/37 ... ... ... 29/6/37 ... ... 67, 69, 71, 73 and 75, South Street, Isleworth 5 6/4/37 ... ... ... 25/5/37 ... ... 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15, Downton Place, Isleworth 14 6/4/37 ... ... ... 25/5/37 ... ... 9, The Square, Isleworth 1 6/4/37 ... ... ... 25/5/37 ... ... 105, 107 and 109, St. John's Road, Isleworth 3 4/5/37 ... ... ... 29/6/37 ... ... 1, 2, 3, 4, 5 and 6, Mitchells Cottages, Worton Road, Isleworth 6 8/6/37 ... ... ... 27/7/37 ... ... 78 and 80, Twickenham Road, Isleworth 2 7/9/37 ... ... ... 26/10/37 ... ... Jasmine Cottage, Southall Lane, Cranford 1 7/9/37 ... ... 26/10/37 ... ... ... 19, Inverness Road, Hounslow 1 5/10/37 ... ... ... ... ... ... Meadow Cottage, Vicarage Farm, Vicarage Farm Road, Hounslow 1 5/10/37 ... ... 30/11/37 ... ... ... 1, 2, 3 and 4, Clarks Cottages, Cranford Lane, Heston 4 16/11/37 ... ... ... ... ... ... 1, Brickfield Yard, Field Lane, Brentford End, Isleworth 1 16/11/37 ... ... ... ... ... ... 32 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 undertakings to render fit accepted. 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. 13, Inverness Road, Hounslow 1 16/11/37 ... ... ... ... ... ... 43, 45, 47, 49, 51, 53 and 55, London Road, Brentford End, Isleworth 7 16/11/37 ... ... ... ... ... ... 1, 2 & 3, Rose and Crown Lane, Isleworth 3 16/11/37 ... ... ... ... ... ... 99, 101, 105 and 107, Twickenham Road, Isleworth 4 16/11/37 ... ... ... ... ... ... 90, Whitton Road, Hounslow (Underground rooms) 1 16/11/37 ... ... ... ... ... ... 66, 68, 70, 72, 74, 76, 78, 80, 82, 84, 86, 88, 90, 92 and 94, Pears Road, Hounslow 15 7/12/37 ... ... ... ... ... ... 33 Inspection and Supervision of Food The following is the record of inspection of food premises :— Meat 1101 Fish 150 Provisions 60 Greengroceries and Fruit 182 Hawkers' Food Stuffs 44 Food Preparation premises inspected 306 Number of other Food Inspections 84 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 1937, 45 samples of milk were taken from retailers in the district. These samples were submitted to the Lister Institute for animal inoculation test, and in 6 cases the presence of tubercle bacilli was demonstrated. In three of these cases the samples were traced to farmers in Berkshire, in two cases to farms in Oxfordshire, and in the remaining case to a farm in Hampshire. The County Medical Officer of Berkshire subsequently informed me that after examination of the herds at the first two farms one cow from each herd was found to be suffering from tuberculosis, the first cow being slaughtered and the second lent to the National Institute of Research in Dairying, to be slaughtered after being used for experimental purposes. In the third case one cow was slaughtered and group samples taken of the remainder of the herd, the results of which have not yet come to hand. With regard to the sample traced to the County of Hampshire, I was informed by the County Medical Officer that, although it had been found impossible to trace the offending animal, one cow in the herd had died calving and had been sent to the knackers between the date of taking the sample and the visit of the inspector. The results of the examination of the Oxfordshire herds have not yet been received. During the year no cows were reported by owners as shewing symptons suspicious of tuberculosis. Routine examination of milch cattle was carried out during the year by Mr. Reginald Wooff, M.R.C.V.S., the County Council's whole-time veterinary inspector, and 504 inspection of cows were made. Three cows were found to be suffering from tuberculosis and were slaughtered." 515 inspections were carried out in respect of cowsheds, dairies and milkshops. Unofficial milk analysis are made by the Medical Officer of Health. Number of firms in the district licensed to sell :— "Accredited" milk 1 (1 shop). "Tuberculin Tested" milk 7 (13 shops) *" Pasteurised" milk 16 (32 shops) (*one of these is a licensed producer of " Pasteurised " milk). Meat Inspection. 1. Meat Inspection.—This is carried out from the point of view of exercising the maximum control. All the Sanitary Inspectors hold special certificates for meat inspection. The slaughter-houses and butchers' shops are, in addition to the visits made under the Meat Regulations, inspected 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 5 visits per month. There were 68 butchers' shops in the district at the end of 1937. 2. Public Abattoirs.—There is no public abattoir in the district. Slaughtering may take place at any time in privately owned slaughter-houses, subject to the requisite notice being given under the Meat Regulations. The question of providing a public abattoir has, in the past, been considered by the Public Health Committee, but after weighing the information obtained from other authorities the matter was adjourned sine die. 3 Action under Section 117. Public Health Act, 1875.—827 lbs. 3 ozs. of unsound meat were seized during the year. 34 4. Diseased Meal.—A total of 3,464 lbs. was surrendered during the year, including 2,606 lbs. of tubercular meat. As circumstances permit, animals are inspected in the lairs prior to being slaughtered, but it often happens that, following the receipt of a notice of slaughtering, the animal is killed before the Inspector has time to arrive at the slaughter-house. A thorough inspection of all animals and organs is carried out to ascertain if there is any post-mortem condition warranting action by this department. Each week one inspector is detailed for duty in the slaughter-houses after the usual office hours, as it is still the practice of butchers to slaughter during the evening. The slaughter-houses are, on the whole, kept, so far as their construction will allow, in a fairly satisfactory condition. The butchers mainly buy in the London Wholesale Meat Markets. 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 he meat exposed for sale. Fixed glazed windows have proved beneficial as a means for preventing contamination and maintaining the saleable qualities of the meat. I again wish to mention that it would be an advantage if regulations were in force under wh'ch a definite demand could be made for fixed windows in every case. Out of a total of 68 butchers' shops in the district, 51 are provided with fixed windows, 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. The following table shows the carcases inspected and condemned during the period under report. In 1937, a separate record of the number of cows killed was not kept. CARCASES INSPECTED AND CONDEMNED, 1937. Cattle, including Cows. Calves. Sheep and Lambs. Pigs. Number killed 102 1 416 2305 Number inspected 102 1 416 2305 All Diseases except Tuberculosis: Whole carcases condemned 1 — — 5 Carcases of which some part or organ was condemned 20 — 38 78 Percentage of the number inspected affected with disease other than tuberculosis 20.58 — 9.13 3.60 Tuberculosis only : Whole carcases condemned — — — 10 Carcases of which some part or organ was condemned 10 — 1 209 Percentage of the number inspected affected with tuber culosis 9.80 — 0.24 9.50 35 INSPECTION OF OTHER FOODS. I have repeatedly drawn attention to the want of perspective with regard to butchers' windows, and the way in which things which are eaten uncooked are exposed for sale in the str.eets and in open shops of different kinds. Large multiple stores are now entering into the catering trade in addition to selling vast quantities of sweets, biscuits and things of that kind, and the multiple stores have an added difficulty in that large numbers of people and children drift through without any idea whatever of purchasing anything, whereas in the ordinary shop the purchaser goes in with a definite object. Food and Drugs Adulteration Act.—I am indebted to Dr. J. Tate, County Medical Officer for the following report, as to the samples purchased in this area during 1937. The total number of samples taken was 285, and 43 were found to be adulterated. Milk. Cream Cakes Lamb's Liver. Vinegar. Number taken 231 4 27 16 Number adulterated 20 3 8 12 With one exception, all the adulterated samples of milk were taken in course of delivery from provincial farmers. The following samples were also taken, but none were found to be adulterated. Brandy—1 ; Whisky—2 ; Coffee—1 ; Cream—1 ; Jam—1 ; Marmalade—1. Number of Prosecutions—14 ; Number of Convictions—14. UNSOUND FOOD, 1937. Tons. cwts. qrs. lbs. ozs. Fish 14 0 Meat 2 0 2 18 14 Poultry 2 23 4 Rabbits 2 26 0 2 2 0 26 2 Nutrition There is nothing much new to record in this direction. The Cookery Book* is launched on the world and is, as I have said elsewhere, travelling far afield. 12,500 were reported as sold when the last payment was made by the publishers and applications are coming in for orders of 500 or more at a time for distribution. One drawback there is however, that rising prices have made the prices which I quoted in the book impossible to attain, but the fact remains that one has had practically nothing but praise from all sides. I have been asked to lecture on Cookery and the Cookery Book to such an extent that I have had to refuse entirely to do anything more until I have definitely retired from office. *(Dr. Nash's Cookery Book, 6d. net, Published by Simpkin, Marshall, Ltd., Stationers' Hall Court, London, E.C.4). 36 Infectious Diseases Scarlet Fever and Diphtheria.—There were 5 "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 the North Hyde School during the year. Use is made of the Dick reaction in connection with query cases of Scarlet Fever at South Middlesex Fever Hospital. Scarlet Fever serum is used in nearly all cases at the hospital. The Staff of South Middlesex Fever 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 242 No. of civil cases removed to Hospitals 211 Percentage of cases removed to Hospitals 87.19 The incident rate of Scarlet Fever in the civil population (99,420) was 2.43 per There was one death from this cause during the year. 1,000. 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 18 No. of civil cases removed to Hospitals 17 Percentage of cases removed to Hospitals 94.4 The incident rate per 1,000 of the civil population was 0.18. Two cases occurred in institutions during the year. One death occurred from this disease. The child died in November and was six years of age. For the last five years the deaths from Diphtheria have been as follows :— Year. 2 Year. 4 Year. 3 Year. 2 Year. 1 1933 1934 1935 1936 1937 It is interesting to record that the total number of cases of Diphtheria notified this year was even lower than last year's figure of 21, and was the lowest since 1895, i.e., over a period of 42 years, during which time the population has increased by roughly 75,000. The incidence of Diphtheria in the District compares with the rest of the County as follows :— Rates per 1,000 of Population. Cases. Deaths. 125 County Boroughs and Great Towns including London 1.81 0.08 England and Wales 1.49 0.07 148 Smaller Towns 1.38 0.05 London Administrative County 1.93 0.05 Heston and Isleworth 0.18 0.01 37 DIPHTHERIA IMMUNISATION. With this report ends my official investigations into the prevention of Diphtheria, which have been carried out all along with the help of Dr. Bousfield. Nowadays the tendency is for the general practitioner to do this work and criticism is being levelled at those who advocate the work being carried out by anyone other than general practitioners. In the early days I advocated the appointment of Dr. Bousfield as one of the best authorities, if not the best, on this matter in order to make the factor of safety as high as possible so as to ensure that there was no set-back to the work which we were undertaking. That this policy has been of value is shown by the fact that in all the years this work has been going on we have not had a single disaster of any kind whatever. As I have reported before, we had a brother and sister who had a personal idiosyncrasy and reacted violently like an attack of influenza, and the inoculations were stopped after the second one, otherwise the record of the years is one of triumphant progress. Of all those immunised two only have subsequently Contracted Diphtheria and in neither case was there any untoward result. It is satisfying to know that we have 5,337 children immunised and 959 who are naturally immune as a result of re-testing. It is also a great satisfaction to know that 42,657 attendances have been made by mothers who feel that what we have done, and what we are doing is worth while. Since 1930, when we had 370 cases of Diphtheria with 23 deaths, we have reduced our incidence until last year we had 18 cases notified as Diphtheria, of which 11 ultimately turned out not to be Diphtheria and only 1 death. I had hoped that my last official report would be able to record an absolutely clean sheet and it was not until the middle of November that the first death occurred. The toll of deaths has been reduced from 23 until the figures for the last four years are 4, 3, 2, 1. It is well to notice how our original satisfaction with T.A.M. has borne the searching light of later investigation, our figures showing that whereas we got a slight re-action, which we call undesirable, for want of a better word, to the extent of only 2.2%, using more recent and more potent preparations that figure rose to 6.4%. Report on Diphtheria Immunisation Clinic Work during the year ended December 31st, 1937. As in recent years, two clinics have been held weekly but it was found to be more convenient to change over one of the Hounslow sessions to the Isleworth Health Centre, so that from 10th September, 1937, there has been one weekly session at Isleworth and one at Hounslow. Dr. Bousfield's report follows :— Annual report on the work of the Diphtheria Immunisation Clinics. "The Diphtheria Prevention Clinics have, as in past years, been well attended. The number of attendances in 1937 was 4,937. Applications for treatment numbered 808, against 693 in the previous year. Certificates of successful immunisation or of natural immunity were issued to 598 children, of these 575 were actively immunised and 23 were naturally immune. (To these figures must be added the Nazareth House cases referred to later in the Report. 86 cases certified immune and 28 were immunised). Most of the immunised children received injections of Messrs. Burroughs Wellcome's T.A.M. given in a dosage of 1 c.c., 1.5 c.c and 1.5 c.c. at fortnightly intervals. The remainder were treated with Alum Precipitated Toxoid (Eli Lilly & Co.) either by means of two injections at fortnightly intervals or as a single injection. The results of the various treatments described above will be given in detail later. It was felt that, as T.A.M. had been so thoroughly investigated in the Hounslow Clinics, in various dosages and at varying intervals, the properties of A.P.T. ought to be similarly tested in comparable circumstances. So much had been written of the excellent results obtained by the use of A.P.T. given as two injections that it was confidently anticipated that we should be taking a step forward by adopting this antigen and method. It was further resolved to determine to what extent the single injection of A.P.T. advocated by the manufacturers could be shown to be successful. Accordingly two groups of Schick positive children were treated by different methods. The first received a single injection of 0.5 c.c. of A.P.T. (Lilly) and were re-Schick tested from 4 to 6 months later. The second group were treated by two injections of the same antigen in dosage of 0.2 and 0.5 c.cms. at 14 days interval and were re-tested at the same period after the final injection as was the former group. It is unfortunate that, at the present juncture, a large proportion of the children so treated is still awaiting a final Schick test, but the results so far obtained are both instructive and 38 surprising. As far as the present work goes, it seems likely that the introduction of A.P.T. (Lilly) did not advance the efficiency of our immunisation procedure. At this point it will be of interest to tabulate the results over the number of years in which we were using T.A.M. (Burroughs Wellcome) practically exclusively as the antigen. These results are based on thousands of Schick positive cases. Below are given the bare figures obtained with A.P.T. (Lilly) which will be discussed more fully later. Prophylactic and dose. Makers. Percentage rendered Schick-negative in three-6 months. Percentage of undesirable reaction. T.A.M. 1—1—1 c.c. Burroughs Wellcome 88.2% T.A.M. 1—1—1 -5. „ 95.0% 2.2% T.A.M. 1—1 -5—1 -5 „ 97.1% A.P.T. 0.5 Eli Lilly 77.8% 6.4% A.P.T. 0.2 and 0.5 (14 days inter. „ 92.4% Details of the A.P.T. Work. Natural Schick negative rate of whole group on which both A.P.T. experiments were made 9.05 Primary Schick tests on these children :— Schick-positive 653 Schick-negative 65 Results of the Single Injection of 0.5 c.c. of Lilly A.P.T. (Re-tests performed from 4 to 6 months after injection). Average age of the Schick positive children in the group 4.42 years Number re-tested to date 202 cases Re-Schick negative 157 cases Re-Schick positive 45 cases Percentage of success 77.8% Average age of children not successfully immunised 6.25 years Results of Two Injections of Lilly A.P.T 0.2 and 0.5 at 14 days interval. (Re-tests performed from 4 to 6 months after last injection). Average age of Schick-positive children in the group 3.97 years Number re-tested to date 119 cases Re-Schick negative 110 cases Re-Schick positive 9 cases Percentage of success 92.44% Average age of children not successfully immunised 4.33 years From the foregoing figures it will be observed that the single injection procedure is far from satisfactory. 77.8% of success only, is an unsound figure on which to base any immunological campaign. The two injection method yielded relatively better results at 92.44%, but that figure can not at present be regarded as comparing too favourably with the 97.1% of success obtained by the use of three injections of T.A.M. (B.W.&Co.) in a dosage of 1 c.c., 1.5 c.c. and 1.5 c.c. at 14 day intervals. The sole advantage of the A.P.T. is that the routine course of treatment requires one less injection than the T.A.M. course. Reactions to A.P.T. injections. All important is the question of how much reaction is produced in the arms of children as a result of any injection. 39 Careful histories have been taken in the case of 515 children who have received injections of Lilly A.P.T. Of these, 33 cases or 6.4%, showed some degree of undesirable reaction. This was usually confined to some degree of swelling, redness and pain or tenderness in the arm. A hard subcutaneous nodule, often quite painless, is frequently noted. No definite case of cold abscess is on record, though there was a query in one case. It will be noted that the percentage of reaction is higher than that met with in the course of T.A.M. injections, where the figure recorded was only 2.2%. The average of the children who reacted to A.P.T. sufficiently for parents to comment on the pain, tenderness, redness or swelling of the arm was 6.7 years. This average age is higher than that of the majority of the children in either A.P.T. group, the figures for the single and double injection groups being 4.42 years and 3.97 years respectively. As far as can at present be determined, it appears that the slightly older children are more likely to develop reactions, even at an average age of only 6.7 years. Also it seems as if younger children are more easily immunised by means of A.P.T. injections, as the average age of the children proving to be re-Schick positive is higher than the average age of the groups immunised. Natural immunity. An interesting example of high herd immunity as a result of a few cases of diphtheria and the presence of a few carriers, was encountered at the end of 1936 and the beginning of 1937. The seat of the small outbreak was Nazareth House residential girls' School, Isleworth. In order to check the spread of the disease, a Schick testing and immunising campaign was advocated by Dr. Nash. The results of the primary Schick tests proved most illuminating. Of 116 children tested, no less than 86 cases, or 71.14% were negative. The average age of all the children was fairly high at 8.87 years. In spite of this the natural immunity was found to be very high, even among the smallest children. 43 children of 6 years of age and under were tested, and only 15 were Schick-positive, a natural immunity rate of 65.1% even among these very young children. 28 of the 30 Schick-positive children were actively immunised, 25 being treated by means of two injections of B.W. & Co.'s A.P.T. (0.2 and 0.5 c.c. at 14 day interval). The remaining three were treated by means of T.A.F. injections, as two of them experienced reaction at the first injection of 0.2 c.c. of A.P.T. All cases were shown to have been immunised successfully when re-tests were performed from 3-4 months later. Three reactions only were reported, in children aged 9, 11 and 15 years of age respectively. The average age of all the primary Schick-positive children was 7.2 years, and of those who were naturally immune 9.4 years. Considerable efforts were made to trace out the process of natural immunisation which had taken place prior to the investigation. Plans were drawn up at the request of Dr. Nash showing the position of the beds formerly occupied by diphtheria cases and carriers in the dormatories, and the relative positions of the children in the classrooms. There appeared to be no detectable relationship between the naturally immunised children and the apparent situation of diphtheria infection within the institution. Presumably there was sufficient intermingling of the children in the ordinary course of school life and recreation to explain the widespread natural immunity acquired by the school as a whole. Duration of immunity. Work has been continued in following up children who have been actively immunised in previous years. 1419 children have now been re-tested at periods ranging from 2 to 8 or more years after the conclusion of their artificial immunisation by means of T.A.M. injections (B.W. & Co.). The results of these re-tests are as follows:— Still Schick-negative 1316 Reverted to some degree of positive reaction 103 Percentage of reversion to some degree of susceptibility 7.2% These results are eminently satisfactory when it is remembered that it has been shown recently (Bousfield, Medical Officer, Jan. 1st, 1938), that of children immunised by means of a single injection of A.P.T. 0.5 c.c. (Parke Davis), no less than 27.5% had reverted to the Schickpositive state at the end of 10-12 months, many of them to a very marked degree. It appears therefore that there is every reason to be satisfied with the fact that all immunisation done in 40 this borough in the past has been based on the soundest lines, and compares most favourably with so-called modern improvements, even if the procedure was a trifle more tedious in the past. In addition it must be remembered that many of our old cases recorded as reversions were only faintly Schick-positive and undoubtedly possessed a potential immunity which would have been fully restored by the first contact with diphtheria infection. This is a phenomenon which is well recognised and accepted when applied to cases in which the original immunisation training has been a thorough one. Conclusions. In considering the results of re-tests in connection with the various antigens and dosages employed, it must be remembered that the average age of the children attending the clinics has been steadily declining as the years pass. This is a very desirable feature from the point of view of conferring immunity at that time of life at which it is most essential, namely infancy and early childhood. In the five years preceeding September, 1935, when a comprehensive report on five years' work at Heston and Isleworth was made, the natural Schick-negative rate of children attending the clinics was as high as 15.18. This figure has declined fairly steadily year by year until the prevailing natural Schick-negative rate of all primary cases tested during 1937 proved to be only 9.05%. Over the same five year period the average age of children attending was 6.24 years as compared with 4.4 years in one A.P.T. series in 1937 and 3.97 years in the other. It is generally held that the older the children, the greater the opportunity of natural immunity or partial immunity having been acquired is present. In other words, within certain limits, moderately old children are supposed to be easier to immunise than very young children. This is probably true in areas where the natural immunity rate is high, but in our district, the reverse seems to emerge from our figures. The youthful age of the children would appear to militate against a successful result from the use of our latest antigen, A.P.T. Still it must be remembered that this investigation followed immediately on the heels of the very highly successful campaign in which A.P.T. as 1.0, 1.5 and 1.5 c.cms. doses was used, and from which such undeniably excellent results were obtained. On the figures available, the T.A.M. gave nearly a 5% better conversion rate than did the two injections of A.P.T. in conditions of age and herd immunity practically identical. It appears, therefore, that the two injections of A.P.T. (Lilly) do not represent any advance in our immunological procedure, while the single injection, which had been advocated by the makers, appeared to be at least one fifth less efficient, from our point of view, than those methods and preparations which we had employed in the past. It is not denied that A.P.T. is a good and powerful antigen. It is contended that the optimum method of employing it may not as yet have been determined. At present another method is being investigated, the giving of two full doses of 0.5 c.c. of A.P.T. at 14 day intervals. It is possible that this will yield better results. In fairness to A.P.T. it must be admitted that two injections of T.A.M. will only yield very poor results, and if A.P.T. were employed as a three injection procedure a very high standard of result could be anticipated with confidence. At the same time efforts at present are directed to producing a high degree of immunity with the smallest number of injections, and it is to this end that the increased first dose in the two injection method is being investigated. It has been stated that better results are obtained from two injections of A.P.T. when the interval is three weeks or more. We have not adopted this longer interval because if the time between injections is too long, parents are likely to forget completely to come again. If they merely have to be told ' Come again not next week, but the week after,' they seem to remember well. Sometimes the best theoretical considerations must give way to a slightly less efficient method on the grounds of what is the most practical method as applied to the parental mind. GUY BOUSFIELD, M.D., B.S., Lond. 41 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 1937, 9 vials of Antitoxin of 8000 units each were supplied to medical practitioners. Smallpox.—No cases were notified during the year 1937. Enteric Fever.—Six cases were notified. Five were notified from the West Middlesex Hospital, and four were not usually resident in this district. Erysipelas.—Forty-five cases of this disease were notified, of whom 31 were of cases in the West Middlesex Hospital. Twenty-six were non-residents in this district. Ophthalmia Neonatorum.—(See page 62). Puerperal Fever.—Twenty-one cases were notified. Eighteen of these cases were notified from the West Middlesex Hospital, of whom 14 were not usually resident in this district. Two cases confined at home were removed to Queen Charlotte's Isolation Hospital with which Hospital we have an agreement, for treatment, and made a good recovery. One case was confined in a Nursing Home and removed to Queen Charlotte's Hospital. Two deaths occurred from Puerperal Sepsis. As from 1st October, 1937, all cases of Puerperal Fever became notifiable as Puerperal Pyrexia. Puerperal Pyrexia.—Sixty-two cases were notified; 61 of these were notified from the West Middlesex Hospital, including 41 who were not usually resident in this district. One case was confined at home and removed to Queen Charlotte's Hospital. Encephalitis Lethargica.—No cases were notified during the year 1937. Cerebro-Spinal Fever.—Five cases were notified; four of these were notified from the West Middlesex County Hospital, all being non-resident in this district. Acute Poliomyelitis.—Three cases were notified. Two cases were removed to the West Middlesex Hospital for treatment. Pneumonia.—There were 124 cases notified—77 notifications were from the West Middlesex Hospital. Sixty-five 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 following table sets forth the numbers of such cases for the last six years :— 1932 1933 1934 1935 1936 1937 Measles 952 108 901 10 1352 174 German Measles 25 13 66 6 15 18 Chicken Pox 194 362 417 537 161 634 Mumps 122 940 153 113 306 1538 Whooping Cough 260 287 144 232 366 276 Upon receipt of information of the existence of a case, inquiry is made by a School Nurse to obtain all necessary facts. Measles.—Reference has been made to the progress of the use of measles serum in my valedictory remarks at the beginning of this report (pages 9 and 10). Influenza.—There were thirty-eight deaths from Influenza during the year, the mortality being 0.38 per 1,000 of the population. Cleansing of Verminous Persons.—Particulars are asked for as to the facilities available in the district for the cleansing and disinfection of verminous persons and their belongings. Neither the Education Authority nor the Sanitary Authority possesses a Cleansing Station. See also pages (24 and 25). 42 TUBERCULOSIS, 1937. At long last one's hopes with regard to the open air school are materializing. The plans are through and the building is in process of erection, and there will be in existence the open air school which I hope will cope with the problems which arise in the district. Pulmonary Tuberculosis.—The number of new cases notified including transfers from other districts during the year was 88, of the new cases, 46 were receiving institutional treatment at the time of notification, and 15 died. There were 46 deaths from Tuberculosis of the Respiratory System as against 49 last year. Nine cases were transferred into the area, after notification in other districts. Other Forms of Tuberculosis.—The number of new cases notified during the year including transfers was 14. Of the new cases, 9 were notified as receiving institutional treatment, and two died. The total deaths were 7, being 5 less than in 1936. Deaths from Tuberculosis of non-notified Cases.—Fifteen deaths occurred in nonnotified cases. Five deaths occurred elsewhere, and were transferred to this district. The following Table gives further particulars of new cases notified and deaths in 1937. Age Periods. New Cases. Deaths Pulmonary. Non-Pulmonary. Pulmonary. Non- Pulmonary. M. F. M. F. M. F. M. F. 0—1 ... ... ... 1 1 ... ... ... 1—5 1 ... ... ... ... ... ... ... 5—10 ... ... ... 2 ... ... 1 ... 10-15 1 ... 1 ... ... ... 1 1 15—20 6 4 1 1 1 3 1 1 20—25 4 6 2 1 ... 4 ... ... 25—35 16 11 ...1 2 3 12 1 1 35—45 20 8 ... 1 4 3 ... ... 45—55 6 1 ... ... 7 2 ... ... 55—65 2 2 ... 1 4 1 ... ... 65 and upwards ... ... ... ... 1 ... ... ... Totals 56 32 5 9 21 25 4 3 Twelve of the deaths from Pulmonary Tuberculosis, and three deaths from Non-Pulmonary Tuberculosis, were not notified. The number of cases of Tuberculosis on the register at the end of 1937 was 426. It is satisfactory to record that the deaths from Tuberculosis in this district have come down from 76 in 1933; 72 in 1934; to 53 in 1935; to 61 in 1936, and 53 in 1937, the death rates per 1,000 of population from Tuberculosis for these years being as follows :— 1933 0.89 1934 0.82 1935 0.58 1936 0.64 1937 0.53 The rate for England and Wales for the year 1937 was 0.69. No action was taken during the year under Section 172 of the Public Health Act, 1936, with regard to the removal to Hospital of infectious cases suffering from Tuberculosis of the respiratory tract. 43 INFECTIOUS DISEASES, 1937, CASES NOTIFIED. Scarlet Fever. Diphtheria. Enteric Fever. Puerperal Fever. Erysipelas. Cerebro-Spinal Fever. Encephalitis Lethargica. Poliomyelitis. Pneumonia. Respiratory Tuberculosis. Other forms of Tuberculosis. Ophthalmia Neonatorum. Puerperal Pyrexia Polio- Encephalitis January 10 1 1 2 5 3 ... ... 27 5 ... 2 11 ... February 20 1 ... 1 2 ... ... ... 18 13 3 1 4 ... March 24 ... ... 3 3 ... ... ... 8 8 1 ... 4 ... April 12 1 ... 6 3 1 ... ... 6 12 2 ... 6 ... May 13 ... ... 1 5 ... ... ... 2 8 1 ... 5 ... June 23 1 ... 2 3 1 ... ... 8 5 1 2 4 ... July 10 ... ... 3 6 ... ... ... 7 10 1 5 3 ... August 16 4 ... 1 8 ... ... ... 8 7 2 ... 6 ... September 24 1 3 2 2 ... ... 1 4 5 2 ... 6 ... October 31 3 ... ... ... ... ... 2 10 6 1 ... 5 ... November 27 2 1 ... 5 ... ... ... 10 4 ... ... 1 ... December 32 4 1 ... 3 ... ... ... 16 5 ... 2 7 ... Totals 242 18 6 21 45 5 ... 3 124 88 14 12 62 ... *Not notifiable after 1/10/37. DIPHTHERIA, 1937 (including Bacterial cases, 3 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. 1 ... ... 1 ... ... ... ... ... ... ... 1 Feb. 1 ... ... ... ... ... 1 ... ... 1 ... ... Mar. ... ... ... ... ... ... ... ... ... ... ... ... Apr. 2 1 ... ... ... ... 1 ... ... 2 ... ... May ... ... ... ... ... ... ... ... ... ... ... ... June 1 ... ... ... ... 1 ... ... ... ... ... 1 July ... ... ... ... ... ... ... ... ... ... ... ... Aug. 5 ... ... 1 1 1 2 ... ... 2 1 2 Sept. 1 ... ... ... ... ... 1 ... ... 1 ... ... Oct. 4 ... 1 2 ... 1 ... ... ... 2 ... 2 Nov. 2 ... ... 1 ... ... 1 ... ... 1 ... 1 Dec. 4 1 ... ... ... 1 2 ... ... 2 1 1 Totals 21 2 1 5 1 4 8 ... ... 11 2 8 44 45 Notifiable Diseases during 1937. 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. Joint Board Hospitals Other Hospitals Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever ... ... ... ... ... 1 1 3 1 ... ... ... 6 4 1 Scarlet Fever 2 5 6 15 18 114 40 16 14 9 3 ... 242 197 14 Diphtheria ... 1 1 1 ... 7 5 ... 3 ... ... ... 18 14 3 Erysipelas 1 ... 2 ... ... 2 1 1 4 4 20 10 45 1 36 Puerperal Fever ... ... ... ... ... ... ... 1 17 3 ... ... 21 ... 21 Puerperal Pyrexia ... ... ... ... ... ... ... 3 49 10 ... ... 62 ... 62 Ophthalmia Neonatorum 12 ... ... ... ... ... ... ... ... ... ... ... 12 ... 8 Poliomyelitis ... 1 ... ... ... 2 ... ... ... ... ... ... 3 ... 2 Cerebro Spinal Fever ... ... 2 ... 1 ... ... ... 1 1 ... ... 5 ... 5 Pneumonia 14 13 6 5 5 9 4 9 20 12 20 7 124 ... 100 Dysentery ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Polio Encephalitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... For Tuberculosis Notifications—see other Table. DEATHS FROM NOTIFIABLE INFECTIOUS DISEASES, 1937. 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 Diphtheria ... ... ... ... 1 ... ... ... ... ... 1 Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... ... Puerperal Fever ... ... ... ... ... ... ... ... 1 1 ... ... 2 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia 10 5 ... 2 ... ... 1 3 11 9 41 Poliomyelitis .. ... ... ... ... ... ... ... ... ... ... ... ... ... Polio- Encephalitis ... ... ... ... ... ... ... ... ... ... 1 ... 1 Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 1 1 Cerebro-Spinal Fever 1 ... ... ... ... ... ... ... ... ... ... ... 1 Erysipelas ... ... ... ... ... ... ... ... ... ... ... 1 1 Total 11 5 ... 2 ... 1 1 ... 2 4 12 11 49 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 1937 :— Enteric Fever Scarlet Fever Diphtheria Pneumonia (all forms) Erysipelas Puerperal Fever Puerperal Pyrexia Cerebro-Spinal Fever Ophthalmia Neonatorum Pulmonary Tuberculosis Other Tuberculosis lincephalitis Lethargica Acute Poliomyelitis PolioEncephalitis Total West Middlesex Hospital 5 8 1 77 31 18 61 4 6 12 4 ... 1 ... 228 Hounslow Hospital ... 2 ... 2 ... ... ... 1 ... 2 1 ... ... ... 8 Hounslow Barracks ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 St. Mary's School ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Nazareth House ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 Totals 5 10 2 80 31 18 61 5 6 14 5 ... 1 ... 238 46 EPIDEMIC OF DYSENTERY. On November 24th, 1937, the existence of an outbreak of a definite type of enteritis was brought to the notice of the Health Department. A circular letter was immediately sent to all the general practitioners in the district requesting them to give what information they could concerning any case of diarrhoea they were treating or had treated during the previous two or three weeks. The response to this was immediate, and all cases notified were visited and complete investigation of the cause and subsequent course of the illness carried out. Examination of the faeces and blood proved the enteritis to be a form of dysentery caused by the bacillus dysenteriae Sonne. Practical difficulties experienced. Unfortunately from the statistical point of view, the epidemic was past its peak before the notification of cases commenced so that several difficulties attended any attempt to produce an accurate survey. In the first place it was impossible to attempt to trace the original source of the infection. The supplies of milk and water, as being the agents most likely to account for such a wide spread epidemic, were both investigated. Most of the milk comes from outside the district so it was not thought necessary, in view of the mildness and the late stage of the outbreak, to incur the expense entailed in pursuing the enquiry further. Water supplies were taken from parts of the Borough where the concentration of cases was thickest. In every instance the water was found to be of the highest hygienic purity and completely free from any dysentery organisms. Another difficulty was provided by the fact that many cases must have been missed where, owing to the mildness of the symptoms, no medical aid was sought. This must have occurred chiefly among the women and children as the adult males found it impossible to carry on with their work while the diarrhoea lasted. To obviate this, as far as possible, a close watch was kept at the various clinics and enquiry was made at the schools regarding any absenteeism due to diarrhoea. Samples of blood and faeces were taken wherever possible and here again difficulty was experienced. In the first place few cases were seen early enough for bacteriological examination of the faeces to be of much importance as, after the 4th day, isolation of the causative organisms provided great difficulty in some cases. Where no information was gained from an examination of the faeces a sample of blood was taken for the purpose of demonstrating the presence of the specific agglutinins which are usually present from 7-21 days after the onset of the disease. By this time the patient was usually quite well and, therefore, apt to resent giving his blood for what were really purely experimental purposes. Also mothers were in the same position regarding blood being taken from their children and only in one case was a sample taken from a child under 14 years of age. Actually it is pleasing to record that, in the main, excellent co-operation and help were afforded by everyone concerned. Features of the outbreak. 1. Clinical Symptoms. The manifestations presented were very varied in their intensity and ranged from slight intestinal irritation, with the passage of 3 or 4 motions, through increasing grades of severity to a much more severe type. The majority of cases were of the mild type and the following was the average history given. The first complaint was of abdominal discomfort with the almost immediate onset of diarrhoea, about 6 to 8 times during the first 24 hours. The motions were very fluid and offensive and, in some cases, green in colour. On the 2nd day the diarrhoea was rather worse, about 10 motions being passed and these contained mucus, and, in a few cases, small quantities of blood. From the 3rd day the diarroea gradually lessened and, by the 4th or 5th, had ceased altogether, the patient by this time feeling practically normal. The temperature in the majority was practically normal throughout. In a few cases it was subnormal for the first two days. In severe cases the initial symptoms were of a much more pronounced nature. The onset was acute with severe colicy pain followed by the frequent passage of very fluid foetid motions which, in some cases, contained blood from the first. Nausea was usually extreme but there was seldom any vomiting. The temperature was raised in most cases during the first two days and sometimes reached as high as 104°F., especially in children. Another feature which was most commonly seen in children was the early onset of collapse in quite a number of cases. This compared with the intense colic of the adult. These acute symptoms lasted as a rule for about 36—48 hours and, during this time, the diarrhoea was very severe, the motions in some cases being over 20 daily and containing mucus 47 and blood. From the 3rd to the 6th day the diarrhoea lessened and had usually ceased by the 7th to the 10th day. Some rather unusual features occurred in the case of a boy aged 11 years which it may be of interest to describe. His illness commenced with a feeling of complete collapse at 12 noon on the 20th November, skin being clammy and face cyanosed. He experienced extreme nausea but did not vomit, nor did he complain of abdominal pain. At 4 p.m. his temperature rose to 104°F. and at 8 p.m. diarrhoea commenced. This was very soon blood stained and contained mucus. Nineteen motions were passed during the night and he complained of the gradual onset of headache and pains in the neck. These symptoms continued during the following day and he further complained of photophobia and, for an hour in the morning, was unable to bear the weight of the bedclothes anywhere near him. The diarrhoea continued, about 20 motions being passed, all blood stained and containing mucus. His temperature was 100°F. Next day the diarrhoea lessened and he felt much better. His nausea left him and his temperature was almost normal. He continued to have 3 to 4 blood stained motions for the next three days and after the 6th day the diarrhoea ceased altogether. By this time he looked, and felt, rather washed out, but went on to make an uninterrupted recovery. 2. Treatment. The treatment was more or less symptomatic and consisted of the elimination of the toxic process by means of a fluid diet and salines and the administration of bowel sedatives. Milk was contra-indicated in any form and, in the more severe type of case, caused aggravation of the abdominal distress. 3. Sanitary action. Little action was necessary on the part of the Health Department as adequate trea ment of the disease and advice regarding disinfection of the excreta, etc., was carried out by the local practitioners. In no case was it found to be advisable to recommend the removal of any patient to hospital for observation or treatment. 4. Epidemiological features. An epidemic of Sonne dysentery of the magnitude of this affecting the London and Home Counties area has hitherto been unknown in this Country, although small outbreaks have been recorded, from time to time. The disease has been much more prevalent in the United States and Scandinavia and while investigating cases of dysentery in Norway in 1919, Thytta stated that it was probably much more prevalent than statistics showed owing to cases not being subjected to bacteriological investigation on account of the mildness of the symptoms. While it is assumed that the spread is due to the passing on of the infection from a patient or convalescent to a contact, it is reasonable to think that, owing to the rapidity with which the disease has spread over such a wide area, some other factor is concerned in the transmission at the beginning of the epidemic at least. Various possibilities have been suggested such as an air borne infection, transmission by flies etc., while the most original seeks to trace a connection between the spread of the disease and the changing habits of seagulls. It was not possible to determine the incubation period with any degree of accuracy. Taking those cases among which a history of contact appeared certain the average time between such contact and the onset of the first symptoms was 1—3 days. In three different families, however, a much longer period than this seemed to be quite definite and one of them appears to be worthy of note. In this particular household four persons were involved, the mother, her two children and the children's nurse. The source of the infection was known, as the mother developed the characteristic symptoms some hours after partaking of a meal at a London Cafe. Nine days later her children both became ill and eleven days after this the nurse who attended them followed suit. The average time of the longer incubation periods was about eight days. As stated previously few cases were seen early enough for bacteriological examination to be really effective and reliance had to be placed chiefly on an accurate record of the history and clinical symptoms. Diagnosis was confirmed by bacteriological or serological examination in 38% of cases only. AGE AND SEX DISTRIBUTION OF CASES. Age. Male. Female. 69 cases were investigated and of these 53 were notified by private practitioners, 6 referred for examination from the various M. & C.W. Centres and 10 followed up after school enquiry. Under 1 year 2 2 1— 5 „ 8 7 5—10 „ 9 7 10—15 „ 5 3 15—20 „ 2 1 20—40 „ 2 10 40—60 „ 3 5 Over 60 „ 2 1 48 It will be seen from the above figures that 50% of cases occurred in children under 10 years of age and 14% in women between 20 and 40. Children under 1 year were relatively immune. One explanation of these figures would be that the children of the 2 age groups 1—10 are either more susceptible to the disease or, because of their tender years and consequent inability to appreciate the supreme need for strict cleanliness, more likely to spread the disease. It would naturally follow, therefore, that their mothers who are the people coming most intimately into contact with them would be the next group to be chiefly affected. Another possible explanation of the figures is that the disease may be transmitted by some article of food or drink common to both mothers and children. Case incidence and distribution. A chart showing the weekly case incidence is appended. The case distribution was wide spread and all parts of the Borough were affected. CASE INCIDENCE AND DISTRIBUTION. Summary and Conclusions. In the foregoing report an effort has been made to record the findings in an outbreak of Sonne dysentery as it has affected this Borough. Mention has been made of the difficulties encountered in attempting to produce a correct statistical record. In view of the numerous boroughs similarly affected it is hoped that this investigation may be of value for purposes of comparison. As appears to be usual in similar outbreaks of Sonne dysentery women between 20 and 40 years of age and children under 10 were chiefly affected. The results from bacteriological and serological examinations were disappointing as negative findings were obtained in many cases who presented the typical features, of the disease. The diagnosis was confirmed in 38% of cases only but all persons presenting the salient features of the condition were included in the report. The infectivity of the stools was highest during the first few days and cultivation of the organism was found to be difficult in some cases even after the 4th day. While the identification of the organism was soon established it was found to be impossible to trace the factor responsible for its early transmission. The main hope, therefore, of discovering such a factor and, consequently, of being in a position to deal with outbreaks in their primary stages appears to rest in the earliest possible diagnosis of the disease. This can only be accomplished by a thorough investigation of every case of enteritis for which a definite diagnosis has not been made, such investigation to include a bacteriological examination and also a serological examination as represented by agglutination reactions. R. H. G. HECTOR DENHAM. 49 Heston Airport. The Airport is growing rapidly and the advent of one of the lines from Croydon is forecast, which will mean a considerable extension of responsibility with regard to the work required. The Airport is acquiring more and more land in order to extend its area, and offices are being provided for the Medical Officer. At the present time the Medical Officer under the Aliens Order is a general practitioner. Prevention of Blindness (Public Health Act, 1925, Section 66 and Public Health Act, 1936, Section 176). No action was taken during the year under Section 176 of the Public Health Act, 1936, regarding the provisions with respect to blindness. 50 Maternity and Child Welfare The opening of the Isleworth Health Centre in April was a red letter day in Isleworth, but, as so often happens, one's forecast was not entirely satisfactory. The design has certainly achieved all I wanted for it. The big hall when it is opened in the Infant Welfare Clinics has the sunshine through, and the vista of the green lawns beyond and the back of Syon Park make a very delightful outlook, and the building is bright and cheerful in a manner which I have not yet seen in any other Clinic. One mistake I made is that the Perambulator Shelter was too small—that will have to be enlarged. In the design I was anxious to avoid the prison feeling that one finds in some of the Clinics in other parts of the country, where the lighting was through clerestory windows and there was no outlook whatever, and the whole place felt like a glorified well. The difference it has made having the windows at each end of the Hall with a vista of gardens and trees is amazing. At the same time there is added ventilation over and above that which is obtained through the clerestory windows on all four sides, in that the windows can be thrown open to the gardens. Another mistake is that three cubicles are not sufficient to keep the Ante-Natal Clinic working at high speed. We find that even four is insufficient, and we are compelled to use screens in the Waiting Room to supplement the three cubicles specially provided for the changing mothers. We thought that three would be ample, but, either it is the rapidity of the work or the dilatoriness of the mothers in dressing that produces the congestion, and had I to design the Clinic again I should most certainly put in five cubicles. The work has grown and has needed an extra session, which was commenced on May 31st, 1937. It is, as I said last year, complete in a way in which I think no other in the country is complete, in that we have Dental beds available at the Eastman Clinic for multiple extractions of pregnant mothers. We still have difficulty with the dental troubles of the expectant mother, and time after time they have put off and put off the necessary treatment until the time at which the Ante-Natal Specialist thinks no further interference should be allowed has arrived. Time after time one gets the mother desiring to put it off until after the confinement not realising to the full that the whole idea is to give her a safe confinement by removing every possible source of sepsis. However, one keeps on educating and the results are encouraging, but sometimes one's patience wears very thin. The attendances of children at all the Centres during the last six years have been as follows:— Year. 1932. 1933. 1934. 1935. 1936. 1937. No. of attendances 31,656 35,110 33,102 36,635 36,567 38,601 The average attendances per session during the year 1937 were as follows:— Douglas Road No. 1. Douglas Road No. 2. Isleworth Centre. Heston Centre. 82.3 57.7 66.4 73.3 The number of children who attended at the Centre during the year, whilst they were under 1 year of age, was 1,093, which shown as a percentage of the notified live births gives a figure of 77.03. As from the 6th September, 1937, on account of the increased numbers attending, it became necessary to put on an additional session on Monday afternoons at Douglas Road. An additional session was also put on at Heston on 30th August, 1937, to cater for the increasing numbers of mothers coming from Cranford, until such time as a clinic in Cranford can be provided. The number of individual mothers and children attending the Centres is shown hereunder. Douglas Road, Hounslow No. 1— 1933 1934 1935 1936 1937 Mothers 860 820 998 998 1174 Children 1078 953 1146 1199 1338 51 Douglas Road, Hounslow No. 2— [/$$$] Mothers 467 513 491 554 450 Children 557 569 602 778 523 Isleworth Health Centre— Mothers 685 562 596 647 880 Children 824 726 729 847 918 Heston— Mothers 435 330 444 482 509 Children 550 387 537 631 799 Sales at Clinics. Quantity. Receipts. £ s. d. Dried Milks 16032 lbs. 1126 13 1 Virol 1589 ½-lbs. 117 19 10 Sugar of Milk 39 lbs. 2 7 9 Oil and Malt 1489 lbs. 35 5 4 Lactagol 1501 tins 75 1 6 Cod Liver Oil Emulsion 5884 bottles 174 1 4 Bemax 2429 tins 48 4 2 Adexolin 2318 phials 90 9 0 Oil and Malt with Parrish's 597 tins 13 11 4 Kalzana Tablets 1440 tablets 1 1 2 Total £1684 14 6 Notification of Births. Number of births notified, as adjusted by transferred notifications. Live births 1419 Still births 36 Total 1455 By Midwives 1231 By doctors and parents 224 Ante-Natal Clinics. It is with pleasure one is able to regard the intimate working between our own Ante-Natal Clinic and the County Council's M. & C.W. Department. Everything has worked as smoothly as possible and there has been no difficulty as far as the patients are concerned in being transferred from one authority to the other. The West Middlesex Hospital has at all times been helpful to a degree. Under these arrangements no less than 344 West Middlesex Hospital patients who reside in the Borough have received their routine ante-natal supervision at the Corporation's Ante-Natal Clinic. Mr. Bowes' report follows :— ANTE-NATAL SERVICES, 1937. In previous years it has been customary in the Report on the Ante-Natal services to summarise briefly the work done. During the last year there has been a large increase in the number of patients as many are now referred fom the West Middlesex Hospital for the greater part of their ante-natal time. In view of the increase of work done it has been thought that a short statistical analysis might be of interest. It will be noted that besides a larger number of patients there has also been a greater tendency for the Clinic to be used as a reference centre for gynaecological and post-natal conditions, and it looks as if this will be of greater importance in the future. The ante-natal work has continued on the usual lines, St. Thomas's, the West Middlesex, and the Grosvenor Hospitals have all given valuable help in dealing with abnormalities which have arisen. 52 The statistical tables which follow are of interest in that they give a general idea of pregnancy and its abnormatities in a developing modern community. GENERAL STATISTICS. Number of first attendances 794 „ „ attendances 2582 „ „ hospital patients 344 Gynaecological cases 17 Post-natal cases 18 Maternal deaths 1 Stillbirths 12 Neo-natal deaths 19 Left district before confinement 13 DETAILED ANALYSIS. Maternal Death.—The patient was a primipara who attended the Clinic in a routine manner. During the puerperium she developed a thrombosis in the popliteal vein and sudden death occurred on the 15th day from Pulmonary Embolus. Causes of Infant Mortality. Total 19. Prematurity 5 Gastro-Enteritis 3 Bronchitis 2 Meningitis 1 Congenital Heart Disease 1 Atelectas's 1 Broncho-Pneumonia 1 Jaundice 1 Asthenia 1 Suffocation (accidental) 1 Hydrocephalus 1 Otitis Media-pyaemia 1 Cases referred to Hospital for investigation and treatment. Total 51. Pyelitis 3 Contraction of the Pelvis 9 Fibroids 2 Threatened abortion 6 for induction of labour 1 Cardiac disease and pregnancy 6 Placenta Praevia 1 Hyperpiesia 6 Diabetes and pregnancy 1 Varicose Veins 2 Shock due to accident 1 Hydramnios 2 Haemorrhage 1 Vaginal discharge 4 Rheumatism 1 Hyperemesis 1 Anaemia 3 Pre-Eclampsia 1 Cases referred to their own medical practitioner for Treatment. Total 20. Pyelitis 3 Toxic albuminuria 7 Gastritis 1 Cystitis 1 Diabetes 1 Hyperemesis 1 Subcutaneous abscess 1 Hyperpiesia 5 Abnormal Presentations. Total 36. Breech presentations 17 Twins 2 External version at Clinic 6 Spontaneous version 5 Version performed at St. Thomas's 5 Breech delivery at St. Thomas's 1 Foetal Mortality Nil ACCESSORY EXAMINATIONS. Cases referred for X-ray. Total 15. Intra-uterine death of foetus 1 Vertex cases 9 Breech 2 Twins 2 X-ray of Chest 1 Wassermann Reactions 2 Urea Concentration Tests 2 Cases treated by iron and vitamin preparations. Total 133. Anaemia treated by iron 112 Vitamin preparations 21 Post-Natal Cases. Prolapse of Uterus 3 Cervical Erosion 1 Debility 3 Vaginal discharge 1 Advised sterilization for medical reasons 1 Laceration of cervix 1 Subinvolution of uterus 1 Backache 1 Fibroids 1 Haemorrhoids 1 Constipation 1 Menorrhagia 1 General advice 1 Poor abdominal wall 1 Six of the above patients were referred to Hospital and three for convalescence. 53 Gynaecological Cases. Total 17. Amenorrhoea 12 Abdominal pain 1 Hypomenorrhoea 1 Sterility 3 Two of these cases were referred to Hospital for further treatment. KENNETH BOWES, M.D., M.S., F.R.C.S. The following are the figures of attendances at the Ante-Natal Clinic :— 1934 1935 1936 1937 Attendances by Expectant Mothers during the year 831 1208 1251 2582 Average attendance per session 14.0 11.5 12.1 19.3 Number of Sessions 59 105 103 134 Number of Mothers attending Ante-Natal Clinic shown as a percentage of total notified live and stillbirths 31.8 32.8 31.2 54.57 Total number of expectant Mothers who attended the Clinic during the year 419 464 444 794 There were in addition 31 Post-Natal Cases, who made 72 attendances. MIDWIVES ACTS. Municipal Domiciliary Service of Midwives. In March, 1937, the Minister of Health intimated that he had decided to comply with the application of the Borough Council for an order to be made under Section 62 of the Local Government Act, 1929, directing that the Council should become the Local Supervising Authority under the Midwives Acts for the Borough in place of the County Council. The order came into operation on the 1st April, 1937. Until such time as a Supervisor of Midwives could be appointed, Dr. E. L. Roberts, the Deputy Medical Officer of Health was appointed to supervise the midwives practising within the Borough. In the special circumstances the Minister of Health deferred the date upon which the proposals were to come into operation, from 30th July, 1937, to 1st October, 1937. The draft scheme for the Municipal Domiciliary Service of Midwives was prepared and discussed with representatives of the local Medical Practitioners and Midwives. The two local Nursing Associations were also consulted. The proposals were submitted to the Minister of Health and received his approval on the 12th August, 1937. Summary of proposals. 1. That eight midwives be employed at the inception of the scheme. 2. That the salary of a midwife who is also a State Registered Nurse be £200 per annum, rising by annual increments of £10 to a maximum of £300 per annum, and, for a midwife who is not a State Registered Nurse, £180 per annum rising by annual increments of £10 to a maximum of £250 per annum. The commencing salary for experienced midwives who are not State Registered Nurses to be £200. That an additional payment of £10 per annum be made to those midwives holding and obtaining the Midwife-Teachers' Certificate of the Central Midwives Board. 3. That the following allowances be made to midwives:— (a) A bicycle be provided by the Borough Council. (b) A telephone be provided at the expense of the Borough Council in the house of each midwife appointed, and that all local calls in excess of fifty per quarter, and trunk and toll calls be paid for by the midwife quarterly. 54 (c) An allowance of £18 per annum be paid for uniform of an approved pattern, and laundry. (d) Drugs and equipment be supplied by the Borough Council on indent. 4. That the following scale of leave be granted to midwives, subject always to the exigencies of the work :— (a) One day in each week. (b) One week-end (i.e. from mid-day on Saturday until 9 a.m. on Monday) each four weeks. (c) Four weeks annual leave. 5. That midwives appointed by the Borough Council be allowed to practise from their homes if, in the opinion of the Borough Council, they are suitable for the purpose, and, if not, that the midwife be required to remove into premises approved by the Borough Council. 6. That a fee of £3 3s. 0d. be charged for the services of a municipal midwife either as a midwife or as a maternity nurse, and that in necessitous cases reductions be made from such fee in accordance with the following scale:— Note.—Assessment is to be made at the time when the midwife is booked. "Family " means the parents, dependent children not working or not earning more than 10s. 0d. per week, and any resident relative or other person looking after the home and not otherwise working. 1. The weekly income to be ascertained as follows:— Weekly wages or salary and/or other income of husband £ Weekly wages or salary and/or other income of wife £ Total Income 2. To ascertain the net weekly income per head:— (a) Deduct. Weekly Expenses, viz., (i) Rent or mortgage repayment £ (ii) Rates and taxes £ (iii) State Insurance £ (iv) Other Insurance £ (v) Fares (if any) £ (vi) Hire purchase payments not exceeding 5% of gross income £ £ Where a doctor is booked and undertakes to attend the confinement and puerperium, deduct 10s. 6d. Net Weekly Income £ (b) Divide. Net weekly income by number in family to ascertain net weekly income per head £ 55 3. Charge for midwife's services to be then ascertained from the following scale according to the net weekly income per head:— No in family (excluding unborn child). Charges for Midwife's Services. 1 person 2 or 3 persons. 4 or 5 persons. 6 or more persons. Where Weekly income per head does not exceed. l1s. 6d. 10s. 0d. 8s. 0d. 6s. 6d. Nil 12s. 6d. 11s. 0d. 8s. 6d. 7s. 6d. 5s. 0d. 16s. 6d. 12s. 0d. 9s. 6d. 8s. 0d. 10s. 6d. 19s. 6d. 13s. 6d. 10s. 0d. 8s. 6d. 21s. 0d. 25s. 6d. 16s. 6d. 12s. 0d. 10s. 0d. 31s. 6d. 31s. 6d. 19s. 6d. 14s. 0d. 11s. 6d. 42s. 0d. 37s. 6d. 22s. 6d. 15s. 6d. 12s. 6d. 52s. 6d. 40s. 6d. 26s. 6d. 18s. 0d. 14s. 0d. 63s 0d. It was subsequently decided:— (a) That in cases where a municipal midwife has been engaged to attend a confinement and it is subsequently found necessary for the confinement to take place in hospital, no charge be made for such services as the municipal midwife may have rendered. (b) That, in cases where a municipal midwife has been engaged to attend a confinement and the woman suffers a miscarriage, the charge assessed under the scale adopted by the Borough Council for the services of the midwife for the confinement be reduced by one half. 7. That when first appointing the eight midwives, married women be eligible for appointment, but that in subsequent appointments only single women be eligible and that single women, when appointed, be informed that they must relinquish their position on marriage. A Supervisor of Midwives was appointed and took up duty on 1st September. This officer was also appointed as Superintendent Health Visitor and Inspector of Nursing Homes. Eight midwives, all of whom had practised locally, commenced duty as Municipal Midwives in October. One of these left the service in December. Most of the cases which these eight midwives had booked at the time of taking up their appointments, elected to be attended by the same midwives under the municipal scheme. Thus we started with 123 cases and during the remaining three months of the year 110 further cases were booked. From 1st October to 31st December 104 confinements were attended by the municipal midwives, 91 as midwives, 6 of these being patients previously booked and resident outside the district, but attended by special arrangement, and 13 as maternity nurses. In working the scheme, patients are given a choice of midwives as far as possible. Midwives have been allotted to certain parts of the district and mothers in each area have the choice of two or three midwives. As was to be expected in a scheme of this character, certain administrative difficulties have been encountered. These, however, have all been successfully overcome, and the service is working very smoothly. It is very gratifying to record that we are receiving a number of letters of appreciation from patients, which, I feel, give some index as to the success of the scheme. As from 1st April, 1937, being Local Supervising Authority under the Midwives Acts, the Council was responsible for the payment of fees of medical practitioners when called in by midwives in cases of emergency. The following scale has been adopted for the purpose of assessing the amount to be repaid to the Council in respect of any fees paid by them to a medical practitioner under the Midwives Acts, when the patient claims inability to pay. 56 Income per head after deducting rent. Proportion of Charge to patient Less than 8/- Nil. 8/ld. to 9/- l/8th. 9/ld. to 10/- 1 /4th. 10/1d. to 11/- 3/8ths. 11/ld. to 12/- ½ 12/ld. to 13/- 3/4ths. 13/ld. and over Full cost. Where, in accordance with the assessment under the scale above, the amount due to the Council is 2/6d. or less, 110 steps are taken for the recovery of such sum and it is written off. Note.—When a medical practitioner is called in by a Municipal Midwife for whose services the patient is not required to pay anything, no application for repayment of the fee is to be made to the patient. The Borough Treasurer suggested an insurance scheme, which was adopted, viz:—"That a woman engaging a midwife be allowed to pay to the Council a sum of 5/- to cover the services of any medical practitioner who may be called in by the midwife in a case of emergency, and that such sum be accepted by the Borough Council in full settlement of any fees that may become payable by them to a medical practitioner in accordance with the Midwives Acts and the Medical Practitioners (Fees) Regulations 1936." The Minister of Health sanctioned the scheme until 31st December, 1938, adding that the experience in some of the districts where similar schemes have been tried, goes to show that there is a risk of considerable financial loss which may not prove to have been justified. It is too early to be able to give any indication as to the effects of this insurance scheme. Forty-six Midwives notified their intention to practise in the Borough; sixteen of these were Midwives at the West Middlesex County Hospital. Notifications were received from midwives as follows:— (a) Sending for Medical Aid—96; (b) Death—of Mother—1, of Baby—4; (c) Stillbirth— 9; (d) Having laid out dead body—Nil; (e) Liability to be a source of infection—2; (f) Substitution of artificial feeding—5. Compensation to Midwives. Four Midwives residing in the Borough voluntarily surrendered their certificates, and one midwife, on account of ill health, was directed to surrender her certificate to the Borough Council, and received compensation under Section 5 of the Midwives Acts, 1936. The Borough Council has also agreed with the County Council to pay a proportion of the compensation payable, upon surrender of their certificates, to two midwives living in the County area, but who had practised in Heston and Isleworth. Post Certificate Courses. Arrangements were made with the London County Council and the Middlesex County Council whereby midwives practising in the Borough were enabled to attend Courses of PostCertificate Lectures and Ante-Natal and Post-Natal Demonstrations organised by those Councils. Several midwives availed themselves of the facilities offered. Toddler's Clinics. Arrangements are being made for the initiation of Toddlers' Clinics and for a Sunlight Clinic, to commence next Autumn. At the time of writing Nature seems to be providing most of the sunlight we require. CHILD LIFE PROTECTION. The Child Life Protection work has continued during the year without much change in the numbers on the register. At the end of the year there were 64 foster-mothers who were undertaking the care of 81 foster-children, compared with 66 foster-mothers and 82 fosterchildren at the end of the previous year. 57 Two deaths occurred during 1937. In the first case the child was brought to one of the Maternity and Child Welfare Centres, looked ill and collapsed, and the foster-mother was advised (by the Health Visitor) to take the child to her own Doctor at once. This advice was followed, and the child was admitted to Hospital immediately, where it died the next day. The cause of death was given as " Collapse due to Diarrhoea and Vomiting." No Inquest was held. In the second case the child was in a poor state when received by the foster-mother at the age of five weeks. The child was seen by two Doctors, and removal to hospital was advised, but the child passed away during the journey to hospital. A Post Mortem examination was carried out, and the cause of death was given as " Right-sided Pleurisy and Congestion of base of right lung, indicating early Pneumonia, probably accelerated by malnutrition due to Diarrhoea and vomiting." It was not necessary to take proceedings during the year under the Acts relating to Child Life Protection. The legal obligations of foster-mothers continue to be made known by notices in the local press, and the display of notices in the Maternity and Child Welfare Centres and outside the Public Health Department. The Health Visitors promptly investigate every case where it is suspected that the undertaking of the nursing and maintenance of a child makes it a foster-child within the meaning of the Acts. The Public Health Act, 1936, came into operation on the 1st October, 1937, but did not entail any great changes in the Child Life Protection work. Under Section 219 (1) of the Act applications were received from the authorities of the four following "Homes" or "Schools" for certificates of exemption from this part of the Act. (At the time of writing this report I can say that these certificates of exemption have been granted for a period ending on the 31st March, 1939, when further applications will have to be made by the authorities concerned):—Royal School for Naval and Marine Officers' Daughters, St. Margarets; Nazareth House, Isleworth; Gumley House, Isleworth; St. Mary's R.C. Schools, North Hyde. Sub-section (2) of Section 219 of the Act gives the welfare authority the power to exempt a person from giving notice in respect of each individual child in cases where children are received for a succession of short holidays. This provision, which would apply particularly in country districts and at the seaside, is not likely to be exercised in this Borough. Section 218 confers upon the welfare authority the power of defraying the expenses of maintenance of a foster-child in a place of safety to which the child has been removed under this part of the Act. This is a useful provision, but it is to be hoped that the very close supervision to which the foster-mothers and their premises are subjected in this area, will preclude our having recourse to it. Orthopaedic Treatment.—There is no detailed scheme but all cases are dealt with as the circumstances require. The Corporation makes a grant of £15 per annum to the Royal National Orthopaedic Hospital, to which hospital cases are referred if necessary, and are subsequently dealt with as the condition necessitates. If in-patient treatment is required this is povided. This arrangement is working quite satisfactorily. 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, (d) Reds provided at Queen Charlotte's Hospital, in case further treatment is required, (e) Municipal Service of Midwives, (f) Sterilized maternity outfits for very poor mothers confined at home. 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 srbsequently of dentures. Where the extractions are numerous, in order that the expectant mother shall get the least possible upset, an arrangement exists with 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. 58 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. Maternal 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. The maternal mortality rate is based on the number of deaths of mothers per 1,000 live and still births. The number of live and still births during the year was 1,518. The incidence of deaths of mothers following confinements in 1937, was 5 mothers died out of 1,518 or 3.29 per 1,000. The rates for the previous years were 1934—2.93; 1935—4.0; 1936—1.95. The rate for England and Wales was 3.11. The rate for 1937 which was 3.29, is higher than for 1936. The causes of death were as follows:— 1. Post Partum Haemorrhage following an abortion (26 weeks). 2. Pulmonary Embolism, Thrombosis, Pregnancy. 3. Septicaemia, Puerperal Fever, Stillbirth. 4. Pyaemia, Abortion. 5. Eclampsia. Four died in Institutions, and one at home. Although there is no Municipal Maternity Home included in the foregoing arrangements made by the Borough Council, there are 78 maternity beds at the West Middlesex County Hospital providing a service which would otherwise become the duty of the Borough Council. CONVALESCENT TREATMENT. As before, there have arisen a few cases where the Ante-Natal Specialist particularly has recommended that the mother be sent away, and also where post-natally the mother requires to be sent away for her health, and provision must be made to take the child. So far these cases have been dealt with satisfactorily, but with the increasing number of mothers now to be dealt with, the demand for convalescent treatment will, undoubtedly, increase, and further provision for this form of treatment will, no doubt, have to be considered as time goes on. DENTAL CLINIC. The following is from the Supervisory Dental Surgeon's Report for the year :— MATERNITY & CHILD WELFARE DENTAL SCHEME, 1937. The 1937 "Looking Backwards" on this section of our Clinic labours, in brief, has been a success, and the seeds so laboriously planted in the years that have sped away are beginning to bear fruit, which in "looking forward " we hope will give an abundant and rich harvest in the field of service to the Mother, and least among us—The Child. The staff have been diligent in their duties. I know of no branch of our work, that has more thrilling scope than the study of the Child, but here is not the place to dilate upon the many characteristics that enable a Child to instinctively draw out of us that best and last ounce of effort to bring relief and a smiling face to it, in its hour of need. To the Mothers, there must be given a large meed of praise for many points; one particularly—their determination to see their children, often unlike themselves, obtain every service our Clinics can offer. A Dental Officer has not always an easy task, however, to allay the anxieties of the Mother towards his well meaning intentions. 59 Supply of Cases.—There was an increase in the number of patients dealt with. Net attendances increased from 3,038 in 1936, to 3,541. Comparative figures:— Appointments were Year. Mothers. Children. Total. 1935 ... ... 3003 1936 ... ... 4103 1937 ... ... 4810 Attendances were 1935 1245 1058 2303 1936 1662 1376 3038 1937 1920 1621 3541 Mothers. Permanent teeth. Children. Deciduous teeth. Total. Fillings 461 376 837 Extractions— Gas 1 379 927 2306 2331 Local Anaesthetic 14 11 25 Dentures supplied to mothers. Year. Upper. Lower. 1936 96 88 1937 101 93 The number of individual mothers supplied with dentures during 1937 was 104. (90 had both upper and lower dentures, 11 upper only, 3 lower only. Details of other work, years 1936 and 1937. 1936 1937 Administrations of General Anaesthetics 625 636 Advice 116 189 Dressings 160 216 Impressions taken 219 235 Charting and Estimating 339 378 Silver Nitrate Treatment 454 576 Scaling and Polishing 79 125 Treatment of Gums 111 139 I. COHEN, l.d.s., r.c.s. (eng.), Supervisory Dental Surgeon. Scale of Charges for Dentures. There was an adjustment made in the dentures scale on which mothers are assessed to re-pay a proportion of the cost of their dentures according to their circumstances. In October. 1937, the Committee decided instead of charging full cost where the income was above 12/ld. per head, the charge was to be three-quarters of the cost from 12/ld. to 13/-, and not until the income per head per week, after deducting rent, goes over 13/ld., do they have to pay full cost. 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 60 Clinics, and also for gifts of prams, toys, clothing, etc., which are given to the other mothers:— Mrs. Gould, Mrs. Darg, Mrs. Allen, Mrs. Smith, Mrs. Matthews, Mrs. Sheppard, Mrs. Whitmarsh, Mrs. Cleave, Mrs. Wagner, Mrs. Buckingham, Mrs. Burgess, Mrs. Jones, Mrs. Jacklin, Mrs. Wicks, Mrs. Northcote, Mrs. Bartholomew, Mrs. Hunt, Mrs. Geoff, Mrs. Nicholson and Mrs. Silburn at the Hounslow (No. 1) Centre; Mrs. Hursey, Mrs. Leatherbarrow, Mrs. Trueman, Mrs. Fitch, Mrs, Huxley, Mrs. Short and Mrs. Zimmerman at the Hounslow (No. 2) Centre; Mrs. Gorringe, Mrs. Widdowson, Mrs. Short, Mrs. Whitten, Mrs. Conway, Mrs. Huntingford, Mrs. Curtis, Mrs. Chance, Mrs. Ralph, Mrs. Roche, Mrs. White, Mrs. Pitt, Mrs. Nardell, Mrs. Mattock, Mrs. Bates Mrs. Wright, Mrs. Hilditch, Mrs. Head, Mrs, Pratt, Mrs. Thomas, Mrs. Vye, Mrs. Warden, Mrs. Newing, Mrs. King, Mrs. Jardine, Mrs. Duncan, Mrs. Taylor, Mrs. Bennett, Mrs. England, Mrs. Higson, Mrs. Price, Mrs. Chapman, Mrs. Thomas, Miss Quirke, Miss Macfarlane, Miss Barratt, Miss Collins, Mrs. Denham, Mrs. Bacon, Mrs. Griffin, Mrs. Ebbutt, Mrs. Newman, Mrs. Chadwick, at the Isleworth Health Centre; Mrs. Rose, Mrs. Male, Mrs. Colebrook and Mrs. Brierley at the Heston Centre. Also one helper from the Heston Branch of the British Red Cross attends each Friday morning at the Heston Centre. Home Visiting.—The visits by the Health Visitors in connection with the Maternity and Child Welfare Work and Public Health work were as follows:— 1st visits to babies under 1 year 1350 Other visits to babies and children up to 5 years 7521 Visits to mothers 500 Inquiries made elicited— Feeding—Natural 984 Artificial 151 Both 72 Sleeping with parents 54 Using comforter 182 Mother working during pregnancy 45 Summary of Nurses' Visits. Total to expectant mothers 286 Total other visits to mothers 214 Total to children under 1 year of age 4452 Total to children between the ages of 1 and 5 years 4419 Visits re Public Health matters, infectious diseases, tuberculosis, etc. 762 Total 10,133 (The above numbers include 768 visits in connection with infant life protection). Health Visitors' attendances at the Maternity and Child Welfare Centre, Ante-Natal Clinics, etc., 1051. Health Visitors' attendances at Diphtheria Immunisation Clinics, etc., 185. Home Help for Mothers.—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 Healthy 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 rate of payment of the Home Help is £2 per week. The number of cases at which the Home Helps have been called upon to attend during the year, was 43. The home helps paid 590 visits (days) to assist in the homes of mothers. The demand for home helps has increased and I think increasing provision will have to be made for this side of the work by reason of the midwifery service, which includes maternity nursing, steadily doing away with the handywoman who formerly acted as maternity nurse and home help. The demand for home helps from this cause is certain to extend. It is also necessary at times to put in home 61 helps when a mother is sent away for convalescent treatment, or has to go to hospital for treatment or operation either before or after confinement. In special cases where the mother is still unfit after 14 days the home help also would be allowed to remain for a longer period until the mother is reasonably fit to carry on. Grants of Milk.—-Arising out of consideration of the Report of the Advisory Committee on Nutrition and the Circular from the Ministry of Health, the Milk Grant Scheme was extended so as to provide milk in necessitous cases free or at a reduced rate to expectant mothers as from the fourth month of pregnancy instead of during the last three months of pregnancy; also to children up to the age ot five instead of up to the age of three, which had previously been the limit for milk grants, unless the case was a very exceptional one and specially certified by the Medical Officer. This resulted in an increased number of grants and increased expenditure on this account. Dealers supplying milk were also required to supply only efficiently pasteurised milk and all were circularised to this effect. The number of grants made during the year was 1315 against 1182 for the previous year. OPHTHALMIA NEONATORUM, Year 1937. Cases. Vision Unimpaired. Vision Impaired. Total Blindness. Removed from District and Deaths. Notified. Treated At Home. In Hospital. 12 4 8 5 — — 7 An agreement exists with the London County Council for the admission of Ophthalmia neonatorum to St. Margaret's Hospital when necessary. One case was sent to this Hospital and made a complete recovery. NURSING HOMES. The powers and duties of the Middlesex County Council under the Nursing Homes Registration Act, 1927 (now under the Public Health Act, 1936), as regards the Borough of Heston and Isleworth were delegated to the Borough Council as from 1st April. There were at that time six registered Nursing Homes within the Borough. Two small homes were closed down, one of these as a result of the keeper being appointed as a municipal midwife. An application was received from two midwives for the registration of a small new Nursing Home. The premises were approved and a certificate of registration was issued. The Inspector of Nursing Homes has kept all the Nursing Homes under review during the year with satisfactory results. 62 Borough of Heston and Isleworth Education Committee THIRTIETH ANNUAL REPORT OF THE SCHOOL MEDICAL OFFICER FOR THE Year Ended 31st December, 1937 CONTENTS. Arrangements for Treatment 11 Blind children 39, 45 Convalescent Treatment 39-40 Co-ordination 7 Deaf children 8, 45 Deformities 43 Dental defects and treatment 8,25,50,51,52 „ „ (Annual Report of Supervisory Dental Surgeon) 26-31 Ear disease and hearing 8, 25, 43 Epileptic children 39, 45 Eye defects 8, 13-24, 43, 48, 49, 51 Findings of medical inspection 8, 43 Following up 9 Health Education 41 Heart Disease and Rheumatism 8, 35, 43, 46 Infectious disease 35-37 Isleworth Health Centre 10 Malnutrition 11, 44 Medical inspections 7, 42 Medical treatment 11, 48 Mentally defectives 39, 45, 47 Milk, Supply of 38 Minor ailments 8, 12,48 Nose and Throat defects 8,24,43,49 Nurses' work in schools 9, 50 Occupation Centre, see under Miscellaneous on page 41 Open Air Education 37 Orthodontic work (Report of the Orthodontic Consultant) 31-34 Orthopaedic and Postural defects 8, 34, 49 Otitis Media (Special Report by Dr. R. H. G. H. Denham) 25 Parents, Co-operation of 38 Parents' Payments 40-41 Physical Training 37 Playground Classes 37 Prosecutions 11, 50 Provision of Meals 38 Ringworm 12, 43, 48 Refraction Clinic (Special Report by Dr. E. L. Roberts) 14-24 School Attendance Officers, Co-operation of 38 School Clinics, see under Minor Ailments on page 12 School hygiene 7 School journeys 37 School Nurses' work 9, 50 Schools in the Area 6 Secondary Schools 28-30,40,51,52 Skin diseases 8,12,43,48 Special Enquiries 41 Spectacles 13-24 Speech Defects 35, 43 Staff 5 Statistical tables 42-52 Teachers, Co-operation of 38 „ Medical Examination of, see under Miscellaneous on page 41 Tonsils and Adenoids 8, 24, 43, 49 Tuberculosis 9, 35, 43, 46 Uncleanliness 11, 50 Visual defects and External Eye disease 8, 13-24, 49, 51 Voluntary Bodies, Co-operation of 38 To the Chairman and Members of the Borough of Heston and Isleworth Education Committee. Ladies and Gentlemen, I beg to present the Annual Report of the School Medical Service for the year ended 31st December, 1937. 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 The Right Worshipful the Mayor (Councillor D. RHYS, M.A., J.P.) (Chairman). Councillor G. RAVENHILL (Vice-Chairman). Alderman A. A. BERGIN, J.P. J. J. BONNETT, O.B.E. J. J. CLEMENTS, J.P. F. C. GREEN. Councillor F. ALDOUS. Mrs. M. M. ASHDOWN. H. G. BODY. H. COLLAR. J. E. DILLINGHAM. A. J. FIELDER, C.C. H. G. HEARN. E. W. HEATH, J.P. L. H. C. HUDD. F. E. KINSEY. R. H. LANGDON. Alderman C. L. LEWIS. H. J. NIAS, M.B.E., J.P. F. SALMON. G. N. SHACKLETON. Councillor R. H. MANNING. P. G. MITCHELL. C. E. NEATE. F. SARD. A. P. SNELLING. D. J. THOMAS. F. J. THOMAS. W. E. TUCKER. A. C. TURNER. E. H. WALLACE. J. WOULFE. Co-opted Members- Miss E. A. ANKRITT. Mrs. E. F. MANNING. J. V. BACKES, Esq., a.r.c.s., a.i.c., d.i.c. E. R. HAMILTON, Esq., m.a., b.sc. Rev. P. W. SHEPHERD-SMITH, m.a. School Medical Officer— ELWIN H. T. NASH, m.r.c.p., m.r.c.s., d.p.h. STAFF School Medical Officer—EI.WIN H. T. NASH, m.r.c.p., m.r.c.s., d.p.h. Deputy School Medical Officer— Mrs. EVA LOUISE ROBERTS, m.b., ch.b., d.p.h., Barrister-at-Law. Senior Assistant School Medical Officer—R. H. G. H. DENHAM, m.d., d.p.h. (Commenced February, 1937). Assistant School Medical Officer—L. J. BACON, m.a., m.r.c.s., l.r.c.p., b.chir., d.p.h. (Commenced August, 1937). Supervisory Dental Surgeon—I. COHEN, l.d.s., r.c.s., eng. Assistant Dental Surgeons—W. A. LILLEY, b.d.s. (manc). B. COOKE, l.d.s. (manc.) L. C. MANDEV1LLE, l.d.s., r.c.s., eng. Miss C. C. JEFFERSON, l.d.s. (manc.) (Commenced November, 1937). Orthodontic Consultant—H. R. EVANS, l.d.s., r.c.s., eng. Orthodontic Demonstrator, Children's Department, Royal Dental Hospital. Certifying Ophthalmic Surgeon—J. D. M. CARDELL, f.r.c.s. Superintendent Health Visitor—Miss J. M. EVANS, s.r.n., s.c.m., New Health Visitor's Diploma of Royal Sanitary Institute, Sanitary Inspector's Diploma of Royal Sanitary Institute (Commenced September, 1937). Health Visitors and School Nurses— Miss B. N. TETLEY, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute. Mrs. A. E. TYRRELL, s.c.m., h.v., and s.n. Miss M. G. GRIBBLE, A.R.R.C., s.r.n., s.c.m., h.v., and s.n. Miss G. M. CLARE, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss E. I. BARTLETT, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss B. P. MANNING, s.r.n., s.c.m., a.r.s.i., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss S. McCARTHY, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss M. O'SULLIVAN, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute. Miss E. LLOYD, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute (Commenced August, 1937). Miss E. C. MIDDLETON, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute (Commenced September, 1937). Miss L. C. PRICE, s.r.n., s.c.m., New Health Visitor's Diploma of the Royal Sanitary Institute (Commenced December, 1937). Clerical Staff— B. W. KILBY (Chief Clerk). P. T. H. CRANDON. Miss R. MARSHALL. H. L. LAW. J. W. DEAN. M. W. LANGFORD. B. C. MALLABAND. E. E. FORREST. R. POWELL. Miss V. D. NICHOLLS. Miss V. GOODBODY. Miss S. M. BALL. Miss M. GARRY. Miss M. A. DIXON. L. H. HAYWARD. G. PITT. Dental Attendant—Miss M. B. MABBS. Apprentice Dental Attendants— Miss V. J. REDGEWELL. Miss A. M. FRAMPTON. Miss E. J. BEMMER. Dental Clinic Clerks— Miss W. SMITH. Miss E. L. ATKINSON. Miss D. A. DOCKRILL. Miss J. DODD. Dental Mechanic (part time)—T. CHENEY. Miss M. I. BULL. Miss J. DONEGAN. Miss B. M. MEADOWS. Miss M. C. OGDEN. Miss K. P. FOSTER. Miss J. E. GALE. 5 ELEMENTARY SCHOOLS IN THE AREA. (on 31st December, 1937). School. Department. Accommodation Number on Registers. Alexandra Junior 428 378 „ Infants 388 322 Berkeley Junior Mixed and Infants' 644 662 Rulstrode Senior Boys 480 432 „ Girls 480 466 Chats worth Junior 400 350 „ Infants' 400 309 Cranford Junior Mixed and Infants' 400 396 C. of E Infants' 108 83 Grove Road Junior Mixed 572 467 „ Infants 326 289 Heston Senior Mixed 440 377 „ Junior Mixed 550 480 „ Infants Infants' 323 292 Hounslow Heath Senior Mixed 480 453 Junior Boys' 398 329 „ ,, Junior Girls 398 331 „ „ Infants' Infants' 436 353 Hounslow R.C. Mixed and Infants' 330 272 Hounslow Town Junior Mixed and Infants' 605 581 Isleworth Blue Boys 177 103 „ Girls' and Infants' 284 130 Isleworth Town Junior Mixed 560 587 „ Infants' 338 290 Marlborough Senior Mixed 640 647 „ Infants' Infants' 400 345 St. Mary's R.C. Boys' 180 128 „ Girls' and Infants' 226 203 Spring Grove Central 436 477 „ Junior Mixed and Infants' 240 258 Wellington Junior Junior Mixed and Infants' 450 415 Woodlands St. John's Infants' 125 90 Worple Road Junior Mixed 260 239 „ Infants' 276 258 Total 13178 11792 The number of children on the School Rolls has increased by nearly 400 during the past year. It is interesting to note that the total number on the registers in 1927 was 6,792. 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. The medical and nursing staff are engaged in school medical work as well as the other health services. This applies also to the clerical staff, so that co-ordination of all the services is complete. There are now 12 half-day Maternity and Child Welfare Sessions each week from which the Medical Officers are able to refer children under the age of 5 years for treatment at the Minor Ailments Clinics, Dental Clinics and Ophthalmic Clinics of the Education Authority. Regular use of these facilities has been made throughout the year. X-Ray treatment of Ringworm can also be arranged. The service of the health of pre-school children is, at present, entirely on a voluntary basis, and personally, I see no hope for dealing adequately with the two to five years group which provides us with many untreated defects, except through Nursery Schools, where with compulsory attendance goes compulsory medical inspection. It is true however, that these children are followed up by the Health Visitors as far as time will allow. Special attention is paid to those who are likely to become Table III cases and when they attain school age they are called to the School Clinics and are kept under observation there. 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 must be borne in mind that the majority of the schools in the district are entirely new, up-to-date buildings erected as a result of the enormous recent growth of the district. 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. Every school in the Borough has been visited twice by a Medical Officer during the year— once for a routine medical inspection, and subsequently for the re-examination of children who had been found to need treatment or observation. The total number of routine medical inspections carried out during the year was 3,856. 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 Disturbance of School Arrangements. No one supposes that the ordinary school curriculum is not disorganised to some extent by the needs of medical inspection especially where all the available accommodation is required for educational purposes. The Head Teachers of the district, however, do their best to make the arrangements satisfactory, but I should like to place on record, as a legacy of my office of School Medical Officer, one unsuitable arrangement, where the medical section has to use accommodation which is unsatisfactory from the medical point of view. It is most annoying to have the constant hum of an electrical transformer when one is trying to get the minor and elusive sounds in some delicate child's chest. Some day one hopes, when one is in one's grave, the perspective with regard to the medical side of school life, particularly in respect of school buildings, will be appreciated. As an example, the design for the Medical Officer's Room at the Hounslow Heath Senior School appeared on the plan to be an improvement on what existed at the time elsewhere, but when it came to filling in the details it was not appreciated that the room which looked fairly comfortable on the plan would be mutilated by the whole of one wall being occupied by the electrical apparatus, thus taking off a considerable portion of the room. 5.—FINDINGS OF MEDICAL INSPECTIONS. Minor Ailments and Diseases of the Skin. A total of 672 cases of various skin diseases were reported during the year, and with the exception of 24 cases, all were referred for treatment. As usual, impetigo was the commonest disease. Table II shows that there were 284 cases of "other skin disease"; these include such conditions as eczema, alopecia, seborrhæa, warts, etc. Visual Defects and External Eye Disease. Routine medical inspections revealed 253 cases of defective vision, 162 being referred for treatment. Ten cases of squint were also discovered, 7 being referred for treatment. At the Special Clinics, 31 cases of defective vision and 5 of squint were referred for treatment. One case of keratitis was referred for treatment. Twenty-five cases of minor disease of the eye were discovered at routine medical inspections, and 254 cases were discovered at the Special Clinics. Nose and Throat Defects. Four hundred and thirty-seven children were found to be suffering from chronic tonsillitis, and of these 194 were referred for operation. Fifty-six children had Adenoids only, 32 being referred for treatment and 24 for observation. In a further 198 cases both conditions were present, 119 children being referred for operation and 79 for observation. Ear Disease and Defective Hearing. Amongst children examined at the routine medical inspections, 32 cases of defective hearing were marked for treatment. A further 68 cases were referred for observation. Special examinations at the Clinics account for 55 cases of defective hearing, and 227 cases of ear disease. Dental Defects. A total of 9,883 children were found requiring treatment at routine dental inspections in the schools. Table IV., Group V, on page 50 gives further statistics in this connection. Orthopaedic and Postural Defects. Eighty-seven cases of deformity of varying degrees were discovered by inspections at the schools and at the Special Clinics. Heart Disease and Rheumatism. Eleven cases of heart trouble were found during the year to need treatment, whilst 58 cases were marked for observation. Eighteen cases of Rheumatism were found to need treatment, and 12 were marked for observation. 8 Tuberculosis. One case (T.B. rt. hip) was found to need treatment during the year. Other Defects and Diseases. Fifteen defects which could not be classified under any other heading in Table II were found during routine medical inspection. The number of "other defects and diseases" found by special inspection was 2,032. Of these, 1,748 were referred for treatment. They were almost entirely minor ailments (minor injuries, bruises, sores, etc.). 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. The Following-up card is " kept alive " until the condition for which it was made out is remedied. Nurses paid 366 visits in this connection during the year. The most difficult feature of this work is the wilful neglect of certain parents whose obstinacy fails to respond to persuasion. Such cases have to be referred to the Committee, who generally decide to pass them on to the National Society for the Prevention of Cruelty to Children. The following is a list of the School Nurses' duties, with brief statistics relating to their activities during the year under review. Duties. 1. Attend Routine Medical Inspections at schools with the Medical Officer, and assist in weighing and measuring children, etc. 2. Attend Re-inspections at schools with the Medical Officer. 3. " Following-up " as outlined above. 4. Attend Eye Clinics. 5. Attend Minor Ailments Inspection Clinics with Medical Officer. 6. Attend Minor Ailments Treatment Clinics and undertake daily treatments. 7. Attend Dental Clinics. 8. Attend Dental Inspections at Schools. 9. Visit Schools and inspect all children for uncleanliness (Cleanliness Survey). 10. Attend Clinics for re-inspection of dirty children (Cleanliness Clinics). 11. Visit children's homes for enquiries in cases of non-notifiable infectious disease. 12. Visit homes of children who fail to attend Clinics or attend irregularly. Summary of School Nurses' work during 1937. Attendances. Routine Medical Inspections 219 Re-inspections 42 Eye Clinics 140 Minor Ailments Inspection Clinics (with Medical Officer) 284 „ „ Treatment Clinics 1332 Dental Clinics 636 Cleanliness Surveys 75 Cleanliness Clinics 58 Other Attendances (Special Clinics, Med. Exam, of Teachers, School Sports, etc.) 60 Total Attendances 2846 9 Visits. [/$$$] Re Infectious Disease 3240 Following up 366 Other Visits 42 Total Visits 3648 ISLEWORTH HEALTH CENTRE. This new building was opened on the 24th April, 1937, by Sir George Newman. It is well to look at what happened before we saw the official opening. The Board of Education set down the sum of £4,500 as the amount which they considered should be spent. The plan which I made for the Clinic to carry out the work in that part of the Borough cost £7,800. I ought to have spent £10,000 as the rooms are practically all just that little bit too small which " spoils the ship for a hap'orth of tar " or £2,200. The Clinic is quite unlike anything in the district, as I intended it should be. The parents using it are delighted with it and it is serving its purpose admirably, but with the rapid progress of things for the betterment of the health of the children in the district, it is going to be too small before very long. I do feel that in these matters vision is wanted. It is little use designing these buildings for the immediate present in order to keep the expenses down, and the rates down, incidentally, but surely in all these matters broader vision is more valuable than parsimony. I purposely designed the building in a form different from anything else in the district so that it stood as a permanent indication of the activities of the Education and other Committees whose services were functioning in it. There are other clinics, not many miles away, which are designed so that they look just like a house, a little larger than the villas nearby. Personally I think that this sort of architecture is a mistake. The building can be made to be its own advertisement by reason of the architecture which has gone to its erection. A plan of the building showing the arrangement of the accommodation is given on the next page. 10 7.—ARRANGEMENTS FOR TREATMENT. (a). Malnutrition. Milk is 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 38. In November, 1936 the following preparations were placed on sale in the School Clinics. I append details of the quantities issued during 1937—the first full year of the scheme. Cod Liver Oil and Malt 1950 lbs. Bemax 204 tins (3½oz.) Cod Liver Oil Emulsion 623 bottles (8oz.) Adexolin 187 phials (½oz.) Cod Liver Oil and Malt Kalzana 2050 tablets with Iron 1322 lbs. These preparations can be supplied free in necessitous cases. The Income Scale which is used in these cases is given in Section 17, Parents' Payments, on page 41. (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 vear to attain the standard of one cleanliness survey per term at each school, it has been possible to increase the number of examinations to 16,942, compared with 15,135 in 1936. Number of visits to schools by Nurses 84 Total number of children examined 16,942 „ „ „ ,, given warning notices 820 „ „ „ „ excluded as verminous 98 Found to have nits— 1. (Few) 581 2. (Bad) 285 3. (Very Bad) 52 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 woman 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 gave up the cleansing of heads in February. The work is neither pleasant or lucrative and it is not surprising that difficulty was experienced in finding a suitable person to carry on. A Mrs. Dopson agreed to take over the work and was specially instructed in the methods of cleansing heads at one of the London County Council's Bathing Centres. She resigned, however, in June. From that time the cleansing of heads has been done at the Isleworth School Clinic by Mrs. Hammond who is paid 10/- per month, as a retaining fee, and receives also the 1/- per head which is paid by the parents. The work is now running smoothly. During 1937 it was found necessary to take legal proceedings in 13 cases, with the following results :— Three cases Dismissed with caution. Three cases Dismissed with costs against parents. Six cases Fined 5/- each. One case Fined 10/-. 11 (c). Minor Ailments and Disease 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. In April the minor ailments treatment centre at the Cranford Temporary School which was opened last year to serve the growing area in that part of the Borough was transferred to the new Cranford Junior School. A treatment centre was also held at the Hounslow Heath Senior School from April to December. 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—94a, Bath Road. Heston—The Village Hall. Isleworth—Health Centre, Busch Corner. Cranford—Junior School, Berkeley Avenue. A Medical Officer attends the Clinics on the following sessions : — Hounslow—Tuesday morning and afternoon. Friday morning. Heston—Thursday morning. Isleworth—Monday and Thursday mornings. Cases are referred to the Clinics from school medical inspections, or are sent in by Head Teachers, School Attendance Officers, and Health Visitors. The majority of the cases, however, are sent in by Head Teachers, who doubtless realise the value of prompt treatment in maintaining a good school attendance. Since the middle of 1929 the Minor Ailments Clinics have been kept open during school holidays (except such general holidays as Christmas Day, Bank Holidays, etc.), but there is always a considerable drop in the attendance when schools are closed, which points to the fact that, but for the vigilance of Teachers and Attendance Officers during term time, many of the cases of minor ailments would go untreated and neglected. Table IV, Group 1, on page 48 shows that 2,468 cases of minor ailments were treated under the Authority's schemes. 2,464 of these were treated at the school clinics where they made 12,199 attendances during the year. In addition to providing daily treatment for minor ailments, these clinics also serve as centres for special examinations by medical officers, and during the year, 6,434 special examinations and re-examinations were carried out. Ringworm of the Scalp. All children accepting treatment by the Authority are sent to St. John's Hospital for Diseases of the Skin, Leicester Square, for X-ray treatment under an agreement made with this hospital in January, 1935. There have been five cases under treatment by the Authority during the year. Three of these were new cases and received X-ray treatment at St. John's Hospital. One case received treatment by application in the School Clinic. The remaining case was one of those inspected in 1934 and mentioned last year. This case cleared up in December. 12 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 Glass filter until the Medical Officer is satisfied that there is no return of the infection. (d). Visual Defects and External Eye Disease. Later in this report will be found Dr. Roberts' Report which I specially asked her to make on the present position with regard to the eye service. I found, on taking up duty here, that parents were being pressed by the optician appointed by the Committee to spend more than their means warranted and also that derogatory remarks were made with regard to the frames which were on sale at a lower price. In going into the matter I found that around London some of the districts were very definitely crippling their service by reason of the prices demanded for the spectacles prescribed by the Ophthalmic Surgeon. Twenty-five shillings was a common price I found in certain areas for extravagant frames and also for astigmatic glasses with high diopter value. This meant when one came to look into it that in many cases the parents could not afford the prices demanded and in the case of the progressive myope whose glasses had to be altered fairly frequently the expense was one the parents could not face, and, moreover, did not face. It was brought home to me that if our ophthalmic service was to be of any value to the chiM the prices paid for the glasses must be within the capacity of the parents to pay. Moreover, there must be, when the parents were faced with the necessity of providing their children with glasses, some certainty of the limitations of the expense they were asked to incur. It was exactly as one found when one was in practice. Many and many a time one found humble people not coming to consult one because of the dread, that is the only word that can be used, the dread of the unknown doctor's bill. Amongst the poor who live so close to the poverty line, it is not the question of shillings but a question of pence that matters and those who had heard that so and so's child had to have spectacles costing 25/- were appalled at the prospect of having to pay what was almost half-a-week's wages for something they could not see the real value of. When I say could not see the value of, the fact that they will try grandpa's glasses on the child, or as I have often heard, the glasses grandma wore before she died, in their abysmal ignorance of what glasses are or are intended to do, it is small wonder that they cavil at the prospect of paying, as I have said, almost half-a-week's wages. There is another factor which makes for difficulty, and that is the vanity of the girls who object to wearing the plain nickel frames, and the fact that other children in the class are wearing the imitation tortoisehell frame is gall and wormwood to them if they are only offered steel or nickel. This one has to face and one finds, as a matter of fact, that the " Windsor " frame, that is rolled gold with a film of imitation tortoiseshell around the eye piece, is the most satisfactory in that it appeals to the vanity of the children and they in turn do take much more care than they do with the nickel ones. In order to counter this difficulty I insisted, first of all, on a flat rate payment so that there was no anxiety as to what payment would be demanded. I started with 4/- which covered a good nickel frame and,, the most important part, lenses of any magnitude. The previous system I found in existence in so many areas was that the child who was most affected was the one whose parents were penalised by the heavy cost of glasses. The response to the new idea was excellent and the number of cases who turned up to be refracted increased steadily. One found, however, that it was desirable to improve slightly the quality of the frames and the contract was ultimately entered into at 4/6d. instead of 4/-. As the news percolated through the district that the payment was a fixed one of comparatively small amount the improvement in the acceptances of treatment steadily rose with it. A still further important point in getting the sympathy of the parents was that one had a contract price for every kind of repair and this was posted up so that they knew exactly what their commitment was, and again the unknown had lost its terrors. The result has been a steady improvement in that we were able last year to say that every child who required spectacles got them. This of course was assisted very materially by the fact that on a wage scale the parents were assessed to pay a reduced amount or even nothing. It is joy to look back on the changes that fifteen years have made, due to the alteration in the policy and the help of an enlightened Education Committee. 13 ✓ Important. s.m. 17. BOROUGH OF HESTON AND ISLEWORTH. Education Committee. Notice to parents whose children have received spectacles through the Eye Clinic. Any child who complains of not seeing properly should be brought or sent with the spectacles to the Isleworth Health Centre, Busch House, Busch Corner, Isleworth, on Saturday mornings between 9 and 10 a.m., or to the Health Department, 94a, Bath Road, Hounslow, between 10 a.m. and 12 noon. No reference slip is required. Enter by the front door and ring the Enquiry bell upstairs. REPAIRS. Spectacles needing repairs can be handed in at 94a. Bath Road, any day of the week between 9 a.m. and 4.30 p.m. Monday-Friday, and between 9 a.m. and 12 noon Saturday. The prices are given below :— Lenses: Two Lenses 3/3 One Lens 1/10 Frames: Shellite. Rolled Gold. Heavy Nickel. New Frame 6/6 5/6 2/- New Bridge 2/- 2/- 1/- New Side 1/6 1/6 9d. Solder Bridge 1/6 1/6 7d. Solder Eye Wire 1/6 1/- 5d. New Screw and Rivet 6d. 6d. 3d. Spectacles: Shellite & Rolled Gold 9/6d. Rolled Gold 8/- Heavy Nickel 4/6d. EL WIN H. T. NASH, School Medical Officer. PLEASE NOTE : If the child attends without a parent, a note must be sent stating what is the complaint, or, in the case of a breakage, authorising the repairs. THE REFRACTION CLINIC. Dr. Nash has asked me to write an account of the work and growth of this Clinic since 1924 when he placed me in charge. Prior to the middle of 1924 when I began the work, refractions and the provision of spectacles had been done by a visiting Ophthalmologist who attended fortnightly during the School Term, or oftener if the numbers warranted it. This provided for the refraction of children with visual defects, but was incomplete, since there was no scheme for the periodic examination of children once spectacles were provided, which is one of the most important aspects of the conservation of vision in children. With a member of the permanent staff in charge giving a few sessions weekly to the workit has been possible to build up a system of care of vision which is really comprehensive within the limits of the work which it is permissible to do at a School Eye Clinic, and having regard to the amount of time which can fairly be allotted to this branch of the School Medical Service. 14 From the outset Dr. Nash gave me a free hand (within the above mentioned limits) to do what I thought necessary and I wish to acknowledge with gratitude the encouragement he has always given me. Five points appear to me to be necessary in any scheme for the care of vision in school children, and it is on these lines that the work has been built up. 1. Detection of visual errors. 2. Treatment. 3. Periodic re-examination of those for whom spectacles are prescribed. 4. Co-operation of parents. 5. A flat rate charge for spectacles, and definite charges for repairs. Points 1, 2 and 3 are obvious, and form part of all "care of vision" schemes, but success is determined by the thoroughness of their application. Point 4 should be an integral part of any scheme, but is often neglected, and 5 admits of some difference of opinion, though in this Borough we are convinced of the superiority of the flat rate of charges as against charges varying with the type of lenses ordered. I. Detection of Visual Errors. Routine Medical Inspection of children in the schools is the chief means of discovering children with defects of vision, although a number of cases are found at the School Medical Clinics to which they are referred by Head Teachers, Nurses or Attendance Officers. Elementary School Children have three routine medical inspections during their school life, viz.:— As Entrants, At the age of 8, At the age of 12. In 1923 it was the custom in this area, as in many parts of the country, to omit the vision testing at the Entrants' Examination on the grounds that a child of five could not read. I was impressed by the possibility of a defect of vision being overlooked for the first three school years, or even longer if the second inspection is missed, and, with Dr. Nash's permission, in 1924 I instituted routine vision testing at the Entrants' Examination, and this has been continued ever since, thus ensuring that information regarding a child's vision is obtained at the earliest moment after entering school. The importance of this was emphasized by the Board of Education Committee of Enquiry into Problems connected with Defective Vision in School Children, who, reporting in 1931 stated in their General Conclusions "that children should be brought earlier under the test than is done at present, when only children who have attained the age of eight are tested as a routine measure." In this Borough we anticipated this conclusion by seven years, and are convinced of its utility and practicability. Testing the vision of children of five presents no real difficulty—it only requires patience. Many children already know their letters when first seen—actually most of them do not pronounce the letters as such, but make the appropriate sounds which is how they are taught the alphabet in the Infant class. These, however, are quite simple to follow. It is much easier, but not imperative, to have someone to point to the letters, as a young child finds it difficult to keep its place when reading. In most Infant Schools the Head Teacher will do this, and she is a great help, as her presence tends to allay any nervousness on the part of the children. Most children, however, respond very well. Young children are usually pleased to show what they can do. The actual testing is done by the Nurse who accompanies the Medical Officer, and for the Infants we always use Dr. Nash's modification of the Snellen test type consisting of the five vowels in "lower case" type, which are the letters and type that the Entrant is most familiar with—whereas other cards are printed in capitals. Any children who cannot read, or whose testing is doubtful, are referred to the subsequent Re-inspection. In three or four months' time most of them can be tested. An exceptional case which still does not know the letters is referred to the Routine Medical Inspection next year— so that at the worst, a child's vision is tested at six years of age. 15 The results obtained are not infallible, but in my experience are as accurate as those of older children and in all cases detection of visual errors by reading a test card is only a rough and ready method, and, if accurately done, can only show the manifest errors; such a test must only serve as a preliminary to indicate which children need refraction. At the Routine Medical Inspection and School Clinic the test used is always the Snellen long distance test, and if a child reads 6/6 or 6/9 in each eye and has no sign of eye strain he is passed as not requiring treatment, on the principle that latent errors which do not impair vision or cause strain do not need correction, and that therefore it is unnecessary to refract such children in order to ascertain the full degree of error. In one respect however this procedure, though generally satisfactory, is inadequate, in that it fails to detect the early myope. A child with a small degree of myopia will for a time read 6/6 without difficulty or strain and therefore remains undetected until such time as the vision fails to a noticeable degree. From time to time children are referred to the Eye Clinic having a visual acuity of 6/24 in each eye or less, who on refraction show 1-2 diopters of myopia. In every case of this kind the child's record is examined to see why he was not referred sooner. In most cases the previous Routine Medical Inspection showed normal vision, and therefore under the present system no one is to blame for not obtaining treatment earlier. It seems clear however that for some months the child has had an increasing loss of vision which could and should have been corrected earlier by the provision of spectacles. Myopia is the most serious defect in growing children in that the defect tends to increase with age. Moderate degrees of Myopia can be satisfactorily corrected by lenses and good vision obtained, but if the defect goes on increasing there comes a point when vision deteriorates in spite of correcting lenses; there are changes in the fundus and in later life blindness may result through detachment of the retina. It is therefore extremely important that Myopia should be detected in its early stages so that all myopic children may be kept under observation and given necessary treatment. Fortunately not all Myopia is progressive, but it is only possible to distinguish between progressive and non-progressive Myopia by frequent examinations. In the Report of the Committee of Enquiry mentioned earlier the importance of the early detection of Myopes was discussed at length and it was advised " that a more searching test is necessary than the one at present employed in the schools for the detection of visual defects." On administrative and financial grounds the Committee felt that it was impossible to suggest the routine refraction of all children, and recommended a modification of the normal testing by placing a + ID sphere before the reading eye, in all children who would otherwise be passed as normal. The! Committee stated that under this test (reading through a + ID sphere) the hypermetropic child will still read 6/6 or more—but the normal or slightly myopic child's visual acuity will be lessened, and in the latter case may be diminished to 6/36. This suggestion appeared a valuable one and was immediately put into practice at the beginning of November, 1931, and was carried on for the whole of 1932, when I reported at length in the Annual Report for 1932 on the results obtained. These were very disappointing, as it was found that 90% of the children, whose vision would be passed as normal under the ordinary Snellen test, had their vision adversely affected by the addition of a + ID sphere to the reading eye. According to the Report of the Committee of Enquiry such children would either be Emmetropic (normal) or Myopic, though one could not disregard the probability that small degrees of Hypermetropic astigmatism would also cause diminution of visual acuity. The number of children tested at Routine Medical Inspections in 1932 whose vision was adversely affected by reading through a + ID sphere was 2,770, so that it was impossible in the course of routine work to refract them, and the difficulty of detection of the early myope was not helped by this additional test. It appeared possible, however, that the degree of diminuation of vision might afford some clue, as one supposed that the early myope might be more severely affected by reading through a + ID sphere than the emmetropic or slightly Hypermetropic Astigmatic child. In my detailed reports (see Annual Reports of the School Medical Officer 1931 and 1932) I showed that in 1932 only 0.81% of the children had their vision diminished by 5 or more Snellen lines, i.e., that a child reading 6/6 with unaided vision read only 6/36 or 6/60 through a + ID sphere. The actual number was 25, and the number being small an endeavour was made to refract them. The next category, viz., decrease of 4 Snellen lines, contained 414 children, a number too large to refract unless made the subject of a special enquiry. The 25 children were treated as special cases and seen on a Saturday morning, but, unfortunately, only 20 children attended. The results here were inconclusive. All the errors were small and in most cases there was 0.25 diopter of astigmatism (9 Hypermetropic Astigmatism, 16 5 Myopic Astigmatism). In three cases only were spectacles prescribed but the remaining 17 were marked for examination next year (1933); and the test with the + ID sphere was continued at all Routine Medical Inspections throughout 1933. Of the 17 children whose vision in 1932 was diminished 5 Snellen lines when reading through a + ID sphere it was only possible to re-examine 11 in 1933 (the others having left)— in all cases the vision remained satisfactory. In 1933 only two children had their vision diminished by 5 Snellen lines and on reexamination their vision remained satisfactory. The results of this additional test were so inconclusive, and definitely gave no help in the detection of early myopes, that the test was dropped at the end of 1933, as it gave a considerable amount of extra work without any advantage over the old system. I am still of opinion, as I reported in 1933, that the most useful reform in the routine vision testing of school children is to increase the frequency of these tests. If all children could be tested annually instead of only at a 3 or 4 yearly interval, an early myope would not remain long without detection and astigmatics would be found earlier. Each child has a dental inspection annually, and it should be possible to arrange for vision testing annually. The only difficulty is one of expense, and up to the present it has been impossible to carry out this much needed reform. II. Treatment. Treatment at a School Eye Clinic consists chiefly in refracting each child to determine the nature and degree of visual error, and the correction of such error by prescribing suitable lenses. Each new case attends the Clinic three times—first for preliminary examination when the vision is noted, also any peculiarities such as squint. The parent is then given the necessary ointment for dilating the child's pupils and paralysing the accommodation (Atropine 1%) with instructions as to its use and a second appointment is given in a week's time. The school is notified that during the use of the ointment no close work is to be done. All children of 14 or over are treated as adults and are given 4 installations of Homatropine at the Clinic and the refraction done during the same session. This gives adequate dilatation and lessens very considerably the interruption of their school work. At the second visit the refraction is done and spectacles prescribed, the measuring of frames being done by the nurse. The third visit is for the purpose of checking the lenses and the fit of the frames, also the child's vision is tested with the new spectacles and the parents given any final instructions. Squint. Only non-paralytic squints are treated at the Clinic. A paralytic squint, being a symptom of disease, needs treatment of a kind not available at a School Clinic and is referred to hospital. Such cases however are rarely found in school children. Most concomitant (non-paralytic) squints have some visual error, and this is corrected by suitable lenses. Often the eyes become straight when wearing spectacles, but many still squint, though in a less degree. The next step is to improve the vision of the squinting eye which at first, even with spectacles, is markedly less than the good eye. This is done by occluding the fixing or good eye, or by the installation of atropine. The effect of this is to exercise the squinting eye, and if begun at an early age and conscientiously carried out very good results are achieved. Unfortunately, however, children are often not seen at the Eye Clinic until they are 8 years or older, when it is much more difficult to restore good vision to a squinting eye. 1 believe, however, that it is always worth while to exercise the squinting eye at whatever age seen, since, even if the vision is not improved, one may be able to prevent further deterioration. Undoubtedly the best results are achieved when a child attends at 3 or 4 years of age, because then it is possible to order constant occlusion of the fixing eye for the necessary period regardless of the amount of vision in the squinting eye. A young child does not resent having its sion substantially cut down and there is no danger in doing so because the child is always witn the mother and is not in the streets alone. With an older child this constant occlusion is not possible in cases where the vision of the squinting eye is very poor, because one thereby condemns the child to carry on its school work and other activities with very imperfect vision—this is naturally resented by the child and incidentally bv the teacher. There is also considerable risk in allowing a child with a very small 17 amount of vision to be amongst modern traffic. The probable result of ordering such treatment would be that the child would not wear the spectacles at all, thereby losing the benefit of the correcting lenses. Actually I have known this to occur—a boy of 9 came to the Clinic having a severe squint, and with very little vision in the squinting eye. He was wearing spectacles with an occluder over the lens of the fixing eye. He had been treated for squint at a London hospital for several years and had been ordered constant occlusion of the fixing eye. This treatment had been faithfully carried out by the mother, but with apparently no result, as the vision was still extremely poor. On enquiry as to how the boy managed to do his school work I found that the boy had always removed his spectacles the moment he was away from his mother. One could not blame the boy, as it was asking too much of an intelligent child to expect him to submit continuously to very impaired vision when by removing the spectacles reasonably good vision was obtained. With older children, therefore, one is forced to give second best treatment, viz., occluding the fixing eye for certain periods daily. Where the vision of the squinting eye is very poor I ask the mother to cover the fixing eye as much as possible when the child is at home; when there is sufficient vision to allow school work to be done a second pair of spectacles is ordered and an occluder attached to the lens of the fixing eye; this pair of spectacles is worn in school, and the child is allowed to sit in the front row in class. In either case the child has use of both eyes when in the streets. Naturally the effect of exercising the squinting eye by occluding the fixing eye depends largely on how conscientiously the treatment is carried out, and in many cases no benefit is achieved because instructions have been ignored or only carried out spasmodically. In cases where the vision of the squinting eye is improved so that the disparity in vision between the eyes is not great or is abolished, an endeavour is made to develop the fusion faculty and obtain binocular vision. Occlusion of the fixing eye is stopped, or reduced in time, and the child is given exercises with a Drawing Stereoscope. This is not done at the Eye Clinic as time does not permit, but is arranged on a Saturday morning, the exercises being supervised by a nurse who fits in the work with her other duties such as Minor Ailments. There is a stereoscope available for use at the three Centres—Hounslow, Isleworth and Heston, so as to make it as easy as possible for children to attend; a Saturday morning was chosen to prevent loss of school attendance. Only those children whose parents are willing to co-operate are recommended for these exercises—no possible good can be done unless the child attends regularly. Actually once a week is usually insufficient to obtain the best results, but it is impossible to spare more time, and by selecting suitable cases benefit is received and in some cases steady binocular vision has resulted. I feel that much more could be done by regular Squint Training Clinics held two or three times weekly with a greater variety of apparatus, but so far this has not been possible to arrange and the number who would benefit by such treatment is not large. Such Clinics are held at some of the London hospitals, but the distance is too great for our children to attend twice or thrice weekly for months. Last year we made a modification of the drawing stereoscope which has increased its usefulness. In the original device the pictures to be traced are enclosed in a Printator block, a bone style is used for the tracing, and after use the slide is pulled out and the drawing is obliterated so that the picture can be used indefinitely. In use, however, with young children, we found that the child pressed so heavily with the style, that the impression remained on the celluloid and the pictures could only be used a few times. To obviate this I had the pictures (black and white drawings) removed from the Printator block and mounted on wooden plaques the same size, the work being done for us most neatly and expeditiously by the Handicraft Class of the Bulstrode Senior Boys' School. Tracing paper cut the size of the plaque is then placed over the picture and attached firmly to the plaque by broad rubber bands, the child traces with a soft pencil and the sheet is removed, the picture being ready for use again for another child or for the same child next week. Not only has this modification removed the necessity for frequent replacement of the picture sets—an expensive matter—but it has also given a permanent record of the child's achievement, as, after use, each tracing slip is labelled with the child's name and date, so that there is a visual record of the progress made. To sum up—treatment of Squint at our School Eye Clinic consists of :— 1. Refraction and provision of necessary correcting lenses. 2. Exercise of the squinting eye by occluding the fixing eye either constantly or periodically. 3. In suitable cases, training of the fusion faculty and establishment of binocular vision by the use of a drawing stereoscope. 18 4. In cases where no improvement of the squint is obtained after 1 and 2 have been tried, reference to hospital for operative treatment. High Myopia. There is no Sight Saving School in the Borough, as the numbers requiring such treatment are too small to warrant such expenditure. Children with high or rapidly progressive Myopia are sent to Special Schools outside the Borough or are given special desks in the Elementary school, with restrictions as to their school work, and are kept under frequent observation at the Eye Clinic. III. Periodic re-examination of children for whom spectacles have been prescribed. Sir George Newman, when Chief Medical Officer to the Board of Education, wrote in his Annual Report for 1929: "All children with glasses should have their visual acuity tested once a year, and if it is found there has been any change for the worse, they should be reexamined by refraction. All children suffering from Myopia should be examined as a routine measure every six months or a year according to the severity or progressive nature of the defect." Systematic re-examination as mentioned in the above extract was begun in this Borough in 1924 and has been built up and improved in the the succeeding years. Ordinarily the interval between examinations is 12 months, myopes however are seen oftener—9 months for slight degrees, 6 months for severer defects, and a lesser period where considered necessary as in children where the defect is rapidly progressing, and the effect of allowing school work requires to be watched carefully. Squints are usually seen every two or three months where squint training is ordered. Parents are informed when the child should be seen again and re-examination notices are sent at the expiration of the period asking parents to agree to further examination and any necessary treatment. Children who are seen at short intervals such as two or three months are given a definite future appointment at their last attendance. Not all parents respond to the re-examination notices—ideally such cases should be followed-up but in practice time does not permit of this being done, as we have always a long waiting list of children whose parents have agreed to treatment. Therefore only severe cases are followed-up, and the others are left until found again at Routine Medical Inspections or the School Clinic, when fresh endeavours are made to have the child re-examined. This procedure applies to all the School Medical work; parents are notified of defects found and every facility is given for treatment to be obtained. If the parents do not avail themselves of the treatment provided, the children have to be left until seen again at a subsequent examination, when treatment is again offered. Serious cases however are followed-up until treatment is obtained, and when necessary Court proceedings are taken. Such a system leaves many gaps, but is inevitable with a limited staff. In addition to systematic re-examination of children with visual defects, any child who is attending the Eye Clinic can be seen by the Eye Nurse on Saturday morning without appointment, in cases where parents think the vision is not as satisfactory as formerly, or there is some complaint about the spectacles. When spectacles are received a printed leaflet is given to the parent, setting out this information, and parents are encouraged to bring the child to see Nurse if there is any suggestion of difficulty with the spectacles, and where necessary, children are referred by Nurse to the next Eye Clinic. I consider this a most valuable adjunct to our Eye Clinic service, as there are many small things which may go wrong with spectacles in the interval of periodic examination at the Eye Clinic. Sides become loose, or the frames out of shape, and sometimes children have been found wearing some other child's spectacles and then naturally complaining that he could not see properly with them. Sometimes children complain about their spectacles in order to avoid wearing them. All cases of complaint need immediate investigation—if there is something wrong it should be put right at once, and if it is only an attempt to avoid wearing the spectacles it is important that this should be demonstrated to the mother, so that she can then insist on the spectacles being worn. Repairs can be dealt with any day of the week by handing them into the Office, but the clerk in charge is instructed not to send any spectacles for repair or renewal in cases where the spectacles have been worn for nine months or longer. Such cases are referred at once to the Eye Clinic as they may need a change of lenses. 19 IV. Co-operation of parents. This is a vital factor in treatment of visual defects in children. It is useless to provide spectacles unless they are worn as directed, and, without the insistence of the parents, few children would wear them, either from dislike or forgetfulness. It is a regrettable fact that many parents will attend with the child for treatment and incur the expense of the spectacles, and yet will not take the trouble to see that the spectacles are worn regularly. I feel that the only way to promote this co-operation is to explain to each parent in simple language what is wrong with the child's sight, and what the lenses do to correct the error; also the importance of periodic re-examination owing to the changes in the eye of the growing child, and the necessity for frames which fit and are in proper shape. An intelligent mother will readily understand these points, and once she grasps the fact that she is the most important factor in the child's treatment she will nearly always respond by the fullest co-operation in order to obtain the maximum benefit. Naturally, however, such explanation takes time and patience and reduces the numbers which can be seen, but I am convinced that it is the only way to obtain satisfactory results and the response of the parents is most encouraging. Fortunately, in this Borough, we have never taken mere numbers as an indication of the value of the work done. V. A flat rate charge for spectacles and repairs. In 1924 we instituted a flat rate charge of 4/0d. for spectacles and definite charges for repairs. Previously charges varied according to the lenses prescribed, prices ranging from 8/- to 13/- a pair. The result was an immediate increase in the number of children to be treated as parents knew exactly what the spectacles would cost, and were not called upon to commit themselves to pay an unknown sum. Definite charges for repairs were also circulated to the parents. In 1925 the number attending for refraction was more than double that of 1923 and a large part of that increase must be considered due to the flat rate changes. Another important aspect of a flat rate charge is that it prevents children with more serious defects who need frequent attention from being penalised by the higher cost of their spectacles. In 1928 we provided an improved nickel frame and two other types of frame in addition to the nickel, the contract price for the different spectacles being :— Nickel, 4/6d. Rolled Gold, 8/-. Rolled Gold with Shellite rims, 9/6d. and these prices are still in force. Nickel frames are the routine ones ordered, but on request a parent may obtain the more expensive type. The more expensive frame was supplied because so many of the older children, beginning to be conscious of their appearance, jibbed at wearing the nickel frame. This is not mere pandering to vanity, but is based on the fact that a child is more likely to wear spectacles which he likes than those he dislikes, and undoubtedly there has been less trouble with senior children wearing spectacles since the better frames have been supplied. Also the fact that there is now a choice of types of frame tends to make both parent and child feel more satisfied —even though, for financial reasons, the cheaper kind is bought—it is then their choice, not that of the Clinic, a psychological factor of some importance. The difference in price is due to the increased cost in the frames, the lenses remaining the same grade throughout, which, though not of the highest quality, are satisfactory in use. Payment for spectacles is made in full where the parents are able to afford it but necessitous cases can obtain them free or at a reduced cost according to the family income. This applies also to payment for repairs. The method of payment for spectacles has varied since 1923. When I took over the work during 1924 the system in force was that all spectacles were sent by the Optician to the Education Department. Parents called there and paid for the spectacles and then brought the child with the spectacles to the Eye Clinic for a final examination. 20 In cases where payment was not made, the spectacles remained in the Education Department, and the child went without, and was not seen again by the Ophthalmic Surgeon. The result of this was that a large number of spectacles had accumulated which had to be paid for by the Authority and which had benefited no one; it was useless to write off the money owing and give the spectacles to the children, as a long interval had elapsed since they were prescribed and the spectacles would not have been suitable. This was an unsatisfactory system and a change for the better was made by having the spectacles delivered to the Health Department so that we had direct control, and, to avoid spectacles being ordered and then not paid for by the parents, none were ordered until half the price had been paid. All cases where spectacles were prescribed but not ordered were followed-up and if at the end of three months they were still unpaid the case was reported to the Committee for further action, which usually resulted in a reference to the N.S.P.C.C. and in the end the child obtained the spectacles. This applied only to parents who were in a position to pay, or who refused to disclose their family income. All necessitous cases were given the spectacles free and without delay. This system worked fairly well, and was a great improvement on the old one—and it remained in force from 1925-1936. During those years, however, there was always a small number of children who were penalised by the parents' neglect to pay, because there was inevitably a delay, often of months before the child obtained the spectacles which it needed. Figures, given later, show that over a period of years the discrepancy at the end of the year between the number of spectacles prescribed and those obtained was not great, but these figures only show the final result, and do not indicate the delay which may have occurred before spectacles have been received, e.g. a child could have spectacles prescribed in January and not receive them until December. This would be shown in the table as spectacles prescribed during the year—1, spectacles obtained during the year—1. In July, 1926, the Committee agreed that all children for whom spectacles were prescribed should receive them at once, irrespective of payment—repairs being done on the same basis. In cases where full payment has not been made, the parent (or child in the absence of the parent) signs that the spectacles have been received. At the end of each quarter all outstanding debtors are notified to the Borough Treasurer who deals with the matter through his Office. This is a splendid system from the point of view of the real aim of Eye Clinics, viz., the conservation of vision, as now there is no delay in each child obtaining the necessary spectacles, and the number of spectacles obtained in the year is the same as the number prescribed. The actual amount still owing both for new spectacles and repairs is not great. From July, 1936, to the end of 1937 the amount outstanding was £18 17s. 4d. and (February, 1938), some of this has already been paid off. The official demand note from the Borough Treasurer has a much greater effect in producing payments from dilatory parents than communications on the subject from the Health Department. Progress of the work of the Eye Clinic since 1923. The numbers attending the Clinic have steadily grown, due in part to the growth of the district, but also to the more complete scheme of work which has been evolved. In April, 1935, the Middlesex County Council's scheme for the provision of treatment for Secondary Scholars at the Local Authority's Eye Clinic came into force which has made a small but increasing addition to the work. Throughout the period pre-school children referred from the Maternity and Child Welfare Centres have been seen though their number has been small. All Clinic sessions were held at Hounslow owing to lack of accommodation in other parts of the area. In July, 1934, the Busch House Centre, Isleworth, was opened and from that date two sessions have been held weekly during term at the Hounslow Centre and one at Isleworth, extra sessions being held when necessary at Hounslow, where there is always a long waiting list. One regular session at Isleworth has been sufficient to keep the work up-to-date, as the Clinic there serves a smaller area, and the response to treatment is not so good. 21 From the middle of 1924 until September, 1936, I did the work alone, but since that date the Isleworth Centre has been attended by one of the Assistant Medical Officers, who has had previous experience in refraction work, and it has been pleasant and profitable to me to have a colleague with whom the work can be discussed. The growth of the work is best shown by the following figures for the years 1923-1937. These figures are those required by the Roard of Education annually and are therefore strictly comparable year by year. Children attending for errors of refraction. SPECTACLES. Prescribed. Obtained. 1923 Part-time Ophthalmic Surgeon. 129 108 103 1924 Whole-time Medical Officer for part of year. 183 150 141 1925 Whole-time Medical Officer. 291 256 247 1926 do. 291 227 218 1927 do. 289 219 213 1928 do. 297 257 250 1929 do. 413 344 327 1930 do. 443 405 392 1931 do. 531 480 472 1932 do. 537 500 490 1933 do. 581 569 559 1934 do. 552 517 498 1935 do. 647 606 595 (Elementary 615) (Secondary 32) 1936 do. 772 540 544* (Elementary 691) *4 Prescribed December, 1935. (Secondary 81) 1937 do. 804 (Elementary (Secondary 700) 104) 541 +6 obtained 535+ January, 1938. It will be seen, therefore, that the number of Elementary scholars attending annually is more than five times greater than in 1923. The school population has also increased, the number on the register in December, 1937, being 11,834, whereas in 1923 the average number was 6,499, the numbers being not quite doubled. Therefore the large increase in the numbers annually attending the Eye Clinic must be chiefly due to the systematic scheme of re-examination and to the greater care in finding and submitting for treatment children with visual defects, and alsj to the increased response of parents to the facilities offered. There are no grounds for attributing the increase to be caused by a larger proportion of children suffering from visual defects than formerly. It will be noted that the number of spectacles prescribed is not as large as the numbers of children attending—this is due to the fact that it is not always necessary to change the spectacles when children attend for their periodic re-examination, although usually some small change or adjustment is necessary. Occasionally also, children submitted to refraction are found not to require spectacles. In conclusion I give figures of the work of the Eye Clinic for 1937. We ended the year with a waiting list of 176 children in the Hounslow area, and the reexamination notices for December had not been sent out. This will necessitate extra sessions early in 1938 in order to bring the work up-to-date. At Isleworth there was no waiting list—consent forms here are received in such small numbers that the children are never kept waiting for treatment, and yet in spite of this the attendance lags behind that of Hounslow, where there is always delay before treatment can be received. 22 1937. Total appointments 2646 „ attendances 2406 „ percentage attendance 90.93 „ number attending for refraction 804 „ „ of spectacles prescribed 541 „ „ „ „ obtained 535 Note. Six children were absent on account of illness from the last session in December and therefore did not receive their spectacles until early in January, 1938. Hounslow Centre. Number of sessions 93 Average number of appointments per session 20.85 „ „ „ attendances 19.19 Elementary Secondary Pre-School Total for Centre Appointments 1677 190 72 1939 Attendances 1546 175 64 1785 Percentage attendance . 92.19 92.11 88.89 92.06 Isleworth Centre. Number of sessions 43 Average number of appointments per session 16.44 „ „ „ attendances „ „ 14.44 Elementary Secondary Pre-School Total for Centre Appointments 562 96 49 707 Attendances 493 88 40 621 Percentage attendance 87.82 91.67 81.63 87.83 Note. The above figures relate only to the sessions of the Eye Clinic and do not include those children seen on Saturday mornings by the Nurse. Aspirations. Although great progress has been made in caring for the vision of our school children and though, in my opinion, we can claim that we give an excellent service, there are still the gaps already mentioned which we have been unable to bridge. My enthusiasm leads me to desire to do still more to ensure the best possible vision for all children, and were it not that time and money have to be considered 1 should advocate :— 1. A shorter interval between the testing of vision in schools, viz., that every child should be tested every year. 2. The provision of a squint training clinic functioning twice weekly. 3. Better provision for the education of High Myopes. 4. Following-up of all children with defective vision so that treatment is prescribed and carried out. I realise however that care of vision, however important, is only one branch of the School Medical Service and that a sense of proportion must be observed in the work as a whole; that, since there is a limit to the spending of public monies, it is impossible to do all that one desires in one branch without cutting down on another and thus upsetting the balance and giving an unsatisfactory service. 23 With the exception therefore of High Myopes whose educational condition we are hoping to improve in the near future by the provision of the Leeds Reading Aid to each child, the remaining aspirations cannot be translated into practice at present, but without aspirations there is no progress, and I shall continue to hope that further advance may yet be made. E. L. ROBERTS. (e). Nose and Throat Defects. Four hundred and fifteen children were referred for treatment on account of nose and throat defects. Of this number, 57 were operated on under the arrangements made by the Authority. In the early part of the year the Borough Council entered into an arrangement with the Middlesex County Council for the operative treatment of our tonsils and adenoids cases at the West Middlesex Hospital. The fee per case was fixed at £1 lis. 6d., which included all medical fees, and maintenance of the patient for 48 hours. In the event of a case needing retention in hospital for a further period, it was agreed that the Education Authority would pay the current daily maintenance charge. This arrangement was made in order to ensure that our cases went into hospital the day before operation and were retained for at least 48 hours. The pressure upon the accommodation at the hospital has so far greatly impeded the full working of the agreement and the year ends with a long waiting list of cases. The introduction of an increased fee made it necessary to reconsider the income scale on which the parents' contribution towards the cost of the operation is based. This scale is given in full under the heading No. 17.—Parents' Payments (page 41). Tonsils and Adenoids. The appreciation of one's efforts on behalf of the children, which, I am glad to say, have met with practically universal approval, seem to leave some persons entirely cold and even hostile. The following is a letter I received with regard to a form sent to a parent in respect of tonsils and adenoids operation, which, if the circumstances warrant it, can be performed either at a reduced fee or free :— " This school children's operation should be quite free, like diphtheria injections. You will find parents will ignore your appeal and refuse to answer the questions on your ' charity ' form. Poor parents nowadays refuse to beg, not even for their children. In U.S.S.R. medical treatment is free to school children without form filling, scrounging for Hospital letters and charity mongering. Another point is why should helpless children suffer on account of callous, mean or indifferent parents." Mr. Elwin H. T. Nash, Chief " Nosey Parker," Public Health Dept., 94a, Bath Road, HOUNSLOW. LOCAL. The manner in which the letter was addressed, and went through the post, should, I suppose, make one feel definitely humble. I am afraid the effect was not what was expected. The gratitude and praise of parents that I have dealt with is one of the things T take into my retirement as a very very precious memory. 24 (f). Ear Disease and Defective Hearing. I am indebted to Dr. Denham who is in charge of the Isleworth School Clinic for the following report. His general remarks apply to the conditions found at all our Clinics. All treatment is of a simple kind and is left to the discretion of the medical officer in charge. We have no Ionization Clinic and any cases thought to benefit by this form of treatment are referred to the West Middlesex Hospital. " Otitis Media. The discharging ear continues to be one of the most troublesome conditions met with in school medical work. The attitude of the parent to this is always interesting as in most cases the fact that the child has a running ear is regarded as a more or less natural state of affairs, but the possibility of the development of a dreaded mastoid is usually the reason which prompts the child's attendance at the clinic for advice. As many as five out of every hundred children attending elementary schools suffer from otitis media and with the possibility of their being subjected later to grave social and economic handicaps the early treatment and possible prevention of hearing defect is a matter of the greatest importance. Unfortunately, one is only too often presented at School Clinics with an already established disease for much to be done in the way of early or preventive treatment as, in at least fifty per cent, of the cases the onset occurs whilst the child is of pre-school age. This would suggest that more careful supervision of the ears should be undertaken at Infant Welfare Centres and more children referred for expert advice regarding the advisability of surgical treatment during the acute stage of the disease. Any child attending the Maternity and Child Welfare Clinic with any ear complaint should be examined with the auriscope and if any defect or other acute condition is found the child should be referred to its own doctor for treatment. It is very important for mothers to be educated to recognise and report the onset of earache as soon as possible after its commencement as it is so often looked upon merely as a symptom of teething which requires no particular treatment. It seems more than probable that if a larger number of these children had their drums incised, less disability would result than is the case when the membrane is allowed to proceed to the stage of spontaneous rupture. In the School Clinics a different state of affairs usually prevails. Here, as previously stated, one is usually presented with an already established disease which presents itself in the form of a monotonous succession of acute exacerbations of a chronic condition. The hearing of these children is tested, the drums thoroughly examined and the quantity and character of any discharge noted. The nasopharynx is then examined for the presence of any septic focus such as septic tonsils or adenoids and attention is also given to the teeth and accessory sinuses. Where the removal of tonsils and adenoids is considered necessary the children are referred either to their own doctor, or, if the parents prefer it, arrangements for the operation are made directly with the local hospital. When treatment at the clinic is considered sufficient the child is usually given the routine one which consists of daily irrigation with a warm solution of Eusol and subsequent insufflation with boracic and iodine powder. It is essential to get the ear as dry as possible before the insufflation of the powder and this is done by dry mopping with pledgets of cotton wool after gentle irrigation with the eusol solution. To ensure thorough drying the swab may be dipped in ether. This treatment has proved very satisfactory and most cases show definite improvement in a very short time. Any case which resists treatment for more than three weeks is referred to hospital for the opinion of an ear, nose and throat surgeon." R. H. G. H. DENHAM. (g). Dental Defects. In taking leave of the orthodontic work there is one thing I should have liked to have seen before I finished and that is that the fee for orthodontic work should be abolished and the work included in the 1/- paid for dental treatment. In a number of these cases the orthodontic deformity is of far far greater importance to the individual, particularly if it is a girl, than any condition of carious teeth which can be replaced by artificial dentures later on. The orthodontic deformity, if it i^ bad, can never be remedied in after years, and the affliction of an inferiority complex which makes a woman's life miserable by reason of a hideous mouth, bears no comparison whatever to the fact that she has lost a tooth or has a gap or that she has twenty teeth filled or that she has lost her molars and that they have been replaced by an artificial set on a partial plate or even that she has a complete artificial denture. I feel that the perspective in these dental matters is not correct and must be re-orientated and these cases must be dealt with on the same basis as the other medical needs by sympathetic treatment in the matter of payment. 25 Again, the child who has been penalised by a parental deformity handed on should not be penalised in the matter of payment by reason that it is afflicted in a more serious manner than its neighbours. In doing this pioneer work there is only one warning I wish to give and that I give in the most solemn manner, there must be for a time in a dental clinic like this which is trying to educate the country, and believe me it is doing this, the necessity to curb the enthusiasm which would deal with every minor departure from the normal, in the same way that in the early days of medical inspection we had to start in a quiet way and educate the public to the necessity of remedying certain defects and breed the confidence which enabled us to progress in the years that followed; so for many years to come until the country has got orthodontically minded I feel it would be a mistake to tackle every minor deformity. The principles guiding the orthodontic work must be (i) is the deformity such as interferes with the mouth as a masticating machine and (ii) is the deformity such as to disfigure the individual and create an inferiority complex which will spoil his life? I am certain that if we are not careful to observe discretion in this matter we shall find limitation or even embargo put upon the work by reason of the expenditure which ratepayers have to face. Until they are sufficiently educated to the need for these matters it behoves us to walk warily like our friend Agag. It is very difficult to curb enthusiasm but there are times when it is politic so to do. I have received the following report from the Supervisory Dental Surgeon :— THE ANNUAL REPORT, OF 1937, OF THE SUPERVISORY DENTAL OFFICER. " Come my friends, 'Tis not too late to seek a newer world." Shakespeare. To the School Medical Officer. Submitting Annual Reports to you, prior to this one, has been a duty of routine; this one has a special value, all its own, where I cannot be unmindful that the wheels of Time have run their allotted duration, and 'ere another Report is due, must be rewound. It is said Sheep are quite right to let the Old Shepherd shear them, a new one might take his place and treat them worse; we as a Staff must go into practice to cultivate the wisdom of experience, and also the wisdom of Hope, when our last goodbyes are spoken. Commencing the Summary of 1937 work, 1 keep before my mind's eye, the injunction : — " Tell it well, or say nothing." A good standard to guide us—-have we taken out of Life more than we put in; by analogy let us apply this to our Clinics. The answer is exultantly " No," for all we have taken as labourers worthy of our hire, we have repaid tenfold. We as a Staff realise it is not the hours we put in that count—it is what we put in the hours. In this Report, one is at a disadvantage compared with back years, viz : " The Health of the School Child " used to give us much which we could pit against our results; under the new regime, such helpful aids are omitted. The next paragraph may perchance answer this moan of mine. The present verdict on the value of statistics, such as are presented in this Report, can be taken from p.116 " The Health of the School Child, 1935," as stated by Sir Arthur S. MacNalty, Chief Medical Officer of the Board of Education : "In so far as these School Dental Statistics are of any value for comparative purposes, the output of fillings, extractions, and other operations, are the only part of the return which merit such consideration." So be it! This standard, is by your Staff accepted without fear of any comparison. 26 Attendances. Statistical Table—1936/1937. Increase over 1936. No of children inspected. Age. 1936. 1937. Nos. % 5 734 1125 6 939 1120 7 928 1151 8 972 1329 9 898 1220 10 939 1319 11 790 1208 12 870 871 13 743 868 14 301 418 15 53 51 8167 10680 Specials 2726 2385 10893 13065 2172 19.9% Numbers found to require treatment 7651 9883 2232 29.1% Numbers actually treated 6568 6959 391 5.9% Attendances made by children for treatment 21400 26113 4713 22.0% 1936. 1937. Increase over 1936. Decrease over 1936 Nos. % Nos. % i days devoted to Inspections 66 84 18 27.2% To treat: Ordinary1612 1993 381 23.6% Gas 192 161 31 16.1% ADMINISTRATION AND COMMITTEE SESSIONS (S.D.O. ONLY)95 108 13 13.6% These Sessions included every section of the Clinic's work, and not exclusively for Elementary Schools. FILLING AND EXTRACTIONS. 1936. Permanent Teeth. 1937. Permanent Teeth. Fillings 8615 10971 Extractions 1711 1654 This shows in 1936 that for every permanent tooth extracted, at least 5 permanent teeth were filled. In 1937 for every permanent tooth extracted, nearly 7 permanent teeth were filled. 1936. Temporary Teeth. 1937. Temporary Teeth. Fillings 1387 1497 Extractions 6948 6539 In many Reports of "The Health of the School Child," the pendulum swung violently between Fillings and Extractions. One year it was this, next year it was that. The present tendency is to discourage too much time being spent on filling these teeth, in view of the evidential value of the same time being spent filling permanent teeth; to put it in a simple way, its like a bush fire—cut away an area clear of bushes, and check the fire spreading, so now we often take out a temporary tooth, to enable us to get at teeth with interstitial cavities, which otherwise could not be got at. GAS ADMINISTRATIONS 1936. 2676 1937. 2700 27 Under this heading, we class all cases where the patient is made oblivious to pain and surroundings, and every description of anaesthetics are employed that can with safety be used. Every form of administration is used, ordinary old time methods, as well as the newest, particularly continuous Gas, which has enabled us to complete- the larger percentages of our cases at one sitting, and further saves us being compelled to send cases to a General Dental Hospital. The necessity for this now and again arises, for very septic and urgent cases, which reach us from the Ante-Natal Clinic, with a very short limit of time for operating. We arc now stocked at both our Clinics with the latest English machines, and Nose pieces. This Department of our work has made advanced progress in technique, and safetymethods. General Remarks. The statistical items already given, are shown at the end of the Report, in the form in which they are submitted, by regulations, to the Board of Education. Let it be remembered these figures only refer to the Elementary Schools, and taken alone do not give a full picture of the Clinic's activities; this is shown in full totality in tables contained in this Report. In view of the large demand for anaesthetics, and ever increasing waiting lists, I am far from satisfied that we are working to the full capacity of our means; this is receiving deep consideration on my part, particularly the necessity for calling in auxiliary anaesthetists so frequently. Ever open Door. All Clinics, can be claimed as "non-stop"; their doors were open all through the year, except for a fortnight, to allow of overhauling the machinery, and for repairs. X-Ray " Victor " Machine. The long, long trail of waiting for the power "to know," rather than " to guess " a diagnosis ending in 1937, and we who had waited so patiently, perhaps impatiently, found our dreams came true; even then the opposition to be overcome, lent zest and energy to conquer those wishful to deprive us of our mess of pottage. In July, ready for the Winter Season opening, a " Victor " Machine was installed at the newly opened Busch Clinic. It is a satisfaction to record, all the points promised in the Dental Officers manifesto, unlike those of the politicians, have scored Bulls Eyes, and on behalf of the Dental Staff, I acknowledge the inaudible and silent tributes of praise on proving that we have got the Staff, we have got a Machine, and we have saved money too. The Dental Staff are still waiting for a withdrawal of aspersions upon their abilities to produce good skiagrams; it is long overdue. The appended figures do not speak, they shout to other Clinics to rouse themselves, and follow the pioneer lead of only three Clinics in England including ours, that have these machines; they will not only save time and expense to Parents, but also to their Authority, but above all, they will be able to do with greater certainty and give more knowledgeable diagnoses, which is the unalienable right of their patients to receive. Cost of Skiagrams produce at Hospitals.s. d. 219 Skiagrams in months cost 5 7 per Skiagram. Cost of Skiagrams produced on our own apparatus. 530 Skiagrams in 5J months (including Dental Officer's time) cost 11 per Skiagram. This includes depreciation on apparatus at 10% and includes cost of time of Staff for exposures, developing, mounting, etc. Secondary Schools. These Schools have been under our care for two years, and a summary verdict I would give is I am an Optimist, albeit, we are far from the results we should expect. Clinic Dental Officers throughout the Country have found difficulties with these Schools in obtaining a high acceptance rate of treatment. 28 The figures attached of our work are on the whole, not too disappointing. It is always well to give a "backward glance" as well as a "look ahead," to ascertain if possible causes that militate against attaining the work results desired. The factors to be noted are:— 1. Failure of the Committee to insist no boy or girl shall be admitted to these Schools, unless he or she has obtained a Certificate of Dental efficiency, freedom from caries, etc., from a Dental Clinic Officer, irrespective of where treatment was obtained. This rule was strictly observed by a S.M.O. under whom I worked for some years. I was selected as the testing D.O.—none got scholarship places till their mouth was in order ; it is surprising how it decreased the number of misfit parents (objectors, chronic absentees, etc.). 1 would recommend it to the Higher Education Committee as applicable to such Schools in this district. 2. I can best describe the paragraph as " Shifting the Centre of Gravity." Before the Great War, in dealing with matters concerning the Child, its health and work, the llead of the family could be relied upon as the centre of gravity in home affairs, to give decisions and implement them. After the war, the gravity centre changed, and the Child of Secondary School age changed places, or usurped them, with and from the parent, and gives the decisions now-a-days. Day by day, we have evidence of this fact ; it is not an infrequent occurrence when advising a parent on Dental matters, for the child to say " I don't want that done", or failing that, the parent asks the child, "Would you like the tooth out?" etc. The result is usually nothing done. I painfully record one recent case (Elementary School) where a parent pathetically asked me what she should do, when her little girl about nine years of age told her point blank she was going to have nothing done. Sad to say, the child won. Nature has given some Mothers the blessed gift of child bearing, and forgotten to endow them with a mental stiffening for the task of rearing them. 3. Want of co-operating by the child. Until we get co-operation from the child, it is useless looking to the parent for it. Our Consent Forms are usually returned to us, marked under " Own Dentist ", whereas examination by a Clinic Dental Officer reveals much dental work is required, and often old work requires renovation. In one School alone we had 178 such cases. The answers can aptly be classed :— " A lie that is all a lie Can be met and fought outright, But a lie that is part of a lie Is a harder matter to fight." Undoubtedly, many of these cases have been under a Dentist—for extraction of a painful tooth, but very few for conservative work. Headmasters and Headmistresses have done everything necessary to aid us in our work, and many cases have helped to unravel unsatisfactory dental records. We on our side can help them, since the S.M.O. has kindly extended our working hours, and we can offer by late appointments, opportunities for missing very little School studies and consequent absences. The extended hours thus prove a boon to Staff and Scholars. Secondary School Statistical Table—1936/1937. No. of children inspected. Age. 1936. 1937. 10 3 4 11 224 142 12 247 264 13 307 300 14 246 283 15 191 231 16 91 96 17 33 20 18 2 4 19 1 1344 1345 Specials 182 171 1526 1516 29  1936. 1937. Numbers found to require treatment 1194 1222 Numbers actually treated 532 798 Attendances made by children for treatment 1796 4164 Half days devoted to Inspections 14 16 FILLINGS. Permanent Teeth 1257 2892 Temporary Teeth 1 2 1258 2894 EXTRACTIONS Permanent Teeth 335 369 Temporary Teeth 61 106 3% 475 Administrations of general anaesthetics for extractions 160 189 Other operations : —Permanent Teeth 1 Temporary Teeth 1 331 1060 INCREASE PERCENTAGE ATTENDANCE DURING 1937 56.7% NUMBER OF PUPILS REFUSING CLINIC TREATMENT 31.4% Orthodontia. The Report under this heading by preference of the S.M.O. is given to the Dental Consultant to write; therefore, no statistical value can be gained by a recital of work details, as we have no other Clinics with which we can pit them; suffice to say, the numbers who ask for treatment continues in a steady stream, at long last the Parents realise its importance, and, value in the future for their children's prospects in life. I am an advocate for the dawn of a day when any child requiring this treatment should obtain it, at a merely nominal fee, even only 1/- per year; it will gradually be patent to those in Authority that this is one of the only ways to secure a fit nation. Further, I am convinced it is work which womeri Dental Officers should specialise in doing; the harvest of cases is plentiful, and the yield is great—nature has endowed them with qualities attuned for success in dealing not so much with the troublesome and nervous child, but with an over-anxious Mother. Our work has been blessed with total and individual results, transformation from dental chaos to dental usefulness and pleasing appearances. The future, the store-house of our ideals, will bring forth from those who have received our treatments, words of gratitude and a determination to see their children if required receive the benefits they had. Dental Staff. Miss C. Jefferson joined us on November 15th, 1937. Clerical Staff. Miss W. Smith commenced duty on July 1st, 1937, as Senior Dental Clerk. The Clerical Staff have earned my thanks and praise. Recognition must be given to the work of all our Dental Officers in the production of Skiagrams at a most economical cost, and which I fear no comparison with those we previously received. Their achievements amply justify the words I wrote in my X-Ray Machine Reports. I am grateful to them. 30 In all that concerns the interests and welfare of the Staff with whom I work, never let it be counted against me that I was a stammerer in words or actions, on, and, in their behalf. A Personal Note. Dr. E. H. T. NASH. " Fare Thee Well." " Sooner or later, must come the hour when closest friends must say FAREWELL." In spite of the ups and downs inherent to persons of different personalities, one looks into the vestibules of memories and concludes, notwithstanding the inevitable clash1 of opinions between daily and close workers, the years can be counted as the roses each of us will gather in the all too soon December of our life. If a little breathing time be given ere we wend our westward way, obliterating the errors we have made, our recollections will find no tinge of regrets. Personally, if I have been a rung in the ladder of your climb to fame and nation known, I am satisfied, the more so when I think, to use phraseology so peculiar to yourself " Peter will be helpless to resist your choice which of the Golden Gates you will go thro', to enter one of the Mansions specially reserved for those who spent their life, doing their Master's will, to all, and especially to the " least among ye." In the emotions of the inevitable parting may these sentiments realise my wish, that they evoke reciprocal attunements. Let neither of us waste time in vainly regretting the past, nor complain against the changes that cause us discomfort, for change is the very essence of life. " Long shall we seek his likeness—long in vain And turn to all of him, which may remain, Sighing that Nature formed one such man, And broke the die—after moulding Nash. (Byron). " Si monumentum requiris circumspice." I. COHEN. ANNUAL REPORT OF THE ORTHODONTIC CONSULTANT. Now that the time has again arrived when I have to place before you my report relative to the past twelve months' activities of the Orthodontic Section of the Heston and Isleworth Public Health Department, I feel that for two reasons it is opportune for me to consider the matter in a somewhat broader manner than heretofore, and at the same time I think that it would be of benefit to place on record some of the difficulties which have been successfully overcome. The two reasons to which I allude are first the approaching retirement of Dr. E. H. T. Nash, the School Medical Officer, to whose enthusiasm and hard work were due in no small measure the original inception of the Orthodontic Clinic. Secondly because the autumn of 1937 saw the Orthodontic Section enter into its eighth working year and there is therefore every justification for a review of the activities and developments which have come to my notice during the five years in which I have held the post of Orthodontic Consultant at this pioneer clinic. Clinic Orthodontics in Practice. Looking back on the large number of cases which have now been successfully treated at the Clinic I would draw your attention to the fact that in spite of some initial doubt these treatments have always been carried out with most sparing employment of orthodontic appliances. Fixed apparatus, entailing as it must a higher cost and a prolongation of treatment, is in my opinion not merely undesirable but is definitely unnecessary in the case of school clinics. By limiting treatment to that possible with simple removable apparatus it has been clearly shown that there is no necessity for what would prove to be another source of expenditure, viz. — rhe employment of a full time dental mechanic. Even taking into consideration the pro rata 31 increase in appliances following upon the progressive rise in the number of cases treated, experience at the Clinic indicates that there has been neither delay nor inconvenience in securing the apparatus which I have had to specify. Another fact which emerges from my experience at the Clinic during the past five years is that my invariable practice of paying careful attention to preventative treatment in the initial stages of malocclusion with a view to minimising the chances of subsequent undesirable developments is a policy which has not only proved successful in the vast majority of cases but is also one inherently suited to the carrying out of orthodontics at school clinics. Preventative extraction of deciduous teeth followed by the judicious use of splint plates has resulted almost invariably in the successful checking of any ensuing and undesirable overcrowding of the teeth. Here again the treatment involved has been demonstrated to be conveniently available within the normal routines of the dental and orthodontic Sections. Realisation of the foregoing achievements prompts me once more to emphasize the immediate suitability of the orthodontic clinic for adoption in our National schools. X-Ray Examinations. When first taking up my duties with the Clinic 1 asked the Council to consider the possibility of installing an X-ray apparatus. This has, in fact, recently been arranged and I am therefore glad of the opportunity to be able to report that I consider the inevitably rather heavy expense involved has proved well worth while. The successful treatment of malocclusion depends to a large extent upon the early recognition and analysis of the defect and its prompt correction. An examination of the patient's mouth by means of X-rays is obviously an invaluable if indeed it is not an essential first step. Prior to the installaton of the X-ray unit it was necessary to arrange for patients to attend the most convenient institution where the means existed for procuring the desired photographs, in your case at the West London Hospital. The facilities afforded there were all that could be wished for and thanks are due to the authorities concerned for their co-operation. Nevertheless although this arrangement gave a good measure of satisfaction from my own point of view it must be obvious that it introduced a certain amount of inconvenience and loss of time for the patient and possibly also for the patient's parents. What is more, treatment could not commence as expeditiously as might have been desired. With X-ray apparatus now available within the Clinic it has become a simple matter to obtain the desired photographic record of the patient's dental condition with the minimum of delay and without subjecting either patient or parents to the probable inconvenience of attending an outside hospital. Beyond doubt, therefore, it can be placed on record here that it is advisable to equip school orthodontic clinics with X-ray apparatus. Extension on National Lines. There is no disputing the fact that a consideration of the problems encountered in the first few years of any undertaking goes a great deal further towards substantiating (or for that matter refuting) the claims of the instigators than does any amount of initial but hypothetical reasoning. You will no doubt remember that one of my misgivings when accepting office as Orthodontic Consultant was as to whether it might not transpire that the comprehensive and specialist treatment of malocclusion which T was determined to assist in providing could not but interfere seriously with the normal routine dental work at the Clinic. Should such interference have been eventually experienced it would undoubtedly have prejudiced the case for the general extension of orthodontic clinics throughout the Country. In actual fact, however, the past year has once again illustrated that a large number of cases can be handled with all the requisite thoroughness and yet not give rise to anv inconvenience or delay in carrying out the normal routine of the Dental Section. It is of interest to note at this point that by the end of 1937 the total number of cases which have come before me stands at no less than 1,322. 32 I would state therefore that in my opinion not the least of the services rendered by your Clinic is that it has established once and for all that given an efficient staff and a well organised Clinic with a carefully maintained routine there is no reason why the practice of orthodontics should not be introduced into any and every school throughout the land. The establishment of such a nation wide service would, 1 am profoundly sure, represent a definite step towards an improvement in National health and must therefore merit serious attention on the part of the Board of Education. The Consent of Authority. There are two further aspects of clinic orthodontics on which considerable light has been thrown during the pioneer work carried out at your Clinic. I refer first to the importance which has been found to attach to the support or otherwise on the part of the children's parents, and secondly to the reaction of those in authority (including those most intimately concerned by virtue of parental authority) to the so-called " aesthetic objection " to the practice of orthodontics. At the outset it was quickly realised that the parents' attitude towards cases of malocclusion was unfortunately one of comparative indifference, it being their firm belief that the cure of such irregularities was best left to Nature. Now lack of support and faith in orthodontic treatment on the part of parents is undoubtedly one of the greatest hinderances which comes the way of exponents of this branch of curative dentistry. It was therefore a source of much satisfaction when it was found that even after the Clinic had been established only twelve months there was observable a distinct orientation of outlook amongst the parents in the Borough. To the lay mind many of the cures effected at the Clinic have been little short of spectacular and no doubt this in itself has prompted the parents' recognition of and confidence in the Orthodontic Section. The barriers of prejudice and indifference which at first caused parents to withhold their consent to examination have now been entirely broken down, and there is no longer present any initial reason which delays the immediate and non-selective application of that preventative treatment at which orthodontia aims. The Aesthetic Aspect. Opposition to the orthodontic school clinic (I refer now to the orthodontic clinics at every state provided school in the country which I hope to see established under a National scheme) sometimes takes the form of alleging that the orthodontist offers as his first contribution the improvement of facial appearance rather than the promotion of a healthy mouth. As you must know, 1 maintain that the correct view of orthodontics is that it sets out first and foremost to ensure a clean and healthy denture for every child and relegates to a secondary position the nevertheless important factor of facial appearance. When one considers the manner in which malocclusion and irregularities predispose the individual not only to dental disease but also to the numerous attendant ills liable to attack the mouth breather, it certainly seems to me totally unnecessary to suggest that the dental profession should profess a greater interest in the righting of facial deformities than in the prevention of disease. Crowded teeth invite decay and therefore the primary concern of the orthodontist must be to equip the child with a normal and hygienic denture; not until this is achieved should there be entertained the idea of treatment for the removal of the undesirable handicaps imposed on the unlucky patient by reason of malformed jaws. Attention to what I have termed the " commercial dangers " of malocclusion must always come second to health. It is admitted that employers of labour are giving more and more consideration to dental hygiene, and rightly so. To those in authority both as parents and as education officers I would say, therefore, that if employers can recognise the importance of the aesthetic aspect far be it from those influencing control of the early life and condition of the child to enforce any unnecessary objection to the removal of detrimental physio-psychological handicaps. 33 Retirement of Dr. E. H. T. Nash. I have referred at the beginning of this report to the coming retirement of Dr. E. H. T. Nash, the School Medical Officer. As you know, Dr. Nash has held office for 17 years, and 1 should like to say here how greatly I have appreciated the opportunity which I have had of being associated with him in connection with this pioneer work. 1 have found him always to be extremely helpful and enthusiastic in providing every assistance necessary for carrying out the aims and objects of the Section. I feel that should the time arrive (as I am certain it must) when the orthodontic scheme becomes in fact a National institution it will undoubtedly be almost entirely due to the foresight and untiring efforts which Dr. Nash has for so long exercised. Moreover, it will surely be a matter for supreme satisfaction when it is recognised that the development of a scheme which must have such far-reaching and beneficial effects on the health of future generations is largely attributable to his work. Finally, may I take this opportunity of expressing to Dr. Nash my sincere good wishes on the occasion of his retirement. In Conclusion. The continued success of the weekly session scheme at your Clinic, as instanced in no uncertain manner by the foregoing considerations of difficulties encountered and overcome during the past seven years, more than ever convinces me that the way is clear for the immediate extension of the orthodontic clinic to embrace the whole of the country. I am profoundly certain that under the authority and guidance of the Board of Education a practical and successful scheme could be inaugurated at once which would prove a most valuable step forward in that promotion of National health which after all is the ultimate aim and object of all concerned in child welfare. H. R. EVANS. (/»). Orthopaedic and Postural Defects. Although handicapped by the absence of a Clinic for the supervision of orthopaedic and postural defects, we have been able to secure expert advice for our cases, and one can only place on record one's gratitude for the manner in which the Royal National Orthopaedic Hospital has co-operated with us in remedying the defects we found amongst our school children during the year under discussion. Thirty children from this area attended as Out-patients. Eleven children received Inpatient treatment at the Royal National Orthopaedic Hospital during the year. The following list shows the conditions treated and the Authority responsible for the charges — Case No. Condition treated. Authority Responsible. 1 Severe postural defect. Local Education Authority. Old Rickets. Kyphosis. 2 Post fracture deformity. do. Limitation of movement, Right Hip. 3 Congenital Torticollis. do. 4 Cyst, internal cartilage, Right Knee. do. 5 Acute Poliomyelitis. do. Curvature of Spine. 6 Spasmodic Valgus. do. 7 Right Pes Cavus. do. 8 T.R. Spine. Middlesex County Council. 9 T.R. Knee (Right). do. 10 T.B. Hip (Left). do. 11 T.R. Spine. do. 34 (i). Heart Disease and Rheumatism. Whilst we have no arrangement for the treatment of Heart Disease and Rheumatism within the ambit of the local School Medical Service, such cases as are recommended for institutional treatment are sent by the Committee to West Wickham or other places according to the nature of their needs. Other cases are kept under observation at the School Clinics, and, with the co-operation of Head Teachers, receive modified schooling and periods of rest. (j). Tuberculosis. The treatment of tuberculosis is in the hands of the Middlesex County Council, and any suspicious case is immediately referred to the County Tuberculosis Officer with whose Dispensary in Bell Road we are in constant touch. One case (T.B. Right Hip) was found to need treatment during the year. This child was admitted to the Royal National Orthopaedic Hospital in March and discharged in July. She returned to whole-time school in November. (k). Speech Defects. In February, 1937, the Speech Training Class was commenced with a Specialist Teacher in charge. The following is a report received from the teacher:— " February-December, 1937. REPORT ON THE SPEECH TRAINING CLASSES. From February until September five children attended the Speech Training Classes, after which three more were added. On the whole good progress has been made by the children, especially in the cases of M.F., P.H. and H.H. The two latter are being discharged from the classes at the end of this term, their speech being now without defect. Although M.F. has made great progress both in the construction of sentences and in pronunciation, his speech is still not normal. I think it is a great pity that his parents are unable to use the opportunity offered them of giving the boy the special education he needs, as I feel that under favourable conditions he is capable of learning far more than he can in the ordinary school. Improvement has not been so noticeable in the cases of E.F. and J.H., both of whom have been absent rather often. Of the three who started in September, one—S.B.—has been absent since her second lesson owing to the illness of her mother who was unable to bring her. The two others, D.H. nd L.A., have started to make good progress." There is no doubt that in some of the difficult cases there is a great need for classes of this type. 8.—INFECTIOUS DISEASE. The rules as to the 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 scheme introduced last year for following up certain cases of infectious disease has continued to operate. By agreement with the Medical Superintendent of South Middlesex Fever Hospital we are notified of every case where there are special conditions that require supervision after discharge. These cases are seen by a member of the Authority's Medical Staff and are kept under observation at the Clinic. 35 The following table shows the infectious disease which occurred among children attending public elementary schools during 1937 and the five previous years. 1937 1936 1935 1934 1933 1932 Scarlet Fever 133 119 124 210 186 105 Diphtheria 10 8 37 44 17 30 Measles 174 1352 10 901 108 952 German Measles 18 15 6 66 13 25 Mumps 1538 306 113 153 940 122 Chicken-pox 634 161 537 417 362 194 Whooping Cough 276 366 232 144 287 260 2783 2327 1059 1935 1913 1688 This table shows the incidence of infectious disease in each school during 1937 :— school. Scarlet fever Diphtheria. Measles German measles Mumps Chicken pox Whooping cough Alexandra Junior 1 – 1 – 65 10 3 „ Infants 2 – 31 l 77 5 34 Berkeley Junior Mixed & Infants 9 – 83 l 163 89 21 Bulstrode Senior Boys 3 – 1 – 16 1 – ,, „ Girls – 1 – – 5 2 1 Chatsworth Junior 1 – – – – 2 – „ Infants 8 l 1 l 21 6 13 Cranford C. of E. Infants – – 4 – 35 2 18 „ Junior Mixed & Infants 2 – – – 59 5 17 Grove Road Junior Mixed 14 1 1 – 42 9 4 „ „ Infants 10 – – 2 60 25 43 Heston Senior Mixed – – – – 11 2 – „ Junior Mixed 4 1 17 — 61 13 2 „ Infants 18 – 1 1 117 25 18 Hounslow Heath Senior Mixed 2 – — — 16 3 2 „ „ Junior Boys 2 – 2 1 56 13 — „ „ Junior Girls 2 – — — 80 21 1 „ „ Infants 8 – 19 3 163 141 37 Hounslow R.C. Mixed & Infants — – — 4 45 49 2 Hounslow Town Junior Mixed & Infants 11 – 4 – 100 66 2 Isleworth Blue Boys 1 – — — 3 — — „ „ Girls & Infants — – – — 10 — — Isleworth Town Junior Mixed 4 1 — 1 4 2 — „ „ Infants — 1 — — 13 7 9 Marlborough Senior Mixed 4 – — — 5 1 — „ Infants 9 3 2 1 33 4 2 St. Mary's Boys 4 1 — — 4 3 — „ Girls & Infants 6 — 3 — 17 8 4 Spring Grove Central 2 — 1 — 19 4 6 „ „ Junior Mixed & Infants — — — — 66 3 13 Wellington Junior 3 — — 2 111 58 14 Woodlands St. John's Infants 2 — 1 — 4 22 1 Worple Road Junior Mixed — — 1 — 7 15 — „ „ Infants 1 — 1 — 50 18 9 Totals 133 10 174 18 1538 634 276 36 The School Nurses continue to visit all cases of non-notifiable infectious disease, and, as has been pointed out in previous years, this work takes up a considerable part of the nurses' visiting time, and when the number of cases is large the other work suffers to some extent. As is 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. In previous years I have only been able to say that there is no Special School in the Borough. This year I can state that an Open Air School is being prepared at Busch Corner which it is hoped will be ready to receive children in the Spring of 1938. Accommodation will be provided for 140 children. The Isleworth Health Centre with the Minor Ailments Treatment Clinic is in the same grounds, and the proposed early opening of an Ultra-Violet Light Clinic in the Health Centre premises will make a most valuable addition to the school medical service of the Borough. (a). Playground Classes. These are arranged in most of the schools. All the newer schools have a playing field on the site in addition to a tarpaved area and full use of this is made for teaching purposes. Several schools make a feature of the School Garden. (b). Open-Air Classrooms in Public Elementary Schools. The following recently constructed schools have almost complete open air conditions :— Heston Junior. Cranford J.M. & I. Marlborough Infants'. Chatsworth Infants'. Similar conditions obtain at the Schools at present in course of construction, i.e. Springwell Infants' and Norwood Green J.M. & I. (c). School Journeys and Camps. (a) SCHOOL JOURNEYS. The Education Committee assist School Journeys for Senior Children by the following grants :— 10/- per head or 50% of the cost per child, whichever is the lesser, plus travelling and maintenance charges of the teachers. During the year the following school journeys have taken place : — Bulstrode Senior Girls—Ryde, I.O.W. 9th to 16th July, 1937. 30 girls. Hounslow Heath Senior School (Boys)—Bournemouth Rotary Camp, Swanage. (b) SCHOOL CAMPS. The Committee decided to appropriate £800 allowed for Coronation Celebrations towards the provision of a permanent School Camp and several areas have been visited in the Surrey Hills and in Buckinghamshire, but a suitable site has yet to be found. The Ham Island Camp near Windsor on the banks of the Thames has again been used by one of the Senior Schools, and the Committee's School Journey grant has been made. 10.—PHYSICAL TRAINING. The Committee have very carefully considered the question of appointing a Physical Training Organiser in conjunction with the Middlesex Education Committee's scheme for the organisation of Physical Training, but they have decided that the time is inopportune. In each Senior School a fully qualified physical training specialist has been appointed and suitable gymnastic apparatus—such as wall bars, benches, ropes, and mats have been provided. At the Spring Grove Central School a new fully equipped gymnasium has been built. The following is a brief description : — 37 " The new gymnasium is the first to be erected for any school in the Borough, the large hall being 60 ft. by 30 ft. and 16 ft. high. One long wall is almost completely composed of three large glazed folding door units opening to a playing field, so that open air conditions are easily obtainable. Twenty-eight sections of wall bars and racks for beam saddles occupy an end and the other long wall, whilst the fourth wall under the balcony has doors to changing rooms, entrance vestibule and store room. Across the gymnasium are two double-double counter balanced booms which can easily be pulled to the sides and ceiling, also ten climbing ropes on a trackway. The storeroom contains water supply, troughs and swab for cleaning the floor and is large enough to contain all the portable apparatus—horse, box, buck, six benches, gymnastic mats on special hooks, Dunlop mats are being used. At the ends are an electric fan, electric clock and a long posture mirror. The electric light units are at ceiling height. The girls' changing room with Nuway rubber mats, has wash-bowls, a dressing table bench with mirrors, lavatories and a shower bath room with 10 cubicles with oil silk curtains. The wall sprays are of the adjustable ball and socket type at shoulder height. The boys' changing room with Roll-up wooden mats has a wash bowl and lavatory attached. The shower bath annexe is of the ' walk-through ' type with sprays on either side. All the showers have hot and cold water, the temperature being controlled by premixing valves.". The policy of the Committee is to provide a fully equipped gymnasium at each senior school and plans have been prepared for such a building at the Bulstrode Senior School at an estimated cost of £6,000. This work is being carried out in conjunction with the drainage and lay-out of the adjacent playing field. As a result of the large playing fields and playgrounds on the school site, physical training activities during the summer usually take place under open air conditions. Special facilities have been given for a physical training class for teachers at the Spring Grove Central School Gymnasium. 11.—PROVISION OF MEALS. Dinners. Selection of Children.—Children are selected by the medical officers at routine or special examinations or by the Head Teachers on application from the parent. The Head Teacher is authorised to grant two tickets, and the case is then referred to the Education Office for assessment. Border line cases of assessments are referred to the Special School Cases Sub-Committee. During December, 1937, 93 children received free dinners and 8 children received dinners on payment of part cost. Approval of Dietaries.—Specimen menus are issued to the Cafes by the School Medical Officer's Staff and a special Sub-Committee of the Education Committee. Meals are provided by 5 local Cafes at a cost of 7d. per head per day. In cases where no local Cafe is available the caretakers undertake the work. Meals are provided during term-time and during holidays with the exception of Saturdays and Sundays. Milk Meals. The number of children having milk at school on 31st March, 1938, was 6,894. Of these, 278 were having free milk and 6,616 were paying part or full cost. Milk is not supplied on Saturdays or during holidays. The full cost is 5d. per week. Children are either selected by the School Medical Officer as a result of routine or special medical inspections or join the scheme voluntarily. 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 1937 a parent or other relative attended in 3,285 instances, representing 85.2 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 trequently given when time is short. 38 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 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. National Society for the Prevention of Cruelty to Children. One potent agent for good in the district is the N.S.P.C.C. and one has reason to be grateful, on many occasions, for the tactful manner in which the Officers of the Society have dealt with the neglect which still occurs in this enlightened area. It must be remembered that a number of these cases are due to want of intelligence, primarily on the part of the parents. There is a certain section of the population whose intelligence quotient is only just above the mental deficiency line and who are not controlled by reason of that fact. This labels them from the point of view of mental assessment as normal citizens, but a number of these cases have not got the appreciation of what a normal citizen's responsibilities are and when this sub-normal mentality is aggravated by alcohol the condition of the children is very often one which has to be dealt with by an agency such as this. 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. All mentally abnormal children, other than those who have been notified to the Local Mental Deficiency Authority, are re-examined frequently and in any case not less than once in twelve months. At the end of 1937 there were 45 children being maintained by the Education Committee at institutions outside the district. Convalescent Treatment. In view of the increasing number of children who appear to be enjoying the advantages of convalescent treatment provided by the Education Authority it may be of interest to describe the types who derive most benefit from such treatment. First and foremost is the child whose parents complain that he has no appetite, is very easily tired, sleeps fitfully and has, perhaps, irregular bowel action. It is sometimes difficult to ascertain the primary cause of this chain of symptoms but in most cases the reason is to be found in one or all of the following:— (1) Irregular meal times or faulty diet, (2) Lack of training regarding regular action of the bowels. (3) Irregular hours of retirement to bed at night. In most cases the mere removal of the child from his faulty environment and routine attention to the above points produces a very satisfactory result. He returns pounds heavier with an excellent appetite and colour and in many cases the teacher notices a corresponding improvement in his school work. This improved mental outlook, which is the natural concomitant of his better physical well-being is one of the most pleasing results that one is able to observe in school medical work. 39 The complaint that the child tires easily, besides being one of the chief symptoms of the above condition is also noticeable as a rule in septic conditions, such as otitis media, nasopharyngeal sepsis, infected sinuses, chronic intestinal stasis, chronic appendicitis, in anaemic states and in girls at puberty. Convalescent treatment in such cases is usually disappointing if undertaken before the primary disease has been investigated. Another type of child who benefits considerably from convalescent treatment is the child of nervous temperament whose condition is either due to or at least aggravated by his parents in their endeavour to make his passage through life as tranquil as possible. The attitude of the parents is understandable as very often there is a history of difficulty in rearing the child and habits once formulated are very difficult to disestablish. It is usually impossible to persuade such parents to allow the children to go away but, in the few cases where it is possible, the results are very gratifying. A further group of children found to benefit very considerably are those with a history of great aptitude for taking colds and consequent nasal and bronchial catarrh. The same type of child who has gone a stage further and shows signs of slight pulmonary fibrosis due to frequent attacks of bronchitis may also gain considerable improvement in general health from a prolonged stay of at least six months. The child with marked pulmonary fibrosis with or without bronchiectasis or severe bronchitis and Asthma is usually a disappointment, however, and seldom derives much lasting benefit from such treatment. From these few remarks it will be seen that there are certain points to be considered before recommending a child for convalescent treatment and, if these are carefully weighed in each case, this type of treatment provides us with one of the surest and quickest means of restoring a child to more or less normal health. 14.—FULL-TIME COURSES OF HIGHER EDUCATION FOR BLIND, DEAF, DEFECTIVE AND EPILEPTIC STUDENTS. Nothing has been done under this heading by the Authority during the year. 15.—NURSERY SCHOOLS. There are no nursery schools in the area. 16.—SECONDARY SCHOOLS AND OTHER INSTITUTIONS OF HIGHER EDUCATION. The Middlesex County Council's scheme for the Dental Inspection and Treatment and Ophthalmic treatment of Secondary School children by this Authority which came into force on the 1st April, 1935, has continued to work smoothly. During the year 1516 children were dentally inspected, and of these 1222 were found to need treatment. 798 children received treatment before the end of the year. 104 Ophthalmic cases were dealt with. Spectacles were prescribed in 77 cases and were obtained in 76 cases before the end of the year. See Statistical Tables on pages 51 and 52. 17.—PARENTS PAYMENTS. During the year one new scale of parents' payments has been introduced, and one scale has been amended. 40 The new scale, in connection with the sale of preparations at the School Clinics (see page 11), is given below :— Sale of Preparations at School Clinics. Number in Family. Weekly income per head after deducting rent 2 Up to 11/6d. Over 11/6d. 3 „ „ 11/- ,, 11/- 4 ,, ,, 10/- „ 10/- 5 and over „ „ 9/- „ 9/- Assessment Free Full Cost The amended scale is in connection with Tonsils and Adenoids, since the new arrangement with the Middlesex County Council for each case to be retained in hospital for 48 hours, has naturally resulted in an increased cost to the Authority. The amended scale is as follows :— Scale of charges for operative treatment of Tonsils and Adenoids. Full cost of operation is £1 11 6d. No. in Family. Income per head after deducting rent. 2 11/6 12/6 13/6 14/6 15/6 16/6 17/6 18/6 19/6 20/6 21/6 3 10/6 11/6 12/6 13/6 14/6 15/6 16/6 17/6 18/6 19/6 20/6 4 9/6 10/6 11/6 12/6 13/6 14/6 15/6 16/6 17/6 18/6 19/6 5 8/6 9/6 10/6 11/6 12/6 13/6 14/6 15/6 16/6 17/6 18/6 6 7/6 8/6 9/6 10/6 11/6 12/6 13/6 14/6 15/6 16/6 17/6 7 and over 6/6 7/6 8/6 9/6 10/6 11/6 12/6 13/6 14/6 15/6 16/6 Parents' contributions Free 3/- 6/- 9/- 12/- 15/- 18/- 21/- 24/- 27/- 31/6 18.—HEALTH EDUCATION. During the year four parties of girl " leavers " from the Spring Grove Central School visited the Isleworth M. & C.W. Centre. Each party was received by the Health Visitor who explained the activities of the Centre, and the Medical Officer in charge gave a talk on the work and objects of the Maternity and Child Welfare Scheme. At the Bulstrode Senior Girls' School a baby care demonstration was given by one of the Health Visitors. The model behaved splendidly and the senior girls showed a thorough interest in the demonstration which included daily care, evening toilet, preparation for bed and attention in the morning. 19.—SPECIAL ENQUIRIES. No special enquiries have been carried out during the year. 20.—MISCELLANEOUS. One teacher was medically examined during the year in connection with her appointment 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-seven children were examined during 1937. 41 ELEMENTARY SCHOOLS STATISTICAL TABLES TABLE I.—MEDICAL INSPECTIONS OF CHILDREN ATTENDING PUBLIC ELEMENTARY SCHOOLS. A.—Routine Medical Inspections. Number of Inspections in the prescribed Groups— Entrants 1343 Second Age Group 1543 Third Age Group 970 Total 3856 Number of other Routine Inspections — Grand Total 3856 B.—Other Inspections. Number of Special Inspections 2808 Number of Re-Inspections 6908 Total 9716 C.—Children found to require Treatment. Number of individual children found at Routine Mldical Inspection to Require Treatment (excluding Defects of Nutrition, Uncleanliness and Dental Diseases). Group. (1) For defective vision (excluding squint). (2) For all other conditions recorded in Table II A. (3) Total. (4) Entrants 7 163 167 Second Age Group 91 163 211 Third Age Group 64 98 121 Total (Prescribed Groups) 162 424 499 Other Routine Inspections — — — Grand Total 162 424 499 42 TABLE II. A. RETURN OF DEFECTS found by Medical Inspection in the Year ended 31st December, 1937. Defect or Disease. 1 Routine Inspections. No. of Defects. Special Inspections. No. of Defects. Requiring treatment. 2 Requiring to be kept under observation, but not requiring treatment. 3 Requiring treatment. 4 Requiring to be kept under observation, but not requiring treatment. 5 (1) Ringworm—Scalp ... ... 5 ... (2) „ Body ... ... 6 ... (3) Scabies l ... 40 1 (4) Impetigo 2 ... 333 ... (5) Other Diseases (Non-Tuberculous) 11 2 250 21 TOTAL (Heads 1 to 5) 14 2 634 22 Eye (6) Blepharitis 7 2 28 2 (7) Conjunctivitis 1 81 3 (8) Keratitis ... ... 1 ... (9) Corneal Opacities ... ... ... ... (10) Other Conditions (excluding Defective Vision and Squint) TOTAL (Heads 6 to 10) 11 4 132 8 19 6 242 13 (11) Defective Vision (excluding Squint) 162 91 31 1 (12) Squint 7 3 5 1 Ear (13) Defective Hearing 32 68 42 13 (14) Otitis Media 15 2 123 2 (15) Other Ear Diseases 9 4 88 14 Nose and Throat (16) Chronic Tonsillitis only 99 212 95 31 (17) Adenoids only 26 22 6 2 (18) Chronic Tonsillitis and Adenoids 58 69 61 10 (19) Other Conditions 3 23 67 87 (20) Enlarged Cervical Glands (Non-Tuberculous) 21 69 17 33 (21) Defective Speech 3 6 8 3 Heart and Circulation Heart Disease : (22) Organic ... 1 ... 2 (23) Functional 7 38 2 10 (24) Anaemia 1 2 1 5 Lungs (25) Bronchitis 3 14 38 21 (26) Other Non-Tuberculous Diseases 3 39 49 45 Tuberculosis Pulmonary :— (27) Definite ... ... ... ... (28) Suspected ... ... ... ... Non-Pulmonary :— (29) Glands ... ... ... 1 (30) Bones and Joints ... ... 1 ... (31) Skin ... ... ... ... (32) Other Forms ... ... ... ... TOTAL (Heads 29 to 32) ... ... 1 1 Nervous System (33) Epilepsy ... ... 1 2 (34) Chorea ... ... 9 4 (35) Other Conditions 1 1 13 17 Deformities (36) Rickets ... ... ... ... (37) Spinal Curvature 3 4 5 ... (38) Other Forms... 13 37 17 8 (39) Other Defects and Diseases (excluding Defects of Nutrition, Uncleanliness and Dental Diseases) 12 3 1748 284 Total number of Defects 511 716 3303 631 43 B. CLASSIFICATION OF THE NUTRITION OF CHILDREN INSPECTED DURING THE YEAR IN THE ROUTINE AGE GROUPS. Age-groups Number of Children Inspected A (Excellent) B (Normal) C (Slightly subnormal) D (Bad) No. % No. % No. % No. % Entrants 1343 20 1.49 1043 77.66 272 20.25 8 0.60 Second Age-group 1543 19 1.23 1240 80.36 281 18.21 3 0.19 Third Age-group 970 4 0.41 790 81.44 175 18.04 1 0.10 Other Routine Inspections — — — — — — — — — TOTAL 3856 43 1.12 3073 79.69 728 18.62 12 0.31 44 TABLE III.—RETURN OF ALL EXCEPTIONAL CHILDREN IN THE AREA. Children suffering from Multiple Defects, i.e., any combination of Total Rlindness, Total Deafness, Mental Defect, Epilepsy, Active Tuberculosis, Crippling, or Heart Disease 2* * See details on page 46. BLIND CHILDREN. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 3 — — 1 4 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 4 1 — 1 7 DEAF CHILDREN. At Certified Schools for the Deaf. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 5 — — — 5 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. 6 12 1 8 27 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 2 — 1 8 45 TABLE III.—continued. 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. — 2 1 — 3 II.—CHILDREN SUFFERING FROM NON-PULMONARY TUBERCULOSIS. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 3 3 1 1 8 B. Delicate Children. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 21 162 1 2 186 C. Crippled Children. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 3 31 1 2 37 D. Children with Heart Disease. At Certified Special Schools. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. — — — 1 1 Children Suffering from Multiple Defects. Combination of Defect. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School. or Institution. Total. Mental Defect (Feeble Minded) and Severe Epilepsy. 1 1 *Mental Defect (Feeble Minded) and suspected Epilepsy. 1 1 *Three Special Schools have rejected this case. 46 STATEMENT OF THE NUMBER OF CHILDREN NOTIFIED DURING THE YEAR ENDED 31st DECEMBER, 1937, 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 3 1 (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 3 1 47 TABLE IV.—RETURN OF DEFECTS TREATED DURING THE YEAR ENDED 31st DECEMBER, 1937. TREATMENT TABLE. GROUP I.—MINOR AILMENTS (excluding Uncleanliness, for which see Group VI). Disease or Defect. (1) No. of Defects treated, or under treatment during the year Under the Authority's Scheme (2) Otherwise (3) Total. (4) Skin— Ringworm-Scalp. (l) X-Ray Treatment 3 — 3 (2) Other 2 1 3 Ringworm-Body 5 1 6 Scabies 43 1 44 Impetigo 335 3 338 Other skin disease 207 19 226 Minor Eye Defects 176 13 189 (External and other, but excluding cases falling in Group II). Minor Ear Defects 196 12 208 Miscellaneous (e.g., minor injuries, bruises, sores, chilblains, etc). 1502 74 1576 Total 2469 124 2593 48 TABLE IV.—continued. GROUP II.—DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments—Group I.) Defect or Disease (1) No. of defects dealt with No. of children for whom spectacles were Under the Authority's Scheme (2) Otherwise (3) Total (4) Prescribed (1) Obtained (2) (0 Under the Authority's Scheme (ii) Otherwise (i) Under the Authority's Scheme (ii) Otherwise Errors of Refraction (including squint) 700 2 702 464 2 459 2 Other defect or disease of the Eyes (excluding those recorded in Group I). — — — — — — — Total 700 2 702 GROUP III.—TREATMENT OF DEFECTS OF NOSE AND THROAT. NUMBER OF DEFECTS Received Operative Treatment. Under the Authority's Scheme in Clinic or Hospital (1) By Private Practitioner or Hospital, apart from the Authority's Scheme. (2) Total (3) Received other forms of Treatment. (4) Total Number Treated (5) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) (i) (ii) (iii) (iv) — 1 56 — — — 48 2 — 1 104 2 — 107 (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. Residential treatment without education. Non-residential treatment at an orthopaedic clinic Residential treatment with education. Residential treatment without education. Non-residential treatment at an Orthopaedic clinic. (i) (ii) (iii) (i) (ii) (iii) Number of children treated 7 — 13 4 — 17 37 49 TABLE IV.—continued. GROUP V.—DENTAL DEFECTS. (1) Number of children inspected by the Dentist (a) Routine age-groups. AGE 5 6 7 8 9 10 11 12 13 14 15 TOTAL N umber 1125 1120 1151 1329 1220 1319 1208 871 868 418 51 10680 (b) Specials 2385 (c) TOTAL (Routine and Specials) 13065 (2) Number found to require treatment 9883 (3) Number actually treated 6959 (4) Attendances made by children for treatment 26113 (5) Half-days devoted to :— Inspection 84 Treatment Ordinary 1993 Gas 161 Administrative Clerical and Committee Meetings 108 2346 ( 6) Fillings :— Permanent Teeth 10971 Temporary Teeth 1497 Total 12468 (7) Extractions :— Permanent Teeth 1654 Temporary Teeth 6539 Total 8193 (8) Administrations of general anaesthetics for extractions 2700 (9) Other Operations :— Permanent Teeth Temporary Teeth 6379 Total 6379 GROUP VI.—UNCLEANLINESS AND VERMINOUS CONDITIONS. (i) Average number of visits per school made during the year by the School Nurses 2.47 (ii) Total number of examinations of children in the Schools by School Nurses 16,942 (iii) Number of individual children found unclean 810 (iv) Number of children cleansed under Section 87 (2) and (3) of the Education Act, 1921 Nil* (v) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 Nil (b) Under School Attendance Byelaws 13 * Note.—113 children had their heads cleansed—by parents' request—under arrangements made by the Local Education Authority (see page 11). 50 SECONDARY SCHOOLS STATISTICAL TABLES TABLE IV—OPHTHALMIC TREATMENT AND DENTAL INSPECTION AND TREATMENT OF SECONDARY SCHOOL CHILDREN. GROUP II. DEFECTIVE VISION AND SQUINT (excluding Minor Eye Defects treated as Minor Ailments). No. of Defects Dealt with. Under the Authority's Scheme Otherwise Total ERRORS OF REFRACTION (including squint) 104 104 Other defect or disease of the eyes (excluding those recorded in Group I) — — — Total 104 — 104 Under the Authority's Scheme Otherwise Total No. of Children for whom spectacles were (a) Prescribed 77 — 77 (b) Obtained 76 — 76 TABLE V.—DENTAL INSPECTION AND TREATMENT. (1) Number of children inspected by the Dentist (a) Routine age-groups AGE 10 11 12 13 14 15 16 17 18 TOTAL Number 4 142 264 300 283 231 96 20 5 1345 (b) Specials 171 (c) TOTAL (Routine and Specials) 1516 (2) Number found to require treatment 1222 (3) Number actually treated 798 (4) Attendances made by children for treatment 4164 51 (5) Half-days devoted to:— Inspection 16 Treatment * Total 16 (6) Fillings Permanent Teeth 2892 Temporary Teeth 2 Total 2894 (7) Extractions :— Permanent Teeth 369 Temporary Teeth 106 Total 475 (8) Administrations of general anaesthetics for extractions 189 (9) Other Operations:— Permanent Teeth Temporary Teeth 1060 Total 1060 * Separate treatment sessions have not been arranged exclusively for Secondary School children. The children have been treated at the ordinary sessions at which Maternity and Child Welfare and Elementary School cases attend. 52